Work Disability Prevention in the Midst of Major Mental Illness and Life's
Trauma
Harold J. Bursztajn, M.D. Psychiatric Services (November, 2001)
An important contribution of the article by Drew and his colleagues in
the current issue of Psychiatric Services is that it reinforces the clinical
observations that to protect individuals post the trauma accompanying major
mental illness, unnecessary delay in return to work is counterproductive for our
patients as well as our society's productivity. Within the spectrum of trauma
related suffering, be it combat related "Shell shock", civilian victimization,
mass trauma as post the Shoah and 9/11, or accompanying unanticipated
consequences of major medical and mental illness, recovery from impairment is
facilitated by an appropriate level of mental health care combined with early
return to an appropriate level of duty or work. While there are important
differences among individuals, and between individual and mass trauma responses,
delay in the provision or availability of appropriate care and a lack of
support, incentives, and motivation for an early return to work, are
prescriptions for the enabling of unnecessarily chronic work related impairment
and disability. On the other hand, early return to work can be a useful by
empowering patients, suffering with, post primary trauma or trauma secondary to
illness, helplessness, to proceed with meaningfully rapid recovery.
The individual and social risks of post trauma chronic work disability
can be reduced by structuring clinical services so as to reduce the treating
clinician being burdened by the dual responsibilities of both being the
patient's treating clinician and potential back to work forensic evaluator.
Treating clinicians who are forced to be the responsible objective forensic
evaluators as to their patients' ability to work are more likely to be
distrusted by patients, especially those who have been previously traumatized by
"acts of man" or by suffering from the shame engendered by the stigma and
demoralization accompanying major mental illness. Clinical efforts are already
all too vulnerable to being misperceived by frightened patients as critical or
judgmental in the midst of the increase in anxiety initially accompanying the
process of confronting unacknowledged fears, avoidance behaviors, conflicts of
motivation and dysfunctional personality traits. Moreover patients' expecting to
be forensically evaluated by their treating clinicians are also more likely to
experience their fears of dependency upon treating clinicians becoming
magnified.
Under the above conditions, clinicians are less likely to have the
freedom to address dependency and secondary gain issues which substantially
increase the likelihood of trauma spectrum work impairment becoming magnified
into "sick role" based chronic work disability. To speed recovery, medical and
mental health care systems need to be designed to empower traumatized patients
by facilitating an early return to work via encouraging patient referral for a
forensic psychiatric evaluation independent of the treating clinician.