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.