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.