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Where pain management meets vocational rehabilitation

Posted May 05 2009 5:11pm

I had a conversation with a case manager yesterday.  The pain management team had asked for the inclusion of several sessions with me to look at coping with pain at work, along with some anxiety management and some exercise extension for a chap who has been off work for about two years with chronic low back pain.  The case manager seemed mystified as to why I might need to work with this man, saying ‘but we’ve already got a vocational plan in place’.

I asked about the plan they had - it involved developing a good working CV/resume, obtaining a work trial, supervising that work trial, helping him develop effective interview skills, and getting him used to the routine of working again.  A good plan for returning to work.

Let me backtrack for a moment to take you through our reasoning for asking for input from me.

This man has been extremely deactivated - worried about harming himself if he moved.  He’d been depressed.  When he had a flare-up of pain he’d stopped everything he was doing.  He was very distressed about the changes in his functional abilities because he’d previously been a very fit and you could almost say ‘go-getting’ man, and for two years he’d been so scared of moving that he’d hardly left the home.  It had taken a long time for him to begin to gain confidence to move from his home environment to community settings.

He’d had some good pain management and had started to develop and use active coping skills - but in his home only.  He had some very strong beliefs about what a man ’should’ and ’should not’ do, and more than that, he had very strong beliefs about what an employer would tolerate.   This lead him to push himself very hard to be ‘normal’ and not accommodate his functional limitations - and you’ll know the consequences of that! Yes, he’d have a flare-up and become deactivated, despondent and distressed.

Over time he had begun to use his coping skills reasonably consistently within his home environment.  As he put it, ‘At home I know I’m the only one who is going to get worried if I leave something until later’.  But when someone came to visit who might judge him, he’d do everything he could to ‘get it all done’ - the coping strategies completely forgotten.  When we discussed going back to work with his pain - his comment was that he knew he would revert to this pattern, so his confidence to be at work - and remain there - was very low, even though working was important to him.

In fact, you could say that working was so important to him that it elicited his internal ’shoulds’ and ’should nots’ so he was bound to avoid using active coping skills because it was so important that he do everything to meet the expectations of his employer.  A high risk situation if ever there was one!

There was clearly a gap between his use of active coping skills at home, and his ability to manage his pain in a work situation.

Now while I value my colleagues immensely, and wouldn’t work without them, we each have an area of expertise. 

My psychology colleagues are brilliant at working with thoughts, beliefs, and introducing concepts of pain management - and yes, developing behavioural change plans. 

My physiotherapy and occupational therapy colleagues are great at helping people develop and use skills to increase activity level and engage in coping skills. 

BUT my area of expertise is the workplace - knowing about the factors that influence behaviour at work, the social and interpersonal situations, the unwritten ‘rules’ of work, the specific demands that are different about the workplace from home or social settings.

When the case manager I spoke to said ‘but why can’t the psychologist help him get confident to do pain management at work’ she had a point - that’s definitely something they can do to a certain extent.  But given the amount of time clinical psychologists get during training to learn about specific workplace and return to work factors (especially those specific to returning to work with chronic pain), that’s a little unfair (especially given the rest of the work our psychologist had to do with this man anyway!).

Knowing about pain management coping skills is one thing.  Knowing which skill to apply when, and how within the context of a workplace is a completely different thing.   It’s complex.  It’s about being cognitively flexible.  It’s about problem-solving on the fly. It’s about feeling OK about having different ways of doing things from before the pain started, and from the way other people do things. It’s about being assertive and telling people about functional limits - admitting vulnerability.  This is not easy to do when you’re a man who has prided yourself in being ’strong’.

Simply telling someone to ‘get on with it’ and use the skills they know about in a workplace can sometimes work.   But for some people, and especially those who have very strong beliefs about how things ’should’ be done, and those who have other vulnerabilities such as low mood, anxiety, pain-related anxiety and avoidance, or an extended period of time away from work, there is more required.

Vocational providers, by and large, are great at helping people look for work, identifying their skills, linking functional abilities to the tasks demanded in a workplace. 

But there are some things that are not always handled well - does the provider have a good grasp of chronic pain management? Do they use consistent models, do they support the strategies that the pain management provider has helped a person develop?  Do they recognise that people with pain have different vulnerabilities - some tend to over-do, as in this man’s case, while some under-do?  And how do they respond to this?  What is the scientific basis for the programme they develop for the person?

There is a dire need to develop really strong links between pain management and vocational management in New Zealand.  The workplace represents one of the contexts that people with pain identify as ‘high risk’ situations - or a situation where they are least likely to use their newly developed coping strategies.   This means additional and specialised help can be needed.  It means skills need to be robust, and professionals helping the person return to work need to be consistent in their approach.

I can’t tell you whether I’ll be able to work with this man.  What I will do is support the team to address some of the contextual issues that are common in the workplace.  And hopefully encourage providers to read more about the process people go through to return to work, so that the right support is given to the right person at the right time.

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