The Psychology of Injury: Applications for Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) has been considered a “gold standard” treatment approach in a range of psychosocial disorders, but only in recent years has its value truly begun to materialize in workers’ compensation. New and emerging applications, including work-focused CBT and expanded delivery channels, continue to increase its viability as an effective strategy in the injured worker population.
It has been well-discussed throughout the workers’ compensation industry that a successful path to recovery is built through a concerted effort on the part of all involved stakeholders; that the contributions of one without the others are limited in their ability to impact outcomes. But truly, there is one stakeholder on which the trajectory of the claim hinges: the injured worker patient.
Return to work relies on the patient’s understanding of what to expect on their journey to recovery – and most importantly, their willingness and motivation to see this journey through.
But sometimes, a patient can get in his or her own way.
THE PSYCHOLOGY OF INJURY
There is an undeniable psychological component to injury and recovery. Anxiety, depression, catastrophizing, fear avoidance – these are all factors that influence the course of a claim in a very real way. In some cases, these psychosocial factors can be even more detrimental to claim outcomes than physiologic factors. In a recent study of workers undergoing surgery following traumatic occupational hand injury, negative affect was a much stronger predictor of delayed return to work than was severity of injury.1 In another study of patients with minor injury, depression was the foremost inhibitor of restored function during the 6 to 12 months post-injury – more so than type of injury.2 Fear avoidance represents another psychological hurdle to physical recovery in that the patient is afraid to participate in active treatment modalities such as physical or occupational therapy. This obstacle to functional improvement leads to poor treatment outcomes, including higher pain and disability levels, and lower return-to-work rates.3
Psychosocial factors not only inhibit strides toward physical improvement, they also can negatively impact the pharmacological aspect of treatment. Depression, anxiety, and catastrophizing are all high-risk predictors for prescription opioid misuse,4 a pattern of behavior that is detrimental to claim outcomes in its own right.
CBT's GROWING ROLE IN WORKERS' COMP
The psychotherapeutic intervention known as cognitive behavioral therapy (CBT) is hardly a new concept. With its roots arguably reaching back to the 1960s, one might describe it as “retro.” For some time it has been considered a front-line treatment for a range of psychosocial issues and conditions – such as alcoholism, social anxiety, and various sleep and mood disorders. But over the last few years, something interesting has been happening in workers’ compensation. Increasingly CBT has been recognized as a valuable component of treatment among injured workers. Payers are now much more likely to recommend CBT for chronic pain claimants who exhibit psychosocial concerns. And this approach is having a profound effect on functional outcomes as well as pain symptoms.
COGNITIVE BEHAVIORAL THERAPY: THE BASICS
- A common form of mental health counseling
- Traditionally conducted by a therapist or other qualified healthcare professional
- A low-cost, low-risk component of overall treatment
- Modifies negative patterns of thinking or behavior
- Helps patients develop healthy coping skills
- Changes the patient’s understanding of pain
- Empowers patients to take a hands-on approach to their recovery
- Can reverse neuroremodeling,5 or the “rewiring” of the brain that may occur following injury
To learn about the effect pain can have on the brain’s neurocircuitry, read the article Understanding Pain: Neuroremodeling in the Spring 2014 issue of RxInformer.
It is important to note that standard CBT is not tailored for a workers’ compensation setting. Its applications are much broader, and therefore there is no built-in focus on return to work. That being said, incorporating return to work strategies into a CBT program that address common mental disorders reaps significant benefits. Not only can this approach speed return to work,8 but application of CBT during job re-entry can address residual depression or a patient’s anxiety about their ability to perform at a pre-injury level, both of which pose obstacles to successful return to work. A patient’s treatment journey does not stop at Day 1 of being back on the job. CBT during the transition can get them over the initial “hump” and ultimately increase work participation as well as the likelihood that the patient’s re-entry to the workforce will be successful over the long term.9
EXPANDING CONVENIENCE, ACCESS
New approaches to CBT are putting a technological twist on this gold-standard treatment strategy, and they are proving effective. Over-the-phone CBT has demonstrated results that are comparable to in-person therapy in disorders that include major depression.12,13 Similarly, Internet-based CBT has a positive impact on work-related outcomes, including improved work engagement.14,15 Smartphone apps are also proving to be a viable tool in the treatment of psychosocial disorders. For example, the mood journal app Moodnotes launched in August and is based on the principals of CBT. The app is designed to aid self-awareness and help patients self-manage their stress and anxiety. For the right patient, putting mental health management right in their hands – literally – can be empowering as well as effective.
There are other benefits of delivering CBT through nontraditional channels, including expanded access to services for patients living in rural or low-population areas where mental health services are limited. It can also reduce or eliminate the need for office visits, which is beneficial from an employer perspective because it reduces time needed away from work for injured workers who are not on leave or have already returned from leave. From a payer perspective, CBT via telemedicine offers potential cost benefits in terms of fewer office visits and transportation services in situations where these would otherwise be necessary.
CBT WITHIN A COMPREHENSIVE STRATEGY
Application of CBT is triggered by the presence of specific risk factors. There are many opportunities throughout the care continuum that can provide the payer with insight into psychosocial factors that may be impacting the claim trajectory. As with any negative factor influencing treatment outcomes, earlier intervention is better, and indeed there is research being undertaken to assess the impact of upfront pain education in individuals at high risk for chronic pain.16
However, psychosocial barriers to recovery can arise at any point of the patient’s journey – whether they are preexisting or they develop 3 weeks or 3 months into a claim. More than 20% of patients develop a new psychosocial disorder within the year following moderate-to-severe injury.17 A comprehensive management strategy takes into consideration these potential factors throughout the entire course of the injured worker’s treatment, and across all aspects of treatment, including pharmacy as well as ancillary components. For example, a full review of medical history triggered by high opioid doses may reveal evidence for comorbid depression, a significant predictor of opioid misuse. In a patient prescribed physical or occupational therapy, when the right data are collected from the treatment provider, signs of fear avoidance or other psychosocial factors that may be impacting therapy adherence are revealed.
The incorporation of CBT into the care of the injured worker demonstrates clear value for its positive impact on both pharmacologic and non-pharmacologic aspects of treatment, while new delivery methods increase the cost-effectiveness and efficiency of this traditional intervention strategy. The future impact of CBT in workers’ compensation looks even brighter as the industry continues to improve its ability to identify the patients who need it.