Article 1: Examining Perceptions, Beliefs & Values - A White Paper
Article 2: Maslow's Hierarchy of Needs
Article 3: A New Lexicon for Industrial Rehabilitation
Article 4: Establishing Earning Power
Article 5: Critical Issues between Impairment & Disability (two-part)

Examining How the Perceptions, Beliefs & Values of Individual Professionals Serving Work-Injured Clients May Affect Their Ethical Behaviors: A White Paper

Foreword:

Rehabilitation professionals are charged with the responsibility of evaluating and assisting people with medical impairments to reach established psychosocial and occupational objectives.  Those processes – evaluating and assisting medically impaired people to become productive – require that rehabilitation professionals adhere to a comprehensive code of ethics as they carry out that work.  Most professionals providing services to others, including physicians, lawyers, and psychologists, are bound by codes of ethics.

A major question in adherence to ethical codes is: How does an individual professional’s perceptions, beliefs, and values determine ethical code compliance?

The Authors

This article evolved from a workshop entitled “Work Injury: How a Professional’s Perceptions, Beliefs & Values Guide Their Ethical Behavior,” which was sponsored and conducted by CEC Associates, Inc., of Valley Forge, Pennsylvania, on April 16, 2004.

The article was framed and drafted by Dr. Jasen Walker, CRC, CCM, President of CEC Associates, Inc.  Dr. Fred Heffner of CEC also contributed to the original draft.

In addition to the principals, the following participants of the workshop read, critiqued, and added content to the original draft:

Maria Babinetz

LRC Disability Management Consultants

Paoli, PA 19301

Francis X. Wickersham, Esquire

Marshall, Dennehey, Warner, Coleman & Goggin

Newtown Square, PA 19073

Alex Karras, Esquire

Danmar Associates

Frazer, PA 19355

Terence Walsh

Paoli Care Management Services

Malvern, PA 19355

Michael D. Schaff, Esquire

Naulty, Scaricamazza & McDevitt, Ltd.

Philadelphia, PA 19103

Stephen Fireoved, Esquire

Lowry Associates

Plymouth Meeting, PA 19462

Background

On Friday, April 16, 2004, CEC Associates hosted a workshop on the topic “Work Injury: How a Professional’s Perceptions, Beliefs & Values Guide Ethical Behavior.”  The workshop was designed to serve professionals, including rehabilitation counselors and attorneys, who work with clients who have been injured or suffered an illness that affects their work status. 

The purpose of the workshop was to develop a dialogue among the participants around the perceptions, beliefs, and values that professionals bring to an encounter with injured or ill claimants and to consider the significance of those concepts in the context of the Codes of Ethics that govern their professions.  The workshop drew approximately half of its participants from those who work in medical and vocational rehabilitation services and half from attorneys who either represent claimants or defend insurance carriers and/or employers.

One of the objectives of the workshop was to use its content as the basis for a “white paper” on the subject.  During the workshop, participants were asked to document their thoughts on specific issues in writing.  Opportunities to do so were provided after the speakers’ lectures, as well as during smaller, breakout sessions.  All of these documented thoughts and reactions were collected by the workshop organizers (CEC).  The preserved content of the participants’ thoughts have become the nucleus of this white paper/article.

Another feature of the workshop was a mock interview with an actor who role-played the part of an injured worker.  The injured worker represented an actual case with all of the identifying content changed to keep the client anonymous.  The mock interview was used as a start point for the discussions in the breakout groups.  This aspect of the workshop proved to be the most interesting to the participants, as indicated on workshop evaluation forms.

Finally, participants in the workshop were invited to volunteer to work toward the creation of a white paper by reading and editing content, as well as contributing original content.  Six individuals took up this task.  Of the six, four are lawyers and two are rehabilitation counselors.  Of the four lawyers, two are defense attorneys and two are plaintiff lawyers.  One of the lawyers also serves as a rehabilitation counselor.

To establish the direction of the workshop, three experienced and respected professionals were asked to address the issues of perceptions, beliefs, and values as these concepts impact the Code of Ethics by which they individually abide.  The speakers and facilitators included:

Speakers:

Andrew E. Greenberg, Esquire, a founding partner of the Chartwell Law Offices, LLP;

Halmon L. Banks, III, Esquire, a partner in the Philadelphia law firm of Martin, Banks, Pond, Lehocky & Wilson; and

Stephen N. Berk, Ph.D., ABPN, a Board Certified Neuropsychologist;

Facilitators:

Stephen Fireoved, Esquire, a partner of Lowry Associates; and

Jasen M. Walker, Ed.D., C.R.C., C.C.M., a vocational evaluator and forensic expert as well as president of CEC Associates, Inc.

Background Note

In March 2004, the Superior Court of Pennsylvania decided a workers’ compensation case that involved claims of vocational malpractice, breach of contract, and claimant emotional distress.  The Court decided that the case should be remanded for further proceedings and relinquished  jurisdiction, allowing the plaintiff to sue the defendants in civil court. (See Taylor v. Woods Rehabilitation Services, et al, 2004 PA Super 89; 2004 Pa. Super, Lexis 312).  This case may represent the beginning of a landslide of lawsuits coming from the Pennsylvania Workers’ Compensation system, which now holds Rehabilitation Counselors accountable to the Code of Professional Ethics for Rehabilitation Counselors.

What is also significant about this case is that the claimant’s arguments in the underlying workers’ compensation matter, Wayne Taylor (claimant) v. Bethlehem Area School District (defendant), relied in part on what we believe to be vocationally dysfunctional Pennsylvania case law that is antithetical to federal standards, such as the Americans with Disabilities Act of 1990.  Plaintiff (claimant) alleged that the defendants “caused negligent infliction of emotional distress because their failure to inform potential employers of plaintiff’s limitations led to the plaintiff’s embarrassment, humiliation, and emotional distress when he attended job interviews and had to discuss his limitations.”

There are significant precedents for Pennsylvania Workers’ Compensation Court decisions that would be based on whether the Rehabilitation Counselor disclosed medical information and descriptions of limitations to prospective employers, but again, those decisions would clearly stand in opposition to the basic tenets of federal statutes.  For example, in 1998, the Commonwealth Court decided Young v. WCAB (Weis Markets) Pa. 537, A.2d 393, in which the court held that the Vocational Counselor failed to reveal the claimant’s history of methadone addiction to prospective employers, thereby violating the prospective employers’ need to know about the claimant’s physical limitations.  In a post-ADA decision, Brown v. WCAB, 7 PAWCLR 212, A.2d. (Pa. Commonwealth, 1992), the appellate court reversed a referee’s finding that work was available within the physical limitations by ruling that the Vocational Counselor had not sufficiently described to the prospective employer the claimant’s restrictions and limitations in detail.

      Under Young and Brown, the employer-sponsored vocational rehabilitation counselor must specifically detail restrictions resulting from the claimant’s impairments and disability.  Otherwise, “job availability” criteria are not met and the employer has not met its burden of proof – even though such disclosure is inconsistent with Title I of the ADA.  It is antithetical to the vocational rehabilitation of medically impaired clients to disclose their medical histories to prospective employers.

      The ADA expressly prohibits employers from asking an applicant about the nature or extent of a disability.  Under the ADA, an employer may ask how an applicant will be able to perform specific job functions and whether a job accommodation will be needed.  Further, a job offer may be conditioned on the results of a medical examination only if it is required of all employees in the same job category and the results remain confidential.  The ruling in the Woods Rehabilitation case seems to be continuing the series of Pennsylvania court decisions in conflict with the ADA. 

Introduction

There is no human activity from which questions about values and ethical principles do not arise.  The objective of the workshop was to conduct a group discussion about professional perceptions, beliefs, and values that would conclude with specific ideas on how to improve the conversation among professionals working with clients who have been injured in the workplace and to enrich the outcomes of such discussions.  The goal in recording the outcomes of the workshop was to write a “white paper” that could be used to extend awareness of the ethical behaviors required of professionals to those unable to attend, to encourage professionals to think about the issues, and to widen the audience for the ideas that emerged.

Ethics is a human practice that involves:

·        deliberation,

·        give and take,

·        active listening,

·        questioning,

·        probing, and

·        creative problem-solving

among participants in a community of shared values.

            (Robert Haas, CEO, Levi Strauss and Company)

Defining and Understanding Perceptions, Beliefs &Values

Participants in the workshop were mailed background materials when they registered.  Among these materials were six basic definitions:

1.      Client/Claimant:

The term “client” should be considered variously depending on the professional reflecting on that term.  For example, rehabilitation professionals might consider the client as either the injured worker or the source of the referral (e.g., claims representative); for attorneys the client is the individual for whom they are providing legal representation.. Defense lawyers will consider the employer/insurance carrier to be their client, and lawyers representing injured workers will perceive their clients to be the injured worker whom they represent.  Unless one is an insurance adjuster, the term “claimant” is not considered appropriate since it does not clearly and specifically identify the source of the professional engagement.

2.      Perceptions:

Perceptions are the result of making observations and having an awareness of what is being observed.  Perceptions derive from the senses (what we see, hear, taste, smell, touch).  The essential aspect of a perception is the idea or concept that is gained by the perceiving: seeing, hearing, tasting, etc.  (There are also extrasensory perceptions, but they are not to be considered here.)

3.      Beliefs:

A belief is a state or habit of mind in which trust and confidence is placed in some person or thing or a tenet or body of tenets held.  Once you have a belief, it influences how you perceive all other relevant information.

A belief bias is the tendency for one’s preexisting beliefs to distort logical      reasoning, sometimes by making invalid conclusions seem valid, or valid conclusions seem invalid.  A belief perseverance is a clinging to one’s initial conceptions after the basis on which they were formed has been discredited.

4.      Values:

Values are based on feelings.  Values are the things we are for and the things we are against.  Values are:

·        freely chosen,

·        chosen from alternatives,

·        chosen after weighing the consequences of each alternative,

·        prized and cherished,

·        shared publicly and shown to others (when appropriate).

“People act on their values, and they do so repeatedly and consistently.”

Raths, Louis E., Sidnewt B. Simon, and Merrill Harmin, Values and Teaching.

        Columbus, OH: Charles Merrill Publishing Co., 1966

When our values are clear, consistent, and soundly chosen, we tend to live our lives in meaningful and satisfying ways.  If we lack values, or our values are confusing and conflicted, we tend to live our lives in troubled and frustrating ways.

            Values are distinguishable from beliefs.

5. Ethical Beliefs:

Ethical beliefs are the framework for moral direction and how one carries out specific conduct.

6. Ethical Values:

Ethical values are principles that constitute the sense of good versus evil, right versus wrong.  These are acquired from culture, life experience with parents and friends, and one’s own analysis of ethical issues (e.g., values clarification).

Nearly every workshop participant represented a group of professionals who are bound by predetermined ethical standards.  Ethical standards of rehabilitation counselors, psychologists, and lawyers were presented to the group for consideration.

The Client/Professional Relationship in Rehabilitation Cases (Identifying and Differentiating the Professionals)

A number of professionals and non-professionals participate in the process of returning injured workers to productivity.  The primary players include the worker’s immediate family, the employer, and the medical professionals in the treatment process.  Case management specialists coordinating the interests of both the employer and the medical providers are also principals.  Frequently, this set of players is extended to include attorneys and vocational rehabilitation specialists.  Two attorneys are involved in many cases: an attorney representing the employer or the employer’s insurance carrier, as well as the claimant’s attorney.

The focus of this workshop was on the attorneys and the vocational rehabilitation professionals providing direct services to their clients.  It is important to note that while the primary role of the defense attorney is different from the role of the plaintiff attorney, both attorneys are covered by the same professional Code of Ethics. 

The Relationship Between Attorneys and Vocational Professionals in Rehabilitation Cases

Rehabilitation counselors are generally brought into a case by employers or insurance carriers directly or through their legal advisors.  Some companies have in-house Disability Management Programs that employ either case management specialists or rehabilitation counselors, or engage third-party providers for the service. 

Depending on the laws governing injured worker rehabilitation, case management professionals and rehabilitation counselors may or may not be welcome by injured worker legal representatives.  In some jurisdictions, rehabilitation counselors or, for that matter, case managers can be perceived as adversaries, representing only the interests of the insurance carrier or employer.  Almost immediately, interested parties defer to their perceptions, beliefs, and values in determining which parties will participate in the delivery and coordination of rehabilitation services to the injured worker, and, moreover, which of the parties will participate in good faith.

Rehabilitation counselors must clearly define their roles not only according to jurisdictional rules, but within the context of the ethical constructs of their professions.  For example, the relationship that a counselor will have with an injured worker from a jurisdiction that “mandates” vocational rehabilitation (e.g., California) may be much different than the counselor’s relationship with an injured worker in a state (e.g., Pennsylvania) that does not recognize vocational rehabilitation as a method of restoring injured worker productivity.  In each case, it is the rehabilitation counselor’s responsibility to clearly define the relationship and parameters according to not only ethical standards but certain realities dictated by the jurisdiction in which services are being provided to the injured worker. Immediately, however, perceptions, whether it be the injured worker’s perceptions, the lawyer’s perceptions, or the employer’s perceptions play a crucial role in the response to rehabilitation counselor intervention.

The Application of Perceptions in Practice

Perception has been used throughout psychology to describe and understand the forming of ideas.  Perception generally forms the basis of cognition, which is the foundation for belief.  Perception may be thought of as “an event in the person or organism primarily controlled by the excitation of sensory receptors,” according to H.B. English’s definition found in A Comprehensive Dictionary of Psychological and Psychoanalytical Terms (1958).  It may be considered a postulate that all behavior, without exception, is completely determined by the perceptual field of the behaving organism, and change in behavior occurs with a differentiation in one’s field of perception.

Perception is also a function of experience.  One should keep in mind that a visually impaired individual may have completely different perceptions of the same event than an individual with unimpaired sight.  Furthermore, when considering perception as a fundamental producer of behavior, it is important to recognize that science has shown that what one perceives is not what exists, but what one believes exists, and what is perceived is what we have learned to perceive as a result of our past opportunities or experiences.  Perception and experience are inextricably linked.

Among critical issues associated with the phenomenon of perception is what the professional brings to the case.  For example, a professional who thinks the client does not want to work based on pre-interview information is applying a perception, perhaps stimulated by prior experience or belief, that may or may not be valid.  Another issue in terms of perception is what specific perceptions may be based on the documentation that accompanies the client rather than direct observation. For example, what have medical providers said in reports about the patient’s motivation? The pre-interview information in the form of documentation may not be reliable. 

Some pre-interview information comes from the treating physician.  The questions here include the quality of the medical history and the comprehensiveness of the history.  The most serious aspect of a medical history is whether the physician understands the difference between a medical judgment and an occupational judgment – between an impairment and a disability. Another source of pre-interview information may be the personnel records from the employer.  Documented records can be useful, but they can also lead to pre-formed perceptions, which may not be valid.  The question becomes one of data validation.

The ethical aspects of perception derive from the validity of the perception.  A perception that the client does not want to work and is more invested in litigation may lead the professional to be less than fully engaged and helpful, and may even result in giving up on the client. 

When do perceptions become beliefs?  Perceptions are more visceral and fundamental than beliefs. One important concept (belief) in assisting a client to return to work is the idea that “everyone can work.”  That is, given job accommodation and job redesign assistance, essentially everyone can be useful and productive (even the paralyzed, through “human implantable ID technology”).  Perception and perceptions, whether valid or invalid, lay the foundation for beliefs and biases that influence behavior.  The professional’s beliefs regarding the value of work alone can dramatically affect the delivery of rehabilitation services to the injured worker.

The Application of Beliefs in Practice

The beliefs about work that a professional (whether rehabilitation service provider or legal advocate) brings to a case are significant.  Beliefs about the role of the individual in the community, politics, socially acceptable behavior, etc., that the rehabilitation specialist or attorney brings to an initial interview are crucial to the ultimate effectiveness of the professional-client endeavor.  So professionals need to be aware of their belief systems, endeavor to understand the belief systems of the people they service, and consider how they go about relating effectively to clients with different beliefs.  Both rehabilitation professionals and lawyers would be wise to be conscious of the beliefs they hold when attempting to bridge critical differences with the closely held beliefs of their clients.  What behaviors should the plaintiff attorney manifest when his or her injured-worker client wants to return to work?  What behaviors does the rehabilitation counselor chose and carry out when the injured worker declares that he does not want to work and would rather pursue total disability insurance of some type?

Another decisive issue is whether professionals have the right to espouse the adoption by their clients of new beliefs.  Are professionals being ethical when they attempt to reshape what are perceived to be non-productive beliefs?   

As a professional Code of Ethics is written and adopted, what is the basis for the belief system underlying the Code?  Generally, codes are composites of the best efforts of the professionals nurturing the profession at the time.  But do they accommodate all circumstances?  When Codes of Ethics do not address all issues, what is the professional’s responsibility to the larger group when he or she encounters a situation that is not perceived to be governed by the Code?

Finally, trying to find data to support a belief is not an uncommon practice, and that practice can be highly unethical.  As the old story goes, Is the drunk leaning on the lamppost more for support or illumination?  Are the data supported or illuminated by beliefs?  A healthy culture (or nation, profession, person) is based on strongly held beliefs.  These beliefs are the foundation for effective action.  But are we open to change our beliefs in the light of new, valid data?  Dogmatism, whether on the right or the left of the political spectrum, is still closed-mindedness.

The Application of Values in Practice

One of the most important issues of “values” is whether a relationship with an injured worker will be more effective if it is carried out as strictly an arms-length, professional relationship, or if the relationship is humanized and personalized.  What, if anything, does the relevant Code of Ethics say in respect to this issue?  Since such issues as sexual harassment or ethical bias can derive from a “personalized” approach (a too personalized approach), how is adherence to the Code of Ethics balanced with one’s personal values in terms of outcome effectiveness?

The challenge for the professional is to create a meaningful basis for cooperation.  In almost every instance, an effective professional-client relationship will depend on the existence of shared values.  Successful relationships derive from, and are based on, an acceptance of the reality that agreement on all issues with the client is not likely, and may not even be desirable.  In the final analysis, values are subject to change, and if a too firmly held value (or belief) is proving not to be productive in a professional’s relationship with a client (or indeed in his or her life), it should be abandoned or the relationship should be terminated.

Another issue that impacts the values a professional brings to a relationship with a client is the recent endeavor to infuse “character education” into the national curriculum.  Character education is an effort to focus on shared values, at least those that hold across cultures, religions, and politics: the values that are universally accepted; minimal, basic values.  The drive for character education is a response to what many individuals feel is the eroded, value-neutral curriculum of the immediate past.  The objective is to instill civic virtues and to create and maintain a responsible society.  So the advocacy of either a “value-neutral” or a “character education” focus is also relevant to the approach professionals take with their clients.

The “Halo Effect”

An important concept from psychology comes into play in terms of pre-formed perceptions, and that is the “Halo Effect.”  The Halo Effect (which is related to the idea of a “self-fulfilling prophesy”) occurs when a teacher, for example, is told that a certain student, or even a whole class, has superior intelligence and then the individual (or class) does, in fact, do extremely well at the end of the year.  Or the converse.  The same applies to a professional providing rehabilitation services to a client. When the professional holds the perception that the client really will not do well in the return-to-work process, the client will not do well.  The issue of “labels” is also related to this concept, and, in the final analysis, whether the professional can indeed bring a “clean slate” to the case is also germane.

The Relevant Standards of Practice and Codes of Ethics for the Respective Professionals (Attorneys and Vocational Counselors)

Professionals providing rehabilitation services, that is, vocational counselors and attorneys, have a responsibility to know the specific Codes of Ethics that pertain to their profession.  The most relevant Codes for vocational counselors are:

·        Code of Professional Ethics for Commission for Case Manager Certification (CCMC)

·        Code of Professional Ethics for Certification of Disability Management Specialists Commission (CDMSC)

·        Code of Professional Ethics for Certified Vocational Evaluators (CVEs)

·        Code of Professional Ethics for the American Board of Vocational Experts (ABVE)

·        Code of Professional Ethics for the Commission on Rehabilitation Counselor Certification (CCRC)

The Code of Ethics for Pennsylvania attorneys is called Rules of Professional Conduct.  The Rules are available on the Pennsylvania Bar Association web site under: Legal Links, Pennsylvania Legal Info, The Disciplinary Board of the Supreme Court, Rules, The Rules of Professional Conduct.

How and Why the Behavior of Rehabilitation Professionals Working with Clients Can Become Unethical

The services of rehabilitation professionals are frequently obtained by an insurance carrier (or self-insured company) to work with and assist injured workers in their recovery following a work-related incident. Often the reason for this type of referral is to reduce the company’s financial exposure to that client’s (claimant’s) injury. Ideally, the rehabilitation professional attempts to facilitate an awareness of mutual interests and encourages the rehabilitation effort and process toward mutually agreed upon and shared objectives with the client.  The rehabilitation professional at times faces a balancing act between being beholden to the needs, desires, and interests of the referral company, and at the same time upholding a moral and ethical responsibility to the injured worker.  These interests may not necessarily be mutually inclusive.  Rehabilitation professionals will at times practice, perhaps unknowingly, unethical behavior when these two responsibilities are in conflict with one another or to some extent challenged by the interests of the referral source.  If and when the rehabilitation professional allows the interests and needs of the referral source to supersede the needs of the injured party, his or her ability to provide a comprehensive and objective rehabilitation service to the injured party may be compromised.

Therefore, it is critical to establish the role of the rehabilitation professional as he/she relates to the client.  When a rehabilitation professional is contracted to provide forensic testimony in an “earning power assessment,” the rehabilitation professional must remain totally objective and neutral. The professional must make an independent and objective analysis based upon an interview, testing, and other evaluative techniques related to the claimant’s background and physical capabilities.

A rehabilitation professional also may be retained to provide assistance to an injured worker in an attempt to locate necessary and effective medical services that will assist the injured party in recuperation and recovery.  This recovery may then be instrumental in decreased physical limitations that lead to better vocational productivity and earning power.  In this case, the rehabilitation professional has a legal, ethical, and moral obligation to both the referral source and the injured worker to establish a professional relationship with the objective to provide valid information to the injured party that will assist in expediting recovery.  As such, the rehabilitation professional has an obligation to maintain the best interests of the injured worker even when those interests conflict with those of the referral source.  Any attempt to intentionally abridge the obligation of providing proper medical information or resources to the injured party would be, in this case, a violation of the rehabilitation code of ethics.

Whether the service is vocationally or medically oriented, the rehabilitation professional has an obligation to make every effort to provide the most objective and comprehensive services possible.

The Responsibility of Experienced Rehabilitation Professionals to Train New Hires to Understand the Significance of Perceptions, Beliefs & Values in Their Work with Work-Injured Clients

Contemporary issues concerning the ethical treatment of prisoners in the American war on terror hold urgent reminders of the need to conform to Standards of Practice and Codes of Ethics.  Not least significant in this issue is where the responsibility for the conduction of the Standard lies.  Are those at the bottom of the professional hierarchy, those delivering direct client/claimant services, responsible, or are the supervisors responsible?  What is clear is that organizations/administrations hold the ultimate responsibility for the practices of their staff members.

That means that managers/administrators are responsible for making the issue a priority and for providing the specific training needed to ensure compliance.  Administrators must either adopt a Code of Ethics and expose staff to its strictures, or better, sponsor the creating of an in-house, company-specific, customized Code of Ethics.  Staff members should be involved in researching comparable codes, discussing the formulation of the code, and writing the code.  Where a relevant code is used as a model for the customized code, employees should have an opportunity to address both those aspects of the model that will be included and those that will not.

Administrators are also responsible for scheduling periodic in-service reviews of the Code of Ethics to serve as a renewed exposure and a chance to determine whether the Code is still relevant and up to date.  Administrators are also responsible for instructing new hires in the content of the Code.

Training Resources

·        The Pennsylvania Chamber of Business and Industry: www.pachamber.org.

·        CEC Associates, Inc.: www.cecassoc.com.

·        National Rehabilitation Association: www.nationalrehab.org.

·        The Rehabilitation Accreditation  Commission: www.carf.org.

·        Center for the Study of Ethics in the Professions: www.iit.edu.

·        A Commentary on the Activity of Writing Codes of Ethics: www.mediation-matter.com.

·        Ethics Resources Center Resources: www.ethics.org.

Compliance/Evaluation Resources

·        American Board of Vocational Experts (ABVE): www.abve.net

·        Commission for Case Management Certification (CCMC): www.ccmcertification.org

·        Commission on Rehabilitation Counselor Certification: www.ccrcertification.org

Conclusions

All professionals who provide rehabilitation services are obligated to abide by the codes of ethics prescribed by their certifying organizations.  Embedded in these codes are the nuances attending an individual’s perceptions, beliefs, and values.  The purpose of the workshop was to focus on these tenets as the basis of a cross-profession (counselors/case managers and attorneys) discussion about the significance of these tenets. 

The most salient outcome of the workshop was that professionals and professional organizations have a responsibility to examine their practices for adherence to their codes of ethics, to revisit compliance with the codes on a regular basis, to update codes as appropriate, and, especially, to assist/train new hires in their professions to be aware of the controlling codes.  

As workshop participants, we offer our collective perception and belief that professionals must continually be aware of their underlying perceptions, beliefs, and values as they no doubt influence behaviors and compliance with ethical conduct.  Although considered expendable by some, beliefs and values are the foundation for behavior that can either construct or destroy, reward or punish, and safeguard or betray. 

References:

1.      Walker, Jasen. The ADA and the PA Workers’ Compensation Act:  Not Friends in Pennsylvania. The Legal Intelligencer, vol. P. 1484, March 9, 1993.

2.      Taylor v. Woods Rehabilitation Service, 2004 Pa. Super., LEXIS 191 (Pa. Super. Ct., Feb. 23, 2004.

3.      Howard, Robert. Values Make the Company: An Interview with Robert Haas, Harvard Business Review, September 1, 1990.

4.      Raths, Louis E., Sidnewt B. Simon, and Merrill Harmin.  Values and Teaching, Charles Merrill Publishing Co., Columbus, OH, 1966.

5.      H.B. English.  A Comprehensive Dictionary of Psychological and Psychoanalytical Terms (1958).

I.            Assessing Return-to-Work Motivation: A Rationale

Injured worker motivation is one of the key issues of vocational disability evaluation and occupational rehabilitation.  Rehabilitation Counselors and Case Managers are frequently disappointed by injured workers’ responses to return-to-work opportunities following periods of lost time.  Rehabilitation professionals, however, are not the only members of the industrial accident/injury system who are either frustrated by or at least concerned with, injured worker motivation.

Employers generally believe that once an injured employee begins to receive wage replacement benefits, they will likely take advantage of the compensation system and ultimately be responsible for increasing the employer’s insurance costs.  Lawyers representing employers regard dubiously any workers’ compensation claimant’s declared reasons for not working, while claimant’s legal representatives self-righteously defend and protect their clients from what are too often characterized as illegitimate return-to-work offers.  Treating physicians try to ameliorate the patient’s musculoskeletal and/or neurological complaints.  However, the complaints are frequently (perhaps inevitably) complicated by, if not the result of, patient stress.

Injured worker (or patient) stress, of course, is often caused partly by the insidious medical/legal/vocational quagmire and/or the internal conflicts known as the workers’ compensation lost time system.  That system is often more adversarial than it need be.  Notwithstanding the complicated framework of the injury-management system in which various stakeholders participate, injured worker motivation is prejudged variously by those who have perceptions, beliefs, values, and needs potentially different than those of the injured worker.

An injured worker’s motivation to return to work is a function of his or her perceptions, beliefs, values, and needs, not those of other stakeholders in the accident/injury management system.  It matters little what stimulates others within the lost time system, all of whom have their own unique perceptions, beliefs, needs, and motivations.  What does matter is what role work plays in the injured employee’s life and his or her desire/need to return to work.  As with most people, injured employees cannot always freely articulate their motivations, and if they could, they would probably be reluctant to disclose their beliefs and attitudes about a return to work following a period of lost time.

Over the years, through thousands of interviews, we have been privileged to hear injured employees’ reasons for remaining out of work.  Those reasons are, of course, quite varied.  Besides the injured workers’ claims that they cannot work physically or mentally, they often share their individual resentments, fears, concerns, desires, and attitudes associated with their accidents and injuries, as well as their relationships with their employers before and after being displaced from the workforce.  Much can be learned from injured employees when they are questioned effectively. 

An injured worker’s return-to-work motivation requires a model of motivation from which appropriate and effective questions can be generated.  But first we must have some appreciation of what work generally means to the culture in which the employee has grown and functioned over the many years preceding the injury.  The notion of motivation can be amorphous, and injured worker motivation in particular is difficult to define and measure.  History informs us that work motivation has its roots in western culture.  The compulsion to work was “created” in the Protestant Reformation, which emphasized that work was a religious calling.  Much has been written about the role of Protestant preachers in the rise of the work ethic. 

The earliest textbooks published in America promoted work values as part of good character and as the formula to success.  Benjamin Franklin was one of the best-known advocates of the value of work.  Poor Richard’s Almanac was translated into many languages and millions of copies were sold in America and abroad.  In his writings, Franklin urged thrift, industry, pursuit of money, and hard work.  “A penny saved is a penny earned,” was Franklin’s way of extolling the virtues of labor and surplus. 

Horatio Alger (1832-1899), a divinity school graduate, was one of the most prolific American authors.  He wrote some 130 books that taught work values to young boys.  Twenty million copies of Alger’s books were sold.  His works include such titles as Strive and Succeed, Arisen from the Ranks, and Bound to Rise, and they typically tell stories of poor boys who became self-made men through their own efforts and perseverance. 

American children in schools from the late 1800s to the 1920s learned to read and write from standard English textbooks such as McGuffey’s Eclectic Readers, the first of which was published in 1836.  The Readers became perhaps the most widely read children’s books in the 19^th century, with 122 million copies of the six readers sold to an estimated four-fifths of U.S. school children.  Among other things, McGuffey’s taught middle-class children the importance of the work ethic: “Work, work, my boy, be not afraid; look labor boldly in the face.”  Public school children were inculcated with the value of work and the notion “you are what you do.”

In the 1960s, as youth in America and much of Western Europe questioned the status quo, psychology and education, too, experienced revolutions, clearly moving away from puritanical and behaviorist frameworks of explaining behavior and toward humanistic/ self-actualization models.  This framework paved the way to an understanding that self-fulfillment and psychological health in general were achievable and generally within the reach of the individual.  That is, mental health, (or, for that matter, neurotic illness) was not controlled by instincts, urges, environmental stimuli, or forces external to, and beyond the control of, the individual, but, instead, a developmental process influenced by society and the individual himself.

Two behaviorists, the forefathers of humanistic psychology, John Dewey (1859-1952) and Edward Thorndike (1874-1949), stressed one important aspect of motivation that had been completely neglected by psychoanalysis and earlier behaviorism, namely, “possibility.”  In psychological theory, it is the concept of possibility that returned responsibility to the individual.

No less influenced by this movement of humanism was the world of work.  Douglas MacGregor (1906-1964) summarized two possible views of management and worker motivation.  MacGregor’s Theory X and Theory Y popularized the notions that management views workers as disliking work and trying to avoid it (Theory X) and/or work is natural and can be a source of satisfaction, and when it is, the worker can be highly committed and motivated (Theory Y).

In the evolution of theory regarding work motivation, Frederick Hertzberg explored specifically the issue of employee motivation.  Hertzberg found that there are two distinct categories of work motivation: “hygiene” and “motivation” factors.  Hertzberg said (Motivation to Work, 1959) that “hygiene” factors do not provide positive motivation, but the absence of these motivators causes dissatisfaction.  The “motivation” factors, on the other hand, address directly peoples’ higher needs and do produce positive satisfaction.  These motivation factors are the ones management must address to achieve employee well-being.

A new term, the “third force,” came into being in the 1960s to refocus increasing productivity away from technology to the role of human beings in achieving increases in productivity.  The pivotal idea was spearheaded by Abraham Maslow.  Maslow conceived of human motivation as developmental.  He classified motivation into five levels and conceived a hierarchy of human needs (see diagram Attachment 1).  Maslow’s Hierarchy of Needs - Physiological, Safety, Belongingness/Love, Esteem, and Self-Actualization - provides the basis for understanding the meaning of work to individuals in general, and the role that employment plays for any particular employee, including the injured worker who happens to be the focus of our attention.

Maslow points out that the hierarchy is dynamic, and the dominant “need” is always shifting.  For example, a musician may be lost in the self-actualization of playing music, but eventually becomes tired and hungry so he or she has to stop.  A machine operator may go to work every day in a factory where he is ignored and treated with indifference only to generate enough money to support his much beloved hobby of antique car restoration, an activity that has brought him esteem and notoriety.  Moreover, any single behavior may combine several levels.  For example, eating dinner with friends or family is both physiological and social.  Indeed, maintaining gainful activity provides money for food and shelter (physiological) and potentially an opportunity for some to achieve a measure of self-satisfaction (esteem).

Maslow also explains that satisfaction is relative.  The hierarchy does not exist by itself, but is affected by the situation and the general culture.  In a work setting, for example, rewards from management or the organizational “culture” can fulfill/increase a worker’s esteem, or in some cases, self-actualization.  Self-Actualization is defined as “the desire to become more and more of what one is; to become everything that one is capable of becoming.”  In other settings, workers may be so threatened by management or the culture that the work itself tends to fulfill the employee’s safety needs (i.e., obeying rules to prevent being fired), but no higher needs.  Unions began in America because they appealed to the physiological and safety needs of workers.

Needs are “pre-potent.”  A pre-potent need is one that has the greatest influence or power over our action.  Everyone has pre-potent needs, but the needs will vary among individuals.  A drug addict will need to satisfy his cravings (physiological) in order to function in society and will not worry about being accepted by others.  A teenager may use drugs because of peer pressure - to feel that he or she is indeed part of a group (a love need).  According to Maslow, “At once other (and higher) needs emerge, and these, rather than physiological hungers, dominate the organism.  When these needs are satisfied, new (and still higher) needs emerge, and so on.  As one desire is satisfied, another pops up to take its place.”  Maslow described the human being as a “wanting animal,” that “rarely reaches a state of complete satisfaction except for a short time.”

In revisiting Maslow’s breakthrough work on motivation, we at CEC Associates, Inc., came to realize that the generalized Hierarchy of Needs model can be applied to the specific efforts of Vocational Rehabilitation professionals in returning injured workers to productivity.  When we began to use the Needs model as a touchstone for return-to-work counseling, we felt that by considering the level of need at which the client was functioning and addressing how that need could be ameliorated, we could experience significantly improved outcomes.  The objective is to move the client up the Hierarchy.

A primary function of Vocational Rehabilitation (VR) professionals is to get injured workers back to work.  In many cases, the employee desires a return to work and the role of the VR professional is to work with the medical professionals and the employer to facilitate the return.  This function is generally called Case Management.  When all of the medical conditions are sufficiently remediated, the client is released to return to work.  There are attendant issues, of course, such as job accommodation and the availability of suitable employment, but largely, when the client is willing to return to work, the vocational rehabilitation process is straightforward.

When the injured employee does not want to return to work, the function of the VR professional must, of necessity, take a different course.  In this situation, the primary focus of the VR professional is to determine the cause of the reluctance and to find solutions to overcome it.  Frequently, the cause of the reluctance is related to the client’s motivation to return to work.  In this case, if an approach to getting the reluctant client to return to work is to be productive, it must focus on his/her motivation to do so.

The hypothesis of this paper is that when Rehabilitation Counselors (RCs) are addressing the client’s motivation, the Maslow Hierarchy of Needs model can be an instructive and useful paradigm for resolving the motivation issue.  Of course, before a VR professional can apply the “hypothesis,” he or she must have an understanding of Maslow’s original work and how it can apply to vocational rehabilitation.  To assist VR professionals to use Maslow’s Hierarchy constructively, this paper provides RC-focused materials that can be used to accomplish that objective.  The hybrid process is called the CEC/Maslow construct.

III.  Maslow’s Hierarchy of Needs Applied to Vocational Evaluation and        Rehabilitation:  The CEC/Maslow Construct

Abraham Maslow (1908-1970) published Motivation and Personality in 1943.  Originally, Maslow’s concept was seen as a general explanation of human behavior, but it quickly became the prevailing theory of workplace motivation.  Prior to Maslow, work motivation was seen as a task-based approach to managing people at work typified by Frederick Taylor’s precise study of men doing specific tasks.  With Maslow, the approach to managing employees turned to the humanistic, and employees have increasingly come to be seen as the key to motivation and productivity increases.

Maslow’s work centered on his interest in human motivation.  He posited a hierarchy of human needs based on two general groupings:

Maslow defined four “deficiency needs” that have to be met/satisfied before one can move to the next highest level.  These deficiency needs, starting with the lowest and moving to the highest, are:

The “growth needs” are grouped into the composite term “Self-Actualization.”  The sub-groups of Self-Actualization are:

The primary purpose of Vocational Rehabilitation is to return injured workers to productivity.  The basic problem is that those resisting a return to work are frequently stuck at some level of the “deficiency needs,” and it is the responsibility of the RC to determine which level that is and to recommend interventions to move the individual to the next highest level.

The critical information for an RC working with a client is knowing how important work is for that individual.  In the present system, an injured worker has his or her basic “deficiency” needs taken care of by replacement wages.  Generally, the replaced wages satisfy the Physiological and Safety needs of the client.  If work never met the client’s higher level needs (e.g., self-esteem) in some fashion and gainful employment was never more than a mechanism by which to satisfy the Physiological or Safety needs, then wage replacement may be a substantial inhibitor to the client’s motivation to return to work.  On the other hand, when wages are interrupted or critical health care discontinued, the deficiency needs are no longer met, and the requisite foundation to attain higher level need satisfaction can be threatened.  What is required is a recognition that potentially both deficiency and growth needs can be satisfied through work, gainful purposeful activity.

To determine the client’s need level for work and for the purpose of designing appropriate interventions, the VR professional will need to ask the client questions.  This article provides a set of questions shaped from Maslow’s “deficiency needs” that the counselor can use to identify where the client is on the hierarchy.  Knowing that level then serves as the basis for recommending specific interventions that should be taken to move the client to again work.  That is, Maslow’s Hierarchy can serve as the theoretical underpinning on which a VR plan is formulated. 

It is important to recognize that the objective is not to make all reluctant clients “self-actualized,” but to determine what the deficiency needs are so that appropriate interventions can be devised.

This paper is an introduction to the CEC/Maslow construct.  (The CEC/Maslow construct is the application of the Hierarchy of Needs to the Vocational Evaluation and Rehabilitation processes.)  The construct is, at this point in time, only theoretical.  It continues to be tested at CEC Associates on an a priori basis through self-evident propositions and direct observation.  What is needed is structured research by other Rehabilitation professionals with access to clients, or perhaps a study undertaken in some relevant college or university program, or, ideally, both.

Starting with the most basic/important need and moving to higher levels, the deficiency needs are:

·        Physiological Needs: hunger, thirst, bodily comfort, etc.

·        Safety/Security: out of danger

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