Article 1: Disability Management Through Organizational Thought
Article 2: Conducting Compelling Vocational Disability Evaluations
Article 3: Explaining Acquired Disability & The Workplace Approach to Managing It
Article 4: Causal Attributions of Acquired Disability: Who is Qualified to Make the Call?

Disability Management Through Organizational Thought

By Jasen M. Walker, Ed.D., C.R.C., C.C.M.

“Act is the blossom of thought, and joy and suffering are its fruits…” – James Allen

Language is the content of thought.  It could be said, “Language thinks you.”  Thought creates ideas, visions, and paradigms from which we create our world, order it, make sense of it, and plan action to change it.  Our individual choice of words to describe the world in which we live can lead to new ways of thinking about that world and new solutions to old problems.  The construct of presenting himself as a “compassionate conservative” once helped President Bush distinguish himself from more rigid and dogmatic Republicans.  The idea that one Democratic presidential candidate proposed a “Department of Peace” in a country perceived to be fighting a war of choice rather than a war of necessity helped define not only the candidate, but his potential policies and actions.

The language that is used in workplace dialogue results in organizational behavior.  In the world of work (and specifically work organizations), employees and, to a larger extent, the leaders of these organizations create the workplace culture. A workplace culture is the environment that evolves into the policies and actions that are the ideas, visions, and paradigms that define operations.  At the foundation of leadership, language is behavior.  The specific words that leaders use are chosen to influence others, preferably toward success but potentially into failure as well.

An administrator responsible for the design and operation of a disability management program for his or her work organization has to appreciate the significance of semantics.  Without a clear understanding of the semantic difference between a “light duty” approach and a “transition-to-work” approach, for example, the manager cannot achieve the kind of outcomes the employer needs.  And the difference is not merely nuanced or shaded; the difference is substantive and critical.  The program manager perceptive enough to understand the relationship between language and thought, and willing enough to take chances on implementing new ideas even if they may be criticized originally, will succeed.  The program manager who cannot make such adaptations will simply perpetuate failed methods.

Among recent organizational concepts is the notion of disability management, the idea that workplace disability can be managed, even prevented!  The word “disability” itself is a modern word that has no direct equivalent in ancient languages.  There is no one word, in either Hebrew or Greek, that means “disability” in the way that we use that word today.  The terms “disability” and “handicap” relate to politics that we adopted when modern social welfare policies began to find another word, “crippled,” inflammatory and costly.  With the evolution of a language that socially defines people as “challenged,” society has offered people in the workplace a new lexicon, including “disability management.”

At the core of managing workplace disability is the language, old and new, that organizational leaders choose to define their policies and procedures toward both an aging and an inclusive work force. Many employers are still experiencing problems managing workplace disability.  These problems can cause management inefficiencies and, in some cases, result in a serious financial drain on the company.  Risk managers and Human Resource professionals are, by training and experience, in excellent positions to assist their organizations by recognizing the problems associated with workplace disability and by educating company managers to the idea that they can address these issues effectively.  This often requires a so-called “paradigm shift,” fundamentally initiated when business leaders think and speak of workplace disability and its management in new terms.  The concept that the specific language chosen is the basis of the thought and action outcomes is quite pertinent to business leaders reconsidering disability and lost work time.  In other writings, we have offered a new lexicon of workplace disability and its organizational management.  Here we suggest that this new lexicon can assist business leaders in formulating more effective policies and procedures for reducing the increasing human and financial costs of occupational disability.  Moreover, we recognize that the practice of workplace disability management was first conceived with creative thought born from language.  We encourage all business leaders to realize the power in the phrase, “Language thinks you, ” and we encourage those who practice organizational disability management to share their “best practices” with others.

The Difference between Impairment and Disability

More than any other distinction, knowing the difference between medical impairment and occupational disability is critical in effectively managing workplace disability.  The American Medical Association’s Guide to the Evaluation of Permanent Impairment defines impairment as “any loss or abnormality of psychological, physiological, or anatomical structure or function.”  Simply put, an “impairment” is an alteration of an individual’s health status as the result of an injury or illness that is assessed by medical means.  Importantly, an “impaired” individual is not necessarily “disabled.”  The World Health Organization defines disability as “any restriction or lack of ability (resulting from an impairment) to perform an activity in the required manner…within the range considered normal for human beings, particularly in social or occupational settings.”  Disability in general may be thought of as the gap between what a person can do and what a person needs or wants to do.  Occupational disability is the difference between what a person can do as result of functional impairment and what a particular job demands.

Many individuals have impairments or histories of impairment; indeed, most of us do.  However, the medical impairment must compromise physical and/or mental function to the extent that it interferes with meeting occupational demands.  Occupational demands can be changed without necessarily diminishing productivity.  Human resource professionals and risk managers, as well as business leaders in general, can employ people with an impairment and not have them experience disability per se.

Unfortunately, we have been inculcated with the belief that physicians, not business managers, make decisions regarding an individual’s employability.  This inculcation and associated miscalculation is often apparent in employer representatives asking physicians, “Can Harry come back to work?”  In reality, the physician probably does not know, and the physician not knowing is often the result of the physician not knowing what Harry’s job requirements truly are.  Moreover, physicians cannot possibly appreciate what Harry’s potentials are for alternative employment within the organization from which he is currently separated by a change in his health status.  Whether that change is temporary or permanent, it all too often need not result in total disability or continuing lost time.

The Induction of Disability

After careful thought, we have realized that lost time from work following injury or illness can be induced.  Old and new terms generated by creative thinkers have helped clarify the reasons for work disability and led to new ways of resolving problems associated with vocational disability.  The language responsible business leaders need to understand to prevent and manage the workplace more effectively includes the terms bureaugenic, litogenic, iatrogenic, and psychogenic.

Bureaugenic work disability is often caused and maintained by the political structures that surround occupational injury and non-occupational disease.  Organizational policies and personal decisions often overlook the consequences of shortsighted and antiquated return-to-work practices such as, “You cannot return to work here until you are 100%,” or, “Return-to-work programs are for workers’ compensation recipients only.”  Although the rising costs of workplace disability, the Americans with Disabilities Act, and innovative movements (including integrated disability management) have resulted in some reevaluation of antiquated bureaucratic responses to lost time, bureaugenic induction of disability through discouraging rapid return to work remains a significant problem for many work organizations.

Some self-insurers of both workers’ compensation and long-term disability programs have failed to realize that, as work organizations, they may be creating return-to-work disincentives for their employees following lost-time injuries or illnesses.  With employees able to receive 75% or more of their pre-injury wage replacement benefits, they are being invited to entertain secondary gain, a natural complication of vocational disability in the modern workplace.  Some municipal wage-replacement systems pay the injured worker their entire salary indefinitely and yet offer no return-to-work or transition-to-work program.  The Social Security Administration has recognized that although most recipients of SSDI are of working age, they do not take advantage of the trial work period available to them.  Both organizational and government bureaucracies can create dysfunctional policies that actually foster and maintain lost-time disability.

Litogenic disability is often the result of the injured party and a legal advocate creating an alliance in an effort to demonstrate that the injured party has been wrongfully treated.  Frequently, this is the result of a third-party action or personal injury litigation arising from a work injury.  The situation becomes even more complex when the workers’ compensation insurer wishes to subrogate or recover damages from the liability litigation resulting from a product or machinery defect, for example.  The legal maneuvering involved in litigation often ignores the importance of gainful activity as a means by which individuals can recover their damages.  What is more, gainful activity is often discouraged by legal representatives who hope to bolster the argument that the injured party has been economically damaged.  These litigations almost always induce or encourage occupational disability and perpetuate lost time.

Iatrogenic means a disability unwittingly precipitated, aggravated, or induced by a healthcare provider’s attitude, examination, comments, or treatment.  Many medical specialists involved in injured worker healthcare believe that occupational injuries must be treated conservatively, that is, with time and non-invasive modalities.  Iatrogenic disability need not be the result only of a surgical intervention that is premature or unnecessary.  Chasing symptoms, prescribing pharmaceuticals that create disabling side effects, and over-prescribing other therapies that fail to result in improvement can prolong vocational disability.  Physician induction of disability can often result from mere suggestion.  The susceptible, all-too-vulnerable patient can hear, or think he heard, the physician say that he was “unable to work.”  Physicians sometimes underestimate or unconsciously abuse the power invested in them by the generally naïve healthcare recipient or the public in general.  When physicians declare that an individual is “unable to work” or is “totally disabled,” the physician is generally overstepping his or her bounds and making a declaration outside of his or her expertise.  The American Medical Association has advised its members to avoid making disability determinations.  Likewise, medical experts should avoid making vocational decisions, and treating physicians should recognize the therapeutic value of an early return to work.  Unfortunately, both work organizations and healthcare professionals still have a great deal to learn regarding the appropriate involvement of medicine in occupational recovery following lost-time injury or illness.

Psychogenic disability results in the claim of an inability to work because the symptoms are produced by mental or psychological factors rather than physical problems.  Depression, substance abuse, personality disorders, and psychosis can lead to psychogenic disability.  Unfortunately, this kind of “disability” is often assessed by healthcare professionals to be a valid reason not to return to work, even when the condition is not necessarily disabling.  Very often psychogenic disability is the result of pre-existing work dysfunctions, which have led the employee into difficult relationships and/or stressful work situations that he or she now wishes to avoid.  Psychogenic disability therefore can arise when employees report symptoms secondary to stress that they attach to a particular cause external to them, rather than taking responsibility themselves for reducing the stress.

[For an excellent text on psychogenic disability and its causes, see Psychiatric Disability: Clinical, Legal and Administrative Dimensions, published by the American Psychiatric Press, Inc. (1987).  For more information on Work Dysfunctions, obtain a copy of Counseling and Psychotherapy of Work Dysfunctions from the American Psychological Association (1993).]

Injured Worker Helplessness

The creative and effective use of language in helping to conceive disability management and prevention also borrows from related disciplines.  Psychology is certainly one of those disciplines.  Nearly 20 years ago, Martin E.P. Seligman, Ph.D., an internationally esteemed psychologist, developed the theory of “learned helplessness” and defined it as the motivational and behavioral deficits displayed by humans when exposed to uncontrollable circumstances.  At around the same time, researchers at the University of Minnesota showed empirically that a non-contingent reward interferes with goal-seeking behavior.  That is, if one is paid for an outcome before the outcome is produced, behavior that might lead to that outcome can be diminished or even extinguished.  Sometimes referred to as “learned laziness,” this theory and Seligman’s “learned helplessness” offer two empirically studied psychological phenomena that have major implications for workers’ compensation systems and disability management programs.

Return-to-work motivation is lost relatively quickly in workers’ compensation systems that lead to an injured worker’s perception of decreased personal power and control.  Most workers’ compensation systems are fertile ground for what we have defined as “injured worker helplessness.”  When the workers’ compensation claimant is legally compelled or “forced” to perform a job search, when compensation checks do not always arrive on time, when healthcare providers do not take the time to explain their findings, and when private investigators are knowingly probing for information from the injured employee’s neighbors, the employee can believe that he or she has lost control over a previously cherished lifestyle.  When others are making decisions for the injured worker and usurping control, learned helplessness ensues.  Simultaneously, the system is financially rewarding the injured worker with wage replacement and encouraging the onset of learned laziness (or defiance).  We know from replicated studies that after six months of lost time following an occupational injury, 50% of injured workers never return to gainful activity, and we also know that after nine months of lost time, that percentage drops to approximately 20%.  Injured worker helplessness and learned laziness could be the reasons for these vocational failures.

Malingering and Co-Malingering

Few people in the disability management business are not familiar with the term “malinger” or its meaning.  What is significant, however, is that even fewer people in Human Resources management know the term “co-malinger” or its meaning.  Therein lies the all-important difference. 

The reality is that in the rehabilitation system, the injured worker is surrounded by a number of other players or “stake holders.”  Whereas malingering is the intentional production of false or grossly exaggerated symptoms by an individual, co-malingering is the result of collaboration in keeping the injured party out of work; the injured person has found a partner, or partners, in his or her efforts to remain disabled.  Surprisingly, employers are often partners in the dance of co-malingering.  Injured workers are frequently viewed as troublemakers, and supervisors are all too willing to assist in the lost-time process by refusing to return the injured employee to work, with or without some type of accommodation.  Perceived as taking advantage of the compensation system, the injured employee is given messages that he or she is unwanted, and if the injured or ill employee is returned to “light duty,” those work assignments are often so demeaning that the employee quickly learns that there is little or no reason to remain at work.  An injured worker can usually find one or more partners, including a physician, a lawyer, a spouse, or any significant other who assists the injured employee in exhausting his or her disability alternatives and compensation options by remaining out of work after the onset of an injury or illness.

Light Duty versus Return to Work

Language drives change.  Any change in the applicable language used is fundamentally disadvantageous in that it hinders communications.  Consequently, the language of change is generally negatively evaluated by the status quo.  One of the concepts most resistant to change in disability management has been “light duty.”

Light duty is a useful term when it is applied to the exertional level of a specific task.  If an employee has been injured and will now and forever be physically unable to do the same tasks he or she did before the injury, then assigning a job with a reduced exertional level is appropriate.  The exertional level of a given job assignment can be determined by a job analysis that measures the physical requirements of the “essential functions” of the job.  If a state-of-the-art job analysis is not conducted, the employer cannot possibly know the exertional level required to perform the job.  “Light duty” or “light work” speaks to a specific job function.

In fact, however, the term “light duty” is generally used to define the process of return to work, and it is here where the term is misunderstood and misapplied.  This misuse of the concept is widespread.  Many, if not most, individual state workers’ compensation laws, government (especially local municipalities) contracts with their employees, and general workplace procedures use the term to refer to all return-to-work situations where the employee has been injured.

The difficulty with this application is that it does not provide for the transition to a more productive employment.  In fact, most employees who have been injured at work can become more productive incrementally than they may be the first day they return to work.  (Further, waiting for a 100% return to health is costly for the employer.)  Often, the transition to more productive employment can be facilitated by work tools, aids, and equipment.  Historically, hand trucks and forklifts became “necessary” when manual lifting could not do the job.  Employers too frequently resist making equivalent cost-effective job accommodations during a transition-to-work process.

Unfortunately, there is generally no distinction between temporary and permanent light duty.  What is needed is a transition-to-work (TTW) program that will guide the progressive improvement of the employee and his or her capacity to gradually assume a more strenuous workload.  There are TTW methods and materials available.  The problem is to make disability managers aware of the existence of TTW materials so that they can redesign their return-to-work programs using them.

A successful disability management program requires a willingness to change the process when and where it is essential to do so.  Distinguishing between “light work” and “light duty” and moving toward more productive TTW models can greatly improve a disability management effort.

Job Accommodation

As technology continues to advance, job accommodation for people with disabilities becomes increasing more feasible and practical. However, employers’ attitudes toward assisting individuals, with or without accommodations, are critical to the process.  Job accommodation constitutes any action or series of actions that make it possible for a person with an impairment to attain employment, to be promoted, to train, or to participate in employer activities.  Job accommodations may include work-site modifications, special aids or devices, modifications of job tasks, or a change in working hours or schedules, but all accommodations involve employer willingness to interact with any employee or new hire to remove barriers to employment and full participation while concomitantly taking advantage of the employee’s strengths.

Conclusion

Workplace behavior is largely driven by the creativity of the company leadership.  At least a portion of organizational leadership and creativity can be found in the ideas, working models, and visions that leaders select from the language organizational members choose and encourage others to use.  This is a fundamental concept in the so-called corporate culture.  Fifty years ago, individuals with physical manifestations of medical impairment were known as “cripples” in the general culture.  That terminology was found to be inadequate both socially and politically and led to societal use of the term “handicapped.”  Handicapped became, in turn, inadequate and misleading, and, more recently, society settled on the term “disabled.”  (Although this term seems to have been accepted by the majority, some people have insisted that we adopt the concept of “challenged,” as in “physically-challenged.”)

Language has its greatest utility when it facilitates human creativity and problem solving.  To a large extent, “shifting the paradigm” can be found when business leaders facilitate organizational creativity and problem solving by encouraging new ways of thinking.   Our thinking will forever be tied to the language we choose and the courage we demonstrate in its application.  Disability management is only one of the myriad of workplace challenges to which the concept “language thinks you” has merit.

Conducting Compelling Vocational Disability Evaluations:
Three Required/Critical Understandings for the Evaluator

By Jasen M. Walker, Ed.D., C.R.C., C.C.M.

Part I – The Need for Thorough Histories and Sufficient Documentation

Vocational Assessment and Occupational Disability Evaluation in personal injury matters challenges the vocational evaluator to be precise and certain in rendering conclusions, more often than not, after only one examination of the injured person.  Vocational experts offering opinions to the court therefore must “attempt to obtain all appropriate reports, evaluations, and other such data which the expert deems essential for determining vocational capacity” (Code of Ethics, Rules of Professional Conduct, R3.5, American Board of Vocational Experts).  In reality, the justice system, relying on forensic expert testimony to facilitate the court’s decision-making, is compelled to expect thoroughness and the highest level of precision possible from the expert.

It has been well-established in medical, psychological, and social research literature that  a thorough history is critical in establishing the source and extent of a presented problem or chief complaint.  Moreover, the subject to be studied or evaluated has a story that certainly predates his or her examination, and that story is always multifaceted.  History from the subject alone can be forgotten, unconsciously distorted, deliberately changed, and provided only from one perspective, that of the person being examined, an individual who is naturally defensive and sometimes distraught.  Reliability of histories is always an issue, and even though the examiner can endeavor to be extremely thorough in history taking, the documented past (i.e., school records, medical records, employment records, and sworn statements from the informant and others) can be essential in providing a more complete picture as the vocational examiner attempts to arrive at a professionally certain opinion on the issue(s) to be addressed in the evaluation.

For vocational experts, career development theory and vocational psychology have offered the person-environment model of occupational fitness and job compatibility.  John L. Holland (1997) has provided both direction and leadership to the field of career development as he studied and described the importance of personality in occupational choice and match.  Donald Super (1984) worked to understand and improve the notion that a person’s familial values and personal beliefs are fundamental to an individual’s vocational identity. Super also found and explained that career development and lifespan benchmarks coincide in a meaningful way.  Recognizing that many adolescents and adults experience a wide range of problems when making a career decision and adjusting to the world of work, Osipow and others (1996) developed a taxonomy of career decision making difficulties that result in occupational indecision.  [Vocational/disability assessment and psychotherapy is explained in greater detail in Part II of the article.]

In addition to foundations of vocational development theory, experts dealing with the problem of workplace disability have benefited from the insights of astute occupational medicine physicians, including Drs. Behan and Hirschfeld (1966). Behan and Hirschfeld offered their analyses of hundreds of case studies, which described occupational disability as a “process” in response to stressful life situations coupled with an “explanatory” accident rather than simply a static result of occupational illness or workplace injury.  Borrowing from the work of Behan and Hirschfeld, Weinstein (1978) aptly portrayed “disability as a process,” with identifiable stages that could be retrospectively identified and described by observers with sufficient information from troubled workers’ histories and pre-accident employment patterns.

More recently, Lowman (1993) has provided an informed and systematic analysis of “work dysfunctions,” the result of a complex interaction of characteristics of the person in the work environment. Work dysfunctions are demonstrated impairment of job capability absent physical or mental disease per se.  Work dysfunctions, most often in the form of employee psychological characteristics, are often the predictors of occupational disability that more frequently than not are viewed retrospectively through careful histories and thorough documentation.

Forensic vocational disability evaluators must take into account the contributions of vocational/career development theorists, occupational medicine professionals, and psychologists when examining the impact of personal injury on a plaintiff’s occupational and economic potentials.  The primary obligation of the vocational expert is to present a fair and reasonable assessment of an individual’s capacity to work, and the capacity to work, both before and after the onset of an occupationally significant injury or illness, is a function of the individual examinee’s numerous personal, social, educational, occupational, financial, and medical circumstances.  Taking thorough histories in each of these domains and gathering all available information through historical documentation pertinent to these areas of the examinee’s life are essential functions of the competent vocational/disability evaluation.

For example, a thorough understanding of an individual’s past psychological adjustment can be critical in understanding that person’s potentials for work.  According to Power (1991) “clients come for assessment with a wide assortment of distinctive vocational assets and problems, including certain emotional difficulties that represent barriers to productivity.  Recognizing all of these factors is important in identifying what vocational evaluation approaches should be used for a particular client.”  An accountant with a history of bipolar disorder may have less potential for future work than an accountant without this form of depressive illness despite the fact that they have the very same cervical spine impairment.

A physically injured adult who has adjusted psychosocially to classroom settings while in high school may very likely have a different response to injury and be more inclined toward future work than an individual who has had a long history of educational absenteeism and failed achievement. When the history of absenteeism is also evident in attendance records from work, the pre-accident statement of motivation to return to work may be even more profound.

Many members of the legal profession have familiarity with the concept of malingering.  Few lawyers and judges, however, understand the dynamics of co-malingering (Mitchell, 1992).  Co-malingering is a social phenomenon in which members of an injured person’s network of family members, friends and/or acquaintances, and sometimes professionals (e.g., a family physician) consciously or unconsciously influence the injured person to avoid productivity.  Co-malingering is often found (and sometimes observed and recorded) in those social relationships that are well-meaning, but contrary to or ignorant of primary axiom of vocational rehabilitation, that is, work is therapeutic. Co-malingerers have their individual agendas, and frequently cannot be identified as members of the injured worker’s social constellation without documentation (i.e., work records, medical documentation, or sworn notes of testimonies).  [Co-malingering is explained in more detail in Part III of this article.]

The sum and substance of this section is essentially that forensic vocational experts, like any other thorough social science investigator, must work toward gathering as much information as possible in order to answer the legal questions of occupational disability, residual employability, and earning power.  These questions are answered only after thorough histories and sufficient documentation are gathered and studied.  Vocational pathways and occupational disability are complex phenomena with numerous antecedents and consequences.  The forensic vocational disability expert’s obligation to the court system is to obtain from the referral source all appropriate reports, evaluations and other such data, that the expert deems necessary for determining earning capacity both before and after the onset of disabling injury or illness.

Part II – The Role of Vocational Evaluation in Providing Psychotherapy to Individuals with Acquired Disabilities

When a clinician encounters an individual who seeks help for mental health problems associated with acquired disability, a thorough vocational/disability evaluation can provide a framework for effective intervention in terms of diagnosis and treatment planning.  Vocational/disability assessment is an effort to explain how mental and/or physical impairment interferes with work functions.  Certified Rehabilitation Counselors, Vocational Psychologists, and members of the American Board of Vocational Experts can assist the clinician and the psychotherapy client in identifying vocational impediments and occupational alternatives through timely assessment as an adjunct to psychotherapeutic intervention.

Vocational/disability evaluation ideally involves a careful review of relevant medical and psychological information regarding the person to be evaluated.  The evaluator invites the client to participate in a structured clinical interview and vocational testing designed to clarify the individual’s mental abilities, vocational aptitudes, occupational interests, and work temperament. 

Although functionality is determined by the healthcare professional, occupational capability or disability is described through the vocational evaluation process.  This process considers, among other issues, the client’s “residual functional capacity.”  Therefore, the vocational/disability evaluation may be timed to take place both before and after psychotherapeutic intervention.  If the underlying problem is identified early in the treatment process, vocational assessment might be performed at that time, and again, perhaps to a lesser extent, following what might be considered a successful intervention.  Successful intervention on an affective disorder, for example, can increase a sense of well being and improve an individual’s employability.

Among the challenges for both the clinician and the vocational evaluator is the ongoing effort to distinguish among impairment, functionality, and disability.  Mental or physical impairment is a change in one’s normal health, sometimes as the result of altered physiology and/or anatomy.  Changes in functionality can be described as how so-called normal or pre-morbid capabilities (e.g., thinking and problem-solving) might be compromised with the onset of identifiable impairment (e.g., brain injury).  Disability is measured by vocational evaluators who fully appreciate how mental and/or physical impairment prevent an individual from carrying out specific types of work.

The clinician will want to remain vigilant as to what aspects of the client’s attitudes and behaviors constitute actual occupational disability and those that may signal “work dysfunctions.”  Lowman (1993) refers to work dysfunctions as “psychological conditions in which there is a significant impairment in the capacity to work caused either by characteristics of the person or by an interaction between personal characteristics and working conditions.”  Some individuals who are relatively intact and integrated are nonetheless unable to deal with a particular work environment or with a dysfunctional supervisor.  Vocational/disability evaluation may become the foundation for an otherwise healthy exit strategy the client may employ in order to leave a “toxic” workplace.  On the other hand, vocational evaluation can identify worker characteristics and capabilities that may be incompatible with particular job demands regardless of the “health” of the work environment.

Physical or mental impairment may constitute a vocational disability in one occupation that would not necessarily be a disability in another occupation.  For example, the loss of binocular vision may prevent a truck driver from continuing in his work, but a thorough vocational/disability evaluation may find that the truck driver can still read at pre-morbid levels and possesses the necessary information processing skills and requisite temperament to function effectively as a motor vehicle dispatcher.  Without thorough vocational/disability evaluation, however, alternative career assessment following visual loss becomes more or less speculation.

Clinicians requesting assistance from a vocational/disability evaluator should also expect the evaluator to provide recommendations regarding the examinee’s vocational potentials through the application of alternative strategies, including, for example, a continuation of psychotherapeutic support while undergoing career change.  Recommendations might also address ways a particular job or occupation might be modified to accommodate an individual with mental and/or physical impairment.  Vocational/disability evaluators generally understand the concepts of workplace modification, job accommodation, and the vocational needs of individuals with different types of impairments.  Sometimes, appropriate job-reengineering, consistent with the Americans with Disabilities Act of 1990, can result in a return to work, thereby increasing both the employer’s and the employee’s job satisfaction.

In some cases, individuals with impairments cannot work because the impairment is so severe or permanent that it totally erodes the client’s employability.  In these cases, the psychologist may be advocating that the individual receive disability benefits, for example, Social Security Disability Insurance.  Vocational/disability evaluation can serve as a basis for arguing total disability if indeed it exists.  Therefore, vocational disability evaluators with forensic experience may serve as good consultants to the clinicians and their clients as they attempt to secure financial support without which mental health concerns worsen.

However, the therapeutic value of work has been well established, and logic would dictate that when an individual is successfully employed commensurate with his or her capabilities, mental health will be enhanced.  Therefore, when appropriate, the clinician would do well to seek an independent and sound vocational/disability assessment to help determine strategies to increase the client’s potentials to establish/re-establish health and happiness through a return to work.

Part III – The Need to Understand and Avoid Co-Malingering

Employers and workers’ compensation claims administrators have encountered the term “malingering” and too frequently think of an injured worker as a malingerer.  Malingering is the intentional production of false or exaggerated symptoms motivated by external incentives, such as avoiding military duty, evading criminal prosecution, obtaining medication or compensation, or leaving and avoiding work.  Employees who malinger are often manipulating the disability insurance systems to gain compensation and avoid work.  It is generally thought in the medical community that malingering is rare.  A more common manipulation of the private or public disability systems is co-malingering, a more or less cooperative venture in which the so-called malingerer finds one or more partners in the subversion of the employer’s disability system safety net.

In an unpublished paper, Ken Mitchell, Ph.D., a nationally recognized disability management consultant, defines co-malingering as the “invisible bond between worker and employer or an agent of either party.”  The manipulation can be intentional or involuntary, passive or active, worker-centered or employer-centered, and limited to a single event or habitual.  Typically, co-malingering is initiated and maintained by a system of beliefs, learned behaviors, and/or intentions that are applied to specific situations in the workplace, but fail to create an effective, mutually satisfying outcome for the employer and the employee.  Co-malingering can be a function of conflicting self-interests, labor relations, and gaps in the disability management system.  Mitchell has found, for example, that only 10% of compensable lost time is due solely to medically imposed restrictions.  This fact derives from a research study conducted by National Rehabilitation Planners, Inc. (NRP).  In the study, Mitchell states: All other reasons for lost time are due to employer- and employee-controlled impediments for return to work, such as:

·        inflexible supervisory decisions,

·        poor injury management practices,

·        breakdown in communications, and/or

·        employer failures to make reasonable work accommodations.

Mitchell concludes: “Co-malingering, while not always the result of an intentional act on the part of either the worker or the employer, is quite often supported and encouraged by the very system it seeks to deceive.”

Any party within the compensation system working with the employee can potentially partner, consciously or unconsciously, with the injured worker to deceive the system.  Rehabilitation personnel, physicians, family members, claims personnel, lawyers, and even supervisors can co-malinger.  Very often a supervisor, for example, expresses relief that an injured worker who has historically been a “troublemaker” remains out of work and will not be allowed to return to work until they are “100%” recovered from their injuries.  The supervisor convinces herself that morale will be better without the troublemaker at work. 

Less overtly, perhaps not realizing it, management and labor all too frequently agree on contractual language that results in co-malingering, such as “no light duty,” or “light duty” that continues indefinitely, or “one cannot work in this organization unless they are fully able, 100%.”  Lawyers representing injured workers have an obvious incentive to keep them out of work, and too often, physicians adopting vocational language inappropriate for the medical profession, such as “the patient is totally disabled,” mislead decision-makers (i.e., employers and/or adjudicators) in the return-to-work and compensation systems.

Although not a medical concept, co-malingering is a significant sociological dynamic of the political landscape of every work organization including the disability compensation system originally designed to assist injured or ill employees “to make them whole.”  The sociological dynamics of co-malingering are much more frequently at play than the individual behaviors associated with malingering.  Only when employers choose to focus on the lost-time system rather than the single individual who has begun losing time can employers truly reduce the unnecessary costs of absenteeism following injury or illness.

Effective disability management requires that rehabilitation specialists determine from the first contact whether the case has co-malingering aspects.  If it does, the successful resolution of the case will have to address the co-malingering factors before assigning any other causal attribute.

To prevent co-malingering and its effects, employers are encouraged to ask critical questions, including:

1)   Does this organization have a pro-active comprehensive system to encourage employee wellness and prevent lost time associated with injury and/or illness?

2)   Has this organization made a concerted effort to combine risk-management, claims administration, health and medical, human resources, and operations, policies, and procedures to prevent lost time through disability?

3)   Similarly, do representatives from each of these departments meet on a regular basis to review company procedures to keep employees on the job and productive?

4)   Are front-line supervisors properly trained in communicating with workers who may be at risk for lost time (disability)?

5)   Does this organization have designated internal case managers who take regular responsibility for effectively communicating with outside personnel regarding claims administration and medical issues related to employees who have lost time?

6)   Does the company have an effective transition-to-work program that trumps the antiquated “light-duty” concepts?

7)   Does the company have essential function job descriptions that include the physical and mental requirements of each position so that physicians are asked to address whether a person can perform essential functions as opposed to “can this employee return to work”?

8)   (Perhaps the toughest question of all) Are the leaders of this organization truly committed to assuming responsibility for maintaining worker productivity rather than abdicating that responsibility of disability management to outside vendors such as third-party claims administrators, case managers, physicians, and lawyers?

References:

Explaining Acquired Disability & The Workplace Approach to Managing It

The following articles examine the logical connection between an “acquired occupational disability” and the strategies needed to manage and cost-control these disabilities in the workplace.

(Part I) Explaining Acquired Occupational Disability

ABSTRACT

We have concluded that acquired disability following trauma must be “explained.”  It is apparent that unless an expert is fully informed of the multitude of pre- and post-injury medical and psychosocial dynamics that surrounds an individual’s claim of occupational disability, the expert may not be in a position to make absolute judgments regarding residual employability, pre- and post-work capacity, or the causal attribution of vocational disability.  Causal attribution is critical in determining disability chronicity following trauma, as the host of contributing psychosocial dynamics effecting unproductive states are often overlooked when investigating the most obvious reason for work absence, a so-called “explanatory event.”  We believe thorough and accurate history-taking is necessary when assessing pre-injury work longevity, determining residual employability, and causally ascribing occupational disability to a particular event.  Acquiring a complete and reliable history through various sources places the expert in a better position to offer a professionally certain opinion.

Background

Central to most personal-injury lawsuits are the issues of vocational disability and lost earning capacity.  When injured people begin losing time from work, they inevitably attribute the vocational disability to the most recognizable event preceding the unemployment – the accident.  In a purely temporal analysis, most observers would agree with the injured party.  That is, a documented event or accident took place and caused subsequent lost time.  However, post hoc, ergo propter hoc (after this, therefore on account of it) is frequently a fallacy and too often constitutes a failure in the cause-and-effect analysis of vocational disability.  How people explain acquired disability can affect how chronic it might become.

It has become our perception over the past two decades that confusion exists in society generally and in our medical and legal systems specifically, as to who is best qualified to describe vocational capability and disability and delineate the various factors to which occupational disability might be accurately ascribed.  Thus, not only does acquired disability have a personal meaning, to be explained by the individual, but of course a larger social context in which professionals attempt to determine who is vocationally disabled and why.  In this article, we will reflect on who is best qualified to professionally describe occupational disability and its causes.

Over the 25 years we have examined thousands of injured people for the purposes of providing them with vocational rehabilitation or evaluating them for forensic consultations, we have learned that vocational disability is as much a function of psychosocial dynamics as medical impairment and resultant functional limitations.  We believe that when one considers not only a medical impairment, but also the constellation of psychological and social forces that are at play both before and after an accident and work injury in particular, one generally comes closer to defining the true cause-and-effect of lost productivity that may occur following an industrial accident or injury.  We also found that thorough and detailed history taking is the key element in the skilled assessment of vocational disability.

Multiple Factors in Disability Analysis

It has been our experience that in the disability equation, one needs to account for the:

1.      worker’s general health preceding the event in question;

2.      work conditions preceding and at the time of the event at issue;

3.      employer-employee relationship;

4.      employee’s self-esteem and psychological strength;

5.      psychosocial factors outside of the workplace; and

6.      social-economic alternatives to remaining productive. 

Let us look at each of these factors and their influences in the lost-time analysis.

Worker Health and Wellness. Minds and bodies are the vehicles that collectively fuel productivity at both the individual and the organizational level.  When mental and physical abilities are not maintained with proper health practices, they naturally deteriorate, and under stress these vehicles can actually breakdown.  Organizations have more or less recognized the importance of health and wellness among their worker populations.  The institutionalization of prevention and early intervention includes such initiatives as smoking cessation plans, employee assistance programs, and exercise facilities available to all workers in particular companies; however, these types of programs are neither universally available nor commonly accepted as means by which employees can remain healthy and productive. 

The degenerating musculoskeletal system, an unavoidable aging phenomenon, eventually becomes prone to injury and disability, particularly in industrial settings.  Workplace mortality rates for longshoremen, transportation workers, and steelworkers, for example, are generally higher than those for accountants, lawyers, and schoolteachers, although more sedentary employees are by no means immune to mental stressors that can precipitate occupational illness.  Absent a focus on worker health and wellness, organizations can serve as the stage on which the aging employee is more or less susceptible to lost time not as a result of a particular event, but because of the degenerative process that makes any body and/or mind vulnerable to occupational stress.

Working Conditions. Workplaces are not always conducive to employee health and wellness regardless of the most enlightened efforts of human resources managers and others in leadership positions.  Many industrial plants are more like dungeons than production facilities.  Workers can encounter hazardous chemical exposures, run antiquated and dangerous machinery, and function in generally unsafe working conditions, whether in non-unionized or unionized workplaces.  Not infrequently, employees who recognize unacceptable conditions surrounding them initiate workers’ compensation claims and associated lost time because mere existence, let alone productivity, in such environments becomes intolerable – particularly as the worker ages and eventually perceives no other exit strategy, not even retirement.

Several years ago upon considering the issues of worker health, working conditions, and the employer-employee relationship, we introduced the metaphor of a “toxic tort” as representing some workers’ compensation claims.  That is, in some instances, the worker filed the claim not because he or she had been injured or become ill, but because the worker considered the occupational environment so potentially harmful or “poisonous,” literally and/or figuratively, that filing a compensation claim was a preferred means to economic survival.

Employer-Employee Relationship. Everyone who toils under supervision has perceptions of leadership, sometimes good, frequently bad.  Employers (and managers) are seen as authority figures by employees who have been inevitably programmed through early experiences with adults who had power over them.  No other relationship than that between the boss and the subordinate has received more attention in books on management, and no relationship has received greater scrutiny in labor-management agreements.  The employer-employee relationship is invariably susceptible to conflict.  Unresolved conflict is often the precipitator of workplace stress, tension buildups, and resultant lost time.

Employee Self-Esteem and Psychological Strength. When an individual experiences a sense of self-worth, and when the same individual realizes personal power, he or she is able to be assertive and make his or her needs known to others.  This is the great striving for most of us, and unfortunately, many of us have not been afforded the building blocks necessary to develop a strong sense of self and self-worth.  Criticized and invalidated by significant others in our early lives, we become workers with tenuous egos and defensive self-concepts, more often knowing what we do not want to happen to us rather than helping create the environments and relationships we do want.  Personal power in the workplace can be diminished by performance circumstances and/or low productivity.  When it does, individuals can become susceptible to workplace injury and/or illness. 

With reduced productivity concomitant to lowered self-esteem, the employee may find it easier to leave the workplace with a “face-saving” injury or illness rather than confront the actual problems that led to feeling helpless and depressed in a work environment that seems to lack compassion, understanding, and support.  Feeling abandoned in a group of your work peers is far more anxiety provoking than becoming absent from work after the onset of injury or illness.  The latter clearly vindicates the “honorably” disabled employee who, in his or her mind, has sacrificed personal health and well-being for the company.

Psychosocial Factors External to Work. All of us experience social demands and psychological pressures outside of work with which we must contend.  When those pressures and demands exceed our tolerance for stress, we are susceptible to illness and/or injury.  “Disability proneness” is a concept built on the idea that certain individuals are more vulnerable than others to the customary pressures of life outside of work.  Personal and financial changes and losses such as relocation, separation/divorce, and other situations to which all of us would have difficulty adjusting can lead to maladaptive behaviors affecting job performance and even work attendance.  Experience has shown that individuals with inordinate psychosocial stressors and limited coping skills may very well be disability prone.  Moreover, the literature on work dysfunction reveals that certain personality types interacting with social and occupational demands are more likely to succumb to these pressures, learn helplessness, and claim vocational disability.

Social-Economic Alternatives to Remaining Productive. For years, we have recognized that a construct parallel to learned helplessness is the phenomenon known as “learned laziness.”  Once deemed the “welfare pigeon” paradigm, learned laziness is the expectation that certain individuals and personality types will quickly abandon motivational achievement behaviors for non-conditional reward, sometimes in the form of workers’ compensation indemnity benefits and/or Social Security Disability Insurance.  With most benefits (e.g., workers’ compensation and/or long-term disability) being paid at rates of at least 66-⅔% of the employee’s pre-accident wages, once-productive workers soon find it difficult to risk losing benefits by returning to the unknown consequences of gainful activity, particularly in an environment that may no longer extend them a welcome.  Many times employers perceive injured workers with mistrust, and too often employers treat injured employees as “damaged goods,” sometimes worse, as a pariah.  With perceived employer disdain following occupational injury and/or disease, the injured worker quickly searches for alternative methods of financial survival.

There is much at stake when an individual claims to be vocationally disabled following accident and/or injury.  Among the stakeholders, we find various ways of explaining how an individual’s disability occurred and why it might become chronic, but in all cases, regardless of the explanation, the nonproductive consequence of people being displaced from work following accident and/or injury is very expensive to individuals, companies, and our economy in general.

The Mercer Human Resources Consulting and Marsh, Inc., 2002 Survey of Employers’ Time-Off and Disability Programs revealed that time-off and disability program costs averaged 15% of payroll in 2001.  More specifically, for an employee earning $40,000 annually, companies surveyed paid $6,000 for time away from work associated with sick days, workers’ compensation costs, short- and long-term disability programs, salary continuation programs, etc.  For years, so-called “acquired occupational disability,” an inability to work following injury or illness, has cost our economy billions of dollars each year ($170.9 billion, according to one 2002 estimate), and yet little attention has been given to the concept of how individuals explain vocational disability.

Causal Attributions of Occupational Disability

Attribution theory seeks to understand how individuals interpret events and how explanatory thinking and behavior tends to correlate with human motivation.  Attribution theory considers how people make sense of their worlds and what cause-and-effect inferences they make about the behaviors of themselves and others.  For years, we have explored the potential role of attribution theory in the cause-and-effect beliefs that people create and maintain when they “acquire” vocational disability.  We have postulated that healthcare providers, specifically physicians, trained in assessing impairment are generally ill-equipped to determine the cause of disability in others.  We have hypothesized that vocational disability tends to be temporary or become fixed depending on an individual’s attributional style. We will again review the difference between medical impairment and vocational disability, and then discuss the multitude of issues surrounding causal attribution of occupational disability. 

Medical Impairment v. Occupational Disability. Medical impairment, an alteration of an individual’s health status, is what is wrong with a body part or organ system and its functioning (American Medical Association, 1990).  Permanent impairment should be determined only at the end of the normally accepted healing period, or when maximum medical improvement has occurred.  Impairment does not determine the impact on the person’s capacity to meet social or occupational demands; disability defines the impact of impairment on occupational functioning.  Medical impairment is evaluated and treated by healthcare personnel.  Disability is assessed by non-medical means, generally by vocational experts and disability evaluators.  What causes occupational disability is often more complex than simply a decrease in physical or mental functioning secondary to a particular impairment.

Occupational disability is often caused by pre-existing medical problems, social dynamics, psychological issues, the lack of work skills that might be utilized in alternative or perhaps less demanding work, and/or economic factors such as the availability of appropriate employment given a medically impaired individual’s “residual employability.”  Nonetheless, how people explain acquired disability is very much a function of the attributions they create.

Attribution Theory. Attribution theory, what Weiner (1986) called “naïve psychology” – the cause-and-effect analysis of behavior made by the man-in-the-street – attempts to explain the mechanisms by which people construe the causes of and arrive at their beliefs about success and failure.  Attribution theory has been linked with achievement-related behavior, such as learning and working, and mental health concepts (e.g., optimism, pessimism, anxiety, and depression).  Attribution theory helps explain not only how individuals perceive their own successes and failures, but also how they causally ascribe the achievement of others.

We postulate that individuals who have medical impairments can attribute occupational disability to an accident or injury for no other reason than a temporal connection – that is, the person became unemployed after a trauma.  Because the injury allegedly resulting in impairment came at the time of or after an accident, then it is implied the accident caused the disability.  We argue that a “time-based explanation” in the determination of what causes occupational disability is often inadequate in explaining disability given the multitude of other factors, including pre-existing medical conditions, that can cause unemployment subsequent to, but not necessarily as a consequence of, the indexed traumatic event. 

For example, a 38-year-old female who sustains a whiplash injury in an automobile accident stops working as an outside sales representative five months after the accident and claims that her chronic regional pain syndrome, diagnosed after the accident, is the cause of her occupational disability.  Careful investigation, however, reveals that this individual was previously treating for rheumatoid arthritis and fibromyalgia.  Her theory as to why she is unemployed with a loss of economic power is that her occupational disability is directly and causally related to the whiplash injury.  A physician treating this person declared that her chronic pain complaints are directly linked to the whiplash injury that has become the basis for the patient’s personal injury lawsuit.  In reality, her chronic complaints of pain and concomitant allegations that she cannot work are multifactorial at least.  Further investigation reveals that this outside sales representative was being disciplined at work for low production.  Additionally, the company for which she worked was being purchased by another entity, and company rumors were that layoffs of sales representatives would occur as a result of the acquisition.

Causal attributions of occupational disability are best made by trained observers or evaluators who fully appreciate the psychosocial context in which causal attributions of acquired disability are made. Occupational disability has been studied from numerous social and psychological perspectives.  Important constructs have been offered to help us  better understand and explain the non-medical antecedents and consequences of vocational disability.  The concepts of Disability without Disease and the Disability Process, Learned Helplessness (and Laziness), Co-Malingering, Locus of Control, Loss of Self Esteem, Disability Induction, Disability Proneness, Illness Behavior, and the Meaning of Work help us understand some of the underlying principles of disability causation.

Disability without Disease and the Process of Disability

In the late 1960s, after spending many years treating injured autoworkers, two occupational health physicians, Drs. R.C. Behan and A.H. Hirschfeld, set forth their idea that injured employees can exhibit “disability without disease” or accident (1966).  Borrowing on this concept, Weinstein delineated the “process of disability” in 1978. 

Rather convincingly, Weinstein graphically portrayed the stages of the disability process.  Weinstein reasoned that the troubled worker faced with negative feedback regarding his or her performance would eventually reach a stage where so-called “tension build-up” would become overwhelming and viewed as “unacceptable disability.”  Weinstein argued that an accident or illness, seen retrospectively as an “explanatory event,” would allow the unacceptable disability to become acceptable and stabilize with medical explanations, diagnostic studies, and eventually unnecessary interventions, such as surgery or chronic pain management involving crippling medications.  Behan and Hirschfeld concluded, “This remarkable capacity of disability to seize an accident as its apparent cause results in terrible chronicity.”

Learned Helplessness (and Laziness)

Walker (1992) offered the concept of “Learned Helplessness” (Seligman, 1975) as a useful framework in understanding how injured workers perceive loss of control in the workers’ compensation system – a system that simultaneously rewards and punishes injured workers.  Learned helplessness is caused by repeated experiences of aversive, uncontrollable situations.  The person caught in a learned helplessness syndrome exhibits passive, resigned, inflexible behavior associated with dysphoric feelings of depression.  Walker described how the workers’ compensation system breeds conditions ripe for injured worker helplessness.  However, he also pointed out that the very same system often financially rewards people non-contingently, thereby also inducing “learned laziness” by making a return to work financially impractical or disadvantageous for the workers’ compensation claimant.  Walker argued that injured workers, trapped in the quagmire of workers’ compensation systems as they are designed (i.e., to make a person whole), generally manifest amotivational behaviors and surrender their will to work.

After proposing learned helplessness as a model for depression and motivational disturbances, Seligman reformulated the learned helplessness model to include the concept of “attributional style.”  That is, individuals with particular attributional styles are more susceptible to learning helplessness. 

Co-Malingering

Lost time from work may be a function of either medical restrictions that are related to impairment as determined by physicians or dysfunction associated with behavior and social relationships that develop both before and after the accident/injury.  At times, injured workers are accused of malingering, the falsification of symptoms to avoid responsibility, including work.  Previous research conducted by members of the National Rehabilitation Planners, Inc., has found that only 10% of compensable lost time is due solely to medically imposed restrictions.  “All other reasons for lost time are due to employer- and employee-controlled impediments for return-to-work, such as:

¨      inflexible supervisory decisions,

¨      poor injury management practices,

¨      breakdowns in communications, and/or

¨      employer failures to make reasonable work accommodations.”

These employment situations may represent a form of “co-malingering,” which Kenneth Mitchell, who coined the term, described as “the mutual actions of employers and employees that extend [the] disability duration and impede early return to productive employment.”  Co-malingering is also sometimes referred to as negotiated disability.  “Employees incur 100% of lost time; employers control 90% of it.”  However, for many years now, we have recognized that other members of the lost-time community can function in relation to the injured employee as co-malingerers, and those other parties include physicians, lawyers, and family members.  Co-malingering appears to be much more common than malingering in lost-time cases.

Locus of Control

Locus of Control is a useful construct in terms of vocational rehabilitation.  At its simplest, Locus of Control is an individual’s perception of the cause of events in one’s life: either one believes he/she controls his/her own destiny (“internal”) or one believes that others, luck, or fate control one’s outcomes (“external”). 

Locus of Control is closely related to the concept of “attribution.”  An attribution is an explanation of what happens to one’s self and/or others.  For those not comfortable with the terminology of psychology, it may be more meaningful to use “explanation” as a synonym for attribution. 

In general, an internal Locus of Control is seen as being more desirable.  Consider the following descriptions of internality and externality:

¨      It is an internal attribution about oneself when one succeeds (I did it myself).

¨      It is an internal attribution about others when they fail (It was their fault). 

¨      It is an external attribution about oneself when one fails (Something/Someone else made me fail).

¨      It is an external attribution about others when they succeed (They got lucky).

Research (Mamlin, Harris, & Case, 2001) has shown the following trends:

¨      Males tend to be more internal than females.

¨      As people get older, they tend to become more internal.

¨      People higher up in the organizational structure tend to be more internal.

 

Although these trends are not absolute, they may serve as a starting point for vocational counselors working with clients.  It is generally agreed that Locus of Control is largely a learned condition.  For a client who is resisting vocational counseling and incidentally exhibiting an external Locus of Control, it may be a useful strategy to work toward reversing that bias.  There are a number of questionnaires that are designed to determine internal and/or external Locus of Control.  Rotter’s original “29-item Locus of Control Questionnaire” is still used, and there are newer questionnaires that are also available.

The value of starting with knowledge of the client’s Locus of Control bias is that an external Locus of Control can lead directly to the loss of control.  The important research in respect to loss of control is Seligman’s learned helplessness.  Since Locus of Control is learned as opposed to innate, clients drift toward learned helplessness as an outcome of having no control over of what is happening to them.  Moving from what may have been an internal Locus of Control to an external Locus of Control is an adaptive response that may be reversed by sharing knowledge of the condition with the client and devising reversal strategies.  Counselors need to be cautioned against simplistic judgments derived from an over reliance on the Locus of Control concept, but sharing knowledge about a reality can seldom be injurious.  Acknowledging personal responsibility is an important first step for clients resisting return-to-work actions.

Loss of Self-Esteem 

Another significant factor in resisting a return to work after an illness or accident is rooted in psychological issues such as depression, anxiety, and low self-esteem.  Frese and Mohr (1987) stated, “Depressed persons who are inactive and pessimistic in their outlook will be unemployed much longer or will become unemployed more readily.”

Weinstein (1978) pointed out that a worker’s loss of self-esteem taking place simultaneously with decreased productivity are two key factors in “unacceptable disability” that requires an “explanatory event,” such as a future accident or injury in order to justify continuing dysfunction and ultimately a prolonged period of lost time from work.  In other words, Weinstein believed that a worker’s loss of self-esteem is a key predictor to future vocational disability even before the accident that will be labeled the cause of lost time!  Furthermore, Weinstein pointed out that following the “explanatory event,” medical, psychological, and social factors may actually work to restore the individual’s self-esteem and allow for one to be declared “honorably disabled,” thereby signaling a stabilization and chronicity to the disability.

In the final analysis, intractable cases of depression and/or personality dysfunction will need to be referred to competent mental health professionals who understand behavioral medicine and the importance of vocational rehabilitation.  Of course, most rehabilitation counselors are not trained as clinical psychologists, but there are interventions that vocational counselors can and should utilize.

Basic interventions that can be applied in counseling clients who are resisting return-to-work would include:

¨      discussing the importance and the value of work with the client;

¨      identifying and discussing psychological issues, especially depression and the loss of self-esteem, and the need to find ways to overcome them;

¨      discussing Locus of Control and Causal Attributions and their significance to motivation and productive return-to-work efforts;

¨      recognizing learned hel