The Role of Psychological Evaluations For Injured Patients

In Greek mythology, Pandora was given a beautiful box by the gods but told never to open it. Finally though, her curiosity got the better of her, and she looked inside. Unfortunately, the box was full of evil things, and once they were released, they were forever beyond her control.

Similar fears are shared by some who worry about the ramifications of performing a psychological evaluation on a patient in rehabilitation. The fear is that psychological difficulties will be uncovered, and once they are, it will greatly complicate matters and add to expense and delays.

In the case of physical rehabilitation though, Pandora's box is already open. All the available data suggest that half and possibly much more of all Worker's Compensation costs are attributable to psychosocial factors (Some of this research can be reviewed at Health Psychology Research and Health Psychology Factoids ). This is a huge problem, and ignoring it will not make it go away.

In most cases, recovery from an injury is a straightforward and relatively inexpensive process. However, in a small number of cases, the costs are extremely high. Frymoyer (1988) reported that about 5% of back pain cases accounted for about 85% of all medical costs. If we compare the medical costs for delayed recoverers versus the other patients using Frymoyer's statistics, we will find that the average delayed recoverer is 57 times more expensive to treat than the other patients. In some cases, this is because the patient with delayed recovery simply has a more complicated medical condition. However, in many cases patients with delayed recovery have no objective medical findings. As far as the best objective medical tests can discern, there are no objective reasons as to why this person should be feeling pain. It is believed that in most of such cases, psychosocial complications are causing or contributing greatly to the delays.

Research has found that if these psychosocial factors can be addressed, delayed recovery can be avoided. Dealing with these factors is not only good treatment, it is cost effective as well. It should be remembered though that there is no hope of controlling these psychological factors if an accurate assessment of them is not made. If these factors are not addressed, then the risk of delayed recovery is greatly increased.

Some of the interventions that we propose are as follows:

1. If a patient has not recovered from an injury in 6-12 weeks, and there does not appear to be any objective medical basis for this, both protocols developed by national societies as well as local protocols in Colorado would suggest that a psychological evaluation is strongly suggested.

• This evaluation is a onetime procedure, as opposed to ongoing psychotherapy.
• Traditional psychotherapy is generally not warranted for persons with injuries. However, a brief psychoeducational approach to pain management using cognitive techniques or biofeedback is often helpful.

2. In some cases, extreme or unusual patient behavior may lead to a recommendation for a psychological evaluation prior to 6-12 weeks.

3. The psychological evaluation should identify what psychosocial factors are present, and which could potentially affect the outcome of rehabilitation. Additionally, it should seek to determine which of these factors may be attributable to the injury itself.

4. Except in unusual cases, extended psychotherapy is rarely indicated for persons who are injured. More commonly, effective interventions may entail the following:

• Identify patients who may be psychologically poor candidates for rehabilitation, surgery, or other interventions, and explore the possibility that managing the psychosocial complications may improve the prognosis.
• Examples of patients who are at risk include those who are depressed, suicidal or angry, who are at risk for dependence on pain medications, who report a history of abuse, who are preoccupied with compensation, or who have conflicts with healthcare providers or persons in the workplace.
• Develop a medical plan which accounts for whatever psychological risk factors may be discovered.
• Implement any psychological interventions necessary, such as brief psychotherapy (more than 4-8 sessions is seldom indicated), Biofeedback Therapy (8-10 sessions is common), or treatment with psychotropic medications such as antidepressants.
• Consult with medical professionals about implementing the treatment plan and addressing any difficulties which may arise.

5. Patients deserve treatment for injuries they sustain, and every attempt should be made to approach the situation fairly. The healthcare professionals involved should attempt to draw up a fair treatment plan for the overall profile obtained from the patient. However, the patient is responsible for making his or her best effort to invest the needed energy in his or her rehabilitation. If the patient is not willing to do this, then this lack of motivation must be addressed.

In retrospect, Pandora could have avoided her problem if her box had come with instructions. Similarly, in medical care, there does not need to be a fear of opening up psychological issues. Quite the contrary, it is the failure to adequately address such psychosocial concerns that commonly drives delayed recovery.

If a surgeon performs surgery without some kind of diagnostics first, the chances of being unsuccessful are greatly increased. Similarly, proceeding with psychological treatment without some kind of initial assessment also runs the risks of producing an ineffective intervention. This is especially true in the worker's compensation, personal injury and other litigated systems, where there is an increased incidence of conflict and secondary gain. A good psychological evaluation will not only identify what the underlying issues are, but also identify a plan for intervention, and apportion causality fairly as necessary.

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