Every injured worker should have access to some level of mental health support. I work with a veteran pain psychologist who is wonderful. 90% of her practice is caring for my patients. If she feels it is necessary, she will refer a patient to one of several psychiatrists for medication management.

Chronic Pain and Mental Health

It is unclear, from the psychiatrist’s viewpoint, what constitutes a diagnosable psychiatric disorder. On my intake questionnaire, I have a simple 0 to 10 scale for anxiety, depression, and irritability. Essentially every injured worker that has been out of work for more than six weeks is greater than a 6 out of 10 on at least two of these scales.  What would be my threshold for a formal referral, especially in light of the fact that my state will not pay for an evaluation in a timely manner? What is even more worrisome to me is the patient who puts down a zero for all three. He or she is just a time bomb.

Diagnosis Problems

In the disability literature, there are hundreds of papers linking stress and disability, but there is not a clear-cut definition of anxiety disorder to aid practitioners in diagnosing an injured worker. How bad does a patient’s anxiety have to be in order for it to be diagnosable? What is the definition of a diagnosable mental health disorder in general?  As there is not a concise definition, I am in a continual battle with worker’s comp trying to persuade them to “buy” a psychiatric diagnosis. While the patient is waiting, what are we to do?  Their stress level climbs even higher as they wait for an answer.

A Case

I saw a patient a few months ago who is a young mother. I have known her for years.  She developed quite severe axial back pain. We had a short but direct conversation about stress and pain. She came in a couple weeks later with her back pain feeling moderately improved but seemed upset. I had a little extra time to talk to her. She started out by saying that she had separated from her husband and was having a hard time finding a job and a place to live. I knew that he had not been working and she was home with two young children. It turns out that he had been regularly beating her. It happened enough that her children felt afraid of her if she yelled at them, but the physical abuse that occurred in front of them seemed OK. If you met her, you would be more than upset. She is one of the nicest people you could meet. Under no criteria would she have a diagnosable psychiatric condition. She really did not know what direction to go. Her mother was helping out the best she could. I emailed my pain psychologist and although she had no funds, she was able to be helped out. On top of that, her husband has chronic pain from failed back surgery.

Stress Management

Every person from elementary school on should be taught stress management and mental health skills. I feel the one factor that determines one’s success in life is the ability to process and handle stress. Even basic stress management tools are extremely helpful.

Support

Every injured worker needs to have access to at a group or organization that teaches these type of skills and offers other support. Individual referrals to psychologists can be figured out more easily in this setting. Losing a job in a capitalistic society is a disaster.  It is bad enough if you are single; it is much worse if you are the breadwinner of a family. Even the thought of being in this situation is mentally crippling.

Labels

A major concern and obstacle to accessing mental health support is our tendency to label people. Injured workers quickly become labeled. This is particularly true if they make the mistake of complaining too loudly or expressing their frustration. They become “difficult” and “manipulative.”  If their stress becomes higher, they may have more pain and ask for more meds. This gets them labeled “drug seekers.”  The list of labels goes on. If a patient is labeled as “anxious” or “depressed,” they are often put on antidepressants and their anxiety is considered “addressed.”  If after a few months they are still depressed, then they might be referred to a psychiatrist or psychologist. By this time, months have passed and often the lives of patients have unraveled.

The Patient is a Person

The patient’s whole life, including her mental life, must be acknowledged from the minute she is injured. Every person that comes in contact with her makes a difference. Even the acknowledgment of her suffering is important.

I made a comment a few weeks ago to David Tauben, who is the head of the University of Washington pain center, and David Elaimy, my surgical performance coach, that they should put on a mini-seminar, “Enjoying the Management of Your Chronic Pain Patients.”  A major part of the enjoyment of being a physician is addressing the whole patient and making the correct diagnosis. If I had just sent the young mother I mentioned above to physical therapy for neck pain, it would not have been helpful. Thanks to the DOCC Project methods, she will be able to get her life back on track and have the tools to live a much more fulfulling life.

BF

The post Everyone Needs Support first appeared on Back in Control.

The post Everyone Needs Support appeared first on Back in Control.

I am on a much-needed vacation this week in Italy.  From 1980 until 1990, my wife lived in Florence.  We have many friends in Italy we like to visit as much as we can.  It is a unique opportunity for me in that she is fluent in Italian and we are able to spend time in our friends’ homes in the heart of Tuscany.  There is nothing quite like sitting down to a home-cooked Italian meal overlooking a beautiful valley.

Last night was one of those evenings.  Our friends not only put us up in their apartment, they had us over to dinner with several other friends.  The conversation drifted towards medical care.  One of the guests had experienced some medical problems of a moderate nature that required several physician visits and a couple of procedures.  He said that the aspect of his care that most struck him was that at no point during his care did anyone from the receptionist to the doctor ask him how he was doing.  Additionally, when he was asked some detailed questions about his condition, he was asked if he was a doctor.  When he replied that he was not, he was told that he had been informed enough and that he should not ask so many questions.  You might imagine his frustration.

I have witnessed a lot of success with the DOCC protocol, but it has become increasingly clear that the protocol is just a framework. It helps organize both the physician’s and patient’s thinking about chronic pain and therefore makes it much easier to create a treatment plan.  It is the patient who organizes and implements the plan. The physician is more in the role of a “coach” as well as being continually aware that there might be a potential structural problem.

About a year ago, I was talking to the pain psychologist I work with about what we were doing that seemed to be more helpful to our patients than either of us had historically observed.  She kept insisting that I was the factor that made the difference.  I was sure it was the DOCC protocol and the work she does.  After more and more positive results, I finally agreed that I played a major role in their recovery.  To clarify, I don’t believe that I have a special gift or am the world’s best doctor.  I simply stay committed to my work with the patient.  With increased attention over the last couple of years, I have seen more patients who had been in pain for decades become pain free.

Through my numerous difficult experiences, I have had many layers of my own personal labels stripped off.  Physicians, especially surgeons, are perfectionists.  It gives us an early competitive edge in high school and college.  It is somehow held up as a virtue by our medical culture and demanded by society.  Unfortunately, it is a complete disaster with regards to our ability to connect with our patients.  By definition a perfectionist is continually judging himself or herself by an unattainable standard.  As I have labeled myself, I have labeled others around me.  As it has been my reality for over 50 years I had no clue that this process was taking place.  I recently wrote an article, “The Cry of Chronic Pain—No One is Listening.”  The essence of the article is that once you have a label of a “chronic pain patient” placed on you, the world, including you, feels that it is just “something you have to live with” and your care becomes essentially palliative care.

I recognize that labeling is universal but it is not constructive.  I am aware that I label people constantly. As I work to become aware of the label I am placing, I am able to eventually see who you truly are.  You are a whole person.  Neither you nor I are the labels we place on each other.

The energy for your healing journey comes from you, not me.  What I contribute is that I am able to see you as a whole person and you are somehow able to remember that part of you that is really you.  When that part of you “wakes up,” there is no stopping you.  You are your own oasis in the middle of the desert.  I cannot ever tell who will engage or when.  The DOCC project is just a rough framework and every journey is completely different.  I am continually energized and inspired by the incredible obstacles you overcome to return to a rich, pain free life.

I recognize that essentially all physicians are compassionate.  Many physicians have figured out this journey and most have not had to experience burnout to learn it.  I am continually humbled by numerous examples of deep compassion by my colleagues.

I always thought I was compassionate. I was very well intentioned and always gave every patient my best shot.  However, the physician burnout rate is around 50% and we truly have a life full of more stress than you can imagine.  If you are just trying to survive, there is only so much you can give.  Additionally we have no resources or tools to help us out.  The safety net is a concrete floor.  It has been shown in several studies that it is during the third year of medical school that compassion takes a dive.

I am not writing this post for you to begin looking for a physician who is compassionate.  It is not a bad idea, but it is not necessary for you to heal.  Remember this process is about you taking full responsibility for every aspect of your care and your life.  You don’t need me.  You don’t need the DOCC project.  You just need to connect with that part of yourself that is whole and wants to thrive. The person who you need to experience compassion from is you. Use whatever means you have at your disposal to figure this out.  It will probably take some outside help but there are multiple resources. Quit trying to “figure all of this out” and just go.

NH, BF

The post Compassion and an Italian Dinner first appeared on Back in Control.

The post Compassion and an Italian Dinner appeared first on Back in Control.