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Preventing secondary psychological injury, Dr Curtis Gray

Safe Work Month and Mental Health Week 2020

Speaker: Dr Curtis Gray, Psychiatrist.

This session explores how to minimise poor recovery and secondary injury after a claim for workers’ compensation is made, and the factors that allow some people to recover from physical and psychological injuries as expected, while others do not.

Particularly relevant for business leaders, employers and return to work professionals, Curtis explains approaches to treatment from a psychiatric perspective and provide insights about how to prevent lengthy absences from work.

Good morning, everyone. Welcome to another special presentation from Workplace Health and Safety Queensland all about "Preventing Secondary Psychological Injury". Our presenter today is Dr. Curtis Gray. I'm Chris Bombolas, media manager for the Office of Industrial Relations, your MC. Firstly, can I acknowledge the traditional custodians of the land on which we meet today and pay my respects to the elders past, present and emerging. I'd like to extend that respect to Aboriginal and Torres Strait Islander peoples watching today. Safe Work Month is held every October and is all about raising awareness of work, health and safety. This year, Safe Work Month looks a little different thanks to COVID-19. And remember, we are in the midst of Mental Health Week. This session will explore how to minimize poor recovery and secondary injury after a claim for workers compensation is made and the factors that allow some people to recover from physical and psychological injuries as expected while others do not. Dr. Gray will establish a basis for understanding normal reactions to injury and the vagaries of psychiatric diagnosis before moving on to the topic of secondary psychological injuries focusing particularly on adjustment depression and adjustment disorder. Dr. Gray will explain approaches to treatment from a psychiatric perspective and provide insights about how to prevent lengthy absences from work. He will also spend a short time discussing how to shape questions to get the most from a psychiatric independent medical examiner. Let's find out a bit more about Dr. Curtis Gray. He's an experienced adult psychiatrist with clinical interest in mood and anxiety disorders trauma and stressor-related disorders. The interplay between medical conditions injuries and mental health. Sleep disorders and their relationship to psychiatry and medico-legal matters related to those areas. Curtis is a senior lecturer with the Queensland University School of Medicine. He recently completed a six-year term as a federal examiner for the Royal Australian and New Zealand College of Psychiatrists Committee for Examinations and a term as assisting psychiatrist to the Mental Health Court of Queensland. He has been a senior staff specialist at the Gold Coast Hospital and in the Department of Psychiatry at Brisbane Prince Charles Hospital where he was also acting clinical director. Curtis is also involved in civil medico-legal work. He's a member of the Faculties of Consultation-Liaison Psychiatry and Psychiatry of Old Age the Faculties of Psychotherapy and Adult Psychiatry of the RANZCP and the Executive Committee of the Medico-Legal Society of Queensland. He holds appointments to the Mater Health Services Mater in Mind Consultation-Liaison Psychiatry Service the Mental Health Review Tribunal Psychosurgery Panel and the Queensland Workers' Compensation Regulatory Services Medical Assessment. Just a reminder, there will be a Q&A session after Dr. Gray's presentation. So if you do have a question for Curtis feel free to submit it via the chat box on your screen at any time we'll get to as many of those questions as we can. All right, it's time now to bring in Dr. Curtis Gray, Curtis.

Thank you very much for that introduction, Chris and thank you to the OIR for asking me to present on this topic. Firstly, I'd just like to echo Chris's comments about the elders and the land on which we are fortunate to give this presentation. I have been mulling over this topic for quite some time in fact, way before I was invited to come and speak because it's one that I see in both clinical and civil medico-legal practice all the time. And I'm hoping to not so much answer a lot of questions that you might have although, I do hope that that might happen but take you through some ways of trying to understand this notion of secondary psychological injury. We have to start with some concepts. Before we do that though I just want to clarify what I'm talking about and a little bit about what I'm not talking about today. So let's start with an example. This is Hayley. She's just been involved in a motor vehicle accident. I hope you can see that she's got blood on her and a neck brace. She sustained a whiplash injury. So that would be considered a primary direct sort of injury from the accident. It was pretty terrifying for her. So she's also sustained from a psychological perspective post-traumatic stress disorder. That would also be a direct or primary consequence of the accident but that's not what I'm talking about today. We're talking about secondary psychological injuries. There is however, some overlap between these two things but I'm not gonna be talking about that today. Rather, I'll be talking about this area those types of problems that can stem from someone who's had a physical injury or illness. And typically, that is what we would call adjustment disorder and sometimes we'll see anxiety disorders or a major depressive disorder as secondary psychological injuries. Secondary psychological injury is not a terminology that arises from psychiatry or psychology. It's a notion that comes, I think from sort of legislation. What it really means is as a response to the original direct injury as in this case would be whiplash. And not surprisingly it would be associated with a whole lot of things like think of Hayley's predicament, pain and sundry losses. Loss of function, loss of her role, loss of income and loss of her future to name but a few. You might also be hoping that I'm will we'll talk about resilience and how to build resilience within the workplace and workers and for example, in Hayley's case, does that play a part? But I'm not talking about resilience primarily today. I will of course touch on it but it's not really the topic of this presentation. It's not that it's not relevant it's just that I'm not talking about it primarily today 'cause we're covering secondary psychological injury. So let's start with the conceptual stuff first. I'll get you to ponder the question while I have a quick drink of water. What is a mental health problem at all? So we're talking about secondary psychological problems. What's a mental health problem? Well, everybody will go through periods in life where emotions such as stress, grief, depression anxiety and so on are experienced and that's normal. So it's a bit of an error sometimes for people to be labeled with a psychiatric condition or a secondary psychological injury when it's really a normal reaction. Symptoms of mental illness then might last longer than would be expected or would be normal in the situation of the physical injury. And sometimes they're not simply just a reaction that one can understand empathically, for example to daily events or in this case to the injury. Secondly, when those symptoms become severe enough to interfere with a person's ability to function. So depression of such severity, anxiety of such severity for example, the person's either unable to or is avoiding going to the workplace. Then they might be considered to have a significant psychological or mental illness. This is when we might make a diagnosis, for example. Now you'd probably be familiar with the DSM. So the "DSM-5" currently the "DSM-IV-TR" are the "DSM-IV" and some might even be familiar as I am with the "DSM III" which is a much older document. What the DSM, so it stands for "Diagnostic and Statistical Manual of Mental Disorders". What it tries to do is operationalize descriptions of mental disorder or psychological conditions. I'm gonna use those terms sort of interchangeably throughout my talk today that have been provided by scholars, authors from Europe and the UK also from America. But the DSM is an American construct. And I've tried to do this for very good reasons to get some degree of uniformity and therefore reliability within the field. And they would largely boil it down to a mental health problem or a condition is the clinical features that I was mentioning before that are beyond normal in the circumstances or not and or affecting function in one or other domains of life. Now, what are the domains of life? Well, Sigmund Freud said something like. It was translated from German so we have to take that into account. But he said something like it was about work and love and he probably meant not working for the man. He probably meant being sort of industrious and productive in some way. And with love, he probably didn't mean romantic love. He was probably talking about relationships. So it's about work and relationships. And of course, there is social and recreational activities in there. Now I wanna talk in analogy. You're looking at, I hope if you've come back from getting your coffee your playing with your Shih Tzu as I did this morning what is a water molecule on the top left two hydrogens and an oxygen. And on the right normally I would ask the audience, what's this? But I'll tell you that's an alcohol molecule. I'm showing you this because those two molecules are and can only be what they are, water and alcohol. But they can't be anything else. They can exist in different forms solid, liquid gas and so on but that is really what they are. They don't have any other possibilities. Psychiatric disorders, oh I'm now showing you the periodic table of elements. So anybody who did chemistry at school or maybe later or touched on chemistry would be familiar with this. It's hydrogen, helium, lithium, carbon all of that sort of stuff. All of those can only be what they are. So a carbon atom is a carbon atom. A chlorine atom is a chlorine atom, so on and so forth. One of my colleagues, Eric De Leacy has a lovely phrase and he says, "Psychiatric disorders "are not like the periodic table of elements." Okay and this can create a frustration. So conceptually, it's important to understand that when we make a diagnosis of say, adjustment disorder it may not be that different from a diagnosis of major depressive disorder or indeed, we might see somebody like Hayley who was in that hypothetical motor vehicle accident right at the start of my presentation who has a condition that's got some features of post traumatic stress disorder and some features of adjustment disorder. And some people would say, "Well, this is really PTSD." And some would say, "Well, now it doesn't meet the full criteria for PTSD. "I'm gonna call it adjustment disorder." Those sorts of tensions and difficulties have existed for a long time and they will continue to exist. And I would encourage you to see them as not a very big deal. That is one of the frustrations in this area but there is a way through it to understand that psychiatric conditions are not like the periodic table of elements. Another way to think about and we're still talking conceptually here is that all psychiatric conditions can be understood in A, B, C, D, E and F way where A refers to affect or emotion, B to behavior C to cognitive which really means mindset, beliefs but also has another meaning in psychiatry which is cognitive intellectual. So that is things like level of consciousness attention, concentration, memory visual and spatial awareness and so on. D standing for demographic. And I always like to make the point a number of times distinguish from normality particularly in the case of a secondary psychological injury. E experiential, which could be amplification of pain. For example, in the nonsecondary psychological injury area where a person has say a psychotic illness say it's schizophrenia that would include things like hallucinations. And F functio for function which I've already touched on. You can sort of conceptualize and describe pretty much every psychiatric condition using this sort of template, if you like. Some conditions are more C, cognitive. So for example, some people will be highly anxious about their health just as some people will be highly anxious about let's say, social interaction. We would call that social anxiety disorder in many cases. And in cases where people are anxious about health matters, we might call that health anxiety which is not a diagnosis but nowadays it gets a diagnosis in the "DSM-5" of illness anxiety disorder and other stuff or the other phenomenon follow from that. So the mood and maybe behaviors. If people are very anxious about their health they might go seek a lot of medical opinions and maybe even interventions at times. Now, this is one of I think the most important points to understand about psychiatric conditions. On the left, those squiggly lines are what you might see on an ECG, a heart tracing if someone's having a heart attack, a myocardial infarction. And underneath that is two skin lesions. The one on the left is benign and the one on the right is a malignant melanoma. In contrast to a lot of other areas in medicine in psychiatry, what we're dealing with is syndromes and people not so much organs and diseases like myocardial infarction, melanoma fractured forearm, whiplash, whatever it is. We're dealing with syndromes and people which are not as discrete as I've explained before as some of these other things in physical medicine. I hope you can read that but it says, "A disease can't non-comply but a person can." So this is one of the difficulties I think with dealing with so-called secondary psychological injuries or psychological conditions, psychiatric conditions that have arisen in the context of a physical injury or illness is that if you are treating for example, the fracture the bone doesn't make decisions. The bone doesn't have free will the bone doesn't say, "Well I'm not gonna do that "'cause I've got something else on." And just as the infracting heart muscle which means being starved of oxygen and blood supply basically. Or the developing melanoma doesn't say, "Oh, well, I don't care about that. "I'm still gonna go out in the sun or so what? "I'm still gonna go and keep smoking, right?" People make those decisions. And that's invariably what we're dealing with in the context of psychological injuries. So there's Barry and Barry has had a melanoma and he's had a myocardial infarction and those things do not have any relationship to the influence that Barry's wife might have over him. She's trying to get him to stop drinking and stop smoking and stop yahooing, but he won't. He's out in the sun, he hasn't put his sunscreen on and those people behind him are Barry's two sons with a couple of their mates and they're saying the same thing. Ah, so what? It doesn't matter dad you've got to live your life, et cetera. We're seeing a bit of this stuff played out in very, very large numbers with the coronavirus pandemic but don't get me started on that. I hope you understand my point here. Now this is a slide that I don't really want you to spend a lot of time on today. I just wanted to put it out there to show you on the left axis where you can see it says stress, distress, disorder, okay? You can look at that. It comes from the World Health Organization in your own time. I understand the presentation is gonna be made available but it's important to understand that only a small percentage of the stress and distress out there in the general community whether it's associated with a primary physical injury or not is actually really diagnosable or should really be diagnosed as a disorder, okay? There's a lot of stress. There's a fair bit of distress but not all of it. A minority is really diagnosable as disorder. And usually, we would say that the more something is like a disorder, the more treatment rather than nonspecific interventions are indicated. Now let's start going into what types of things do we see? How are we doing for time? Good, very good. All right, one of the maxims in medicine and in psychiatry is that common things occur commonly. So this is colloquially out there in the community with the saying, if it looks like a duck and it walks like a duck and it quacks like a duck it's a duck, right? What are the common things in mental health that we see? We see anxiety, we see depression, we see alcohol. All of those are associated with poor well-being physical and mental and illness. So in secondary psychological injury these are the things that we would commonly see anxiety, depression, alcohol abuse. I'm hoping now that you're starting to get some ideas about what you might ask about or screen for if you're fortunate enough to be in a position to actually do that with some of your employees or injured workers or the people that you work with. Also, that says sleep disturbance. Sleep disturbance is endemic, right? Throughout the community and highly associated with anxiety, depression and alcohol. And the two commonest presentations to general practice are I'm feeling tired all the time and I can't sleep. So those two things, those two phenomena might offer you a bit of a way in if you're thinking about intervening with your injured workers. These are the things that you could reasonably be at least thinking about or maybe asking about. And stress, whether that comes from an injury a primary injury or an illness or not is of course, highly related with all of these things. Now, I'm hoping that my animation will bring up slowly. I hope you can see it appearing, the word somatization. Somatization basically means the presentation of physical symptoms or concerns about physical health as a manifestation of underlying distress. And we see in community surveys a very large percentage of patients with anxiety and depression also suffering with somatization. And so, these would be the the typical the common sorts of problems. The reason I put the animation on the somatization to come up so slowly is because it appears slowly. It sort of creeps up on people. I saw a man just this week who sustained an injury to his left hand and he required surgery. And all of that's gone very, very well but over time, he has become increasingly concerned. At one point, he thought because he still had symptoms after the surgery and a little lump developed that he had cancer. His concerns were able to be allayed but he still has pain. And his conceptualization of the pain is that pain equals tissue injury, equals tissue damage therefore, one should not do anything that causes pain. That is one version of somatization. But that's crept up very slowly in the context of the injury having been addressed, operated on and basically recovered quite well except with some residual pain but that's a whole other topic. I would say though, a really great way to engage somebody if you're in a position to do so about any of these matters is to ask them about their sleep. I've never met anybody who gets even vaguely offended if you ask them, oh, how are you sleeping, right? It's a great way in. It might be a strategy that you can utilize to begin a conversation around whether or not somebody is experiencing some secondary psychological symptoms and a secondary psychological condition. It could be your starting point. Okay, let's just look at the notion of depression for the moment. Is that really an illness? I mean, everybody feels depressed from time to time. When would we think it was an illness or a condition? Well, let's go back to those principles if it lasts longer and by definition in the sort of learner textbooks and journals and so on we would say, if somebody is persistently depressed for more than two weeks, it's probably a condition. So if it comes and goes, if it's a bit transient if it's not so long, maybe that's just normal variation. So duration and the other thing is impairment. So I'm touching on some points that I've made earlier in the presentation just to reinforce them really to sort of come back to that notion of is this person's symptoms or are this person's symptoms indicative of a psychiatric condition or a psychological condition? And therefore, in the context of a physical injury perhaps a secondary psychological injury. So we look for impairment, we look for duration. Now, what might make a person more likely to develop a secondary psychological injury? Well, in psychiatry and psychology we see, we're trained to see things in a very complex multidimensional and interactive way. Many things funneling all in together to give you a condition a syndrome, a presentation at the time. One of those things would be understood as vulnerability factors. The point here though is that these are not necessarily conditions in and of themselves because everybody has certain sorts of personality for example, vulnerabilities. Sometimes they can be very helpful and sometimes they're not. There is no point having a boundary rider so someone who is protecting the boundary of your property who isn't a little bit suspicious and paranoid, right? There is no point having a lighthouse keeper with the amount of solitude they have to go through being a person who's highly gregarious. Those personality types would struggle but those personality types aren't necessarily conditions in and of themselves but they could be vulnerabilities in particular situations. So some personality types can render some people vulnerable to depressive symptoms in the context of stressful life events. What are the typical stressful life events? Well, the big ones out in the general community losing a job, moving house renovating a house is a big one, divorce, et cetera. I don't need to tell you I think what these are. The most stressful event usually there's a fair bit of agreement is the loss of child. But a physical injury of course, is a stressful event but more so for some people than for others 'cause it might have greater meaning. Some people will manage that quite well. I think usually those people who are more on the optimistic side those people who are sort of more balanced in their attitudes, in their behaviors are gonna do better in the context of stressors versus those who are maybe prone to worry a bit more inclined to blame themselves for misfortune maybe more pessimistic about the future. Just to cite one example. The current American president is a person who's very unlikely to develop a depressive reaction because he never blamed himself for any misfortune and he's not really pessimistic about the future. So that's not to say if he didn't lose the election he wouldn't have a major reaction. He's just not likely to be depressed unless things go very, very badly for him. But a person who's balanced, optimistic takes life in their stride, sees things as challenges rather than unable to be overcome is much more likely to do well in the context of stressors. So if we're talking about adjustment to physical illness you might think that it's sort of linear like this. So on the scale, the Y scale, isn't it? The emotional distress. So further up is more emotional distress and time is on the X scale. You might think that the point of the injury a person's gonna be at their most distressed and then that'll continue for a while. And then things will gradually settle as they adjust to it over time maybe over three to six months. No, it's more like this. So the adjustment process tends to be somewhat up and down, peaks and troughs. And there are points where people will be just as bad some months later as they were sort of shortly afterwards. But then you hope in the longer term either with or without treatment or intervention that things will settle down and people will come to a reasonable adjustment they'll come to terms with whatever it is that has happened. Whiplash, maybe chronic pain, fractured femur whatever it might be, internal injuries, okay? So the point there is to not be too sort of hung up about predicting what the adjustment process might be like and to be prepared to see that it might fluctuate. physical recovery from physical injuries can be like that too. Maybe not so much with the very discrete example of a broken bone which is just likely to knit or mend over a certain period of time depending on the size of the bone and so on. But with a lot of other things there are phases of recovery and so, it is with psychological adjustment. This is a much more complex way of looking at it but this would be something I think that would be very familiar to those in the audience who are trained in psychology or OT or mental health of any sort. If we start the life event at the top in this case of secondary psychological injury we're talking about a physical injury that's obviously a stressor that acts upon the personality features the vulnerabilities, maybe previous experience. The guy I was telling you about before who hurt his left hand he started to develop pain in his shoulder and turns out he's got a tear in one of his tendons in the shoulder but he's experienced with his hand has him worried that he's going to be suffering a chronic course of chronic pain maybe need another operation for his shoulder. And of course people who have had prior psychiatric disturbance all of that, as we work around go past three o'clock coming down towards six o'clock we have the influence as with Barry of interpersonal relationships. Barry, the guy who was in the footy audience before the footie crowd. The influence of interpersonal relationships and social supports all of that contributes down at six o'clock to the notion of coping which is really a conscious effort by the individual to adapt to the situation through positive behaviors and attitudes that sort of help the person adjust. And successful adjustment round at nine o'clock off to the left is what usually happens but there'll be a percentage of people who go on to really struggle and develop what we'd call an adjustment disorder. So they would have depression, anxiety that lasts longer than one would expect that is associated with some sort of impairment. Now, how common is that? Well, I'm actually not aware of any work that's been done in the secondary psychological injury area so much but a lot has been done in hospitalized inpatients and outpatient populations attending GPs and hospital outpatients and so on. And some of this will be very familiar to those of you who've worked in hospitals or general practice and with claimants I suspect. So you'd see anxiety, you'd see depression the prevalence there of four to 16% in medical inpatients is probably an underestimate. So in fact, if you went and screened all of the patients within any of the major public hospitals you might find that even up to 20, 25% will have significant depression symptoms. And that's associated with increased mortality greater symptom burden, so things like pain higher utilization of medical services and allied health and costs and it's associated with decreased quality of life and less function. Also anger and regressive dependency. So those who have done any rehabilitation I suspect the physios and the OTs in the audience would be nodding. You would have seen angry patients you would know what I mean by regressive dependency. So patients becoming a little infantile, I guess and overly dependent on others to do for them rather than doing the rehabilitation for themselves. And this raises questions of theoretical issues like secondary gain. Things like getting attention from caregivers and in some settings, compensation. And then treatment noncompliance which can be a big problem. It gets under everybody's skin. When this happens, particularly in the context of major illnesses or injuries and rehabilitation. And sometimes it's a temporary respite or a rebellion against being vulnerable or really rebellion against a perception of the staff trying to exercise some sort of control. Again, I think this is a little bit of what's going on with the whole COVID debate at the moment where large segments of the population are arguing to just open up because the health stuff is overly controlling. So people have a reaction and of course, we're all entitled to hold our views. But it makes it very difficult if somebody is injured or ill and going along a treatment and rehabilitation pathway with in this context some implications for returning to work. This is the "DSM-IV" diagnostic criteria for adjustment disorder. In case you're wondering I won't go through that is really I hope you would understand what I said before but there it is for you. The point I wanted to make is and this is perhaps for those from work cover especially that sometimes the adjustment disorder diagnosis can still stand if the person has returned to work because their work impairment may have ceased but they might be impaired or struggling in some other way. Social and recreational activity. They might be a nightmare at home going off even maybe physically violent domestically violent towards family, not seeing friends that sort of thing but they're maintaining their tone at work. Just because they're maintaining the tone at work doesn't mean that they're okay. So a diagnosis of adjustment sort of might be maintained even if the person has returned to work. That's entirely separate from whether or not it's needing to be still under the auspices of work cover for management of course. Now, what about in relation to treatment? So one of the very good question and can I say I'm actually having a little look at the questions that are coming through on one of the other monitors here and they're very good questions. They're the sorts of questions that I would be asking even if I don't have answers to them which is an unfortunate reality, I'm sorry to say. But one of the questions was about treatment. So in relation to adjustment disorder unfortunately, there is not a lot of research around but there is some. And so, we really have to sort of follow that. So in clinical practices three approaches to treatment that are worthy of consideration and ideally able to be implemented. And this has as it's underpinning the nature of the stress response. So the first thing is removing or modifying the stressor now that's very difficult if, for example the person has chronic whiplash and chronic pain, okay? But there might be some things that can be done if not to remove it, to modify in the workplace. Secondary, secondarily, I should say. No, secondly, facilitating adaptation to that stressor the chronic pain, for example using various psychological therapies. And I put various psychological therapies because even though cognitive behavior therapy has a big body of evidence behind it for a lot of conditions particularly with respect to anxiety it's not always acceptable to all patients. Some people prefer a more conversational type of approach and really you have to tailor the treatment to the individual. But some sort of psychological therapy to help them get through. In a pain setting, I will often be recommending a multidisciplinary pain approach or even maybe a formalized program because within that a patient or a claimant will get a lot of education about pain, what it means how to manage it and how to cope. Then the next component, there's only three is addressing the symptomatic response to the stressor. So the stressor might be chronic pain with medication or behavioral approaches. And we might also use medication to treat some of the symptomatology, anxiety or depression. Okay, but we've also got to consider, as I mentioned before the natural history. We need to consider the chronicity of the stressor. Not all stressors are just a one-off thing. The motor vehicle accident was a one-off for Hayley that I mentioned right at the start of the talk but the whiplash is not, it's chronic. And over time, some of these initial responses might evolve or morph into another condition. As I mentioned before, major depression, generalized anxiety or something else. Now, this is a model of integrating concepts in depression. I know people will be interested in the notion of vulnerability factors preexisting factors, how can they be modified? And that's up there on the left top in the predisposing factors. The bottom line, just as one example is the meaning of the event. That is the key issue. That's why I put a key next to meaning of events in relation to the stressor or the chronic stressor how that impacts upon the individual's life. So for example, Hayley has some chronic pain from the whiplash. She is a worker who sits at a monitor all day. The meaning of that for her might be that she won't be able to manage that type of work. So that's going to be important. On the other hand if she was in a role that didn't require that or if there was she knew reasonable adjustments made the meaning may be quite different. She might say, "Yeah, I've got a bit of pain "but I know I'm gonna be looked after." So the analogy is that of a key and a lock. So the lock is like all of the predisposing factors and the key is the precipitating factor. If the key fits the lock, you might see a condition. This is how the Black Dog Institute talks about depression in this very complex integrative way. You can read that for yourself. The main reason I put that there was to cue you to the existence of the Black Dog Institute as a resource. There are some wonderful resources for mental health in the workplace and the management of mental health problems from the Black Dog Institute. I know that there is a lot of others the WHS section of the Office of Industrial Relations, for example New South Wales has a similar one. These are all terrific resources but as a psychiatrist I would highly recommend Black Dog Institute. And in fact, when Fiona invited me to give the talk asked for some recommendations about resources. I said, "Yeah, I've got three for you." Number one, Black Dog Institute number two, Black Dog Institute number three, Black Dog Institute. Okay, now this is maybe a bit difficult to see but it is another one of these integrative approaches to looking at what you might think of as a journey for a patient or a claimant or an employee who has had an injury or an illness from symptom development all the way through to ill health retirement looking at different stages. I'm not going to go through that in the interest of time because I know that you'll be able to get access to it yourselves but I wanted to highlight a couple of things. Now, this comes not from the area of secondary psychological injury research but just from sort of sick leave and people being absentees and really with illness but I think it has some relevance. So long-term sick leave is associated with psychiatric disorder. So if someone's been off for a long period of time there's a reasonable chance. It doesn't make the case for it but there's a chance that there's a psychological condition. So if someone's had an injury and they're off for a long time maybe they've developed a secondary psych condition. So is it reasonable, say to screen such employees or claimants? There might be some workplace factors that are relevant here and they are this is reasonably well identified. High job demands with low job control low coworker support, low supervisor support low procedural justice, low relational justice and a high sort of effort reward imbalance. So in other words, I'm putting in a lot of effort and I'm not getting much back. And I think those things are probably relevant in some secondary psychological disorders as well. What about with recovery? A lot of factors have been associated with poorer recovery preinjury health status, age, gender admission status the severity of the injury, the body region psychological comorbidities, pain, so on. But unfortunately, it's poorly understood. There are so many factors that it makes it very hard to make one particular recommendation or even two. Each case needs to be looked at individually. And of course, it depends on the psychological injury. If someone was very, very depressed their treatment approach might necessarily need to be different to somebody who was moderately anxious. From a treatment point of view and I think it has relevance for claimant management staff management, rehabilitation management. This is a key quote from William Osler the grandfather of medicine. "The good physician treats the disease. "The great physician treats the patient who has the disease." So you gotta to take that into account. So the management on the left is well with optimal patient care has contributions from evidence-based medicine that pertains to the specific diagnosis which secondary psychological injury is not, it's a concept an overarching concept. But also the shared decision making between the patient and their treatment providers taking into account all of the stuff that I've got on the right there the biopsychosocial issues, spiritual, cultural issues least restrictive environments, if possible looking at the immediate requirements versus the short and long term. Over time it's increasingly team-based and of course, occurs in the context of legal and administrative frameworks which I would love to chew the fat with audience members at some point about. One of the questions I was mentioning earlier that often comes up in my mind is how reasonable is it for employers to contact their workers when they're off? Because some workers seem to really like it and dislike it when it doesn't happen. And some find it an intrusion and become very paranoid and suspicious about it. And that makes it tough, I think, for managers. I don't know why I put that, I just love the slide. What can you do? Depends on who you are. What's your role? Are you a manager or are you an OT for example working with the organization? What's your relationship with the injured worker? What's your skillset? You probably shouldn't be doing stuff you don't feel comfortable to do. What sort of personality and coping style are you? And individually, there are factors as well. Can you bring something to the endeavor that others may not be able to bring through a skillset? And what might you be able to engage others, what's available? Well there's a bit of a stepwise fashion employee assistance, see your GP phone lines and various websites. Again, I recommend the Black Dog Institute. And then organizationally is it reasonable to say to screen? If people have been off, would you screen them for pain and depression say a month after the injury especially if they've had a long hospitalization? Medically, that's a very reasonable thing to do psychiatrically but I don't know if you're able to do it organizationally. Maybe we can talk about that at some point in some form. That is where I'm gonna finish and take some questions. Thank you for what I presume is your attention.

Remember if you do have a question then put your name and the question into the chat box and we will get to Dr. Gray as soon as we can. We're just setting up our studio for a Q&A session. Quickly, Doctor, while we're waiting to get to the first question, there's a few of them already. Earlier on in your talk you mentioned about personality types. I'm a gregarious sort of character. I love people, I'm trusting and I give people the benefit of the doubt that sort of thing. So should I rescind my job applications for the lighthouse keeper job and for the boundary rider? So they're probably not for me?

They are definitely not for you. That is a good take-home message. Well, I don't know it intimately but I know your career and I reckon you're perfectly placed.

Thank you, I think. Let's go to the questions.


And the first one comes from Kat and she says, "Hi, Curtis. "It would be really interesting to hear your thoughts "on potential secondary psychological injuries "resulting from the Victorian lockdown." And this is a huge prickly issue at the moment. Lockdown versus no lockdown versus isolation does that compound things, so your take on--

Yeah, okay, so, Kat I don't know that you're going to be entirely happy with my answer. I don't know that this is really a secondary psychological injury. We could talk about secondary psychological injuries from people who have contracted COVID-19. That's not quite the same as what you're asking, I think but there is an enormous amount of distress and fatigue really amongst the population where lockdown has occurred. And my primary thought about this is something that I didn't really mention or highlight in the talk but that we have in Australia significant barriers to people engaging with treatment services. And with the very best intentions and the very best efforts of everybody in the whole sort of patient illness journey treatment providers continuum it's still might not be enough at the moment for people to get very prompt treatment and they might not be able to access it. How do you access treatment during lockdown? There's a whole lot of problems associated with sort of telemedicine rather than face-to-face. You can't do a physical examination, for example and there's problems with providing treatment and treatment services are becoming somewhat overloaded as well and stretched. And so, people's access to treatment. It was on the news today that there was some sort of disagreement about the government's extra funding for mental health services. How should that be organized? Where should it be? And one of the professors was saying what we really need is greater access rather than just more sessions at psychologists because people can't even get in in the first place.

Okay, hope that helps, Kat. Here's a question from Anna and we thank her for joining us this morning. Is there a recommendation for adjustment to injury counseling as standard even at some kind of threshold in a client?

Yeah, terrific question, Anna. Look, I don't know whether there's a recommendation and if there was I don't know where that would come from. From a clinical perspective you probably or you may or may not be aware that years ago when there was a traumatic event there was a form of intervention called Critical Incident Stress Debriefing. And so, everybody was involved in the event let's say an explosion or a fire or something terrible. Everybody would be brought together and there'd be this type of thing sort of a debrief and so on. Well, it turned out that the results were poorer when that was done. And we think that probably that's because some people don't need it and they find it intrusive and most people are in fact resilient. So I think the answer is probably not but a better approach is for ideally, injured worker and employer or treatment providers rehabilitation team to be aware of the potential signs so that early intervention can occur if required.

Next question's Curtis comes from... Well, this'll be a tricky one so you have to be on your best behavior for this one from the Psychological Health Unit, right? At WHSQ, so okay, Curt, can you provide an example of an organization which has used a best practice approach to a return to work following a psychological injury?

I can think of a few that have not but there's one that comes to mind. So I won't provide a lot of details about the case but I'm actually very happy to name the organization. And it was Department of Education, Gold Coast region. Great work if anybody is from the Department in that region with my patients. I'm in the role of treatment provider. That person was firstly, dealt with just immaculately. The language that was used by the employer, her boss and those involved in the rehabilitation process including QSuper, great work by QSuper was fantastic because she never felt stigmatized she never felt devalued or invalidated in any way. And that meant that she trusted the people that she was ultimately having to work with to affect things like reasonable adjustments in the workplace. She was able to be exempted from some duties which were particularly stressful and difficult for her. And I would say supported to work up to two days a week all at the same time as we were trying to help her gradually develop her resilience and her stress management so that those things could actually be increased. So yeah, at a number of levels it was done really, really well. It started with engagement and having the injured worker experience a strong sense of trust and support in the workplace.

Now viewers is Tracy at QPS police link. Who's joined us, right? And Tracy asks, can you recover completely from adjustment disorder or do the symptoms just reduce to a more manageable place?

Yeah, again, a very, very good question, Tracy. I mean the short answer is, yes people often recover completely from adjustment disorder particularly in the context of a single discrete stressor that then never recurs or is not chronic. So if somebody has an injury, physical injury and they recover very well from it and they get on yeah, we would probably expect, recovery full recovery. And that's not to say that they wouldn't from time to time be a bit bothered or a bit upset about the injury or whatever the stressor was. That would be normal and understandable but the duration of symptoms the severity of symptoms and the associated impairment in those different domains of functioning would settle and would basically sort of go away. When there's a chronic stressor it's a bit more difficult because the person is carrying that along with them all the time.

Sarah, thank you for joining us this morning. A question from Sarah, for you, Curt. As an employer how do we better support injured workers to recover from their physical injury and reduce the risk of secondary mental injury?

So this is a really a very big question and sort of warrants some unpacking I guess, Sarah. Again, a very, very good question but I'm probably not the right person to answer the question about the recovery from the physical injury 'cause that would depend on the nature of the physical injury. Is it a broken femur versus a whiplash versus some sort of penetrating lung injury, for example? Will require very different things. But from a psychological perspective I think some of the things that I touched on with the previous answer are really important. It's about trying to get engagement with your injured worker and having them as part of the process and seeing you as part of the process in their recovery but in the right place. Not taking the place of treatment provider, supporting them not invalidating their difficulties or their symptoms or their struggles. And if possible of course, facilitating alternative reasonable adjustments in the workplace.

Yana joined us. And Yana has a question for your doc. Is there a place for reinforcing normal and is some degree of psychological adjustment part of the normal response to an injury or illness?

So I'll answer the second question first, Yana. Yes, that's where I think it's important to have some good ideas around what is a normal reaction because it's obviously not a good thing to be sort of labeling somebody as suffering a psychological or psychiatric condition when it's normal. Just as it's not so good to be missing the sort of signs and the triggers for the possibility of a psychological condition. The first question, can we have the first question from Yana back again, please guys? We've just lost it on the screen is there a place for reinforcing normal? Well, I think the answer is yes but it very much depends on how it's done because if you're a boss or a coworker who or a line manager or something who is not or even someone who's contracted from outside to see the person, who's not trusted and the person's struggling and you sort of take an unempathic approach and tell them, well, it's just normal, get on with it which I have seen happen. That can be very unhelpful. On the other hand, if you're a trusted coworker boss, therapist, whatever a lot of people will find it hugely relieving to be told that you know what you're going through this is normal in the circumstances, it's okay. It doesn't mean that you're suffering a psychological conditional or going crazy.

We do have one final question to bring us home and it comes from Lenny. How do we engage with and encourage GPs to be more proactive in referring for early intervention to reduce the risk of secondary mental injury e.g. early referral for adjustment to injury counseling, et cetera?

Right, that gold medal question, Lenny. Well, it's very difficult. I think the question is more about sort of engaging with GPs through a process of increasing awareness. So I think it's a collaborative effort by all of us in the field to try to raise that awareness amongst GPs of the possibility of secondary psychological injury and what they might be able to do. I'm reasonably positive about screening but if you were say a case manager I dunno who you work with Lenny but if you are a case manager and you were sort of picking up some signs or indications that maybe there's a secondary psychological injury happening it wouldn't be unreasonable to just make a call to the GP and raise your concerns. I think most GPs would be aware of that. They're very time poor. So it'd have to be very quick and targeted though.

Thanks for all your questions today. Thanks for joining us today. Doc, just one final quick take-home message to leave our viewers with.

Be on the lookout. Yeah, it's about awareness, I think, Chris secondary psychological difficulties are reasonably common. If your awareness is better you're much better placed to be able to intervene appropriately.

Yeah, from a workplace, health and safety perspective let's have some key messages that we'd like our viewers to well, firstly, deliver to them and then obviously, there are some tips as well. One in six Australian workers experience mental health in any year and mental illness is now the number one reason for sickness, absence and long-term incapacity. Mental health problems are costly. And let me just say that absenteeism and low performance due to mismanaged mental health conditions cost Australian businesses up to $12 billion annually. And of course, one in six Australian workers experience mental health in any given year. And with the workplace being a site where workers spend up to 1/3 of their waking weekday hours there is an opportunity to provide crucial support for intervention or interventions. Secondary psychological injuries are primarily related to adjustment e.g. loss, change and pain and are associated with emotional changes such as depression and anxiety coping styles and psychological makeup and available supports and treatments if necessary. Adjustment responses are often not linear and we should beware of the following workplace role factors. High job demands, low job control, low coworker support low supervisor support. And you touched on all of these, Curtis. Low procedural justice, lower relational justice and high effort reward imbalance. Have I got that, right?

Got it, yep.

[Chris] Thanks very much for joining us today.

My pleasure.

And the good news is for people who may have missed something during your presentation or would like to go back and perhaps review something that you said we will have that presentation online very, very shortly.


As I said earlier we are halfway through Safe Work Month 2020 but there are still plenty of events to enjoy including a session on intelligence enabled work, health and safety and a chat with ex Olympian, Hayley Lewis. If you haven't already done so just pop onto our website and register for a presentation which interests you. You can also access heaps of free resources from Included in those resources are industry and topic-specific video case studies podcasts, speaker recordings and webinars and films to help you improve your WHS and return to work outcomes. And Dr. Curtis Gray's session will be up there very, very soon. If you wanna go back and check up on this morning's presentation we will be sharing that online as I said, in the coming days. Thanks for tuning in today and supporting Safe Work Month and Mental Health Week. Remember work safe, home safe.