What Can We Do to Close the Gap Between Outcomes in Comp and Non-comp Injuries?

In my April 4 article, I listed some explanations the Workers’ Compensation Research Institute (WCRI) offered as to why outcomes after work injuries are inferior compared to outcomes for the same types of injuries in the non-comp medical arena.

The WCRI listed injured employees’ poor expectations for recovery, perceived injustice, job dissatisfaction, and lack of family and community support systems as factors that could negatively affect case duration.

I also offered the hypothesis that work injuries disrupted injured employees’ lives and created additional stress. In turn, this puts those individuals into the “fight, flight or freeze” state of the autonomic nervous system. The hormones released in these states are not conducive to optimal healing.

So if an injured employee does not have the resilience to move back up the autonomic ladder to the parasympathetic state governed by the ventral vagus nerve (where the physiology of healing is optimized), healing does not progress as smoothly or quickly.

Instead, muscles stay tight, sleep is disturbed, inflammation persists and the injured employee continues to feel distress. Moreover, if the injured employee experiences or perceives the workers’ compensation system itself as adversarial, this could also keep that individual in “fight, flight or freeze.”

There is a segment of patients with relatively simple injuries who take longer (sometimes much longer) to heal than anticipated. In the workers’ compensation arena, some stakeholders refer to these patients as “the difficult 10%.”

I believe that if we were to look closely, we’d find that many (perhaps even most) of the cases that frustrate everyone involved — from the patient and treating clinician to the employer and adjuster — are ones in which injured employees are stuck and can’t climb up the autonomic ladder.

Their brains interpret their situations as being threatening or dangerous, and they do not know how to move past dysfunctional beliefs and emotions to reach the place where healing can proceed apace — where mind and body are coherently connected.

I ended the post by promising to offer suggestions for simple, specific ways all stakeholders in the WC arena could facilitate a return to “normal life” for injured employees by helping them move back up the autonomic ladder into the parasympathetic state.

I planned to send you the top three to five ways to do this because I love lists. But after writing more than 800 words, I threw my list away and distilled this down to its essence:

The most effective way to assist injured employees to move into a state conducive to healing is to provide cues of safety.

As Dr. Bessel van der Kolk states in his New York Times bestselling book, The Body Keeps the Score, “Being validated by feeling heard and seen is a precondition for feeling safe.”

Based on my professional experience, after the initial anxiety, pain and uncertainty associated with work injuries, injured employees can start moving back up the autonomic ladder if they feel seen and heard.

This doesn’t mean that you have to agree with everything injured employees say. It does mean respecting their right to feel what they feel. As we have learned from the neurosciences, trauma is not just an event that took place sometime in the past. It’s also the imprint that the experience left on the person’s mind, brain and body.

To heal, the body needs to learn that the danger has passed. It’s the injured employees who continue to perceive threat and danger in their environment who fail to improve as anticipated after a work injury. To return to proper functioning, a persistent emergency response must end. The body needs to be restored to a baseline state of safety and relaxation.

3 Cues of Safety Every Stakeholder Can Offer

1. Positive Body Language

Since 80 to 90% of human communication occurs in the nonverbal realm, when you’re meeting with an injured employee in person, an important cue of safety comes from positive body language. Author Scott McLean explains in his book The Basics of Interpersonal Communication that there are nonverbal behaviors you can exhibit to communicate a sense of safety. An acronym often used to help remember these behaviors is SOFTEN:

• Smiling can put the individual at ease and generate positive feelings.
• Open posture indicates approachability and a willingness to interact. Crossing arms, legs or hands can send the message that you are not open to hearing about a person’s problem.
• Leaning forward slightly, whether standing or sitting, indicates you want to hear what the person has to say. For our physiology to calm down, we need a visceral feeling of safety, and sensing we are truly heard and seen is critical for that to happen.
• Tone of voice is an important cue of safety. Our nervous system is primed to listen to the intonation and intensity of someone’s voice to detect whether it’s safe to approach that person. The polyvagal theory, developed by Stephen Porges, PhD, found that sound patterns of the voice (i.e., variation in pitch, loudness and duration) are cues to down-regulate defensiveness and are important in social bonding.
• Eye contact conveys that you are paying attention. Avoid gazing directly into the pupils as that can seem too probing. Gaze within a four-inch orbit of the eyes, and ideally maintain eye contact for 85% of the encounter.
• Nodding occasionally shows attentiveness to and understanding of what is being told. That encourages injured employees to move forward with their story, rather than repeating points because of uncertainty as to whether or not you are listening.

2. Offering Your Full Attention

The processing capacity of the conscious mind is estimated to be 120 bits of information per second. To understand just one person speaking to us, we need to process 60 bits of information per second. This means that multitasking while on the phone with an injured employee — reading emails, thinking about our to-do lists, even planning what to have for dinner — can interfere with accurate processing of information and lead to misunderstanding. When we’re speaking in person to injured employees, they can sense when our attention drifts. Focusing our minds on what they are saying while offering the body language cues listed above is important to creating a feeling of safety.

3. Communicating in a Style Based on Empathy

A communication style based on empathy first elicits the injured employee’s thoughts about the situation, only then offering information that particular individual needs. So when talking to injured employees, adopting a methodology that is a dialogue — rather than a lecture or a command — is useful in helping individuals who are initially wary, mistrustful, stressed, suspicious, angry, anxious or feeling like “victims” to move up the autonomic ladder.

• • ASK: Interviewers should first seek to understand what an injured employee feels or sees as a threat (such as not being able to pay bills while on modified duty, not getting all the care needed, not recovering sufficiently to ever return to regular activity etc.) and ask the individual to tell them what the problem means in that person’s own words.
  • LISTEN: Listening helps the interviewer to understand how the injured employee is making sense of their situation and to identify gaps in that person’s understanding. The interviewer should reflect back the injured employee’s understanding in a nonjudgmental manner, without making the person feel unintelligent and without shaming or blaming.
  • INFORM: With the injured employee’s permission, the interviewer can provide new (accurate) information that directly addresses the person’s sense-making and reasoning. What’s key is that instead of telling the injured employee what to do without first knowing what that person thinks or believes, the interviewer proceeds with respect and concern from a place of understanding. This makes it much more likely that the employee will accept the information provided and act on it.

Based on my observations, it’s very tempting when busy to skip to “Inform” without first listening and understanding the injured employee’s sense-making. However, in the long run — especially when dealing with injured employees who have a dysfunctional way of thinking about their situation and/or negative emotions fueling their experience of pain — it saves time and energy to follow this sequence.

In the book Motivational Interviewing in Health Care: Helping Patients Change Behavior, the authors wrote: “When it comes to dealing with life’s problems, the answers we believe and act upon are often not the ones we are given or told — but the ones that truly make sense to us — the ones at which we arrive ourselves.”

Remember, anger is born of powerlessness. Foisting information on people that they are unwilling to hear creates resistance and can feed the anger that many injured employees already feel. This in turn becomes a barrier to smooth recovery. As a physician, I’ve learned that the hard way.

After 43 years in medical practice and 32 years in the WC space, I think that we could avoid many (if not most) of the cases with delayed recovery that we label “difficult” if we all acted from an understanding of what patients and injured employees believed, offered more useful information if those beliefs were inaccurate or unhelpful and guided them on the best ways to return to normal after a work injury without making them feel judged or unfavorably compared to others who got better faster. I believe that focusing more on compassionate human interactions rather than high-tech interventions would be beneficial to everyone in the WC space.

To quote Van der Kolk again: “Feeling listened to and understood changes our physiology; being able to articulate a complex feeling, and having our feelings recognized, lights up our limbic brain … In contrast, being met by silence and incomprehension kills the spirit.” &