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Treatment Principles for the Provision of Psychological and Counselling Services

PURPOSE

This document aims to facilitate a shared understanding of the delivery of psychological and counselling services under the NSW WorkCover and Motor Accidents Compensation schemes.

People who sustain work or motor vehicle related accidents may experience a range of psychological effects that reduce their capacity to recover and return to pre-injury activities. The types and frequency of interventions to address these issues vary considerably from one person to another. What is ‘reasonable and necessary’ or ‘reasonably necessary’ funding will depend on the nature of the disability experienced and the injured person’s circumstances.

These Principles have been developed to:

  • promote return to usual lifestyle activities and return to work outcomes
  • inform treating practitioners of the expectations of the MAA and WorkCover NSW for the management of injured persons
  • provide treating practitioners and insurers/agents with guiding principles for the provision of psychological and counselling services to injured persons
  • ensure that psychological and counselling services are goal oriented, evidence based and clinically justified
  • inform decisions about ‘reasonable and necessary’ or ‘reasonably necessary’ funding of services and assist in the prevention and resolution of disputes.

PRINCIPLES

This document contains a set of principles for the provision of psychological and counselling treatment to injured persons:

  1. Measurable treatment effectiveness is demonstrated.
  2. Treatment goals relate to improving function and resuming usual activity, including return to work.
  3. A biopsychosocial approach is essential for the management and treatment of persistent pain and psychological injuries.
  4. Treatment focuses on self management by the injured person.
  5. Treatment is based on the best evidence available.

PRINCIPLE 1

MEASURABLE TREATMENT EFFECTIVENESS IS DEMONSTRATED

Key messages

  1. Treatment effectiveness is demonstrated through the achievement of functional goals.
  2. Best practice includes the use of functional and standardised outcome measures to demonstrate progress toward, and achievement of, agreed functional goals.
  3. Functional outcome measures are:
    1. specific
    2. behavioural
    3. appropriate to the injured person’s condition
    4. related to the goals of treatment
    5. related to the impact of environmental and personal factors on recovery.
  4. Standardised outcome measures are:
    1. reliable
    2. valid, normed and responsive to change
    3. appropriate to the injured person’s condition
    4. related to the goals of treatment
    5. sensitive to the impact of environmental and personal factors on recovery.

A treatment outcome is an improvement in the functional status of an injured person as a result of psychological intervention. Outcome measures are relevant psychological indicators used to assess the presence of unhelpful beliefs or cognitions, problem behaviours and activity limitations. Regular use of outcome measures to monitor progress informs and provides justification for treatment decisions. These can include continuing, changing or ceasing treatment or referring the injured person to another treatment practitioner.

Assessment and review of psychological functioning should include measurable indicators of the injured person’s functioning and not rely on symptom reports alone (eg using questionnaires to screen psychological symptoms). It is preferable to measure outcomes in regard to activity participation.

When to measure

Outcome measurements need to be used regularly to review progress. Baseline measurements should be taken as early as possible. Reassessment should occur as soon as change could be reasonably expected, given the injured person’s condition and the type of treatment provided. Reassessment is generally required every four to six sessions; however, treatment frequency, access to services (eg in rural areas) and cancellations should be considered in determining appropriate reassessment timeframes.

Functional (non-standardised) outcome measures

Demonstration of progress toward agreed goals and recovery is most effectively indicated via the measurement of functional outcomes. This includes progress toward returning to normal activities which may include work, driving, transportation, sleep patterns, social and recreational activities, shopping and domestic responsibilities.

Functional outcomes may be identified through a behavioural assessment, and involve the development of behaviour-specific and situation-specific measures aimed at targeting unhelpful behaviours.

Standardised outcome measures

Standardised outcome measures are rigorously developed questionnaires applied in a prescribed manner, for which reliability, validity and responsiveness are known. Using standardised outcome measures is a robust method of measuring an injured person’s status. Test selection must be appropriate to the problem and provide information pertinent to functional and return to work outcomes.

Examples of commonly used standardised outcome measures include:

  • Beck Depression Inventory (BDI–11)
  • Beck Anxiety Inventory (BAI)
  • Depression, Anxiety, Stress Scale (DASS)
  • Symptom Checklist (SCL9OR).

Scales for identifying key risk factors for problems with persisting pain (eg measures of catastrophising, fear-avoidance beliefs, self-efficacy), as well as disability and pain measures (eg Multidimensional Pain Inventory), should be considered.

Application and interpretation of standardised measures requires awareness of and sensitivity to:

  • response bias
  • mood determining responses
  • motivation issues
  • malingering
  • appropriateness of norms.

PRINCIPLE 2

TREATMENT GOALS RELATE TO IMPROVING FUNCTION AND RESUMING USUAL ACTIVITY, INCLUDING RETURN TO WORK

Key messages

  1. Goals are functional and SMART – Specific, Measurable, Achievable, Relevant and Timed.
  2. Progress toward goal achievement is regularly assessed and recorded.
  3. When an injured person is not progressing as expected, the treating practitioner is responsible for implementing an alternative treatment plan.

Focus of treatment

Psychological and counselling services should:

  • improve the injured person’s capacity to return to usual activities
  • incorporate collaborative goal setting, education, pacing and positive reinforcement
  • promote self management skills, such as active problem solving and strategies, to deal with relapses, which will minimise dependence on treatment providers.

Treating practitioners should consider all the contributing risk factors when forming treatment plans. The effectiveness of treatment should be regularly assessed and progress toward goal achievement recorded. Treatment goals should be modified if circumstances change or significant barriers to returning to usual activities are identified. When functional improvement is slow or absent, the cause/s should be identified and, where appropriate, expectations in relation to recovery should be adjusted. It may be appropriate to recommend the injured person be referred to another healthcare practitioner.

Role of the treating practitioner

Treating practitioners should explain their role to the injured person at the initial appointment. This includes assessment, goal setting, collaborating with other health professionals involved and helping the injured person to achieve treatment goals. Treating practitioners should also explain the injured person’s role and responsibility in the treatment process. Treatment should focus on the injuries sustained in the accident or work incident. Treating practitioners should actively support an integrated and collaborative approach which promotes effective communication and common goals between key parties. Treating practitioners must ensure that their practices are in adherence with the requirement of the Code of Conduct and/or legislation of their relevant board or association.

It is not the treating practitioner’s role to make referrals or coordinate the injured person’s return to work, advocate for the injured person in relation to the management of their claim or coach them through litigation or other compensation processes.

Goal Setting

Goals focusing on measurable improvement in return to usual activities should be developed in collaboration with the injured person at the beginning of treatment. Goals should be SMART.

S

SPECIFIC

Names the particular variable of interest (eg “social outings with friends”, “hours at work on modified duties”, “time management”)

M

MEASURABLE

Has a measurement unit (hours, 0 to 10 scale)

A

ACHIEVABLE

Is likely to be achieved, given the diagnosis and prognosis for the person’s injury and environmental constraints

R

RELEVANT

Is relevant or important to the injured person and other stakeholders

T

TIMED

States a timeframe within which the goal is expected to be achieved

Examples of poorly constructed treatment goals:
Examples of SMART goals:

To improve driving confidence

To be able to drive between home and work (15 kms) within three weeks

To reduce anxiety

Successfully manage stressful work situations with manager during the next week by practicing healthy assertion, using helpful self-talk and diarising the outcomes

To increase social interaction

Visit or telephone a friend twice in the next week

To return to work

Return to modified work duties for three hours per day, five days per week within three weeks

Treatment limitations

In some cases, the likelihood of returning to pre-injury functional capacity is diminished. It is particularly important in this situation that psychological treatment still focuses on improvement in functional ability, is goal oriented and clinically justified. Where little or no progress is being made, ongoing passive treatment should be avoided. Such treatment may reinforce illness behaviour, lead to possible treatment dependency and reinforce psychological distress and problems with persistent pain.

PRINCIPLE 3

A BIOPSYCHOSOCIAL APPROACH IS ESSENTIAL FOR THE MANAGEMENT AND TREATMENT OF PERSISTENT PAIN AND PSYCHOLOGICAL INJURIES

Key messages

  1. A biopsychosocial approach maximises recovery and minimises the impact of persistent pain and/or ongoing psychological injury.
  2. Psychosocial and biological factors that influence the injured person’s experience of pain, disability and psychological distress are assessed and managed by treating practitioners.
  3. Early identification of the barriers to recovery, particularly psychosocial risk factors, helps determine the most effective treatment approach.
  4. Treatment planning includes identifying, considering and addressing any environmental factors (personal and workplace) impeding the injured person’s recovery.

By definition, the biopsychosocial approach includes management of the multiple factors that can affect function and return to work. The International Classification of Function (World Health Organisation 2001) encompasses a biopsychosocial approach and classifies these factors as:

  • Bio – Body structures and function
  • Psycho – Personal and environmental factors
  • Social – Activity, participation and environment

According to this approach, abnormality results from the interaction of genetic, biological, developmental, emotional, behavioural, cognitive, social, cultural, and societal influences.

Maximising recovery of function and/or return to work

Current evidence indicates that the biopsychosocial approach to psychological injury management is most effective in improving function and facilitating recovery. Accordingly, treating practitioners should:

  • accurately determine the injured person’s psychosocial risk factors for disability
  • set clear, specific and functional goals related to resuming normal activity, including work, as early as possible, even if pain is persisting
  • encourage appropriate expectations

Collaboration with key parties such as doctors, insurers, employers and other service providers is essential from the outset to ensure agreement on treatment goals. It is also crucial to select a management approach specific to the individual injured person’s risk factors.

Flags Model

The “flags model” is a well documented framework for identifying factors that impede recovery and prolong the likelihood of disability1. The model, summarised in Table 1, can be used to identify barriers and guide decision-making if an injured person fails to progress as expected.

Table 1: The Flags Model

Factor
Barrier (Flag)
Examples

Biological
(Body structures and function)

Red Flags

Serious pathology Co-morbidity

Psychological

Orange Flags

Clinical depression PTSD
Psychiatric illness Personality disorder (eg antisocial) Forensic setting

Psychosocial (Personal and environmental)

Yellow Flags

Unhelpful coping strategies (eg excessive resting, activity avoidance) Emotional distress

Anger disguised as anxiety or depression
Passive role in recovery Expectation of delayed RTW Overly solicitous or unsupportive carers

Social
(Activity, participation and environment)

Blue Flags

Low social support (at work, amongst family, friends or community)
Perceived unpleasant work Low job satisfaction Perception of excessive demands

Performance management Perceptions of discrimination, harassment or bullying

Social isolation

Environmental (Systemic)

Black Flags

Threats to financial security Legislative criteria for compensation
Financial disincentives Nature of workplace

(eg heavy)

Overcoming barriers to improved function and return to work

To ensure “flags” or barriers are addressed in the shortest timeframe, there are several questions the treating practitioner should ask themselves and the injured person:

  • Which barriers are preventing the injured person from returning to function and/or work today?
  • Are the identified barriers being addressed specifically to facilitate:
    • return to work – has a plan for suitable, modified or alternate duties been developed, supported and communicated?
    • return to usual activities – has a plan been developed to assist with return to usual activities?
  • Is the treatment being provided improving the injured person’s psychological health, function and/or return to work as expected?
  • Would another form of evidence based treatment improve the injured person’s rate of recovery?

The following management strategies may also be of use:

  • educating the injured person about their responsibilities in the recovery process (eg compliance with their treatment program or offer of suitable duties to return to work)
  • informing the injured person of the treating practitioner’s obligations when treating compensable persons (eg ensuring treatment adheres to “best evidence” recommendations and “reasonably necessary” or “reasonable and necessary” requirements)
  • liaising with the key stakeholders to facilitate return to work
  • liaising with other treatment providers (eg physiotherapist, general practitioner)
  • recommending, when indicated, that the injured person’s general practitioner refer them to a psychiatrist or other service provider with particular expertise.

If the necessary supports for return to work are not in place, the treating practitioner should consult with the case manager and recommend that these be provided. Direct liaison with the insurer case manager and return to work coordinator (for WorkCover cases) may be required.

Ongoing psychological problems

Chronic psychological problems can result from the interaction of many factors including pre-existing problems, compensation issues or concurrent emotional problems not related to the compensable injury (such as death of a close relation, marital and family problems or work related issues). As far as possible, treating practitioners should separate these unrelated psychological issues. Such factors should be identified and addressed at initial assessment or as early as possible to ensure that treatment focuses on the compensable injury.

In some cases, treatment goals will not be achieved unless these unrelated factors are recognised and addressed separately (eg through an intervention that is not related to the compensable injury). Suggesting an independent psychological assessment may help the identification and management of such factors. Treating practitioners should focus primarily on the assessment and treatment of the compensable injury.

Persistent pain

Pain lasting longer than three months can be referred to as persistent or chronic pain, and is usually the result of a complex relationship between physical and psychosocial factors. Personality traits, mental health issues, counterproductive beliefs and past experience can affect and reinforce the pain experience.

A biopsychosocial approach is essential to achieving successful treatment outcomes for this group. The injured person’s individual response to, and understanding of, pain needs to be actively managed and developing a schedule of appropriate activity may be useful rather than harmful.

Strategies for overcoming persistent pain include:

  • encouraging the injured person to “act as normal”
  • setting appropriate expectations regarding changes in pain and function
  • challenging counter-productive beliefs about the injury, the appropriateness of different treatment types and the importance of return to work and normal activity
  • reinforcing wellness behaviours and promoting self management strategies
  • setting an end point for treatment
  • referring the injured person to another treating practitioner if treatment is not resulting in functional improvement.

It is not reasonable for treatment to continue indefinitely (see “Planning for self management and independence from treatment”, Principle 4, page 14).

PRINCIPLE 4

TREATMENT FOCUSES ON SELF MANAGEMENT BY THE INJURED PERSON

Key messages

  1. Empowering the injured person is a key treatment strategy and is incorporated in all phases of injury management.
  2. The injured person is empowered when they:
    1. are educated about the nature of their problem, appropriate management strategies and their prognosis
    2. have appropriate and effective self management strategies
    3. manage their condition as independently as possible.
  3. Treatment of an injured person with pain and/or psychological injury is based on education and focused on function, return to work and promotion of self management.
  4. An injured person with ongoing psychological injury and/or persistent pain is educated about relapses and provided with strategies to manage these episodes.

Actively involving the injured person in their treatment is an important component of effective rehabilitation. Education and developing self management strategies are the keys to empowerment.

Education

Education and early expectation setting are crucial to ensuring the injured person can play an active role in their recovery. An injured person may develop counter productive beliefs that lead to entrenched feelings of distress and illness behaviours. Education helps them understand their injury and its management, make choices, overcome restrictive beliefs and modify their behaviour, leading to improved functional outcomes.

Topics that treating practitioners should address when educating the injured person include:

  • the respective roles of the injured person and treating practitioner
  • the nature of the condition, expected recovery timeframes, treatment goals (short and long term) and timeframes to achieve these goals
  • the benefits of active treatment and self management strategies
  • the importance of improving function through return to usual activities.

Influencing beliefs about recovery

Restrictive beliefs can be a major obstacle to an injured person’s ability to return to functional activities and work. These beliefs may include:

  • fear-avoidance
  • catastrophising
  • lack of acceptance
  • low self-efficacy
  • blame
  • perception of injustice.

The following strategies may be useful in influencing restrictive beliefs:

  • improving awareness of the beliefs and their negative impact
  • reviewing and testing their accuracy
  • generating alternative beliefs that are open to change
  • reinforcing and practising alternative beliefs in everyday settings
  • providing written materials to enhance the intervention.

The impact of personality

Sometimes it may be the case that significant personality factors are hindering treatment. Considering personality factors in the design of treatment strategies and management plans can help to reduce the risk of long term disability in individual cases. However, it must be remembered that before injury, the injured person had the same personality and was functioning without compensation support. Personality factors therefore, should not become the focus of treatment. If clarification of factors impeding recovery is needed, consider referral for independent assessment.

For assessment of personality factors, administration of a reliable and valid personality test is recommended, such as the Minnesota Multiphasic Personality Inventory Second Edition (MMPI–2) and the Personality Assessment Inventory Revised (PAI–R).

Self management strategies

Self management strategies are essential when dealing with persistent psychological issues and pain. The injured person should be encouraged to take control of their rehabilitation and drive the management of their recovery, using active strategies to control their symptoms and learning to function despite their symptoms.

Examples of individually tailored strategies include (not exclusive):

  • goal setting
  • activity scheduling
  • psychoeducation
  • observing, monitoring and challenging unhelpful beliefs
  • exposure based approaches to feared and/or avoided situations through homework activities
  • problem solving
  • relaxation techniques
  • a regular exercise program
  • managing medication usage
  • establishing a healthy and consistent sleeping routine
  • pacing strategies to minimise risk of relapse
  • learning acceptance of their injury and disability.

Planning for self management and independence from treatment

The key measure of treatment effectiveness is the ability of the injured person to independently manage their condition and resume usual activities. Independence does not mean being symptom free, but rather living a functional and productive life while self-managing symptoms if they arise.

By following a biopsychosocial approach and the principle of empowerment, most injured persons should become independent of treating practitioners. Planning and preparation for discharge should begin at assessment (eg the treating practitioner and the injured person may agree on a set number of treatments and a plan for gradually reducing their frequency over a defined period of time). This creates an expectation that, as the injured person becomes more independent, so will their reliance on treatment reduce.

Relapses

Relapses are inevitable with ongoing psychological injury and persistent pain, often occurring during times of increased activity or stress. Treating practitioners need to educate injured persons to expect relapses and understand the reasons why these may occur. They should provide injured persons with strategies to manage these episodes while continuing with their active rehabilitation.

Useful strategies for relapses include:

  • cognitive challenging techniques (including problem solving)
  • awareness of stress triggers and early application of coping strategies to avoid escalation of stress
  • reminders to check for unhelpful thinking patterns (eg catastrophising)
  • modification of daily activities with limited use of rest
  • written plans for implementing self management steps for relapses
  • communication with significant others such as family, co-workers, employers and medical practitioners, about their role in helping the injured person to manage relapses
  • applied relaxation
  • physical exercise
  • a review of activity pacing and goal setting is useful if the relapse persists.

A relapse can appear to be a deterioration of a previous injury. In some cases, a relapse may mask issues that are not related to the compensable injury such as stressful life events or underlying problems. Psychological treatment should identify the trigger/s for the relapse and focus primarily on the compensable injury. Treating practitioners should aim to identify and, as far as possible, separate psychological issues that are not directly related to the compensable injury.

PRINCIPLE 5

TREATMENT IS BASED ON THE BEST EVIDENCE AVAILABLE

Key messages

  1. Treating practitioners use the best evidence available to inform their treatment decision making.
  2. Systematic reviews, (evidence based) clinical practice guidelines and critically appraised papers provide the most comprehensive and objective source of research evidence.

Extensive research literature exists on the efficacy of various treatment modalities and clinical decision making must be directed by this evidence. Evidence based practice:

  • offers treatment that has the best chance of success
  • avoids treatment that is likely to be ineffective
  • increases the likelihood that psychological treatment complements and assists other evidence based medical and physical treatments that injured people are likely to access.

Treating practitioners need to integrate the “best research evidence with clinical expertise and patient values”2. Integrating these three components (evidence for treatment, expert opinion and injured person’s characteristics such as needs, preferences, culture and socio-economic position) enhances the delivery of evidence based treatments.

Where is the best evidence available?

The most accessible source of research evidence is “pre-appraised” evidence such as systematic reviews, clinical practice guidelines and critically appraised papers and topics. Examples include:

  1. The Cochrane Library <http://www.cochranelibrary.com> is a free website that includes systematic reviews of research evidence.
  2. Australian Psychological Society (APS) evidence based guidelines can be accessed by APS members at <http://www.psychology.org.au/>, click on “Members Resources”, then “Psychology Interventions”.
  3. The National Health and Medical Research Council (NHMRC) presents evidence based management of acute musculoskeletal pain at <http://nhmrc.gov.au/publications/ synopses/cp94syn.htm>.
  4. Specific health related journals such as Clinical Psychology Review, Journal of Occupational Rehabilitation, Pain, Clinical Journal of Pain, European Journal of Pain, Journal of Consulting and Clinical Psychology also contain regular treatment reviews and present critically appraised papers that evaluate high quality research reports.
  5. The National Guideline Clearinghouse <http://www.guideline.gov> is a public resource for evidence based clinical guidelines.
  6. Return to Work Knowledge Base provides concise, evidence based information on return to work for employees, employers and treating professionals <www.rtwknowledge.org>.
  7. Accident Compensation Commission, New Zealand has developed Persistent pain assessment instruments: a compendium – April 2008. This is a handbook used to assess persistent pain. It covers the following areas: pain assessment, psychological instruments, functional assessment and general health/quality of life. The CD version (ACC4606) can be ordered from the publications section <www.acc.co.nz>.

GLOSSARY OF TERMS

Compensable injury – CTP

An injury may be compensable if the person’s injury was caused by a motor vehicle accident.

Compensable injury – Workers Compensation

An injury may be compensable if it was sustained by an employee and work was a substantial contributing factor. For a psychological injury, the injury is not compensable if it is the result of reasonable action by the worker’s employer.

Functional outcomes

Indicators of an injured person’s participation in activities such as suitable employment and/or activities of daily living.

Functional outcome measures

Assess the health of the injured person, including changes – as a result of an intervention – to that person’s participation in suitable employment and other activities of daily living. Outcome measures are used to communicate and provide evidence to others about the effectiveness of treatment.

Injured person

Claimant as defined by the Motor Accidents Compensation Act 1999 or worker as defined by the Workers Compensation Act 1987 and Workplace Injury Management and Workers Compensation Act 1998. Refers to claimant or worker with psychological problems.

Persistent pain

Pain of longer than three months duration can be referred to as persistent or chronic pain, and is usually the result of a complex relationship between physical and psychosocial factors.

Psychological injury

Psychological injury is a term to describe a range of mental disorders, diseases or illnesses and may include conditions such as depression, anxiety, adjustment disorder and post traumatic stress.

Reliable

Consistent; always yields the same results in the same situation.

Reasonably necessary (WorkCover)

Funding decisions are based on the reasonably necessary criteria:

  • treatment must be appropriate
  • availability of alternate treatments
  • cost considerations
  • effectiveness of treatment
  • acceptance of treatment by clinical peers (evidence based)

Reasonable and necessary (CTP)

Funding decisions are based on the reasonable and necessary criteria:

  • related to the accident
  • of benefit to the claimant
  • proposed service is appropriate to the condition
  • provided by an appropriate provider
  • cost considerations.

Return to work (RTW)

A timely, safe and durable return to paid employment for which the person is suited, having particular regard to their capacity, pre-injury employment, age, education, skills and work experience.

Treatment

Therapeutic treatment given by direction of a medical practitioner.

Valid

Accurate measure; the extent to which a measure actually measures or shows what it claims.

  1. Main, CJ, Sullivan, MJL & Watson, PJ 2008, Pain Management: practical applications of the biopsychosocial perspective in clinical and occupational settings, Churchill Livingstone.
  2. Sackett, D, Straus, SE, Richardson, WS et al 2000, Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edn, Churchill Livingstone.