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By Dr Peter Cotton FAPS
Health Services Australia & Insight SRC

Peter is a clinical and organisational psychologist who has consulted with most Australian workers compensation authorities on the management and prevention of work-related psychological injuries. He held an appointment with the former National Occupational Safety and Health Commission as a subject matter expert in workplace mental health, and is currently involved with a number of jurisdictional prevention and clinical quality assurance initiatives.

This article discusses the issue of work-related psychological injury in Australia through a review of selected recent developments and current hot topics across the domains of prevention, early intervention and return to work management.

Work-related psychological injury continues to be a challenging issue across all Australian workers compensation jurisdictions. Claims are continuing to increase in most jurisdictions and claim costs for psychological injury are consistently higher relative to other injury types. In the Commonwealth public sector, psychological injury claims are actually declining, but this is not necessarily indicative of improved early intervention and prevention practices. Rather, changes to the Safety, Rehabilitation and Compensation Act introduced in April 2007 have effectively reduced access to compensation benefits for psychological injury.

On this issue, there is some debate about the overall value of restricting compensation for work-related psychological injury. A recent analysis of data from all Australian jurisdictions has failed to find any long-term cost savings resulting from increasing exclusionary provisions for psychological injury claims (Guthrie, 2007). Several sociological and psychological factors may explain this finding including changes in presenting symptoms (e.g., psychological distress expressed more through somatic symptoms) and shifts in clinical diagnostic practices and liability attributions made by clinicians. Certainly from an organisational behaviour perspective, employee ‘withdrawal behaviours' are known to be somewhat fluid at a macro level, and can shift between accentuating psychological and musculo-skeletal symptoms, absenteeism and turnover.

This situation is suggestive of the proverbial balloon that, when pushed down in one place, bubbles up elsewhere. One thing that is clear is that the problem cannot be legislated out of existence. Thus, in the Australian Commonwealth public sector it seems probable that as a consequence of the legislative changes, we will start to observe an upsurge in non-specific musculoskeletal injuries with significant underlying psychological features.

The limitations of these ‘back end' legislative approaches reinforce the need to increase resources focused on ‘front end' prevention and early intervention initiatives. In this respect, there have been significant developments in Australia over the past decade.

The prevention of psychological harm in the workplace

Selective overview of developments in Australian jurisdictions

Occupational health and safety legislation in some States (e.g., Victoria and Queensland) has made more explicit the obligation on employers to risk manage reasonably foreseeable ‘psychosocial hazards' in the work environment. From 2005, Queensland Workplace Health and Safety introduced ‘psychosocial inspectors', alongside the traditional occupational health and safety inspectors, to specifically target and review workplaces where substantive harassment and bullying problems are identified. This initiative seeks to increase the focus on early intervention and addressing systemic contributing factors.

Apropos of the issue of workplace harassment and bullying, most jurisdictions have now developed comprehensive guidance materials. From a prevention perspective, the materials produced by the Australian Public Service Commission (2006) are exemplary. Going beyond traditional hazards identification and control measure frameworks, the APSC materials promote a strategic organisational approach including a focus on selection and induction processes, leadership behaviours, policy and education, performance management and monitoring organisational health.

WorkSafe in Victoria has recently sponsored psychosocial risk management research conducted by Maureen Dollard and colleagues. This research has demonstrated that employee consultation processes and engagement in identifying and managing psychosocial risks can improve wellbeing outcomes and thereby contribute to reducing the incidence and cost of psychological injury compensation claims (Victorian Workcover Authority, 2006). Since 2003, Comcare (the workers compensation insurer for all Commonwealth public sector employees) has funded and endorsed a number of psychosocial risk management and organisational prevention initiatives.

The New South Wales WorkCover Authority is currently sponsoring a major organisational prevention pilot with a range of participating organisations. This research is using leadership and work team climate assessment data to guide development programs targeting managerial and work team cultural behaviours (including both risk and protective factors) known to influence employee wellbeing outcomes and workers compensation risk. This project is underpinned by the organisational health framework (Hart & Cooper, 2001).

The South Australian WorkCover Corporation, based on recent research linking perceived organisational support to the incidence of workplace injury and outcomes, is currently sponsoring research seeking to develop a composite measure of organisational support. The goal is to determine the prospects for benchmarking and increasing organisational accountability for injury prevention and return to work outcomes. Along similar lines, over the past decade our research and consulting group has been working with an aggregate measure of work team climate that is strongly correlated with a range of discretionary performance and wellbeing outcomes.

The influence of organisational factors

There is emerging evidence that specific leadership styles contribute towards a range of negative wellbeing outcomes. For example, excessively directive (command and control) styles appear to be correlated with higher levels of workplace interpersonal conflict and harassment. Similarly, popular styles (laissez-faire leadership), where leaders want to be everyone's friend and avoid difficult conversations, contribute to more entrenched problems which eventually erupt into confrontation and major conflicts when they are addressed.

The excessively directive and popular styles can be contrasted with supportive leadership, which is a more rounded style in which leaders exhibit a balance between supportive, limit-setting and directive behaviours - command and control leaders are directive without being supportive, whilst popular leaders are supportive but poor at providing direction and drawing the linein- the-sand. From an organisational perspective, such findings suggest considerable potential for prevention leveraged through focusing on targeted leadership development initiatives and accountability mechanisms at the work team level. One example of specific organisational factors influencing workers compensation costs can be seen in Table 1. These data present correlations derived from linking comprehensive leadership and climate assessment data with individual level workers compensation data for both psychological and physical injuries in an Australian public sector organisation (Cotton & Hart, 2008).

Table 1. Organisational influences on workers compensation costs
Correlations¹ between organisational climate factors and workers compensation claims (results based on 151 individuals) 
Climate factor 
Workers compensation claims
Total weeks paid
Total cost
Teamwork
-0.26
-0.24
Organisational values and Code of Conduct are supported
-0.19
-0.18
Individual morale
-0.17
-0.17
Performance feedback
-0.16
-0.15
Demonstrating organisational values
-0.15
-0.14
Supportive leadership
-0.15
-0.15
Quality work outputs
-0.15
-0.15
¹Whilst these specific correlations are not particularly strong, it should be noted that we do find correlations in the vicinity of .4 and above, depending on which injury categories or types of withdrawal behaviours are being examined, as well as other characteristics of the organisational climate and operating environment.  

 

The results provide some clues towards developing work environments that help to minimise the incidence and cost of injuries in the workplace. They suggest that the lowest workers compensation costs occur in work teams that: have strong team morale and are focused on quality customer service; exhibit collaborative peer working relationships; and have managers who are supportive, show a high level of behavioural integrity and model organisational values, as well as provide high quality formal and informal feedback. These interlinked leadership and climate factors appear to generate a positive and supportive environment in which individuals are less likely to be injured (possibly because they are more vigilant and/or more inclined to address any emerging symptoms earlier), and individuals who may suffer any genuine injury are much more likely to seek to return to work as early as possible. It should also be noted that promoting these workplace protective factors does not necessitate any trade-off with organisational performance.

Summary observations

Psychosocial hazard frameworks have significantly advanced traditional risk management approaches. However, one weakness is that they can be prone to confounding symptoms with causes and are not designed to identify workplace health protective factors. The particular strength of more organisational and systemic approaches to prevention is that they can assist in identifying underlying structural and climate-related contributing factors as well as key protective factors. Moreover, because these approaches typically identify linkages with performance outcomes, they tend to have more face validity with organisations and can be more readily integrated into performance management frameworks. Additionally, research has indicated that there is generally more improvement achieved in employee wellbeing outcomes for the same resource allocation, when the focus is on building workplace protective factors as opposed to only reducing psychosocial hazards (Cotton & Hart, 2003).

This being said, occupational health and safety regulatory frameworks have increased the impact that psychosocial risk management approaches can exert on organisations. Hence both approaches have a role to play in preventing psychological harm in the workplace.

Psychological injury early intervention

The impact of mental health initiatives

A key development in early intervention over the past decade has been the advent of a range of public mental health initiatives in the workplace and workers compensation jurisdictions. Beyondblue: the national depression initiative, established in 2000, has contributed to a marked increase in awareness about the issue of depression, early identification in the workplace, and good practice workplace and clinical management strategies. Mental Health First Aid, developed by Betty Kitchener and Anthony Jorm at ANU in 2001, is another initiative where workplace personnel are trained in the workplace management of employees exhibiting a range of acute mental health problems. This program has also had strong take-up across a wide range of private and public sector organisations.

The Work Outcomes Research and Cost-Benefits (WORC) study that is being conducted by Professor Harvey Whiteford and colleagues from the University of Queensland has worked with over 60 Australian public and private sector organisations and obtained data from over 92,000 employees. For the first time, we now have high quality data on the incidence and trajectory of working Australians suffering from clinical depression and other mental health problems, as well as their response to early intervention treatment and the subsequent impact on work performance.

Initial WORC research has shown that 6.7 percent of Australian employees in any organisation suffer from clinical level depression each year, and that their attendance and job performance significantly deteriorates. Moreover, around 65 percent of these
individuals have not sought any treatment in the previous 12 months and seem to ‘bunker in' as a way of coping (Whiteford, Sheridan, Cleary & Hilton, 2005). Accordingly, there is an increased risk that these individuals will become entangled in complicated performance and attendance management programs and conflicts, as well as an increased prospect of workers compensation claims.

The WORC study has demonstrated the substantive return on investment (in hard dollar terms) achieved by organisations engaging in proactive health surveillance initiatives and encouraging high risk individuals to access evidence-based mental health treatments. Available evidence suggests that this is a viable early intervention strategy for reducing the number of employees who experience mental health problems from progressing into the workers compensation arena.

Another reason why workplace-based early intervention is so crucial is because it is now well established that health outcomes for individuals with the same clinical profile are worse if they have an accepted workers compensation claim - this will be discussed in the next section.

It can also be noted in passing that there is now increased access to clinical psychologists and other psychologists under the recently implemented two-tier Medicare arrangements. This effectively increases the treatment and care options - in addition to traditional employee assistance programs - for workers experiencing significant mental health problems.

Early intervention for employees exposed to serious incidents

Another area where significant change is occurring concerns the early intervention practices that organisations use to support employees exposed to serious incidents. The recently published Australian Guidelines for Posttraumatic Mental Health (ACPMH,
2007) specifically contra-indicate traditional structured group psychological debriefing protocols and particularly those approaches that include a focus on recounting traumatic experiences and ventilating feelings. As a result it will become increasingly likely that organisations that require employees to participate in these approaches will be legally liable for any ongoing adverse psychological responses.

Alternative psychological first aid protocols are gradually replacing traditional group debriefing approaches. These protocols emphasise the role of immediate practical support, use of naturalistic support networks, morale maintenance initiatives (e.g., organisational leaders engaging and demonstrating support), monitoring, and access to specialist mental health treatment (particularly trauma-focused cognitive behaviour therapy) for high risk individual employees. Evidence now indicates that the most effective way to prevent full-blown posttraumatic stress disorder is by facilitating early access to this type of high quality mental health treatment.

Treatment and return to work

Factors influencing return to work outcomes

The mechanisms through which compensation status contributes to worse health outcomes are not well understood. There is now some recognition that claims administration processes can impact on return to work outcomes. For example, delays in claim acceptance determination can foster uncertainty and distress, as well as more adversarial interactions between a worker and insurer. Organisational justice research suggests that when these claims are finally determined, factors related to redress of perceived inequity and unfair treatment can contribute towards entrenching work disability.

The lack of available modified or appropriate alternative work duties is also a well recognised factor contributing to the duration of work incapacity. Moreover, it is increasingly evident that poor leadership practices can increase work avoidance and thereby prolong periods of incapacity.

There is also emerging evidence, from a number of jurisdictional clinical quality assurance projects, concerning highly variable outcomes associated with the provision of clinical treatment services to employees. There is evidence that medical practitioners, psychologists and physical therapy providers often do not adequately identify and address ‘flags' (i.e., potential psychosocial barriers including work problems, performance issues, conflict with the immediate manager, pre-existing psychological problems etc.) that can derail the effectiveness of standard clinical treatments including psychological therapies. Evidence suggests that where these flags are identified early, communicated to rehabilitation providers and other relevant stakeholders and actively managed, return to work outcomes are improved.

It has long been suspected that clinical service providers who assume an excessive advocacy role or exhibit combative interactions with other legitimate stakeholders (e.g., employer representatives and insurers) achieve worse return to work outcomes. Further, many clinicians, including psychologists, continue to view return to work as something that occurs subsequent to treatment.

Recent Canadian research has shown that clinical service providers who view return to work as a primary treatment modality in and of itself, work collaboratively with third party funders, and communicate regularly with employers, improve return to work outcomes and reduce workers compensation costs by up to 50 per cent (Bernacki ,Toa & Yuspeh, 2005). This type of research suggests that additional specialised training may be needed to work effectively with workers compensation and transport accident populations.

Particular challenges for psychologists working with transport and work injury populations

One major challenge for psychologists is what I would describe in terms of a ‘holistic client-centred ideology' that many practitioners seem to rely on. This is where the treating psychologist defers excessively to the injured worker's moment-by-moment experience and concerns, usually without any underpinning clinical formulation and associated systematic treatment focus. As a consequence, work avoidance issues tend to be unwittingly reinforced over time, other pre-existing life problems become refocused on the contemporary work injury, adversarial interactions with other stakeholders increase and the injured client develops an expectation of open-ended access to psychology treatment.

Under these circumstances psychological intervention can continue on a regular basis over a number of years without any demonstrable improvement in symptomatic and functional indicators. Moreover, some psychologists appear to find it difficult to disengage and cease treatment, even where there is no demonstrable value in ongoing psychology sessions over and above standard GP care and monitoring.

A related issue concerns the marked under-utilisation of exposure-based interventions with work and transport accident related presentations across all jurisdictions. Exposure-based techniques are amongst the most effective psychological interventions in this area but do require considerable skill to maintain client engagement and apply effectively. Inadequate use of exposure interventions can reinforce work avoidance behaviours and increase long-term disability.

Clinical quality assurance initiatives

In the past few years, a number of compensation authorities have increased their focus on clinical quality assurance issues and have retained in-house clinical expertise. Probably the most advanced jurisdiction in this area is Victoria. WorkSafe implemented the Clinical Framework for the Delivery of Psychological Services in 2006 in consultation with the APS. The Victorian Transport Accident Commission and WorkSafe have also established panels of medical practitioners, psychologists and physical therapists who undertake secondary treatment reviews, provide clinical advice and encourage practitioners to align their treatment with established best practice.

Conclusion

Notwithstanding a number of ongoing challenges, there is now much greater acceptance across all Australian jurisdictions of the role that evidence-based psychological interventions can play in injury prevention and improved health and return to work outcomes. Psychosocial risk management and strategic organisational prevention approaches can substantially reduce the incidence of workplace psychological harm but need to be much more widely implemented. Moreover, appropriate organisational health monitoring systems can achieve a sustainable balance between managing employee wellbeing and performance imperatives. There is also considerable scope to augment a range of cost effective early intervention identification, support and treatment initiatives to reduce the number of employees who are experiencing mental health symptoms from progressing to full-blown psychological injuries. Finally, recent research and quality assurance programs are now rapidly clarifying the skill sets and good practice clinical treatment and management that can enhance return to work outcomes.

The author can be contacted at Peter.Cotton@hsagroup.com.au.

References

Australian Public Service Commission (2006). Respect: Fostering a workplace free of harassment and bullying. Retrieved on 24 June 2007 from www.apsc.gov.au.

Australian Centre for Posttraumatic Mental Health (2007). Guidelines for the treatment of adults with acute stress disorder and posttraumatic stress disorder. Retrieved on 10 December 2007 from www.acpmh.unimelb.edu.au/resources/resources-guidelines.html.

Bernacki ,E., Toa, X., & Yuspeh, L. (2005). A preliminary investigation of the effects of a provider network on costs and lost time in workers compensation. Journal of Occupational and Environmental Medicine, 47, 3-10.

Cotton, P., & Hart P.M. (2003). Occupational wellbeing and performance: A review of organisational health research. Australian Psychologist, 38(2), 118-128.

Cotton, P., & Hart, P.M. (2008). The influence of organisational factors on employee wellbeing and withdrawal behaviours. Manuscript in preparation.

Guthrie, R. (2007). Why we don't need stress claim exclusions. Paper delivered at the WorkCover Western Australia Injury Management Conference, Perth, October 2007.

Hart, P.M., & Cooper, C.L. (2001). Occupational stress: Towards a more integrated framework. In N. Anderson, D.S. Ones, H.K. Sinagil & C. Viswesvaran (Eds.) Handbook of Industrial, Work and Organisational Psychology Vol 2 (pp. 93-114). Sage: London.

Whiteford, H.A., Sheridan. J., Cleary, C.M., & Hilton, M.F. (2005).The work outcomes research cost-benefit (WORC) project: the return on investment for facilitating help seeking behaviour. Australian and New Zealand Journal of Psychiatry, 39 (Suppl.2), A37.

Victorian Workcover Authority (2006). The 2004-2005 Stress Prevention Study in the Victorian Budget Sector. Retrieved on 10 June 2007 from www.workcover.vic.gov.au.