Work is the context

For many years I’ve worked in pain management and tried to help people return to work as the completion of their rehabilitation. Why? Well, apart from it being a great thing from an insurer or funder’s point of view, it’s actually what people want.

Having been through my own return to work rehabilitation after my concussion, I can personally describe some of the effects of return to work efforts – and the fears and concerns I had (and still have to some extent). However, as you know I don’t like to rely on my own personal opinion, so I thought today I’d describe the comments of participants in the pain management programme I work in.

The question participants are asked is ‘What does work mean to you?’

And their responses?
The first group of comments is that ‘work is necessary for money’, and the second ‘to get case managers off my back’ – and then some more thoughtful responses.

Here people say very clearly that work is about meaning and purpose in life, the activity that organises the day, the topic of conversation, the social interaction, the belongingness to a community, contributing to society, identity and self worth and competence.

For some interesting snapshots of what workers say (at least a group of them in the US), listen to this series of podcasts on ‘Meaning of work’. And for a slightly different take on the meaning and value of work, this community arts project by Lara Lepionka provides a wonderful doorway into the meaning of work to ‘ordinary people’.

When they are not working, participants agree that it may be fine initially, but rapidly becomes a much less positive experience. Some health researchers state that stopping work hastens ill health and death. At the very least, participants in the pain management programme agree that they don’t want to remain off work – but they lack confidence to actually return to employment.

When I read assessments of workplaces carried out by various therapists, something is missing. Each assessment covers the physical activities, the equipment, the tasks, the physical environment – but given the amount of time we typically spend in a workplace, I see very little description of some of the fundamental aspects of the culture of a workplace. More importantly, the relationships between people in the workplace are rarely mentioned.

If we return to social learning theory (remember Bandura?), and our behavioural fundamentals, we can see that responses from people within an environment are a particularly potent influence on both behaviour and belief. It’s surprising then, that assessments of the workplace, particularly when an individual is having trouble returning to work, don’t even mention attitudes, beliefs, or behaviours of the other people in the workplace. Workers spend roughly 8 or more hours in a work environment, have strong opinions about their workplace (whether they like it or lump it!), and among some of the so-called ‘black flags’ and ‘blue flags’ (see this 2002 BMJ article), the individual’s perceptions of the workplace and the organisational and task demands of the workplace feature as risk factors for people to fail to return to work.

Even in comprehensive pain assessments, although mention is made of work and past working history, mention is rarely made of the person’s belief about whether they will return to work (which is probably one of the most predictive questions for RTW I know of!), and even less of the employer-employee relationship or the social-cultural and organisational factors in the workplace.

There are multiple reasons for people having difficulty returning to work. One of the most commonly cited reasons, given by case managers, employers, and treating clinicians is ‘lack of motivation’.
It’s time to deconstruct ‘motivation’ and explore what motivation consists of – if we follow Prochaska and DiClemente’s Transtheoretical Model of Change, it’s made up of two major components: importance and confidence.

People are ambivalent about moving forward because the ‘good things’ about change are balanced by the ‘not so good things’. In returning to work, the ‘good things’ are all those reasons given by the participants in the pain management programme. The ‘not so good things’ are much more varied, and require individual assessment and problem-solving.
Most of the ‘good things’ about returning to work are things that make up the ‘importance’ dimension – things that people value.
Many of the ‘not so good things’ are about confidence to achieve those valued goals.

Motivation is therefore much less about lack of ‘importance’ of returning to work – in fact, for some people I would think that it’s precisely because work is so important that they are stuck. Why risk failure for something that is so important? Motivation in the case of people returning to work involves confidence that the individual can achieve within a workplace to the desired and required standard of performance.

What is all this commentary leading to?

  1. Pain assessments for people experiencing work disability simply must assess the social and cultural aspects of the workplace – both past workplace and present (especially if the person still has a job)
  2. Workplace assessments can’t just consider the physical, but also organisational, interpersonal and ‘cultural’
  3. When someone is having trouble returning to work at least one question should be asked: ‘do you think you will return to work?’
  4. When someone is having trouble returning to work, ‘motivation’ needs to be deconstructed: it’s more complex than simply the presence of secondary gain, laziness, lack of desire.  The importance and confidence an individual has for returning to work must be assessed, and the process of (often) building confidence initiated.

Pain may well be the cited reason for someone not being able to return to work – is it the real reason?  Disability from pain is a very complicated beast, pain intensity is not, by itself, the major factor.  When we start to look at it in more detail (which we will do tomorrow!), it could be any number of things.  If we fail to clearly identify the specific factors in any one individual, we run the risk of prolonged absence from work which is not desireable for anyone.  At the same time, what we know from motivational interviewing is the more we push against resistance the more defended that position will be.  Simply implying to someone that they are ‘not motivated’ will not achieve the desired goal if it is actually about confidence to manage the barriers around working.

Have a great day – sorry there are no specific references today, but I will make up for that very soon indeed!

In the meantime, you can’t really go past Chris Main and Chris Spanswick’s book ‘Chronic Pain: An Interdisciplinary Approach’ for a good description of the process of disability, incorporating the ‘blue and black’ flags.

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