Yesterday I started to talk about returning to work with chronic pain. I mentioned that it’s often not the degree of importance an individual places on returning to work that engenders resistance – it’s more likely the lack of confidence the person has towards the process, the fear that this won’t work out and they will fail…
A story or two might help detail some of the issues that people I work with encounter when they’re returning to work. Now I recognize that the people I see are possibly at the more complex end of the spectrum than many, so these stories might well be more extreme than what many clinicians see, but at the same time they illustrate where things go wrong.
A note: vignettes used in this blog are composites of people I’ve worked with, so their confidentiality is respected.
Bill is a man in his late 50’s, a bluff bloke with a long career (about 30 years) as a sheet metal worker. He developed back pain in his mid-30’s but managed to remain at work for about 10 years by pushing himself during the day and ‘collapsing’ at night. He did stop work after his GP advised him that his work was ‘not doing you any good’, suggesting to Bill that he should take time off to ‘give your back a rest’ and maybe consider a new job.
Bill is a man who has limited reading and writing skills. He doesn’t like being around people very much, his beard is impressive – and he hasn’t cut it for many years! He loves working with his hands and not only has he been a sheet metal worker, he has a green thumb and grows his own veggies, has a garage workshop and a partially restored classic car in it, and he likes to go fishing and bushwalking.
He doesn’t like bending. He is quite afraid to bend forward, sideways, to reach up or down, or to carry heavy objects. While he can walk for hours on flat ground he’s not comfortable walking over rough ground or slopes. He believes that his back is fragile and that his pain means that there is ongoing damage. His GP has reinforced this by telling him that he needs to be ‘very careful’ with his back – or else (but didn’t elaborate on what the ‘or else’ means).
When Bill looked at returning to work, he was sent to a local vocational provider who promptly told Bill to get rid of his beard because ‘no employer wants to see you looking all bushy and scruffy’, advised him to ‘dolly up’ his CV (although Bill saw that as lying to prospective employers), and asked him to go door-knocking to get interviews.
Needless to say, Bill ran a mile. He had worked in an industry where his personal appearance was quite appropriate. He had never had a CV. He had few skills and a lot of anxiety about being around people let alone asking for an interview, and finally – he had no idea about what kind of work he could do.
But worse than that: he was fearful of bending, his GP reinforced this, and his past work experience and limited literacy meant that the only work he thought he could do was well beyond him.
If you think that’s sad, can I say Bill’s case is not isolated. He’s one of many people who get conflicting messages, hear advice that isn’t tailored to individual needs and doesn’t address individual concerns – and the likelihood of Bill returning to work without effective support is minimal.
Here’s another case, with a different ending.
Max has been a farmer all his working life, a shepherd with a leasehold farm. He hurt his back and for three years was given three-monthly blockades for pain relief. About six months before we saw him, he was told that these wouldn’t continue and he would now need to ‘learn to live with’ his pain. Unfortunately Max had learned to be very afraid of having pain, feeling overwhelmed by it, and, like Bill, avoiding all movements that made his pain worse. This meant he didn’t sit, he avoided bending to put even his sock and boots on, he spent hours lying down because this was more comfortable than any other position and he told us he was experiencing ‘death by DVD’.
Max had been through two attempts to return to work. He had decided that farming was out of the question, so his case manager referred him to a vocational provider who found a work trial in an agricultural company. The first work trial failed after a week because Max couldn’t manage the drive to work and the four hours he was expected to do in the warehouse (which involved lifting and bending to pack orders). The second failed when he was given ‘stocktaking’ to do as a task – this consisted of counting screws and bolts for the four hours he was expected to be there. Needless to say, he hated it and he stopped after about a month.
Max became very depressed, and his confidence for working was at an all-time low. He attended a pain management programme, but things only got worse immediately after it, partly because we emphasized that his pain was likely to remain the way it was. He was bitterly upset at the loss of his role, that his masculine sense of self was being eroded, and he couldn’t do all the things that he knew were ‘his’ jobs to do around the home.
It was a long, hard six months of work with us. We used CBT for mood management, graded exposure for his movements, and a lot of work to help Max identify the skills he still had and could use in the workplace.
He finally said that if we were right that he wouldn’t damage his back, then why couldn’t he consider returning to farming? I couldn’t think of any reason why (although he wasn’t physically able at this point), but from then on he started to really work hard on his movements and fitness. We arranged for another work trial, this time in an outdoors recreational area where Max was able to try out a range of activities like moving irrigation, checking fence lines, and planting. After a few flare-ups that resulted in Max feeling rather afraid but eventually managing to remain at work (with the support of his GP, our team and the local vocational team), Max has now returned to full time work. He’s been there for six months now, and does all the tasks involved including cutting down trees, operating heavy machinery, repairs to fencing, irrigation and so on.
The best thing? Max sent us a photograph recently of him holding a large opossum (they’re a pest in NZ) at arms length after having shot it in the bush when out hunting.
Returning to work for Bill and Max is a lengthy process. It involves commitment by all the team members and particularly commitment to the same message – that it’s possible to go back to work, that it’s healthy to do so, that pain doesn’t mean damage, that it’s possible to cope with even high levels of pain and carry out very heavy work, and that we as a team have confidence in the person’s ability to make it. It also means acknowledging that one size does not fit all. It’s not always necessary to conform to ‘white, middleclass’ dress code or presentation. It’s entirely feasible to return to really heavy work provided the person is confident that he or she is not doing damage. That choosing ‘the wrong kind of work’ that doesn’t suit the person’s skills, preferences or experience does not work.
We ALL have a role in instilling confidence that people with chronic pain can manage normal activities. I can’t say that it’s easy, and it’s certainly not quick. It does rely on really good teamwork and a consistent approach. It take hours of coordination via phone, email, face-to-face, letter. But to see Max’s face with that huge possum held at arms’ length, and to hear from him that he still has pain but he can manage it – that’s why we do it!