Rebuilding work identity

I love helping people return to work.  It’s got to be one of the most rewarding parts of pain management for me because not only is work important for health, it’s a major part of our day, and it’s a whole lot about individual identity.  So helping people reconstruct their sense of self to the point where they can go to an employer and say ‘I can do this for you’ with confidence is an enormous challenge.

To feel confident enough to put yourself on the line to an employer despite chronic pain is a challenge.  It involves at least some of the following (and yes, this is mostly from my experience on this post!):

  1. Good self efficacy for managing pain – to the point where fluctuations in pain intensity can be taken with equanimity
  2. Strong knowledge of what you can do
  3. A sense of yourself as OK despite limitations (reconstructed identity as a worker)
  4. Ability to communicate effectively, especially when it comes to doing things differently so as to accommodate functional limitations
  5. Underlying routines and habits that can maintain optimal functioning in a work environment

I’m going to put myself out here – I think that although some of this work is considered within pain management contracts for ACC (our national accident insurer), I think much is missing.

There are some assumptions held by people about work.  Sort of a Calvinist view that everyone ‘should’ work, that work ‘should’ be done dutifully albeit not really enjoyably, and that everyone ‘should’ know what kind of work they can do – or be grateful for the chance to go to work so be happy with whatever is provided.

This somewhat simplistic view of ‘work ethic’ ignores some really significant issues – and as a result, the programmes for returning to work for people with chronic pain, along with the pain management programmes, don’t seem to address them.

A couple of vignettes might help illustrate the problems:

  • Angus is 58, a truck driver, he has long-standing low back pain, what he calls a ‘crook’ heart, and a recent seriously sprained ankle that is still niggling.  He knows he can’t manage a full working day, but his job has gone and he is getting pressure from his case manager to return to work.  Functionally he is able – but he needs to change the way he does activities AND cope with ongoing pain that he gets worried about, and this is difficult for him.
  • Caroline is a very busy teacher.  She loves teaching but is finding it very difficult to communicate to the Principal that she can’t keep up with the out-of-school activities that are expected from her.  She’s struggling because she knows what she used to expect from herself is not appropriate now, but finding it difficult to negotiate changes and help people adjust their expectations.
  • Kevin is bitterly unhappy that his last employer was never prosecuted for the accident in which he hurt his hand.  He has always been a very fit person and had moved up ‘through the ranks’ at work to become a production manager, so had no paper qualifications.  Now he is not confident that he can either maintain the hours he used to do (and that he sees as normal), or that he can honestly tell an employer that he will be reliable.  He doesn’t know what kind of job to go back to because his previous work involved using both hands all the time in skilled movements (making furniture).

Each of these people has had pain management – but not specifically targeting the things that are important for them for returning to work.  While they have all been workers and obtained jobs in the past, it’s difficult doing the same thing now.  They have different work habits, restricted functional abilities, and need to change from ‘tried and true’ ways of living life and responding to pressures than they’ve needed to before.

How often are these problems directly addressed in a pain management programme?

I’m struck by the blithe way in which some people are told ‘You can’t go back to your old job, you probably need to look for something else.’  And while many vocational providers are good at eliciting transferable skills – they don’t appear to readily address altered worker identity.  Neither do they appear to recognise the need for people to both be honest with an employer and openly discuss their pain and how they manage it.  It’s not OK to tell someone to lie about their health at a job interview!

There are some fundamental factors that clinicians can ask about to help someone identify their concerns about returning to work:

How much do you believe the following statements:

  • I may do damage to my body
  • I may put other people at risk of harm because I may not do my job well
  • I am not reliable and I might let my employer down
  • My medications make it difficult for me to concentrate, or they are not allowed in my workplace
  • I need to get my pain under control before I start thinking about returning to work
  • I look as though I am well, and people may misunderstand how much I can actually do
  • I can’t return to my previous job, and I don’t know what else I can do
  • If I go to work, the rest of my life outside of work suffers
  • I don’t know how to talk about my health problems to people at work
  • While I can manage my pain at home, I don’t think I can manage it at work

If we can help people feel confident to be unconcerned about these things, we may be able to help people move from pain management at home to living life well and working.  And yes, occupational therapists (among others) can help with this!

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