One of the most satisfying experiences I have in my job is seeing someone who has been off work for ages finally return to work. It’s like seeing the person open up and bloom again.
I often see people who have been off work for several years – most of them don’t have jobs to return to, and most of them have experienced a couple of attempts to return to work that have, for some reason or another, failed. Often pain is given the blame for this, and the remedy is thought to be ‘develop pain management skills’ – and I guess in part that’s true. But not completely.
There is a difference between using pain management skills at home, where for the most part, activities can be picked up and put down as needed, and at work where other demands are present. There’s an element of discretion about when and how things are done at home. People can, if they want to, take it a bit quietly on days when their pain is worse, and fit things in more readily on days when they’re feeling better. Not so at work! At work we have to do things to fit into an external timetable – deadlines exist! There are jobs we have to do that are not so forgiving – we have to do them in a certain way, or at a certain time whether we’re feeling great or not.
And therein lies the one of the reasons I think there is a gap between pain management and returning to work. There’s a whole lot more riding on being able to keep going at work.
Let’s take a case like Allan. Allan has been off work for three years now. Before his accident he’d been working for two years as a night supervisor in a food production factory, and before that he’d been the primary caregiver for his wee girl who is now 8 years old. And before that he’d been a professional athlete.
When he hurt his back he thought it would resolve quickly – but after a series of unsuccessful nerve blocks attempting to ‘find and obliterate the cause’ of his pain, and after two multidisciplinary physical rehabilitation programmes, he finally had to accept that his back pain wasn’t going to just go away.
He lost his job after he tried to return to work for about six weeks on a graduated return to work programme. Allan had an occupational therapist visit his work place and was advised that he could do X, Y and Z tasks – but this wasn’t practical given the nature of the work, not even as a supernumerary. Like many employers, his employer didn’t have any ‘selected duties’, and needed to employ someone else to cover Allan’s shift, and eventually told Allan that he couldn’t come back to work until he could manage certain tasks. Allan’s employer terminated his employment after both of them decided that he wasn’t going to make it back in the next two or three months.
Allan was finally referred for pain management, and attended a three week interdisciplinary pain management programme. He struggled with many of the concepts, particularly activity regulation (pacing was his least favourite word!), and he experienced panic when trying to use relaxation techniques. He had been using a walking stick, and although he tried to stop using it during the programme, shortly afterwards he fell, and the stick became an ongoing fixture. Allan was trying very hard to learn how to do things differently – but needed another twelve week programme of pain management using a cognitive behavioural approach before he could consistently maintain even his normal home activities.
Work was out of the question initially. Allan’s confidence was shot – he knew he could do ‘some’ pain management, but much of what he did involved minimising fluctuations in pain, and when he did have an increase in pain he’d either push himself very hard to ‘get the job done’, or he’d use medications or rest to get through the tough patch.
Let’s make one thing clear, Allan really wanted to go back to work. He told me he felt worthless, not a ‘real man’ because he wasn’t providing for his family and he felt trapped in his own home. His confidence though, was at rock bottom.
The specific issues he saw as obstacles to going back to work were:
- Managing his pain without resorting to prn medication
- Coping with the side effects of his medication
- Confidence to tell an employer that he would be reliable
- Confidence he could be reliable and work consistently
- Confidence to be assertive and let others know what he could and could not do
- Worry that he would increase his pain and the other important aspects of his life would be under strain
- Feeling out of touch with the technology and specific skills in the workplace
- Not knowing how to present himself positively in a job interview – how would he answer those tricky questions about the time he’s had off work and about his health?
- Knowing his own functional abilities – he knew what he couldn’t do, but not what he could rely on doing consistently
- Identifying specific job options now that he couldn’t work the way he used to
You can see that the gap is not just about job seeking skills, although that’s certainly a part of it, but it’s also about how to use his skills to be reliable at work – to experience pain but persist and be consistent with his output.
How confusing it would be for Allan to be seen by a vocational provider who had a limited knowledge of chronic pain management. How scary would it be for Allan to start to return to work after having failed in the past. How demeaning to feel inadequate about his own skills and lack confidence to ask for help not only with every day work technology, but also with his pain (after all, that’s what lead to his loss of job early on).
The literature on returning to work after illness or injury is clear. It’s not simply about coping with pain, it’s not simply about coping with disability, it’s not just about finding work, it’s not just about the person with the pain problem. Vocational management is anything that helps a person remain at work or return to work – and it includes all of us on the team, including the employer.
For the most extensive review on vocational management that has been published recently, go to here for the executive summary of the report into vocational rehabilitation ‘What works for Whom’ by Waddell, Burton & Kendall (2008).
Go here for a great set of downloadable documents about work and health (Working for Health, UK government)