or years case managers have been encouraging early intervention in the return-to-work (RTW) process. But after a life-changing injury, a state of unhappiness, discontent, and frustration often develops in the injured worker regardless of when case management services are introduced if those services are not handled properly.
We who are involved in this process sometimes do things in our interpersonal relationships that are counterproductive to the opportunity for RT~. When we do, that opportunity sometimes is lost. This article about RTW strategies assumes that the employer wants the injured employee to return to the workplace and that the employee also wants to return. Sometimes, however, this assumPtion is false. With the increased sophistication of disability management programs, including telecommunication links between case managers' and insurance carriers' computer systems, interpersonal relationships become even more important. Robert Hall, PhD, assistant professor and director o f the Work and Health Technology Center at San Diego State University, said, "Case management professionals intuitively understand that much of what happens (or fails to happen) in a disability proMay/June1998
gram is a function of human behavior and complex interaction between individuals. "1 Interpersonal relationships very well may be at the core of successful RTW plans. These relationships in case management should be conducted in a humanistic manner; that is, each and every individual in the process, especially the injured worker, should be treated with courtesy, dignity, and respect. Injured people are not just the sum of their parts and are not just "the back injury on line two" or "the Cumulative trauma injury in the front office." A humanistic philosophy maintains that when individuals are given appropriate information, they can and do make good decisions about their lives. This philosophy also postulates that people seek meaning, purpose, and value in their lives. An example of a work community in this article is railroad employees. A railroad employee with no education, not even a high school diploma, can earn $50,000 to $75,000 per year, depending on his or her specific classification and overtime. Generally speaking, railroad employees have four things in common: most love their work, receive excellent compensation, think being a railroad employee is a matter of tradition, and, in certain circles, enjoy the high status attached to this occupation. So why is returning to work as difficult for these employees as for other injured workers?
Process of Transitions Job Shift, 2 written by Dr. William Bridges, discusses the psychological process that individuals go through when they experiencea transition in life. In this book and in one called Transitions: Making Sense of Life's Changes, 3 Bridges writes about a state of mind called "the neutral zone," an ' "in-between state." This phenomenon also describes the state of mind of injured workers. The idea of a transition, "an inner psychological process occurring because of an outer event," appears to provide an explanation for resistance to R T ~ . Bridges discovered that a transition is a natural process resulting from a major life event, such as divorce, illness, injury, loss of a job, the death of a loved one, and many other events. He postulates that the transition process is composed of three phases: endings, neutral zone, and beginTCM 56
Not only are iniured employees physically disengaged from the workplace, but psychologically they tend to be emotionally isolated from coworkers and the working environment. nings. Injured workers themselves, employers and payers, and even case managers respond in ways that may force injured workers into such a transition. A breakdown in interpersonal relationships seems to accelerate this process. If these injured individuals are in a neutral zone, according to the theory, they have passed through what Bridges calls an ending experience. Generally speaking, the ending experience has four aspects: disengagement, disenchantment, disidentification, and disorientation. We as professional partners in the RTW process may contribute unwittingly to the ending experience that occurs between the employee and the workplace. When people are injured and unable to work, the event of the injury can be said to disengage them from the workplace. The old systems that reinforced the employees' roles and guided their behavior are no longer a part of their daily experience. Not ~only are injured employees physically disengaged from the workplace, but psychologically they tend to be emotionally isolated from coworkers and the working environment. When these employees realize that their world is no longer as they thought it was, disenchantment can occur. When they perceive that the organization or other individual is not supporting them, their "enchantment" or good feeling about the employer or coworkers can break down. For example, if no one representing the company phones injured workers to find
out how they are doing, the seeds of disenchantment are planted. Another example is discovering that their supervisor or other personnel have made disparaging comments about them or their injuries. In some cases, employees who are unable to work are excluded from company events, such as Christmas parties, picnics, or employee meetings. A more drastic form of disenchantment occurs when an employee discovers that the employer has placed surveillance on his or her activities. The third aspect of the ending experience is disidentification. Jobs or occupations tend to define us and are an important part of our identity. No longer being a train engineer or a production worker can be a source of frustration, confusion, and panic. The loss of signs of the old identity and the temporary assumption of a sort of nonidentity can be very frightening. For example, some railroad employees have been devastated that they are unable to return to work in that capacity. Efforts to assist them in career development to pursue another vocation sometimes seems a formidable task. Disorientation is the fourth aspect of the ending experience. When people are disoriented, they appear to be lost and confused. A feeling of not knowing where they are going deepens as disabled workers become disengaged from the workplace, disenchanted with the employer, and disidentified from their occupational role. The belief that their life has a direction tends to breakdown. Planning for the future becomes a casualty of the disorientation experience. For the injured worker, this time can bring feelings of emptiness and confusion. When the injured person experiences these psychological processes of disengagement, disenchantment, disidentification, and disorientation, Bridges says he or she is passing through the ending experience within the transition process. This passage sets the stage for the neutral zone. Again, the way in which interpersonal relationships are conducted may contribute to the injured person's transition away from the workplace. Once the person has gone through the ending experience and is in the neutral zone, the window of opportunity for returning that individual to work probably has closed.
The Ripples of Disability A person's work life tends to have a rhythm of its own. When an individual is disengaged from the workplace because of an injury, the situation puts stress on all members of his or her family. This stress can upset the balance or harmony in family relationships, which further adds to the upheaval the person may be experiencing. Family disharmony can aggravate other developmental issues with which family members may be dealing. For example, alcohol abuse by the employee may begin or intensify as a result of being disengaged from the workplace. The alcohol issues further add to the family's stress. Case managers, especially those who perform on-site management, are in a unique position to facilitate understanding of what is happening within the family. These case managers may be able to observe and communicate how the injury is affecting the family, which in turn may affect that RTW window of opportunity. The family structure breaking down can contribute to the overall ending experience through the disidentification and disorientation process. If all four aspects of the ending experience take place, the injured individual may be forced into the beginning phase of the transition process--which may translate into the injured person pursuing a new occupation and thus not returning to his or her former work. Once such a person is in the neutral zone, reintroducing the idea of returning to the old workplace is very difficult.
~rategies What strategies or interventions might avert the ending experience and thereby a transition away from the workplace? Injured employees should be reengaged in the workplace as soon as possible. If they are unable to return to light duty or some formalized transition program, they should be reengaged through other activities, such as committees (eg, safety committee) or some special project related to problemsolving. Keep these individuals engaged in the workplace and work process by encouraging attendance at employee meetings and company events. Soliciting their advice about problems within their departments also may be a way to keep them engaged. (These suggestions are in lieu of light duty or transitional programs that require a certain number of hours actual-
A case m a n a g e r inadvertently m a y be d r a w n into the surveillance process either by arranging for or being a part of conversations related to the results.
ly on the job.) To maintain injured workers' enchantment with the workplace, the company should demonstrate it cares about their well-being. Provide the individual with immediate medical care and communicate trust. Case managers should think twice about being involved in surveillance. A case manager inadvertently may be drawn into the surveillance process either by arranging for or being a part of conversations related to the results. Do not allow negative comments to be made in meetings or posted on bulletin boards about people involved in on-the-job injuries. Also, provide accurate information to injured workers and help them with problems related to receiving compensation benefits from the insurance carrier. Case managers also can help injured workers continue to identify with their jobs or work roles. If appropriate, discuss other RTW options that may be similar to their old jobs. Involve them in projects and keep them informed about what is happening at the workplace if they are unable to return immediately. If at all possible, have these employees come to the work site to discuss problems within their department or consider specific products or projects in which they may become involved. Reinforce their value as employees to the company.
Also help these workers continue to be oriented about the company and their jobs, value, and future with the employer. Keep them apprised of ways they can contribute to the mission of the company and maintain their value and sense of self-worth.
Conclusion All of us have a core need to be engaged in meaningful pursuits and to feel valued at our workplace. Responding in a humanistic manner to injured employees requires integrity in all aspects of the RTW process. Be careful of disability management programs that provide financial incentives for key staff members who are directly involved in managing the RTW program. Lawsuits have been brought against key staff members because of financial incentives that were provided to them. Such incentives lead to the deterioration of the disability management program. In summary, respond humanistically to injured individuals, realizing that you have only a brief period to keep these employees engaged, enchanted, identified, and oriented to their work and workplace. Do not allow anger, frustration, distrust, fear, and undue stress to define the relationships you have with the injured worker and they have with the company. 71
References 1. Hall R. Case managers and disability management programs. The Case Manager 1997;8(2):67-72. 2. Bridges W. Job shift: how to prosper in a workplace without jobs. Menlo Park (CA): Addison-Wesley; 1994. 3. Bridges W.. Transitions: making sense of life's changes. Menlo Park (CA): Addison-Wesley; 1980.
Lewis Vierling, MS, NCC, NCCC, CRC, CCM, is vicepresident and career~rehabilitation consuhantfor Mc/RS and a partner in McCollom- VierlingAssociates. He has 23 years of experience in counselingand career transition issues and has been a case managerfor 13 years, specificallyassisting individuals in goal-setting and careerplanning. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/91087
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