During the past few years, we have seen an increased recognition of the importance of addressing mental health in construction workforces. It is well documented that this group demonstrates a significantly disproportionate risk of suicide for a variety of reasons, including a stoic culture, high-pressure work environments, transient roles with expected layoffs, social isolation, construction site safety complexities and a high prevalence of substance use. This mental health crisis commands a substantial and fully justified level of attention in awareness and targeted intervention.
What is perhaps less well appreciated, however, is the equally disproportionate risk of developing secondary psychological complications after a workplace injury. If ignored, the development of psychological distress post-injury can lead to catastrophic claims outcomes. More importantly, this gap in effective injured worker care can lead to delayed recovery, the development of chronic psychiatric disorders, disability, and significant degradation of a worker’s quality of life.
Workplace Mental Health and Injury Outcomes
Among employees with comparable injury types and similar medical severity, there is significant variability in claim length, development of disability, return to work, and time to maximum medical improvement (Steenstra et al, 2015; Ashley et al, 2017; Hayden et al, 2019). Understanding individual and systemic factors that contribute to this variability is a key component in the early identification of claims that are at risk for escalation as well as in developing innovative biopsychosocial models of care that optimize both medical and financial outcomes. As a result, there has been a greater focus on the psychosocial determinants of both health and workers compensation insurance claims outcomes.
The need for continued exploration of these factors is highlighted by a disturbing finding from the National Health Interview Survey conducted from 2004–2016. This study demonstrated a 32% higher prevalence rate of self-reported psychological distress among occupationally vs. non-occupationally injured workers (Gu et al, 2020). These results point to a set of psychosocial and psychological factors unique to individuals injured at work.
Psychosocial Determinants of Health and Outcomes in Occupational Settings
There is a large body of medical literature demonstrating the contribution of a wide variety of biological, social, and psychological factors to the progression of and/or recovery from both acute and chronic conditions. In an occupational setting, however, it is becoming clear that an employee’s concerns and fears after a workplace injury go well beyond purely medical issues and that these concerns have very significant effects on outcomes. While most individuals suffering work-related illness or injuries return to work rapidly and without complication, a meaningful minority experience prolonged or permanent absence from the workforce (Gewurtz et al, 2018). What is unique about these latter cases? Data captured from recorded conversations with insurance adjusters has shown that, on average, claims cost 3.5 times as much and end in litigation 2.5 times more frequently when the words “fear” and “afraid” are represented.
This is consistent with numerous studies that have demonstrated that fear, catastrophic thinking, anger, perceived injustice about the injury or incident, and feelings of loneliness and victimization place injured workers at risk of delayed recovery and secondary complications, including mental health disturbances and the development of chronic pain syndromes. These factors may be even more important in construction workforces, which have traditionally demonstrated a culture of stoicism around acknowledging and seeking out support for mental and emotional distress.
Collectively, this evidence points to injured workers’ lack of trust in the construction workers compensation system, which represents an existential threat to optimal health outcomes.
Addressing Flaws in the Worker’s Compensation Process
In 2018, the RAND group published a study on the challenges of the worker’s compensation system from the perspective of workers, employers, claims administrators, state agency leaders, and occupational health care providers (Dworsky & Broten, 2018). Among the themes identified were:
- The impression that the care provided to injured workers is often of low quality despite increased spending, potentially leading to avoidable disability, and certainly to suboptimal medical outcomes.
- System complexity, delays, and excessive disputes raise costs and create an adversarial relationship between employers and employees.
- Fragmentation of care and failure to evaluate and treat workers holistically with an overemphasis on the injury and less on the injured worker can result in isolation, ostracization, and under or overtreatment of the injured worker.
These perspectives correctly led the study authors to conclude that “Severe problems with worker’s compensation care demand innovative solutions.”
Considering these findings in the context of the higher prevalence of self-reported distress after occupational vs. non-occupational injuries, a target for potential intervention begins to emerge.
The Importance of Self-Efficacy in Workplace Mental Health and Injury Outcomes
Two common themes that have been associated with both a successful return to work after an injury and avoiding secondary psychological distress are social support from managers and co-workers and personal factors including attitude and self-efficacy (Etuknwa et al, 2019). On the other hand, systemic and personal factors that forestall return to work are multifaceted. These include delays in initial medical evaluation, diagnosis, and the start of definitive treatment, along with the injured worker’s mistrust, fear, and uncertainty. There is also evidence that failure to return to work sets in motion a cycle through which the act of staying at home increases feelings of loneliness, victimization, and perceived injustice, all of which can inhibit or delay recovery (Main et al, 2010). This contributes to the concept of “the malingering worker,” who is believed to be purposefully non-participatory in their care and disincentivized to return to work. In most cases, it is unlikely that failure to reintegrate into the workforce is a conscious decision with nefarious intent. Rather, fear, uncertainty, and mistrust guide a worker’s decision not to return to work, and the longer one is away, the more difficult the reintegration process becomes. However, there is evidence that a willingness to return to work represents a modifiable health-related behavior that can reduce the likelihood of developing chronic pain and secondary psychological injury (Mills et al., 2019).
How then do we encourage and support workers in modifying this behavior?
One possibility is to leverage and attempt to improve a worker’s locus of control. In behavioral science and psychology, an individual’s locus of control refers to their perception of their own ability to influence outcomes. People are generally classified as having either an internal or external locus of control. The former generally believe that outcomes are consequences of their own actions, while the latter tend to feel that these outcomes are most strongly affected by external factors over which they have little or no control. In healthcare, there is clear evidence that an internal locus of control is positively correlated with health outcomes, satisfaction with one’s health, and lower levels of psychological distress and mental health diagnoses (Kesavayuth et al., 2019).
This is particularly relevant in the workers compensation system, where, as shown in the RAND study, it is felt that, rather than fostering self-empowerment, system complexity and delays promote victimization and adversarial relationships. These factors, along with a lack of social support from employers and healthcare providers, may significantly impair an injured worker’s perception of self-efficacy and promote an external locus of control to the detriment of the construction worker’s mental health.
Conclusion
Treatment after a work-related injury must address more than just physical symptoms and injury-specific medical concerns. Effective workplace injury management must address the injured construction worker’s mental health concerns with a focus on developing an advocacy-based collaborative relationship to address fears and promote health-related behaviors, including returning to work as early as possible. Rather than relegating injured workers to the role of patient victim, the goal must be to create systems that promote health partnerships in which employees feel they can contribute to their own recovery by enhancing their locus of control and self-efficacy through the recovery process.
Frequently asked questions
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References
Ashley, J., Cashdollar, W., Etcheverry, R., & Magill, K. (2017). Transition back to work: policies to support return to work after illness or injury. Available at: https://www.dol.gov/sites/dolgov/files/ODEP/research/saw-rtw/TransitionBacktoWork_PoliciestoSupportRTW_FINAL.PDF
Dworsky, M. & Broten, N. (2018). How can workers’ compensation systems promote occupational safety and health? Stakeholder views on policy and research priorities. Santa Monica, CA: RAND Corporation. https://www.rand.org/pubs/research_reports/RR2566.html
Etuknwa, A., Daniels, K., & Eib, Constanze. (2019). Sustainable return to work: a systematic review focusing on personal and social factors. Journal of Occupational Rehabilitation, 29:679-700.
Gewurtz, R.E., Premji, S., & Holness, D.L. (2018). The experiences of workers who do not successfully return to work following a work-related injury. Work, 61, 537-549.
Gu, J.K., Charles, L.E., Fekedulegn, D., Ma., C.C., Violanti, J.M., & Andrew, M.E. (2020). Occupational injury and psychological distress among U.S. workers: the national health interview survey, 2004-2016. Journal of Safety Research, 74, 207-217.
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Kesavayuth, D., Poyago-Theotoky, J., Tran, D. B., & Zikos, V. (2019). Locus of control, health and healthcare utilization. Economic Modelling, 86.
https://doi.org/10.1016/j.econmod.2019.06.014
Main CJ, Foster N, Buchbinder R. How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Pract Res Clin Rheumatol. 2010;24:205–217.
Steenstra, I. A., Busse, J. W., Tolusso, D., Davilmar, A., Lee, H., Furlan, A. D., Amick, B., 3rd, & Hogg-Johnson, S. (2015). Predicting time on prolonged benefits for injured workers with acute back pain. Journal of occupational rehabilitation, 25(2), 267–278. https://doi.org/10.1007/s10926-014-9534-5
