Without work all life goes rotten. But when work is soulless, life stifles and dies.
As the 1990s unfold and the 21st century is not far off, the American worker is apt to experience changes in the workplace. These changes will be the result of technological, sociopoli ticaJ, and other factors. Of course, young people just entering the workplace will not really experience such changes.
Regardless of the degree of change experienced, however, some fundamental psychosocial principles are operative regardless of the individual's occupation, place of employment, and other demographic characteristics. This article summarizes these processes and provides some information regarding the etiology of psychological work injuries and the diagnostic methods needed to evaluate the injured worker.
The definitions and the psychosocial functions of work will be presented first, followed by the psychological reactions to job loss or unemployment. With this as background, the central focus of inquiry - the criologie paradigms of psychological work injury - will be presented followed by additional factors to consider and general methods of evaluation.
WORK AND ITS PSYCHOSOCIAL FUNCTIONS
If one looks in Webster's dictionary seeking to define "work," one is struck with its numerous definitions. For example, work is variously defined with, "to exert oneself in order to do or make something," "to operate effectively; to be effectual," "to produce results or exert an influence," "bodily or mental effort exerted to do or make something; purposeful activity; labor; toil," and so on.
Chaplin defines work from three perspectives:
* physically - "the action of a force acting against a resistance,"
* physiologically - "the expenditure of energy during bodily activity," and
* psychologically - "the completion of a task."1
For present purposes, perhaps the best way to define work is to describe its nature and psychosocial functions for people. Hayes and Nutman,2 describing involuntary unemployment or job loss in the absence of work injury, characterized the following seven functions of work.
* Work is a source of income. This First function of work suggests that men and women are motivated to work to maintain or even enhance their material well-being. If this were the only reason, it would follow that once the typical person has all the money necessary for material possessions and well-being, then that person would stop working. In 1953 and again in 1969, Kahn3 asked this of working men. Kahn found that in older men (55 to 64 years old) , 60% would have continued working in 1953, and about 55% would have continued working in 1969. Results also showed that for the youngest age group (21 to 34 years old), about 90% would have continued working in 1953, and about 85% would have continued in 1969. Accordingly, the responses to this question vary depending on the age group sampled and show a very slight downward shift from 1953 to 1969. Nevertheless, many men wanted to continue working regardless of financial resources. It would, of course, be interesting to ask this question today to both men and women, particularly in light of women becoming increasingly active in the work force.
* Work is a form of activity. One rational for wanting to continue working - even with full financial stability - is that work fulfills the need to be active. The so-called principle of "least effort" posits that an organism feels dissatisfied during and following the expenditure of energy. Researchers, however, have found that animals will engage in high activity following periods of forcibly restricted activity. Conceivably, there is some optimal level of human activity where lower amounts are unpleasant and tend to result in an mercase in activity level. Higher amounts, on the other hand, result in fatigue and also are unpleasant and tend to result in temporary decrease in activity.
* Work structures time. Work determines at what time people awaken and for how long they will be away from home and for what reasons. In addition, work structures what is actually done at home or away from home. Work, too, provides a timetable of progressing through work life up to retirement. It differentiates days off from work and workdays. When people are not working, for whatever reason, this tends to blur the way they have previously structured their daily lives.
* Work is a source of creativity and mastery. In 1943, Hendrick4 postulated the ' 'work principle.' ' He stated that pleasure is derived from work as a consequence of the satisfaction of the "instinct" to master and to manipulate the environment. Work is primarily motivated by the need for efficient use of "muscular and intellectual tools" in the environment. Hendrick's theory was that pleasure is sought by effective use of the brain for the manifestation of ego functions that enable people to master their environments. In addition, through work, creative activity can stimulate people and provide them the opportunity, for example, of coming up with novel ideas on how to complete a task.
* Work provides opportunity for social interaction. This function conveys the fundamental nature of people-namely, to be with other people. The workplace can be a source of support and empathy to help solve home life dilemmas and work productivity problems, to learn how to cope with a moody boss, and so forth, through friendships established there. Many people who do not work miss these interactions.
* Work is a source of identify People are, in large measure, known in terms of what they do and what they have done in the work world. In rural communities, people have "roots" because they know about each other's qualitative existence through cumulative knowledge of their family and friends. People know each other as members of this or that family, church, club attendance, and so forth. In urban areas, however, the job title and description carries more of a communication of identity and more in the way of status value. In relationships that are superficial and short-lived, one's work identity carries great value relative to introducing oneself and forms the basis of an introduction to the identity of another person.
* Work gives a person a sense of purpose. A bond forms between the person and the society where that person produces or does something and, therefore, feels needed. Work behavior gives people an opportunity to be useful and to satisfy needs for approval, recognition, and attention by producing or doing something for others.
Numerous clues show that work is essential to the maintenance of mental health. Por example, people who sleep too much tend to slow down in their mental efficiency and capacity to problem-solve in the environment. Significant, too, is that people who do not work may often turn to drugs, become involved in aggressive destructive activity, or may become depressed. When the work week is reduced or diminished for whatever reason, healthy people may find work alternatives rather than explore leisure time.
Freud described love and work as cornerstones of healthy adaptation. He viewed work as the single most important way of absorbing hostility and aggression. It is not surprising then that work activities occupy more of a person's time than any other form of activity, including sleep. Work behavior is certainly not always manifested in a "job," but is extended to many areas of a person's life, such as maintaining a household, a family, and raising children.
Thus, work has to do mainly with the mastering of the environment. Beyond providing the basic necessities of life, work functions to form the framework on which mastered activity is structured in time, is a source of identity, gives a sense of purpose, and provides a place to relate to others.
EFFECTS OF JOB LOSS IN Ttt ABSENCE OF INDUSTRIAL INJURY
Given this background on the functions of work behavior, it is important to understand what may happen to a person when involuntary job loss (unemployment) occurs - where work injury has nothing to do with not working. It is clear from this background that if a person loses his or her employment, a corresponding loss of the major environmental source where these functions are satisfied or achieved occurs.
The psychological reactions to unemployment may not be that different from the injured worker population. The person who feels stressed at work or who has injured a part of the body may be psychologically impaired not only in the workplace, but also in other aspects of daily life. It is assumed that the unemployed person can fully function both in work and nonwork contexts and is, therefore, not impaired to compete in the open labor market - but only after healthy resolutions of the reactions to unemployment have been manifested.
Protracted periods of unemployment may cause various psychosocial problems. Many investigators5-8 have described these unemployment reactions. Hopson and Adams5 identified seven transitional stages that the unemployed person may go through from the point of work cessation (also noted in Hayes and Nutman2). These stages produce varying levels of self-esteem changes and are described below.
* Immobilization. The first stage is one of immobilization, where there is a feeling of shock and numbness. The individual at this point is unable to reason clearly, plan, or understand what has happened relative to the news that he or she has lost a job.
* Minimization. This stage is characterized by marked denial and an attempt to maintain a positive attitude as if the event had not occurred. This produces an artificial increase in self-esteem that may not last very long.
* Depression. The third stage is depression. Most people confronted with repeated objective evidence of not working may come to realize that some changes in their lives must be made. These individuals become reactively depressed because they are first feeing the feet that changes must be made relative to finding another job - while at the same time not knowing exactly how to make these changes by mastering the environment and procuring another job in the open labor market.
* Acceptance of reality - letting go. The fourth stage is acceptance of reality - letting go, where eventually the unemployed person has to accept a changed reality. It is at about this time that he or she has to let go of the assumptions of the pretransitional situations and find new ways to cope. Mental flexibility relative to alternative plans to secure a job must take place. This, in effect, can be a stressful event, and self-esteem decreases.
* Testing. This stage is motivated by feeling bad; that is, feeling depressed and anxious, but nevertheless forced to act The individual begins to feel a little better as he or she tries out new behaviors and attempts to develop new ways of coping with the situation of job loss by arranging job interviews. As the fifth stage of testing continues, more perceptual processes occur that are adaptable to flexibly scanning additional available job alternatives.
* Search for meaning. By "search for meaning," Hopson and Adams3 were suggesting some success in obtaining job leads and generally feeling hopeful following job interviews. At this point, self-esteem increases beyond the testing stage in the search for meaning stage, followed by even more increased serfesteem in stage seven.
* Internalization. By this stage, the person has internalized and integrated at some level of consciousness the entire seven-stage process.
In this version of the transition reactions to job loss, the entire process from the point of job loss is a growth process that in time may make the individual feel better than he or she did prior to losing the job. In effect, the person has problemsolved and mastered the threat and challenge of job loss.
Job loss or unemployment may produce a succession of mostly negative reactions that can in the end lead to rewarding forms of adaptation. People who are not psychologically healthy may not be able to react to the trauma of job loss successfully. Similarly, if an individual fails to find employment, the various functions of work behavior will not be available and reactive psychiatric illness may occur.
Most injured workers have a recent or immediate history of not working. What one finds, therefore, is a most complex individual with regard to ascertaining the relative impacts of job injury, not working, and adjustment to infirmity or whatever psychiatric diagnoses are in evidence. Further complicating psychiatric/psychological evaluations of the injured worker is the discovery that some people have demonstrated psychiatric problems in their past histories that make them much more vulnerable to developing psychiatric problems because of work injury and work cessation, than would be found in persons with better psychosocial histories.
ETIOLOGIC PARADIGM OF THE PSYCHOLOGICALLY INJURED WORKER
The etiology of psychiatric iilness in a person who has been injured within the workplace must be determined. For the sake of discussion, one must remember that because of work injury, the person is not working and the psychosocial functions of work are not operative or being satisfied in the injured worker. Also, the injured worker may be unable to seek another job or return to regular employment because of the work injury (physical, psychological, or both).
In these situations, the injured worker may initiate a workers' compensation claim against the employer. The employer, or the workers' compensation insurance carrier, may be charged with the responsibility of paying benefits because of alleged psychological harm, as well as psychiatric disability thought to have occurred at the workplace. Usually, attorneys representing the injured worker and the employer (and its insurance carrier) are involved. It is necessary for the evaluating psychiatrist and psychologist to determine objectively if the injured worker's present psychiatric condition and disability were directly caused by the workplace or if what happened in the workplace aggravated or worsened preexisting psychiatric conditions. Obviously, if neither of these alternatives is correct, the person's psychiatric illness is not regarded as industrially caused.
In the 1960s, a series of articles by Hirschfeld and Behan appeared that continue to be relevant.941 The so-called "accident process" was the focus of the articles, and one of die articles11 described a paradigm (Figure 1) that continues to be useful in evaluating the injured worker from a psychiatric perspective. Hirschfeld and Behan found that the causes of a work "accident" were likely to be found in the past histories of many but not necessarily all injured workers. As depicted in Figure 1, the individual's personality difficulties may likely contribute to a troubled life situation in environments perhaps both in and out of the work situation. The combination and interaction of the personality difficulties and the troubled life situation might cause depression, anxiety, or some other syndrome that is unacceptable as a disability to the individual.
Hirschfeld and Behan's Paradigm of the Injured Worker*
Updated Paradigm of the Injured Worker
As the psychiatric syndrome intensifies over a period of time, the individual may be vulnerable to developing some form of illness and may have an accident. An accident can be in the form of a minor physical trauma - at that point creating a sense of unconscious freedom from the individual's previous personality difficulties and troubled life situation. Complaints of pain, therefore, far in excess of what most physicians would predict based on examinations and laboratory studies, become an acceptable disability, thereby masking the past histories of underlying personality problems and a troubled life situation. Accordingly, the psychiatric disorders at both A and C in Figure 1 have been present long before the accident at D. Individuals with these kinds of preexisting problems who go through this process to the accident can be described as being unaware that they are "in search of an accident" to happen at work. This accident may mask not only preexisting problems, but also may be psychologically compensable in complex ways relative to gratifying dependency needs. As this entire process spirals and goes untreated, "chronic invalidism"12 may take place.
Paradigm of the Psychologically Injured Worker
An update of this paradigm of the etiology of psychiatric problems in the injured worker is shown in Figure 2. This etiologic paradigm demonstrates the injured worker whose cumulative past histories of problems have made him or her vulnerable for workplace injury, and the evaluating doctor must then determine whether the injury worsened or aggravated these complex preexisting conditions.
On the other hand, an individual who sustains a psychological work injury may not have a significantly problematic past history. The paradigm depicting this is presented in Figure 3. The injured worker's psychiatric condition could be seen as a direct product of what happened within the workplace and this further contributed to impairment or disability within the workplace.
Clearly, in order to establish which of these paradigms is correct, the psychiatrist and the psychologist must interview the person thoroughly, review all medical and occupational records and other records appropriate to a given case (such as military records and school transcripts), and review the results of psychological test data. Rather than concluding that either of these paradigms is most likely correct, it may well be that some other paradigm best depicts a given situation (eg, despite the worker's long history of psychiatric problems, the head injury at work is the most probable explanation for brain pathology and accompanying neuropsychological deficits).
GENERAL METHODOLOGICAL CONSIDERATIONS
The Hirschfeld and Behan paradigm11 of tracking the psychosocial processes leading to work injury and disability, along with the updated versions, should clearly demonstrate the complex and likely mutually interactive factors that must be considered in the diagnostic process. These factors include:
* the impact of the documented physical or psychological injury(ies) in the workplace,
* the impact of not working (relative to the seven functions of work) ,
* the impact of each of the treating and evaluating doctors up to this point,
* the impact of the adversarial nature of opposing attorneys, deposition (s) taken from the injured worker, etc,
* the impact of troubled life situation (s) (if not ruled out) in immediate, recent, and past nonwork histories,
* the impact of preexisting DSM-JIlR, Axis I, Axis IJ, and Axis III disorders (if not ruled out),
* the impact of genetic predisposition of emotions, mental, and personality illness,
* the cumulative impact of previous employment performance,
* the impact of the employer's attitudes, family members' and friends' attitudes, and vocational rehabilitation professionals' attitudes,
* the impact of the initial physician/nurse contact following the injury at work, and
* the impact of the insurance company and the attitudes of claims handlers.
Because of the nature of this particular population of patients, it is not advisable for the psychiatrist or psychologist to conduct the evaluation alone. The expertise of a psychiatrist, with current knowledge of general medicine, is mandatory hi this type of evaluation as a means to thoroughly review all medical records, often including very important hospital records. The expertise of a clinical psychologist, with knowledge in psychological assessment, is also mandatory because test data can be of help not only in determining diagnostic conclusions, but also in determining functional strengths and weaknesses relative to the levels of work impairment.
Figure 4. The four cornerstones and the central keystone in the interdisciplinary psychialiic/clinical psychologic evaluation of the injured worker.
Within the context of the interdisciplinary evaluation team, both the psychiatrist and the psychologist should interview the patient. The clinical psychologist must conduct an interview of such length and content as to interpret psychological test data with the knowledge of contextual variables. In addition, the psychologist must have access to relevant medical, psychiatric, occupational, and other records in order to better understand the nature of the patient's problems and better interpret the test data.
Figure 4 depicts the most important aspects of information- and data-gathering processes within the context of the psychiatric/clinical psychology interdisciplinary evaluation team. The ultimate goal for the interdisciplinary team is to provide referral sources with fair and unbiased companion reports that clearly describe diagnoses, causation, and whether functional work impairment exists in a person who has filed a workers' compensation claim. Taking into consideration all the factors and variables described in the previous sections of this article, the interdisciplinary team can best approach these complex diagnostic reasoning tasks.
1. Chaplin JP. Dictionary of Psychology. 3rd ed, rev. Laurel, 1985.
2. Hayes J, Nutmaii P. Understanding lite Unemployed: The Psychological Effects of Unemployment. New York, NY: Tavislock Publications; 1981.
3. Kahn RL. On the meaning of work. J Occap Med. 1974; 16:716-719.
4. Hendrkk I. The work and pleasure principle. Psychiatr Q. 1943; 12:87-97.
5. Hopson B, Adams J. Towards an understanding of transition: defining some boundaries of transition dynamics. In: Adams J, Hayes J, Hopson B, eds. Transition. London, England: Martin Robertson; 1976.
6. Harrison R. The demoralizing experience of prolonged unemployment. Department of Employment Gazette. April 1976; 339-348.
7. Eisenberg P, Lazarsfeld PF. The psychological effects of unemployment. Psychol Bull. 1938; 35:358-390.
8. Kauffman HG. Professionals in Search of Work: Coping With the Strass of Job Loss and Underemployment. New York, NY': John Wiley & Sons; 1982.
9. Hirschfeld AH, Behan RC. The accident process, I: c-uological considerations for indusirial injuries. JAMA. 1963; 186:193199.
10. Behan RC, Hirschfeld AH. The accident process. II: toward more rational treatment of industrial injuries. JAMA. 1963; 186:300-306.
11. Hirschfeld AH, Behan RC. The accident process, UI: disability: acceptable and unacceptable. JAMA. 1966; 197:125-129.
12. Nemiah J. Psychological complications in industrial injuries. Arch Environ Health. 1963; 7:481-486.
Hirschfeld and Behan's Paradigm of the Injured Worker*
Updated Paradigm of the Injured Worker
Paradigm of the Psychologically Injured Worker