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COURAGE TO COWARDICE:
OPTIONS FOR WORKPLACE TRAGEDY
by Robert C. Larsen, M.D., M.P.H.
Learning Objectives
Abstract
Employees respond in a variety of ways to a framework of benefits when injured or made ill by occupation. Disability tends to be viewed as a state relative to an individual. While using case examples, the author describes personal characteristics as well as organizational factors that affect the ultimate outcome. Rather than using psychopathologic concepts, the attributes of courage, resilience and loyalty are contrasted with such feelings as anger, misunderstanding and victimization. Employers, with assistance from occupational physicians, should consider incentives for overcoming disability.
Introduction
O |
ver the last century employment law in the United States has evolved to encompass a set of protections regarding employee health and safety. Workers' compensation law is one set of protections in a safety net of other state and federal statutes covering such issues as minimum wage, equal protection, child labor, unemployment benefits, Social Security and non-industrial disability.1 Employees today take for granted many protections that exist which only came about as the result of hard fought battles between labor and management. While the employee of the early 20th century assumed the risk for working in a manufacturing environment with numerous environmental hazards, the early 21st century American employee has the expectation that in most circumstances a no-fault system will apply to any injury incurred. The nature of the work environment has evolved as have the types of injury and illness that one might incur as an employee. The concept of what constitutes an injury or disability has certainly changed over time. No longer does one consider just singular events but rather we understand that occupational exposure over time can bring about conditions such as asbestosis and black lung disease. In the early 20th century, when this author's great-grandfather was killed while helping to build the Lincoln Park Lagoon in Chicago, protections did not exist that would allow his family to receive death benefits and remain as legal aliens in this country. Many decades later when I witnessed the crush injury of a co-worker while employed in the Construction Materials Division for W.R. Grace & Company, the reality of the risks involved in being a working person hit home. There are innumerable ways in which employees place their health and well-being at risk. Hazards are inherent to activities such as harvesting, mining, working in the elements, law enforcement, money exchange, building construction, transportation, heavy equipment operation, manufacturing, healthcare, fire fighting and so many other forms of arduous or treacherous activity. While life in general has its hazards, employment activity because of the challenges involved in producing goods and services has an associated cost of injury and exposure to those involved. This author intends to look at the concept of occupational injury and illness along with other forms of work-related tragedy as forms of natural occurrences for which government, employers, and employees and their representatives need to be prepared. The response to tragedy is contextual. Individuals respond based upon benefits, rewards and available options.
The concept of an occupational injury or illness no longer involves merely such obvious conditions as amputations, hernias and toxic exposure. A myriad of factors have led to accepted industrial claims for such diagnoses as multiple chemical sensitivities, fibromyalgia, carpal tunnel syndrome, Gulf War syndrome and post-traumatic stress disorder. Employee protections initially put into place to address acute physical injury have evolved to cover claims of long-term employee burn-out. Additional employee protections have come about over time which have involved accommodation of disabilities.2 In situations where such accommodation is not provided, vocational rehabilitation may be necessary. These employee protections along with wage replacement and permanent disability benefits are a form of assisting and compensating the employee confronted with the tragedy of work-related injury/illness. This author contends that employees and their support systems then respond in a variety of recognizable ways to this administrative and legal framework of benefits. Consideration should be given for the use of incentives directed at employees, employers, insurers, health providers and others involved in the injury/disability process toward the goal of overcoming adversity as opposed to giving in to such. A system of recognition and reward for courage overcoming impairment is contemplated.
Optional Responses to Tragedy
Loyalty, commitment and courage are virtuous traits in any given worker. Do they accrue over time as elements of individual growth and development? Are they attributes for which profiles exist so that organizations can recruit candidates already possessing them? Are they fostered by the company through example and leadership? Perhaps a combination of individual growth and development, careful selection, and reenforcement by the organization are all operative.
What causes an employee to excel is both intrinsic to the person and encouraged by the entity he/she represents. Loss, challenge and conflict may be met by a response where the individual fails. Self-esteem is reduced and at least the perception is that support has not been forthcoming from the organization. Yet a very different outcome is seen when the employee feels a kinship with peers and management. Similar forms of adversity can instead be viewed as an opportunity to prove one's self. Product development, intellectual achievement and customer service come forth where the alternative is stagnation, disability and alienation.
People work together usually with the purpose of producing goods or services of value to others. In that process employees are subjected to various types of physical and environmental stressors. Some of these may be predictable and thus expected. Unexpected and unplanned for stressors are perhaps most noxious as they can unduly challenge the individual's ability to appraise and cope.3 Whether common or not these influences are often experienced as adverse. Physical insult and injury is accepted as a part of life and the work process. Even psychological injury is considered to be a risk for occupations fraught with adversarial interchange. So how is it that some employees become fortified by the same circumstances that cause disability in others?
Carlos Rivera is a forty-five year old heavy equipment operator for a utility company. He has worked for his employer for eighteen years. Three years ago he was operating a crane when the machinery came into contact with high voltage wires. He was electrocuted in the process with co-workers coming to his aid. Emergency medical intervention could not prevent irreparable damage to the upper extremities. Mr. Rivera went through a lengthy convalescence though ultimately returned to work with his crew members. His employer made modifications to the equipment he operated which allowed him to use controls with a prosthesis on the non-dominant arm and absent digits on his primary hand. He reported symptoms consistent with phantom limb pain and depression. However, he made no use of analgesic nor psychotropic medication. When asked how it was that he had not applied for a disability retirement, he stated that he enjoyed his work and wanted to be an example of perseverance for his three children.*
There is little doubt that clinicians and social scientists could debate what allowed for this man to respond as he did. Yet it would be too simplistic to conclude that he is merely opting for a path of reward or recognition. While heroic acts are generally brief in duration, overcoming adversity of the type experienced by Mr. Rivera requires sustained effort. His response exemplifies courage. To win the Medal of Honor takes bravery while surviving an odyssey requires the persistence of Ulysses. Support from the organization as well as the larger society is also necessary. Mr. Rivera's case demonstrates courage intrinsic to the individual with accompanying support and assistance by the employer and the healthcare system.
Two cousins John White and Charles Smith grew up in a community where their families spent much of their time together and the two young men ended up as best friends. While they had gone off to different colleges they later founded a telemarketing agency though they were unsuccessful in growing the company. Instead they both went to work for a children's home where Mr. White was employed as a counselor and Mr. Smith was a lower-level administrator. They were both somewhat critical of decisions made by the facility manager. They each complained at times about the physical facility, the program of services available to residents, and safety concerns. Within months of coming to the home they found themselves dealing with a break-in. The incident involved an armed intruder looking for a teenager who had been residing at the facility. Mr. White and Mr. Smith were instrumental in distracting the intruder which allowed all of the children and staff to escape unharmed. Local police responded. The children were temporarily moved while increased attention was given to security at the facility. Mr. White, Mr. Smith and another staff member did not return to work. They each were referred for counseling by the employer. They each obtained legal representation and opted to see a different psychologist than that selected by the employer. One year after the incident in question the three employees have made demands that they be provided with counseling services (for reported fears of further untoward events), financial support and retraining. Profound themes of anger and mistrust toward the employer and its representatives are put forth. Both Mr. White and Mr. Smith consider that they had acted heroically in saving the children yet they feel that they should never have been placed in such a vulnerable situation. Not only do they each state that they cannot return to the exact worksite, they claim to have lost faith with employers and institutions in general. Mr. White is interested in obtaining business training to become a manager himself while Mr. Smith does not know what he might be capable of, if he cannot function as an administrator. The treating psychotherapist for both men offers the same diagnosis of post-traumatic stress disorder. The prognosis is listed as guarded.*
The scenario described in this case demonstrates how a critical incident that seemingly turns out well can still have adverse consequences for the work site. The criticism that these two employees had for the management team that predates the critical incident clearly affected their response to the event in question. Despite giving attention to security issues and recognizing the need for acute intervention, once the matter had been reported to the police, the employees took the position that these actions were too little and too late. An adversarial relationship became apparent in the employer/employee relationship. An awards dinner to recognize the two employees for their actions at the time of the critical incident never took place. The two men proceeded over time to emphasize how their lives had been irreparably changed for the worse. Rather than viewing themselves as having demonstrated courage they emphasized their sense of vulnerability. The treating counselor concurred with the conclusion that these men would harbor feelings of anger, victimization and mistrust on an ongoing basis. Some months after the incident took place it was apparent that no intervention would allow for a rapprochement between the parties involved. In the author's analysis, what could have resulted in two employees being commended and valued has instead become a source of litigation and prolonged disruption. Employer resources in this case cannot compensate, from the disgruntled employees' perspective, for the pent-up animosity and resentment.
Psychiatric Syndromes in the Modern Workplace
Emotional, behavioral and interpersonal problems are commonly experienced by employees at work and elsewhere. They run a spectrum from time-limited adjustment disorders to lifelong forms of mental illness involving depression, psychosis and other chronic disorders.4 Mental conditions may be expectable, mild symptomatically and non-disabling. Alternatively, they are not always predictable and they can be recalcitrant to treatment and severely disabling. At times the workplace is simply the passive stage for the playing out of an employee's psychopathology. In other cases employment circumstances can actually contribute to if not precipitate an initial episode which brings someone to the attention of mental health practitioners. Not uncommonly depression and anxiety are secondary consequences to serious physical injury and disability. When taken as a whole mental disorders represent an enormous challenge as well as burden to society. According to a World Health Organization study, in 1990 mental disorders accounted for five of the top 10 disabling conditions worldwide.5 The forecast is for conditions such as major depression, anxiety disorders, bipolar disorder, schizophrenia and alcoholism to represent the most common sources of disability when compared to all other medical causes. Thus, employers and policy makers need to be mindful of the common occurrence of psychiatric syndromes when involved in the process of healthcare planning. It is all well and good to commend the individual who demonstrates bravery and sustained courage when dealing with employment tragedy, but without supportive resources such employees will be far less likely to achieve a satisfactory outcome. The following case demonstrates how resources that are poorly implemented can bring about an undesired result.
While working beyond his normal work shift, Herbert Brooks is asked to clean up a chemical spill at a medical laboratory. This thirty-five year old man finds himself fighting off acrid fumes. He is initially told that soap and water should be able to resolve the matter. More than one hour into the task he is told by a co-worker to leave the area immediately. The office building is evacuated and he finds himself approached by a local hazardous material team who instruct him to disrobe and don a set of special coveralls. The initial ambulance on the scene refuses to transport him as the chemical(s) had yet to be identified. When at the emergency room he is told that the Material Safety Data Sheet for the culpable hydrochlorine compound indicates that there should be no long-term consequences. Some days later the employee is released to normal duties by the treating occupational medicine physician. Referral is made for mental health services at the point that Mr. Brooks panics upon entering the worksite. Many months go by and eventually he reenters the laboratory structure. However, he describes an existence in which he remains convinced that his life has been foreshortened. No amount of reassurance can assuage his fears. He sees himself as infirm and routinely presents at urgent care centers with unfounded physical complaints. He submits that all he desires is to be made whole once again. Mr. Brooks has spent many months meeting with a counselor who has taken a supportive approach. However, the mental health practitioner has not confronted his patient about the misperception of information regarding the exposure and continued unfounded fears. Mr. Brooks has received re-enforcement for his perception that his body's resilience and ability to fend off insult has been weakened. Psychotherapeutic chart notations from both individual and group psychotherapy describe Mr. Brooks as having incurred a serious insult that will continue to adversely affect his health and longevity. No effort has been taken by the treating psychotherapist to actually review reporting of other treating and evaluating doctors relative to the exposure incident.*
In this case what is seen is the assumption of marginal functioning in response to an acknowledged exposure. Mr. Brooks demonstrates a lack of resilience and faith. An incident that had been psychologically disturbing for the applicant has in large part been allowed to linger as a result of re-enforcement by a treating clinician. This man is actually being encouraged to take on the role of an invalid, far more than the circumstances justify. A lack of communication amongst treating clinicians as well as an actual disdain for the facts on the part of the treating psychotherapist have helped to bring about a less than optimal outcome. While Mr. Brooks is back at the workplace, he now sees himself as needing mental health services on an indefinite basis. He has become highly dependent as he passively defers to his psychotherapist. Group sessions have become his major social outlet. He describes life as a miserable struggle from which he hopes to be saved. He views his existence in terms of who he was pre- and has become post-exposure, such that in the past he was "normal" and now he is "different." He remains fixated on the notion that if the passage of time alone cannot cure him, he needs others to understand that he is still frightened when being around chemicals in general. He has been told that symptoms of anxiety once established can become an everlasting part of one's existence. Mr. Brooks' scenario is one in which coordination of resources and benefits did not take place and the end result is unsatisfactory when measured by quality-of-life and functional ability. This unsophisticated man of modest intelligence never had the chance to respond courageously as he was not disabused of his misunderstanding about the exposure. Clinicians who are inexperienced or have little interest in knowing pertinent facts can unfortunately prolong and intensify the response to tragedy. The next case illustrates how appropriate intervention can assist the individual employee to exemplify resilience rather than remain a victim.
Linda Chan had come to her first full-time job soon after completing her undergraduate studies at a state university. She took pride in having completed her undergraduate degree in the rigorous field of biochemistry. She had escaped with other family members while she was a teenager from her homeland in Southeast Asia. After coming to the United States she learned English and excelled in the public school system. After completing high school she went on to study at a local junior college while living in her family's home. She met an engineering student from her homeland and the couple were married prior to her completing her undergraduate studies. Within her first year of employment as a quality control inspector she had made it clear to the employer that she was interested in taking night classes toward the goal of attending pharmacy school. She found her hopes literally crushed as a result of her dominant hand being mangled while working alone in the plant's laboratory. She describes a horrific incident in which her hand became caught in a piece of machinery with her being unable to extricate herself or to easily bring the equipment to rest. After multiple surgeries and many months of rehabilitation, Ms. Chan was left with a non-functional, cosmetic prosthesis and the conviction that she no longer had a future. Employee and employer representatives agreed upon providing psychiatric services in addition to the necessary medical care. Issues of guilt and shame were addressed within the psychotherapeutic context. Couples sessions were provided to allow Ms. Chan to discuss her negative feelings with her young husband. She has found herself convinced that she may simply have to accept her profound limitations, though initial steps have been taken toward exploring options for a functional prosthesis. Ms. Chan responded remarkably to giving birth to her first child. She again saw herself as lovable and became invested in her family's future. She no longer wishes to pursue her dream of applying to pharmacy school. Instead, while continuing to experience some features of anxiety and depression, she plans to return to an alternative job position using her technical skills. She evidences neither bitterness nor resentment regarding her fate.*
A common accompaniment to courage is resilience. Ms. Chan has demonstrated resilience in her response to being a refugee and immigrant. She had overcome adversity in the past but the disfiguring injury and amputation have seriously challenged her. For a time she no longer saw herself as capable or having value. Her case if administered as a "standard disability" claim will most assuredly not achieve optimal results. Assessing a level of disability and providing medical care are necessary but not sufficient developments. Assisting Ms. Chan to view herself as able has been a further goal. With a good prosthetic outcome she may see others as supporting her. If given the required encouragement and financial assistance, she may find the courage to complete her retraining. The necessary ingredients appear to be present for this employee to enter the next chapter in her life going beyond the role of accident victim.
Courage, Loyalty and Productivity
The four cases discussed herein have examined the interplay between injury and adversity, courage and loyalty, and organizational support. No four scenarios could possibly cover the range of permutations when considering how the individual, the organization and society can respond to any given employee's challenge. In the best-case scenario the individual, such as Mr. Rivera in Case I, responds by demonstrating resilience and courage. This individual achievement is only possible when society, through its legal and healthcare systems, provides effective intervention. Quite a different outcome can take place when employee motivation and fortitude are either absent or misdirected. As in the case of Mr. White and Mr. Smith, the legal and healthcare interventions instead culminate in an adversarial process that is expensive for the employer and its insurer while resulting in two individuals putting their lives on hold. After a time the employer in that scenario can only take on a defensive posture. No doubt the work group suffers and productivity is adversely affected. The importance of a coordinated effort at reducing symptomatology, improving functional ability and renewing collaborative interchange is seen in the case of Mr. Brooks. The failure in that situation stems in large part from a healthcare provider who reinforces a response of assuming the victim role. Resilience as a positive prognostic indicator is seen in the case of Ms. Chan. A courageous response on her part has been fostered by a coordinated effort of the legal and healthcare systems. The individual's chances for success at returning to a productive status markedly increase when benefits are directed toward assisting the individual in becoming as whole as possible. One element to the necessary employee benefits or services to be provided in many scenarios during which the employee is dealing with trauma or tragedy is the mental health system. Based upon a review of business and healthcare studies certain authors have made the case for providing quality mental health services as a cost-effective means for improving productivity.6 The analysis for providing mental health services is the result of economic considerations from an epidemiologic standpoint. Those authors put forth considerations from a public health perspective as well that envisions the role of primary, secondary and tertiary prevention concerning various forms of mental health services to employees with mental disorders.
This author in a separate publication had similarly taken the position that a coordinated effort at mental health services, claims review, supervisor training and mediation services could reduce the incidence as well as the untoward outcomes of workers' compensation claims.7 The position taken in that publication was that rather than merely changing the definition of what constitutes an injury, an alternative set of interventions was proposed toward the goal of reducing the occurrence of claims. Early intervention and appropriate, effective benefit delivery were seen as measures in addressing a real problem for the modern American workplace. Health risk factors have become a focus of recent research. The HERO (Health Enhancement Research Organization) study involved a retrospective review of medical claims and health risk data which concluded that depression and managing stress were extremely costly risk factors when looking at medical costs.8 Those authors looked at other risk factors such as smoking, sedentary lifestyle, high cholesterol, hypertension, poor diet and other factors yet concluded that depression and stress were perhaps far more costly to employers and the society in general. Whether using an econometric model or one that considers individual case scenarios, there appears to be a defensible position for the value of mental health services coordinated with other appropriate benefits at achieving the goal of increased productivity. The econometric model concludes that it may be cost-effective in regard to overall healthcare costs to provide a range of mental health services to employees. The position taken in this paper is that qualitative factors such as courage, loyalty and external support are variables that can be addressed on a case-by-case basis as circumstances warrant. Where a structure exists that allows a capable employee to receive effective treatment, rehabilitation and other benefits, there is likely to be an offset against the costs of healthcare, disability and reduced productivity.
Further studies will no doubt take place regarding econometric models for examining the value of certain treatment interventions as they affect disability costs. This author proposes that pilot studies are needed at this point to consider the value of employers developing a structure of benefits and services for protecting employees against expected tragedy and trauma. We have evolved as a society such that individuals who incur obvious physical injuries at work are provided appropriate clinical intervention and disability benefits. That same system can encourage prolonged disability and often neglects the more complex problem of assisting the individual in returning to the workforce. For such fundamental change to take place it is likely that employers will need to be convinced that a program of services and benefits will actually be of value. Organizations such as the Robert Wood Johnson Foundation might well be recognized sources of financial support for such pilot projects. Certain jurisdictions have included incentives for employers to develop programs at returning employees to modified or alternative duties following disabling injuries. However, the economic climate in California is now such that there is serious question as to whether provisions in Assembly Bill 749 regarding return to work incentives will materialize in any significant form.9 Recent legislation in California has in large part eliminated vocational rehabilitation benefits for industrial injuries.10 Further "reforms" have used monetary incentives for employees that encourage return to work.11 Disabled employees accepting modified duties are to receive increased disability benefits compared to employees who do not.
It is quite possible that employers will remain focused on cost containment of healthcare services and continue to fight the merits of individual claims in the legal system. Perhaps when the obvious costs for dealing with tragedy and trauma in the workplace can no longer be ignored, a philosophical difference in perspective may allow for testing the concept of reenforcement of courage. If risk factors such as emotional distress and stress response are in fact no less expensive to employers than smoking and alcohol consumption, then working with challenged employees dealing with significant identifiable traumas may eventually become commonplace. From both a business and humanitarian perspective that would appear to be more desirable than a system that instead not uncommonly ends in disability and litigation. A comprehensive approach to dealing with employee tragedy instead contemplates recognizing and rewarding true courage as well as disability.
References
1. London DB, Zonana HV, Loeb R. Workers' compensation and psychiatric disability. In: Larsen RC, Felton JS, eds. Psychiatric Injury in the Workplace. Philadelphia: Hanley & Belfus; State of the Art Reviews; 3:4; 1988.
2. Americans with Disabilities Act, Public Law 336, 101st Congress, USA, July 26, 1990.
3. Lazarus RS. Psychological Stress and the Coping Process. New York: McGraw-Hill, 1966.
4. Larsen RC. Psychiatric syndromes common to the workplace. In: Rom WN, ed. Environmental and Occupational Medicine, 3rd Edition. Philadelphia: Lippincott-Raven, 1998: 881-889.
5. Murray CJL, Lopez AD. The Global Burden of Disease. Cambridge, MA: Harvard University Press; 1996.
6. Goetzel RZ, Ozminkowski RJ, Sederer LI, et al. Business case for quality mental health services: why employers should care about the mental health and well-being of their employees. J Occup Environ Med. 2002; 44:320-330.
7. Larsen RC. Workers' Compensation stress claims: workplace causes and prevention. Psychiatric Annals. 1995; 25:234-237.
8. Goetzel RZ, Anderson DR, Whitmer RW, et al. The relationship between modifiable health risks and healthcare expenditures: an analysis of the multi-employer HERO health risk and cost database. J Occup Environ Med. 1998; 40:843-854.
9. AB749, Chapter 6, Statutes of 2002, State of California.
10. AB227, Chapter 635, Statutes of 2003, State of California.
11. SB899, Statutes of 2004, State of California.