Psychological Treatment Issues during Compensation Claims
Secondary Gain or Cry for Help?
A proportion of people who have been involved in an accident or traumatic incident develop psychological symptoms or disorder. The most commonly occurring of these disorders includes Adjustment Disorder, Phobias, Depression and Post Traumatic Stress Disorder. In addition some individuals will develop physical symptoms or an exacerbation of their post-incident physical symptoms as a manifestation of their psychological distress, perhaps the most commonly occurring of these being chronic pain. Many of those who do develop post-incident psychological symptoms, whatever form they take, will make a gradual recovery without intervention over a period of months but for some symptoms persist over some years or become permanent. One of the important questions that any psychiatric or psychological assessor must consider when carrying out a medical-legal assessment is whether these individuals with persistent symptoms are likely to benefit from psychological treatment. Because of the relatively limited supply of suitably experienced therapists and the high cost of treatment it is important that decisions about treatment consider all the relevant factors that contribute to either success or failure.
Some psychologists and psychiatrists who provide treatment for individuals post-trauma are reluctant to provide treatment if the person is involved in ongoing litigation because they have a belief that any treatment will be unsuccessful. The weight of this argument centres on the notion that as long as there is a potential for secondary gain attached to the index incident (such as a financial incentive) an individual is unable to recover because this will lead to reduced secondary gain. However, many authors in the psychological literature have highlighted that the issue of recovery from an index event is not straightforward and involves a number of interacting bio psychosocial factors, only one of which is secondary gain. This article will outline the main bio psychosocial factors as identified by the scientific literature that can also contribute as well as make recommendations about therapy for those with persistent symptoms.
Within the literature on health related outcomes and compensation cases there has been some evidence to suggest that litigation is bad for one’s health (Harris et al., 2005). It could be argued that this is because of two major factors. Firstly, that litigation is itself a stressful process that not only adds to the stress already being experienced by the injured person but also keeps the index incident to the forefront of the person’s conscious awareness. The second factor that prevents a person making a successful resolution of their symptoms is that of secondary gain. This can be material, such as financial reward, or it may be driven more by emotional need, such as the additional attention and support that the person gains by being injured, or it may be that the person gets out of doing things that they do not normally enjoy, such as a boring or unpleasant job. The secondary gain may be driven in a conscious manipulative manner such as when a person actively fakes or exaggerates physical or psychological symptoms or it may arise from unconscious psychological processes such as the magnification of pain or physical symptoms that can occur in an individual who lacks good self-awareness but has been traumatised and is suffering elevated anxiety and mood disturbance.
There is recent evidence in the scientific literature to support the view that at least some individuals are influenced by secondary gain of the financial type. For example, Cassidy et al. (2010) found that individuals who were involved in litigation that provides financial assistance to compensate for pain and suffering do not recover as quickly as those with similar injuries who are not involved in litigation. Also in a recent study Littleton et al. (2010) found that the health status of people with mild to moderate musculo-skeletal injuries was worse in a group claiming compensation compared to a group not doing so. However, they found recovery rates were the same between the two groups and suggested that some of the motivation to claim compensation was related to the level of distress, pain experienced and factors related to the index incident. A recent meta-review of the literature in this area by Spearing and Connelly (2011) concluded that the overall evidence does not support the view that being involved in litigation is bad for health although they acknowledged that many of the studies they reviewed suffered from methodological weaknesses.
If financial gain was the motivation for prolonged symptom duration it would be reasonable to argue that once ligation was completed a spontaneous recovery of symptoms would be seen. This is, however, not supported by the literature. In one study examining two severely injured groups, one litigant, the other non-litigant, at 4 months and 10 years post injury Wood and Rutterford (2006) found no differences between the groups on measures of cognitive ability to suggest underachievement either at an early stage of recovery, when the litigant group was assessed medico-legally, or after an interval of 10 years post injury. Measures of psychosocial outcome and psychological morbidity at 10 years post injury also failed to show any significant differences between the groups. The authors agued that the process of litigation did not have any long term effects in respect of illness behaviour. Similarly, Koren, Arnonand Klein (2001) found the best predictor of recovery from chronic PTSD was the initial level of post-traumatic reaction immediately after the accident, with severity of initial reaction to the trauma beingthe major risk factor for non-remitting chronic PTSD regardless of ongoing litigation. So, at the present time it is not clear just how much being involved in litigation is influencing symptom perception or recovery rates but it does seem clear that there is no overwhelming evidence to suggest that it plays a major part either.
There is evidence to suggest that there are a number of other factors that can influence symptom severity and recovery rates. For example, there is evidence that factors associated with the index event can have an effect. Some traumatic experiences lead to higher rates of psychological disorder than others. One study found PTSD symptoms developed in 11.6% of respondents who had suffered a sudden injury or accident, in 22.6% of those who had experienced physical assault and in 80% of those who had been raped (Breslau, Davis, & Andreski, 1995) . Interestingly the actual severity of the index event is not a good predictor of psychological outcome and the IUS/ABI Rehabilitation Working Party in 2004 reported that even apparently minor accidents can have a significant impact on a client, leading to greater physical deterioration and disability and slower psychological recovery rates.
Beliefs than an individual develops about the event that lead to anger, blame or a sense of injustice have also been found to influence the course and outcome of recovery in a negative fashion (Atherton et al, 2006; Cameron et al., 2008; Carroll et al., 2008., Cassidy et al., 2000), as does pre-existing vulnerability to psychological disorder and lack of emotional resilience (Breslau, Davis, Andreski & Peterson, 1991; McFarlane, 1989). It is our experience that the latter is one of the more significant factors in both symptom severity and delayed recovery process. Social support or perceived lack of support is also a significant factor in terms of recovery from ill health generally. However, it is perceived lack of social support that is relevant rather than actual social support. Hence, a person may appear to have close family to support them but if the person does not perceive them to be close and supportive they are unlikely to confer any advantage in terms of recovery.
Within our own medical legal practice many of those individuals who engage in litigation report that a major motivator for doing so has been to gain access to treatment for their injuries. Where psychological symptoms are concerned this is quite understandable as many NHS Psychological Services will not provide treatment for those involved in road traffic accidents. Usually Cognitive Behaviour Therapy is the treatment of choice as evidence indicates that CBT is effective for a range of psychological disorders including chronic pain, anxiety, depression, PTSD, phobias and general psychological distress (Morley et al.; 2009). Increasingly EMDR is also recommended particularly when the person is experiencing persistent symptoms such as flashbacks, nightmares and intrusive thoughts about a traumatic incident. For those with chronic pain disorders of bio psychosocial origin CBT, within a multidisciplinary pain clinic setting is usually preferable to stand alone CBT as both psychological and physical therapies can be designed to work alongside each other.
We have audited our reports over the past three years and although this is not a controlled study found that of 58 cases, where treatment was recommended and we saw them for a second assessment or received detailed therapy case notes for comment, 52% showed a significant improvement, 32% some improvement and only 16 % showed no change or got worse. This suggests that the majority of those referred for treatment do get better despite being involved in ongoing litigation. However, we accept that we do not have data on those for whom treatment was recommended but for whom we have no subsequent information.
In conclusion, although one must not underestimate the role of secondary gain in medical-legal assessments and disability it is important to consider these within a wider bio-psychosocial framework. Often what may appear to be a secondary gain may be a cry for help. Psychological assessment can help to identify areas for intervention and intervention is often effective despite ongoing litigation. Indeed effective and appropriate psychological treatment can be the key to avoiding longer term and seemingly disproportionate disability following accidents and traumatic events.
Atherton, K., Wiles, N.J., Lecky F.E., et al (2006) Predictors of persistent neck pain after whiplash injury. Emergency Medicine; 23: 195 – 2001
Breslau, N., Davis, G.C.,& Andreski, P (1995) Risk Factors for PTSD Related traumatic events: A prospective analysis. American Journal of Psychiatry. 152, 529 – 535
Breslau, N., Davis, G.C., Andreski P., & Peterson, E (1991). Traumatic Events and post traumatic stress disorder. Archives of General Psychiatry. 48; 216 – 222.
Cameron, I.D., Rebbeck, T., Sindhusake, D et al (2008) Legislative Change is Associated with Improved Health Status in People with Whiplash. Spine. 33: 250 – 254
Carroll, L.J., Holm, L.W., Hogg-Johnson, S et al, (2008) the role of pain coping strategies in prognosis after whiplash injury; Passive coping predicts slowed recovery. Pain 124 18- 26
Cassidy, JD., Carroll, LJ., Cote P et al (2000) Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash. New England Journal of Medicine. 342: 1179 – 1186.
Cassidy, D.J., Benidix, T., Rasmussen, C et al (2011 RE; Is Compensation Bad for Health? A Systematic Meta-Review – Letter to the editor. Injury. 41, 683-92.
Harris, I., Mulford, J., Soloman, M., Van Gelder, J., & Young, J. (2005)Association between compensation status and outcome after surgery: a meta-analysis. JAMA 293: 1644 – 52.
IUS/ABI Rehabilitation working party document (2004) Psychology, Personal Injury and Rehabilitation. International Underwriting Association of London. UK.
Koren, D., Arnon, I., & Klein, B (2001) Long term course of chronic posttraumatic stress disorder in traffic accident victims: a three-year prospective follow-up study. Behaviour Research and Therapy. 39. 12 1449 – 1458.
Littleton, S.M., Cameron, I.D., Poustie, S.J et al (2010). The Association of Compensation on Longer Term Health Status. Injury. 41. 1016 – 1021.
McFarlane, A.C (1989) The Aetiology of Post traumatic morbidity. British Journal of Psychiatry. 154; 221 – 228.
Morley,S., Eccleston., C and Williams, AC (2009). Psychological Therapies for the Management of Chronic Pain. Cochrane Review, 15 (2)
Spearing, N.M & Connelly L, B (2011) Is Compensation Bad for Health? A Systematic Meta-Review. Injury. 42 15-24
Weighill, V.E (1983) Compensation Neurosis: A Review of the Literature. Journal of Psychosomatic Research. 27: (2) 97 – 104.
Wood, R. Ll & Rutterford N. A. (2006) The Effect of Litigation on Long Term Cognitive and Psychosocial Outcome after severe brain injury.Archives of Clinical Neuropsychology, 21,3,239-246