Mind games

Historically, insurers have always assumed physical injury to be the biggest predictor of the degree of dysfunction a person will suffer as a result of an accident.

Increasingly, attention is now being focused on the psychological impact of accidents and why failure to understand and prioritise this element of the rehabilitation process can delay recovery, make medical outcomes worse and affect compensation levels.

Dr Edmund Bonikowski, a consultant in rehabilitation medicine and chief executive of rehabilitation services provider, Kynixa, believes insurers are slowly waking up to the importance of psychological interventions - but says there is still a long way to go before there is consensus on the issue.

"Psychological rehabilitation has received considerably less attention in the UK than it has in countries such as Finland and Australia," he says.

"Yet we know that a purely physical rehabilitation model is inadequate and that rehabilitation programmes are far more likely to succeed if they allow for psychological screening and monitoring following an accident.

"Without doubt, the physical, social and psychological effects of injury influence each other and should not be seen in isolation."

A report in 2004 by an IUA/ABI rehabilitation working party found that in about 20 to 30% of cases, victims suffered disability and distress significantly greater than might be expected from physical factors alone. In about five per cent of cases, physical and social outcomes were affected to an almost inexplicable extent.

Such disproportionate outcomes had a sizeable effect on treatment costs, complexity of case handling and level of compensation.

"A claimant can have a minor trip but if, for example, he or she also has a history of depression or difficulty in the workplace, they can go way off the scale of psychological dysfunction and may need a lot of help to deal with psychological problems and get back into any job," says Dr Bonikowski.

"Much can depend on the severity of the trauma and the claimant's pre-injury state of health.

"After serious road accidents, for example, it is highly probable they will suffer some degree of depression, anxiety, post-traumatic stress disorder or specific phobia.

"If this is not detected early enough, they may feel that going back to work or being in social group situations are almost impossible challenges."

Medical and social care disciplines recognise the critical importance of psychological interventions on speed and levels of recovery. Dr Bonikowski believes it is now up to insurers to adopt this understanding.

Overcoming psychological obstacles to return to work

Jonathan, 36, a veneer cutter in a furniture workshop, had a horrific accident at work last January when both femurs in his legs were crushed when stack of MDF boards fell on top of him after he tried to move them.

He was taken to his local hospital at Evesham and, because of long waiting lists, had to wait two days before he was operated on.

The bones in his legs were fixed by the insertion of metal rods which ran from his hips to his knees.

Jonathan lives with his partner in a ground floor maisonette. With her help, plus help from his family and friends - and the installation of a few pieces of equipment - he was able to cope on his own during the day.

"I was a keen cyclist and had good upper body strength so could lift myself out of my wheelchair," says Jonathan. "After four months in a wheelchair, I progressed to a zimmer frame, then crutches and finally (walking) sticks."

Jonathan is now in a phased eight-week return to work. While his legs feel stiff, physiotherapists have told him there is no reason why he won't soon be able to return to the fitness level he was at before the accident.

While he remained positive throughout his recovery, he experienced constant flashbacks of the accident and was anxious about returning to work.

"When I first came out of hospital I had horrible dreams about being crushed and squashed," he said. "They went after a couple of months but, as I became more mobile, I became more frustrated."

"I became quite angry with work for allowing the accident to happen there - I had to focus the blame on something. I was also very nervous about going back to work and being in the workshop itself."

Rehabilitation services provider, Kynixa, arranged for Jonathan to have five sessions with a clinical psychologist in Redditch.

His case manager, Pippa Smith, said the timing of psychological intervention was critical as clients were often reticent in accepting they needed psychological help.

"You need to establish a rapport with the client before suggesting they ought to consider it. Many clients do not want to believe they are suffering from stress and that they would benefit from help in dealing with it," she says.

"The problem for Jonathan was that the post-traumatic stress he experienced following the accident was intrinsically linked to his place of work."

Jonathan says that talking about his anxieties and anger to a psychologist, who could provide objective help in analysing his feelings, gave him the confidence to believe he could begin working again.

"When I went back to work a few weeks ago, I did have some flashbacks, but the psychologist encouraged me to talk it through and not keep it bottled up.

"Now I am glad to be back at work," he says.