Include psych evaluation in initial treatment plan

It’s cheaper to deal with problems sooner

You’ve probably had clients with traumatic injuries or illnesses who just didn’t get better during the rehabilitation process — even when there was no physical reason for it.

When patients fail to make progress even though the physical evidence says they should, there may be underlying psychological issues, says Laurence Miller, PhD, director of psychological services for Heartland Pain and Rehabilitation in Lantana, FL.

"[Many] will call for a psychological assessment as a last resort, when the patient isn’t progressing and they’re pulling their hair out and can’t figure out why the patient isn’t getting better," Miller says.

Psychological management costs less

But it’s quicker and cheaper to deal with the problems early on, he adds.

"Studies and research have found that the inclusion of psychological management in any type of rehabilitation ends up costing less in the long run," Miller adds.

Most payers don’t routinely include psychological components in their treatment, but from the standpoint of patient care and expense reduction, it’s cheaper up front, he says.

He recommends a baseline psychological evaluation as part of any treatment plan to determine whether the patient could benefit from psychological services, biofeedback, or behavior modification.

"The less time since the injury, the smaller problems you’ll see. If you wait until later, you’ll have a firmly entrenched professional patient who is dejected and demoralized, and they can be much harder to treat and tough to handle," he adds.

Miller recommends a psychological component in the rehabilitation treatment plans for all patients rather than waiting until the last minute.

Assess recovery at six months

"I don’t believe everybody has to have extensive psychological treatment, but they should have an upfront psychological evaluation to see what role psychology can play in their recovery," Miller adds.

Whether a patient is experiencing chronic pain from a herniated disk or is recovering from a stroke or a spinal cord injury, he or she can expect to return to some semblance of stability within the first six months, Miller says.

"If at six months, a patient is continuing to experience severe problems that can’t be traced to a physical cause, ask the primary care or secondary care provider what is going on," he advises.

When you read the reports on the patients, look for indicators such as "the patient is not exerting maximum effort" or "the patient is not meeting his goals," Miller adds.

Physicians don’t always understand the nuances in psychological disorders. They may not know if the patient is malingering or if the symptoms are psychological, he says. That’s why it’s important that the patient’s psychological function be evaluated by someone with mental health expertise.

If you refer a patient for a psychological evaluation, call it stress management, not psychotherapy, Miller advises.

"But if they are resistant to it, it’s not something you can force down their throats," he adds.

There are a number of reasons why patients fail to get better when all the medical evidence says they should. They may be depressed and lack the will and motivation to meet their goals, or they may not have a clear goal in mind. In some cases, the providers may set the goals too high for patients to meet, setting them up for failure, which further demoralizes them and stops their motivation.

Or they may have a hidden agenda that impedes progress. For instance, a workers’ compensation patient may be anticipating a large financial settlement. A patient may be angry at the system because he got hurt at work and the only way to get back at his boss or the job is to remain impaired. Or, the patient may subconsciously enjoy being in a dependent role that allows him or her to manipulate other people.

When a patient isn’t getting better to the extent that you think they should, make an assessment and decide if it’s related to the injury, or to psychological aspects, such as the family or the larger social situation, Miller says.