Supporting and motivating employees in the RTW process video transcript
Video transcript of Rehabilitation Case Manager Forum – Supporting and motivating employees in the RTW process on 24 March 2021.
Watch the video from the Comcare forum.
I’m now delighted to introduce our first guest, Dr Jacqui Stanford. Jacqui is a health psychologist and a director at Empower Rehab, a clinic which specialises in providing interdisciplinary pain management, as well as working with clients presenting with a range of psychological presentations. Thank you so much for presenting to us today, Jacqui.
Thank you very much. And when I talk about some of the different things that we can do in supporting and motivating employees with return to work, I’m speaking as a psychologist who works with lots of clients in helping them get back to work. I’m also an advisor at WorkSafe. So, I’m involved in overseeing and contributing to a lot of different strategies to how we can help people in both recovery and return to work.
Before I start looking at some of the strategies, though, I think it’s important to acknowledge the challenges that we can find. And there are times where we can work with someone in getting back to work and it goes smoothly. And they’re the lovely ones. They’re the easy ones. Really today, what I want to talk about is what you can do, some different strategies and tools you can use when it’s not going so well, when there’s challenges there.
Some of the challenges that I’ll often hear is they’re resistant, they say “Yeah, but”, whatever you put forward, they’re always saying why it won’t work. You might have treaters who are overly protective. My doctor will tell me when I can return to work”, “Until all my symptoms go, I’m not able to work”. Often people go “When my pain is gone”. “When I’m no longer depressed”. “When the anxiety is finished, then I can work”.
It might be no collaboration from treaters, and Suzanne is going to be able to talk more about how to effectively work with treaters. It might be they’re not motivated. I often hear people say they don’t follow through on what was suggested. They came up with a plan, but they didn’t do it. And often I hear then they’re not compliant. They might be focused on other activities, “I need to get back to looking after my kids and doing things around the house, work’s not a priority yet”. These are some of the challenges that can happen when we’re looking at helping someone get back to work.
Interestingly, though, there’s another side. These are some of the other comments that I hear regularly. “My concerns haven’t been addressed”. “They don’t really understand, they’re not listening to me”. “They just care about work; they don’t realise how much this injury has impacted every part of my life”. “They don’t take into account the problems I’m having with this, or the relationship with this person, they tell me I should just make it work”. “They just sent through a plan and tell me this is what I’m meant to do. There’s no way that’s going to work”. “They only ever contact me when they want something. I don’t think they really care, I’m just a number”.
In order to get a good return to work, to get a good outcome, we need to address all of these barriers. Now thankfully, those barriers are not all there for every worker that we’re working with. But they are common. And I’m assuming all of you can think of other barriers that you’re aware of that have come up for you as well. Simply pushing and sticking to your agenda, all it will do is create more resistance. So we need to find a way to get the collaboration there so that we can move forward together, each of us in our roles, the employer, any return to work support people, treaters, family members all need to be there.
And one of the things I think is really important is we need to be talking more about recovery and return to work. Recovery needs to come first. However, not full recovery, because work actually can enable recovery. So, what does recovery and return to work look like? The really important thing to recognise is its individual, it’s not going to be the same for any two people. Because even if someone has the same injury, the same incident, how it affects each person is going to be different. At the moment, I’ve got a client who has an injury, and for him, recovery for him is him being how to run a marathon. Now there’s many of us here who don’t want to run a marathon even without an injury. And that’s not going to be important to us. So, we need to understand what it is for each person, what is recovery.
As we have that curiosity, and as we draw that out of people, we actually get a whole lot of information that we can use to help them as they move forward. Recovery needs to be integrated into every return to work discussion. It’s the ‘and’, it’s not all or but, it’s ‘and’. We need to look at your recovery, the supports that are needed there, and part of that is looking at what a return to work can look like. When we use the word ‘and’, it brings together things that enable us to move forward more effectively.
So, we need some recovery, to engage in return to work. If someone has a physical injury, and they might need surgery, or there’s a recovery process, they might need to go through it. But I think sometimes those more overt physical injuries and surgeries feel clearer. OK, the doctor said six weeks till they’re able to drive. Well, we’re not going to be looking at return to work for that period of time. I think though when we have chronic pain, or there are mental health injury issues that we need to consider, it’s harder to know how much recovery do we need to engage in the return to work process? Because we want to then use enough to get it started, but then use the workplace as part of the rehabilitation that can further enhance recovery as well.
So, to me, it’s going well, what are the barriers to return to work? That is the amount of recovery we need to start with. If someone’s sleep is so disturbed, they can’t get up in the morning and get to work on time, we need to improve their sleep enough to be able to get them to work. If someone is so anxious when you mention the word ‘work’ they have a panic attack, they’re not going to be able to return to work.
So, when we look at recovery, it’s managing the symptoms well enough while focusing on improving their function. Recovery needs to look at all areas of someone’s life. One of the really easy ways I find to draw this out is to ask someone, “So since your injury, since the incident of work, since the depression started, what’s changed in your life? What are some of the things you struggle with? How are you going at home? Personal care, domestic activity, social, leisure, work?”. As you start to draw out all the things that are changed, we start getting an insight into what needs to be addressed.
Sometimes, and when we look at chronic pain, so I’m involved in running a pain management program, when we look at pain management, we need to increase function in order to reduce the pain further. Same with mental health issues. Engaging in work or engaging in social and leisure activities is what can actually help improve someone’s mood, rather than simply waiting for mood to improve. I think many of us would have experienced aspects of that over the last 12 months, with the pandemic going on, when we’re not able to engage in our social, leisure and normal activities, it impacts our mood. Our natural antidepressant, our natural pain management strategies is our life. So, we need to actively help engage people in all areas of function, including work.
So when we specifically look at return to work planning, one of the really important questions is to ask someone “When do you think you’ll be able to return to work?”, or “When do you think you’ll be able to reengage with your normal duties?”. Ask them when they think. Because the biggest predictor of when someone will return to work is firstly how long they’ve been off work. But that takes time. We don’t want to wait for that. The next biggest predictor is what people believe. They can get certificates of capacity, they can get treaters to support, they will find someone to support what they’re thinking.
But I think sometimes we ask this question, but what we don’t ask often enough is why. And even more important, what else? Because I find the biggest barriers to people’s recovery and return to work is not the first thing they mentioned. It’s the second, third and fourth. “So, when do you think you’ll be able to return to work?”. “Well, my doctor says I need six more weeks of this treatment, and then I can consider it”. “What else?”. “Well, I hate my colleague, they think I’m faking it”. Ah, now we’re starting to get some of the barriers.
“Well, the duties are meaningless. I keep getting overlooked for promotions, and it’s not going to work”. As we draw out those second, third and fourth barriers. They are the reasons we get stuck in someone’s return to work and their recovery. We need to address each barrier. Ignoring them, does not make them go away. If anything, I think of them like elephants, when you ignore them, we end up with a herd of elephants that are stampeding through the recovery and return to work process.
Now, what that means, addressing the barrier, doesn’t mean we can fix everything, but it’s addressing it in some way and not ignoring it. And definitely not just doing reassurance. I think many times what we do as humans to try and help someone who’s anxious or concerned is we provide reassurance. “Don’t worry, just take it one step at a time, you’ll be fine”. Think about it for yourself. When you’ve been stressed or concerned by something, and someone tells you not to worry, what’s your first reaction? I hear most people say to me, “I feel like punching them. They don’t understand, they don’t get it”. So, we need to find a way to address the barrier.
Now for you, you might not be the one addressing each of the barriers. It might be engaging with treaters and asking for their help. Working with the employer and getting their help. But I think sometimes we don’t communicate enough around those barriers, and they sit there and impact on the recovery process. So, we need to find out what they are and find a strategy around it.
When we then are looking at Return to Work Plan, asking people, “How confident are you out of 10 you’ll manage this, and why?”. We want confidence to be seven out of 10 or higher. If someone says 10, I generally don’t believe them, because otherwise they’d already be back at work, they’d already be doing it. If someone says less than seven, ask them, “What would make you more confident?”. Because one of the traps that I see we can fall into is, if someone’s not confident in managing a return to work, we just reduce it. “Well, if you’re not comfortable managing 15 hours, let’s start with 12”. But guess what, it might not be the number of hours that’s the problem. It might be the fact that their sleep is disturbed, and they’re not waking up till 10 o’clock. And if I could start work at 12, in the middle of the day, then their confidence would go up. Or it may be that if they could have a colleague that they know that they can go to if they’re struggling, is what is going to make the biggest difference.
What we need to do to find this out, though, is to ask with curiosity, and allow silence. We generally, as humans in our culture, we do not allow enough silence. We ask a question, and then we jump in with our answers. We make assumptions. And then they agree. So, we think we’re on the right topic. But sometimes people haven’t actually had the time to think, so we need to give them that space to consider what it is.
I remember having a client recently, who was doing four hours a day in her work role and struggling. So, the physio said, “Well, let’s not increase your work hours”. And I said, “Hang on a second. Let’s find out more. Why do you think you’re struggling with four hours?”. “The four hours is really intense; I just don’t get a break. I’m on the go. And I’m struggling with it”. I said to her, “What would happen if you did a five-hour shift?”, “Oh, it would be so much easier, because then I get a 15-minute break”. If we hadn’t actually asked those questions, I can guarantee she’d probably still be on a four-hour shift, six months later. She’s now full return to work, because we actually found the barrier and realised by increasing her work was actually going to make it easier.
Similarly, we have those that when they have more hours, they feel like they can get more of their job done, so their stress is less, rather than simply giving someone less work hours to try and manage stress. And I assume we’ve all experienced that in our work at different times, sometimes a bit more time would actually make it less stressful, rather than less time. So, keep asking questions and listening.
I suppose the question though is, what if they’re not motivated? I get asked a lot about motivation. And motivation is a word that I’m pretty passionate about because I think we have a really poor understanding about what motivation is, and what influences it. We often, when we think about motivation, we think about the feeling of being motivated. We all like that feeling. But really, motivation is our reason for acting or behaving in a particular way. Motivation is actually a process. It’s a process that initiates guides and maintains behaviour. Notice how in there nothing is about feelings?
Think about it for yourself. How many of you have gone to work without feeling motivated to go to work? How many of you have ever cleaned your house without feeling motivated to clean your house, or have gone for a walk or a run without feeling motivated? As humans, we do not need to feel motivated to engage in an activity. Yet we often have this as our conversation with people. And somehow, we’ve got to gee up some motivation feelings from somewhere.
Interestingly, the feelings of motivation normally come from doing, not from not doing. But we can be motivated. But being motivated is our reason why we do something. And again, this is really subjective. This is really individual. And this is what we need to tap into with each worker that we’re working with to find out what their motivation is.
I think if I did a survey with you now, and asked each of you, why do you go to work? There will be multiple different answers. Some of you will say financial, others will say I enjoy it, it’s expected of me, I’m part of society. Some of you will go I don’t know why, I just do. Others, it’ll be achievement. Others, it’ll be expectations from family members. There’s a whole lot of different reasons why each of us go to work.
So, when we look at how to work with people’s motivation, we need to understand what it is that people want. We need to understand what the worker wants. But we also need to understand what treaters, what the employers need. Unless we’re looking at what each party needs and wants, we’re going to end up with a tug of war, but not a tug of war of two ends of a rope, probably an octopus level of tug of war, pulling in eight different directions and going nowhere. Only when we understand the needs, wants and desires of each person, and find a plan that can effectively work with each of those, do we get a sustainable return to work. It has to work for everyone. So, we need to listen and understand. And as I said before, it’s not just finding the first barriers, we need to understand their second, third and fourth barriers, they will be the things that get you stuck.
So, it’s good, easy, we’ve just got to find what’s important to everyone, gets one recovering, and then get them back to work. Except it’s not that easy. How can we influence these things? What is it we can do to actually achieve this? Its language is really important. And the biggest tool that each of us have in our role is communication. So, what I want to do is spend a few minutes now talking about some communication tools that will help you in achieving a focus on recovery, identifying the barriers, working out a Return to Work Plan.
The first thing I will say with communication is please do face to face wherever possible. Telehealth, Zoom, something wherever possible. Verbal when it’s needed. And written only when it’s a summary after a verbal or if you are closed for all other options. The reason being communication is about sending a message and receiving a message. In order to get that as effective as we can be, we need opportunity for clarification, we need collaboration. As I said, unless we get all eight legs of the octopus working together, we’re not going anywhere. We need to have that collaboration. The amount of times that I get sent a questionnaire, “Please send an update about your client”. I feel like I’d be curious what I could put on there, and what would happen with that information. Because there’s no opportunity for anyone to clarify what I mean by something or the implications about it. But a five-minute conversation can help us get on the same page so much more easily.
Also, of course, determining suitable time. One of the challenges I think we have in helping people in the return to work process is, we all have different agendas, timeframes, and rhythms that we’re working with. One of the biggest things that I think can get different stakeholders or parties offside, is when we don’t feel like our time is respected or appreciated. So, when you’re working with a worker as well, just because you’re ready to call them doesn’t mean it suits them. Find a time that is suitable for whoever it is you’re wanting to speak to.
Curiosity. Listen to understand. One of the things we do terribly as humans, this we don’t listen to understand, we generally listen to respond. And this is, with communication, I assume each of you listening communicates well, lots of times. You’ve got a job, you’ve got relationships. What I’m talking about is the sticky tricky ones.
When we are in a sticky or tricky relationship, what our brain does is, it becomes defensive. Our brain will find the points of disagreement. Think about when you’ve argued with your partner. When you’re having an argument, do you listen to understand where they’re coming from? Or are you actually coming up with your response while that’s happening? Are you looking at how you can defend and justify your position? That is exactly what will be happening with workers that we’re working with as well.
So, we need to listen to understand. And if you’ve got a relationship, someone you’re working with, that you find it hard to be curious, a couple of tips that make it helpful. Use a curious tone. Curiosity is something that actually conveys quite well even when it’s faked. So, it’s a higher pitch, it’s a slower tone. And what I love is, when you fake being curious, we actually become curious. So, if you’re not feeling curious about someone, change your tone, communicate differently, and draw out that information. And another way to help listen to understand is to ask a follow up question. Because in order to ask an intelligent follow up question, you need to have listened to what you’ve just heard.
Once we’ve got a good understanding of where someone is coming from, in order to move forward, we need that collaboration. We need points of agreement. Generally, we need at least two points of agreement before we can move forward with someone. We will do this naturally in relationships that work well. And one of the tools that I encourage people to do, is when you’re going into a sticky or tricky conversation, is come up with eight points of agreement before you go into it. What that does, it means you have to have thought being curious and interested in what’s going on. And what it means is you can use more naturally the points of agreement as they come up.
So, if I’m working with my client Bob on helping him get back to work. If I said to him, “OK Bob, today we need to look at what we’re going to do with getting you back to work”. I can guarantee half my Bobs would go “Oh, I don’t think I’m ready for work yet”. Resistance, defence is already up. Whereas if I say to Bob “Hey, this injury has really impacted your whole life. Your life is not the same way, and you’ve still got ongoing pain. And you’ve said to me, it’s really important that you want to get back to what you were doing before the injury. And that involved kicking the footy with your son, fishing with your mates, work, feeling like you’re contributing, that independence, is all stuff that’s really important to you. So, what I want us to do today is start looking at what that return to work pathway could look like, whilst we’re also making sure those other areas of your recovery are being looked at as well”.
As we create those points of agreement, what we’re doing is, instead of facing each other, almost in opposition, we’re coming around alongside that person, which allows us then to walk forward with them. Now, these points of agreement, if it’s a really sticky, tricky relationship, use three, four, five points of agreement, repeatedly. As soon as you feel like you’ve lost someone, as soon as you’re getting the ‘yeah, buts’, the defences, we need to go back to where you were on the same page and use more points of agreement.
So, it might be saying to Bob, “I know you don’t feel ready to return to work yet. I know you’ve got a lot of concerns of how that’s going to work. What is really helpful is let’s start looking at a plan, so we can take it one small step at a time”. What happens is when we validate those points of agreement, they don’t need to keep repeating them. We’ve already said it, so their defences can start lowering, and a plan is easy to come forward with.
Another thing that’s really important is to give people choice. Now the placebo research is fascinating. The placebo research when we look at it, we know that a lot of medication has a high placebo effect. And we know that that can be influenced by the size of tablets, the colour tablets, what we’re told about it, all of those things. One of the things that I find most interesting though is, you give people the choice between two placebos. They’re both sugar pills. If they’ve chosen which one, they want, they get an even better result.
Think about it for yourself. When you feel like you’ve got choice in life, how much more empowered do you feel than when you’re told what to do? I think one of the challenges we have in any compensation scheme is how do we empower injured workers to be functioning adults within the system, rather than accidentally take away their ability to choose and move forward and have autonomy? We need them in the driver’s seat.
So simply having two options, “Hey, would you prefer I touch base with you each week or each fortnight?”. “Would it work better for me to call you in the morning or the afternoon?”. Two options you’re happy with. When you give choice, 90% of people will choose one of those two options. The 10% will go “Actually I’d prefer three weeks”. That’s OK. But that’s now only 10%. Whereas if you’re telling someone “I’ll call you in the morning”, “Oh, that doesn’t suit me”, “Well, I’ll call you in the afternoon”, “Well, that doesn’t suit me either”. And we can get stuck very quickly. We want to keep the door open and help have options that they are happy with. And the more you have an understanding, compassion, and curiosity about people, the more likely you are going to select options that they are happy with as well.
So, a couple of key things from my perspective that I see in return to work planning. As I said, we need the worker in the driver’s seat. The biggest predictor of return to work is the worker, they are the biggest factor. We need them in the driver’s seat with support. I use that analogy with my clients all the time. I’m like, “Where are you in your car at the moment? Are you in the driver’s seat, or in the backseat? What’s in the driver’s seat of your recovery at the moment? Is it the pain? Is it the depression? Is it your employer? Who and what is taking control at the moment? And how do we get you back in the driver’s seat?”.
I love clients because they add to my analogies. They go “I’m not in the backseat, I’m in the boot”. “I’m holding on to the back-bumper bar of my life at the moment”. “I don’t think I’m even engaged with my life. I’m running behind my life”. So, it becomes a really beautiful tool to say “OK, so what can I do to help you get back in the driver’s seat? I’m not getting in the driver’s seat of your life. I’m not going to tell you what to do. I can give you advice, guidance, strategies, I can help support you, but ultimately, it’s up to you”.
One of the most regular things I see though with return to work planning, the classic Return to Work Plan for someone who hasn’t been working is Monday, Wednesday, Friday. The big problem that I see with this is it implies that someone needs a rest day. It basically says to someone we’re going to get you doing enough work on the Monday that you need Tuesday to recover. Which means we’re pushing too hard. I talk to my clients; now occasionally there’s workplaces where consecutive days aren’t possible. And some of them might have had non-consecutive days in their pre-injury hours and roles. What I’m talking about is the full-time worker, though, or the person who normally works Monday, Tuesday, Wednesday. We want consecutive days in any return to work plan.
What I love is I’ve done so much training in this, so if I speak to occ rehab providers, they go, “Well, the GP wants the rest day”. I speak to the GP and they say, “Well, the employer wants it every second day”. Everyone passes the blame on to some other party. Guess what? I hear it from everyone. What we want to do though is have consecutive days to communicate, hey, we want to make sure that you’re managing your work really well. And the only way that we know you’re managing your work well is if you can back it up the next day, and cook dinner, and spend time with the kids in the evening. When we can get your work level the right amount where you can do all of that, we know we’re on the right track.
I’ve never had a treater or client disagree with that concept when they realise why. We want to make sure this is sustainable. We all know that when there’s a failed return to work, the second one’s harder, the third one’s harder, and it gets harder still. We want to make this sustainable. So, let’s make sure that you can back it up.
The other problem that I see is, that plans don’t change often enough. Now, as humans, we don’t like change, generally. In particular, we don’t like transition, the bit between the change. So, what I do is I get my clients to discover that change is the normal, that’s not the change, we’re going to make such small and regular changes, that change is now normal. So, our Return to Work Plans that we set up, we would have people changing their work, often every week, by smaller amounts. Sometimes every shift, by a small amount. So, the change becomes normal. Whereas sometimes I see plants where it almost becomes like four weeks of a certain amount of something. The challenge then is by about week two, the person is starting to stress about week four. By week three, they’re petrified of what’s happening at week four. That stress and anxiety will exacerbate any mental health symptoms and exacerbate the pain and make it harder to progress.
As well though, the challenge is if you said to someone, “Do you think we should start with three or four hours a day? Or how many hours do you think would be good to start with?”. They say three or four. Most Return to Work Plans that I then see, people go, “Well, let’s see how you go with four”. We jump on the higher ones, good, because we’re getting closer to the return to work, we want. The challenge with that is we don’t know how confident they are. The challenge is that it can easily see you just pushing return to work. I’ll say to someone “How confident are you could manage the four hours a day?”. “Oh, I’ll give it a go”. “Out of 10, how confident?”. “Oh, I’m not sure”. “Out of 10, how confident?”. “Oh, five?”. “How confident are you you can manage three hours a day?”. “Oh yeah, that’d be much easier”. Start with the three. We want the wins; we want the runs on the board. Success breeds success. Failure breeds failure. We want to make it manageable. Get the wins early, they won’t feel like you’re pushing as much. And it makes it easier than to make the next increase.
And don’t make assumptions about the barriers or solutions. As I said, I run a pain management program. The number of people who do manual handling in their role, they have a physical injury, so they’re given sedentary duties. They’re now required to sit at a desk for seven hours a day. Think about it. How many of us have ended up with a sore back from sitting in a car all day, on an aeroplane? Sedentary duties don’t necessarily help someone, partly because sitting could actually exacerbate it. Or it might be the tasks are so meaningless that the stress around how meaningless the duties are adds to the problem.
Or we’ve got one at the moment in our clinic who’s just returned to work, and they’ve been put into a small isolated office. This person is an extrovert. They’ve given her really quiet space to work, probably with the best of intentions. She thinks she’s been put in jail to work, is what it feels like to her. We need to ask and find out what their concerns are, what the barriers are, and get them to come up with the solutions. They generally can come up with better ones than any of us can, because they actually know their concerns more so.
So, when we look at supporting and motivating someone with return to work, we need to draw on what their motivations are, what their recovery needs to look like. We need to collaborate, get on the same page with them, not get them on the same page with us. We need to get on the same page with them. If there’s a discrepancy in where each of you are coming from, you can only change your position. So, it’s your job to get alongside them in order to move forward. You can’t drag someone kicking and screaming. It doesn’t work, whether as parents with your kids, or with helping someone return to work, we need to collaborate in order to move forward.
So, thank you for listening. Hopefully there’s some strategies there that you can take away, and I’ll head back over to you Kayleen.