By Dr. Michael Lacroix
Associate Medical Director, Disability and Absence Management Services
Freud may be long dead, but his idea that many of our behaviors are driven by unconscious motivations has stood the test of time. Many disability claimants who present with physical symptoms are actually solving psychological conflicts with their symptoms.
The book 1,000 Years, 1,000 People: Ranking the Men and Women Who Shaped the Millennium1 ranks Austrian psychoanalyst Sigmund Freud number 15 in terms of lasting influence, just one notch behind Karl Marx and one above Napoleon. Albert Einstein was number 17 and Copernicus, 18, which tells you something about the extent of Freud’s contributions, at least according to the authors.2
Impressive. But why are we talking about Freud in the context of disability insurance?
Truth be told, many of Freud’s ideas have not stood the test of time and have been relegated to the dust heap of ideas by contemporary psychologists. What makes Freud still relevant today, however, and particularly relevant to those of us in the absence and disability world, is his insight about the role of unconscious motivation. It’s not so much his specific ideas about the nature of the unconscious but the broader notion that many of our thoughts and actions are driven by motivations that lie “below the surface” of consciousness, where they are not directly accessible to conscious awareness, yet still influence us powerfully. Freud was not the first one to turn to unconscious factors to account for behavior, but he was certainly its greatest popularizer.
The concept applies to all of us. Who among us has not at one time or other looked in the mirror and asked ourselves, “Whatever possessed me to do or say that?”
The concept of unconscious motivation applies to many disability claimants, but it is unfortunately often confused with malingering. Malingering refers to conscious lying. A malingerer tells you that he experiences pain in his back when in fact he knows very well that he doesn’t, and his motivation seems clear: he lies to you in order to get your company’s money. Unfortunately, particularly with “subjective” symptoms, determining if someone is lying is not straightforward. Is he lying consciously to get your company’s money, or could it be that he is lying to himself to satisfy some unconscious motivation of which he is unaware?
Let’s consider a couple of examples.3 In one very common situation, a young woman is torn between her role as a mother and the family’s need to have her provide financial support. A whiplash injury can set the stage for what psychologists call psychogenic pain, that is, pain of psychological (unconscious motivation) origin, as contrasted with both pain of clear organic origin and malingered (faked, conscious) pain. Maintaining a strong pain focus after the strictly physical problems are resolved allows the woman to solve the psychological conflict: she can stay home with the kids without feeling guilty that she is letting the family down financially.
Another typical case involves a man who, stemming perhaps from an abusive childhood, has developed tremendous dependency needs that have gone unmet — he longs to “feel the love.” This man may have been working at two jobs from the age of 11 in an attempt to prove his worth to his parents and others, without getting the love and recognition he craves. As it happens, when he is 40, an accident allows for these needs to be fulfilled at last, as his spouse and children rally and start caring not only physically but also emotionally for their injured spouse/parent. Maintaining his symptoms allows the man (unconsciously) to get his emotional needs met.
The folks in these examples do warrant diagnoses, but to the frustration of many who handle disability and workers’ compensation claims and who like clear-cut answers, the diagnoses come from the psychological manuals, not the orthopedic ones. You have probably heard of conversion disorder or somatoform disorder or somatic symptom disorder.4 These are the more typical diagnoses in these types of cases, all of which are symptomatic variations reflecting the unconscious origin of what looks on the surface like physical symptoms.
Of course, there are other, more straightforward ways psychological factors influence symptoms. Depression is probably the most common of these psychological factors. In a widely cited study of more than 400,000 employees, the Integrated Benefits Institute reported that the prevalence of depression is close to 30% among workers but that 70% of these depressed employees are left untreated and that 97% of employees who file a claim for depression also report other comorbid conditions.5 Have you ever noticed how many pain patients are prescribed antidepressants? Increasingly, the evidence suggests that there is an intimate link between depression and chronic pain.6 Other psychological conditions have also been found to be important, including anxiety. To quote one authority, “It is becoming clear that the relationship between major depressive disorder, anxiety, and pain runs far below the surface” (italics added).7
So, if Freud has not left the building and if psychological factors also impact nonpsychological disability, what’s a disability manager or adjuster to do?
My advice is three-fold. First, don’t stick your head in the sand. If you have reason to believe that psychological factors are involved in a particular disability claim, take a look because the odds are that, left alone, the condition will get worse.
Second, keep your own limitations in mind. Unless you have training in orthopedics, you should not be making physical diagnoses or wielding a surgical knife. The same applies north of the neck. If you have a claim with what looks like a complicating psychological overlay, get the right mental health expert to evaluate the claimant. Just because a claim has a psychological component does not mean that it cannot be resolved. But you need to have the correct understanding about what is driving it. A solid evaluation is worth the investment. At Aetna, all claims coded as involving mental health are automatically referred to our in-house behavioral health unit. This integration of behavioral resources has helped reduce disability claim durations consistently by an average of 11 days.8
Finally, don’t assume that treatment will have to go on for years and years, and that only board-certified psychologists and psychiatrists can provide treatment. In part due to the influx of new patients coming on board through the Affordable Care Act, health plans and medical practices are learning to make much better and more targeted use of so-called “physician extenders”— the physician assistants, nurse practitioners, and nurses. You don’t need an MD to diagnose a head cold. The mental health field has been leading the way in this area for years. Many mental health specialists with master’s-level training are highly trained in delivering a variety of psychotherapy treatments and do so very effectively. Even “medical” nurse case managers can often learn to deliver targeted psychological treatment — provided they have the right understanding of the case and the right training, as I noted in a previous article on the DMEC website.9
By emphasizing the importance of unconscious motivation for behavior, Freud also steered us toward solutions. In the last 100 years, we have developed cognitive-behavioral and other psychological interventions, now rigorously validated by the National Institutes of Health. Thanks to number 15 Freud, not only do we now have a better understanding of some of the factors that drive disability claims, but we also have a better handle on how to remedy them.
- Gottlieb AH, A Gottlieb, B Bowers, B Bowers. 1,000 Years, 1,000 People: Ranking the Men and Women Who Shaped the Millennium. New York: Kodansha International. 1998.
- http://www.tostepharmd.net/hissoc/top100people.html (accessed April 4, 2016).
- JM Lacroix. Separating the real from the malingered, and fact from fiction. Case in Point. 2011. Abstract available at http://www.industrycortex.com/datasheets/profile/506661845/new-ce-supplement-separating-the-real-from-the-malingered-and-fact-from-fiction
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. APA: Washington. 2013.
- Integrated Benefits Institute. The full costs of depression in the workplace. 2009. https://ibiweb.org/?ACT=65&id=jL-4ltU6KYYO9LDhFfligpUVKXheWfBAhTfqFPy2n3HidG4t-qJRA2aNwNcT0A4p7i2bwBJf7MSgKYBfa4S5lg.
- National Institute of Mental Health. (2015). Depression and chronic pain. 2015. http://www.nimh.nih.gov/health/publications/depression-and-chronic-pain/index.shtml. Accessed Aug. 21, 2015.
- V Maletic. (2012). What is the connection between anxiety, depression and pain? PsychCongress Network. 2012. http://www.psychcongress.com/blogs/vladimir-maletic/september-7-2012-831am/what-connection-between-anxiety-depression-and-pain. Accessed Aug. 21, 2015.
- Case in Point 5th Annual Platinum Awards. 2014.
- JM Lacroix. Disability: It takes a village. @Work. Feb. 16, 2015. http://dmec.org/2015/02/16/disability-it-takes-a-village/.