The "RTW" process is a pretty individualized process for me. Question one is always about what the worker feels ready to do—it’s rare for me to be convinced the worker is ready when they don’t think so, and probably rarer still for a resistant worker to make a successful RTW. If the worker is resistant, it's important for the psychologist to understand why, and if appropriate, address the underlying issue. Getting the worker on board is very helpful, if it’s at all possible. RTW should be a cooperative process, and everyone involved needs to recognize that.
On the other hand, we have to struggle with the process of avoidance, and make sure that the worker isn’t giving into an avoidant strategy when they could and should take on more. I think this is a matter of testing the ground prior to RTW—you can get a lot of sense of their readiness from how they handle tasks outside of work, such as shopping, yard work, exercise, social interaction, etc. If I can’t get them going in the community, chances are they're not ready to get going at work. This will also let me know how they are handling any provoked symptoms, and give me a chance to help them to practice coping strategies.
Next we have to consider what they’re ready to take on in comparison to the job demands. A good understanding of what the job entails, and what accommodations are available, is necessary. Personally, I like to leave WSIB up to the task of interacting with the employer as much as I can—the RTW Specialist is a wonderful resource. Workers are often highly anxious around WSIB interaction, so getting the RTWS involved early is important. It can take an incredibly long time to move from “I think we’re ready” to the client walking through the door at work.
Finally, we need to consider restrictions vs. accommodations. A restriction should be that which the worker clearly cannot do. Physical safety to self and others is the top priority here. For example, someone with significant deficits in focus and concentration shouldn't be in a position where a momentary lapse can put someone in danger.
Psychological safety is a more nebulous concept (and more controversial—cf. the concept of “trigger warnings.” How much discomfort is reasonable as we navigate an unpredictable world? How much should the world adjust to our emotional distress? That's a whole other blog post!)
An accommodation is that which the client can do with modification to the task. We need to push workers to experience some discomfort—to the extent that they can handle it. There’s a lot of judgment in that. Some anxiety may be reasonable; a panic attack may cross the line. How is their impulse control when under stress? Will sleep be disrupted by anxiety, pain, or shiftwork, , and if so, how will that impact on their emotional regulation? Will the worker lash out verbally at coworkers or customers? Can adjustments to work demands or schedules be made to mitigate that risk while the worker re-adjusts and continues healing?
Then there's the issue of bias. Underlying the whole thing is the role of the health care professional in an economic system: As we push our client back to work, is that because getting referrals depends on returning workers to work quickly, or because (as I’ve seen) the referral letter specified an arbitrary, a priori expectation of a RTW date? Is it our job to treat our patients, or to ensure that insurers don’t lose money on a claim? Is it our job to get people back to work because work is best for them, or because work is best for the employer, the insurer, our reputations, and our economy? Do we resent those who have access to benefits while others have to work? Does the concept of “milking the system” whisper in our ears, poisoning our perceptions of the disabled worker? Are we just acting as the pawns of The System, believing we’re acting for our client’s best interests when in fact The System is so deeply entrenched we don't see how its influence affects us?
Or, alternatively, are we advocating for our assessment of our client's needs...or for our client’s preferences? Are we afraid of losing the relationship with the client if we push them outside of their comfort zone? Do our hearts bleed in the face of our client’s pain and distress, causing us to want to protect them—but keeping ourselves from pushing them to be all that they can be? (And is all that they can be just another cog in the machine? Aren't other ways of being in the world just as valuable as being a "productive worker"? Is it moral to return a worker, injured in a good job, to work which is less satsifying?)
There may not be a clear answer for many of these variables--the RTW process demands careful assessment, not only of the client, but of my own political and economic biases. The best I can do is communicate as openly and honestly as I can with my client, while standing up not for the client's preferences but for my assessment of their actual restrictions and need for accommodations, and working as co-operatively as I can with all the players--but always with the client's best interests at heart.
Dr Jonathan Douglas