Work and mental health: Learning from return-to-work rehabilitation programs designed for workers with musculoskeletal disorders

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Abstract

Despite the high costs associated with mental health problems in the workplace, few studies have yet been published on the design and evaluation of return-to-work rehabilitation programs for workers with mental health problems. In fact, the best-documented return-to-work rehabilitation programs concern workers with musculoskeletal disorders (MSKD). For this clientele, a disability paradigm has been adopted which explains the multicausality of work disability. Long-term work disability is no longer seen simply as the consequence of impairment, but rather as the result of interactions between the worker and three main systems: the health care, work environment and financial compensation systems. A return to work is thus influenced by a complex set of interrelated factors that must be taken into account in any intervention. Parallels can inevitably be drawn in the field of mental health in the workplace, where individual and organizational factors are involved and must be taken into account in the return-to-work process. This paper presents the first results of an exploratory study aimed at determining the possible links between work rehabilitation programs for workers with MSKD and those for workers with mental health problems. To this end, the components of a work rehabilitation program for workers with MSKD, the Therapeutic Return to Work (TRW) program which addresses psychological factors, work environmental factors and factors related to the involvement of the various stakeholders in the rehabilitation process, are described through a multiple-case analysis and mapping of interventions. The results support the relevance of adopting the disability paradigm and considering the return-to-work clinical activities conducted with workers with MSKD (and their mechanisms of action) in the design of work rehabilitation programs for workers with mental health problems.

Introduction

Mental health problems are currently one of the leading causes of worker absenteeism (WHO, 2005). Forty percent (40%) of wage loss insurance costs are linked to mental health problems (Stephens & Joubert, 2001). Moreover, people affected with this type of problem are absent from work for longer periods of time than workers whose absences are due to other disorders. Also, the longer the absence, the more difficult the re-entry into the labour market (St-Arnaud, St-Jean, & Damasse, 2004a). This situation is worrying and yet very few studies have been published on the design and evaluation of return-to-work (RTW) rehabilitation programs for workers with mental health problems. Indeed, several authors describe organizational approaches to primary and secondary prevention (information on mental illness, detection of depression in companies, improvement of employee assistance programs, support measures in companies, etc.), but few of them describe re-integration measures (tertiary prevention) which consider at the same time the worker, his work environment and the various stakeholders involved (Michie et al., 2004, Putnam and McKibbin, 2004). The tertiary prevention approaches that have been documented are mainly oriented towards cognitive behavioural interventions involving problem-solving and stress management strategies centred on the individual and do not focus on the work environment and concerted action among the various stakeholders (Nystuen and Hagen, 2003, van der Klink et al., 2003). In the field of psychiatry, other studies report on the difficulties of employment integration programs for people suffering from severe mental disorders (for example, schizophrenia and other psychotic disorders) but few studies examine the difficulties related to the RTW process for those who have been absent from work due to a common mental health problem (Goldner et al., 2004, Kirsh et al., 2005). In the field of occupational health, studies focus more on people with physical disabilities. Moreover, the best documented work rehabilitation programs are designed for this clientele (Corbiere and Shen, 2006, Franche et al., 2005, MacEachen et al., 2006).

In particular, work rehabilitation programs for workers with musculoskeletal disorders (MSKD) have been extensively evaluated in recent years. Socio-economic incentives linked to long-term absences as well as evolving views on work disability undoubtedly account for the proliferation of studies in this area. Clinical practice has evolved from a medical and fragmented perspective (in which the focus was on reducing the impairment or, more positively, on improving the individual’s capacities) towards a global perspective centred on the disability paradigm, in which psychosocial and socio-economic factors and, more recently, workplace-based interventions and early intervention are taken into account (Loisel et al., 2001). Long-term work disability is thus no longer seen simply as the consequence of an illness (or impairment), but rather as the result of interactions between the worker and three main systems: the health care, work environment and financial compensation systems (Loisel et al., 2001).

Furthermore, several authors confirm the importance of taking into account the dimensions related to the work environment and the roles of stakeholders involved in the RTW process, regardless of the type of disorder (Baril et al., 2003, Durand et al., 2002, Loisel et al., 2001, St-Arnaud et al., 2003). The work environment is said to be involved in almost 90% of accounts of people who are absent from work for mental health reasons (St-Arnaud et al., 2004a). Thus, for both workers with MSKD and those with mental health problems, RTW interventions must consider the influence of a complex set of interrelated factors (clinical, psychological, work environmental and related to the involvement of the various stakeholders) (Corbiere and Shen, 2006, St-Arnaud et al., 2006, Waddell et al., 2003).

A review of programs which are designed for workers with MSKD and which may be widely applied to workers with mental health problems (Briand, Durand, St-Arnaud, & Corbiere, submitted for publication) has shown that only two programs (2/50), the Multi-disciplinary Work ReEntry Rehabilitation Program (Feuerstein et al., 1993) and the Sherbrooke Model (Loisel et al., 1997), contain all the components identified as relevant, that is, those advocating an optimal return to work (Corbiere and Shen, 2006, Franche et al., 2005, MacEachen et al., 2006). This article will examine one of these programs, the Sherbrooke Model implemented in a natural environment, as a first step towards assessing whether it is possible to transfer RTW interventions designed for workers with MSKD to workers with mental health problems.

Section snippets

Goals of study

Based on the body of knowledge and expertise developed in the area of work rehabilitation for workers with MSKD, the main goal of this article is to present the first results of an exploratory study aimed at determining the possible links between the RTW process for workers with MSKD and that for workers with mental health problems.

The specific goals of the study are:

  • to describe the clinical activities conducted by the rehabilitation professionals in a work rehabilitation program which address

Context: the Therapeutic Return to Work (TRW) program

The described program, namely the Therapeutic Return to Work (TRW) program of the Centre for Action in Work Disability Prevention and Rehabilitation (CAPRIT) (Durand et al., 2004, Durand et al., 2003), is the application of the Sherbrooke Model in a natural environment (Loisel et al., 1997). Loisel et al.'s study involved a randomized clinical trial with the prior agreement of all stakeholders and the case management of workers with MSKD in an acute or subacute phase. In its application without

Results

The results (see Table 1) led to the identification of four steps in the TRW process and several rehabilitation models which can serve as a link between these two fields (Anthony et al., 2002, de las Heras et al., 2003, Farkas et al., 2001, Fougeyrollas et al., 1998, Kielhofner, 2002).

Discussion

This study sought to establish a link between workers who are absent from work due to MSKD and those who are absent from work due to mental health problems, in order to lay the basis for the design of return-to-work programs in the area of mental health, based on a person-environment dynamic.

The multiple-case analysis based on intervention mapping showed that, regardless of the nature of the impairment, the psychological variables, work environmental variables and variables related to concerted

Conclusion

The goal of this study was to initiate an examination of the first parameters for the design of return-to-work programs for workers who are absent from work due to mental health problems. The results confirm the importance of adopting a common understanding of rehabilitation and of how the work disability situation is produced which takes into account the complex and multi-causal nature of work disability, i.e. the interaction between the dimensions of the person and of all the systems involved

Acknowledgments

This project was made possible thanks to two postdoctoral grants awarded to the principal author of this article: one from the Réseau Provincial en Adaptation et Réadaptation (REPAR) in Quebec and the other from the Fonds de Recherche en Santé du Québec (FRSQ).

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