Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression

Psychology of Modified Duty

The Concept of Alternate Duty

modified dutyWhen you treat an injured worker, you quickly receive from the employer a job description for alternate duty. Too often, the employer is simply describing what the patient did when s/he sustained the back, neck, knee injury…robbery, assault, MVA or workplace violence.

Sometimes, the alternative duties are virtually the same as those performed when the injury occurred. (This is a particular problem when the work-related injury is associated with posttraumatic stress disorder since it most often entails returning to the stimuli of the pre-injury environment.)

Even when the position truly is adapted to an injury, there are many problems apparent and inherent in what we call “modified” (or sometimes alternate, light, etc) duty. The patient may lack the skills, temperament, patience or emotional stamina to function in the new setting. This may appear to be “wholly irrelevant,” but, in fact, each time the patient fails in a modified duty situation, s/he becomes more resistant to returning to his/her employer. And while the job appears simple or elementary to us, it can be demeaning to the patient. For example, a sedentary job illustrates to co-workers that the patient is no longer fit for the pre-injury assignment.

An even more concerning situation arises when the treating clinician releases the patient without discussion. The patient simply “hears” that s/he has been released by the ATP. The patient perceives this as collusion or that the treating doctor has been strong-armed by the insurer. In either case, the response of the patient varies from annoyance to resentment and to fear.

There is an even more insidious factor. The patient has “heard” that when s/he returns to work in modified duty, such work is not permanent even if the limitations resulting from the injury are, in fact, permanent. Thus, the patient strongly believes that functioning in the modified/alternate duty job is the first stage of being terminated.

I have found it crucial to discuss return to work at length with the patient. It is critical to determining what s/he understands to be the purpose and role of the alternate duty being offered. It does, in fact, matter how the patient sees this release and this proposed alternate position. If the patient is uncomfortable and/or distrustful, this is an opportunity to assist him/her in dealing with these concerns or asking for further modification or clarification from the employer.

The central issue is that the patient feels that life has changed, the employer’s response has changed and that there are reasons to doubt that the employer is truly creating a long term solution to a potentially life-changing injury.

Academy of Psychosomatic Medicine

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