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Application of a Relational Lens to Workers’ Compensation Case Management

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And this presentation is the follow-on which looks at using relationality as a means of improving WCB case outcomes. In which I attempt to draw relevant parallels between criminal restoration and restoration in Indigenous contexts and the WCB system…

Background

  • In the Hummingbird Project I outlined recommendations to improve WCB outcomes:
  • Include restorative justice training for WCB case managers as a way of transforming interactions
  • Carry out pre-screening of all WCB claimants to detect the presence of early-life trauma
  • Use that pre-screening to proactively intervene in at-risk cases
  • Creation of a supportive transitional community of healing with the ultimate goal of restoration to work
  • This was largely based on my nine years of experience within the appeal system, where I noted a pattern of cases involving the development of permanent disability from relatively minor injuries, usually because of chronic pain issues
  • That progression was often assisted by the presence of an adversarial relationship between worker and case manager; conversely it could be stopped by an unusually supportive relationship

Introduction

  • There are many parallels between the typical starting conditions for restorative justice and an injured worker:
  • We have an injured party
  • There is an implicit injurer – the workplace
  • The injurer sometimes expands to include the employer and the WCB staff
  • There is a need for physical, emotional and sometimes spiritual healing
  • The path to restoration potentially transforms all parties
  • This axis: injured —- injurer reflects many of the case studies in the justice system with victim —- offender
  • The parallels suggest a restorative approach to injured worker case management might be appropriate
  • All workplace injury involves disassociation between person and place
  • All workplace injury requires a journey, not always to perfect health, but sometimes to a place of living with permanent injury and disability
  • The restoration from disassociation involves the journey to a new home
  • This parallel resonates deeply with restorative justice principles
  • The reality of some injured worker case management is not healing:
  • Highly policy-focused
  • Begins with a presumption of denial of benefits (rather than a generous system designed to facilitate return to work, a worker must prove the right to benefits).
  • Often the decision-making is predicated on denial first, when the statutory framework intends the contrary: approval first (Ison, 3.3.37, 3.3.38, 1989)+
    • My approach is based on a particular characterisation of the return to fitness:
    • The return to fitness is best characterised as a journey:

    Se hace comino al andar” “You make the way by walking” (Neumark, p. 271, 2004)

    • That journey may be made more healing, more restorative, by the participation of a community.
    • That community may improve outcomes; an adversarial relation will worsen outcomes.
    • That the ultimate goal of the WCB system is not minimizing costs or management of the accident fund, but the restoration of health and return to work.
    • To achieve this requires setting the right place, creating safety, and providing voice.
    • This approach is very different than what is reflected in most of the appeals cases I participated in. (over 500 over the course of 9 years)++
  • Propose that this system could be reconceived so as to become transformative through:
    • The Re-Creation of Context
    • The Re-Imagining of Place
    • The Creation of Real Safety
    • The Provision for Real Voice
  • Because this is literally a healing journey, an area rich for understanding through metaphor rather than policy

Re-Creation of Context

  • The existing WCB system is posed as a linear process only
  • …when the reality is some cases will have many recursions (return to an earlier stage)
  • Those recursions are negatively interpreted as a lack of injured worker commitment.
  • First change in context is to understand that healing is individual and unpredictable.
  • In spite of the WCB acknowledgement of the individual, not borne out in praxis.
  • That difference between lived-out reality and stated reality requires new context.
  • An injured worker enters liminal space analogous to a re-birth to a different reality (Lederach, 2011)
  • Liminal space is frequently frightening as it awakens fundamental questions of being.
  • As a disabled person, my first challenge was answering questions:
    • “Who am I now?”
    • “Does the disability define me, or do I define the disability?”
    • “What does this mean to my relations, my work, to all the external things that define me?”
    • “If my work defines me, and I can no longer do that work, where do I find new meaning?”
  • Some WCB case manager understanding of an injured worker does not reflect the liminal reality of their emotional and spiritual situation.
  • This context must be based holistically around the reality of each injured worker.
  • Stated another way (following Lederach’s presentation, 2011): how does this system demonstrate the love of neighbour above self (where self reflects both system and case manager)?
  • Healing and return to work conceived as a linear process only
  • Note that this is a creation of policy, as WCB medical therapists see reality differently
  • There is a shift in world-view between medical care-givers and case managers
  • Conceptual models and metaphors both “reveal and hide aspects of a complex reality” (Lederach and Lederach, p. 55, 2010)
  • Linear metaphor presupposes certain presumptions which are not helpful (Ibid, p. 56-7):
  • Forward progress is good
  • Backward movement is a setback (language in case management letters would speak of getting recovery ‘back on track’)
  • A more nuanced metaphoric model of restoration (rather than return-to-work) and true healing is needed.
  • Such a model could look at the violation of injury as central rather than the injury itself (Sharpe, p. 179)

Re-Imagining of Place

  • Workplace injury is a violent act, analogous to an attack on person.
  • Particularly when disability results, focus turns to personal safety. (Lederach and Lederach, p. 63)
  • Compounded with an adversarial relationship with a case manager, WCB facilities become places of further threat and possible injury.
  • Combined with the focus on personal safety, this limits the possibility of healing, and makes the WCB the new source of workplace injury.
  • The place should support the development of a revised personal narrative as the foundation of identity. (Sharpe, p. 188)
  • In some cases surveillance of workers began with scheduled appointments at WCB rehabilitation centres.
  • Worker response once revealed was to see the rehabilitation centre as a place of danger.
  • The fundamental violation of place destroys creation of a place of healing. (Sharpe, p. 188)
  • Similar violation of relationship by case manager ordering surveillance.
  • Worker conclusion is similar to Australian aboriginal’s feeling of ‘not being seen’ and needing to ‘feel like a person again’. (Lederarch, 2011 quoting Judy Atkinson)
  • Paradoxically surveillance has the effect of leaving the worker “present but invisible”. (Lederarch, 2011 quoting Judy Atkinson)
  • Places of healing should be focused on achieving that end goal.
  • WCB rehabilitation centres should be centres of holistic healing (place seen to be multidimensional, including spiritual and emotional connections). (Ross, p. 45)
  • The case manager’s office should also be a place of holistic healing.
  • The metaphor of the circle, manifested as the Medicine Wheel, reflects healing places better than the linear, western, scientific model. (Monchalin, p. 33-5)
  • This ‘great wheel of relationship’ incorporates all places and all persons in the care cycle. (Monchalin, p. 27)
  • Shifts the dominant question from ‘What is my job?’ to ‘How am I related to all others in the healing process?’ and ‘How do I create safe space for all people?’
  • The need is to create physical places that are communities of total healing.

The Creation of Real Safety

  • Injured workers have been violated once, in the workplace injury.
  • Real danger in future violation because of vulnerability in recovery.
  • The entire WCB apparatus needs to become a place of safety, so healing can result.
  • This requires a focus on all relationships so a safe, restorative place may be created. (Llewelyn et al, p. 284)
  • This leads to the need for a relationship founded in equality and mutual respect for all parties, if the process is to be restorative (Ibid, p. 299).
  • Healing will result from a team, in relation, all focused on the end goal – a process which is inclusive and participative (subsidiarity). (Ibid, p. 302)
  • This allows the creation of real safety for the injured person, so they may engage in the risky processes of healing and development of a new personal narrative. (Sharpe, p. 188)
  • Sharpe also provides us an image of what those safe relationships will manifest (Sharpe, p. 187):
  • Inclusive, reflecting all impacted interconnections (for example, the family and friends of the injured person are usually not included).
  • Voluntary.
  • Dialogic, allowing open communication between all.
  • Supported, building safety in all aspects.
  • Without the sense of real safety, the ability for healing and restoration is compromised.

The Provision for Real Voice

  • “Victims need an opportunity to tell their stories in their own way, in a setting of their choice…” the alternative breaks down, “…any personal attempt to construct a coherent and meaningful narrative.” (Sharpe, p. 190 quoting Herman, J. 2005)
  • Part of the healing and restoration process is re-building a personal narrative or personal identity.
  • This also must acknowledge that the entire extended circle of relationship is wounded by the workplace injury.
  • “Individual healing is thus a socially situated activity.” Includes giving voice to the entire community of injury. (Ross, p. 237)
  • The voices of the injured are sometimes suppressed to follow policy. Such an approach reverses the proper order of questions:
  • How does this person fit into our process; versus,
  • How can we best fit our process to this person’s (community’s) needs?
  • The healing journey is most effective relationally, including repair of fractured relationships. (Sharpe, p. 192)
  • This will require overhaul of the present client-centred process, which is in reality a process-centred process (i.e., it is the process’ needs which are the focus of all activity).
  • Only through the provision of real voice to the community of injury (worker and extended circle of family and friends and co-workers) and the community of rehabilitation (the extended care team) is real restoration possible.

Conclusions

  • A more nuanced metaphoric model of restoration (rather than return-to-work) and true healing is needed.
  • Physical places involved with rehabilitation need to be safe places of total healing, considering the inter-relationship of all participants.
  • Without the sense of real safety, the ability for healing and restoration is compromised.
  • Only through the provision of real voice to the community of injury (worker and extended circle of family and friends and co-workers) and the community of rehabilitation (the extended care team) is real restoration possible.
  • The WCB claim process is one that fundamentally involves restoration and development of new personal narrative (e.g., new identity).
  • The WCB first encounters the worker in liminal space, where past definitions no longer apply.
  • The goal of the entire healing team (medical and case management) is to journey with that individual through liminality and out to new reality. That new reality will usually include some return to work.
  • This fundamental restructuring of interactions would result in better outcomes in compensation cases.

Endnotes

+Profession Ison wrote (1989) about the WCB tendency to deny as the first step in adjudicating some claims. This is particularly present in the opinions provided by WCB-employed physicians:

Where an injury arose in the course of employment, the claim must be allowed unless there is affirmative evidence of an alternative cause, and evidence that the employment was not contributory.

[…]

In practice, this statutory presumption has commonly been ignored, and it has even been replaced by contrary presumptions in the process of adjudication.

This was used as a pivotal assertion in assessing a worker’s claim for compensation based on the rupture of a subarachnoid aneurysm that occurred at work.

Decision No: 2011-698, 2011 CanLII 48880 (AB WCAC), <http://canlii.ca/t/fmllh>, retrieved on 2017-08-07

++ A startling encounter I had with a WCB case manager at a public meeting outside of the WCB context started me thinking about this injured worker – case manager relationship. When she found I was in the appeal system she very proudly said, “I have never had an appeal filed for one of my cases.”  I had seen already that there were case managers whose names seemed to frequently appear in appeal cases, and often in the context of an adversarial relationship that used destructive words to describe the worker’s symptoms: malingering, somatic, and also included the use of surveillance by private investigators. That interaction was the first time I had conceived there was a different way to deal with injured workers.

This was later reinforced in a discussion with a colleague who had previously worked as a rehabilitation counsellor at the WCB rehabilitation centre. He related that in his day, part of his job was to keep an injured worker connected with the work community, often starting with bringing them back into the workplace for coffee breaks. He sadly related that this work had all ceased as a cost-cutting measure, replaced by policy-driven requirements which placed all the onus on the worker. If the worker did not respond to that onus, they were sometimes marked as ‘uncooperative’ and had benefits restricted or eliminated.

References

Ison, Terence G. (1989). Workers’ Compensation in Canada, 2nd ed. Toronto: Butterworths.

Lederach, J.P (2011). Narratives of Care: The Social Echo of Community Transformation, http://emu.edu/now/attachment/2011/john-paul-lederach/ viewed 19 June 2017.

Lederach, J.P. & Lederach, A.J. (2010). When Blood and Bones Cry Out: Journeys through the Soundscape of   Healing & Reconciliation. New York: Oxford University Press.

Llewelyn, J., Archibold, B., Clairmon, D., Crocker, D (2013). Imagining Success for a Restorative Approach to Justice, Dalhousie Law Journal, 36(2), 281-316.

Monchalin, Lisa, (2016). The Colonial Problem An Indigenous Perspective on Crime and Injustice in Canada.   Toronto: University of Toronto Press.

Neumark, Heidi B. (2003). Breathing Space: A Spiritual Journey in the South Bronx. Boston: Beacon Press.

Ross, R. (2014). Indigenous Healing: Seeing Justice Relationally. Toronto: Penguin.

Sharpe, S. (2013). Relationality in Justice and Repair: Implications for Restorative Justice in T. Gavrielides and V.   Artinopoulou (Eds.), Reconstructing Restorative Justice Philosophy.

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Written by sameo416

August 7, 2017 at 4:40 pm

Posted in Uncategorized

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