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The Actuary The magazine of the Institute & Faculty of Actuaries

Health claims psychological factors

According to the Department for Work and
Pensions, each week about 17,000 new peo-
ple are certified by their GP as having been
absent from work through illness for the past six weeks. Of these, 14,000 or so will return to work before their period of absence extends to six months. However, of the remaining 3,000, approximately 90% will prove to be long-term sick, the vast bulk of them never returning to work.
After a typical episode of physical ill health there is an expectancy of a return to work and to full social activities as soon as the illness has disappeared. However, this ideal is not always achieved. It may be that the original medical condition is actually more debilitating than was originally foreseen, or that some unexpected or undiagnosed complication intervenes. It may be difficult to determine the causes of the delayed return to work, but it is now becoming clear that psychological factors often play a part.
The pattern of illness
Physical illnesses generally have a cycle, often with a relatively sudden onset, getting worse for several days and then resolving either spontaneously or with the benefit of a medical or surgical intervention. There then follows a variable period of recovery. For many common medical conditions this cycle is completed within six weeks. By that time nearly all minor medical conditions, such as sprains, upper respiratory tract infections, and gastrointestinal upsets, should have completely recovered. Moreover, many more serious medical and surgical conditions, such as an operation for appendicitis, an uncomplicated removal of a gall bladder, or even a minor heart attack, should normally be well on the way to recovery.
Doctors are increasingly aware of the role that psychological ill health may play in retarding the recovery process. A person who suffers a serious heart attack, which may lead to a bypass procedure, may have had one or more episodes of being extremely frightened. These episodes may trigger all sorts of long-standing and serious psychological symptoms, such as anxiety and depression. Although the outcome of the medical and surgical treatment may be judged to be completely satisfactory, the patient may continue to be significantly depressed, with corresponding limited physical activity and withdrawal.
Even conditions such as back pain may have associated psychological conditions that not only make the physical symptoms (pain) worse, but also prevent a return to normal physical and work-related activities.
The co-existence of physical and psychological conditions is common, though it is not always recognised. Generally, physical conditions are thought to be fully responsible for a patient’s condition. This attitude can lead to multiple physical investigations (for example, scans) and potentially inappropriate treatment (for example, physiotherapy). Unless psychological ill health is specifically looked for, it will not be found. Psychological interventions will not be considered and the patient’s ill health will persist.
In cases where psychological ill health is not recognised, or it is inappropriately treated (for example by antidepressants alone), secondary patterns of behaviour will quickly become established. These may preclude a return to work, and could involve the person’s becoming increasingly reluctant or fearful of resuming their normal duties.

The role of psychology
Where does psychology fit in? Looking at table 1, it is clear that the most frequently occurring cause of disability can be ascribed to what might be termed ‘psychological disturbance’. However, what table 1 shows is purely the primary cause of disability. Imagine someone that has been ill and away from work for, say, six months. Whatever the original cause of their disability, it is likely that they will feel anxious, stressed, and even depressed at the situation in which they find themselves. It will frequently happen that these psychological impairments will impinge on the rate at which the person recovers from the physical aspects of their illness.
Relating this to income protection insurances, it does seem that there is a strong case for the majority of claimaints that seem likely to be long-term to be given a psychological assessment at an early stage in the claims process. Not only will this help to identify the existence of any psychological factors that might exacerbate the situation, but it should also prove possible from the assessment to identify the claimant’s motivation in the recovery process. This will include establishing whether there is any possibility of malingering, thus enabling the insurer to focus claims management on those cases where the claimant is well motivated to return to work.
The ideal times for psychological assessment are before claim admittance or at a stage where recovery seems protracted. Typically, a comprehensive psychological assessment will cost about £500 a modest price when compared with an average claim reserve.

Psychological treatment
Psychological treatment will not be successful with all forms of mental illness. The most severe forms (psychotic disorders such as schizophrenia, or personality disorders such as psychopathy) are firmly in the domain of the psychiatrist. Happily, these conditions are rarely seen as income protection claims. The more common forms of psychological ailments (stress, anxiety and depression) are treatable by a qualified clinician (see table 2), especially if treatment can begin before the condition has become deep-rooted and a full range of avoidance techniques learnt.
In the past, counselling has often been seen as an appropriate treatment for these conditions. Although counselling has its place, it needs to be borne in mind that many counsellors will have had basic or minimal training and that treatment is non-focused and is therefore frequently ineffective for the disorders mentioned above.
The forms of treatment generally used by appropriately trained clinicians for the most common range of ailments seen with income protection claims are cognitive behaviour therapy (CBT) and eye movement desensitisation and reprocessing (EMDR).

Cognitive behaviour therapy
CBT has been increasingly used over the last 40 years, since its introduction by Aaron Beck. He contended that the way we think about ourselves, the world and others determines our mood and consequently our behaviour. Thus an anxious person’s view of the world would be one of danger or threat; they would regard themselves as vulnerable, other people as hostile.
In CBT, the client makes use of self-monitoring strategies to get baseline information on how they use their time, what is most likely to upset them, and when that is likely to happen. They are taught to ‘capture’ negative dysfunctional thoughts. These thoughts are then systematically challenged with the help of the therapist and with a specific protocol. CBT is conducted in hour-long sessions and the client carries out homework between sessions.
Eye movement desensitisation and reprocessing
EMDR was developed in 1987 by Francine Shapiro and has been increasingly used since for a wide range of ailments. Research on memory and emotional distress increasingly shows that strong emotion incapacitates the brain’s ability to process information in a helpful way. During an EMDR session, the therapist will help the client to focus simultaneously on various aspects that are relevant to the present problem. This will include relevant memories, thoughts, feelings, and physical sensations. While focusing on these aspects of the problem, the therapist simultaneously stimulates the client’s brain through eye movements, sounds or other techniques. This enables the reprocessing of psychological and emotional material.
As a form of treatment, EMDR could be regarded as a little odd. What will help medical professionals and lay people in accepting the valuable role it can play are the recent SPECT (single photon emission computed tomography) studies illustrating positive changes in brain activity after a session of EMDR.
EMDR, like CBT, is conducted in hour-long sessions. Unlike CBT, it does not require homework, a distinct advantage in many cases.
Both EMDR and CBT are provided by specially trained mental health professionals. Their background training enables them to apply these evidence-based treatments to those psychological conditions which have been shown to respond positively. There are an increasing number of mental health professionals with additional training in EMDR and CBT.
The cost of psychological treatment is unlikely to exceed £2,000 to £3,000 a small percentage of an average claim reserve.

Challenges ahead
Managing income protection portfolios presents many challenges for all involved. Greater use of psychological assessment and treatments should help, and enable insurers to achieve better results both in helping genuine claimants speed up their return to work, and in improving the overall management and profitability of the portfolio.