A worker recently came to us shortly after a traumatic event.
We arranged to complete the CMS-8 (which alerts the WSIB to the presence of a psychological injury) within days. But his family physician was able to see him slightly sooner.
He was keen to start his treatment as soon as possible. Since the form explicitly calls for completion by a physician or nurse practitioner (psychologists check “Other” and write in “Psychologist”), it was a perfectly reasonable step for him to rely on his family doctor to complete the form.
The family physician used a couple of quick symptom checklists, and reported the diagnosis: “Depression. Anxiety.” He noted a need for a psychologist.
He didn’t specifically mention the need for a psychological assessment. But in my experience, when a worker is newly injured, WSIB always wants a psychological assessment completed. “Depression and anxiety” might just be symptoms, rather than the best diagnostic explanation. The two forms the physician administered probably took a total of five minutes to complete; it was clearly not intended to be a comprehensive evaluation.
But I knew that WSIB needs much more information than that. They have important questions: Is the presentation realistic, or distorted? Is the workplace incident the full source of the symptoms, or were there previous issues? If there were pre-existing issues, do they fully explain the current presentation, or (as is far more common) have they been made substantially worse by the new incident, and will they complicate treatment?
I called the Case Manager, and left a message, explaining that the physician had completed the CMS-8, but we were ready to complete a psychological assessment, just as soon as it was approved.
And then we waited. And waited. We called the CM again—still no luck. Finally, we did hear from the CM, who told us that she couldn’t make a decision yet, because she needed more information.
“But we’ve been asking for a psychological assessment!” I said. “A psychological assessment will give you all the information you need!”
“Oh, we don’t need a psychological assessment,” she replied. “We’ve already got the diagnosis from the physician.”
“No, you don’t,” I countered. “At best, you’ve got a preliminary diagnosis, which may be better explained by PTSD or perhaps something else. To understand this injury, we need an in-depth history, and we have to rule out other issues. Two screening measures is very different from a psychological assessment!”
“Well, I think I’ve got a diagnosis,” she said. And then she gave what she felt was the diagnosis: “Major Depression and Generalized Anxiety Disorder.”
Which is NOT what the physician had recorded. He’d noted “depression and anxiety”—were those short forms of the official diagnoses the Case Manager had interpreted accurately? Or were they symptoms, in need of further investigation?
When I complete a CMS-8, I generally indicate that my diagnostic formulation, at that point, is provisional. A psychological assessment will be needed to determine the diagnosis with greater precision.
This is literally the first time I’ve ever come across a case where a claim for a psychological injury was being opened without the evidence from a psychological assessment.
But a psychological assessment costs somebody money. And what we’re seeing at WSIB today seems to have a lot to do with saving money: Laying off hundreds of Case Managers; increasing reliance on Artificial Intelligence; and a heightened level of scrutiny of any restrictions that may be necessary given the injured worker’s impairments.
The physician was perfectly competent in his actions. He did what family physicians do: Make a rapid determination of the most pressing symptoms, and make recommendations for both time off work, and psychological treatment.
But what if the diagnosis, so quickly assigned, isn’t the best explanation? “Generalized Anxiety Disorder” is characterized primarily by cognitive and physiological symptoms of anxiety: that is, worry. Worry is future-oriented. GAD doesn’t require a precipitating event. It’s not usually associated with nightmares. It doesn’t include re-experiencing emotions provoked by a traumatic event.
It also requires a duration of six months’ worth of symptoms to make the diagnosis. It is, in this case, extremely unlikely to be the best label for the injury.
It’s also not the diagnosis the physician recorded.
Meanwhile, the injured worker is experiencing a frustrating delay in receiving necessary treatment.
This isn’t the worker’s fault. Although it’s designed for psychological injuries, the CMS-8 form doesn’t even clearly indicate that a psychologist can complete it. It was perfectly reasonable to take it to his physician, based on what the WSIB website says.
It’s also not the physician’s fault. As I said, his actions were clinically reasonable.
But I’m disappointed that I didn’t get the chance to complete the form myself. After working with WSIB since the mid-90s, I’ve learned a huge amount about how the system works, what it requires, what to put in, what to leave out.
I know what employers have the right to know, and what they don’t have the right to know. I know how to handle requests from Case Managers, or other insurers that might be involved. I know what’s relevant, and perhaps most importantly of all, I know how to walk the fine line between advocating for my assessment of the worker’s needs, and advocating for the worker’s preferences—all while working collaboratively with everyone involved, which includes forging a relationship with Case Managers, Return to Work Specialists, and others.
This specialized knowledge is hard-won. And it’s even more important today, because this year, WSIB opened up its mental health treatment programs to Registered Psychotherapists and Social Workers.
They may well know how to treat a psychological injury. But knowing how to navigate WSIB is its own competency. And it’s not the same. It’s a skill that takes years to develop.
Some day, these professionals, like me, will have deep knowledge and experience—if they don’t get frustrated and walk away from working with WSIB, which many thinner-skinned professionals do, when faced with intensive paperwork demands and constant phone calls questioning our judgment.
But until that time, deep experience is an absolute necessity when dealing with such a complex and demanding system. Injured workers need professionals who understand the difference between having a diagnosis and the policies that determine entitlement to benefits. They need to know the difference between symptom reduction and functional recovery. They need to be able to communicate their recommendations clearly, and be able to navigate the processes behind maximum recovery and return-to-work readiness.
Healthcare providers can have gobs of experience treating psychological injuries, but knowing the system is every bit as demanding and important.
An experienced psychology clinic brings clinical expertise to the process:
· Evidence-based assessment and treatment options
· Familiarity with WSIB documentation, treatment pathways, reporting requirements, and what will and won’t get authorized
· The ability to translate clinical findings into meaningful descriptions of occupational limitations and recovery
· And the ability to communicate clear, relevant information to caseworkers, physicians and employers.
Perhaps most importantly, we bring the ability to collaborate with all the parties, while staying true to our objectivity—and while making sure that WSIB knows that.
A WSIB worker once told me sweetly, “Wow, I really appreciate the passion with which you advocate for your patient.”
Nice, huh? You’d think so. Except I knew exactly what she meant. The subtext was: “You’ve crossed the line into advocacy, so I’m going to disregard your input.”
And that’s why I said: “I know precisely what you mean, and let me make it clear: I never advocate for my patient. I advocate for my assessment of the patient’s needs. ALWAYS.”
I suspect most workers would be perfectly happy to have WSIB skip the psychological assessment, and just accept a claim on the basis of a couple of quick screening measures.
Those claims will be a lot more likely to fall apart if the employer decides to contest them. The demands of a psychological assessment are nothing compared to the stress of fighting for your rights at the WSIB Tribunal.
By gathering and communicating the strongest evidence early in the claim, an experienced psychologist can help to prevent a claim from being challenged.
PS: This story has a happy ending—so far. The CM accepted the claim, and THEN approved the assessment. The problem is: The injury on record (Major Depression and Generalized Anxiety Disorder) may not match the results of our assessment. Maybe that won’t make any difference. It’s hard to say—because I’ve never been in this situation before. But at least we’ll soon be able to share the precise diagnosis, and develop a treatment plan specific to it.
—Dr Jonathan Douglas
