October 14, 2015
Let’s stop using words with a “nocebo” effect!
I hereby nominate the first three candidates — the terms “I can’t”,”injured worker,” and “injury”– for elimination from the lexicon of workers’ compensation because they are causing harm. After having talked with Kristina Phillips again about her trouble with her workers’ compensation claim, I see the negative impact those three terms have had on her life.
Kristina’s had a very rocky course with initial denials of coverage for some parts of her injury, long delays of authorizations for specialty as well as rehabilitation care, unhelpful advice from the state’s ombudsmen, an unresponsive attorney, multiple court hearings, etc — all while she has been living with ongoing pain and limitation of motion. She’s better, but not ALL better yet — and it’s been 18 months since she was attacked on the subway.
As we talked, she remarked that she finally woke up and realized that in order to get better she HAD to stop using the phrase “I can’t” and replace it “HOW CAN I do this?” Every time she said “I can’t”, her world got smaller. She was becoming a hermit. She had stopped leaving the house whenever it rained or during commuting hours because she was avoiding the New York subway system. Because they are so crowded, Kristina was concerned about being jostled which causes her pain. She was unwilling to explain her situation to strangers and ask them not to lean into her or push her, much less ask them to move their stuff so she could sit down. Shortly after she swore off “I can’t”, she realized she also had to start asking for help. Once she became comfortable with telling people she has a problem, it has been gratifying to see how kindly most of them respond. The new approach has allowed her to expand the times when she can use the subways — which means she is out and about more frequently now.
That got me to thinking. I had heard Kristina mention her “injury” several times. She kept talking about it as though her wounds are still present, despite the fact that her injury occurred 18 months ago. In fact, those injured tissues have probably been healed for more than a year. What she’s actually dealing with are the consequences of the injury, not the injury itself.
Calling oneself “injured” is similar to calling oneself “sick” — in a vulnerable state with life disrupted, out of commission, off on a sideline away from the regular rhythm of life. Someone who describes themselves as “recovering” or “dealing with the aftermath” may be struggling, but it’s because they are wending their way back into the mainstream of life.
I suddenly realized that the WORD “injury” has probably been intensifying Kristina’s distress and symptoms, and delaying resolution of this episode in her life. That is by definition the “nocebo” effect — the evil twin brother of the placebo effect, in which words or beliefs or sugar pills relieve symptoms and allows healing. So, I recommended that “injury” should be the NEXT term she stops using to describe her current situation. And on the spot, I educated her about the basic biology of how fast tissues heal.
It depends on the type of tissue. Generally speaking, the cornea of the eye heals in about 24 hours; a simple skin wound usually takes 7-10 days; bones and muscles often take 6 weeks, sometimes 8 to 9 and occasionally 12 weeks. Nerves can take months (and sometimes years) to regrow. But as a rough rule of thumb for most injuries, all the tissues have usually healed by 90 days — no matter what happened. Additional gains may be made slowly for a year or more, often as the result of rehabilitation and reconditioning. Function and comfort often continue to improve after healing is complete.
One way to see this clearly is to take the case of a person who suffered a major body burn — a widespread and deep one that went down into the muscle. The burning itself was over in minutes. Some areas of skin and underlying tissues were destroyed and other areas were left damaged and weeping. The tissue healing process was in full swing by 7 days and by the time it was complete, had produced extensive scar. The skin was as healed as it was going to get, but it left behind stiff and painful scar. The scar is a CONSEQUENCE of the injury, not a sign that the burn injury is on-going. Rehabilitation for burn patients focuses on minimizing the impact of scarring on appearance and function.
Kristina listened hard and seemed to “get it” – but not completely. She is still in the habit of viewing herself as “hurt” (fragile). When something happens and she feels pain, she may be interpreting it as a sign she is being damaged or re-injured further – rather than seeing herself as a person who is stuck living with the painful (but harmless) consequences of a previous injury.
So, in my view, the most accurate way to describe Kristina’s situation is that she HAD an injury and is still dealing WITH and recovering FROM its effects. The injury is in the past. It is not accurate to say she still HAS an injury. The choice of words make a real difference.
And lastly, the term “injured worker” has got to go because those words communicate no possibility of either recovery or a positive future. How can people who’ve had an accident at work ever consider themselves well as long as they are being called by that name? That term doesn’t even hint at the fact that the vast majority of people who have an injury recover promptly and heal completely. The unlucky people who don’t end up fully healed are left with things like scars and stiff joints, not unhealed wounds. The previous term “claimant” was discredited and abandoned because it was too impersonal — but it did not doom the person to a negative and unchanging future.
All along, Kristina has been strongly motivated to get better and get back to earning a good living. She has been doing everything she can to get herself better and to advocate for herself in the “systems”. Imagine the “nocebo” impact of these three terms on a person without the inner resources Kristina has brought to bear!
What does this mean for you? If you are involved with the workers’ compensation system, please abandon the term “injured worker” and “injury” when discussing events longer than 3 months ago. Talk about “recovery” or “recuperation” instead. And maybe we should go back to “claimant”, or an even better term. For now, a few of my colleagues and I have started saying “affected person”. And if you are a person who had a musculoskeletal work-related injury more than 12 weeks ago, please assume that your tissues are healed. And, like Kristina start saying “how can I do this” instead of “I can’t.” It is time to start dealing with the consequences of that injury and get the whole thing behind you. Focus on accepting what you’re stuck with (at least for now), rehabilitate yourself, get back in the best shape you can — and focus on minimizing its impact on the quality of your life and your future!