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6.5.1 Brief intervention counselling to assist with adjustment to disability or injury and/or pain management
A disability or injury can result in a range of challenges and changes in a person’s life. These changes may include barriers to a person being able to reach their rehabilitation goals. Therefore, early intervention through counselling to assist the individual to adjust to the disability or injury or to ongoing pain can provide skills and strategies to equip a person to more effectively manage issues as they arise.
Counselling to assist an individual to adjust to disability or injury teaches a person a range of self-management strategies for coping with the life changes that a disability or injury can bring. Counselling aims to provide options and alternative ways for looking at and managing situations in their daily life, and to provide support to a person during their rehabilitation as they adapt to living with "a new normal".
Counselling to assist with pain management is designed to help a person to manage their pain, so they are able to function the best they can in their life despite the presence of pain. Counselling can focus on helping a person to predict their patterns of pain and to learn how to manage their pain through the use of psychological and behavioural strategies.
Counselling for adjustment to disability or injury and pain management are designed to be short term interventions which facilitate self-management. Where the individual does not respond to these brief interventions, referral for comprehensive assessment and treatment is to be initiated.
Counselling to assist adjustment to disability or injury and pain management under a rehabilitation plan
Brief intervention counselling for adjustment to disability or injury and pain management provided under a rehabilitation plan is in addition to any ‘treatment’ provided under the DVA Health Card system. For treatment to be provided under the card system, there needs to be a clinical indication/diagnostic indicator and accepted liability for the condition, for example, a pain syndrome or adjustment disorder. There are two exceptions to this rule. The first is where the person has a Gold Card which entitles the holder to treatment for all health conditions, whether they are accepted or not. The second is where a person has been provided with a White Card to assist them to access treatment for mental health issues through the non-liability health care provisions.
However, time limited (generally 6-8 sessions) adjustment to disability or injury counselling and pain management counselling can be provided through a person’s rehabilitation plan as part of an early intervention approach to prevent the development of more serious conditions and to assist clients to develop better coping strategies. For this reason, these types of counselling can be offered without there being a clear link to a condition for which the department has accepted liability.
This approach is consistent with the Australian Government Response to contributing lives/thriving communities – review of mental health programs and services, which signals a shift in the way Australian Government mental health programmes and services are delivered. Prevention, early intervention and stepped care are some of the key reform platforms which underpin the provision of adjustment to disability or injury counselling and pain management counselling as part of a rehabilitation plan.
Regardless of which DVA health card a veteran is using to access treatment, it is very helpful if treatment is outcome focused and includes goals that the health provider and the client are working together to achieve. Having a clear treatment plan which focuses on improving functioning assists with building the client's confidence and focus on recovery.
Identifying clients who may benefit from counselling
There is no requirement for DVA to have accepted liability for adjustment disorder or chronic pain issues for the person to be provided with time limited adjustment to disability or injury counselling or pain management counselling as part of a rehabilitation program. Rather, Rehabilitation Coordinators are requested to use the following "flag" system to consider each client’s individual circumstances, and identify whether the client would benefit from these types of counselling as an early intervention tool. Early intervention in this context means utilising brief intervention counselling as a tool to preventing symptoms escalating and developing into an adjustment disorder or a chronic pain syndrome. It does not mean that the intervention needs to be delivered soon after the client's service injury or disease.
Where one or more flags are raised, then adjustment to injury or disability counselling or pain management counselling should be considered.
Flags - Medical
Serious diagnosis of condition/injury
Other serious diseases
Failure of treatment (eg. unsuccessful surgery, difficulties in finding appropriate medication to address health issues)
Flags - Mental health
Mental health disorders, including anxiety and depression.
Medication, substance and/or alcohol misuse
Unhelpful beliefs about pain and injury (e.g. a belief that the pain is due to a major underlying illness/disease which has not been diagnosed, a belief that avoidance of activity will help recovery, a belief that there is a need for passive physical treatments (such as medication only or doing nothing) rather than active self-management such as exercise, physiotherapy, or seeking appropriate evidence-based treatment
Prolonged psychological distress that is impacting recovery (e.g. depression, anxiety, anger, bereavement, frustration)
Poor coping strategies (e.g. fear of pain and aggravation caused by everyday activities, catastrophising about pain, illness behaviour (constantly focusing on what they cannot do, rather than what they can do), overreaction to medical problems (eg. major fears expressed about what appear to be minor issues)
Client perceives inconsistencies and ambiguities in information about the injury and its implications (may indicate that fear is creating barriers to understanding what the impact of an injury may be)
Providers being unable to answer person’s and /or families’ worries about the nature of the injury and its implications, despite provision of clear and comprehensive information.
Flags - Perceived features of work or the social environment
Unsupportive management at work
High demand/low control in the person’s workplace or home life
|Difficulties in sustaining long term employment|
|Presenting with a variety of perceived barriers to applying for jobs or accepting offers of employment|
|Self-imposed pressure to succeed leading to the person over-committing to their work role by, for example, working additional hours and creating a risk of burnout|
Perceived time pressures (may indicate that the person is having difficulties coping at work or at home)
Lack of job satisfaction
Work is physically uncomfortable for the person
Employer’s rehabilitation policy deters gradual reintegration into suitable work, consistent with the person’s medical restrictions or does not address mobility and safe access to workplace facilities
Rehabilitation Coordinators are asked to be mindful of these flags when reviewing cases and addressing correspondence or communication from providers and/or clients. It is important that Rehabilitation Coordinators look holistically at a client’s circumstances.
Where medical and mental health flags are identified, rehabilitation providers are to consult with clients and their General Practitioner (GP) and be pro-active in alerting the Rehabilitation Coordinator to the need for time limited counselling (generally 6-8 sessions) to assist with adjustment to disability or injury or pain management as part of a rehabilitation plan. Rehabilitation Coordinators are expected to approve these sessions as a matter of priority.
If the client has not had a rehabilitation assessment at this point, and a file review indicates that medical and mental health flags are identified, then it is important that a referral for a rehabilitation assessment occurs as quickly as possible and that the referral information includes a reference to the need to explore brief intervention counselling programs.
Where the flags are only psychosocial then there may not be the same need to consult with the client's GP. However it is still important that the Rehabilitation Coordinator is proactive in approving the adjustment to disability or injury or pain management counselling.
Where the flags are only environmental, there would be many advantages to utilising the specialist skills of a Rehabilitation Counsellor or provider with specific expertise in vocational rehabilitation to address workplace issues, in addition to approving counselling to assist with adjustment to disability or injury or pain management.
If through early intervention, a client can be provided with strategies to self-manage their condition(s), this can prevent the escalation of a person’s symptoms and avoid the possibility of the client becoming even more unwell or hindered in the progress of their rehabilitation.
Stepped approach for providing support with adjustment to disability or injury and pain management
A stepped care approach is designed to ensure that people are provided with targeted assistance at the right level and at the right time. The level of assistance can vary from low intensity, early intervention through to high levels of care for those with severe and complex ongoing health conditions.
If an individual is not returning to expected functioning after a disability or injury, the following stepped approach applies:
- Where there are psychosocial and environmental flags, provision of counselling to assist with adjustment to disability or injury or pain management under a rehabilitation plan. The aim of which is to help a person develop strategies to self-manage the impact of their conditions (this includes both their accepted and non–accepted conditions).
- Where there are medical and mental health flags, the rehabilitation provider is to consult with the treating GP, be proactive in highlighting the need for brief intervention counselling with the Rehabilitation Coordinator and if approved, organise provision of counselling to assist with adjustment to injury or pain management under a rehabilitation plan.
- Where there is a concern about the client's current medical or mental health status, an option would be to request that the individual undergo the ADF Post Discharge GP Health Assessment and depending on the outcome, they could then be referred for the brief adjustment to injury or pain management counselling intervention. More information about clinical resources for GPs can be found on the At Ease portal.
- If the issues are going to take longer to resolve, resulting in the development or exacerbation of a mental health disorder, then the client should be encouraged to seek support under the Non-Liability Health Care (NLHC) provisions. In this case, the mental health condition does not have to be accepted by the Department. For more information please refer to DVA Factsheet HSV109 Non Liability Health Care.
Additionally clients should also be encouraged to lodge a claim for conditions which are likely to continue to have an ongoing impact. This can be done at the same time a claim for NLHC is lodged.
Where the family is being impacted by the condition, the client should be encouraged to contact the Veterans and Veterans Families Counselling Service (VVCS). This service provides free and confidential, nation-wide counselling and support for relationship and family matters that can arise due to the unique nature of military service. This includes the family of current or former serving members with operational service and members who have served in domestic or internal disaster relief operations, border protection operations or served in the Royal Australian Navy as a submariner; been medically discharged; or been involved in a training accident that resulted in serious injury to any person. For more information on eligibility, please refer to the client section of the VVCS website or call VVCS on 1800 011 046.
Who can deliver this type of counselling?
These counselling programs may be offered by a Rehabilitation Counsellor, who is a member of a relevant peak industry body, a Psychologist, a Mental Health certified Occupational Therapist or a Mental Health Credited Social Worker.
The skills and experience of the person providing adjustment to disability or injury counselling or pain management counselling is important, not just their qualification or their profession. When considering a person’s skills and experience, relevant factors may include whether the person is providing evidence based counselling, whether the person has previously been appointed to a pain management clinic or a group pain management program and how long the person has been providing the counselling for. If you have any questions or concerns about whether a service provider is able to provide appropriate counselling, please contact firstname.lastname@example.org.
It is important that the individual rehabilitation consultant who is managing the client’s rehabilitation case, does not also provide pain management counselling or adjustment to injury or disability counselling. For further information please refer to section 11.5 of this manual.
Case study example
A client has an accepted back condition. She has been on a rehabilitation plan for three months, but is finding it difficult to engage in activities approved under the plan, and hence the rehabilitation goals are not progressing within expected timeframes. The rehabilitation provider notices that the client is continually referring to her back pain limiting her ability to undertake activities and that she is spending more time at home lying down as a way of managing her pain. There are no other medical or mental health issues identified that could impact on the client's recovery. The provider discusses this with the client and they agree that pain management counselling would be helpful so that the client can learn to manage her back condition and pain more effectively. The provider discusses this with the DVA Rehabilitation Coordinator who approves an 8 week pain management counselling program as part of the client's rehabilitation plan.