Workplace Psychological Injury Report For Stakeholders

WORKPLACE
PSYCHOLOGICAL
INJURY A MIXED METHODS
INVESTIGATION INTO
WORKERS’
COMPENSATION CLAIMS
RESEARCH SUMMARY
REPORT FOR STAKE
HOLDERS
Rod Gutierrez
Injury Management Solutions
Pat Bazeley
Australian Catholic University
© Dr Rod Gutierrez
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, transmitted in any
from or by any means, electronic, mechanical, photocopying recording or otherwise, without the prior written
permission of the publishers.
National Library of Australia

Cataloging -Publication Data:
Workplace Psychological Injury Research Summary Report for Stakeholders
Includes Index.
ISBN 0-9775370-0-5
Research Report 2 For Stake Holeders

Contents
Chapter 1 .........................................................................4
Introduction.......................................................................4
Occupational Stress versus Psychological Injury: ........5
Chapter 2 Relevant Research Literature...........................6
Interactional Theories of Occupational Stress .............4
The Demand Control Model...........................................4
Empirical Evidence for the Model ..............................5
Psychological Injury Research Literature .....................8
Substantive Findings in PI Literature .........................9
Methodological Issues in PI Research .........................18
Theoretical Perspectives on Psychological Injury:
Claims as Functional Communication........................21
Chapter 3 Research Design ............................................29
Participants and Sampling...........................................29
Chapter 4 Main findings and Implications .....................32
Prevention and Management of Psychological Injury.32
Conclusions..................................................................36
References ....................................................................37

Introduction Chapter
1
The exponential increase of psychological injury (PI) claims seems to be a global problem facing many
countries in the developed world, especially those that have established workers’ compensation systems to
protect workers. In the US, claims for workers’ compensation exceeded $53 billion in 2002; of this, PI costs
have been estimated at in excess of $1.2 billion annually (Thompson Williams, Reno, & Burton, 2004; Webster
& Bergman, 1999). Similarly, in the Netherlands, rates for work-related stress have been on the increase for
several decades. As an example, in 1967 mental disorders accounted for 11 percent of employee disability
claims, But this figure has tripled over the last 33 years (de Jonge & Dollard, 2002; Dollard, 2003).
Australia has not remained unaffected by this significant problem, with stress related workers’ compensation
claims accepted by the Federal Compensation Agency ComCare Australia increasing by 20 percent per annum
since the inception of the system in 1989. By 1990 this situation had resulted in payouts of approximately
50 million Australian dollars (Bull, 1996). It has been suggested that when considering hidden costs, such
as loss in productivity benefits, and other fees paid by Government Departments, the real costs of these
claims is probably closer to $150 million (Fisher, 1995). Further, the Australian Workplace and Industrial
Relations Survey (1995) concluded that 26 per cent of people rated work stress as the second largest cause
of work-related injury and illness (Mitchell & Mandryk, 1998). It has been suggested that the situation has
reached crisis point, with costs of workers’ compensation claims in Australia amounting to $200 million per
annum across states, territories and jurisdictions by 2001-2002 (National Occupational Health and Safety
Commission, 2003; Stebbins, 2003).
At state level, all states and territories in Australia provide access to workers’ compensation schemes to injured
workers. A similar trend can be seen across the states in terms of claims for compensation for work-related
PI. In reviewing the data it is evident that while the number of claims for PI remains small, there is an inverse
relationship to the cost of these claims on workers’ compensation systems (Miller, 2003).
In NSW in 1999–2000 there were 1577 accepted claims for PI, comprising 17% of all occupational disease
claims (WorkCover Authority NSW, 2001). The average cost of each claim was $20,617, with total costs
amounting to $33 million. By 2003/2004 claims incidence had almost doubled and cost mounted to 89.7
million (Workcover Authority NSW 2005). In Victoria, PI claims were the third most expensive types of
claim after circulatory disease and back injury claims (National Occupational Health and Safety Commission,
2003). Similarly, Queensland has not escaped this alarming trend, where during the period 2000–2001 the
average cost of a claim was $17,249, double the cost of the next most expensive claim.
This trend is evident across all states and territories (Miller, 2003). It would appear that across all Australian
states and territories, the major contributing factor to the high cost associated with claims for PI is the
prolonged time injured workers tend to stay away from the workplace following a PI claim as opposed to other
claims. This means that the major cost is associated with ongoing weekly payments to the claimant (Guthrie,
1995; Toohey, 1995).
The rise in PI claims is often identified as an outcome of high levels of occupational stress in the workplace,
regardless of the manner in which occupational stress is defined in the numerous theories that have surfaced
in the past 20 or so years. In spite of an upsurge in research effort, there is little agreement between theoretical
Research Report 4 For Stake Holders

Chapter
1
camps about the manner in which occupational stress occurs or about the mechanics of its impact on
individuals (Hart & Cooper, 2001). Nevertheless, it is apparent that many theorists agree that occupational
stress variables, however defined, have a significant and causal impact on PI claims (Byrne, 2002; Clarke &
Cooper, 2000; Dollard, 2003; Sauter, Murphy, & Hurrell, 1990; Schirmer & Lopez, 2001; Tisza, Mottl, &
Mathews, 2003).
A thorough review of the literature, however, reveals that there has been relatively little research into PI
claims specifically; that is, scant research has been conducted particularly in regard to PI claims and claiming
behaviour, apart from the general occupational stress research (Haines, Williams, & Carson, 2004; Kendall,
Murphy, O'Neill, & Burnsnall, 2001). Close inspection of the literature indicates that the notion that PI
claims are associated with high levels of occupational stress, irrespective of how this construct is defined and
measured, is based on the presumption of a logical, linear relationship between occupational stress as causal
and PI claims as outcomes of work stress variables. In fact, there is scarce evidence based specifically on PI
claim research data that would confirm such a cause-and-effect relationship.
One of the most well researched occupational stress theories is Karasek’s (1979) Job Demand-Control (JD-C)
theory, also known as the strain hyporesearch. In this theory two major variables, demand and control, are
defined as having a causal impact on occupational stress variables as measured through a variety of methods
including surveys, questionnaires and physiological measures (de Jonge & Kompsier, 1997; de Lange, Taris,
Kompier, Houtman, & Paulien, 2003; Karasek, 1979; Karasek & Theorell, 1990). The theory predicts not only
main effects for both demand and control variables, but also an interaction effect where high levels of demand
and low levels of control are predicted to result in high levels of psychological and physical strain (Karasek,
1979). Strain has been associated with a number of adverse health consequences (Karasek & Theorell,
1990).
Johnson (1989) criticised the strain hyporesearch as excessively simple. He added a further variable, social
support, to the bi-variate equation, arguing that social support has a mediating or buffering effect on both the
demand and control variables of the model. From that point, the theory came to be known as the Demand-
Control-Support (JCDS) theory of occupational stress (Johnson, 1989; Karasek, 1979; Karasek & Theorell,
1990).
Since the JCDS was first proposed in the early 1990s, it has stimulated one of the most significant research
efforts to be found in the occupational stress literature, and the theory has been called upon to explain the
rising incidence of PI claims (Karasek & Theorell, 1990). Whether this theory does in fact explain claims
for compensation in mental ill-health cases associated with workplace injury has not been satisfactorily
investigated. Large scale epidemiological studies have been shown to offer the most support to the theory
(de Jonge & Kompsier, 1997). However, adequate research is needed applying the theory to bona fide PI
claimants.

Occupational Stress and
Psychological Injury
Research Liteature
Chapter
2
Interactional Theories of Occupational Stress
Central to interactional theories of stress is the notion that factors in the environment interact with individuals
to give rise to behavioral responses. The most important and influential of interactional theories is the Job
Demand Control (JD-C) theory (Karasek, 1979). This and its more advanced version, the Job Demand Control
Support (JDCS) model (Karasek & Theorell 1990), are discussed in detail. As previously mentioned (p. 25)
this theory plays an influential role in psychological injury, forming the basis for Toohey’s (1992) model
explaining psychological injury claims, and it is therefore central to the current study.
The Demand Control Model

Karasek (1979) rejected the concept that job characteristics are linearly related to worker health, proposing
instead that these characteristics may in fact act interactively in affecting worker health (Cox et al., 2001).
Structural and organisational aspects of the work environment are seen to be the central sources of stress,
rather than the personal characteristics or demographics of an individual (Karasek, 1979).
Karasek (1979) proposed that two central variables, job demands (the psychological stressors involved in
accomplishing the work) and job control (the level of ownership over the work) are likely to produce strain,
depending on the interrelationship between them. He argued that job demands are mediated by the degree
of decision latitude afforded to the worker within the work environment. Decision latitude is defined as "the
individual’s potential control over his tasks and his conduct during the working day" (Karasek, 1979).
The JD-C Model (see figure 1) predicts that high levels of demand and low levels of job control are likely to
result in high levels of psychological and physical strain. Karasek (1979) suggested that "psychological strain
results not from a single aspect of the work environment, but from the joint effects of the demands of a work
situation and the range of decision-making freedom available to the worker facing those demands" (p. 287).
In the same vein, low levels of demand and high levels of control result in low levels of strain. High levels of
demand accompanied by high levels of control result in what Karasek termed an "active job". It was proposed
that active jobs, although demanding, are only moderately stressful, due to the mediating influence of high
control. The model predicts that a combination of the two main variables, demand and control, produces strain
effects greater than the simple additive effect of each variable (Jones, Bright, Searle, & Cooper, 1998).

Research Liteature
Chapter
2
Figure 1. The Demand Control Model adapted from Karasek (1979).
As the model developed, another variable was added; that of social support (Johnson, 1989). This expanded
version of the model has come to be known as the Demand-Control-Support Model (JCDS). The dimension
of social support is seen to encompass all levels of social interaction available within the workplace, such as
support from work peers, from supervisors and from management (Johnson, 1989). It is argued that social
support plays an important part as a mediating factor between demand and control, acting as a buffer against
the effects of psychological strain in the bi-variate interaction (Theorell, 1997).
Empirical Evidence for the Model

Since it was initially proposed in the late 1970s, Karasek’s theoretical model has instigated a significant
research effort, and it has been argued that the model has taken on a paradigmatic role in the research literature
and in guiding new research in the field (de Jonge & Kompsier, 1997). The research conducted has culminated
in a substantial body of knowledge, with an array of research studies investigating diverse occupational
groups, in different international contexts, ustilising divergent methodologies, with a variety of physical
and psychological measurement outcomes of strain, both physical (e.g. heart disease) and psychosocial
(e.g. depression) (Karasek, 1979; Karasek & Theorell, 1990; Landsbergis, 1988; Mausner-Dorsch & Eaton,
2001; Stansfeld, Fuhrer, Head, Ferrie, & Shipley, 1997;Williams, Barefoot, Blumenthal, Helms, Luecken,
Pieper, Siegler, & Suarez, 1997). The research studies provide highly complex and conflicting, at times even
contradictory results that cannot be readily compared (Jones et al., 1998).

Chapter
2
Epidemiological Studies
Initially, the model was developed through the secondary analysis of data sets of heterogeneous samples.
The data were generally derived from large scale surveys. The data sets were correlationally analysed, and
evidence for the model was bolstered by findings which suggested that the theory predicted coronary heart
disease (Alfredson, Karasek, & Theorell, 1982; Karasek, Theorell, Schwartz, Schnall, Pieper, & Michella,
1988).
The research effort then moved towards conducting epidemiological research, with the specific intent of
testing the JCDS model giving way to large-scale national studies which also focused predominantly on the
prediction of cardiovascular disease from the demand-control interaction (Johnson & Hall, 1988). Johnson
(1988) created a variable which he called "iso-strain" (isolation strain), derived as a product term for the
standardised demands, control and support measures. In a later study comprising a sample of 7219 employees
in Sweden, results indicated that the high iso-strain group had a higher progression of cardiovascular disease
mortality and morbidity (Johnson, Hall, & Theorell, 1989). Additionally, the study showed that workers
who experienced high levels of iso-strain reported symptoms earlier in life and had the tendency to develop
vascular disease at a more rapid rate than workers in the low iso-strain group.
Evidence for JDCS theory from Homogeneous Occupational Groups

As the research momentum progressed, a number of studies were conducted which sought to test the theory
with homogeneous groups of workers. Here, the manner in which job control, demand and support interacted
with each other on measures of strain, physical and psychological factors was the focus of research.
One such study was conducted by Parkes, Mendham and Von Rabenau (1994) with a sample of 145 health
care workers. This study revealed that most of the physical complaints of strain were reported when there was
a combination of high psychological demands, low decision-making latitude and poor social support.
In the Australian context, Dollard (1997) conducted one of the first longitudinal studies into the model by
accessing a sample of 107 nurses employed in a medium sized public hospital in rural Australia. The findings
provided support for the JDCS model, with both interaction and buffering effects present and evident across
measures of strain.
Also in the Australian setting, Dollard and Winefield (1998) conducted a large scale investigation accessing
419 correctional officers. Their findings lend support to the JDCS theory in that workers experiencing higher
demands and low control over their work were assessed as suffering from the highest level of psychological
strain. Additionally, workers with the highest iso-strain jobs (as described above) were shown to suffer from
higher levels of strain than those in lower iso-strain jobs.
More recently, De Jonge, Dollard, Dormann, Pascale, Le Blanc and Houtman (2000), conducted another
Australian study with a varied sample of 2485 human services workers, utilising a cross-sectional survey
methodology. Their findings provided support for the model, illustrating several interaction effects between
demand and control on measures of strain such as emotional exhaustion and somatic health complaints. The
main interaction effect of the theory was shown to be present in the results, where high demand and low control
resulted in high levels of strain. Further, the authors concluded that active jobs, those with high demands but
also high control, resulted in positive outcomes as predicted by the model, including high job satisfaction and
job challenge.

Research Liteature
Chapter
2
Other research, however, has not supported the JDCS model. Much of this research has been longitudinal.
For instance, Parkes (1991) studied 264 education students taking a one year course leading to a teaching
qualification. He found that following measures taken at 3 and 4 months, only demand was a significant main
effect, while control was not related to strain as measured by indicators of anxiety and social dysfunction.
Thus, no support was found for the strain hyporesearch. Similarly, in a large scale Australian study of 2100
government employees working in Sydney in diverse occupations, who were accessed at intervals every
three years, the results show no evidence of main effects of demand, control and support on measures of
cardiovascular health (blood pressure). Further, as could be expected, the interaction effect was also absent
(Chapman, Mandryk, Frommer, Edye, & Ferguson, 1990). Findings which do not lend support to the JDCS
model have been reported widely (Hjollund, Jensen, Bonde, Henricksen, Kolstad, Anderson, et al., 1998;
Johnson, Hall, Ford, Mead, Levine, Wang, & Klag 1995; Landsbergis & Hatch 1996).
Given the large numbers of studies conducted using the model and the sometimes contradictory results
reported, reaching conclusions regarding its utility has been difficult until recently when several well
executed systematic reviews of the literature were conducted. De Jonge and Kompsier (1997) found that the
research conducted could be divided into four categories: epidemiological studies, cross-sectional studies
(homogeneous and heterogeneous samples), psycho-physiological research and intervention studies.
In concluding their review of the JCDS model, de Jonge and Kompsier (1997) suggested that epidemiological
studies afford the most support for the model, but that the supposed interaction between demand and control
is often not supported by the research.
These results are largely consistent with a later systematic review of the literature by Van Der Doef and Maes
(1999) that assessed 63 separate studies of various versions of the Karasek JD-C and JCDS models, and
found that support for the model interactions was equivocal and not universal. It was, however, suggested
that the literature provides considerable support for the strain and iso-strain hypotheses, while support for the
moderating effect of job control and social support was less consistent.
In contrast, in a more recent systematic review of the literature, de Lange et al. (2003) reviewed 45 of the best
available longitudinal research studies conducted into the JCDS model. By including only longitudinal research
in their review, de Lange and her colleagues argued that conclusions regarding the direction of causality of
variables could be made. They found only modest support for the strain hyporesearch across research that was
rated "high quality" with only "8 out of a possible 19 studies finding the expected combination of additive and
multiplicative interaction effects of the JCDS" (p. 300). There was, however, strong evidence, mostly from
self-report measures of health and wellbeing, that work factors affected health measures over time.
Criticisms of the JDCS Model

The JDCS Model has not gone uncriticised. Several problems have been identified with what has come to
be known as the "strain hyporesearch" (de Lange et al., 2003). The model has been described as being over-
simplistic, ignoring other relevant variables which may have a moderating effect on demand and control thus
resulting in the addition of further variables (Johnson 1989). Despite the addition of the third key variable, the
model continues to be criticised for its simplicity (Cooper, 2002b), its inability to take into account individual
differences, and its lack of applicability to the rapidly changing workplace (Jones, Bright, Searle, & Cooper,
1998; Kristensen, 1995). Additionally, the lack of independent or objective assessment of job characteristics
remains a methodological and practical weakness (de Jonge & Kompsier, 1997).

Chapter
2
Furthermore, there has been little success in applying the theory with regard to its most basic assumption,
that is, that control has a moderating or buffering effect on demands, and therefore jobs with high demands
could be modified by providing more control in order to reduce strain. The moderating effect has not been as
easily obtainable in applied research as would be predicted from the theoretical model (Van Der Doef & Maes,
1999).
Some have argued that the research effort has lost sight of the fact that the model was developed with the
notion that the structure of jobs has an impact on workers’ health rather than on workers’ perceptions of their
jobs (Morrison, Payne, & Wall, 2003). Morrison and colleagues suggested that much of the research designed
to study the JCDS theory does not actually measure job characteristics, with some notable exceptions (Van
Der Doef & Maes, 1999), but rather individuals’ perceptions of their jobs have been measured. Consequently,
Morrison et al. argued that the individual and not the job had become the unit of analysis. They suggested that
there is evidence to support the contention that individuals’ perceptions of their jobs have an explanatory role
to play in workers’ health outcomes, in view of the fact that the variance explained by the jobs themselves is
actually small. As a result, they argued for a re-conceptualisation of the JCDS model in terms of redefined
variables based on "perceptions" and "self assessed symptom" measures (p. 217).
From the foregoing account of the JDCS model it can be concluded that the model has been one of the most
important developments in theoretical thinking within the field of occupational stress over the last two decades.
The sheer simplicity of this three-factor model seems attractive to researchers; however, the simplicity does
appear to come at a cost. The model is not universally validated by research findings and there have been few
successful attempts at applying it in the field. Additionally, there have been limited efforts at translating the
model to the context of work-related mental disorders, with one notable exception (Toohey, 1992, 1995) which
is further expanded in the following chapter.
Psychological Injury Research Literature

In introducing an analysis of substantive findings in the PI research field, two important issues need to
be discussed at the outset. First, PI claims research has developed out of a need to contain the ever-rising
costs and personal impact associated with such claims. It is argued that researchers have been investigating
PI more closely due to the failure of occupational stress constructs to explain their occurrence and inform
intervention.
Secondly, over the past 20 years, there has not been a cumulative accrual of research-based knowledge regarding
PI as a construct worthy of concerted scientific investigation. This deficiency in the buildup of empirical work
over time has resulted in a set of research studies which lack a unifying relationship. It is evident that there
have been several researchers worldwide for whom PI has been of interest, and these researchers appear to
have studied PI in the context of local workers’ compensation systems. Researchers, therefore, often work in
isolation within their idiosyncratic systemic constraints. Consequently a substantial proportion of the research
has been conducted in the absence of an overarching framework, resulting in a body of literature which is both
piecemeal and unsystematic. Thus, the research effort into PI claims has been largely fragmented over time,
resulting in an un-amalgamated construct which is frequently overlooked in the wider context of occupational
stress research.

Chapter
2
Substantive Findings in PI Literature
When one examines the interaction between theoretical perspectives of occupational stress and PI it becomes
apparent that there is an almost complete lack of empirical research in the field of PI as a distinct entity from
occupational stress research (Kendall et al., 2001). One reason postulated is that occupational stress researchers
tend to see the submission of a claim as the onset of a rehabilitation process rather than as the continuation of
occupational stress (Kenny, 1995).
In contrast to the general literature on occupational stress, research interests have only recently been
directed towards PI as a distinct concept for scientific inquiry (Koch, 2005). A review of the literature was
conducted using the major citation databases available (i.e. PycLit, PsycArticles). Two main requirements
were established for studies to be considered PI research, separate from occupational stress research. Firstly,
the context of the studies needed to be workers’ compensation and secondly, the research had in some way
to evaluate compensation claimants within the system. These parameters yielded 18 studies that fulfilled the
criteria for inclusion.
Closer analysis of the selected literature suggests that research can be largely classified into three major
types of studies, depending on the research design and the manner in which the investigators gained access
to PI claimants. For the purposes of this detailed literature review, past research has been categorised into the
categories indirect, direct or mixed studies.
The first category of research can be described as indirect, because claimants are not accessed directly in
the research process. Rather they are examined via the review of archival files which hold information
about the claimants; such files consist of documentation including insurance records, claim reports and
medical certificates. The files reviewed are typically owned by employers, insurers, treatment providers or
compensation authorities (e.g. Colotla, Bowman, & Shercliffe, 2001; Cotton, 1995a; Islam, Edla, Mujuru,
& Doyle, 2003; Lippel, 1999b; MacDonald et al., 2003; Maffeo, 1990; McCall & Horowitz, 2004; Toohey,
1995). Secondly, in a number of studies of PI, workers’ compensation claimants have been accessed directly
either by interview, self-report questionnaire or case study (Cotton, 1995b; Dollard, Winefield, & Winefield,
1999; Eliashof & Streltzer, 1992; Haines et al., 2004; Kendall, Guy, Muenchberger, Murphy, & O’Neill, 2003;
Larsen, 1995; Nowland, 1997; Russell, Young, & Hart, 1995) .
The third category of research consists of combined studies, which use a design that accesses claimants both
directly and indirectly, implementing parallel components in a mixed methodology and action research. The
literature review yielded just one such study (Dollard et al., 2002).
Access to Compensation for Psychological Injury

Some of the studies listed here were primarily concerned with the manner in which compensation systems
deal with individuals and their related workplace precipitating factors in providing access to compensation.
One of the first studies examining contributing factors in PI was that of Maffeo (1990), who performed an
archival content analysis of 34 claim files which were identified as containing a psychological component as
the cause or the effect of compensable disability. Claims were then categorised by the cause of disability and
four causes were identified from the claim: PI, environmental factors, work-intrinsic factors and interpersonal
factors. Findings from this study suggest that three out of four claims alleging psychological complications
for traumatic injury were unsuccessful; in other words, liability was declined by the insurer. The major reason
proposed for the rejection of claims was weak medical documentation in support of the claim. Furthermore,

Chapter
2
claims in the environmental category yielded mixed outcomes, with claimants citing “loud noise” and “work
in highly enclosed spaces” both compensated, whereas no claims involving “overtime” were successful.
Additionally, in relation to the category of “interpersonal causes” Maffeo’s (1990) most salient finding was
that none of the 10 claims citing supervisor harassment was accepted for compensation. Maffeo concluded
that most claims cited more than one cause for the onset and were therefore of multi-factorial genesis.
Importantly, he also concluded that when one cause which was generally not accepted as compensable was
cited by a claimant, other causes which may well have been compensable were often overlooked in the liability
determination process. It was also noted that the pattern of the case outcomes tended to parallel that of other
jurisdictions, where sudden, one-time and easily definable events were more readily compensated than other
less well defined situations. Maffeo argued that the burden of proof of a causal relation between and injury and
employment is easier to make in such cases.
Maffeo (1990) also concluded that many professionals attempting to substantiate work-related illness or injury
failed to do so, possibly due to their being unaware of the standards by which their medical reports would
be evaluated. In a context where claimants largely depended on the treating professionals for meeting the
burden of proof of the existence of an injury or condition and its work-relatedness, poor professional evidence
supporting the injury of condition nearly always led to the claim being denied.
What is interesting about Maffeo’s research is that an attempt was made not only to try to match workplace
situations with psychological distress but that efforts were made to determine the types of claim which the
compensation system accepted versus those it rejected. The research design in Maffeo’s study required that
participants be undetermined claimants, that is, claimants whose claims had not yet been accepted or declined
by the system. This criterion therefore allowed comparison across both groups.
The only other study to recruit undetermined claimants was conducted by Lippel (1999), who examined
expert witnesses and decision-makers within a Canadian Workers’ Compensation jurisdiction with regard to
perceptions of men’s and women’s work as well as life circumstances, as reported in 185 compensation files,
and followed an archival file review and content analysis methodology. Findings from the study demonstrated
both quantitative and qualitative disparities in access to compensation, based on gender. Type of stress at the
source of the claim did not explain the difference. It was concluded that acute stress claims relating to one clear
and significant, often traumatic, stressful event were usually easier for claimants to justify, whereas chronic
stress claims based on a series of less significant stressful events were more difficult to prove. In addition,
Lippel found that when both women and men complained of chronic stressors, men fared significantly
better than women, with men’s claims accepted 67.5 per cent of the time compared to only 26.1 per cent for
women.
Lippel (1999) further analysed the percentage of stressors accepted by the court compared to those alleged
by the claimants. Lack of social support was accepted for compensation 54.8 per cent of the time overall, but
when gender was held constant, this stressor was accepted for 38.1 per cent of males compared to only 31.4
per cent of females. Role conflict was accepted 50 per cent of the time overall, but only 43 per cent of the time
for females compared to 66.6 per cent of the time for males. It was apparent that access to compensation for
PI was more difficult for women than for men. Further, Lippel found that the outcome was not explained by
personal problems, previous psychiatric history, legal representation or other likely factors. These findings led
the author to conclude that structural discrimination was inherent within the Canadian Workers’ Compensation
system, which worked against women, where women’s work was more likely to be perceived as being banal,
unimportant or not unusual.

Research Liteature
Chapter
2
Similarly, in a study accessing public servants in Australia, Dollard et al. (2002) found that PI claims were
about four times more likely to be declined by the insurer compared to other types of claim. It was also
concluded by the researchers that the belief (on the part of the insurer and employer) that PIs were exaggerated
seemed likely to increase suspicion, tending to prolong the process determination of claims.
In summary, two research studies have been concerned with the manner in which compensation systems
accept or deny liability for PI claims. To draw conclusions about claimants’ access to compensation it is
necessary to recruit undetermined claimants, that is, individuals whose claims for compensation have not yet
been assessed, and therefore claims which are neither accepted or denied by the system. From the research
reviewed it can be concluded that sudden, one-time and well defined workplace events had a higher likelihood
to be compensated, whereas interpersonal factors tended to be overlooked by the system for compensation
(Maffeo, 1990). Also, compensation systems may have inbuilt structural inequalities where certain types of
claimant may be treated differently based on gender or other factors (Lippel, 1999).
Common Workplace Contributing Factors

Researchers in PI have frequently attempted to isolate workplace factors that were seen as contributing to the
onset of distress at work and therefore PI. Several researchers have attempted to isolate the circumstances
most frequently cited by claimants or in claim files.
In the Australian context, Toohey (1992, 1995) conducted the largest study in this field in Australia. Toohey
headed the Quality of Working Life project (ComCare Australia, 1993), which was conducted within
Commonwealth agencies between 1989 and 1990. This study involved several methods of data analysis,
including analysis of archival statistical data held by ComCare and analysis of compensation claims made for
stress-related conditions, incorporating an archival file review of 232 claims which were sampled from several
Commonwealth agencies. Data gathered from the file reviews included precipitating factors, profile of leave
and demographic factors. Toohey found that the most frequently cited workplace precipitating factors in claim
files were workload (26%), trauma accounted (10%), conflict with supervisors (9%) and forced relocation or
redeployment for (9%).
Similar factors have been found relevant in the Canadian context. Lippel (1999) analysed the percentage
and rank for frequently reported workplace precipitating factors in 170 compensation files, finding that that
conflictual relations were most frequently reported (48.6% of files reviewed). This was followed by overwork
(33.6%), negative evaluation (25.7%), low social support (23.5%), worker responsibility (23.5%), lack of
control (21.2%), lack of recognition (11.7%), lack of training (10.1%), and high workforce turnover (7.3%).
In Australia, Dollard et al. (2002) found that with regard to factors influencing the submission of a claim, 45
per cent of injured workers interviewed identified the cause of the injury as resulting from the general work
environment, reporting such situations as high workload, unsafe work environment, management change,
working in isolation, interpersonal conflict and harassment. A further 25 per cent of injuries were the result of
a critical incident, while 35 per cent entailed multiple factors such as chronic work environmental issues and
a critical incident.
Dollard et al. (2002) concluded that even when the injury was a result of a critical incident, work environment
factors such as management practices, unsafe work practices, and fear of returning to work were noted as
triggers that led to the submissions of claims. Further, the highest levels of stress were reported at the time
of injury. With regard to the role of management actions, 50 per cent of injured workers had received a
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performance appraisal preceding the injury. Of the injured workers who had received a performance appraisal,
workers’ satisfaction with the quality of the appraisal was significantly related to overall job satisfaction.
Other researchers have attempted to go a step further from simple identification of workplace contributing
factors towards prediction of PI claims from workplace precipitating factors. Dollard and Winefield (1999)
conducted a study attempting to predict work stress compensation claims and return to work in welfare
workers. The study was based within a welfare agency with a high proportion of stress-related workers’
compensation claims and with mounting costs associated with these claims. The authors interviewed all 19
staff members within the welfare agency who had made a compensation claim for work-related stress during a
12 month period. Results indicated that PI claims had been made by 6 male and 13 female workers, consistent
with the gender distribution of staff within the organisation. Sick leave days for each of the 19 subjects were
compared to the departmental average. The average number of sick days for the claimants was 9.7 compared
to the organisational average of 4.5. In addition, the claimants took twice as many sick days during the years
before their workers’ compensation claim than their non-claimant counterparts.
According to Dollard and Winefield (1999), the nature of the injuries being claimed fell into three categories:
a critical incident only (3), a critical incident on top of chronic stress cause (6), and chronic work stressors
alone (7). Critical incidents involved a number of different difficult interpersonal situations, such as being
taken hostage, verbal threats, verbal abuse from colleagues, death threats, complaints and physical abuse.
Chronic stress included high workload, unmet needs for training, conflict with fellow workers, management
of escalating grievances, job dissatisfaction through lack of recognition and promotional opportunities, the
nature of the work environment, high demands and very high responsibilities, redeployment, chronic turnover
in managers, and job inflexibility.
Importantly, the study also evaluated claimants’ perceptions of their managers’ and supervisors’ responses
to their problems. Here, 56 per cent of claimants rated their supervisors’ responses as “bad”, 25 per cent as
“average” and only 18 per cent as “good”. Dollard and Winefield (1999) demonstrated that stressful workplace
situations were only the commencement point of claims. How supervisors and co-workers responded to the
claimants’ expressions of distress was seen as a critical factor in the long-term solution of the claim. Thus
the quality of relationships between supervisors and claimants appeared to be critical in both the onset and
resolution of claims.
Dollard and Winefield (1999) argued that on the basis of their results, it would appear that management
supervisors and co-workers were more frequently reported as sources of stress than were clients (interacting
with the public). Additionally, critical incidents had a profound affect on claimants. Claimants citing critical
incidents had better return to work outcomes than those who reported chronic work stressors as participating
factors in their claim. The authors suggested that claims where critical incidents are involved may be seen as
more legitimate for workers than those which occur as a result of ongoing work issues.
In another study attempting to predict PI, Haines and Carson (2004) investigated correlates of workplace,
personal and environmental factors in a sample of participants who had claimed workers’ compensation for
PI, compared to those who had not made a claim. The researchers evaluated cognitive distortions, irrational
beliefs and coping resources as individual factors across the four groups, and stressful life events, daily hassles
and work environment factors as environmental variables for comparison. They found that the compensation
group (those who had claimed workers’ compensation) was distinguished from the other groups purely on the
basis of work environmental factors.

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Additionally, Haines and Carson (2004) suggested that workplace factors may influence the decision of
claimants to seek help for the management of their symptoms of distress. However, none of the factors
predicted individuals lodging a workers’ compensation claim. The authors pointed to the difficulties
encountered in obtaining large sample sizes for the purposes of PI research as a possible explanation for their
inconclusive results.
From the initial endeavours to find measures of association between workplace contributing factors and
PI, certain studies arose in which the aim was to establish measures on the basis of well established
psychopathology rather than based on the status of a claim as accepted by an insurer (Cotton 1995b; Eliashoff
& Stretzer 1992; Larsen, 1995). Researchers sought to verify the presence of psychological distress prior
to isolating workplace contributing factors or clinical caseness, where “caseness” refers to the fact that a
claimant has been independently assessed by a clinician for the existence of a significant work-related disorder
or condition, and has in fact been designated as a clinical “case”, not just a person engaging in self-reported
description of unspecific psychological distress (Tennant, 2001).
Eliashof and Streltzer (1992) examined 26 PI claimants. They found two distinct sub-groups of claimants
within the sample. Firstly, 24 per cent of claimants experienced what the authors termed significant stress
at work. Members of this group were assessed as suffering from more severe psychiatric illness and fewer
personality disorders. A larger group (56%), however, had psychiatric symptoms that were precipitated by
interpersonal issues. Most of the individuals in the second group perceived that they had been unfairly treated;
they fulfilled criteria for personality disorders and were by and large more focused on issues relating to their
claim than in addressing their distressing symptoms.
In the same vein, Larsen (1995) employed a case study methodology (n=3) to document the manner in which
workplace factors affected claimants suffering from objectively and independently assessed psychological
distress. The study aimed to address the causes and prevention of workers’ compensation stress claims.
Larson provided case histories in the context of workers’ compensation for three distinct types of “psychiatric
injury”. He described the first case as mental dysfunction developing secondary to an initially physical injury
(physical-mental claim). The second case was that of a claimant experiencing a disorder as a consequence
of recognisable psychological trauma in the workplace. The third case was that of a claimant suffering from
stress stemming from chronic stressors. Larson pointed towards modifications in the work environment as the
main intervention strategy to be implemented in the prevention of PI claims, suggesting implementation of
employee education and training, mediation services, employee assistance programs, early intervention and
psychiatric examination, together with frequent insurer claims reviews.
In an account of psychological dysfunction in occupational settings, Cotton (1996) provided the breakdown
of unpublished research he conducted into 195 claimants assessed by a clinical psychologist with the purpose
of establishing the work-relatedness of their presentations (presumably before the determination of liability
for workers’ compensation claims) from an unnamed Commonwealth agency. No details regarding the
design of the study or the procedure followed were given by Cotton; however, he did provide a breakdown
of stress compensation claimants classified according to primary diagnosis. According to Cotton, the
breakdown indicated that non-clinical “vocational discontent” issues were reported by 20 per cent of the
sample, “adjustment disorder” was diagnosed in 20 per cent, and “clinical syndromes” accounted for 15 per
cent. However, no detail was provided as to the most frequently occurring clinical syndromes. “Maladaptive
personality style” (a notion proposed by the author, see Cotton, 1995) was the largest classification with 40 per
cent of claimants falling under this category.

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It is unfortunate that Cotton did not formally publish his study (Cotton, 1995b), as no assessment of the
methodological quality and procedure of this study can be made. Nevertheless, this unpublished study appears
to be the first large scale assessment of compensation claimants with verified clinical caseness in Australia.
Forman and Murphy (1995) presented three case studies consistent with three major causal themes in the
workplace: “uncertainty”, “control” and “social fabric of the workplace”, related to actual stress claimants.
Foreman and Murphy defined a “stress” case as “an employee who has been off work with an accepted claim
for a work-related stress disorder” (p. 135). The authors engaged in a useful discussion of work redesign
issues in light of their own experience in managing PI claims, suggesting that many PI claimants are in need
of relocation from their work environment to a different place of work. Foreman and Murphy considered
that interpersonal conflict played a significant role firstly in the development of distress and secondly in
complicating a return to normal duties due to the breakdown in workplace relationships.
From the literature presented, it can be concluded that researchers have made many attempts to identify
workplace factors believed to be contributing to PI claims. It is apparent that claimants often cite more than
one reason or factor in attributing their distress and, as such, PI claims appear to be mutifactorial in nature.
Some of the most frequently encountered workplace contributing factors include the type and amount of work
demands, the level of control available to the claimant, claimants’ involvement in traumatic events or critical
incidents, interpersonal conflict and harassment, and poor social support at work.
Duration, Cost and Risk of Psychological Injury

As discussed above, Toohey (1992) conducted one of the largest scale studies in the Australian context. That
study is perhaps most remembered for illustrating the vast disproportion of cost and time lost between stress-
related claims and other claims across Commonwealth agencies, where PI claims represented 4 per cent of
all claims yet accounted for 16 per cent of the total cost of all claims made (ComCare, 1993). This figure
continued to rise and by 1993, stress-related claims accounted for 4.6 per cent of all claims but made up 18
per cent of the total cost (Toohey, 1995). Toohey (1992, 1995) argued that stress-related claims were more
costly due to the fact that once claimants submitted such a claim they were more likely to remain off work for
a longer period than claimants seeking compensation for non-stress-related claims.
In another Australian public service study, Dollard et al. (2002) found that with regard to factors influencing
the duration and costs of claims across the public sector agency, approximately 60 per cent of the costs
associated with psychological claims occurred when the claim duration was in excess of 24 months. There
was a 46 per cent chance that an unresolved claim at 12 months would reach 24 months. PI claims were about
four times more likely than other types of claim to be declined by the insurer. In the same vein, the belief
that PIs were exaggerated seemed to be likely to increase suspicion and then prolong the investigation and
determination of claims. Here again, the longer the claimant remained off work the higher the costs associated
with the claim. In addition, Dollard et al. concluded that predictors of time off work included low level of
support and friendliness of co-workers and managers, low satisfaction with physical work conditions, as well
as low satisfaction with opportunities for promotion.
In another study concerned with the quantification of cost, McGovern et al. (2000) were interested in the
expenses incurred by the Minnesota Workers compensation system which were attributable to physical
workplace assaults, which frequently culminate in PIs. The researchers conducted an epidemiological study
accessing records from the entire system and found that on average such claims amounted to US$17,000 and
were substantially more expensive than other types of claim.

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The latest addition to the indirect research design model (as described on page 63), has been the use of
epidemiological research techniques in very large scale studies which access the claims incidence data of
whole compensation systems. This epidemiological approach has been used, for example, to evaluate the risk
of violence and aggression at work, based on the rate of compensation claims made by injured workers who
have been involved in violence-related incidents causing PI. In an effort to isolate risk factors for physical
assaults, Islam, Edla, Mujuru, Doyle and Ducatman (2003) conducted a large scale analysis of claims data
from the state-managed West Virginia Workers’ Compensation Department. The incidence of workplace
injuries resulting from physical assault was estimated for the period 1997 to 1999, and 2,122 compensated
injuries that were associated with workplace violence were identified
The incidence of assault injuries was 108.2 cases per 100,000 employees per year, with women having a
higher incidence than men. In addition, healthcare workers, public safety officers and teachers accounted for
almost 75 per cent of all assault injuries. Within these three occupations most at risk, there were differences in
relation to seasonality and timing of assaults, perpetrator/victim relationship and the type of injury suffered.
It was concluded that the healthcare sector sustained the bulk of the assault injuries in West Virginia. Within
the healthcare sector, a higher proportion of men than women were involved in assault injuries. The study was
successful in identifying three high-risk occupations which needed to develop strategies to avoid workplace
violence (Islam et al., 2003).
From the foregoing discussion of PI cost duration and risk factors it can be concluded that PI claims tend
to be more costly to compensation systems than other claims. The major reason for the disproportionate
attribution of costs appears to be related to the fact that PI claims tend to last longer than other types of claim.
Additionally, attempts have been commenced to conduct large scale system-wide epidemiological studies to
isolate potential risk factors so that these can be addressed in order to achieve a reduction in incidence and
therefore cost.
Outcomes Following Psychological Injury

There have been several studies primarily concerned with the outcome of PI claims (Colotla et al., 2001;
Dollard et al,. 2002; MacDonald et al., 2003; Nowland, 1997; Rusell, Young, & Hart, 1995). While the
methodologies of these studies vary substantially, the limited research conducted seems to indicate that
prognosis for PI claimants is poor.
Colotla et al. (2001) utilised indirect archival file review to access numerical data held in workers’ compensation
records, through content analysis of Minnesota Multiphasic Personality Inventory-2 (MMPI-2) profiles of PI
claimants. Measures across time were available, allowing for comparison of scores obtained from claimants
on two separate occasions. The aim of this study was to establish the retest reliability of the MMPI-2 in the
injured worker population. Apart from establishing that the MMPI-2 provided consistent and stable results
across time in injured workers, the study also shed some light on the psychological status of PI claimants over
time. Pertinent results indicated that claimants were significantly more distressed at the time of the second
MMPI-2 administration than the first, the time lapse being 21.3 months on average. The findings suggest that
claimants failed to recover from their psychological distress despite psychological intervention accessed in
the intervening period.
Further, in their study of an Australian public service agency, Dollard et al. (2002) found that injuries resulting
from the work environment were associated with extended periods of stress related leave from work. High
levels of stigma were seen to be associated with extended periods of time off work.

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Also in the Australian context, teachers suffering PI have been directly empirically studied with the aim
of predicting return to work outcomes following work-related PI, using a number of predictor variables:
demographic data, psychometric assessment, perceived psychological state and the manner in which the case
was managed (Russell et al., 1995). The participants in this study were 95 primary and secondary school
teachers who had suffered a work-related “stress injury” (p. 237) and had a workers’ compensation claim
which was accepted by WorkCover.
The best predictor of return to work was the amount of time claimants had off work prior to making an attempt
to return, where the longer the time spent away from the workplace, the less the likelihood of claimants
returning to their jobs. Additionally, best predictor of the return to work outcome was an early attempt made
by claimants to return to work, within 505 days of the date they last attended work (date of injury). The authors
proposed that the longer claimants remained off work, the more prone they became to the development of “an
inappropriate sick role including the development of secondary gains inhibiting subsequent plans to re-join the
work force” (Russell et al., 1995, p. 243).
Russell et al. (1995) also found that primary school teachers were more likely to return to work than secondary
school teachers, and that females were more likely than males to return. Finally, they determined that
claimants’ perception of their health status as measured by a self-report questionnaire was also a significant
predictor of return to work, where negative self-perceptions of health status were associated with poor return
to work outcomes. This finding is consistent with that of MacDonald et al. (2003), who conducted a study of
PI claimants suffering from posttraumatic stress disorder and reported that over one third of claimants in the
sample did not return to work at all, while over a quarter of claimants needed to obtain new employment.
Moreover, a well executed qualitative study of systemic factors was conducted within the South Australian
Workers Compensation scheme which accessed important stake holders including: claimants, employers,
insurers and health professionals Kendall et al, (2003) found that once claimants enter the compensation
system they are faced with several subsystems which often have their own competing agendas including
the medical, statutory claims and rehabilitation, and the legal subsystems. It was suggested that there is an
inherent conflict of interest between these subsystems in that their individual agendas not always aim for the
same outcome. Consequently, the conflict of interest often results in the overall compensation system failing
to adequately fulfil its intended role. Further, the researchers suggest that the system not only fails at providing
support structures to claimants allowing for successful transitions back to work; but that claimants seem to
frequently exit the system worse off than when they entered it. This important theme found repeatedly across
the sample under study was termed ‘the irony of the system’.
From the scarce research into outcomes of PI it can be concluded that claimants would seem to have poor
prognosis, both for recovery from clinical symtomatology and for returning to gainful employment, with a
substantial number of claimants never being able to work again following the onset of a significant work-
related mental disorder.
Methodological Issues in PI Research

Psychological research has traditionally followed the positivist philosophies in its scientific undertakings.
This has resulted in a well developed experimental design legacy which has lent itself to the study of most
psychological variables. Increasingly, however, shortcomings have been identified in the suitability of the
positivist approach to examine complex, mutifactorial and interrelated social variables (e.g. Patton, 1990).
Organisational psychology and occupational stress research have not escaped these criticisms, with researchers

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calling for more in-depth analysis in these fields through the use of interpretivist research and mixed methods
(Cooper et al., 2001; Hemingway, 2001), as well as the use of qualitative analysis (Kendall et al., (2003).
Others have suggested that given the scarcity of work done, research of any orientation would be welcome
with regard to workplace PI (Kendall et al., 2001; Nowland, 1997; Stebbins, 2003).
In critically reviewing the literature on PI presented so far, it becomes apparent that the research conducted
into PI claims is largely exploratory. It addresses some basic questions about who claimants are, and under
what kind of workplace situations workers become distressed. For this reason, it is suggested that the research
has taken a largely descriptive approach to the study of PI.
There are some major methodological problems apparent in a significant proportion of the research conducted.
Firstly, small sample sizes affect the majority of the studies reviewed here, with a significant proportion of
reported research studies consisting of case study research with usually fewer than four participants (e.g.
Eliashof & Streltzer, 1992; Foreman & Murphy, 1995; Larsen, 1995; Nowland, 1997). Even where larger
samples of claimants have been assessed directly, sample sizes were still modest (e.g. Dollard et al., 1999;
Haines & Carson., 2004; Kendall et al., 2003). It is suggested that finding research participants is difficult for
two major reasons: first, although the cost of claims is high, the actual incidence of PI at work is comparatively
low (although increasing) in relation to the total number of persons employed. For instance, in NSW there are
in the vicinity of 1500 claimants per year (WorkCover Authority, 2001) from an estimated 2.8 million full-
time or part-time employed persons in NSW (Australian Bureau of Statistics, 2005).
Secondly, PI claimants are not an easily identifiable group within the wider community. For this reason, it is
generally necessary to access this population through intermediary parties such as insurance companies (e.g.
Toohey, 1992), employers (e.g. Dollard et al., 2002) or government departments (e.g. Colotla et al., 2001).
The access to a sample population through an intermediary poses its own difficulties, including the need to
overcome issues of claimant confidentiality and informed consent to participate in research. Additionally,
possible restrictions may be imposed by third parties with regard to access and publication of research
findings, which at times may result in research results never seeing the light of day (e.g. Cotton, 1995b above).
Thus it becomes evident that the study of PI is indeed a challenging prospect, in view of the very nature of the
participants and the constraints imposed by workers’ compensation systems and associated bodies and their
respective internal regulations.
The next important issue of discussion in this methodological review relates to the amalgamation of claimants
as research participants into groups based mostly on PI claim status alone. Most of the research conducted has
accessed heterogeneous, undefined occupational groups (e.g. Colotla et al., 2001; Lippel, 1999; MacDonald
et al., 2003; Maffeo 1990) while other researchers have accessed single occupations (e.g. Dollard et al.,
2002; Dollard and Winefield, 1999; Russell et al., 1995). No study has simultaneously accessed multiple
occupational groups in order to investigate the possible contribution of claimant’s occupation in relation to
workplace precipitating factors, outcomes or other substantive findings in PI.
Another issue in need of discussion is that the assessment of clinical caseness constitutes a substantial problem
in PI research. It is difficult to compare PIs from different countries and possibly even from different states
within the same country, because of legislative and systemic differences. This situation makes the clear
definition of work-related mental disorders or conditions imperative. To this end, some researchers have
managed to classify claimants under study objectively by establishing clinical caseness; that is, they have not
merely relied on the fact that the claimants had an accepted workers’ compensation claim, but they have also
independently assessed the claimants for the presence or absence of a mental condition (e.g. Cotton, 1995b;
Eliashof & Streltzer, 1992; Larsen, 1995), and in doing so they have established clinical caseness.
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Through the establishment of clinical caseness, cross-referencing of workplace factors with patterns of
psychological distress becomes possible. Only three of the reviewed studies established clinical caseness.
In the studies without verified clinical cases it is not possible to cross-reference specific patterns of distress
(diagnoses) with specific workplace contributing factors.
A related, equally significant but separate issue limiting PI research studies is the lack of independent
verification of reported workplace precipitating factors. Whereas some researchers have undertaken to
establish clinical caseness (e.g. Cotton, 1995b; Eliashof & Streltzer, 1992; Larsen, 1995), no researcher to date
has made an attempt to independently verify the presence or absence of reported workplace events, factors
or situations which have allegedly precipitated claimants’ distress through independent assessment of alleged
(versus verified) workplace factors. For this reason, the substantive findings of the research discussed above
are based on information regarding the work factors as reported by claimants or as reported by claimants to
their treating doctors (secondary information). The implications of relying on self report have already been
outlined in Chapter 2 (page 42) and prove to be a major problem for PI research.
The stage of liability determination is another crucial issue in PI research. The majority of studies of PI have
enlisted claimants for whom claim liability has already been determined and which have therefore been
categorised as “accepted” claims under workers’ compensation schemes. The problem arises, however, when
we are interested in finding out about the workers’ compensation system itself and the way in which injured
and non-injured claimants are dealt with by the system. If we are interested, for instance, in the way in which
work factors affect workers and the extent to which these factors influence the development of a compensable
disorder, and we have access only to claimants whose claims have been accepted, only limited conclusions
regarding the causal effects of workplace factors can be drawn in the absence of a control group of claimants
who have been classified as non-injured (denied claims). Of the reviewed studies, only two (Lippel, 1999a;
Maffeo, 1990) have included both accepted and declined compensation claimants, enabling the researchers to
make comparisons across the two groups.
Lastly, when PI claimants have been studied both directly and indirectly, this has been done through cross-
sectional studies, with some notable exceptions (Colotla et al., 2001). The overwhelming lack of longitudinal
studies makes the course and progression of PI claimants over time an area needing urgent research attention,
in regard to both the resolution of clinical symptoms and the process of returning to work following an
injury.
In summary, PI research displays some substantial methodological limitations mainly related to small sample
sizes across many of the studies, which may restrict the generalisability of the findings and therefore reduce
the utility of some research results. Furthermore, the majority of the research undertaken has not controlled for
clinical caseness and therefore conclusions attempting to link workplace factors with patterns of psychological
distress are open to criticism; specifically, findings may be a function of the way in which the psychological
distress has been defined in each case, due to the absence of an independent assessor who can impose a set of
objective criteria for inclusion or exclusion in target clinical presentations.
Moreover, the majority of studies have been conducted with claimants who have accepted workers’
compensation claims; these participants are therefore “in the system”. Difficulties arise when conclusions
are drawn or need to be drawn about the process of accessing workers’ compensation or about the system
itself, when the available samples are constituted only of participants who have already been granted access.
Controlling for the stage of liability determination by recruiting claimants whose claims have not yet been
accepted or denied by the system becomes of key importance, when researchers are interested in the manner

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in which claimants are assessed and treated by the compensation system at large and when differentiation
needs to be made between claimants granted access versus those excluded by the system. It is argued that
the methodological limitations outlined here are so significant and wide ranging that they bring into question
many of the research findings discussed above.
Theoretical Perspectives on Psychological Injury: Claims as Functional Communication

Traditionally, PI claims have been regarded as a natural consequence of occupational stress. The issue of PI has
been regarded as causally linked to occupational stress in a linear manner, where high levels of occupational
stress within an organisation have been seen as responsible for the steady rise in workers’ compensation
claims for mental dysfunction. Research examining the causes of PI mostly has been conducted within a
stress-strain approach, as discussed in Chapter 2. Limited work, however, has been conducted in regard to the
conceptualisation of PI in its own right, and its possible causes.
In the Australian context, Toohey (1992, 1995) has proposed an explanation for the rise in PI claims in
Commonwealth agencies, extending Karasek’s (1979) theory by suggesting that job factors such as demand
and control could lead to the development of strain. Toohey additionally argued that lodging a claim for
compensation is an avenue that can be pursued by a worker in order to communicate his or her dissatisfaction
with the work environment. Toohey termed this avenue of action “Functional Communication”, describing
it in the following terms: “In this model, dissatisfaction with work is understood as stress and manifested in
the language of illness. The use of illness is a strategic or functional procedure for people to communicate
dissatisfaction in a safe and acceptable manner” (Toohey, 1995, p. 57).
Thus Toohey (1995) spoke of the “metaphor” of stress, suggesting that stress is merely a functional way in
which unhappy employees can express their dissatisfaction, presumably to their employers, in a sanctioned
and safe manner. Claims for PI, then are seen as medicalised industrial relations. This philosophical approach
to PI has since dominated the management of PIs within Commonwealth agencies.
Toohey (1995) proposed that “the language of stress” is primarily responsible for the conversion of upsetting
workplace events into their interpretation as illness. He argued:
A worker can verbalise feelings with the words “I am stressed” so making an expression of emotion.
Secondly this verbalisation of feeling or emotion when made to medical practitioner can result in a
medical certificate for the condition of “stress”. Thirdly, should the clinical condition be deemed work-
related and certified accordingly, the clinical condition “stress” can be regarded as legitimate sick leave
and potentially compensable illness. (p. 55)
Suggestions that occupational stress, or mental illness for that matter, are nothing more than metaphorical
conversions of social and moral problems into disease had their currency in the late 1960s to mid-1970s. The
anti-psychiatry movement popularised alternative views to the biomedical reductionist model which was the
status quo, with scholars such as Thomas Szasz, R. D. Laing and Michel Foucault, among others, holding
controversial and at times extreme views on the subject (Nye, 2003). Nye eloquently described the essence of
the anti-psychiatry movement:
These scholars were opposed to the popular idea of a “medical model” of social analysis that assumed
that social and individual pathologies were expressed symptomatically and could be diagnosed and
cured according to an organic conception of health and disease. In the critical perspective laid down
in this work, medical discourse reinforced a conception of reason as the enlightened self interest of
the rich and powerful and located the domain of unreason among women, the mad, the poor, and the

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criminal classes. However, these writers accomplished that most beautiful of intellectual operations: a
perfect inversion of the orthodox position. Criminals were victims of labeling, stereotyping and racial
and economic injustice; the mad were explorers of new psychological horizons of personal liberty; and
the rebellion against sexual gender norms was a form of self-emancipation. In this scenario, the real
villains were the doctors, psychiatrists and behavioral scientists who had used their knowledge and
authority to shore up the “establishment” and to segregate and pathologise the recalcitrant. (p.116)
Functional Communication theory, as proposed by Toohey (1992;1995), takes on a heavily Szaszian flavour
by suggesting that there can be differentiation between the idea of illness and the actuality of illness through
the analysis of the individual process of diagnosis. In this analysis, certain questions need to be answered in
the affirmative in order to establish if a person is in fact ill and therefore able to be described as a patient.
Toohey based this assertion on the work of Szasz (1990), suggesting that the differentiation of a patient from
a non-patient can be made on the basis of the reporting of pain and the observability of lesions in the person
reporting pain. Those reporting pain in the absence of observable lesions, it is argued, are often labelled as
mentally ill. Such labelling is based on the biomedical reductionist model, under the assumption that illness
can occur only if there is an organic, readily identifiable somatic cause. Mental illness, however, often has no
readily identifiable somatic or physical lesion to which to attribute it, and that in turn opens the biomedical
model to criticism as it is unable to explain the etiology of symptoms which afflict the mind (Pilgrim, 2002).
Szasz (1990) viewed the idea of mental illness as crucially ingrained in the fabric of society. He suggested that
the idea of mental illness “shapes the behaviour of family members towards one another, of politicians and
legislators towards the citizen, of judge and lawyer toward the criminal, of journalist and writer toward his
subject, and in the end of every one of us to everyone else” (p. 87). Szasz took his ideology against psychiatry
and the idea of mental illness to the extreme, suggesting that individuals had a basic right to suicide and that
mental health workers interfered with that right by providing clinical intervention and what he termed coercive
treatment methods (Szasz, 1986).
In alignment with Szasz, Toohey (1992) concluded that pain in the absence of a demonstrated lesion can
be communication of “individual feeling” only. He suggested that “stress events”, including t6hose defined
by Karasek (1979) (i.e. trauma, conflict, relocation, performance counselling, demands and control) are
experienced by employees in the context of poor or limited management strategies to resolve these issues. As
a consequence, he suggested that employees “self manage” the resultant problems through illness, whereby
they interpret their feelings of disquiet and upset as individual stress. Their status as “ill” legitimises absence
from work through medical certification and sick leave, thus formalising avoidance behaviour. Toohey further
suggested that recognition of an injured worker as a patient provides “justification for retreat from personally
unmanageable situations or alleviation of responsibility” (p. 67).
The suggested approach implies that a PI claimant is by definition a dissatisfied employee, presumably wanting
a matter resolved. The metaphor of stress suggests that PI stands for something other than what it seems. The
theory asks that we reject the notion of stress, and mental illness for that matter, in workers’ compensation
because stress and, by consequence, a PI cannot exist in the absence of physical lesions. Consequently, the
injury is not real; it is a metaphor and means something quite different. This philosophy immediately shrouds
the claimant in a veil of suspicion. The implied question to the claimant is: Given that stress doesn’t really
exist, what is it really that you seek?

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It is possible to imagine how well such an approach would be received by those managing large government
departments or private organisations. This approach allows managers, administrators and governments to
simply negate PI claims, metaphorically explaining them away as unresolved industrial relations, employees
expressing dissatisfaction, a problem that doesn’t actually exist, and a metaphor for something else. When
looked at in this light, it is not surprising that the Functional Communication approach has received much
acceptance from those agencies. In fact, much of the management strategy to deal with stress-related problems
within the Commonwealth sector has been based on the work of Toohey, which has sparked a number of
management initiatives including the Quality of Working Life project (ComCare, 1998), which has been
the basis of ComCare’s intervention and management policy for occupational stress since the early 1990s.
Despite this policy position and intervention strategy, compensation claims within the Federal jurisdiction
have continued to mount (ComCare, 2003).
Higgins (1996) expanded the concept of Functional Communication by discussing some of the perceived
practical implications of the process. He argued that, as the gatekeepers to the compensation system, medical
practitioners must make an assessment of whether claimants are engaging in Functional Communication and
therefore expressing dissatisfaction with work or whether there is in fact an illness present. Higgins suggested
that although symptoms may be reported by the claimant, these may not in fact be congruent with a recognised
condition in need of treatment, and may be more to do with dissatisfaction with aspects of the workplace.
Additionally, Higgins argued that the very act of a claimant consulting a treating doctor with regard to self-
reported symptoms of psychological distress lends itself to the medicalisation of work problems. Furthermore,
other factors apply pressure on the doctor, such as the doctor-patient relationship, which may interfere with the
doctor’s medical certification decision, making it more likely for a claimant to receive a medical certificate for a
work-related disorder. Higgins suggested that the certificate then opens the door of the workers’ compensation
system, the worker becomes a claimant, and a work problem becomes a medical problem.
According to Toohey (1992; 1995), Functional Communication consists of three specific component factors.
First, there is the assertion that a claim for compensation can be used by a claimant as a means of communication
or that the act of submitting a claim is a form of communication. Second, the theory suggests that the content
of this communication, that is, the compensation claim, is in fact communicating the dissatisfaction of the
worker with the work or the work environment. Third, the theory proposes a five stage linear process whereby
verbalising “I am stressed” as an expression of emotion culminates in medical certification which allows the
claimant to access the compensation system.
In evaluating Functional Communication it is necessary to assess each of the three components separately in
order to make judgments about the utility of the theory. The first notion, that claims for compensation can be
conceptualised as a form of communication, seems well based. In lodging a compensation claim, the claimant
is setting in train a legal process designed to redress, to compensate for alleged dysfunction. In practical terms,
the lodging of a compensation claim also has an impact on the social context of work in that the situation
is placed on record and claim lodgment has clear consequences associated with it both for claimant and
employer.
The second component, relating to what is being expressed in the communication that occurs by the lodgment
of a claim, seems less well based. Toohey (1995) clearly contended that claimants communicate dissatisfaction
through the language of illness by “verbalising feelings of stress”. However, he made this assumption on the
basis of archival medical certificates and documents relating to claimants, not directly on the basis of claimant
accounts of events. In other words, Toohey based his assertions regarding the content of communication on
secondary and at times tertiary accounts of what claimants had alleged occurred to cause their “‘stress”, as
Chapter
2
contained in medical reports and documentation found in files. Toohey attempted to tell us what claimants
were communicating through claim lodgment, without first asking the claimants themselves; his data set
provides no direct access to claimant accounts of their claim-related experiences and precipitating situations.
In addition, although Toohey suggested in his research that the precipitating factors to a claim were
multifactorial, he concluded that the communication taking place had a singular message, the expression of
dissatisfaction. In so doing, he employed a contradiction in logic. In this regard, one could offer an alternative
and logical suggestion that different claimants communicate different messages, or even that multiple
messages could be communicated through claim submission. Furthermore, the content of the communication
occurring through claim lodgment may prove to be a function of the precipitating factors of the claim, where
different workplace situations may be associated with different kinds of message.
Thus the content of the communication that occurs through claim lodgment is clearly debatable. It is evident
that there are alternatives, not the least of which is the possibility that the claimant is expressing severe
psychological distress rather than mere dissatisfaction. A distinction needs to be made between dissatisfaction
as described by Toohey (1995, p. 55) in terms of “an expression of emotion” and psychological dysfunction
in the clinical sense which goes far beyond an emotional impulse and requires substantially more than just the
verbalisation of emotion to become clinically relevant This distinction has been made by Cotton (1995) who
suggested that dissatisfaction with work or what he terms “vocational discontent” (p.100) is to be regarded
as separate from and distinct to clinical syndromes. For this reason, Functional Communication theory could
never explain, for example, the impact of traumatic critical incidents on a worker who develops anxiety-
related distress resulting directly from workplace events, given that that the impact of the incident is clearly
greater than mere dissatisfaction and enters the realm of clinically relevant distress.
The third component of the theory of Functional Communication, that relating to a five step process whereby
a dissatisfied employee becomes a compensation claimant, is striking in the sheer simplicity of the suggested
process. The process revolves around the worker, the medical practitioner and the verbalisation of emotion
by the worker. The linear model, depicted in Figure 4, suggests that when a worker verbalises the emotion of
being stressed to the medical practitioner, the result is a medical certification for the condition of stress. If the
clinical condition of stress is deemed to be work-related, then the dissatisfied worker gains access to legitimate
sick leave and potentially to the compensation system.
What is problematic about the five stage linear process suggested by Toohey (1992) is that the workplace
precipitating factors are entirely left out of the equation. The psychological effects that workplace events,
situations and relationships can have on a worker are entirely ignored by the suggested process. In essence,
the development of “occupational stress” occurs in the doctor’s office and has little to do with what happens
in the workplace; it is seen as entirely separate. There is no attempt to link the potential impact of work on
the worker’s health. Indeed, the context of the occupational stress problem is entirely unaccounted for in
Functional Communication theory.
Another substantial issue of concern regarding the theory of Functional Communication is that Toohey (1992)
expressed an a priori allegiance to the paradigmatic position of the anti-psychiatry movement by pointing out
throughout his research that the “mental illness interpretation” of stress is rejected in favor of the metaphoric
interpretation as proposed by Szasz (1990). It needs to be noted, however, that Toohey was in fact rejecting
the inability of a reductionist biomedical model of health and disease to appropriately explain issues of
mental illness. In adopting Szasz’ paradigm, Toohey re-enforced the biomedical model position that illness
cannot exist without a physical lesion or that illness must be organically based (Kinderman, 2005; Kushner,

Chapter
2
1998; Pilgrim, 2002). This is an anachronistic view, not only because there have been substantial advances
in medical science which link mental illnesses such as schizophrenia to brain dysfunction (Torrey, 2004), but
also because psychiatry and psychology for that matter have substantially moved forward from the stalemate
of the late 1960s and mid-1970s, by the development of more progressive paradigms.
The anti-psychiatry movement was influential in bringing about a change in thinking regarding the etiology of
mental illness, culminating in the formalisation of the biopsychosocial model by 1980 (Engel 1980; Pilgrim,
2002). The biopsychosocial model relates to a position most eloquently argued by George Engel (1980), who
proposed that bio-reductionist accounts of mental disorder needed to be replaced with more inclusive and
holistic explanations based on the findings of general systems theory. Engel suggested some basic assumptions
to be adhered to within the model. The first is that mental disorders arise in individuals who live as part of a
whole system. The second is that the system has physical elements which are both sub-personal (biological
systems) and supra-personal, including psychosocial systems (family, community, society, culture). The third
assumption is that the biological and psychosocial elements can be conceptualised as hierarchically organised
systems, with the lower levels of organisation being necessary for the higher levels to exist. The final
assumption of the model is that attempts at explaining mental disorders which refer to sub-personal factors
only (i.e. the biomedical model) will fail to comprehend the complexity of the whole system and will therefore
be reductionist (Pilgrim, 2002).
In contrast, Toohey’s views are aligned with a rather extreme paradigmatic position; a position which ignores
the interrelatedness of the biological, medical, psychological and social aspects of complex human systems in
which PI claims occur. The alternative holistic biospychosocial paradigm not only addresses the shortcomings
of the medical model in explaining mental illness but actually provides a solid ground from which the
complexities of mental illness can be unravelled. The biopsychosocial model may prove more availing than
simply negating or dismissing the existence of a mental illness and choosing instead to believe it to be a
metaphor.
Since the publication of Toohey’s (1995) work, significant efforts have been made to change the labelling
of stress claims. In fact, as a result of Toohey’s work, ComCare ceased accepting medical certificates not
complying with approved or recognised diagnostic labels. Consequently, the word “stress” is no longer
accepted by compensation bodies as a sufficiently clear term in explaining the distress which injured workers
may experience (Guthrie, 2003).
In the context of a systemic and multifactorial paradigm, it is possible to evaluate Functional Communication
in order to clarify and examine the content of communication expressed through claim submission. It is argued
in this research that the biopsychosocial model of mental illness is capable of differentiating dissatisfaction
with work through emotional “disquiet and upset”, as described by Toohey (1992), from psychopathology as
clinically significant and damaging distress impacting on claimants. One of the purposes of this study is to
replicate Toohey’s archival file review, using actual claimant and employer interview data rather than claim
forms and medical documentation, with an alternative assessment paradigm, in order to evaluate the theory
of Functional Communication.

Chapter
2
The research design employed in the study is essentially a dialectical mixed methods examination of claim
files, consisting of a primary quantitative content analysis which is guided, challenged and informed by
exploratory and elaborative qualitative analyses of the data. Qualitative and quantitative approaches are
integrated throughout the research process, to allow both generalisation and particularisation of the insights
gained from the data. The research design is illustrated in Figure 2.
Figure 2. The Research Design
As seen in Figure 1, the research questions are concerned with unlocking knowledge contained in archival
workers’ compensation files. The data is qualitative by nature, which imposes methodological constraints on the
analysis. In response to the research questions and in view of the qualitative data, three discrete but integrated
components were implemented to retrieve and analyse the data. Firstly, an exploratory file review utilising
interpretivist procedures was undertaken in order to “eyeball” the data and refine the coding instrument as well
as to familiarise the researcher with recurring themes. Relevant themes, concepts and events identified in the
exploratory analysis were then added to the already existing content analysis instrument (Toohey, 1992), to
allow coding for the presence or absence of such occurrences.

Research Design and
Methodology
Chapter
3
Once the exploratory analysis had been undertaken and the content analysis instrument modified, the qualitative
(textual) archival data of 157 files were converted to quantitative (numerical) data through content analysis.
The data were then analysed according to statistical analysis principles. Salient results from this analysis
were then selected for further investigation through interpretivist methods and qualitative data analysis using
inductive reasoning, utilising the full text of the claims files as data.
The final section of the study incorporated a detailed qualitative analysis of 18claim files. The aim of this
analysis was to shed light on important aspects raised in the quantitative section of the study. The qualitative
interpretive analysis followed a coding system derived from grounded theory using the constant comparative
method as developed by Strauss and Glaser (1967), which uses qualitative data as units of analysis from which
it is possible to build theoretical frameworks based upon the data itself.
Results from both major quantitative and qualitative analyses were then triangulated, resulting in convergence
and elaboration of findings through the integration of both methods.
Participants and Sampling

The current research accessed archival case files of PI claimants assessed for the purpose of liability
determination. Contained in each case file, among other documentation, was a stress investigation assessment
report, which had been conducted in relation to the claim for workers’ compensation submitted by a claimant.
The report was a detailed document explaining the intricacies of the case, containing transcripts of interviews
(statements) pertaining to the claimant, as well as collateral informants including employer representatives
and sometimes treating doctors and co-workers. Additionally, the views of the independent assessing
psychologist with regard to diagnosis and its attribution were documented in the case file. The participants of
this research can be best described, therefore, as claimants seeking workers’ compensation benefits under the
NSW Workers’ Compensation System, viewed through their case files.
In the case of PI claims, many insurers used the “Stress Investigation Model” (Fisher & Cotton, 1995),
developed by ComCare, the Federal compensation agency, to assist claims staff in determination of liability.
An agency which conducts stress assessments on behalf of insurance companies provided access to archival
investigation records. The records were selected for the study on the basis of their informed consent status,
where only claimants who had agreed to release their records for the purposes of research were selected for
incorporation into the sample. In all, 157 files were selected for inclusion in this study. All archival records of
assessments conducted between April 1999 and July 2002 which contained an informed consent form were
eligible for study once the files had remained inactive for a period of more than 3 months. The archival case
files were selected consecutively, on the basis of informed consent status, to ensure a quota of at least 20 for
each of five work areas to allow enough participants across cells.
This method of sampling lent itself to the classification of cases according to the work environment in which
the participants were employed. This type of classification yielded five distinct categories, as illustrated by
Table 1.

Chapter
3
Table 1. Participants by Occupational Group
Law enforcement Teaching Custodial Public Private enterprise
general
22 20 64 25 26
The sample size was selected on the basis of providing adequate comparative numbers across the categories
as well as a total sample size which was large enough to draw inferences regarding the data. Thus a minimum
quota of 20 files was set for each occupational group, which allowed at least 5 cases in 2x2 tables for statistical
analysis. There was a disproportionate number of custodial files, due to the fact that this occupational group
was over-represented in the assessments available. Although the files found for this group could be categorised
into adult custodial and juvenile custodial, such a division was not considered necessary given the similarities
in the work environment and the types of duties which each group undertook.

Relevant Findings and
Implications for Stake Holders
Chapter
4
This study has provided some important insights into PI claims in NSW. Firstly, it supplied some initial data
to describe claimant characteristics in the context of the workers’ compensation system across a broad sample
of claimants seeking compensation. Secondly, the study questioned key assumptions regarding the underlying
causes of PI claims in NSW. It was argued that PI claims have become entangled with general occupational
stress research, which tends to take a narrow view of potential contributing factors to occupational stress,
constructing over-simplistic stress-strain models that are unlikely to account for a complex mutifactorial
construct such as PIs in the workplace. Similarly, two theoretical standpoints that had been proposed
specifically to explain the development of PI at work were evaluated and disputed.
The study has also illustrated the manner in which, over the past 20 years, PI research has developed through
a research tradition that has sought to clarify the factors that contribute to the development of compensable
psychopathology.
Figure 3. Definitional model of Psychological Injury (PI): a Biopsychosocial-politico-legal entity.

Implications for Stake Holders Chapter
4
Secondly, the research has documented the state of affairs in 157 claimants of PI claims in NSW, a number
equivalent to approximately 10% of the claimants in a given year. The quantitative analysis clarified the
relationship between claimant characteristics and workplace contributing factors, with specific regard to
resulting patterns of psychopathology as assessed by biopsychosocial diagnosis. Additionally, logistic
regression models were applied to predict important outcomes to further clarify factorial relationships.
Unlike previous research based on undetermined claimants, which found significant differences in access to
compensation based on gender (Lippel, 1999), the present study found no significant gender differences in
the rate of claim lodgment or access to compensation. Similarly, it was also established that no differences
were found across occupational groups in relation to the rate of reporting of different workplace precipitating
factors (with the exeption of trauma). This finding reinforces an important discovery of the current research:
that the work environment or, more specifically, job specific factors, do not appear to have a significant bearing
on the development of PI. Rather, high levels of interpersonal conflict, specifically interpersonalised conflict,
coupled with low support appear to be substantially more important in this field. Thus, poor human-to-human
interactions as opposed to human-to-job interactions in the context of work appear to bear the responsibility
for the development of PI claims.
Thirdly, the research has evaluated two theoretical positions explaining the occurrence of PI claims. According
to the theory of Functional Communication, the direct causation is that PI claims are metaphoric expressions of
dissatisfaction. On the other hand, according to the JCDS theory of occupational stress, an increase in claims is
likely to be due indirectly to the strain caused by high demands, low control and low support. The findings of
this study do not lend support to either theory when applied to PI claimants. Issues of interpersonal conflict and
social support in the workplace emerged as the most significant variables in the study of PI, and these issues
are in urgent need of further research. The findings of the study indicate that dissatisfaction with work was
not the only message expressed by claimants through claim submission and that Functional Communication
theory, as defined by Toohey (1992, 1995), significantly overestimates the proportion of individuals who could
be said to submit compensation claims in an attempt to express dissatisfaction with the workplace, particularly
when implementing a biopsychosocial apparoach. Additionally, it became apparent that claimants who sought
to use compensation avenues to address issues of dissatisfaction as opposed to issues of psychopathology
could be identified by forensic psychological assessment.
Fourthly, the mixed methodology has facilitated the development of a substantive theoretical framework to
explain the development of PI claims in NSW, based on the archival data and following a grounded theory
approach using methodology derived from the constant comparative method. The framework forms a starting
point in the long road to clarifying the expensive problem of PI claims at work. The framework offers a
theoretical process to explain the way in which PI claims occur and the context in which they develop. It also
explains the manner in which workplace and personal factors interact to set in motion the process whereby a
worker becomes a compensation claimant, and its associated trajectory. The framework is thus presented as
an alternative to Toohey’s 5 stage linear process and is based on the notion that the factors leading to PIs are
substantially more complex and interrelated than previously suggested.
Finally, the study has advanced the use of mixed methodology in PI research by successfully integrating
qualitative and quantitative components through the process of methodological triangulation. Thus, through
corroboration and complementarity of methods, new insights into the nature of PIs in NSW have emerged.

Why do we keep missing the
boat?
Chapter
4
Prevention and Management of
The findings of this study provide an explanation for the insightful observation of Kendall et al. (2001) that
despite the exponential increment in knowledge about occupational stress and its ill effects, there has been an
equally exponential increase in the cost and number of occupational stress claims over the past 10 years. A
plausible explanation for this situation is that the "counter-intuitive situation" facing researchers in the field is
largely attributable to the fact that to date, there has not been a well defined theoretical model incorporating
the available understandings of PI, apart from a rather unclear notion of PI as "stress claims". On this basis,
there have been attempts to explain the incidence of stress claims as consequences of occupational stress
as explained by varied theoretical positions (Byrne, 2002; Clarke & Cooper, 2000; Dollard, 2003; Sauter
et al., 1990; Schirmer & Lopez, 2001; Tisza et al., 2003). It is suggested, however, that the serious lack of
understanding of PI as a theoretical entity, separate and distinct from occupational stress constructs, has
substantially affected attempts made to curtail its incidence and manage its consequences, leading as a result
to a growing and significant social, political, and most importantly, health problem.
In view of the findings of this study, there seem to be substantial shortcomings in many of the stress-strain
theories that have been postulated to account for the occurrence of occupational stress and PI. It is also evident
that the paradigmatic position from which the theories have been developed seem to be no longer relevant
(Kenny & Cooper, 2001). If we are to have an impact on the ever-rising costs of PI claims, it will be necessary
to develop intervention strategies that actually address the important factors that appear to be predictive of
compensated psychological distress in the workplace.
Further, we have for two decades been placing all our efforts into stress-strain research in the hope that
understanding occupational stress will lead to a reduction in PI claims. It is clear, however, that if serious
attempts are to be made at reducing the financial and personal costs of these claims it is necessary to implement
research efforts directly into PI and to develop interventions specifically applicable to it. In other words,
in view of the fact that PI does not seem to be appropriately explained by occupational stress theoretical
perspectives, it is not possible to expect that interventions based on such theoretical bases will impact in any
real terms on PI claims. The value of continuing to develop interventions on the basis of simple two- or three-
component theories such as the JCDS model has been called into question, in view of the changing nature
of working conditions (Cooper, 2002a) and also due to the significant problems in applying such theories to
practice (Jones et al., 1998).
Dollard et al, (2002) suggested that there are significant delays in claim determination associated with a high
level of suspicion on the part of insurance companies regarding the veracity or exaggeration of PI claimant’s
distress. A significant implication for policy based on the findings of this study is that the level of suspicion
and the amount of resources directed towards investigation of PI claims and liability determination seems
unnecessary given that on the basis of these results, a substantial majority of claimant are in fact suffering from
psychological disorders substantially brought about by their employment. While acknowledging that claim
investigations assist in determining the presence or absence of “reasonable actions” pertaining to claims as
described in the Workers Compensation Act, 1987 as well as establishing diagnostic status; it is proposed that
the initial efforts in dealing with the PI problem should be focused towards claim resolution and management
rather than the prolonged investigation of PI claims.

Implications for Stake Holders Chapter
4
Thus it may be more productive for insurers to deal with PI claims at least initially, on a ‘without prejudice’
basis, as is already permitted by current legislation, where insurer funded interventions may take place,
without an a priori commitment to ongoing liability for the claim.
In addition, the results indicate that there is a significant difference in the manner in which claimants and
employers perceived the presence of workplace precipitating factors. When claimants reported the presence
of certain workplace precipitating factors, in the majority of cases (for 7/8 factors) employers did not agree
that these factors or situations were present. By taking the view of the independent psychologist as a middle
ground, it was possible to infer the direction of the disagreement. The one factor where all three stakeholders
disagreed was with regard to the presence of low support in the workplace. Here, employers overestimated
the amount of support provided to claimants, whereas claimants underestimated the amount of support they
received from their employers. It is important to note that the employers’ overestimation of level of support
was greater than the perceived underestimation of level of support as reported by the claimants, in relation to
the “baseline” provided by the psychologist’s estimation.
Similarly, there was disagreement across claimants, employers and independent psychologists in regard to the
presence of interpersonal conflict. When examining the disagreement in more detail it was apparent that the
main difference was in the rate in which employers and claimants perceived the existence of conflict. Here,
when claimants identified the presence of conflict with employers, employers tended not to not agree that
conflict was present. By referencing the views of the assessing psychologist it was possible to determine that
the conflict did exist between claimants and employers, but employers seemed unable or perhaps unwilling to
recognise it.
In applying the findings discussed in the foregoing account, it becomes imperative to acknowledge that there
is a significant difference in the manner in which the reality of events surrounding a compensation claim are
likely to be perceived by claimants and employers. Intervention strategies should therefore be targeted at
minimising the perceptual divide between these two stakeholders, as resolution of claims is unlikely to be
achieved if only one side of this bipartisan relationship acknowledges the existence of a problem. To this end,
the implementation of effective workplace communication training, at least at line management level, may be
required.
Both the quantitative and qualitative results of the current study point towards interpersonal conflict as an
important concept for PI, with independent psychologists verifying its presence among a large proportion of
the sample. Further, results of the study indicate that negative human interactions such as interpersonal conflict
are predictive of the acceptance of claims for compensation. Therefore, the identification and management of
these complex interactions at work need to become foci for intervention.
In further expanding the foregoing discussion, it is suggested that conflict resolution measures need to be
developed that can be implemented in the context of everyday employment. An important finding in this
regard comes from the qualitative analysis undertaken in this study, which found that although interpersonal
conflict was present across most of the sample under study, there was a qualitative difference in the nature of
conflict when it became interpersonalised.

Implications for Stake Holders
Chapter
4
Interpersonal conflict emerged as an important concept from the data, suggesting that when conflict became
internalised, therefore affecting the individual at a personal rather than a work level, it tended to have a
substantially more detrimental impact on the individual worker’s mental health. This is an important finding
with implications for practice, where it may be necessary to train both employers and claimants regarding
the difference encountered and the potentially damaging impact of interpersonal conflict. Changes to internal
policies and procedures as well as to communication strategies in the workplace may curtail the incidence of
interpersonal conflict, and this is identified as a starting point for the development of PI focused intervention
strategies.
It is suggested that humans are social beings and workplaces are human institutions and that interpersonal
conflict comes as part and parcel of being employed and holding a job, therefore some level of interpersonal
conflict at work would seem inevitable. What is important, therefore, is the manner in which interpersonal
conflict is managed in the workplace. For this reason, there is a need for workplaces to develop and establish
their own readily accessible and visible conflict resolution policies and practices, to clearly outline the
expectations of employers and workers regarding the process whereby interpersonal conflict is to be resolved
at work when it occurs.
Interpersonal conflict, however, cannot be resolved if its existence is not identified or acknowledged. The non-
acknowledgement of interpersonal conflict when it is evidently present (to an independent third party, i.e. the
assessing psychologist), as was found to be the case between claimants and employers, is an important issue
requiring intervention attention. It becomes apparent, therefore, that there is a need to develop interpersonal
conflict detection as a form of intervention, in order to assess the presence and extent of interpersonal conflict
at work, particularly between workers and their employers. Hence, interpersonal conflict must be detected and
acknowledged prior to be being addressed with efforts to resolve it.
Moreover, the results of this research provide a level of clarity regarding the clinical presentations most likely
to be associated with PI claims. Until now, at a practical level there has been little empirical research in this
field that could inform clinical practice. In light of the findings of this study, the results suggest that when a
claim for PI is lodged the psychological dysfunction associated with the employment is likely to be determined
to be one of three major groups of clinical symptomatology: major depressive disorder, anxiety disorders and
adjustment disorders. From a clinical perspective, the types of intervention both at work and in the clinic are
likely differ depending on the presenting symptoms and subsequent diagnostic classification. It is possible,
then, to move away from non-specific labels such as “stress claim” to more relevant and precise descriptions
of work-related psychological dysfunction.
While conceding that the use of diagnostic labels does not come without its problems, it is argued that there is
a substantial benefit in identifying the kinds of PI claims that arise at work by virtue of the symptomatology
which accompanies them. Such diagnostic identification could see evidence-based interventions targeted at
specific clinical presentations.
The results of this study also highlight the incidence of traumatic events or critical incidents at work as an all
too frequent workplace precipitating factor with over one third of all claims associated with traumatic incidents
in the context of work. Thus, it becomes apparent that there is a need for both the prevention and strategic
management of trauma in the workplace. Employers may need to develop specific policies and procedures to
deal with these situations when they arise and there need to be clear steps taken to manage traumatic reactions
at work.

Chapter
4
Furthermore, it is possible to appreciate that the research has potential for application particularly in the field
of occupational rehabilitation of injured workers suffering from PIs. At present, there is scarce evidence in
the literature regarding the rehabilitation of PI claimants and their associated return to work process, either
at claim onset or over time. It is proposed that workplace based rehabilitation will be markedly different
depending on the psychological condition suffered by the claimant, and therefore that diagnosis-specific
treatment and workplace intervention programs may need to be developed. It can no longer be assumed that a
single type of intervention for “stress claims” will be applicable across the three distinct groups. For instance,
the treatment and intervention received by a claimant suffering from posttraumatic stress disorder following
a critical incident may include, inter alia, a desensitisation component, a gradual return to work, and anxiety
management techniques, and should be substantially different from that received by a claimant suffering
from major depressive disorder as a result of interpersonal conflict at work, who might in turn require conflict
resolution/mediation and cognitive restructuring.
Consequently, a significant practical implication of the findings of this study is that what has traditionally been
referred to as a “stress claim” is not a single uniform entity. Thus, attempts at singular and blanket management
strategies are unlikely to be successful in achieving return to work outcomes.
Implications for Theory

Importantly, this research has clarified the role of accepted occupational stress variables as applied to PI
claims. The findings suggest that there is an urgent need to separate traditionally conceived occupational stress
variables (e.g. demand and control) from PI. As explained in detail in Chapter 4, PIs are biopsychosocial,
legal, political constructs which are unlikely to be explained by the stress/strain relationships often described
in the occupational stress literature. It is argued that PI claims have for too long been assumed to be the result
of occupational stress variables in the workplace, and that there is a clear need to establish PI research in its
own right, separate from occupational stress as a related yet discrete area of academic enquiry.
As discussed in Chapter 4, an aim of research was to evaluate two theoretical positions: the Job Demand
Control Support (JDCS) theory of occupational stress (Karasek & Theorell, 1990) and the Functional
Communication theory of psychological injury (Toohey 1992, 1995).
The first theoretical position under evaluation predicts in the first instance that when workers experience
stress in the form of high demands and low control over the manner in which they decide to undertake and
perform these demands, high levels of physical and psychological strain are likely to result (Karasek, 1979).
This theory, as discussed in Chapter 2, therefore suggests that “stress” leads to “strain”. The research reported
here suggests in contrast that stress-strain variables as described by Karasek do not have a significant bearing
on PI claims. In fact, demand issues were reported in a minority of claims (17%), and control issues by an
even smaller minority (4.5%). Furthermore, when these factors were assessed by an independent psychologist,
demand and control were found to be even less prevalent (1% and 6% respectively).
This research has demonstrated that poor support appears to play a significantly more important role than
that of a mere moderating factor as proposed by the JDCS model (Karasek & Theorell, 1990). Lack of social
support, as verified by independent psychologists, was predictive of the presence of the three main categories
of psychopathology found in the study, depression, adjustment and anxiety. Hence, poor social support has
emerged as a significant predictive factor in the development of PI claims, with its contribution to PIs being
greater than just a buffering effect between the two factors of demand and control.

4
The present study calls into question the ability of simple bivariate or the slightly more complex trivariate
theories to explain PI. On the basis of the results, it is suggested that the application of simplistic occupational
stress theories to claiming behaviour is unlikely to progress theoretical understanding of this field. Further, this
study has illustrated that the social or human aspects of the work environment, such as support and personalised
interpersonal conflict, are principal precipitating factors to psychopathology resulting in PI claims. Significant
research and intervention attention needs, therefore, to be diverted to these psychopathogenic elements.
These findings are in accordance with organisational health theory (Hart & Cotton, 2001) which suggests that
workplace “climate” appears to be a crucial factor of relevance in the occupational stress literature in general,
but also specifically to PI claims.
The second theoretical position under evaluation, the Functional Communication theory (Toohey, 1992,
1995), proposes that PI claims are metaphoric expressions of dissatisfaction with the workplace. Toohey, in
congruence with the anti-psychiatry position (Szasz, 1996), rejected the notion that work factors can impact
on the mental health of workers because he did not accept the notion that mental illness can occur in the
absence of professionally verifiable physical lesions. Thus according to Functional Communication theory,
unless claimants show evidence of an organic (work-related) cause for their dysfunction, they are construed as
expressing dissatisfaction with work through the submission of a compensation claim.
This research took a different view, as discussed in detail in Chapters 3 and 4, suggesting instead that mental
illness, and consequently PI claims, are biopsychosocial and therefore multifactorial in etiology. It was
also suggested that work factors can and do impact on workers’ mental health through the development
of biopsychosocially based mental disorders which at times may be attributable to the employment of
workers. Additionally, it was argued that dissatisfaction with work and clinical psychopathology are vastly
different concepts. Cotton (1995) was the first in this field to differentiate dissatisfaction with work, what he
termed “vocational discontent” (p. 100), from clinical psychopathology in the context of PI claims within a
biopsychosocial diagnostic framework.
The results of this study lend support to the contention that a proportion of claimants do indeed submit
claims for compensation in the absence of clinically relevant distress and in an effort to manage vocational
discontent issues in the workplace, or what Toohey described as the expression of dissatisfaction with work
through Functional Communication (Toohey, 1992, 1995). Importantly, however, the proportion of claimants
submitting claims for this purpose in the present sample was small (8%). Qualitative assessment of the expressed
communication of a sample of non-diagnosed claimants indicated that the content of their communication was
qualitatively different from that of claimants with diagnoses. Those with diagnoses expressed psychological
dysfunction as opposed to vocational discontent or dissatisfaction with work.
The findings of this study suggest that dissatisfaction with work is not the only message communicated by
claimants though claim submission. The communication of dysfunction and indeed the communication of
multiple messages arise as alternatives to the singular communication theorised by Toohey (1992, 1995).
These alternative explanations for claiming behaviour became apparent only when the phenomenon under
study was examined with the paradigmatic lens of the broader, more intricate and holistic biopsychosocial
model (Engel, 1980).
Furthermore, it was found on the basis of the present sample that the vast majority (81%) of claimants were
independently assessed as having sustained psychopathology that was substantially attributable to their
employment. This finding suggests that the workplace can indeed become psychopathogenic, where the

4
rsearch has established that certain workplace factors appear to be important determinants of diagnostic and
claim liability outcomes. The matching of claimant characteristics against workplace factors has opened the
door to the possibility of making more direct links between workers and the potential harmful impact of
employment conditions and situations at a psychological level.
Conclusion
A short answer to the initial question posed by this research on why we keep missing the boat when
managing and preventing psychological injuries. Firstly, due to the absence of an overarching, unifying
definitional construct of psychological injury which has seen psychological injury entirely entangled with
and considered a by-product of ‘occupational stress’. Thus, we have to date relied on ‘occupational stress’
theories and associated management strategies in combating psychological injury based on the assumption
that ‘occupational stress’ leads to claims. The association between these two factors however has only
recently commenced to be empirically analysed and tested on actual claimants. Results suggest that
occupational stress variables and job intrinsic factors in particular (levels of demand and control), are not as
important in the development of psychological injury as previously thought. Rather the wide range of
complex human interactions found in the workplace particularly: interpersonal conflict and low perceived
support in the context of work appear to be substantially more predictive of compensated mental disorder
claims.”

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The Demand Control Model

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Empirical Evidence for the Model

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Evidence for JDCS theory from Homogeneous Occupational Groups

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Criticisms of the JDCS Model

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Psychological Injury Research Literature

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Access to Compensation for Psychological Injury

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Common Workplace Contributing Factors

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Duration, Cost and Risk of Psychological Injury

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Outcomes Following Psychological Injury

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Methodological Issues in PI Research

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Theoretical Perspectives on Psychological Injury: Claims as Functional Communication

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Figure 2. The Research Design

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Participants and Sampling

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Figure 3. Definitional model of Psychological Injury (PI): a Biopsychosocial-politico-legal entity.

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Implications for Theory

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