Most absences from work are short-lived regardless of the underlying cause.1 But every claim manager has experience of protracted claims, where they struggle to understand the reasons that prevent the person returning to their occupational role.
Where the cause of protracted absence is a mental health disorder, the claimants have often engaged with a variety of psychological therapists and been medicated by their psychiatrists for anxiety, but to little effect. The person has seemingly reasonable day-to-day functioning, but as time passes looks increasingly unlikely to return to work – a position often supported by their treating professionals.
Working through the very best practice bio-psycho-social models has taken the management no further forward and the Company Medical Advisor, devoid of further ideas, suggests calling time on intensive, proactive management of the claim and negotiating a mutually acceptable long-term solution.
What might the claims management process, the treating professionals and the claimant be missing to help restore a sense of wellbeing, facilitate a return to work with all the benefits that can bring and potentially resolve the claim?
One Possible and Under-Recognised Avenue to Explore is Embitterment.2
Like anxiety, embitterment is an emotion known to everyone. It is a commonly experienced emotion after an insult or injustice, the responsibility for which is felt to lie externally (e.g., with company managers or a business partner).
For the most part, embitterment is fleeting or “stimulus bound“ for a specific situation. For some, by contrast, it becomes an intense and persistent reaction to a perceived injustice, humiliation, or breach of trust.
The person’s appraisal of the situation, rather than the “objective” severity of the event, is crucial. The duration, intensity and impairment that accrue differentiate normal from pathological embitterment. Accompanying features such as low mood, unbidden thoughts, helplessness, and distress when reminded of the problem are common. In its most severe form thoughts of revenge, aggression and even homicide can occur. These people do not relent but pursue their cause in a dysfunctional manner, sometimes with prolonged legal battles.3
The problem has a history, being recognisable in Kraepelin’s early 20th century description of “querulant delusion” and the concept of “Hwa‑Byung”, a “Korean folk illness” associated with frustration, pain, anger, and a desire to take revenge in response to a social stressor.4
The majority of those seen at claim where embitterment may be a factor (in the author’s experience) receive a label of Major Depressive Episode, often with anxiety. This may, to some extent, speak of the limitations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases and Related Health Problems (ICD) models but also to the co‑morbidities that are associated with the embitterment.
Depression and anxiety should both be amenable to routine medical and psychological treatments, but in the presence of embitterment are often found to be ineffective and lead to disengagement. This then prompts questions about severity when no active treatment is being offered.
The prevalence of the disorder – if it is a disorder – has not been clearly established. A web-based survey in Korea suggested 45% of adults aged 18 to 35 experienced increased levels of embitterment related to their exposure to negative life events,5 but the findings cannot be regarded as robust or generalisable. However, the common-sense association with a wide range of life events that would not meet the definition for post-traumatic stress disorder (PTSD), are well described.6
Of particular interest related to work are disrespectful behaviour, harassment, rudeness, bullying and emotional abuse, all of which leave the person feeling humiliated with a sense of injustice and poor self-esteem. Justice has been described as the basis for social behaviour that gives a person their sense of “controllability” of the world. The need to redress the perceived wrong can take on an obsessive quality that can result in additional symptoms and impairment of function.
Although the claims triggers are medically defined – injury or illness – claims management must be much more rounded in scope. The medicine must be right – appropriate medication at appropriate doses for an appropriate length of time with changes in line with accepted guidance – but this alone is unlikely to lead to restoration of healthy function if there is neglect of the psychological and social aspects of the situation.
Those who experience severe embitterment have been labelled “treatment-resistant” to standard psychotherapeutic interventions and are difficult to engage, as they reject help from others. Nevertheless, psychological approaches are available, based on cognitive behaviour therapy principles, called wisdom psychology.
Wisdom is an important tool to help solve the problems we all encounter in our lives. It has been defined as “the ability to solve insolvable problems” and is an important contributor to life satisfaction. Enhancing the “wisdom competencies” of the individual is at the heart of the therapy.
Many do not see their emotional reaction as the problem and believe the sole cause of their distress is how other people have behaved, so developing empathy, tolerance of uncertainty, a long-term perspective and forgiveness are significant challenges. To counter this the therapist uses case studies to help overcome the block, reframing the negative life event, and developing new perspectives on the future.7
Occupational health doctors have been advised to focus on how the person is coping, clearly distinguishing this from any perceived injustice. This helps to ensure that appropriate boundaries are maintained; the injustice is for others to deal with. While understanding that medicalising “difficult behaviour” is often counterproductive, recognising the presence of embitterment by occupational health teams is vital to nurture fruitful relationships within the workplace.8
From a claims management perspective, it is important to identify any “non-medical” issues (e.g. problems at work) and the consequences. Although it is not for the claims assessor to manage workplace issues, understanding the drivers of the absence encourages the engagement of the resources most likely to effect positive change. If the problem is a conflict at work, repeated medical assessments are unlikely to be fruitful.
By contrast, involving appropriate services within the place of employment and psychological therapies specifically aligned to the problem could be much more helpful. Not every market is able to get this involved or even have contact with the employer. This is generally more common in the group insurance space where there may be existing relationships with human resources and awareness of what wellness and other resources an employer can offer. To recognise and deliver this kind of intervention co‑operation between disciplines with complementary skills is paramount.
Core Criteria of Post-Traumatic Embitterment Disorder (PTED)9
- A single exceptional negative life event precipitates the onset of the illness
- The present negative state developed in the direct context of this event
- The emotional response is embitterment and feelings of injustice
- Repeated intrusive memories of the event
- Emotional modulation is unimpaired, patients can even smile when engaged in thoughts of revenge
- No obvious other mental disorder that can explain the reaction
- Additional symptoms are feelings of helplessness, self-blame, rejection of help, suicidal ideation, dysphoria, aggression, down-heartedness, seemingly melancholic depression, unspecific somatic complaints, loss of appetite, sleep disturbances, pain, phobic symptoms in respect to the place or to persons related to the event, and reduced drive
- Duration is longer than three months
- Performance in daily activities and roles is impaired
Linden argues strongly that PTED should be included in ICD and DSM as a distinct disorder (Table 1).10 It is not the author’s intention to draw any specific conclusions on that matter, but like stress and burnout it remains outside of the official rubric of illness. Nevertheless, embitterment as a state of mind will be recognised by many claims managers as a stumbling block to a claimant’s regaining their wellbeing and the benefits that work can bring.
Recognition and naming of the problem coupled with signposting to the right kind of psychological therapy early during a claim is likely to be more effective than intervention five years down the line when the problem has become intractable and unlikely to shift whatever the input.