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- Validation and Reflection   
Clinicians are commonly stymied by slow recovery or a parade of continuous obstacles to gaining reasonable activity tolerance through conditioning.  If return to work is the expected outcome, the patient may well be struggling to survive in a confusing contest where return to work seems to the patient as but a guarantee of being a failure.  Sometimes being trapped in the contest causes patients to embellish symptoms, display pain behavior and display frustration with our ineptitude at solving the problem.  Don't be too harsh in your judgment.  The reasons why someone cannot overcome limitations can be due to innumerable combinations of physical, emotional, cognitive and social factors.  Patients benefit more from our honest help to consider options than our judgment. 
Slow Recovery Approach -1. Validation.  When recovery is slow, review the history, physical and special study findings to affirm no "Red Flags" have emerged.  Then be a helpful partner in trying to build activity tolerance and show concern for slow progress for those having difficulty reaching comfortable activity goal. Validate their situation with assurance that you understand it is difficult and do not doubt the pain.  Reflect questions toward increasing activity tolerance with an appreciation that it is not easy. Echo when possible that, "If it is so difficult now (to regain activity tolerance), what is the chance it will be easier that as you get older? You can address, "What will you do if, for any reason, you do not get back to your former job or activity? What will you do until retirement?" If the patient is not sure, suggest gathering some information about your options. The patient may not need options immediately but while having time, some planning may become prudent in the next few months or at sometime before retirement age. This validates your acceptance of the patient by caring for his or her future and continued reflections toward being active or considering options suggests our willingness to help. 
Validation displaying your acceptance of a difficult situation can help the patient feel much more in control, knowing that he or she is not tied to a particular outcome if feeling caught in a "return to work contest." Offer to help the patient start a spiral notebook (see Table 14) to record information about potential options (Patient Discussion Handout # 4) and review notebook progress on each visit. Only information and understanding de-emotionalizes decision-making. 
Table 14: Shortened Discussion Handout # 4 Spiral Notebook approach to Options 
Start a Career Option Notebook 
Staple Patient Discussion Handout # 4 inside the cover of a spiral notebook.  Record each phone call on a separate page for future reorganization. Gather information in four phases. 
1.  Call agencies and educational institutions  
- Seek community colleges and training institutions for interview and guidance. 
2.  Call employers about careers that sound good to you in localities of interest.  
- Mostly to see if opportunities really exist and for names of employees in area of interest. 
3.   Call employees to see up side and down side and for recommendations about getting to where they are (best information available). 
4.   Review those that sound best for you with college or training counselor, then work out a budget. 
No Effort to Explore Options? - 2. Continue Reflection back to increasing activity tolerance even as issues become more obvious. Some patients require coaxing to gather information about possible options.  A patient's lack of response to a few suggestions to gather information sets the stage. While you continue to reflect issues toward the needed activity, show concern by validating that you feel for his or her dilemma but eventually you must discuss the apparent "insane behavior".   
- "It would be insane for me to think that spine symptoms alone keeps someone from making a few phone calls to figure out how to save one's own livelihood and perhaps a family's future. Other issues usually are involved. You may need to see a counselor to sort out the reasons for such INSANE BEHAVIOR." 
- If the patient trusts that you have his or her best interest in mind or fears seeing a new person, the the rejoinder will be, "Reasons like what?"   
- "Insane behavior can be explained by insanity, alcohol abuse, insanity, drug abuse, insanity, illiteracy, insanity, depression or insanity (depression with accompanying anxiety are usually a given by this time in the course of delayed recovery). 
- The patient usually chooses something other than insanity to discuss either with you or a counselor. 
       Without an opportunity to contrast seemingly insane behavior, approaching any of these emotional issues can result in anger and avoidance.  Thus, bringing up the insane behavior triggers the patient to defend his or her actions with admissions of either insanity, illiteracy, alcohol or drug problem, depression or better yet, by overcoming the activity limitations through conditioning.   
       Though rare, if the patient is insane, back care is usually easier! Back care can accompany reading classes. With addictions, back care can continue after abstinence or detoxification, but I suggest doing so only while participating in Alcoholic Anonymous (AA) or Narcotics Anonymous (NA) meetings daily for at least 3 months. After weeks of trying to survive in the injury contest or return to work contest, patients commonly sense no reasonable options to failure, and are occasionally helped by antidepressants even without addictions.  The process of discussing insanity behavior occasionally strikes a chord that brings logic back to decision making. In any case the process commonly gets sensitive issues on the table for a concerned clinician willing to help a troubled patient with difficult issues. 
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