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Job related traumatic events may result in mental health injuries. For example, systematic reviews report that first responders are four to five times more likely to develop PTSD compared to the general population. Additionally, studies in the U.S. have found the rate of depression following a job-related physical injury is, at least, three to four times higher than that found in the general population.
These findings emphasize that mental health problems following work-related trauma are common. However, access to mental health treatment for work-related mental injuries within Workers Compensation (WC) systems has not been previously systematically reviewed.
WC benefits are provided in many developed countries and have been designed to protect employees who are injured on the job (for information about WC systems across global contexts, see http://www.ehjournal.net/content/10/1/103, and https://en.wikipedia.org/wiki/Workers%27_compensation). For the current article, we examined WC coverage for mental health conditions following an employment-related injury with a particular focus on PTSD within the U.S.. We were interested in the consistency of qualifying criteria for mental health coverage following an on-the-job injury. Statutory language refers to four types of injuries: (1) physical – physical injuries – which describes a physical cause (e.g., gunshot wound) that results in a physical injury (e.g., paralysis); (2) physical – mental injuries – which describes a physical cause (e.g., gunshot wound) that results in a mental health injury (e.g., PTSD); (3) mental – physical - which describes a mental cause (e.g., witnessing a suicide) that results in a physical injury (unremitting headaches); and (4) mental – mental – which describes a mental cause (e.g., witnessing a homicide) that results in a mental health injury (e.g., PTSD).
WC in all states and the District of Columbia cover physical-physical injuries. In Montana, this is the only type of coverage available. Physical-mental injuries were covered in 16 states and only 19 states covered mental-mental injuries. Furthermore, 16 states required “extraordinary” or “unusual” circumstances to qualify for “mental – mental” benefits. In these states, the use of the qualifying terms (e.g., “mental health injury”, “extreme stress” “traumatic event”) was not based on psychological research. Reliance on state statutes to define what constitutes an “extraordinary” circumstance has resulted in idiosyncratic and conflicting interpretations. One Court summarized the three primary statutory approaches to defining the term “unusual stress”:
“One approach requires claimants to show that they were subjected to unusual pressures compared to other employees in the same workplace with similar responsibilities; another approach measures the pressures experienced by a claimant against those encountered by all employees doing the same job…and a third approach requires a showing that a claimant experience pressures of a significantly greater dimension than those generally encountered by all employees in a working environment.”
Within this framework, determination of benefits for a police officer who witnessed a suicide, for example, would depend on which standard applied. In the “unusual pressures” scenario, because other officers are subjected to similar workplace stressors, benefits could be denied. However, if the standard were all employees doing the same job, also referred to as the “similarly situated” standard, denial of benefits could be predicated on the fact that most employees do not develop PTSD. Finally, if the claimant resided in a state where “all employees” served as the comparison group, the unique stressors of police officers are easily discernible and might result in approval of a WC claim. Note, however, that such conditions do not apply to work-related physical injuries.
From the point of view of developing PTSD, the similarly situated standard is contrary to the scientific literature on cumulative trauma, wherein an individual exposed to multiple traumas might be expected to be more vulnerable to developing PTSD, compared to those exposed to few traumatic events. Additionally, among states that require extraordinary or unusual circumstances, the definition of “extraordinary” does not rest on empirical knowledge of trauma, but may rely on guidelines that are antiquated. We found that WC coverage, particularly at the state level, is inconsistent with national trends towards parity in insurance coverage for mental health conditions.
Within the U.S. context, we recommended the adoption of a uniform standard of mental health coverage to include both state and federal plans that are consistent with national insurance requirements. Such a plan would cover treatment for all mental health conditions the same as physical conditions. Second, we recommended that independent medical evaluation assessments of mental health injuries fall within the purview of doctoral level professionals who have the training, expertise, and statutory scope of practice to legally diagnose and treat these conditions. Third, and most importantly, we believe that the inclusion of psychological science in WC insurance statutes will improve the validity of legislative statutes. Utilizing an evidence-based approach to issues such as the definition of a trauma and the role of cumulative trauma could improve the application of WC statutes, particularly if data-based psychological principles were to permeate case law. We believe the evidence is clear that the integration of mental health coverage into the WC insurance system is not only cost-effective for employers and insurers but will provide relief for workers and facilitate their return to work.

About the Authors

Edward Wise, PhD, has been in full time private practice for over 30 years and has been extensively involved in the areas of providing psychotherapy, psychological assessment, forensic evaluations and disability determinations. He has published over 30 peer reviewed articles in the areas of personality assessment, post-traumatic stress disorder, and treatment effectiveness. He is a Fellow of the A.P.A., Society of Personality Assessment and Distinguished Practitioner in the National Academies of Practice. He is the past recipient of the APA Award for Distinguished Professional Contributions to Independent Practice and Distinguished Professional Contributions to Clinical Psychology (Div. 12).
J. Gayle Beck, PhD, is the Lillian and Morrie Moss Chair of Excellence in Psychology at the University of Memphis. Dr. Beck’s current research focus is on the mental health consequences of intimate partner violence. She heads up the Athena Project at the University of Memphis, a research clinic that provides free assessment and treatment services to women who have experienced domestic violence. In addition to her work with the Athena Project, Dr. Beck also is active locally and nationally with her field. She is the Past President of the Society of Clinical Psychology (Division 12) of the American Psychological Association and a Past-President of the Association of Behavioral and Cognitive Therapy. Her career has been guided by the belief that empirically-grounded treatments offer the possibility to reduce emotional problems.


Wise, E.A. & Beck, J.G. (2015). Work-related Trauma, PTSD, and Workers Compensation Law: Implications for Practice and Policy. Psychological Trauma: Theory, Research, Practice and Policy, 7(5), 500 - 506.