One minute Rodney Mullins* was talking with his best friend, Larry, deep in a mine shaft beneath Logan County, W.Va. The next minute, the roof had caved in and Larry was covered with debris. Mullins dug him out as quickly as he could and began administering CPR. Yet minutes later, Larry died in his arms.

For the next 11 years, Mullins kept trudging down into the mines, every day facing death just as Larry had. He survived six roof falls. The last one, in 2000, hurt his back so badly that he could no longer work.

Like many miners who’ve been injured or seen friends injured or killed, Mullins battled feelings of worthlessness and turned to alcohol for solace. But unlike many miners, he went to a psychologist for help. In 1999, he began therapy with David Blair, PhD, of the Center for Health Psychology in Charleston, W.Va., with funding from West Virginia’s workers’ compensation program. Mullins says Blair is key to helping him cope.

“I’m at home by myself all the time with this really bad physical pain, and then I start having the flashbacks,” says Mullins. “I’m a quiet person. I’m not big on talking. But Dr. Blair has helped me a great deal.”

Blair has, for example, provided grief counseling, encouraging Mullins to visit Larry’s grave and talk to him to help work through his loss. He’s also worked with Mullins on pain-management techniques and other strategies to help him deal with his daily chronic back pain.

But if it weren’t for his wife’s insurance, Mullins would no longer be able to see Blair. Following the lead of many other states, West Virginia recently privatized its workers’ compensation program. Only North Dakota, Ohio, Washington and Wyoming still have state-run programs. In 2006, West Virginia partially transferred its program to BrickStreet Insurance, a private insurer, because it was running out of funds. The program went fully private in 2008. The result, say Blair and other psychologists in the state, is a demise of psychological and other rehabilitation services for miners.

Privatizing the program may have saved the state money, but its disability rates have skyrocketed, rising more than 34 percent since 2002, according to the Social Security Administration. There is no way to prove a connection between privatization and increasing disability rates; the Social Security Administration attributes the high numbers to workplace injuries, unhealthy lifestyles and a lack of jobs.

But the fact remains that no other state has more workingage adults receiving Social Security benefits. These days, most miners go straight onto disability pay, without any chance of physical or psychological rehabilitation.

‘Culture of fatalism’

Part of the tragedy here, says Blair, is that miners are particularly prone to experiencing and witnessing injury and death, and thus psychological distress. Yet culturally, they are less likely than the average citizen to seek psychological help.

“These are men who make sure to say, ‘I love you,’ to their spouses before they leave each morning because they might never see them again,” he says. Many are descended from generations of miners and have lost relatives and friends in the mines. Like Mullins, they’ve often seen buddies hurt right next to them, and have been hurt themselves.

Many keep doing the job, though, because they don’t see any other choice, Blair says. Often they have a high school education or less, and in rural West Virginia, jobs are scarce. Plus, the coal-mining pay is good — $80,000, sometimes up to $100,000 a year. Compare that with the pay at Wal-Mart, a fifth of that at best, and factor in that mining is a family tradition, and the choice begins to make sense.

For some, there is also a thrill to descending deep below the earth’s surface and facing danger, says Blair. Some enjoy the camaraderie of being with their buddies, and the selfworth that comes with an ability to provide well for their families. However, the constant danger can alter their sense of reality, almost erasing a sense of future. “In the winter, they go into the mines when it’s dark and they come out when it’s dark,” says Blair. “The hours are long, and picking up a sixpack on the way home is a typical way to relax and forget the danger and fear.”

After an injury, drinking and drugs are also a way to numb the pain, he adds. Oxycontin abuse has ravaged the southwestern part of the state, where mining is most prevalent. Some cities in the southern coalfields are being called “drug cities,” says Blair.

Back to work

The decline of access to rehabilitation services is only fueling disability and drug abuse, Blair believes. These days, injured miners typically receive physician evaluations, then medications, with no chance for vocational and psychological rehabilitation services.

One now-defunct program that used to provide such services was Oasis Occupational Rehabilitation, which had branches in Morgantown, Beckley and Charleston. The program employed physical and occupational therapists, psychologists and rehabilitation counselors, who combined physical reconditioning with mental health support groups. The daily four-week, full-time program began at 8 a.m. and featured exposure-based occupational rehabilitation. In other words, if a miner was injured while “cribbing” — stacking wooden planks to hold up a roof — the program made sure he could comfortably crib again before graduating him, explained Jeannie Sperry, PhD, a psychologist who worked in its Morgantown branch with fellow psychologist Richard Gross, PhD.

Sperry and Gross say that the program’s evidence-based, multidisciplinary format produced positive outcomes: For the most part, miners who measured as depressed when they began the program no longer registered as depressed after graduation.

“It’s not typically the injury that stops people from going back to work,” says Sperry, director of behavioral science education for the West Virginia University department of family medicine. “It’s the shift in lifestyle and psychological issues. This program got you back on your feet.”

The addition of social and psychological support to physical rehab proved potent, says Sperry.

“Miners were getting up in the morning on a set schedule, hanging with their buddies again,” she says. “They got their self-worth back, and when they finished the program, they were ready to go back to the mines.”

Sofa bound

The support miners give each other is key because the mining community is tight, says Randy Venable, outpatient services director at FMRS Health Systems in Beckley, W.Va. But this insularity can also make them leery of “head shrinking” strangers, says Venable, who heads mining disaster response teams.

“This is a tough-minded group, and they pride themselves on being self-sufficient,” says Venable. So he felt a surge of unexpected fulfillment when he connected with an affected miner right after the powerful April 2010 explosion at Upper Big Branch Mine, which killed 29 miners and spurred ongoing investigations and litigation against mine owner Massey Energy.

What made the difference, he says, is that a disaster coordinator on his team talked to the miner right on the accident scene and brought him to Venable. This helped establish Venable as an insider with the 40-year veteran of the mines, who sees Venable for help with post-traumatic stress disorder and the survivor guilt he feels after losing a nephew, a cousin and friends in Upper Big Branch.

When working with miners, Venable says, psychologists must modify treatment methods in two important ways. First, they need to understand the mining community and what it’s like underground. Second, they need to be as frank and realistic about mining dangers as miners are.

“When you deal with other types of trauma, you’ll often use cognitive restructuring to help people see that this event is unlikely to recur,” says Venable. “You can’t do that with a straight face with a coal miner.”

Another cultural characteristic of miners is being actionoriented, says Blair. This is a group for whom 12-hour shifts, six to seven days a week is commonplace, and for whom constant movement is part of life, he explains. “For a lot of these guys, it’s like an unseen hand pushing you forward, and you have to keep moving,” he says. But post-injury, many miners are at risk for inertia. “It’s typical that, because you’ve been working so many hours, you have no hobbies. And now you’ve also lost your main identity as the breadwinner, and you’re just sitting doing nothing.”

Contributing to this lethargy is disability-related pain, says Gross, Sperry’s former colleague at Oasis. “If there’s chronic pain, miners might cope with it by avoiding activities that could perpetuate the pain and disability. From there, they might lapse into helplessness and hopelessness — the disability mindset.”

Gross, an associate professor at WVU, still sees miners with chronic pain individually in his work with the university’s pain management center. But he says the treatment is not multidisciplinary, incorporating physical and occupational therapy, which research has shown to be more effective.

Traditional treatment also doesn’t include critical social support, says Sperry. “In our program, it was the miners being with their buddies every day, them encouraging each other that especially mattered,” she says. “Now that the program’s gone belly up, they’re not getting that group support. And they just don’t have that same success individually. I hope that health-care reform can help with this.”

Sperry and other psychologists in West Virginia want to see funding for evidence-based multidisciplinary rehabilitation built into government efforts to improve access to health care — also a major legislative priority of APA’s Practice Directorate. In the meantime, West Virginia’s disability rolls will probably continue to swell. And, unlike Randy Mullins — who was able to tap his wife’s insurance — most injured miners will have no access to psychological or other rehabilitation services.

Bridget Murray Law is a writer in Silver Spring, Md.

*Rodney Mullins is a pseudonym being used for the protection of patient confidentiality.