Andrew Brown, MD

Work is central to many people’s lives. The average person spends one-third of their adult life working, yet psychiatrists may neglect the importance of work. We address drug use, family life, and psychiatric symptoms, but may not fully appreciate how those factors are relevant to our patient’s work

Nonetheless, work is tied to the surge in mental health concerns precipitated by the coronavirus 2019 pandemic. As we consider anxiety, depression, substance use, spousal and child abuse, and loneliness, all of which have been found to increase following disasters, we must not forget how the pandemic is affecting our workforce. For instance, in this time of increased social isolation, video technology has been used to maintain a sense of connectedness among employees. This very much reflects the centrality of work to mental health and social cohesion.

However, psychiatrists will find it difficult to ignore the centrality of work over the coming months; the response to the COVID-19 pandemic has already led to a surge in unemployment not seen since the Great Depression. More than 1 in 10 eligible workers filed unemployment claims in the past month in 50 states and territories, and economists anticipate more job loss will follow.

When a patient loses their job, a psychiatrist must respond actively and swiftly for many reasons. Employment fulfills essential biological, psychological, and social needs. It is the means by which we sustain ourselves, comprises a large part of our identity and social community, and typically determines how we spend most of our waking hours. As such, job loss is profoundly disorienting, challenging the very meaning and purpose in life. It directly impacts self-esteem and perceptions of self-worth, precipitates anxiety, and increases the chance of becoming physically and mentally sick.

Unemployment is associated with lower self-esteem and motivation, and an increased risk of substance abuse and suicide.

 The loss of an individual’s capacity to meet their basic needs through work is compounded by the loss of structure and shared experience that work typically confers. Because work fulfills such a broad range of human needs, job loss generally leads to a loss of well-being.

When a patient loses their job, the psychiatrist has 4 tasks: (1) triage and treat imminent emergencies; (2) treat acute or latent psychiatric symptoms medically or psychotherapeutically; (3) support the patient by helping them to recognize vulnerability, identify feelings, and enhance personal support systems; and (4) prompt the patient to realistically evaluate their future job prospects.

Treating emergencies and psychiatric disorders, as well as discussing the effects of job loss on personal and interpersonal variables can lead to improvement. This can be done informally or psychotherapeutically. Helping the patient to identify social support systems they have in place and how to utilize these systems can be helpful. As with any episode of clinically significant depression, anxiety, or psychosis, medication may be indicated.

Returning to work is the ultimate goal for the majority of our patients. To evaluate job prospects realistically, take a work history once the initial crisis and reactions have been explored. The assessment of a work history is not typically taught during residency training and is often not part of a clinical interview. A work history provides important information about a patient’s functionality. Components of a work history include:

What did their parents do for work? What did the patient think about the parents’ occupation?

What did the patient expect to do for work when they grew up?

How did the patient end up in their current job?

What was the patient’s motivation for accepting past jobs?

What were the patient’s expectations with past jobs?

Did past jobs live up to those expectations?

What are, or were, the daily tasks of the current or most recent job?

What skills/training/qualifications does the patient possess?

What are the current job market opportunities?

What interpersonal areas have they struggled with during past employment (eg, too aloof or too friendly)?

Answering these questions can assist patients in identifying what they may wish to do for employment in the future, including a potential change in career. Expectations, skills, and qualifications can be realistically assessed through discussing patient responses to these questions. The psychiatrist can serve as a sounding board for the patient’s ideas about future employment and help the patient cultivate adaptive perceptions, expectations, and realistic future plans.

How does the psychiatrist serve this function? Perhaps the most important principle to consider is the psychiatrist’s role in serving as both a source of reality testing and of integrating the self. By listening to the occupational hopes and integrating these with the current reality and the work history, the psychiatrist can explore what is possible in a career. The psychiatrist and the patient can uncover a wider range options for work than would be discovered by the patient in isolation.

It is clear that the pandemic will continue to impact the economy, the job market, and work. It is likely that many aspects of work—such as where, how, and for whom work is conducted—will change, and many changes will persist beyond the pandemic. We may wish to recall that our society, economy, and work situations were far from perfect prior to the pandemic; perhaps the crisis can be re-framed as an opportunity for our patients to seek healthier and more meaningful work situations.

Job loss is likely to affect far more people than COVID-19 itself. Psychiatrists are uniquely positioned to sustain the unemployed individual’s sense of efficacy, identity, and purpose during these difficult times. By understanding and supporting our patients, we can help them avoid a downward spiral of helplessness and despair that could otherwise follow job loss.

is Assistant Clinical Professor of Psychiatry at Chicago Medical School.

is a Department Psychiatrist at Boston Police Department.

is an Adjunct Professor of Psychiatry at the University of Southern California, and Chair of the Committee on Work and Organizations for the Group for the Advancement of Psychiatry.

is a Forensic Psychiatry Fellow at the University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine.

is President-Elect for the Group for the Advancement of Psychiatry.

is Adjunct Voluntary Faculty at Northwell Health System.

1. Galea S, Merchant RM, Lurie N. The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention. 

2. Chiwaya N, Jiachuan W. The coronavirus has destroyed the job market in every state. 

https://www.nbcnews.com/business/economy/unemployment-claims-state-see-how-covid-19-has-destroyed-job-n1183686

3. Jin R, Shah C, Svoboda T. The impact of unemployment on health: A review of the evidence. 

4. Warr P. Work, Unemployment, and Mental Health. Oxford, England, Oxford University Press; 1987.

5. Lee A, Wong J, McAlonan G, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. 

6. Darity W. Employment discrimination, segregation, and health. 

7. Kawohl W, Nordt C. COVID-19, unemployment, and suicide. 

8. Stam K, Sieben I, Verbakel E, et al. Employment status and subjective well-being: The role of the social norm to work. 

9. Committee on Psychiatry in Industry, Group for the Advancement of Psychiatry. Job loss, a psychiatric perspective.Mental Health Materials Center; 1982.

Articles

Job loss may negatively impact your patient’s mental health. Read about how you can help.  

My Patient Just Lost their Job … What Do We Do Now? 

Group for the Advancement of Psychiatry, Work and Organizations Committee

Unprecedented numbers of Americans are losing their jobs due to 

. For people still working, and those returning to work after telecommuting for a while, it is natural to have some level of worry and concern.

Given that, when patients describe psychiatric symptoms (eg, anxiety, insomnia, irritability) – psychiatrists should ask about workplace issues. If during that discussion a patient describes a concern about their safety and mentions thoughts about quitting their job, we strongly encourage the psychiatrist to help the patient uncover and process the underlying issues.

In this podcast, Dr Sean Sassano describes a way of evaluating and supporting such a patient. Specifically: (1) evaluating the underlying workplace issues (eg, concerns regarding an inability to engage in social distancing); (2) treating target symptoms (eg, claustrophobia associated with wearing a mask); (3) assessing workplace issues realistically, without catastrophizing them; (4) predicting, and discussing, the real-life ramifications of quitting a job.

 This is Ashley VanDercar. I am a psychiatry resident and a fellow with the 

. Today, I'll be interviewing Dr Sean Sassano. Dr Sassano is a private practice psychiatrist in Los Angeles, California. He specializes in anxiety disorders and obsessive-compulsive disorders.

 This is Sean Sassano. I am a psychiatrist in private practice in Los Angeles, California.

, but briefly: why is it so important right now, during COVID-19, to ask about workplace issues, even if it doesn’t directly implicate the presenting problem?

 Our patients’ symptoms occur in the context of where they are working. The reason that symptoms may be manifesting is oftentimes because there is something going on in the workplace. That can be either real or perceived by the patient; but there oftentimes is a workplace situation. Having a discussion with the patient about what exactly that workplace situation or stressor is – be it an overly demanding supervisor or the fact that a coworker had COVID-19 this past week – that can really go a long way toward helping us understand the patient. It can also go a long way towards helping us figure out exactly how to treat the patient.

Sometimes, the workplace situation actually is contributing to someone’s anxiety. There are difficult scenarios that could exist. If someone is working in a factory line, they may not be following the social distancing requirements. They may not be wearing the personal protective gear. It really could be based in reality, the anxiety that the person is experiencing.

 Let’s say the presenting problem was anxiety … you asked more questions and learned that there was a legitimate underlying workplace issue – like the factory worker example you just gave. You talk about it more, and you hear them starting to weigh out whether it is in fact worth going back to work. What do you, as a psychiatrist, do to support the patient in processing this?

 One of the first steps that I would recommend someone do when they’re concerned about a situation, is see if they can come up with some realistic estimate of the probability of that feared outcome happening. If we're talking about COVID-19, what we're talking about is potentially the patient getting sick or them getting other people sick. It's certainly difficult when you don't have a ton of information to go on, when estimates might be uncertain. One thing that you could do is to ask yourself: “Do I have a realistic estimate here? Or, am I vastly and greatly overestimating the probability of this disastrous outcome occurring?”

Oftentimes, we tend as humans to catastrophize things. There's a protective element to that. Looking for the worst-case scenario can help you plan for that and then try to prevent that from happening. But, oftentimes, it runs away from us.

 What if it’s not worry about getting sick … but rather, that the patient’s job requires that they wear a mask. The patient tells you they just can’t do it – it makes them too anxious. What do you, as the psychiatrist, do now?

 The first question I would ask is: “What are you going to do if you don't go to work? How are you going to be able to support yourself?”

 So how do you help them move through it?

 So, first it always bears going beyond just the initial discussion with the patient. When they say: “I'm scared of wearing a mask,” what we really want to do is try to figure out what exactly the feared catastrophic event is that they're worried about. It could be something like the claustrophobia, or that they’ll have a panic attack because they feel claustrophobic. It could be that these masks aren't sufficient in terms of preventing them from contracting COVID. It could be a number of things. Figuring out exactly what it is that the patient is scared of is a very good first step.

The next step, as I mentioned earlier, is trying to realistically determine the probability that these feared events may happen. We don't want to spend too much time on that. But, if someone has decided, or is acting, like there is a 100% chance that they're going to have a panic attack every time they put a mask on … there's a little bit of discussion, and a little bit of retrospective analysis, to see just how likely that really is, and how often that has happened in the past for them.

It really does become a matter of becoming less afraid of being afraid. So, as a therapist, we don't try to get rid of fear. We try to manage our reactions to fear. Fear of fear is something that we try to work on. One of the ways we work on that is with exposure therapy. In this sort of scenario, what I might recommend, is that we're going to wear masks all day long. We're going to wear a mask for the hour that we’re together in my office. We may even do things like mimic the feeling that you can't breathe. Holding your breath is a great example, or hyperventilating.

The exposure-based therapy is really helpful in preparing someone for these scenarios. Another way that you could do that is with something called imaginal exposure, which is where we imagine being in that situation at work and having a panic attack. Or wearing a mask and thinking you're going to have a panic attack. The more we get used to these ideas, by habituating to the ideas, or by learning that these are not things you're going to voluntarily avoid … this simple act of us approaching these scary things tells our brain to stop being scared of them and gets us much better at managing how we respond.

Changing the perception of the situation harkens back to psychotherapy techniques and asking yourself: “Is there something that I am misperceiving about the situation? Perhaps if I had a more accurate perception, it might not cause the same emotional or physical reaction.”

The other option is to do some problem solving. If the patient is telling you that there are certain workplace situations that aren’t conducive to health, then see if there's anything that they can do in the workplace. Either talking to their manager, or talking to human resources, and seeing if something can be changed about the actual situation.

Beyond that it starts to become: are you in the market for a different employment opportunity?

 What if they … think they need to leave their job. How do you help them think through, and process, that?

 I think the first question that I would ask is: what has been the function of work for them? And: what are they going to be doing if they're not working?

How do they see this impacting their day-to-day activities? Then, we may have a discussion about what it is going to be like if they don't have the structure of work.

Beyond that, I would ask if there's anything that they'll miss about work. If there's anything that getting back to work would serve to assist them with. Then, I would ask them about their long-term plans, both financially and in terms of their own identity. How do they see this playing into that?

 What if, despite these discussions, the patient feels that their mental health condition is such that they are going to quit, and they are going to file for disability benefits. What is your role then?

 One thing that you can certainly try in those sorts of situations, is to imagine two paths for your future. Then ask: “If you stay on the path of disability, where do you see yourself in three or five years? Do you like where you end up? And if we take a different path, where we really try to get you back to work, where do you see yourself in three to five years?”

Once we have that sort of idea, we can start building up a little bit of momentum and motivation in one direction or the other.

 When we’ve talked in the past, you’ve mentioned the importance of someone returning to work as quickly as possible. Why is this important?

 The longer somebody stays out of work – and this goes for so many things – the more we start to develop a habit, the more ingrained it becomes, and the more anticipatory anxiety we have about changing that habit.

So, I always try to get people to return to work as soon as they can. We don't want to overdo it and have them fail. But, this is one of the reasons why we oftentimes try a graduated return to work – where someone starts working a few hours a day, or a few days a week, and then slowly builds up from there.

The longer you are out of work, the more it becomes a habit for you, you start losing skills and you start losing motivation and you get fairly ingrained into the “I am disabled” role. We all play out certain roles in our lives. Other people start to believe those roles too and reinforce those as well. The longer that you're in that role, the more you start to identify with it.

 Today, Dr Sassano talked about the importance of asking our patients about their workplace concerns when they come to us with a psychiatric symptom. If workplace concerns do exist, he discussed how to help them realistically process the concern rather than catastrophizing them. He also talked about how to target specific symptoms with therapies, exposure therapy, imaginal exposure … and how, if a patient voices a desire to leave their job, you as a psychiatrist can help them process that thought – thinking through the long-term ramifications. And, then, if they do choose to leave work, how to emphasize the importance of returning to the workforce as quickly as possible, to avoid having being out of work and viewing yourself in a disabled role, become a habit.

How to Support and Evaluate Patients Experiencing or Fearing Job Loss in the Era of COVID-19

How and Why Clinicians Should Take a Thorough Work History During COVID-19 and Beyond

How to Help Support Patients Who Are “Essential” Workers

Episode 4 of 4: How to Evaluate and Manage Psychiatric Symptoms Related to Workplace Concerns

Podcasts

Unprecedented numbers of Americans are losing their jobs. When patients describe psychiatric symptoms (eg, anxiety, insomnia, irritability), psychiatrists should ask about workplace issues.

How to Evaluate and Manage Psychiatric Symptoms Related to Workplace Concerns

In this podcast, Dr Andrew Brown, a member of the Group for the Advancement of Psychiatry, Work and Organizations Committee provides his views on how we – as psychiatrists – can help support those of our patients who have anxiety associated with the categorization as “essential.”

Although states are relaxing their “stay at home” orders, the nature of work has fundamentally shifted since the beginning of COVID-19. Unemployment has skyrocketed. Those employees that have remained employed have been separated out into those who are doing “essential” and “non-essential” work. Working with the public and especially in “hot-spots,” can be an anxiety-producing prospect.

In this podcast, Dr Andrew Brown, a member of the 

, provides his views on how we – as psychiatrists – can help support those of our patients who have anxiety associated with the categorization as “essential.”

Specifically, he discusses how we can: (1) normalize their fear and anxiety surrounding the risks of 

; (2) provide supportive therapy that strengthens their confidence in their own decision-making ability; (3) employ self-disclosure, selectively, to humanize our self and emphasize the shared nature of the current crisis. 

This is Ashley VanDercar. I’m a psychiatry resident, and a fellow with the Group for the Advancement of Psychiatry. In today's episode I'll be interviewing Dr Andrew Brown. Dr Brown is the lead psychiatrist for the Boston Police Department. He'll be discussing how we, as psychiatrists, can help support our patients during COVID-19. Specifically, those patients who are essential workers.

This is Andrew Brown. I’m a psychiatrist with the Boston Police Department.

So, Dr Brown – how do you distinguish between fear and anxiety? Because, at least with the patients that I've seen they seem to be meshed together. There is such a pronounced feeling. These people, who have gone their whole lives to become what they are – whether that's in the tech sector, the health care sector, etcetera – are, many times, now afraid to go out and do their job.

They see their friends, who are “safe at home.” They're going out to provide an essential service. But - they feel, mixed together, a fear of going out, and anxiety. This is just overpowering for some of them.

 Fear is often a very rational, reality-based response to a situation that is threatening or potentially threatening. It is important to be aware of one's fear. An appropriate idea for us to communicate is that we are glad that they're feeling fearful. We need to, in essence, normalize it.

A lot of the immediate aftermath of officer involved shootings tends to involve an enormous amount of overwhelming fear. One of the most important and therapeutic things that one can do is normalize the response. With COVID-19 I think that is also applicable. It's rational to have fear. We want to normalize that response.

Then, of course, there's anxiety. Which is really quite distinct from fear. I think most people, once their attention is called to the distinction, are fairly able to distinguish between the two.

So, I hear you distinguishing between fear and anxiety. It sounds a lot like the DSM distinction between the two. Fear, being the emotional response to the “now” threat. Whereas, anxiety is looking at - they refer to it in the DSM as anticipation - of the future threat.

This becomes challenging with COVID-19, because the fear is also anticipatory … it keeps going on and on. It has no end date in sight. Given that merging, of fear and anxiety – although they are distinguishable, there is also great overlap.

How do you suggest that we support our patients?

We need to play to the patient’s strengths. We need to ask, and know:

How is it you got into this critically important field?

What is it about your temperament, your talents, your makeup, your skills, your way of being in the world … that equips you so well to do this type of work?

If one listens carefully to that kind of orientation, you’ll get clued in pretty quickly about what interventions are needed…

So, what you're suggesting is almost like a psychodynamic guided intervention; looking at the patient’s strengths and why they got into their field in the first place, and then helping to guide them and provide support.

But let's back up. Give me something a little bit more basic. Some recommendations that we can give right at the “get go.”

Common sense basic mental hygiene: get plenty of exercise, take care of yourself, get plenty of sleep, meditate, pray, stay connected to other people, don't be overly concerned about asking for help. But, I think what's unique – that we as psychiatrists have to offer when folks come to us with concerns (e.g., “hey my friend gets to stay home safely, why do I have to go out and expose myself to this risk?”), is the ability to understand where this individual is coming from. In other words, to try and understand what this particular individual's concerns are 

What we do conforms more closely to what is called coaching.

That makes a lot of sense. I think the frame of coaching as opposed to therapy is really in line with a form of supportive therapy that we're doing. Being a coach is another way of viewing that type of therapy. 

But the line, between being a coach, and helping people to realize their strengths, can become a little bit esoteric. Especially with people who have family members at home; their anxiety and their fear are both very rational. They're trying to figure out how to deal with their desire to fulfill their professional obligations and expectations, and their fear and anxiety about bringing something home to their family. So, how do you help people process rational anxiety when it interferes with an essential service?

 The first thing one does is essentially acknowledge the reality, the legitimacy, of many of the fears that they're having. Simply say to the person: “Yeah this is really a predicament that you're in … that we're all in right now. This is a really tough call. I understand why this is arousing so much anxiety in you. In a sense, I'd be more worried if you weren't anxious.”

The definition of anxiety, as opposed to fear, is that fear tends to be circumscribed – with a localized readily identifiable threat. So, as a result we can do things to neutralize the threat. Anxiety is usually just generalized and pervasive (like, the Greek God Pan). He was sort of omnipresent. We call it a pandemic because it's everywhere.

This is not the time to do exploratory therapy. Perhaps to explore a little, but the only reason we're exploring a little is so that we can support the troops in the field.

One thing that I do, that I think people feel is extremely helpful is, support people’s capacity to make good decisions. No one knows what's going on or what to make of this pandemic. We know a little bit, but we still don't know nearly enough. We don't know how to protect ourselves individually. We don't know how to protect ourselves as a society.

People feel very comforted when you learn enough about them to legitimately inform them that you're very impressed with their capacity to make good, reasoned, enlightened, decisions and judgements. I think that goes a long way.

A lot of what fuels anxiety at times like this are the thought of “what am I going to do?”. So, all we have to do, in our job, is give patients the level of self-confidence that they need; and acknowledge that it's an extremely difficult time for everybody. For ourselves as well as them. Because we're human beings in the same situation. Help them reason and figure out some type of compromise that they can live with, about their essential job.

It's not just the patients that are experiencing this, but it's us – as mental health professionals. How would you recommend that we handle our own countertransference, when we're in the same boat as many of our patients? How do we avoid letting our own anxiety infiltrate these sessions, when we're trying to be a neutral, supportive, coaching practitioners?

 I'll tell you a little bit about my own personal experience working with police officers.

We learn very early in our training that self-disclosure is a very dicey kind of thing. We're told that you should only do it under a certain set of circumstances. You should never do it spontaneously without thinking about it. You should always explore why the patient is asking.

I took that to heart. I'd always done that. But … what I found in the police department, is that there's no way I can do the work I do with that kind of attitude (at least with police officers, at least with that culture).

I have had to completely put that notion away. Generally, when officers ask me about my personal life (which they do all the time), within reason, I simply tell them.

They knew they couldn't trust me as soon as I ask them something like: “Oh why are you so interested in where I went to medical school?” So I think it'll go a long way when you're working with patients in this crisis to simply acknowledge (as long as it's true): “Yeah it's totally normal, now, to feel a little scared … to feel a little bit indecisive … to really not know what the acceptable risk is.”

 If you were to enumerate three things that psychiatrists should focus on when they're working with essential workers who have both fear and anxiety, about doing their job … what would those three things be?

One very important principle is normalization. It’s a very novel experience for just about everyone. Very few people have lived through anything remotely similar to what we're going through now. Normalize these reactions that are really quite appropriate and correspond to the reality of the situation.

The other thing to keep in mind, that's implicit in the first principle, is that in times like this we do a little bit of exploration of the particular individuals’ vulnerabilities. But the only reason we're exploring the individual’s history and specific situation is to figure out how they got to be where they are now (as an essential worker). Then we can help support the strengths that have enabled them to get through life quite successfully and adaptively.

Implicit in those two general principles is that I wouldn’t be overly reticent to self-disclose. (For instance: “When I came to work this morning, I didn't know … should I wear a mask? Should I not wear a mask? Is that just going to make people more panicked?”)

As psychiatrists, our role is to support those nascent or quite developed capacities.

So today, Dr Brown has discussed how we, as psychiatrists, can help support essential workers.

Normalizing fear of an identifiable threat, and anxiety about generalized unknown threats;

Providing supportive therapy in the midst of the acute crisis, meaning that we’re supporting a patient’s strengths, capability, and abilities as decision-makers; and,

Loosening up restrictions on self-disclosure, as a way of humanizing ourselves to allow our patients to benefit the most they can from therapy, given the collective nature of the shared stress associated with COVID-19.

In this podcast, Dr Andrew Brown, a member of the Group for the Advancement of Psychiatry, Work and Organizations Committee and lead psychiatrist for the Boston Police Department, provides his views on how psychiatrists can help support patients who have anxiety associated with the categorization as “essential.”

Dr Daven Morrison of the Group for Advancement of Psychiatry Work and Organizations committee provides his views on how and why psychiatrists should take a thorough work history, especially now, during the COVID-19 pandemic.

Group for Advancement of Psychiatry, Work and Organizations Committee

A patient’s job is a large part of their identity, and key to helping them navigate the world in times of opportunity and in times of strain. In order to understand this important part of a patient’s identity, a psychiatrist must get a thorough work history: an employment narrative. This information helps us support our patients during times of economic crises – when they are likely to have employment insecurity. The information can also help us understand a patient’s past and present functionality, in the real-life setting of work. This is particularly important right now, with 

A thorough work history starts with a patient’s childhood, and then naturally flows through their higher education and training, and how they ended up in their current or last job. It also involves an assessment of a patient’s role in their work organization, including conflicts with peers and supervisors. Even the most effective people use sounding boards to gauge the quality of their work products and need help integrating other life pressures to efficiently attend to work. Psychiatrists have a unique capacity to be that sounding board, and to help patients maximize their work and home lives. This ability is key during times of significant job loss, like the current pandemic.

In this podcast, Dr Daven Morrison, an organization psychiatrist and member of the 

, provides his views on how, and why, psychiatrists should take a thorough work history.

 My name is Ashley VanDercar. I am a psychiatry resident, and a fellow with the Group for Advancement of Psychiatry.  Today we will be talking with Dr Daven Morrison, an organizational psychiatrist.

: Good morning, I am Daven Morrison, I am an organizational psychiatrist.

 We’re talking today because of your specific interest and expertise in work psychiatry. At the moment, with the global pandemic of COVID-19, work is becoming more important in terms of people’s relevance and their perspective on work. With those patients who are still at work, or those who have lost their job, or have a lesser degree of financial and work security, it’s important that we know the right questions to ask.

So, today, I was hoping you could give us a little bit of guidance about how to get a work history, and why that’s important.

 I think the most important reason to get a work history is that it is the clearest insight into how the patient, or the person, sees themselves as the center of initiative. So much of dealing with crises, like COVID, or other things, has to do with either being a passive person, or someone who is taking active control. Work provides an insight into one’s own self, and how we see ourselves as the center of initiative: someone who is taking action on the world.

 As we go along, we are going to have a lot of new patients that are going to be seeking care: people who are unemployed, people who are essential service workers, and whether they are referred through their employee assistance program, or they are self-referred, there are some predictions that psychiatrists are going to get a lot of new patients.

So, when you have a new patient, what questions should you ask to get a work history? When I started residency my work history was basically: (1) Do you have a job? (2) What is your job? That was the extent of my work history.

I know from talking to you and reading some of the work that you and the Group for Advancement of Psychiatry have written, that work history is a lot more. You can use the work history as a looking glass into the patient’s functionality.

Take us through the questions that someone should ask a new patient, to get a work history.

 Well, just like any part of the psychiatric history, I think it’s really important to consider it as a narrative:

What is the story of work in their lives?

How does their job fit into the larger system of what the organization is trying to do?

How does the organization make it (How do they make money? What is on the horizon for them?)?

What I’ll do is walk through how I think about work in a person. The questions naturally flow from there. Most people generally had a first job, or first responsibility (“Your job is to make the bed, your job is to set the table.”). The family has their expectations of what needs to be done to take care of the family. That begins in essence, a person’s work ethic, how they feel about work, how it ties to their sense of self. For example, in Chicago, in the municipalities, often the workers are following in the path of others who worked in the police or fire department.

This can also tie to the COVID crisis. We did not have much money growing up; if you wanted anything, you needed to get a job. In most people’s lives, there is a need to get a job for pay. Often it is mowing the lawn, or babysitting, or shoveling snow. That is the beginning of: “If I make an effort, if I work, I’ll get paid for it.”

Then, when you come to formal employment, there are lots of important things to ask.

First, is, how did they get their job?					

Second, did they have anybody who had an eye on them?					

“You sure looked like you put in extra effort when you were working that summer at the grocery story, I knew you’d be a leader at the grocery store someday.”

There was a mentor, somebody saw the talent and effort.									

What did they see that they liked about their work?

Obviously, of course, these things are going to tie to their sense of self, and what motivates them intrinsically, beyond money, to do what is required to stay employed. This is a very important question right now with the COVID crisis.

The other thing that is very important, that tends to blend in, is that a lot of times when psychiatric symptoms come to us, they come from conflict with a supervisor. That often has to do with conversations around performance. Critical question to ask are:

What categories are they asking about in terms of gauging your performance?

Who provides input into your performance?

How do they (the patient) evaluate someone else’s work?

If you ask the patient to talk about the last performance appraisal 

 gave, it can give you a sense of how they think about work. A big part of work, as you think about your patients, is how they fit in the overall system.

I am an organizational psychiatrist. The organization is essentially my patient. I put the organization on the couch:

Where is it dropping the ball and not executing?

A lot of times what can happen, is someone is well liked; and for that reason they are not told how well they (don’t) fit in the system.

It’s really important when you ask about work, to ask:

Psychiatrists are able to ask a lot of personal questions, but one of the most personal questions is how much money do you make. That’s not necessarily easy to ask. But it’s very important, because it can give you a sense about how the person feels about themselves. They may have a sense about how other people are paid around them. This may be making them withdrawn, disengaged, or sabotage. This can also give you a sense of the relative importance of their job to the overall system.

I became really interested in performance appraisals, why they go right and why they go wrong, because I was seeing a lot of executives who were derailing.

 So those are questions about the current job. I remember reading in the Group for Advancement of Psychiatry Workplace Dysfunction book (or one of the monographs), about the importance about asking about childhood perspectives:

Asking about what someone’s parents did for work.

What they thought they were going to be when they grew up.

Then, tying those things together, so that you can look at their psyche about work when they were a kid.

So, what you’re asking about is a longer sense of identity. How they are similar to, how they are different from, their parents, even the grandparents. When you do a deeper dive into work history, perhaps you’re not trying to resolve or understand a workplace conflict. You’re trying to understand the meaning of work for them in the bigger picture: who they are, where they’re going, who they want to be, or how they determine success.

What did you talk about at the kitchen table?

For example, a lot of times, the executives I’ve worked with over the years, that are very successful, are the first people in their family to have a college degree. Their parents are blue-collar workers who did whatever they could to make sure the rent was paid and food was on the table; and that there was money left over to pay for college. “You are going to go to college” - that was the expectation. “I’m coming into my career as the hope of my parents, and even my grandparents, to do better – to live the American dream!”

So, there are long-term things for a psychiatrist to consider, relative to the different “buckets” of a person’s life, being filled in the right way.

I advocate for work. The other dilemma is: are you working so much 

 be with your family, that your work isn’t being cared for? These are the kinds of balance and integrated questions that a psychiatrist can consider, as they are advising people in the work world.

 So, what I hear you saying, is that when you’re asking questions of a patient, the work history and doing a deeper dive is really important. Some questions that you might want to start off with, are:

Dr Daven Morrison provides his views on how and why psychiatrists should take a thorough work history, especially now, during the COVID-19 pandemic.

In this podcast, psychiatrists from the Group for Advancement of Psychiatry, Work and Organizations walk us through assessing how a patient's work ties to their sense of identity. They describe ways to validate a patient's feelings, provide reassurance, and help manage their emotions.

COVID-19 has produced job loss that is, at least in our lifetime, unprecedented. Many of our patients have either lost their jobs or are insecure about that prospect. As psychiatrists, we are uniquely situated to help support these patients through these difficult times.

First, however, we must assess how a patient’s work fits into – and makes up – their identity. With that knowledge, we can validate their feelings, provide reassurance, and support them. Support takes many forms. It includes urging patients to stay (electronically) connected, helping them manage their feelings of uncertainty, and encouraging them to prepare for the future.

In this audio recording, Dr Fara White, a member of the 

, Work and Organizations committee, provides her views on how to evaluate and support patients facing job loss, or insecurity. 

 My name is Ashley VanDercar, and I’m a psychiatry resident, and a fellow with the Group for Advancement of Psychiatry.

 is a global pandemic. As a result of this pandemic, there are record numbers of people who are losing their jobs. As a psychiatrist, these are our patients; patients who either have job loss, or fear losing their jobs. Dr Farah White has a private practice in psychiatry, which is located in Manhattan - that is her patient base.

 I’m a private practice psychiatrist in Manhattan. It (COVID-19) has changed life in the city as we’ve come to know it.

 When you have a patient who has lost their job, or is in the process of losing their job, what do you do? How do you evaluate them, and treat them psychiatrically, to support them?

 So, I usually try to assess how big of a part of someone’s identity their job is. There are some people that, it’s so indistinguishable from who they are as a person, that job loss, or job change - really shatters their sense of self.

If someone has been successful for a big part of their lives, I always try to have them keep in mind that this is not a reflection of anything that they’ve done. Rather it’s a reflection of the world that we’re living in now. As we start to rebuild, the odds of that person becoming successful again in their chosen field, however it may change, are pretty good. We will be able to reconstitute, in some way; certainly, from a financial point of view.

 You mentioned trying to assess how big of someone’s identity their work or job is. But what do you do next? Can you walk us through the steps, when a patient is in front of you with this issue?

 Well, I think the first thing is to really validate their feelings, and what they’re going through. Especially now, with all the “bad news” in the world, it is hard to have compassion for something like a job loss (if you look at the bigger picture). But our job, as a therapist, is to really support that person’s experience – whatever they’re going through. Whether it’s a loss in their portfolio, a job loss, or dealing with a loved one who is sick with this horrible virus.

That’s sort of the role; and, to be aware of our own feelings … our own counter transference about the patient, or concerns that we have. Like: what is it bringing up in the therapist?

The number one priority is our emotional health and physical well-being. So, I’m telling people to work with what they have, which may be as limited as some space in a yoga mat, or a podcast that they enjoy. Use this as an opportunity to reconnect with a partner, or kids, or pets.

In this podcast, psychiatrists from the Group for Advancement of Psychiatry, Work and Organizations committee walk us through assessing how a patient's work ties to their sense of identity. They describe ways to validate a patient's feelings, provide reassurance, and help manage their emotions.