Andrew O. Brown, MD

Although virtually all physicians have experienced a sense of exhaustion in the context of unceasing demands from work, burnout is often ignored by health care leaders. Even if its presence is acknowledged, burnout tends to be misunderstood. Prior to the pandemic, lack of understanding on the part of health care organizations exacerbated the problem, as this left physicians and other health care workers feeling resentful and, in some cases, even betrayed. The onset of the pandemic amplified the problem, as the moral authority and guiding purposes of physicians were relentlessly attacked by “anti-vaxxers” and other propagandists who were intent on spreading misinformation and disinformation.

At least that is what we suspected. In order to determine whether or not this was the case, we conducted a literature review and harvested some of the more exasperated voices in social media.

 We found that there was a significant rise in burnout across health care providers. There were differences around gender, age, race, and other factors including specialty, which is known. Therefore, a need already exists to engage leaders in this challenge.

Unfortunately, there are common inadequate responses to burnout data and engagement studies by leaders that are making it worse.

“Not one more mandatory lecture on mindfulness!”

“We do not need more pizzas sent to the lounge!”


Does it matter that burnout exists? Yes. Its consequences are broad and deep. These include medical errors and premature departure from the profession. Interpersonally, burnout manifests as irritability and lack of full personal engagement at work, which harms teams and affects work quality. And, has COVID-19 had an impact? Also, an emphatic 

 Many worry about erosion in the quality of care because of the disengagement from the work (divided attention, fatigue from poor sleep, etc) and fears of harm both to the patients and to the profession itself, given the loss of so many skilled and experienced practitioners.

For those who have influence over physicians and within health care systems, we offer 3 recommendations:

1) It is important to recognize that the governance of organizations is on the threshold of significant change. The general theme relates to “sustainability”—ie, changing our way of working so that it aligns with values beyond profit such as diversity, equity, and inclusion (DEI) and preservation of the biosphere—humanity’s life-support system. Our future survival demands that we pay attention to things beyond “the bottom line,” and leaders in the world of accounting are taking notice.

 We need to attend not only to the biosphere that physically sustains us but to fairness and functionality. These problems relate directly to burnout because physicians and other health care workers need to feel that their work and work organizations contribute to the creation of a kind of world in which they would like to live

2) The investment dollars and momentum for environmental, social, and governance (ESG) frameworks and sustainability are impressive. But that is not the whole story. We must pay attention to things that are both financially and 

material. Physicians and other health care workers should be encouraged to advocate for changes—and leaders should listen to them when they do so.

3) The third challenge entails recalling that the need to derive meaning is at the core of human psychology. Each situation is different, and each situation has its own meaning. As psychiatrist Viktor Frankl, MD, PhD, observed, “Between stimulus and response, there is a space. In that space is the power to choose our response. In our response lies our growth and our freedom.”

 Working toward a goal that has a value outside of oneself is psychologically material and alleviates the individual’s sense of insignificance. This challenge is particularly salient in light of the increasingly fractious and normless culture within which we find ourselves.

is a clinical assistant professor of psychiatry at Rosalind Franklin University’s Chicago School of Medicine, and past president of the Academy of Organizational and Occupational Psychiatry. He is also a member of the Group for the Advancement of Psychiatry (GAP) Committee on Work & Organizations; the Institute for Fraud Prevention (IFP); and the Tomkins Institute of Applied Studies of Motivation, Emotion, and Cognition. He is a co-author of

 A.B.C.’s of Behavioral Forensics and Psychiatry of Workplace Dysfunction

 and a regular contributor to the B4G™ blog,

is a department psychiatrist at the Boston Police Department and immediate past president of the Academy of Organizational & Occupational Psychiatry. He is a co-author of

Getting serious about people over profit: addressing burnout by establishing meaning and connection

2. Galanis P, Vraka I, Fragkou D, et al. 

Nurses' burnout and associated risk factors during the COVID-19 pandemic: a systematic review and meta-analysis

3. Preber B. ESG investing needs standards to prevent fraud and greenwashing. 

. November 22, 2021. Accessed September 1, 2022. 

https://fortune.com/2021/11/22/esg-investing-needs-standards-to-prevent-fraud-and-greenwashing/

4. Brown AO. What makes work feel meaningful? 

. May 21, 2022. Accessed September 1, 2022. 

https://workosophy.org/2022/05/21/what-makes-work-feel-meaningful/

The Will to Meaning: Foundations and Applications of Logotherapy

Articles

Leaders of health care institutions may want to pay closer attention to burnout, as more environmental, social, and governance frameworks take shape.

Can Sustainability as a Source of Meaning Help Leaders Unlock Employee Burnout?

Much of being able to find a path to health—especially mental health—is finding work that helps you to make contributions. So, what can psychiatrists and other mental health clinicians do to further foster this notion in their patients?

Brown AO. What makes work feel meaningful. Workosophy. May 21, 2022. Accessed July 29, 2022. 

http://workosophy.org/2022/05/21/what-makes-work-feel-meaningful/

Brown AO. How ideology demeans work. Workosophy. June 14, 2022. Accessed July 29, 2022. 

http://workosophy.org/2022/06/14/how-ideology-demeans-work/

 is a clinical assistant professor of psychiatry at Rosalind Franklin University’s Chicago School of Medicine, and past president of the Academy of Organizational and Occupational Psychiatry. He is also a member of the Group for the Advancement of Psychiatry (GAP)–Committee on Work & Organizations; Institute for Fraud Prevention (IFP); Tomkins Institute of Applied Studies of Motivation, Emotion and Cognition. He is a co-author of 

A.B.C.’s of Behavioral Forensics and Psychiatry of Workplace Dysfunction

, and a regular contributor to the B4G™ blog, bringingfreudtofraud.com.

“The mentality that animates workers who see their work as a calling is strikingly simple: They believe their work is contributing to the construction of a world within which they would like to live.”

Dialogues on Work and Psychiatry, Episode 1: The Importance of Contributions

Slideshows

Problems with any one of these domains can disrupt an individual’s capacity to sustain work capacity.

5 Domains of Functional Assessment for Disability Evaluation

FROM THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

This article discusses the return to work plan as a solution to the clinical and systemic problems arising from psychiatric disability. The systems that govern administration of “disability” benefits should be guided by:

 The treating psychiatrist is relieved of the fear that if he or she acknowledges the truth, ie, the presence of (or potential for) preserved work capacity, his or her patient will suffer.

 The patient is supported for engaging in behaviors that are reasonably expected to culminate in restoration of the work-reward relationship and a healthy patient-psychiatrist-workplace system.

Among many problems inherent in the American disability system is the medicalization of work stress and its inappropriate conversion into psychiatric diagnoses, which implies impaired or loss of ability to function. This “medicalization” decouples the normal work-reward dynamic in a way that reinforces disability-seeking behaviors. Potential solutions to problems of disability require a multisystemic approach. In the psychiatrist’s office, solutions include the paradigm of “truth and resolution”; in practice, the re-coupling of work and reward as a goal, and support for disability reform (eg, the use of standardized functional assessments) but with careful consideration of its possible consequences.

Psychiatrists’ challenges to disability claims

There are challenges to the psychiatrist’s support of a patient’s claim for disability. While it seems obvious that a psychiatrist simply wants to diagnose accurately and make appropriate recommendations, the situation around disability is wrought with pitfalls and is quite complicated. The addition of an economic, potentially income-providing relationship forever changes the treatment dynamic. Supporting a disability claim could mean both administrative (in the form of documents initially justifying, then recertifying the claim) and legal (requiring other documentation or testimony related to the assessment) liabilities. Withholding support for disability benefits could lead to anger, violence, medical board complaints, negative online reviews, or litigation on the part of the patient. The psychiatrist might also feel burdened with significant counter-transference guilt.

A solution to this is “truth and resolution.” These best practices allow psychiatrists to conduct patient care in such a way that they can acknowledge the objective reality of return to work. It includes recognizing the pitfalls of misdiagnosis as well as potential excessive physical, emotional, and financial expense to the patient, the employer, family members, and medical specialists and administrators. These expenses can include unnecessary workups, treatment referrals, and cost to systems as benefits are paid and work production is lost, and the beginning of a process that can result in lifetime disability for a patient.

“Truth and resolution” as a treatment approach ensures that providers “first do no harm.” Importantly, it requires training in occupational assessment, which has been a noted weakness among psychiatrists. This training would include review of the difference between impairment and disability, discerning patient job requirements in interviews, consideration of somatic symptom disorders, and curricula that addresses the implications of a patient’s engagement with a disability system and prognostic factors affecting a return-to-work.

The idea of promoting patient behaviors oriented toward restoring the work-reward relationship is an intuitive one which has been investigated in studies of disability and return-to-work across several medical specialties. Some approaches have focused on workplace accommodations. A 1998 review found that patients offered modified work after a workplace injury were about two times more likely to return-to-work than those who were not.

 A 2005 systematic review found that the duration of disability for patients with musculoskeletal and other pain conditions was reduced by offers of work accommodations and communications between medical providers and employers.

Other approaches to the return-to-work have considered stress and perception of support at work. A 2002 literature review found that a “non-supportive work environment” was associated with disability or retirement for cancer survivors.

 A later study found that “perceived employer discrimination” led to lower return-to-work rates for breast cancer survivors.

 Conversely, a 1998 prospective cohort study found that strong social support was a feature of patients who returned to work after lower extremity fractures.

 This suggests that interventions aiming to encourage actual or perceived support in the workplace could improve chances of a patient’s return.

Investigators have researched therapy when high work stress is identified. In a small Dutch study, patients with adjustment disorders were more likely to return to work and return to work earlier if they were treated with an activating, stress awareness training much like stress-inoculation training.

 Physician interventions in return-to-work and disability scenarios have also have some limits. Dasinger and colleagues

 found that a physician’s proactive communication consisting of understanding, questions, and recommendations about the patient’s work and workplace was associated with patients’ return to work within the first 30 days of disability for low back pain. Moreover, a physician’s explicit recommendation for returning to work was associated with a nearly 60% increase in return-to-work rates in patients with more than 30 days of disability. Unfortunately, these effects disappear in the first case and nearly lose statistical significance in the latter case when workers reported “high job strain” in the workplace.

In addition to changes in clinical approaches between doctor, patient, and employer, government systems have attempted systemic changes in assessments in attempts to reform disability systems. In this process, however, significant consideration must be paid to repercussions of changes made to vital disability benefit systems. In recent years, the United Kingdom has adopted a new functional assessment tool, the Work Capability Assessment (WCA). This tool has been used not only to assess new disability claimants, but also to reassess more objectively over 1 million claimants who had already been granted disability benefits.

Recently published research reveals that the WCA reassessment process was associated with increases in behavioral health symptoms, antidepressant prescribing, and completed suicides.

 To date, other nations conducting similar disability system reform (eg, the Netherlands, Australia) have not reported such trends. Still, the far-reaching social impact of such programs must be considered before the implementation of systemic disability reform.

Dr Long is Committee Chair, Work and Disability Consultant Private Industry, the Courts, and the Legal Profession; Dr Flinton is a Child and Adolescent Fellow in the National Capital Consortium, Walter Reed National Military Medical Center, Bethesda, MD; Dr Brown is Department Psychiatrist, Boston Police Department, Consulting Psychiatrist, Boston Fire Department, Work and Disability Consultant, Private Industry and Government; Dr Sassano-Higgins is Adjunct Professor, Department of Psychiatry, University of Southern California; Dr Morrison is Clinical Assistant Professor of Psychiatry and Behavioral Sciences, Chicago Medical School.

The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.

1. Krause N, Dasinger LK, Neuhauser F. Modified work and returns to work: a review of the literature. 

2. Franche RL, Cullen K, Clarke J, et al. Workplace-based return-to-work interventions: A systematic review of the quantitative literature. 

3. Spelten ER, Sprangers MAG, Verbeek JHAM. Factors reported to influence the return to work of cancer survivors: a literature review. 

4. Bouknight RR, Bradley CJ, Luo ZH. Correlates of return to work for breast cancer survivors. 

5. MacKenzie EJ, Morris JA, Jurkovich GJ, et al. Return to work following injury: the role of economic, social, and job-related factors. 

6. Van der Klink JJL, Blonk RWB, Schene AH, et al. Reducing long term sickness absence by an activating intervention in adjustment disorders: a cluster randomized controlled design. 

7. Dasinger LK, Krause N, Thompson PJ, et al. Doctor proactive communication, return-to-work recommendation, and duration of disability after a workers’ compensation low back injury. 

8. Barr B, Taylor-Robinson D, Stuckler D, et al. “First, do no harm”: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study. 

This article discusses the return to work plan as a solution to the clinical and systemic problems arising from psychiatric disability.

Disability and the Concept of Return to Work

For the Committee on Work and Organizations, From the Group for the Advancement of Psychiatry

Imagine: Your patient has complained about a disagreement with his boss, who he thinks is criticizing him unfairly. You have prescribed an antidepressant and have been helping the patient communicate better with the boss, but the hostility between the two has escalated, and the boss terminated him. At his request, you supported his application for Social Security Disability Insurance (SSDI).

His application was denied, and he is suing SSDI for the denial and his former employer for discrimination based on the Americans With Disabilities Act (ADA). He wants you to provide a forensic expert psychiatric opinion that he is disabled, and that the denial of benefits has psychologically damaged him permanently. You feel caught in a bind, and you are. By stepping out of the treater role, either into the role of disability evaluator or forensic expert, you assume risks inherent in this role combination.

This article highlights some of these major risks. The take-home point is that treaters should avoid role duality if at all possible, preserving the role as treater and referring disability and forensic evaluations to a colleague trained in this area. The following principles apply to psychiatrists who are asked either to support a patient’s disability application or offer forensic expert opinions if litigation ultimately ensues because disability is denied.

The treater is an advocate for the patient’s mental health. The treater absorbs what the patient says without question and makes treatment decisions accordingly, viewing suspected distortions or exaggerations only as part of a complicated clinical picture. If the treater suspects malingering, treatment is terminated.

In the role of disability assessor or forensic consultant/expert, the psychiatrist is not an advocate for the litigant, instead he or she strives for honesty and impartiality in the assessment. Especially as expert, any signs of advocacy for the litigant leaves the expert open to a challenge of bias from the opposing side and may result in the expert’s being discredited by the fact-finder.

A possible exception exists in the case of a patient with acute and unambiguous impairment and debilitation (eg, florid psychosis, delirium, mania, profound neuro-vegetative depression) in which an appropriately qualified forensic expert cannot be obtained, the treater has not conducted the disability functional assessment, and the patient has been denied disability benefits. Since the psychiatric conditions listed create functional impairment and therefore are generally considered to be disabling, at least temporarily, the treater may be obliged to render an expert opinion in court.

Ethics require that information divulged in treatment sessions remains confidential. If the treater has also agreed to be the patient’s disability assessor or forensic expert, an ethical bind results, particularly in the latter role. In practicing within ethical guidelines the disability examiner or expert advises the litigant that there is no treatment relationship and no confidentiality exists in the interview. Anything discussed in the interview might appear in the report, which will be shared with either the disability insurance company and employer (if a disability exam) or the attorneys involved in the litigation process. In embracing dual roles, the treater who has breached patient confidentiality in order to provide a complete and honest opinion risks not only the patient’s angry termination of treatment but also an ethics complaint or even a retaliatory malpractice lawsuit.

If the treater should become incapacitated, die, retire, or take an extended leave of absence, the replacement treater should be able to garner the important treatment issues from the record. If the treater is also the disability assessor or forensic expert and the patient shares crucial information that could harm the disability claim or legal case, the treater faces another bind. Documenting this may be the ethical choice but risks termination and/or retaliation by an angry patient if the disability or legal case suffers accordingly, not to mention worsening of the patient’s mental health. This bind can lead the treater to sanitize the record, thereby including only medications and benign information and omitting any potentially damaging therapeutic revelations. An independent disability assessor or forensic expert does not have this bind since no treatment relationship exists.

The treater focuses on helping the patient rather than formulating opinions on diagnosis and causality of symptoms. Many treaters conduct a limited mental status examination, if any, and instead focus on current symptoms.

The disability examiner needs to conduct a comprehensive evaluation and functional assessment so that an independent opinion on disability can be rendered. The forensic examiner must defend opinions on both diagnosis and causality of the diagnosis in deposition or at trial, since valid legal claims of emotional injury are translated into psychiatric diagnoses caused by the disputed circumstances.

The disability examiner should review collateral information, especially work records, but additionally must understand the mental functions required by the job and explain how any psychiatric diagnoses impair the person’s ability to carry out the job tasks. Psychological testing may be useful.

The expert must also defend the diagnostic opinions by reviewing multiple cross-sectional sources of information including mental health, medical, employment, legal, and other pertinent records. Objective psychological testing is important in order to check for consistency with the diagnostic hypotheses. In either role, a complete mental status examination is essential.

In addition to the psychiatric diagnoses, the disability examiner must discuss any collateral factors that may underlie the request for disability, such as family problems and severe financial problems, as with the IRS and creditors. Some diagnoses, such as PTSD, are easily malingered by review of symptoms posted online. Treaters involved with the Veteran’s Administration clinics and hospitals in which PTSD checklists are administered routinely face a unique responsibility to minimize inappropriate use of the system by these patients.

Although treaters may initially obtain information about the patient’s medical, mental health, developmental, and family histories, rarely does inquiry go beyond these areas-often because of time limitations. Follow-up sessions are usually brief checks that inquire about response to medications and adverse effects without discussion of other issues such as current life circumstances and collateral stresses.

By contrast, the disability or forensic examiner usually has a single interview in which to gather sufficient information to formulate opinions regarding diagnosis and causality. This usually results in a lengthy inquiry into historical and present circumstances without any follow up. The disability exam involves a functional assessment, which may not be required in a forensic evaluation.

The treater makes arrangements with the patient for the payment of services. Disability examiners contract with insurance companies or independent third parties to conduct the exam; the particulars and payment are decided at that time, and the fee may be different than that charged for treatment.

Forensic examiners usually contract with the retaining attorney regarding payment for time and expenses to conduct the examination. Usually forensic consultation is more costly than treatment. If treaters also assume the forensic role and charge more accordingly, questions arise such as who is responsible for payment of services. Usually it is the litigant’s attorney, but if the psychiatrist is also providing treatment, attorneys may ask that the evaluation be charged to the patient’s medical insurance provider. This creates another ethical problem: what portion of services should be described as treatment and what is the risk to the treater for an ethical complaint because of disparate charges for treatment versus expert work?

The treater who also assumes the dual role as either a disability examiner or forensic consulting expert faces ethical risks because of the inherent binds in the dual role, including advocacy, confidentiality, integrity of the medical record, diagnosis, causality, limited inquiry, and financial reimbursement. Dual roles leave the treater opining on the patient’s disability claim open to question by the disability insurer, who may then request an independent assessment.

If the treater is also the forensic expert, he or she will be open to attack by opposing attorney at deposition and trial, and the treater/examiner’s credibility, impartiality, and motives for functioning in this dual role may be questioned and memorialized in the public legal record. Worse, if the treater/forensic expert testifies at trial while the patient watches a withering cross-examination by opposing counsel, the patient’s legal case may be compromised and lost. How will the patient/litigant respond to the treater’s loss of credibility? Will the patient terminate treatment and retaliate legally against the treater?

These are some of the important reasons why, barring certain exceptions, treaters who are asked by their patients to function as a disability assessor or forensic expert should strongly consider declining and remaining in the treatment role alone, referring the patient to an appropriately trained colleague. If asked to testify for the patient, the treater may testify as a fact, but not an expert witness. A possible exception exists when a patient who exhibits signs of acute and unambiguous impairment and debilitation has been denied disability benefits, and a qualified disability examiner or forensic expert cannot be obtained. Such conditions may temporarily require the treater’s assuming a dual role, but the treater should document the reasons for role duality and the limitations this imposes on the treatment process of treatment and disability or forensic assessment, clearly explaining these limitations to the patient, insurer, and the courts.

Dr Long is Committee Chair, Work and Disability Consultant Private Industry, the Courts, and the Legal Profession; Dr Brown is Department Psychiatrist, Boston Police Department, Consulting Psychiatrist, Boston Fire Department, Work and Disability Consultant, Private Industry and Government; Dr Sassano-Higgins is Adjunct Professor, Department of Psychiatry, University of Southern California; Dr Morrison is Clinical Assistant Professor of Psychiatry and Behavioral Sciences, Chicago Medical School.

The treater who assumes a dual role as either disability examiner or forensic expert faces ethical risks because of the inherent binds in the roles.

Treater, Disability Assessor, or Forensic Expert: A Trap in Disability Claims

From the Committee on Work and Organizations, Group for the Advancement of Psychiatry

One of the most perplexing challenges for psychiatrists who interact with the workplace is the competing forces for and against mental health. As previously argued, work is of paramount importance for the mental health of any person, especially an adult.

 Building off of what we have argued to this point, the intersection of work, health, the patient, and the doctor becomes decoupled as disability is considered. If returning to work is not thoughtfully planned for, the whole delicate web can fall apart.

We are a group of psychiatric professionals whose work varies. At times we are focused 100% on clinical, other times we are 100% focused on the work environment, and much of the time we are focused on the intersection. This 

 exploration of work and disability focuses on the challenges of the workplace manager, the employee with whom there is a conflict related to performance, and the psychiatrist who is tasked with the challenge to determine disability.

For many of the cases we see there is a great deal of ambiguity or gray space. There are some cases where there is clear evidence of the onset of a mental illness independent of workplace dynamics, yet in many others there is not. As in all systems, there is a critical balance to find between what is pathological and what is supporting mental health.

How might the psychiatrist support mental health at work?

To the workplace organization, the mental health system seems fraught with traps to undermine productivity: decreased production, lost hours, and distracted and “on edge” supervisors all tracking back to performance issues of employees. For managers, the role becomes confusing and even frustrating. They most likely do not know what “toxic” means, much less how to handle “periods of irritability, down moods,” or how to grant “occasional time to be away from work.”

Many managers are not trained in the various regulations such as the Family and Medical Leave Act (FMLA), and they can be particularly perplexed by options for dealing with employees who are distressed to the point of distraction and deteriorating performance. In fact, although not always written explicitly, the manager feels incompetent because the psychiatrist or the plan generated by the Employee Assistance Program (EAP) carries with it many implicit requests “to be a therapist.”

On the psychiatrist’s side of things, the doctor is at risk of unspoken feelings of incompetence as well. Physicians are trained to be knowledgeable and confident in their point of view, and a treatment plan is the foundation of this training. Yet, most psychiatrists are quickly out of synch with the workplace as it relates to disability.

Here is an abbreviated list of why psychiatrists can also feel incompetent:

 They have not been trained to see the workplace from the managers’ point of view.

 They do not know how to analyze a system like a workplace or a work environment that can include interacting internationally or virtually, and to decide who is responsible for what aspect of the work flow.

 The terms toxic, stress, and even PTSD are often used imprecisely in the workplace without the discipline or clarity typically used in medical assessments and treatment plans.

 Their allotted time with patients is shrinking.

 The expertise on the Internet to pursue disability is large and growing every day creating an asymmetric knowledge for the doctor compared with the employee.

 Most psychiatrists do not understand effective and ineffective performance management systems or competent leaders of healthy workplace cultures.

In our preliminary survey-based research, “Psychiatry of Workplace Dysfunction-Tools for Mental Health Professionals, Managers, and Employees,” the findings indicate that psychiatrists generally feel incompetent addressing common psychiatric challenges to the workplace, such as how to compose a thoughtful return to work plan.

 Moreover, the survey findings suggest that residency training directors feel unprepared to design curricula that cover these shortfalls.

In the end, the patient’s anxiety about returning to work combined with direction from family, friends, or the Internet has the potential to cause the patient to single-mindedly pursue disability. The powerful emotional affects generated in the sessions about returning to work overwhelm the treating doctor and the worker patient. The compounding forces to pursue disability create demands on the patient and on the psychiatrist. This combined with the distress of an overwhelmed manager leads to an adversarial and misaligned system that rapidly escalates. Thus, ironically the employee, psychiatrist, and manager all play a role in the decline of the overall mental health of patients. Specifically, it harms the ability of the patient and the manager to learn how to resolve conflict.

This is not new. Our committee has explored this dynamic for over 40 years with the original position paper, “What Price Compensation.”

Long absences from work make it difficult to return to work, for a number of reasons:

• The anxiety associated with being accepted back into the group

• The unconscious tendency of the group to exclude fellow members during their absence

• The concern about being able to perform one’s duties at excellent levels

• The effect of injury on one’s self-esteem during the period of “doing nothing and not contributing”

There is a missing piece that can help the manager, the psychiatrist, and the employee find common ground: a pathway to returning to work while managing mental illness and its sequelae. Our larger mission is to support both the managers at work as well as psychiatrists with their patients to understand the forces leading to mental health.

In the previous article in our series on disability we highlighted the need to address the concept of functional assessment.

 It is important to note, however, that because symptoms are subjective, functional assessments don’t always provide a true picture of the patient’s disability. If the patient is being coached on how to respond to assessments, the problems affecting the doctor-patient and/or the employee-manager relationships are worsened. Psychiatrists must work with the patient to improve functioning gradually, paralleling the return to work plans that are regularly used by other medical practitioners (eg, orthopedists). The goal is to avoid permanently eliminating work from patients’ lives.

 Long B, Brown AO, Sassano-Higgins S, et al. A complicated case of psychiatric disability. 

 Long B, Brown AO, Sassano-Higgins S, et al. Disability: overview of concepts psychiatrists need to know. 

 Long B, Brown AO, Sassano-Higgins S, et al. Functional assessment for disability applications: tools for the psychiatrist. 

 Long B, Brown AO, Sassano-Higgins S, et al. The psychiatry of work: is residency training adequate? 

 Group for the Advancement of Psychiatry. What Price Compensation? Committee on Psychiatry in Industry, Vol IX, Publication No. 99; June 1977.

 Committee on Work and Organizations, Group for the Advancement of Psychiatry. 

Psychiatry of Workplace Dysfunction: Tools for Mental Health Professionals, Managers, and Employees

. New York: Oxford University Press; 2018.

One of the most perplexing challenges for psychiatrists who interact with the workplace is the competing forces for and against mental health.