Ashley VanDercar, MD, JD

GROUP FOR THE ADVANCEMENT OF PSYCHIATRY, COMMITTEE ON WORK & ORGANIZATIONS

Work is central to many people’s lives. The average person spends one-third of their adult life working, yet psychiatrists may neglect work when assessing a patient’s well-being. 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 disease 2019 (COVID-19) 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, during this time of increased social isolation, employers have been using video technology to maintain a sense of connectedness among their employees. This very much reflects the centrality of work to mental health and social cohesion.

Psychiatrists will find it difficult to ignore the centrality of work over the coming months, as the the pandemic has led to a surge in unemployment not seen since the Great Depression. Individuals filed more than 58 million initial unemployment benefit claims between March 14 and August 22, 2020, and economists 

When a patient loses their job, a psychiatrist must respond actively and swiftly. 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 determines how we spend most of our waking hours. As such, job loss is profoundly disorienting, challenging the very meaning and purpose of life. It directly affects self-esteem and perceptions of self-worth, precipitates anxiety, and increases the chance of physical and mental illness.

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

 This is compounded by the loss of structure and shared experience that work typically confers. Thus, 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 

Treating emergencies and psychiatric disorders, as well as discussing the effects of job loss on personal and interpersonal variables can lead to improvement. Clinicians can do this informally or psychotherapeutically. Helping the patient identify their social support systems and how to use them 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, psychiatrists should take a work history once the initial crisis and reactions have been explored. Assessing a work history is not typically taught during residency training and is often not part of a clinical interview. However, a work history provides important information about a patient’s functionality (

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

How to Evaluate and Manage Psychiatric Symptoms Related to Workplace Concerns

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

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

How do psychiatrists carry out this function? Perhaps the most important principle to consider is their role in serving as a source of reality testing and as a means of integrating the self. By listening to the patient’s 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 may uncover a wider range options for work than the patient would discover in isolation.

It is clear that the pandemic will continue to affect the economy, the job market, and work. It is likely that many aspects of work—such as where, how, and for whom it 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 reframed as an opportunity for our patients to seek healthier and more meaningful work situations.

Job loss is likely to affect far more people than 

 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 the downward spiral of helplessness and despair that can otherwise follow job loss.

Dr Morrison is an assistant clinical professor of psychiatry at Chicago Medical School in Illinois. Dr Brown is a department psychiatrist at Boston Police Department in Massachusetts. Dr Sassano-Higgins is an adjunct professor of psychiatry at the University of Southern California, and chair of the Committee on Work & Organizations for the Group for the Advancement of Psychiatry. Dr VanDercar is a forensic psychiatry fellow at the University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine in Ohio. Dr Long is the president-elect for the Group for the Advancement of Psychiatry. Dr White is an adjunct voluntary faculty member at Northwell Health System in New York City, New York. 

1. Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Intern Med. 2020;180(6):817-818.

2. Chiwaya N, J Wu. The coronavirus has destroyed the job market in every state. NBC News. Updated August 27, 2020. Accessed November 30, 2020. 

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

3. Jin RL, Shah CP, Svoboda TJ. The impact of unemployment on health: a review of the evidence. 

5. Lee AM, Wong JGW, McAlonan GM, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. 

6. Darity WA Jr. Employment discrimination, segregation, and health. 

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

8. Stam K, Sieben I, Verbakel E, de Graaf PM. 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. 

Articles

Unemployment is associated with an array of social and psychological complexities, directly affecting patients' self-esteem and perceptions of self-worth. When a patient loses their job, the psychiatrist has 4 tasks.

My Patient Lost Their Job…Now What? 

For more information on the referenced concept, “the curse of knowledge,” see 

To listen to the podcasts that Dr VanDercar discusses in this video, see 

is a forensic psychiatry fellow at University Hospitals Cleveland Medical Center / Case Western Reserve University. From 2019-2020, she was one of the Cotswold-Looney fellows with the Group for Advancement of Psychiatry.

Videos

Ashley VanDercar, MD, JD, discusses the use of podcasts as a teaching tool, and how they can help bypass the “curse of knowledge.” 

The Use of Podcasts as a Teaching Tool 

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. 

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. 

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.

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? 

In law school, students are taught how to act, dress, and talk in court. They are told where to stand, what color suit to wear, what to say, and how to say it. They practice in lifelike simulations, held in courtrooms.

Psychiatrists—often called to testify in court—receive little if any of this training.

 They can feel unprepared when they first step on a 

stand. This article will help psychiatrists feel more comfortable with the testifying process by providing some necessary vocabulary, an outline of the judicial process, and practical tips on courtroom behavior.

There are many types of courtroom proceedings.

 There are hearings, in which judges make preliminary decisions on specific judicial issues, such as a civil commitment hearing. There are depositions, in which attorneys “discover” what the other side’s witnesses plan to say at trial. Finally, there are trials, in which cases that did not settle or otherwise resolve are ultimately decided.

Each of these judicial proceedings has its own set of rules and procedures, which vary from state to state. Psychiatrists can be asked or subpoenaed

 into any of these venues to testify under oath. This article focuses on trial 

, but the concepts are useful in any context.

When a psychiatrist testifies, it is either as a party or non-party. In criminal court, there are defendants and prosecutors. In civil court, there are plaintiffs, who file suit, and defendants, who are being sued. If a psychiatrist is sued by their patient, the patient becomes the plaintiff; the psychiatrist becomes the defendant. If that psychiatrist testifies at trial, they testify as a party.

More commonly, psychiatrists testify as a non-party—either as a fact witness or as an expert witness.

 A fact witness testifies about what they personally experienced. An expert witness testifies about their opinion. For example, after a car accident, a pedestrian who saw the collision would be a fact witness. A psychiatrist hired by the plaintiff to assess psychological damages would be an expert witness.

Another example would be a bank teller injured in a bank heist who sues their employer for emotional distress. If the bank teller (as the plaintiff) subpoenas their treating psychiatrist to testify about the bank teller’s pre-existing psychiatric condition, that psychiatrist would be a fact witness. If the bank teller’s attorney hires a psychiatrist to conduct an independent medical examination (after the robbery), that psychiatrist would be an expert witness.

Fact witnesses are usually unpaid. Expert witnesses are paid by the retaining attorney or the court. 

 can serve in a consulting role (reviewing a case and giving advice about trial strategy or chances of success) or a testifying role (reviewing a case and forming an opinion, and then testifying about a specific issue)—or both.

 In the bank teller example, a testifying expert witness could be asked to form an opinion on whether the bank teller had posttraumatic stress disorder and, if so, whether it was due to the bank robbery. In many states, physicians are required to offer their opinions with reasonable medical certainty. This is a legal standard that most often means more likely than not. For a summary of some of the roles, and responsibilities, of psychiatrists in court, see the 

As a witness, you should take advantage of your attorney’s expertise. Attorneys are trained in courtroom procedure. If you are a defendant, your attorney is on your side and should be a particularly helpful resource (make sure you meet with them before any proceeding). If you are a non-party witness, you should still avail yourself of the attorney who hired or subpoenaed you to ask logistical questions.

When you are asked to appear at a court proceeding, make sure you know where you need to be and at what time. Judges do not tolerate lateness. Plan to arrive at the courthouse at least 30 minutes early. Bring a government issued identification card. Know which courtroom in which you will be testifying and where you should wait (inside or outside of the courtroom). As a witness, you will not know exactly when you will be called to testify; you might be given a window of several hours. Bring relevant materials to review or a book to read.

When your name is called, go straight to the witness stand. At some point, either on the way there or once you sit down, you will be sworn in. The courtroom is the judge’s domain. Unlike a hospital, you are a guest. Act accordingly.

During a trial, questions are asked in a very stylized format. Your attorney will begin with direct examination. You should have discussed your testimony with your attorney before the trial and educated them on pertinent psychiatric concepts. Their ability to ask the right questions will depend on how well you have helped them understand your analysis and psychiatric opinions.

During direct examination, your attorney will guide you through a series of open-ended questions. Your fundamental responsibility is to present your opinions cogently and convincingly. On cross-examination, the opposing attorney will ask specific questions based on what was covered during direct examination.

The American court system is adversarial. One of the main purposes of cross-examination is to discredit you and/or your opinion. The key role of an opposing attorney is to knock you off balance. After cross-examination, attorneys have a chance for redirect, to help rehabilitate you (in the event any damage was done) and to give you an opportunity to clarify your answers. Then there is re-cross—the opposing attorney’s second chance to discredit you.

Your value as a witness is not just in what you say, but how you say it and how you come across (how credible you are). No matter how smart you are, if the judge or jury do not believe you, you will be an ineffective witness.

You always need to tell the truth, even when it goes against the side for which you are testifying. You need to be professional and likeable. Particularly with jury trials, it helps to act like the jury expects you (as a doctor) to act and look like they expect you to look.

Juries decide whether to believe a witness, including an expert witness, based on what they deem credible

 Credibility is judged on a variety of factors. This includes your professional credentials (where you went to school, how long you have practiced, what you have published, and so on), whether you appear biased, and your conduct.

Just like we evaluate our patients’ demeanor and appearance, judges and juries evaluate a witness’s demeanor. An important aspect of demeanor is attitude. It is okay to be nervous. It is not okay to be grandiose, entitled, or overly professorial. The worst sin is to appear arrogant. Do your best to be likeable.

Likeability is hard to teach. Even people who are likeable in real life can become hostile on cross-examination. It is helpful to view cross-examination as a tennis match; a series of volleys between 2 sides. Wait for the entire question to be asked, then pause and think. Only answer the question that is asked. Do not feel as if you need to keep talking. Embrace the silence, or pregnant pause, which opposing attorneys may use strategically to get a witness to keep talking.

Do not let the opposing attorney provoke you8, which they often try to do. For instance, if you are a defendant in a medical malpractice claim, the plaintiff’s attorney might lead you through a series of yes or no questions (eg, whether you ordered a series of tests you believed unnecessary)— knowing that you will answer “no” on each question. This can feel uncomfortable. Maintain your poise and calm demeanor. Take the high road. Be your professional self and avoid getting into arguments with the cross-examining attorney.

Your professional identity should come across in your appearance 

). Your look serves as jury’s first impression.

 Do not wear anything distracting, such as bright clothing or “loud” jewelry. Dress as if you are going to a job interview. Wear a nicely tailored, crisply pressed, dark-colored suit. Men should wear a light-colored dress shirt with a simple tie. Women should wear a high-cut blouse and closed-toe shoes, preferably with a low heel. Both men and women should pay particular attention to their grooming, making sure their hair is neatly styled.

It takes years of practice to become a stellar witness. But, even their first time, a psychiatrist can do a good job testifying.

 Just prepare adequately, remain calm, tell the truth (in easy-to-understand language), and remember that you are there as a doctor.

The courtroom is designed to be adversarial. To be an effective witness, credibility is key. Witness credibility hinges not just on what the witness says, but how they say it and their overall demeanor.

is a forensic psychiatry fellow, University Hospitals Cleveland Medical Center.

is professor of psychiatry, Case Western Reserve University School of Medicine. He serves on 

1. Williams J, Elbogen E, Kuroski-Mazzei A. Training directors’ self-assessment of forensic education within residency training. 

 17th ed. Chicago, IL: Thomson West; 2008.

3. Mossman D. ‘You’ve been served’: What to do if you receive a subpoena. 

4. Piel J, Resnick P. Psychiatrists as Expert Witnesses. 

5. Gutheil TG. The psychiatric expert witness. 

https://www.psychiatrictimes.com/view/psychiatric-expert-witness

6. Brodsky SL, Griffin MP, Cramer RJ. The witness credibility scale: An outcome measure for expert witness research. 

7. Discovery and depositions. In: Gutheil TG. 

 Washington, DC: American Psychiatric Press, Inc. 1998:59-75.

The Expert Expert Witness: More Maxims and Guidelines for Testifying in Court.

 Washington, DC: American Psychological Association. 1999:108-111.

9. Pitera M. Courtroom attire: ensuring witness attire makes the right statement. 

Strategies to remain calm under pressure; to be clear and concise; and to know what is expected in courtroom battles.

Tips for Testifying in Court

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 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.

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?

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.”