Group for the Advancement of Psychiatry

by David A. Sasso, MD, MPH, for the Group for the Advancement of Psychiatry Committee on the Arts and Humanities.

August has long been known as the therapist’s holiday, the month when psychoanalysts traditionally pause intensive work for time away from the office. There are countless references to the difficulties patients may encounter during this late summer month, caricatured to hilarious proportions in the 1991 movie 

Here is a look at a historic August vacation interrupted and some lessons for the unprecedented predicament of psychotherapy in the age of a pandemic.

On August 26, 1910, 2 men were seen taking a long stroll through the streets of Leiden in Holland. Both in their early 50s, one would go on to live another 29 years, and one would be dead by the following May. From a distance, perhaps they appeared to be old friends or colleagues, engrossed in deep conversation. Locals may have guessed that one was seeking counsel from the other and in some distress. While the name of the town, Leiden, is said to come from a Germanic word meaning “canal” or “river,” the German word 

 also means to suffer or to endure. The 2 participants in this Friday afternoon promenade were in fact Gustav Mahler and Sigmund Freud. And far more than a casual chat, it was a single extended 4-hour therapy session: the brief psychoanalysis of Mahler by Freud.

Many have written about the details of the encounter. Mahler had been working on his never completed 10th symphony and had become greatly distressed that his wife, Alma, was having an affair with architect Walter Gropius (whom Alma would go on to marry 4 years after Mahler’s death). Freud made several interpretations that astounded Mahler, including surmising the name of Mahler’s mother and identifying a “mother fixation,” suggesting that Mahler was “seeking his mother in every woman.”

 This analysis gave Mahler some relief and helped him to connect 2 childhood memories: a scene of conflict between his parents and hearing a folk-song played on a hurdy-gurdy in the street. Freud later recalled, “Mahler thought from this moment on, deep tragedy and superficial entertainment were tied together indissolubly in his soul and that one mood was inevitably tied to the other.”

Leaving aside the content of the session, the context is instructive. Mahler had previously made and broken 2 appointments with Freud earlier that summer, and when he requested a third, the only solution was to meet near the spot in southern Holland where Freud was spending the month. This was inconvenient for Freud; not only was he on vacation, but he also was exhausted by the recent International Congress of Psychoanalysis at Nuremberg and was recovering from a bout of colitis.

 He was also far from his office, so the meeting had to be conducted on foot. Freud later described details of his session with Mahler in now-jarring disclosures to his analysand Maria Bonaparte some 15 years later. Noting his departure from typical August holiday norms, he confessed, “I made an exception in receiving someone during my vacation, but a man like Mahler . . .”

This snapshot of Freud runs counter to how many view him and his theories today. There are some who imagine Freud to have been rigid in his thinking and his psychoanalytic frame unbending in its approach. That may have been the advice he gave to others, but, for better or for worse, he often broke his own rules, as in this case: seeing a patient in the middle of his vacation, conducting therapy outside the office, for any local passersby to see. In many instances, Freud’s behavior with his patients would not be considered Freudian at all in the 

As we reconcile the challenges facing the practice of psychotherapy today with myriad restrictions necessary to stem the spread of the novel coronavirus, there are lessons to draw from the man whose legacy, unfortunately, is sometimes ridiculed as inflexible, rule-bound, and out-of-date.

Before the pandemic, many psychiatrists would have dismissed the possibility of effective psychotherapy occurring through video. Yet, by necessity, the field has adapted and learned to shed the trappings and comforts of carefully decorated offices, couches, and armchairs, and distance from homes, pets, and children. Just as Freud made do with a set of circumstances that prevented him from working in his accustomed way, today’s psychiatrists can take a lesson. The safety and boundaries of the enclosed office, with a therapeutic frame sealed off from the outside world are, paradoxically, no longer safe, so we have turned to virtual settings.

As we slowly and cautiously work toward a practice where space can be shared between therapist and patient, perhaps Freud’s “walking cure” can be enlightening. Sessions out of doors may still seem as hard to imagine as video sessions were for many therapists just months ago. But perhaps in the coming months they may offer a starting point to think about reconnecting in person with our patients in a safer shared physical space than the office. Issues around confidentiality, admittedly, will not be easy to resolve. How will we create, flexibly but thoughtfully, new frames in order to maintain the holding environment and expectation of privacy that makes the consulting room sacred?

As you ponder these questions, if you have never listened to the first movement of Mahler’s painfully gorgeous and unfinished Symphony No. 10, find a moment to do so this month in honor of a peripatetic therapy session that took place 110 years ago.

is a child and adolescent psychiatrist and musician in New Haven, CT, where he serves as Assistant Clinical Professor in the Child Study Center at the Yale University School of Medicine.

Members of the Group for the Advancement of Psychiatry Committee on the Arts & Humanities: David Sasso, MD, MPH (Committee Chair); Anish Ranjan Dube, MD, MPH, Volunteer Clinical Faculty, University of California, Irvine; Donald Fidler, MD, FRCP-I, Professor Emeritus, West Virginia University; Andrew Lustbader, MD, Associate Clinical Professor in the Child Study Center, Yale University School of Medicine; Chris Snowdy, MD, Program Director, USC Child and Adolescent Psychiatry Fellowship; Kenneth J. Weiss, MD, Robert L. Sadoff Clinical Professor of Forensic Psychiatry, Perelman School of Medicine, University of Pennsylvania, andHelena Winston, MD, Assistant Professor, Department of Psychiatry, University of Colorado.

2. Jones, Das Leben und Werk von Sigmund Freud. In: Floros C. 

 New Haven: Yale University Press; 2004: p. 208.

4. Maria Bonaparte, unpublished diary. In: Feder S. 

The advantages of Freud's technique as shown in his analysis of the Rat Man

Articles

As we slowly and cautiously work toward a practice where space can be shared between therapist and patient, perhaps Freud’s “walking cure” can be enlightening. 

The Walking Cure

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.

I’m really urging people to stay connected remotely. If they had a friend at work that they used to have conversations with every morning over coffee, try and continue that – in some way shape or form. It gives a sense of stability.

 When you say to recognize our own counter transference are you alluding to the fact that we’re all going through this simultaneously? That’s kind of hard … right? For a lot of us, we’re not only dealing with the uncertainty and everything going on in our own lives, but then all day all of our patients. The topics are COVID nonstop (the same things that we’re feeling!). Which is really hard.

 Yeah. Well, that has been unprecedented. I haven’t been in practice for that long, but I’ve never had any experience like this. We’re going through something collectively, having (as a therapist) to sort of realize: “What am I bringing to the table? What are my anxieties about this? Will things ever be back to normal?” Then having to hear that from patients who are going through it in their own way.

It is really a challenge. Just to have some awareness of what is going on is really important.

 How do you push someone, who might be having some difficulty getting out of the “here” and “now,” into realism?

 One of the things that we should all practice managing right now, is our feelings about uncertainty. That can be really difficult … to be in a space where we don’t know when, or if, certain businesses are going to re-open.

A lot of friends, and patients, in private practice, have had to furlough their staff, with the intention of hiring them back. But when that’ll be, no one is really sure. It’s a really uncomfortable feeling.

There’s nothing that we can necessarily do to change the outcome. Other than to stay safe for ourselves, and make good choices about social distancing. This is something that’s bigger than any one individual. Just recognizing that, and learning to cope with that – is going to be important.

 Do you do medication management for your patients?

 What are the biggest symptoms that you’re seeing, related to this fear about work?

 I think, an increase in anxiety is the biggest one. I do see that there’s more hopelessness, and it’s hard to be excited about the future right now. Especially since this sort of all fell apart in New York at a time when people were looking forward to spring break and our summer plans. Now all of that is up in the air.

It’s a hard thing. Will we ever have some happy times ahead?

 How are you treating that with medications? What are you doing differently than you would normally do, or what are you doing the same?

 I’m trying to not use medication to manage this crisis; it’s coming from the outside. We’re trying to understand: what is coming from the patient, and what is coming from the external factors? Where do we really were stand? How long can we hold out before we make major (medication) changes?

Certainly, increasing doses of anti-depressants. Normally, around this time, it’s getting sunny, people are getting hopeful, and the days are getting a little longer. A lot of times, for people that have a seasonal component of their depression, this would normally be the time that we would be starting to come down on their medication. But, this year doesn’t sound like we’re going to be doing that.

 Insomnia is a pretty tough and tricky thing to treat with medication. Because there’s no end in sight for this, it’s important for people to find other ways to sooth themselves; from maintaining good sleep hygiene, to CBT measures, and really figuring out how to sleep on their own.

But the other difference, is that for most people they’re not waking up to go to work. They’re working from home. They’re not really getting into their car. So, it’s really changed - not only how we sleep at night, but also how we function during the day.

 So, what are you telling people whose identity is made by work? Let’s take, for instance, a doctor, or an executive, or head of a hospitality company. They’ve been fairly stable, and you’ve been seeing them for some therapy over the years – maybe some mild medication management. Now, their entire routine is gone.

What are your instructions to them, to make it through this?

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.

Author | Group for the Advancement of Psychiatry

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