Kenneth M. Settel, MD

The 48-year-old executive sat in my office clenching his fist and pounding the table. As the chief operating officer of a technology manufacturing business, he was at another impasse in successful management. He could not reinvest in the latest technology, he could not fire ineffective managers, and now he could not lead a new strategic operational plan. Although nominally in charge, he was held captive by his wife's family -- the founders and owners of the business. Without the authority to make independent decisions and operate the business as he deemed necessary, the executive watched helplessly as his competition slowly nibbled away at his market share. His mother-in-law would not yield her remaining grip over the operation. His brother-in-law resented the executive's superior position in the company. The executive's wife was alienated from her mother and brother and resented her mother's absence during her childhood while her parents developed the family business. She now saw her husband also trading family time for work time. 

With experience treating individuals and families, psychiatrists can readily appreciate the influence of family dynamics on the management and leadership of a family business. Emotional strings get pulled as family allegiances and resentments interface and interfere with sound business judgment and practices. Guilt, rivalry and love are powerful forces that play out in work situations that are dominated by members of the same family. 

Psychiatrists consulting to these organizations can perceive these passions as they are replayed in the workplace. Helping people understand the forces that influence their decisions in family businesses and work through these rivalries and resentments can give leaders the opportunity to sort through the questions of what is best for the business and what works best for the family.

There are other strong emotional issues that emerge in family businesses. Transition of leadership is fraught with conflict when a founder must yield power and lose his "baby." Choosing a successor means separating family loyalties from good business judgment. Sorting through the irrational feelings and mourning the loss of attachments may be a part of what is needed to resolve these difficulties. Psychiatrists bring to the consultation their understanding of people and families and their drives, motivations and conflicts.

In another consultation with a large national law firm, I was asked to explore the high attrition among associates and low morale throughout the firm. Long grueling hours of often repetitive and tedious work were compounded by harsh criticism from supervisors and no personal guidance from mentors. A general atmosphere of disrespect marked life at the firm. 

The partners were also feeling pressured by a system that communicated negative messages, rather than showing appreciation and praise for what went right. Competition and back-biting existed at all levels. The managing partner, although well-meaning, had no professional management training and an erratic management style. He maintained an air of isolation and aloofness from the other lawyers. Alienation flowed from the partners down to the associates and on to the support staff. Attorneys at all levels were quitting and the prospects of recruiting the best new lawyers were dimming. The situation was approaching crisis proportion when I was asked to assess the problem and offer a solution.

As the first step, I brought people at all levels together to hear their concerns. This initial intervention communicated the message that the managing partners truly cared and that they recognized something was seriously wrong. They demonstrated that they heard the staff's concerns and were committed to taking definitive steps to correct them. Thus began a process of listening and soul-searching that ultimately led to a firm-wide retreat and a commitment to reaffirm the company values and change the corporate culture.

The outcome of my work with the management team led to a restructuring of the firm along the lines of affiliative and interest groups. This restructuring was based on the understanding that people have legitimate needs for appreciation, affiliation, and personal learning and growth. In the end, there was a significant improvement in morale and a reduction of attrition.

In another consultation situation, a multinational research, manufacturing and sales company was plagued with bottlenecks in evaluating and bringing to market new products. There was conflict between two groups -- one was responsible for developing and then quickly delivering new products to the market and the other was responsible for testing and validating the safety of these products before they were released to consumers. The group responsible for evaluation and safety insisted that the other group was too quick, careless and sloppy in their safety review procedures. 

A woman with a background in evaluative science headed the safety group, and men with professional degrees headed the other group. Their differences in graduate training, experience and gender created a hierarchical skew, leaving the woman feeling marginalized. The interpersonal rivalries, hurt feelings and internal competition were threatening the success of the entire organization. The senior executive overseeing the operation could not see a way out. He requested guidance in understanding and managing the conflict.

A diagnostic assessment started with interviews of everyone involved. People aired their grievances, talked about their work and relationships with each other and changes in the organization due to very rapid growth. There were new pressures as departments expanded faster than they could accommodate and as the industry underwent market shifts, including the need for more rapid turnaround from discovery to marketplace.

After appreciating what had changed and what they missed from the old ways of doing things, the warring managers needed assistance in developing a respectful understanding of each other and in working in more productive, cooperative relationships. Restructuring the division into working teams with rewards for successful team outcomes rather than competition helped contribute to a success.

Psychiatrists' training can offer insight into understanding and resolving problems with erratically functioning and underperforming managers or subordinates. A call from a supervisor to "fix" a problem employee often turns out to be a fascinating detective exercise. What is presented in the initial call as one kind of problem often turns out to be more complex, especially when viewed from the other players' perspectives. An employee who is a problem to one manager may be a star performer for peers or subordinates. A person whose performance has slacked off may be reacting to changes in the work environment, management, work task or assignment. Sometimes they may be grappling with non-work-related problems such as illness, personal loss or family pressures.

Just as with a comprehensive psychiatric evaluation, one tries to assess the difficulty, what has been openly discussed with the employee and what approaches have been tried to change things. It is also important to understand the culture of the work environment. In working to clarify and define the problem, people begin to see things in a different light when they are actively engaged in understanding their contribution to what went wrong. This new understanding can lead to new approaches toward resolution. When this originates from within the struggling work group, there is often greater commitment to the solution.

In other situations, management may need more directive assistance and teaching in dealing assertively with problem employees. They may also need training in how to offer feedback, serve as mentors and deliver effective supervision. In this way, the psychiatric consultant serves both as a teacher/trainer and an effective role model for delivering supportive supervision.

Suggesting structural changes and accommodations in the work environment can also have a profound impact. Rearranging the organization and assignment of work can reduce conflict and create more effective teams. Sometimes roles need to be clarified and defined, leading to more explicit understanding of expectations and improved work performance. Sometimes an employee with valued skills may be mismatched for a given job. Changing jobs, shifting responsibilities, offering coaching or sometimes just firing an ineffective worker all must be considered. These are all areas where a skilled and knowledgeable psychiatric consultant who understands the workplace may offer effective contributions.

Training and teaching people about the role of the leader and what to expect of people in the workplace is valuable in clarifying rational and irrational expectations that might otherwise lead to workplace conflict and poor morale. Executive coaching offers opportunities for psychiatrists to use their understanding of human behavior and people's drives and ambitions to directly teach and guide managers.

When psychiatrists work with employees in organizations, their role is different from that of a therapist. Although therapeutic skill and acumen are helpful, the actual consulting and coaching relationship is not a therapeutic one. The workplace is an environment where a designated task must get done. Management coaching addresses performance at work. It assists people in understanding the behavior of those in the workplace and finding suitable ways to respond to them. It aims to help the individual shape their responses and performance. It may assist those being coached in creating a more humane work environment, one that is respectful of emotional and personal needs and strivings. The management coach often develops a personal relationship with the person being coached. While it is productive to explore any personal problems that affect performance at work, the coach may sometimes need to refer individuals to off-site settings more appropriate for resolving any personal psychological conflicts that may be interfering with effective management.

Working in the organizational world is very different from the work we do as clinicians in several respects. Organizations do not want to be "treated," nor do they want to be left with ambiguous or open-ended engagements. They need more immediate understanding where some impact or change can be demonstrated and appreciated. They also need to see the psychiatrist not just as a medical doctor, but as someone who understands business, organizations and the complexity of problems in the workplace. It needs to be clear that the consultant appreciates the influences of finance, the marketplace, leadership, and organizational growth and development on the function of executives, managers and subordinates.

Traditional business consultation addresses organizational problems from a structural, financial, strategic or behavioral point of view. Psychologically informed consultation employs an understanding of personality issues and unconscious drives and motives -- such as aggression, envy, dependency and love -- as they affect behavior in organizations and the workplace.

Psychiatrists consult to organizations in a variety of roles. The simplest and most direct is the mental health consultant who assesses healthy and pathologic behavior, determines fitness to work, and workplace health and well-being. As in the examples above, there are many additional ways psychiatrists have been able to use their training in psychology to communicate a unique understanding of conflicts and problems at work.

Consultation work offers an exciting and rewarding balance to the practice of a clinical psychiatrist. Clinical practice and consulting practice serve to enhance and inform each other. Consulting work expands the understanding of an individual patient's workplace issues, and clinical work with patients lends a deeper perspective to individual issues in the world of work. The total experience enriches the professional life and experience of the clinician.

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Several case examples of how psychiatrists can be a valuable asset in a workplace environment are given. What are the similarities and differences between this situation and clinical practice?

Kenneth M. Settel, MD

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