A Complicated Case of Psychiatric Disability

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

Bob, aged 50 years, worked as a factory manager for a large corporation but had problems getting along with peers and managers. Ultimately, he was fired for initiating safety policies without consulting with his supervisor and mandating compliance in his subordinates, who complained, leading to his termination. In his spare time, Bob renovates and sells (ie, flips) houses.

He went to his psychiatrist because of PTSD symptoms that he alleged were caused by the harassment he was subjected to and to wrongful termination by his employer. He wants his psychiatrist to complete his forms for disability. Bob had been discussing his problems about getting along with coworkers and superiors but said that he had finally “realized that the issue is my job. I’m always stressed and working full time has eliminated any space to work on myself and decompress. I just found out that I’m eligible for permanent disability with full pay based on my tenure—isn’t that wonderful?”

Countertransference

If this was so wonderful, then why was Bob’s psychiatrist filled with countertransferential dread? The concept of patient-defined disability seemed problematic. Work was indeed a source of ongoing angst, but Bob had been employed for years. Even if his current work environment was truly damaging, he was clearly capable of performing another substantial job, if not presently, then at some point in the future.

Patients who confess to struggling at work feel differently than patients who request disability. As the psychiatrist’s countertransference reaction revealed, the problem is one of role reversal between the treater and patient. Patients do not make functional assessments on themselves, professionals do.

If a psychiatrist determines that a patient is profoundly functionally impaired as demonstrated by the patient’s report of symptoms and the manifestations thereof, such as difficulty performing job tasks, evaluation for disability is the next step. The disability evaluation should be performed by a third-party mental health professional, as the treating psychiatrist has an inherent conflict of interest: his or her task is to advocate for the patient’s mental health, not disability compensation—to listen and understand, to demonstrate empathy, and to alleviate suffering. The task is also to instill hope and confidence, and to restore functioning. In many cases, deeming a patient “disabled” can be highly counter-therapeutic.