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One of the most perplexing challenges for psychiatrists who interact with the workplace is the competing forces for and against mental health.
From the Committee on Work and Organizations, Group for the Advancement of Psychiatry
One of the most perplexing challenges for psychiatrists who interact with the workplace is the competing forces for and against mental health. As previously argued, work is of paramount importance for the mental health of any person, especially an adult.1-3 Building off of what we have argued to this point, the intersection of work, health, the patient, and the doctor becomes decoupled as disability is considered. If returning to work is not thoughtfully planned for, the whole delicate web can fall apart.
We are a group of psychiatric professionals whose work varies. At times we are focused 100% on clinical, other times we are 100% focused on the work environment, and much of the time we are focused on the intersection. This Psychiatric Times exploration of work and disability focuses on the challenges of the workplace manager, the employee with whom there is a conflict related to performance, and the psychiatrist who is tasked with the challenge to determine disability.
For many of the cases we see there is a great deal of ambiguity or gray space. There are some cases where there is clear evidence of the onset of a mental illness independent of workplace dynamics, yet in many others there is not. As in all systems, there is a critical balance to find between what is pathological and what is supporting mental health.
How might the psychiatrist support mental health at work?
To the workplace organization, the mental health system seems fraught with traps to undermine productivity: decreased production, lost hours, and distracted and “on edge” supervisors all tracking back to performance issues of employees. For managers, the role becomes confusing and even frustrating. They most likely do not know what “toxic” means, much less how to handle “periods of irritability, down moods,” or how to grant “occasional time to be away from work.”
Many managers are not trained in the various regulations such as the Family and Medical Leave Act (FMLA), and they can be particularly perplexed by options for dealing with employees who are distressed to the point of distraction and deteriorating performance. In fact, although not always written explicitly, the manager feels incompetent because the psychiatrist or the plan generated by the Employee Assistance Program (EAP) carries with it many implicit requests “to be a therapist.”
On the psychiatrist’s side of things, the doctor is at risk of unspoken feelings of incompetence as well. Physicians are trained to be knowledgeable and confident in their point of view, and a treatment plan is the foundation of this training. Yet, most psychiatrists are quickly out of synch with the workplace as it relates to disability.
Here is an abbreviated list of why psychiatrists can also feel incompetent:
1) They have not been trained to see the workplace from the managers’ point of view.
2) They do not know how to analyze a system like a workplace or a work environment that can include interacting internationally or virtually, and to decide who is responsible for what aspect of the work flow.
3) The terms toxic, stress, and even PTSD are often used imprecisely in the workplace without the discipline or clarity typically used in medical assessments and treatment plans.
4) Their allotted time with patients is shrinking.
5) The expertise on the Internet to pursue disability is large and growing every day creating an asymmetric knowledge for the doctor compared with the employee.
6) Most psychiatrists do not understand effective and ineffective performance management systems or competent leaders of healthy workplace cultures.
In our preliminary survey-based research, “Psychiatry of Workplace Dysfunction-Tools for Mental Health Professionals, Managers, and Employees,” the findings indicate that psychiatrists generally feel incompetent addressing common psychiatric challenges to the workplace, such as how to compose a thoughtful return to work plan.4 Moreover, the survey findings suggest that residency training directors feel unprepared to design curricula that cover these shortfalls.
In the end, the patient’s anxiety about returning to work combined with direction from family, friends, or the Internet has the potential to cause the patient to single-mindedly pursue disability. The powerful emotional affects generated in the sessions about returning to work overwhelm the treating doctor and the worker patient. The compounding forces to pursue disability create demands on the patient and on the psychiatrist. This combined with the distress of an overwhelmed manager leads to an adversarial and misaligned system that rapidly escalates. Thus, ironically the employee, psychiatrist, and manager all play a role in the decline of the overall mental health of patients. Specifically, it harms the ability of the patient and the manager to learn how to resolve conflict.
This is not new. Our committee has explored this dynamic for over 40 years with the original position paper, “What Price Compensation.”5
Long absences from work make it difficult to return to work, for a number of reasons:
• The anxiety associated with being accepted back into the group
• The unconscious tendency of the group to exclude fellow members during their absence
• The concern about being able to perform one’s duties at excellent levels
• The effect of injury on one’s self-esteem during the period of “doing nothing and not contributing”
There is a missing piece that can help the manager, the psychiatrist, and the employee find common ground: a pathway to returning to work while managing mental illness and its sequelae. Our larger mission is to support both the managers at work as well as psychiatrists with their patients to understand the forces leading to mental health.6
In the previous article in our series on disability we highlighted the need to address the concept of functional assessment.3 It is important to note, however, that because symptoms are subjective, functional assessments don’t always provide a true picture of the patient’s disability. If the patient is being coached on how to respond to assessments, the problems affecting the doctor-patient and/or the employee-manager relationships are worsened. Psychiatrists must work with the patient to improve functioning gradually, paralleling the return to work plans that are regularly used by other medical practitioners (eg, orthopedists). The goal is to avoid permanently eliminating work from patients’ lives.
Dr Long is Committee Chair, Work and Disability Consultant Private Industry, the Courts, and the Legal Profession; Dr Brown is Department Psychiatrist, Boston Police Department, Consulting Psychiatrist, Boston Fire Department, Work and Disability Consultant, Private Industry and Government; Dr Sassano-Higgins is Adjunct Professor, Department of Psychiatry, University of Southern California; Dr Morrison is Clinical Assistant Professor of Psychiatry and Behavioral Sciences, Chicago Medical School.
1. Long B, Brown AO, Sassano-Higgins S, et al. A complicated case of psychiatric disability. Psychiatric Times. 2019;36(4):26-27.
2. Long B, Brown AO, Sassano-Higgins S, et al. Disability: overview of concepts psychiatrists need to know. Psychiatric Times. 2019;36(5):20, 26.
3. Long B, Brown AO, Sassano-Higgins S, et al. Functional assessment for disability applications: tools for the psychiatrist. Psychiatric Times. 2019;36(6):19-20.
4. Long B, Brown AO, Sassano-Higgins S, et al. The psychiatry of work: is residency training adequate? Psychiatric Times. December 2014.
5. Group for the Advancement of Psychiatry. What Price Compensation? Committee on Psychiatry in Industry, Vol IX, Publication No. 99; June 1977.
6. Committee on Work and Organizations, Group for the Advancement of Psychiatry. Psychiatry of Workplace Dysfunction: Tools for Mental Health Professionals, Managers, and Employees. New York: Oxford University Press; 2018.