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

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.

Group for Advancement of Psychiatry, Work and Organizations Committee

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 Group for the Advancement of Psychiatry, Work and Organizations committee, provides her views on how to evaluate and support patients facing job loss, or insecurity. 

Transcript:

Ashley VanDercar: My name is Ashley VanDercar, and I’m a psychiatry resident, and a fellow with the Group for Advancement of Psychiatry.

COVID-19 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.

Fara White: I’m a private practice psychiatrist in Manhattan. It (COVID-19) has changed life in the city as we’ve come to know it.

Ashley VanDercar: 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?

Fara White: 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.

Ashley VanDercar: 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?

Fara White: 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.

Ashley VanDercar: 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.

Fara White: 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.

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

Fara White: 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.

Ashley VanDercar: Do you do medication management for your patients?

Fara White: I do, yes.

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

Fara White: 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?

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

Fara White: 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.

Ashley VanDercar: What about insomnia?

Fara White: 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.

Ashley VanDercar: 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?

Fara White: I usually instruct them to keep things as normal as possible. To wake up in the morning, to get dressed … to work with what they have. Which may only be getting some support, either from me, or from family members – or from other people in their business. To really band together to support each other through this time. Then, to be able to see beyond it. It doesn’t feel like it now, but in three months, six months, things will be different…

We have to be prepared. We will be reopening and be able to rebuild, but it will be difficult and it’s going to take a lot from us, in terms of our emotional energy.

Ashley VanDercar: A lot of people who have previously been going to work during the day, are now trying to work at home. This presents its own set of complications. What are you saying about that? What support are you giving people to help them to deal with family, when they’re trying to work from home?

Fara White: For people who are lucky enough to have their own space, I recommend that they use it, and make it comfortable. Have as much of a division between work, and home, as they can. That’s not always possible – especially in a place like New York.

To the extent that they can, they should try to keep some sense of normalcy. To try to use this as a period – for instance, for physicians, to try to get their CME credits. Read those books, those journals that have been sitting there … that you never ever have time to look at.

So we need to each ask: how can we make use of this time to better ourselves professionally? Then, when we do come back, we’re up to date in terms of evidence-based stuff.

I know for me, I’ve had a lot of reading for analytic training. It has always sort of taken a back seat; but now, I’ve been able to look at.

Basically: try and use this time in some way, so it doesn’t feel like a total loss.

And, also get our minds off the news. We really have to limit what we take in. Of course, it’s so important to stay aware of what’s happening. But at a certain point, people might reach their capacity to hear about horrifying things that are happening. And that’s the time to turn it off.

Ashley VanDercar: In this session, Dr Fara White helped us to figure out how to help and assess our patients who are dealing with job insecurity or job loss. She walked us through assessing how someone’s work fits in as part of their identity. She then went on to explain how to validate their feelings, providing reassurance that their job insecurity or loss isn’t about anything that they have done. How to help them to stay connected, and manage their feelings of uncertainty – specifically, by using their off time to better themselves professionally when possible … and prepare for the re-opening of society.

And, while doing all of this, as a psychiatrist, recognizing your own counter-transference – and recognizing that this is a collective experience.

Transcript edited for clarity. -Ed