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Unprecedented numbers of Americans are losing their jobs. When patients describe psychiatric symptoms (eg, anxiety, insomnia, irritability), psychiatrists should ask about workplace issues.
Group for the Advancement of Psychiatry, Work and Organizations Committee
Unprecedented numbers of Americans are losing their jobs due to COVID-19. 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.
Ashley VanDercar: This is Ashley VanDercar. I am a psychiatry resident and a fellow with the Group for the Advancement of Psychiatry. 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.
Sean Sassano: This is Sean Sassano. I am a psychiatrist in private practice in Los Angeles, California.
Ashley VanDercar: So, we talked about this in Episode 2 and Episode 3, 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?
Sean Sassano: 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.
Ashley VanDercar: 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?
Sean Sassano: 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.
Ashley VanDercar: 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?
Sean Sassano: 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?”
Ashley VanDercar: So how do you help them move through it?
Sean Sassano: 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?
Ashley VanDercar: What if they … think they need to leave their job. How do you help them think through, and process, that?
Sean Sassano: 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?
Ashley VanDercar: 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?
Sean Sassano: 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.
Ashley VanDercar: 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?
Sean Sassano: 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.
Ashley VanDercar: 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.
Transcript edited for clarity. -Ed
More in this series by the Group for the Advancement of Psychiatry, Work and Organizations Committee
Episode 3 of 4: How to Help Support Patients Who Are “Essential” Workers
Episode 4 of 4: How to Evaluate and Manage Psychiatric Symptoms Related to Workplace Concerns