Unemployment is associated with an array of social and psychological complexities, directly affecting patients' self-esteem and perceptions of self-worth. When a patient loses their job, the psychiatrist has 4 tasks.
GROUP FOR THE ADVANCEMENT OF PSYCHIATRY, COMMITTEE ON WORK & ORGANIZATIONS
Work is central to many people’s lives. The average person spends one-third of their adult life working, yet psychiatrists may neglect work when assessing a patient’s well-being. We address drug use, family life, and psychiatric symptoms, but may not fully appreciate how those factors are relevant to our patient’s work.
Nonetheless, work is tied to the surge in mental health concerns precipitated by the coronavirus disease 2019 (COVID-19) pandemic. As we consider anxiety, depression, substance use, spousal and child abuse, and loneliness, all of which have been found to increase following disasters, we must not forget how the pandemic is affecting our workforce. For instance, during this time of increased social isolation, employers have been using video technology to maintain a sense of connectedness among their employees. This very much reflects the centrality of work to mental health and social cohesion.1
Psychiatrists will find it difficult to ignore the centrality of work over the coming months, as the the pandemic has led to a surge in unemployment not seen since the Great Depression. Individuals filed more than 58 million initial unemployment benefit claims between March 14 and August 22, 2020, and economists anticipate more will follow.2
When a patient loses their job, a psychiatrist must respond actively and swiftly. Employment fulfills essential biological, psychological, and social needs. It is the means by which we sustain ourselves, comprises a large part of our identity and social community, and determines how we spend most of our waking hours. As such, job loss is profoundly disorienting, challenging the very meaning and purpose of life. It directly affects self-esteem and perceptions of self-worth, precipitates anxiety, and increases the chance of physical and mental illness.3 Unemployment is associated with lower motivation, and an increased risk of substance abuse and suicide.4-7 This is compounded by the loss of structure and shared experience that work typically confers. Thus, job loss generally leads to a loss of well-being.8
When a patient loses their job, the psychiatrist has 4 tasks: (1) triage and treat imminent emergencies; (2) treat acute or latent psychiatric symptoms medically or psychotherapeutically; (3) support the patient by helping them to recognize vulnerability, identify feelings, and enhance personal support systems; and (4) prompt the patient to realistically evaluate their future job prospects.9
Treating emergencies and psychiatric disorders, as well as discussing the effects of job loss on personal and interpersonal variables can lead to improvement. Clinicians can do this informally or psychotherapeutically. Helping the patient identify their social support systems and how to use them can be helpful. As with any episode of clinically significant depression, anxiety, or psychosis, medication may be indicated.
Returning to work is the ultimate goal for the majority of our patients. To evaluate job prospects realistically, psychiatrists should take a work history once the initial crisis and reactions have been explored. Assessing a work history is not typically taught during residency training and is often not part of a clinical interview. However, a work history provides important information about a patient’s functionality (Table).
Work history questions help patients identify what they wish to do for future employment, including a change in career. Expectations, skills, and qualifications can be realistically assessed by discussing patient responses. The psychiatrist can serve as a sounding board for the patient’s ideas and help the patient cultivate adaptive perceptions, expectations, and realistic future plans.
How do psychiatrists carry out this function? Perhaps the most important principle to consider is their role in serving as a source of reality testing and as a means of integrating the self. By listening to the patient’s occupational hopes and integrating these with the current reality and the work history, the psychiatrist can explore what is possible in a career. The psychiatrist and the patient may uncover a wider range options for work than the patient would discover in isolation.
It is clear that the pandemic will continue to affect the economy, the job market, and work. It is likely that many aspects of work—such as where, how, and for whom it is conducted—will change, and many changes will persist beyond the pandemic. We may wish to recall that our society, economy, and work situations were far from perfect prior to the pandemic; perhaps the crisis can be reframed as an opportunity for our patients to seek healthier and more meaningful work situations.
Job loss is likely to affect far more people than COVID-19 itself. Psychiatrists are uniquely positioned to sustain the unemployed individual’s sense of efficacy, identity, and purpose during these difficult times. By understanding and supporting our patients, we can help them avoid the downward spiral of helplessness and despair that can otherwise follow job loss.
Dr Morrison is an assistant clinical professor of psychiatry at Chicago Medical School in Illinois. Dr Brown is a department psychiatrist at Boston Police Department in Massachusetts. Dr Sassano-Higgins is an adjunct professor of psychiatry at the University of Southern California, and chair of the Committee on Work & Organizations for the Group for the Advancement of Psychiatry. Dr VanDercar is a forensic psychiatry fellow at the University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine in Ohio. Dr Long is the president-elect for the Group for the Advancement of Psychiatry. Dr White is an adjunct voluntary faculty member at Northwell Health System in New York City, New York.
1. Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Intern Med. 2020;180(6):817-818.
2. Chiwaya N, J Wu. The coronavirus has destroyed the job market in every state. NBC News. Updated August 27, 2020. Accessed November 30, 2020. https://www.nbcnews.com/business/economy/unemployment-claims-state-see-how-covid-19-has-destroyed-job-n1183686
3. Jin RL, Shah CP, Svoboda TJ. The impact of unemployment on health: a review of the evidence. CMAJ. 1995;153(5):529-540.
4. Warr P. Work, Unemployment, and Mental Health. Oxford University Press; 1987.
5. Lee AM, Wong JGW, McAlonan GM, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry. 2007;52(4):233-240.
6. Darity WA Jr. Employment discrimination, segregation, and health. Am J Public Health. 2003;93(2):226-231.
7. Kawohl W, Nordt C. COVID-19, unemployment, and suicide. Lancet Psychiatry. 2020;7(5):389-390.
8. Stam K, Sieben I, Verbakel E, de Graaf PM. Employment status and subjective well-being: the role of the social norm to work. Work Employ Soc. 2016;30(2):309-333.
9. Committee on Psychiatry in Industry, Group for the Advancement of Psychiatry. Job loss, a psychiatric perspective. Psychiatr Serv. 34(5):465. ❒