How and Why Clinicians Should Take a Thorough Work History During COVID-19 and Beyond

Dr Daven Morrison of the Group for Advancement of Psychiatry Work and Organizations committee provides his views on how and why psychiatrists should take a thorough work history, especially now, during the COVID-19 pandemic.

Group for Advancement of Psychiatry, Work and Organizations Committee

A patient’s job is a large part of their identity, and key to helping them navigate the world in times of opportunity and in times of strain. In order to understand this important part of a patient’s identity, a psychiatrist must get a thorough work history: an employment narrative. This information helps us support our patients during times of economic crises – when they are likely to have employment insecurity. The information can also help us understand a patient’s past and present functionality, in the real-life setting of work. This is particularly important right now, with COVID-19.

A thorough work history starts with a patient’s childhood, and then naturally flows through their higher education and training, and how they ended up in their current or last job. It also involves an assessment of a patient’s role in their work organization, including conflicts with peers and supervisors. Even the most effective people use sounding boards to gauge the quality of their work products and need help integrating other life pressures to efficiently attend to work. Psychiatrists have a unique capacity to be that sounding board, and to help patients maximize their work and home lives. This ability is key during times of significant job loss, like the current pandemic.

In this podcast, Dr Daven Morrison, an organization psychiatrist and member of the Group for the Advancement of Psychiatry, provides his views on how, and why, psychiatrists should take a thorough work history.

TRANSCRIPT:

Ashley VanDercar: My name is Ashley VanDercar. I am a psychiatry resident, and a fellow with the Group for Advancement of Psychiatry.  Today we will be talking with Dr Daven Morrison, an organizational psychiatrist.

Daven Morrison: Good morning, I am Daven Morrison, I am an organizational psychiatrist.

Ashley VanDercar: We’re talking today because of your specific interest and expertise in work psychiatry. At the moment, with the global pandemic of COVID-19, work is becoming more important in terms of people’s relevance and their perspective on work. With those patients who are still at work, or those who have lost their job, or have a lesser degree of financial and work security, it’s important that we know the right questions to ask.

So, today, I was hoping you could give us a little bit of guidance about how to get a work history, and why that’s important.

Daven Morrison: I think the most important reason to get a work history is that it is the clearest insight into how the patient, or the person, sees themselves as the center of initiative. So much of dealing with crises, like COVID, or other things, has to do with either being a passive person, or someone who is taking active control. Work provides an insight into one’s own self, and how we see ourselves as the center of initiative: someone who is taking action on the world.

Ashley VanDercar: As we go along, we are going to have a lot of new patients that are going to be seeking care: people who are unemployed, people who are essential service workers, and whether they are referred through their employee assistance program, or they are self-referred, there are some predictions that psychiatrists are going to get a lot of new patients.

So, when you have a new patient, what questions should you ask to get a work history? When I started residency my work history was basically: (1) Do you have a job? (2) What is your job? That was the extent of my work history.

I know from talking to you and reading some of the work that you and the Group for Advancement of Psychiatry have written, that work history is a lot more. You can use the work history as a looking glass into the patient’s functionality.

Take us through the questions that someone should ask a new patient, to get a work history.

Daven Morrison: Well, just like any part of the psychiatric history, I think it’s really important to consider it as a narrative:

• What is the story of work?

• What is the story of work in their lives?

• How does their job fit into the larger system of what the organization is trying to do?

• How does the organization make it (How do they make money? What is on the horizon for them?)?

What I’ll do is walk through how I think about work in a person. The questions naturally flow from there. Most people generally had a first job, or first responsibility (“Your job is to make the bed, your job is to set the table.”). The family has their expectations of what needs to be done to take care of the family. That begins in essence, a person’s work ethic, how they feel about work, how it ties to their sense of self. For example, in Chicago, in the municipalities, often the workers are following in the path of others who worked in the police or fire department.

This can also tie to the COVID crisis. We did not have much money growing up; if you wanted anything, you needed to get a job. In most people’s lives, there is a need to get a job for pay. Often it is mowing the lawn, or babysitting, or shoveling snow. That is the beginning of: “If I make an effort, if I work, I’ll get paid for it.”

Then, when you come to formal employment, there are lots of important things to ask.

• First, is, how did they get their job?
• What was their education?

• What was their training?

• Second, did they have anybody who had an eye on them?
• “You sure looked like you put in extra effort when you were working that summer at the grocery story, I knew you’d be a leader at the grocery store someday.”

• There was a mentor, somebody saw the talent and effort.
• How did that mentor come to be?

• What did they see that they liked about their work?

Obviously, of course, these things are going to tie to their sense of self, and what motivates them intrinsically, beyond money, to do what is required to stay employed. This is a very important question right now with the COVID crisis.

The other thing that is very important, that tends to blend in, is that a lot of times when psychiatric symptoms come to us, they come from conflict with a supervisor. That often has to do with conversations around performance. Critical question to ask are:

• Who does your performance appraisal?

• What are they expecting?

• What categories are they asking about in terms of gauging your performance?

• How does that tie to your pay?

• Who provides input into your performance?

• How do they (the patient) evaluate someone else’s work?

If you ask the patient to talk about the last performance appraisal they gave, it can give you a sense of how they think about work. A big part of work, as you think about your patients, is how they fit in the overall system.

I am an organizational psychiatrist. The organization is essentially my patient. I put the organization on the couch:

• Where is it healthy?

• Where is it pathological?

• Where is it functioning really well?

• Where is it dropping the ball and not executing?

A lot of times what can happen, is someone is well liked; and for that reason they are not told how well they (don’t) fit in the system.

It’s really important when you ask about work, to ask:

• Who can do the work?

• Where does it come from?

• When you are done, where does it go?

• How is it paid for?

Psychiatrists are able to ask a lot of personal questions, but one of the most personal questions is how much money do you make. That’s not necessarily easy to ask. But it’s very important, because it can give you a sense about how the person feels about themselves. They may have a sense about how other people are paid around them. This may be making them withdrawn, disengaged, or sabotage. This can also give you a sense of the relative importance of their job to the overall system.

I became really interested in performance appraisals, why they go right and why they go wrong, because I was seeing a lot of executives who were derailing.

Ashley VanDercar: So those are questions about the current job. I remember reading in the Group for Advancement of Psychiatry Workplace Dysfunction book (or one of the monographs), about the importance about asking about childhood perspectives:

• Asking about what someone’s parents did for work.

• What they thought they were going to be when they grew up.

• How they actually ended up in their job.

Then, tying those things together, so that you can look at their psyche about work when they were a kid.

Daven Morrison: So, what you’re asking about is a longer sense of identity. How they are similar to, how they are different from, their parents, even the grandparents. When you do a deeper dive into work history, perhaps you’re not trying to resolve or understand a workplace conflict. You’re trying to understand the meaning of work for them in the bigger picture: who they are, where they’re going, who they want to be, or how they determine success.

There’s also issues of:

• What did you talk about at the kitchen table?

• What’s important?

• What is a meaningful job?

For example, a lot of times, the executives I’ve worked with over the years, that are very successful, are the first people in their family to have a college degree. Their parents are blue-collar workers who did whatever they could to make sure the rent was paid and food was on the table; and that there was money left over to pay for college. “You are going to go to college” - that was the expectation. “I’m coming into my career as the hope of my parents, and even my grandparents, to do better – to live the American dream!”

So, there are long-term things for a psychiatrist to consider, relative to the different “buckets” of a person’s life, being filled in the right way.

I advocate for work. The other dilemma is: are you working so much to be with your family, that your work isn’t being cared for? These are the kinds of balance and integrated questions that a psychiatrist can consider, as they are advising people in the work world.

Ashley VanDercar: So, what I hear you saying, is that when you’re asking questions of a patient, the work history and doing a deeper dive is really important. Some questions that you might want to start off with, are:

• What did the patient’s parents do for work?

• How did the patient feel about their parents’ job?

• What did the patient expect to do for work when they grew up?

• How did they end up in their current job?

• What was the motivation for taking their job?

• What were their expectations for that job?

Then, looking at their work conflict history, and questions, to figure out whether their job lived up to their expectations.

Daven Morrison: That’s a very nice synthesis. What I would add to that is: we play a very nice role that I don’t think hardly any other professional does. The accountant doesn’t do this. The internist doesn’t do this. The lawyer doesn’t do this. The financial advisor doesn’t do this.

We ask: how are you living an integrated life?

We want to look at work and dive deep into it and explore the meaning. Then take a look, with them, at their “future you,” asking:

• Where do you want to be in five years?

• How do you want to engage more with work?

• Or ratchet it down (and make sure that you have a life outside of work … not only for family but also for your own personal needs)?

Ashley VanDercar: This conversation with Dr Daven Morrison has helped provide a little bit of guidance about the importance of the work history. Work tells you how a patient sees themselves. In the crisis of COVID-19, when so many of our patients have already lost their job, fear losing their job, or otherwise have reduced income – it is especially important that we take a good work history: a narrative … their story. This type of history, as Dr Daven Morrison described, starts with the patient’s childhood:

• What their parents did for work.

• What they thought they would be when they grew up.

• Their education, training, and mentoring that led them into the workforce.

• Their first job, how long they held it, why they switched jobs.

• How they got into their current or last job.

• How they fit in the overall organization.

• How their work was evaluated.

• How much money they made (or make).

• Any conflict at work.

These questions are very important. They are important because, as we cope with COVID-19, as we help our patients to cope with COVID-19, we need to support them. We need to help them recognize their vulnerability, to help them advance – and appropriately and realistically evaluate their prospects in the workforce. The work history is important, as a psychiatrist, to let us do this.

Transcript edited for clarity. -Ed