My Patient Just Lost their Job … What Do We Do Now?

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COMMENTARY

Work is central to many people’s lives. The average person spends one-third of their adult life working, yet psychiatrists may neglect the importance of work. 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 2019 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, in this time of increased social isolation, video technology has been used to maintain a sense of connectedness among employees. This very much reflects the centrality of work to mental health and social cohesion.¹

However, psychiatrists will find it difficult to ignore the centrality of work over the coming months; the response to the COVID-19 pandemic has already led to a surge in unemployment not seen since the Great Depression. More than 1 in 10 eligible workers filed unemployment claims in the past month in 50 states and territories, and economists anticipate more job loss will follow.²

When a patient loses their job, a psychiatrist must respond actively and swiftly for many reasons. 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 typically determines how we spend most of our waking hours. As such, job loss is profoundly disorienting, challenging the very meaning and purpose in life. It directly impacts self-esteem and perceptions of self-worth, precipitates anxiety, and increases the chance of becoming physically and mentally sick.³ Unemployment is associated with lower self-esteem and motivation, and an increased risk of substance abuse and suicide.^4-7 The loss of an individual’s capacity to meet their basic needs through work is compounded by the loss of structure and shared experience that work typically confers. Because work fulfills such a broad range of human needs, 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. This can be done informally or psychotherapeutically. Helping the patient to identify social support systems they have in place and how to utilize these systems 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, take a work history once the initial crisis and reactions have been explored. The assessment of a work history is not typically taught during residency training and is often not part of a clinical interview. A work history provides important information about a patient’s functionality. Components of a work history include:

• What did their parents do for work? What did the patient think about the parents’ occupation?
• What did the patient expect to do for work when they grew up?
• How did the patient end up in their current job?
• What was the patient’s motivation for accepting past jobs?
• What were the patient’s expectations with past jobs?
• Did past jobs live up to those expectations?
• What led to past job transitions?
• What are, or were, the daily tasks of the current or most recent job?
• What skills/training/qualifications does the patient possess?
• What are the current job market opportunities?
• What interpersonal areas have they struggled with during past employment (eg, too aloof or too friendly)?

Answering these questions can assist patients in identifying what they may wish to do for employment in the future, including a potential change in career. Expectations, skills, and qualifications can be realistically assessed through discussing patient responses to these questions. The psychiatrist can serve as a sounding board for the patient’s ideas about future employment and help the patient cultivate adaptive perceptions, expectations, and realistic future plans.

How does the psychiatrist serve this function? Perhaps the most important principle to consider is the psychiatrist’s role in serving as both a source of reality testing and of integrating the self. By listening to the 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 can uncover a wider range options for work than would be discovered by the patient in isolation.

It is clear that the pandemic will continue to impact the economy, the job market, and work. It is likely that many aspects of work—such as where, how, and for whom work 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 re-framed 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 a downward spiral of helplessness and despair that could otherwise follow job loss.

Dr Morrison is Assistant Clinical Professor of Psychiatry at Chicago Medical School. Dr Brown is a Department Psychiatrist at Boston Police Department. Dr Sassano-Higgins is an Adjunct Professor of Psychiatry at the University of Southern California, and Chair of the Committee on Work and 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. Dr Long is President-Elect for the Group for the Advancement of Psychiatry. Dr White is Adjunct Voluntary Faculty at Northwell Health System.

References

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2. Chiwaya N, Jiachuan W. The coronavirus has destroyed the job market in every state. NBC News. Accessed May 7, 2020. https://www.nbcnews.com/business/economy/unemployment-claims-state-see-how-covid-19-has-destroyed-job-n1183686 

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5. Lee A, Wong J, McAlonan G, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry. 2007;52:233-240.

6. Darity W. Employment discrimination, segregation, and health. Am J Public Health. 2003;93:226-231.

7. Kawohl W, Nordt C. COVID-19, unemployment, and suicide. Lancet Psychiatry. 2020;7(5):389-390.

8. Stam K, Sieben I, Verbakel E, et al. Employment status and subjective well-being: The role of the social norm to work. Work Employ Soc. 2016;30:309-333.

9. Committee on Psychiatry in Industry, Group for the Advancement of Psychiatry. Job loss, a psychiatric perspective.Mental Health Materials Center; 1982.