What Is Organizational and Occupational Psychiatry?

Organizational and occupational psychiatry (OOP) is the subspecialty of psychiatry that focuses on work, its importance in the lives of individuals and work organizations. The importance of work to the mental health of individuals is reflected in the quote attributed to Sigmund Freud: "Love and work are the cornerstones of our humanness." Freud is also purported to have said that the goal of psychotherapy is to be able to "love and work" and that the ability to "love and work" defines mental health. Precise sources for these quotes are difficult to find, but Freud was certainly not alone in this view, with multiple thinkers and researchers sounding the same theme (Hazan and Shaver, 1990).

Organizational and occupational psychiatry represents the extension of psychiatric knowledge and skill to the day-to-day functioning of individuals in the workplace and their organizations, with the goal of helping both function better. To this end, psychiatrists have played an important role both in the treatment of workers and consultation to organizations since the early part of the 20th century. These roles have included service as in-house medical directors to major corporations, retained consultants and providers of employee assistance program (EAP) services (Sperry and McLean, 2003). The level of psychiatric involvement in work-related issues has fluctuated over the years; however, the importance of mental health issues in the workplace has grown steadily.

Recognizing that patients and their employers would benefit from the services of psychiatrists who are knowledgeable about workplace issues, the American Psychiatric Association formed the Committee on Psychiatry/Business Relations in 1998. That committee has given rise to the National Partnership for Workplace Mental Health, among other projects.

Organizational and occupational psychiatry is a field with tremendous growth potential and practice opportunities for those psychiatrists who are open to understanding the business world, interested in functioning outside traditional clinical settings and willing to take on the challenge of building a new area of practice.

What Does OOP Do?

Broadly speaking, OOP can be divided into issues related to the functioning and health of the larger organization (organizational) and issues related to individual work-related mental health concerns (occupational). Yet the distinction is not always clear, as the interface between individual and organizational workplace issues is often significant and complex.

Perhaps more than any other subspecialty of psychiatry, OOP provides an outlet for the diverse training and interests of psychiatrists. The field offers opportunities for those with interests ranging from psychoanalysis to psychopharmacology, from executive coaching to disaster medicine. Organizational and occupational psychiatry services can be as straightforward as a single session Social Security disability evaluation or as complex as a consultation to a large organization experiencing disabling conflicts among leadership. The educational offerings at the most recent meeting of the Academy of Organizational and Occupational Psychiatry (AOOP) reflect the diversity of OOP; AOOP information is available on their Web site at <www.aoop.org>.

In many cases, OOP involves consulting to and working as part of a team, with the OOP consultant playing a leading role. The pressure on the consultant can be significant, as important business decisions that may affect an individual's employment or the financial status of a company may turn on the consultant's recommendations. Organizational and occupational psychiatry consultations are often clinical in nature and aimed at improving the functioning of an individual or organization. In some cases, the entire organization is the patient, while in others, it is a single employee. Engagements may be short- or long-term, with the successful consultant commonly re-engaged by the same client for assistance on similar and sometimes unrelated issues.

The best way to explain the work of OOP specialists is to offer some examples of the assignments frequently undertaken by practitioners.

Brief Evaluations

Social Security disability or workers' compensation evaluations. These are single session evaluations (one to two hours) that include record review and follow guidelines established by the Social Security Administration or state administrative agency requirements, respectively. Of the many OOP activities, these evaluations and initial workers' compensation evaluations are most similar to standard psychiatric evaluations (Williams, 2001, 1999). They are an excellent way to become familiar with workplace issues and meet attorneys and others involved in the field. Second-opinion evaluations in both settings are more complex, requiring the review of additional records, administrative decisions and reports.

Disability insurance evaluations. These evaluations may be requested by employers, insurers or attorneys representing individual applicants, insurance companies or employers. They can range from fairly straightforward to more complex assessments, depending upon the issues involved, the stage of the application and whether the matter is headed toward litigation. Medical and personnel record review is involved, as well as direct evaluation with a detailed work history, and interviews with collateral sources, including family members. Insurers generally provide a set of questions to guide the examination and report-writing. As practitioners gain experience and exposure in the field, they tend to be asked to evaluate claims at higher levels of the process (e.g., second opinions of previous evaluations).

Fitness for duty evaluations. These are primarily requested by employers who have concerns about an employee's cognitive abilities or emotional stability as they relate to ability to function or the employee's potential for violence. Like disability evaluations, these can range from fairly simple to highly complex. Fitness for duty evaluations rely even more heavily on interviews with collateral sources familiar with the evaluee and the job functions. In some cases, background investigations, police reports and other nontraditional information sources are utilized. An appreciation of organizational dynamics and an understanding of such concepts as "person-environment fit" increase the quality of these evaluations (Sperry, 1993).

Medium-Term Engagements

Assessment of impaired or disruptive executives and professionals. These evaluations are requested by regulatory agencies, diversion programs, employers, practice groups, or partnerships and attorneys. They can be highly complex, with significant consequences for the evaluee's and the organization's future. In addition to the direct examination, record review and information from collateral sources required for other assessments, these involve significant clinical questions. The requesting party generally wants to know the nature of the problem and whether something can be done about it, and if so, what. The evaluator may be asked for specific recommendations regarding potential referrals to provide the recommended interventions (e.g., finding a therapist to treat the disruptive executive).

Interventions for impaired or disruptive executives and professionals. Organizational and occupational psychiatry practitioners may be called upon to provide direct interventions, either by a third party, the individual or a colleague who has performed the initial assessment. These interventions involve our traditional psychiatric skills, such as psychotherapy and medication management, but must be informed by knowledge of the patient's field, organization and its specific stresses.

Organizational consultations. These consultations are among the more complex activities of OOP specialists. They tend to be requested when one or more members of a work group engage in behavior that is disruptive to the organization or where conflict among individuals and its impact can no longer be ignored. Diagnosis of the problem generally requires extensive interviews with individuals at all levels of the organization and an understanding of both the micro and macro environments of the organization. Solutions are generally found in looking at the system as a whole and how individual behaviors and pathology interact with that system.

Policy and procedure development. Organizational and occupational psychiatry practitioners with expertise in workplace violence, sexual harassment and disaster management are retained to help organizations develop policies and procedures. In addition, they may be retained to help provide training to the organization and its staff.

Long-Term Engagements

In-house consultants. Organizations with an appreciation for the importance of mental health issues may retain an OOP specialist as a consultant or, in some cases, as a full- or part-time employee.

Employee assistance program services. Employee assistance program services have traditionally been the province of alcohol counselors, social workers and psychologists. Psychiatrists are often sought out to provide consultation to EAPs and several psychiatrists have developed and operated successful EAPs.

Threat assessment/crisis management team members. Psychiatrists with expertise in workplace violence and crisis management, especially those who have helped develop disaster plans or workplace violence policies, can be valuable members of organizational threat assessment or crisis management teams on an ongoing basis.

These are just some examples of areas where OOP specialists practice. Some of this work can be, and has been, done by general psychiatrists or other subspecialists. Organizational and occupational psychiatry subspecialists are generally preferred for these assignments, however, because their interest in and familiarity with the world of business adds value. Beyond the standard mental status examination that is used as part of a fitness for duty evaluation, for example, OOP specialists apply their knowledge of the stresses inherent in the evaluee's specific occupation; the status of the industry; conflicting business, personal and legal concerns; organizational dynamics; psychotherapy; psychopharmacology and general medicine. As noted above, few aspects of psychiatry provide such an opportunity to integrate as much of our psychiatric skill sets.

Getting Started

Organizational and occupational psychiatry is not an easy field in which to get started. The business world has traditionally been skeptical of psychiatry and its potential contributions to the workplace. It is unclear whether this is due to the association of psychiatry with severe pathology, a perceived bias against business on the part of psychiatrists, or a combination of these and other factors. Psychiatrists who have been successful in the field have done so by building it as a part of their general or other subspecialty practice. For example, forensic psychiatrists who develop expertise in employment-related forensic matters and relationships with employment attorneys may be called upon to assist with other workplace mental health issues. Psychotherapists who work with executives and professionals may be asked to work with larger groups to assist them with organizational issues. Regardless of the starting point, personal relationships and trust are essential to building a practice in OOP. The party seeking the service, whether it is an insurer, attorney, employer or government agency, must have confidence in the psychiatrist's ability to consider the often-complex individual and organizational issues, to be sensitive to the needs and concerns of the workplace, and to be objective and accurate. Perhaps most importantly, the psychiatrist must be able to express how psychiatric theory applies to the situation at hand, and to do so in plain English. The successful OOP consultant blends into the business environment through language, dress and interest in the field. The psychiatrist who fulfills these qualifications on the first assignment is often asked to provide additional consultation or other services.

One of the dilemmas when offering a new service is deciding what to charge. Organizational and occupational psychiatry services are generally not covered by insurance, although certain types of government-ordered evaluations may have a set hourly rate. There are no hard and fast rules in setting a fee, but there are certain pitfalls to avoid. Organizational and occupational psychiatry consultation services can generally be charged at the psychiatrist's fee for service rate for psychotherapy (assuming that the psychotherapy rate is within the standards of the community). An additional premium can be charged above and beyond that rate, depending upon the complexity of the assignment and the experience level of the consultant. The fee and how it is charged, i.e., flat fee or hourly rate, should be established before the assignment is begun. The consultant should be prepared to negotiate the fee with the client. Common errors, in addition to failing to set the fee in advance, include overcharging, failing to itemize the charges for services provided, poor record-keeping and lack of responsivity to client needs.

Training and Resources

At present, there are no fellowships in OOP. Subspecialty continuing medical education courses are offered, such as the Door County Summer Institute, and isolated OOP-related presentations can be found at the annual meetings of the American College of Occupational and Environmental Medicine, APA, and the American Academy of Psychiatry and the Law. The greatest concentration of OOP courses and practitioners is at the AOOP annual meetings. The AOOP is the subspecialty body dedicated to OOP issues and development, with the largest offering of seminars and training.

References:

References

1.

Hazan C, Shaver PR (1990), Love and work: an attachment-theoretical perspective. Journal of Personality and Social Psychology 59(2):270-280.

2.

Sperry L (1993), Anatomy and physiology of organizations. In: Psychiatric Consultation in the Workplace. Washington, D.C.: American Psychiatric Press, pp17-47.

3.

Sperry L, McLean AA (2003), Psychiatry, productivity, and health: a brief history of psychiatry in the workplace. In: Mental Health and Productivity in the Workplace: A Handbook for Organizations and Clinicians, Kahn JP, Langlieb AM, eds. San Francisco: Jossey-Bass, pp71-87.

4.

Williams CD (1999), Social security disability evaluations. Available at:

http://aoop.org/archive-bulletin/1999winter04.shtml

. Accessed April 23, 2004.

5.

Williams CD (2001), Worker's compensation IMEs-Part 1. Available at http://aoop.org/archive-bulletin/2001fall04.shtml. Accessed April 23, 2004.