Typically, psychiatrists spend a significant portion of practice time attending to complaints, symptoms, or suffering that derives from work experience. In many practices, the workplace constitutes the most common source of problems with which patients present. A variety of terms and phrases are used to refer to adverse work experience. Some terms originate in popular culture, others appear to have legal connotations, whereas others are clothed in medical jargon that suggests that work has precipitated a specific pathophysiological process. Although the terms used to characterize work experience are insufficiently illuminating, the suffering that induces clinical presentation is not only real but often profound.
We should first consider why work, in general, has the potential to cause so much suffering. For there is nothing intrinsic to activity involving effort done to achieve a purpose or result (ie, “work”) that would necessarily lead us to expect that so many patients would identify it as a source of distress.
Core Negative Experience at Work
Patients who present clinically with work-related suffering and symptoms invariably report painful emotions and perceptions. Precipitants to clinical presentation tend to be induced by one or more “core” negative experiences at work. Narratives that refer to a hostile or toxic workplace almost always feature an event or situation at the workplace that precipitated an intense emotional reaction. When patients present with problems arising from an adverse work situation, the patient typically feels one or more of the following: unrecognized or mis-identified; disrespected; criticized, rejected, or discriminated against; intimidated; shamed or humiliated; and harassed, “singled out,” or “targeted.”
Insofar as phrases such as “work stress,” “toxic workplace,” and “hostile workplace” can obscure the core emotional experience that precipitates clinical presentation, it is critically important for the psychiatrist to recall that patient distress is probably generated by one or more of the above-referenced experiences.
Defining Dimensions of Work Are Clinically Problematic
Although it is not difficult to appreciate the negative valence of any of the above-referenced experiences, work has two defining dimensions that explain why the location of such an experience (ie, “work”) intensifies its impact.
Necessity and Survival
Work is the means by which the employee's survival is predicated. Hence, workers tend to experience problems at work as threats to survival.
Supervisors and employers exercise real world authority over the employee. Objective authority vested in the supervisor and employer is typically amplified significantly by a tendency in employees to appraise themselves based on perceptions relating to their employer's treatment of them.
The two dimensions overlap considerably, insofar as the extraordinary authority that employees impart to employers is in large part attributable to the tendency to look upon employers and supervisors as safeguarding—or as potentially threatening—the employee's survival.
The enormous authority that employees bestow upon supervisors and employers is reminiscent of the child-parent relationship. Hence, the exquisite sensitivity of employees to the real and perceived attitudes, communication, and behavior of supervisors and employers and the frequency with which perceived slights and offenses at the workplace eventuate in complaints of emotional harm, injury, and illness at work.
Employees Emotionally Invest in Employers
Although employees identify the workplace as the locus of the distress, symptoms that arise in the context of workplace experience can affect patients even when they are not performing job duties. The term cathexis denotes a concentration of mental energy on a particular person, idea, or object, especially to an unhealthy degree. A tendency to cathect employers and supervisors frequently manifests clinically in ruminations about a significant workplace event or situation. Anxiety, mood, posttraumatic, and substance use disorders are often regarded as having been precipitated or exacerbated by work stress.
Although employers exercise real authority over employees, the degree of that influence varies enormously. Whereas some employees have limited alternative employment opportunities, others may have an unrealistically diminished sense of their own capacity to survive in the absence of a job at their employer. Distress attributed to a workplace situation is typically coincident with the degree of emotional investment that a patient has in his or her employer.
The Stressful Workplace: Begin by Precisely Locating the Source of Stress
The first task in a psychiatric evaluation of a patient presenting with work stress involves identifying the source of stress. Although the importance of identifying the source of stress may be assumed to be self-evident, a pervasive tendency to regard the term “work stress” as sufficiently explanatory reflects the extent to which the problems subsumed under the term remain unaddressed in a clinical context. The official definition of work stress—harmful responses to job requirements—is generally not useful as the source of stress is often not reducible to the demands of the job.1
Work stress is used to denote the presence of a situation or event at the workplace that is perceived to have negatively affected the patient. The term is typically employed as a means of communicating the felt experience of pressure and the patient's sense that such pressure is excessive and unhealthy. Because patients use the term to convey their felt experience, the term itself implies little about the specific origin, nature, or form of the problem. The patients' report of stress constitutes nothing more than an indication to inquire more deeply into the patient's subjective experience at work.
Work Stress: Theoretical Models Are Often Misleading
One of the most common problems underlying suboptimal treatment and management of workplace problems resides in a tendency to associate reports of work stress with a specific and well-defined psychophysiological phenomenon (eg, biologically mediated dysfunction in the hypothalamic-pituitary-adrenal axis). Reference to a hormonally mediated process may be assumed to represent a full explanation for the presenting problem. Such a tendency tends to short-circuit necessary aspects of evaluation by reducing a complex problem to a simple—and often highly misleading—term that leaves the problem unidentified.
Theoretical models that explain work stress in terms of well-defined constructs tend to mislead the evaluator. The three prevailing theoretical models of work stress are generally antithetical to accurate clinical assessment and effective treatment.
Models that assume that complaints of stress are attributable to excessive work demands ignore the everyday reality that clinical complaints are inextricably linked to employee interpretation of such demands.2 Attitudes, expectations, perceptions, and emotions inform the employee's interpretations. The magnitude of demand is often less salient than the employee's sense that he or she is being singled out, or the sense that responsibility for the workload is distributed in an unjust manner, or that the employee's hard work or contribution is inadequately recognized by the supervisor. The magnitude of workplace demands rarely constitutes the whole story when patients present with work stress. Complaints more frequently relate to a specific aspect of work experience (such as a problematic relationship with a supervisor). Schematic supply-demand models limit awareness of the critical importance of developing an understanding of the specific dynamics that precipitated the patient's presentation.
Models that emphasize work-reward imbalance accurately identify a deep psychological need to couple work with reward.3 However, the sense that one's work is being insufficiently rewarded rarely leads to clinical complaints of work stress.
Models that emphasize an employee's sense of injustice at work closely approximate the emotional experience of many patients who present with work stress. Assessment of the patient's specific work circumstances, and patient perceptions regarding such circumstances, is critically important.4
Any work event or situation may be described as stressful. The term's lack of clinical relevance is underscored by the fact that absence of work itself (ie, unemployment) is among the most stressful situations that can be encountered relative to work.5
Precisely Identify the Workplace Situation that Is Described as Stressful
Patients who present with work stress are typically struggling to adapt to a specific event or situation at the workplace. The complaint implies that the working situation has become less tolerable. Although the intensity or extent of work demands may constitute an element in the overall clinical picture, the problem most often does not reside primarily in the magnitude of demands but rather in the patient's interpretation of such demands. The patient's experience of workplace demands is most often informed by the patient's experience of the supervisor and employer, perceptions of whether the work demands are fair or just, and the patient's overall experience of authority figures at the workplace.
Work Stress Entails an Internal Reaction to an External Situation
There is a general tendency among clinicians to assume that stress reported by the patient is constituted exclusively as a problem that is external to the patient. Such a tendency often leads to poor clinical decision-making and outcomes. A clinician can encourage a patient to unnecessarily leave work due to an assumption that solving the patient's problem resides in separation from an external situation over which the patient has no influence. Although complaints of stress involve a situation that is external to the patient, it is the patient's perceptual, interpretive, emotional, and symptomatic response to the external situation that leads the patient to present clinically. The situation that the patient identifies as stressful is mediated by prior experience, expectations, and interpretations. The clinician must explore the perceptions, interpretations, emotions, and symptoms that the workplace induces, as the way in which the patient frames his or her experience of the stressful situation typically constitutes the focus of psychotherapeutic assessment and treatment.
Although the ability of treating clinicians to directly impact the workplace is constrained, the decision to present clinically with complaints of work stress allows the patient an opportunity to examine assumptions, interpretations, and behaviors upon which their report of stress is predicated. When such an analysis is undertaken it is generally possible to identify ways in which the patient may unknowingly contribute to the experience of stress.
Psychotherapeutic treatment may modify the patient's internal experience of their work situation to render that situation more tolerable. In other cases, the patient determines that he or she is disinclined to remain exposed to the reality-based situation that prevails at the workplace. In such cases, treatment should support the patient's efforts to extricate himself or herself from the work situation in a manner that does not precipitate separation from the workplace and its consequences.6
The Hostile Workplace
Although the experience of unfriendliness or opposition can be challenging regardless of the context within which such behavior is encountered, hostility encountered at the workplace can be particularly problematic. It can be deeply distressing because it is experienced as a threat to the employee's survival. When the situation is not constructively addressed it endangers the patient's capacity to support himself or herself. Perceptions of hostility that originate from a workplace authority figure tend to induce anxiety. Patient's typically report that they feel singled out or targeted. Narratives often suggest that an employer may be seeking to push out the employee. When fears induced by such situations are associated with the prospect of job termination they can lead to persecutory ideation and anxiety. In such cases, the patient's sense of powerlessness, victimization, and persecution is often striking, as is the patient's apparent inability to extricate from the distressing situation.
The conviction that hostility at work is attributable to a patient's race or gender is common. Employment law may reinforce such perceptions because statutes that seek to address unjust treatment at work pertain to harassment. Hostile conduct is only considered harassment if it is based on race, gender, or other attribute associated with an employee's membership in a statutorily protected class.7
The patient who experiences persecutory anxiety and ideation at work is at high risk for poor clinical and functional outcomes. Although symptoms that accompany persecutory anxiety can be acute, the principal risks are longer term. The patient's efforts to protect herself or himself from the perceived persecutor often undermines the patient's work situation further, and, in so doing, leads to further deterioration in the psychiatric condition. The following processes commonly ensue:
- The patient lodges complaints to protect herself or himself from the perceived malevolent intentions of a supervisor or employer. Such employees typically present with anxiety in the context of anticipated reprisals from the employer. The employer feels under attack from the employee and engages in its own self-protective action. The employer's attempts to protect itself from the employee are interpreted by the employee as additional evidence of persecution (the legal term “retaliation” is often used.) A vicious circle ensues in which employer and employee engage in antagonistic action toward each other. Each party sees itself as defending against the hostile acts of the other and neither party perceives itself as contributing to the conflict. The patient's fear of persecution is exacerbated and transformed into a chronic condition.
- Patients who experience persecutory anxiety at work are inclined to physically separate themselves from the source of perceived persecution. Claims of work incapacity are often advanced as a means of economically facilitating such separation. Although such a “solution” provides limited short-term relief from anxiety through separation from the perceived persecutor, it creates numerous other risks and reality-based problems (such as the prospect of termination and long-term unemployment) that contribute to the development of chronic anxiety and maladjustment.
The Toxic Workplace
The term “toxic workplace” has no standard definition. Researchers have characterized any behavior that is harmful to the organization as toxic.8 Nearly one-fifth of workers in the United States said they faced a hostile or threatening work environment in a 2017 survey conducted by the Rand Corp., Harvard Medical School, and UCLA, and a recent survey of tech workers found that more than one-half of tech workers said they believed they were working in an unhealthy work environment.9,10
When complaints are attributed to a toxic workplace, it is important to recall that the problematic emotions, perceptions, and symptoms captured in the term “toxic” reside in the patient, regardless of the degree to which the psychiatrist is inclined to characterize the workplace as toxic. The term “toxic” is clinically significant because it suggests that the problematic work situation induces intolerably negative emotions and perceptions in the patient. The internal locus of suffering is relevant to emphasize because, although patients may emphasize an external source of distress, the problem that is most proximate to the patient's suffering and most amenable to psychiatric treatment is generally not the workplace itself but rather the patient's reaction to the toxic situation. In most cases, the psychiatrist can exert no direct control over what occurs at the workplace. The psychiatrist's role is critically important, however, and involves supporting the patient as she or he responds to feelings induced by the workplace in a manner that is adaptive (or even creative).
Psychiatric Treatment Objectives Versus Legal Agendas
Patients may seek legal redress as a means of protecting themselves from supervisors or employers that are perceived by the employee as hostile, unjust, or persecutory in intent or behavior. The presence of legal involvement can profoundly impact the patient's response to treatment because objectives that derive from a patient's legal agenda diverge from and are often diametrically opposed to the goals of psychiatric treatment.
When confronted with a patient who presents with a legal agenda the psychiatrist should try to discern the extent to which the prospective patient's legal agenda is compatible with effective treatment. If the psychiatrist determines that the patient's legal agenda is incompatible with treatment goals, the psychiatrist should explain why it is not possible to effectively treat the patient under the circumstances and describe what would need to change in order for effective treatment to occur.
Treatment of Workplace Problems: Principles and Recommendations
Assume an active role. Do not assume that the workplace problem will spontaneously resolve. An active and intensive clinical response is necessary. Explicitly communicate an intention to support the patient's attempts to address the problem. Meet regularly and frequently. See what is possible to learn about the patient's workplace.
Address both internal and external dimensions of the problem. The workplace—just like a marriage—involves two parties. Focus on what the patient, not others, may be able to control or change. Is an attitude, expectation, or behavior in the patient contributing to the workplace problem? Is the patient repeating an adverse early experience at the workplace? Skillfully and compassionately explore such possibilities. Encourage the patient to consider reality-based perspectives from others.
Collaborate with the patient and possibly the employer to problem solve. Brainstorm as part of a comprehensive process to develop, organize, and implement a plan to constructively address the problem. Determine if it is realistic to expect resolution of the problem at the employer. If not, focus on supporting the patient's efforts to decathect the workplace by securing new employment. Communicate that the decision to keep or leave a job is the patient's and that you will support the patient regardless of the choice rendered.
Engage other professionals. The steps necessary to address the situation may be beyond the understanding of psychiatrists. Enlist assistance from other medical professionals (eg, organizational psychiatrist, vocational counselor, job coach, occupational therapist) who can contribute to resolution. Consider obtaining authorization from the patient to elicit perspectives from the workplace.
Avoid separation from the workplace. Supporting absence from work does not address and frequently compounds the workplace problem. Workplace problems and the clinical conditions to which they give rise tend to worsen and grow more complicated when avoided. Focus treatment on precisely identifying and constructively addressing the reality-based problem. If it is not possible to keep the patient at work, actively address the risk of job loss.11
Break the cycle. Patients frequently repeat patterns of early experience at the workplace. Repetitive patterns of attitude and behavior are often maladaptive. Cultivation of insight into the role of the patient's early experience relative to the current workplace problem is most valuable when coupled with the provision of intensive support for the patient's capacity to develop new and more adaptive patterns of response. The presence of legal involvement can profoundly impact the patient's response to treatment because objectives that derive from a patient's legal agenda diverge from and are often diametrically opposed to the goals of psychiatric treatment. (Table 1).
Goals of Treatment Versus Legal Objectives
Assessment and treatment of patients who present with workplace problems entails the active involvement of the treating clinician, as such problems cannot be expected to resolve spontaneously and tend to worsen when clinicians remain passive. The clinician needs to focus attention on the specific event or situation that is distressing to the patient. Terms such as “work stress,” “hostile workplace,” or “toxic workplace” are used by patients to refer to a wide range of experience and tend to “short circuit” adequate assessment and treatment when such terms are used by clinicians as a substitute for thoughtful evaluation. Patients tend to need help in two general areas: symptoms and the symptoms' cause. Although clinicians readily address symptoms that derive from the patient's reaction to a work problem, patients also need help addressing the work problem itself. Failure to actively address the work problem in treatment frequently leads not only to profoundly negative clinical outcomes but also culminates in profoundly negative functional, social, and economic consequences. Conversely, engaging with the patient to actively and adaptively address workplace problems not only improves clinical outcomes but allows patients to establish patterns of response to reality-based demands that will allow them to function and flourish independently on an enduring basis.
- Centers for Disease Control and Prevention. Stress at work. Accessed January 7, 2021. https://www.cdc.gov/niosh/docs/99-101/default.html
- Karasek RA. Job demands, job decision latitude, and mental strain: implications for job redesign. Adm Sci Q. 1979;24(2):285–308. doi:10.2307/2392498 [CrossRef]
- Siegrist J. Adverse health effects of high-effort/low-reward conditionsJ Occup Health Psychol. 1996,1:27:41.
- Barling J, Frone M, Kelloway KE. Handbook of Work Stress. Sage Publications; 2005.
- Waddell G, Burton AK. Is Work Good for Your Health and Well-being?Stationery Office; 2006.
- van der Noordt M, IJzelenberg H, Droomers M, Proper KI. Health effects of employment: a systematic review of prospective studies. Occup Environ Med. 2014;71(10):730–736. doi:10.1136/oemed-2013-101891 [CrossRef] PMID:24556535
- Mathers CD, Schofield DJ. The health consequences of unemployment: the evidence. Med J Aust. 1998;168(4):178–182. doi:10.5694/j.1326-5377.1998.tb126776.x [CrossRef] PMID:9507716
- US Equal Employment Opportunity Commission. Harassment. Accessed January 7, 2021. https://www.eeoc.gov/harassment
- Rand Corporation. American workplace is physically and emotionally taxing; most workers receive support from boss and friends at work. Accessed January 7, 2021. https://www.rand.org/news/press/2017/08/14.html
- Wharton School, University of Pennsylvania. So your workplace is toxic: how can you fix it? Accessed January 7, 2021. https://knowledge.wharton.upenn.edu/article/workplacetoxic-can-fix/
- Kates N, Greiff BS, Hagen DQ. Job loss and employment uncertainty. In: Kahn JP, Langlieb AM, eds. Mental Health and Productivity in the Workplace. Jossey-Bass; 2003:147.
Goals of Treatment Versus Legal Objectives
|Goals of evaluation and treatment
||Opposing legal objectives
|To diminish symptoms and distress associated with an adverse employment situation
||To demonstrate that employment inflicted harm
|To develop or restore the patient's sense that he or she has the authority over his or her mental health
||To demonstrate that the employer was entirely responsible for the employee's injury and suffering
|To foster emotional growth by imparting the sense that the patient's way of framing and interpreting his or her experience as work is as important to his or her mental health as objective occurrences at work
||To demonstrate that the employer's actions caused harm to the employee and that employee was defenseless (ie, had no internal resources that he or she could employ to defend himself or herself against the employer)
|To foster a sense that the patient renders—and is responsible for—choices that can lead to expectable consequences; to develop the patient's sense that he or she can assume some control and responsibility for the situation
||To demonstrate that the employer is responsible for the patient's situation and mental health
|To develop the patient's sense that people and authority figures are rarely “all good” or “all bad”
||To assert that the patient's suffering was inflicted by amalevolent authority figure
|To diminish symptoms and distress and to reverse an impairment that precludes work capacity (in claims of work incapacity)
||To demonstrate illness and impairment are present to an extent that precludes work capacity (in claims of work incapacity)
|To develop insight where the supervisor is described as “hostile;” to cultivate the sense that one's attitudes are behaviors (albeit unwittingly) and may have contributed to the supervisors or employer's response to the patient
||To demonstrate that the patient's treatment at work is attributable to the patient's membership in a legally protected class