Psychotherapy and the work place.

eing psychiatrists is a large part of who we are. We spend as much as a third of our everyday lives in that role. As we sit with psychotherapy patients, how often do we think about their work identity and the many issues that come up as they work? How aware are we of their present level of functioning as workers? Do we consider work functioning as part of our measure of mental health, recalling Freud’s definition of mental health as the capacity to love and to work? Do we think of full-time parenthood as being a challenge to both of those capacities, since the home is also a workplace? During my residency, we had frequent case conferences with Brian Bird, author of Talking with Patients, 1 a fine book that could help to ameliorate our dehumanizing medical scene if reprinted today. Generally, a hospitalized patient would be presented and then interviewed by Dr. Bird. He almost always eased into a friendly discussion about the patient’s work life. The patient would light up, get animated, and discuss themes that were enlightening about both the person and the illness. Numerous fresh observations about psychodynamic issues emerged from these interviews. Similar psychodynamic observations can emerge from reading the vivid self-portrayals of working people in Studs Terkel’s Working. 2 Terkel interviewed dozens of people about their job lives—everyone from industrial designers to prostitutes—and presented their stories in their own words. All the complexities of life emerge in the work environment, and these case studies make worthwhile teaching material. Depression, anxiety disorders, and substance abuse are by far the most common psychiatric disorders that interfere with full productivity in the workplace, and they are a source of major concern to employers. Personality disorders also create a lot of difficulty but are less often identified as mental illnesses. As we talk with patients about their work lives, we see how major psychodynamic processes can contribute to these crippling conditions. How do people come to choose their vocations? Granted, innate abilities play a part, but early life experiences also have a profound effect. Consider the child with several sports injuries who becomes an orthopedic surgeon—or the child who struggles with a very difficult, depressed, or borderline mother who winds up in psychiatry or nursing. Perhaps the boy whose father spent time building things with him will become an architect or builder; or the daughter of a musician will herself become a musician; or the kid whose father gave her wires and doorbells to fool around with at the age of 5 will become a computer scientist or electrical engineer. These early influences on career choice—based on identifications, reaction-formations, coping adaptations, or simply loving support and encouragement—may show up in contentment or, conversely, ambivalence about one’s occupation. Transference of feelings from parents to present-day overseers may foment problems in relationships with supervisors, leading to such situations as the line worker who is at odds with every boss. An art student who couldn’t complete his work assignments discovered in psychotherapy that he was going into the field to fulfill the dreams of a very narcissistic father who saw his son as an extension of himself rather than as a person in his own right. Freed up from internal conflict about this constraint, he could begin to develop his own distinctive style.