Spring 1995, Vol. 4, No. 1

Psychiatry's role in changing health care and the workplace: January 1995 Meeting

By Brian Grant, M.D.

Jeffrey P. Kahn, M.D., (New York, NY) opened the meeting by addressing psychiatry's role in these changing times in health care and the workplace. The traditional orientation of psychiatry is toward the individual; those involved in organizations and occupations add attention to systems. Businesses tend to focus on clear individual or organizational problems that take on sufficient importance to management. Business and psychiatry need to learn about and from each other, with perhaps the greatest need for us to learn from business, since we are trying to sell our services and we need to truly understand the needs and perspectives of our common clients. Particular areas requiring attention include the needs of organizational cultures, many of which are experiencing change and dysfunction; coaching of executives, both those in distress as well as those wishing to optimize their effectiveness; addressing issues of disability; and grappling effectively in the heady environment of health care and political change.

Joseph M. Canella, M.D. spoke first. Dr. Canella is the Corporate Medical Director of Mobil Corporation and Past President of ACOEM (American College of Occupational and Environmental Medicine). He gave an overview of occupational medicine, and the reciprocity of needs and interests between it and psychiatry. Occupational physicians face many challenges in helping their companies where there is overlap. These include dealing with distressed employees, workplace violence, substance use and abuse. The challenges inherent in working for positive health changes and behaviors from the inside of organizations were raised, and the need for patience in bureaucracy is evident.

Len T. Sperry, M.D., Ph.D., and Director of the Division of Organizational Psychiatry at the Medical College of Wisconsin-addressed the challenges of understanding and diagnosing organizations. Several methods have been used to accomplish this task. He suggested that there are five main components of a diagnosis: situation and stressors; the stage of the organization; the subsystems; synchronism/fit; and the organizational diagnostic impression. These are largely parallel to components of individual diagnoses: chief complaint and history, past history, family and social history, mental status exam, and diagnostic impression. The five subsystems of an organization include: strategy, structure, culture, leader and follower. These are all superimposed on and concurrently help create and change a particular organizational environment. Using Microsoft as an example, he noted the need for a certain match between individuals and particular organizations. As described in a recent article, this corporation requires very bright people given to very long hours, high energy, and single-mindedness.

He described the life-cycle of many organizations as: birth, expansion, professionalization, consolidation, early bureaucratization, and late bureaucratization. As the organization ages, there is a tendency to lose the drive and vision that the organization had at creation. At this point organizations sometimes need assistance to manage transitions between phases which to a large degree may be natural and unavoidable.

Elmore F. Rigamer, M.D., Medical Director, U.S. Department of State, presented Managing Change in Organizations. He notes that our times present major changes for physicians, who as a group are having to deal with their collective loss of autonomy. Change in organizations are a given, and occur regularly to allow for survival. The primary unit in any organization is the individual. The proper climate for change includes a high need for change, an openness to change, a commitment to change, a belief that change is possible, and having some control over the change process. Those who most welcome change are at the top and among the new members. Those in the middle who are entrenched in the present are the least amenable to change. Changes can be rational, based on re-education, or coerced. Pitfalls for change result in unplanned or unforeseen changes, rationalistic bias, technocratic problems, and resistance. Consultants to management in dealing with change should help these managers understand the many responses to change, so that these can be addressed in the process, hopefully leading to a better outcome.

He aptly noted that the common impetus for change is a desire to avoid economic disaster, or a wish to improve financial performance. Change can and does threaten individuals' roles, status or working conditions to the point of job or income loss. This may be seen as a violation of a psychological contract, regardless of what might be real, or legal. A broken psychological contract or employee who is dysfunctional for other reasons may result in the three A's: apathy, aggression and absence.

In trying to renegotiate a new psychological contract one must ask: how to trust a changing organization; how to commit when one may be let go; how to be more capable at the time one leaves; and how to develop adaptive competencies. Successful managers of change achieve gratification from seeing the organization change, accept being criticized and disliked and understand psychological projections. They also balance taking action and listening, tolerate ambiguity, and give people time to grieve and mourn loss. Those managing change are most successful when they can make opportunities for people to realize their ambition and express their values, use continuous truth because organizations are paranoid, involve others, state the unspoken changes and expectations, and renegotiate the psychological contract.

Boris Astrachan, M.D., Professor and Head of the Department of Psychiatry at the University of Illinois at Chicago; and his son, Joseph H. Astrachan, Ph.D., Associate Professor and Associate Director of the Family Enterprise Center at the Coles School of Business, presented Consulting to the Family Owned Business. There are over 12 million family businesses in the U.S. They represent 50% of the GNP. There are conflicting interests and needs between those of family members and their relationships, and a business they may be associated with.

The consulting psychiatrist should think of the business as the entity being treated, with the individuals viewed as its components. Many case examples drawn from the audience were used to illustrate the conflicts that present in the family business, as well as the consultant's challenge of deciding when and where to jump in and assist. Few family businesses survive from one generation to the next. This is due in part to the tax structure which makes inheritance of assets very difficult. Businesses that do survive across generations have several common attributes: a good strategic plan, a healthy board of directors, and frequent family meetings where expectations are aligned. Differences between the training and working style of the psychiatrist were contrasted with the style and concerns of a business manager or owner.

Harold M. Visotsky, M.D., Professor of Psychiatry at Northwestern University Medical School, described the growth of managed care and the impact of this phenomenon on medical practice and health care economics. The impact of this system is profound, with increased market penetration. Its appeal derives from promises of reducing the cost of medical care for those who pay for it. Price, volume and intensity of services are all affected, presumably downward. There are associated shifts from inpatient to outpatient care, shift of financial risk to practitioners and patients, and a shifting of patients to physicians who charge less and consume less resources. Concerns arise when costs are shifted to the beneficiary or when quality of care is diminished.

To illustrate this situation, he used IBM's efforts during the mid-1980s to control rapidly expanding mental health costs while maintaining their employee-oriented corporate culture. IBM emphasized accessibility, flexibility and quality. Indicators of quality included provider characteristics, appropriate procedures, continuity of care, re-admission rate and absence of unusual practice patterns. Vendors were required to have a demonstrated quality program. The program contributed to considerable reduction in costs from the inception in 1989 to the present.

There are 36 million uninsured Americans, and 15-30 million who are underinsured. Suggested solutions include national health reform, with the provision of mental health care within any reform. Dr. Visotksy described several transforming economic factors, including increased competition. Information technologies are also an important component of the future of health care. These tools will allow outcome measurement, expert systems, large relational databases, and electronic claims processing. Multiple challenges exist to establishing proof of value. Multiple emerging trends in behavioral health and medicine in general were described.

Dale Masi, D.S.W., of the University of Maryland, and Stephen H. Heidel, M.D., University of California San Diego, addressed Violence in the Workplace: Clinical and Policy Issues. Dr. Masi gave an overview of the problem, deriving from her work in EAPs and with the Postal Service. That department created a violence prevention committee which has members from the highest levels of labor and management. Prevention of violence via policy, prevention, and training are critical, along with post-violence intervention. Concern about violence is extending to addressing threats, stalking, and sexual harassment. Occupations at greatest risk for violence include sales and services. Perpetrators are employees, customers, relatives, former employees, and other non-employees.

Factors affecting violence include economic issues--downsizing, discipline, refused workers' compensation claims, and denied promotion. Alcohol and illegal drugs are often associated with workplace violence. The problem of not taking threats seriously was described, with an example of overt prior threats, with victims being named, but the warnings largely ignored, or at least not taken seriously.

Threat monitoring is important, including response, evaluation, and intervention procedures. Pre-employment screening and psychological and criminal background checks are being used in some settings. She stressed that there is a potentially wide gap between a workplace violence policy and response to such violence. One needs a reporting policy, and a designated response team that works under established guidelines. The team should be multi-disciplinary, involving management, labor, medical and legal staff contributions. A workplace policy to deal with violence was recommended, including strong language and explicit follow-through. The importance of knowing which employees are being stalked by outsiders or who have restraining orders against such people was stressed, as this can often lead to the perpetrators entering the workplace in search of their victim.

Dr. Heidel presented the warning signs of workplace violence. These include threatening comments, threats of violence or murder, reference to previous incidents of murder, reference to weapons, stalking, paranoia, anger and litigiousness. Among the mentally ill, violence is most prevalent in the face of drug abuse, with declining prevalence in depression, schizophrenia and other disorders. However, his data did not suggest that the mentally ill, with the exception of substance abusers, are a particularly violent group. The role of the psychiatrist can include serving as consultant to the employer, as therapist for victim or as evaluator and therapist for the accused. Factors to consider in evaluating future risk of violence include: past violence, patterns of violence, drug and alcohol use, mental illness, ownership of weapons, criminal and court records, institutional history, military history, work history, and sexual aggression history.

Robert A. Haines, M.D., Medical Director and Second Vice President, UNUM Life Insurance Co. of America, presented Disability in the Private Sector. The differences between various disability programs was described. These systems include the private disability carriers, Social Security Disability, and Workers' Compensation Disability. In each sector there are differing levels of proof required, with the lowest threshold in the private disability sector. The private policies are further divided between group or employer-based and individual policies. The trend in disability is an increase in claims and losses, and less recovery. New claims for neware on the increase. Those involved in underwriting such claims are suffering losses and being forced to try new tactics, including leaving the business.

Individual claims among higher income individuals are a leading area of change. Claims for disorders such as chronic fatigue, carpal tunnel, and psychiatric disorders are on the increase. Many of the purported physical claims actually may be somatic manifestation of psychiatric conditions. Psychiatric claims as an absolute number are on the increase; depressive and anxiety disorders are the most prevalent. The duration of disability in all disorders is on the increase, but psychiatric claims lead the way. The longer the claim, the more likely it is that this claim will be psychiatric in nature. Unfortunately, many treatable psychiatric disorders, presenting in the disability context, do not seem to respond to the expected course of duration and/or treatment.

Previously low claim filing professions were sought out for policies and were sold such policies at a competitive rates. These professions, including medicine, law and accounting, are now filing costly claims. Reasons for this include the changing economy, professional changes, and a changing work ethic and expectations among many. The concept of the "unacceptable disability state," often emotional, was described. This state can become acceptable when the underlying issues are converted to a physical syndrome, which in turn is not likely to respond to normal medical intervention due to the psychological origins.

The industry is responding to these changes in a variety of ways. This includes more active claims management during claims processing; eliminating or reducing own-occupation restriction; more flexible premiums; incentives for rehabilitation; closer underwriting scrutiny; health promotion efforts including stress management; and ergonomic and psychological workplace re-engineering. Disability companies are hiring many more medically-trained staff as well. The challenge of obtaining high-quality functional assessments from treating physicians was raised.

Finally, Henry M. Evans, M.D. and Mark Levey, M.D., of Analytic Consultants, Ltd., (Chicago, IL) presented a case study involving an individual employed in a large organization. This individual manifested repetitive work dysfunction. The detailed consultation was described which involved both individual and group intervention. The subject of the organization, a manager, used many psychological defenses to address her discomfort in the workplace, including splitting and projection. The consultants had many challenges, including forming an alliance with the subject, while serving the client's interests as well.

 
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