Managing Minds at Work: The Occupational Medicine Prescription
What leaders can learn from occupational health physicians to improve well-being and mental health at work and better manage related risks.
Many leaders have been managing employee well-being by looking in the rearview mirror — at someone who is too far away, hard to read, perhaps unwell, or just cautious or nervous. They are watching out for the wrong things (bikes in the photo) and focusing too much on their own reflection, which is the sharpest.
Instead, they should train managers for current and, even more importantly, future human challenges around thinking of workers as minds at work.
Responses are always late and insufficient. Costs increase, performance lags, and researchers and leaders commiserate on workplace challenges, the new generation, and how to support stressed, distracted, bored, agitated, negative, and increasingly angry workers.
The battle is on between TikTok and the Time Clock. Social media is replete with employees and others glorifying “Quiet Quitting” and “Lazy Girl Jobs,” defying bossware, trying to figure out if you’re working at home, and exposing managers who may be toxic or employees just having a bad day. Who is to say whose privacy is violated? Leaders and managers are exhausted — CEO resignations are up 50% over 2022.
So, about 320 years after the publication of Bernardino Ramazzini’s “Dissertation on Workers’ Diseases” (De Morbis Artificum Diatriba), we are still searching. In the 1890s, US companies started to have social secretaries to support workers, later mostly to promote sobriety at work, etc. Since then, the government has regulated (safety, working hours, vacation time, and sick time) and companies have provided (more benefits around sports, fertility, and, recently, mental health, etc).
Yet since Gallup tracking started in 2006, only about 1/3 of workers in the US are engaged, and in Europe, that figure is even lower at 13%. The latest survey shows overall well-being and mental health at a nadir in a polarized and stressed digital world, yet mental health and cognitive well-being are essential to performance.
This suggests that we have been wasting human capital at a phenomenal rate. Workers who are well are less likely to engage in absenteeism and presenteeism (being at work but not well or unable to perform at their best) and fraud (at work nominally but applying for another job or flirting with that idea, being on dating sites, willfully underperforming, etc.). Companies that chose the “hard numbers” to save $2 on toilet paper because they lack the soft skills to address underperformance repeat the trap of managing organizations by spreadsheet rather than eye contact and shared understanding of expectations.
In addressing these issues, companies tend to focus downstream (time off, wellness seminars, massage vouchers), but mental health at work is about work — matching the job demands to the job resources, being sure that individuals have the skills they need, improving the manager/”managee” relationship, and reminding workers that they, too, have agency in the workplaces they create.
In the health context, matching job resources and demands for depressed and anxious workers requires thinking about how their pathology affects their human capital and what demands to make of a set of cognitively depleted workers.
The evidence suggests that addressing the mental health and disengagement crisis among American workers is not in HR, not in apps and predictive analytics, nor slogans, corporate wellness programs, and easy fixes. It is the collaboration of leaders with those who understand humans at work, their brains and bodies — such as occupational medicine clinicians, but also organizational psychiatrists and psychologists, as well as physical medical and rehabilitation physicians and therapists.
We can learn from them at several levels:
First, they understand the role of work as a source of mental health, the severe consequences of separation from work, and the challenges of staying at work in a meaningful way.
Second, they know how to listen and form therapeutic alliances with individuals who are usually stressed and sometimes confused, elusive, or downright deceptive. They know how to leverage this alliance through crises.
They also know the tension of allegiance. Occupational doctors are at the center of the central challenge of business at the moment — sustaining productivity with an increasingly stressed and less resilient and perhaps belligerent workforce. Similarly, managers are told to be closer to their reports and understand and support them while they are being pushed to perform no matter what.
Finally, they are focused on healthcare and workforce trends and can be good planning partners, especially post-Covid.
Below, they share ideas on how to support an individual in need of intervention, invest in preventive care, think of the workers as beings in their social context, and understand the tension between supporting employees and driving business goals.
Supporting a struggling individual
Finding the sweet spot that reinforces health (in particular mental health) and mitigates illness and health decline is the overall goal. Many difficult calls need to be made when evidence trumps dogma, and doctors must know and follow the rules and sometimes enforce policies that are generally out of date or individually inappropriate in a particular context.
The notion of “therapeutic alliance” — the trusted partner relationship between a patient and physician — becomes distorted and confused with too many agendas. Doctors take patient histories, assess patients, formulate plans, and mitigate symptoms with treatments. Managers direct, control, motivate, develop, organize, and plan the work. When the employee is doing well, there is a strong alliance with coworkers, including the manager. When psychiatric or physical symptoms impair an employee’s ability to work, the system gets complicated.
Managers can learn a great deal from how doctors work. And doctors can learn more about what is going on at work to maximize the effectiveness of their diagnoses. For doctors to truly help, they must understand the work and the employee and why there is a crisis now. For managers to truly help, they must be honest and take responsibility for how expectations were missed and what they can do to allow for a leave.
Allowing for a leave for health or grief is relatively easy compared to the hard challenge of “pointing the thumb” at ourselves when performance-related management conversations have been poor. This requires the employee, the manager, and the doctor to understand the crisis as realistically as possible while keeping the North Star of returning to work.
Even for physical injuries, mental health plays a major role in work disability and recovery from work injuries. Anxiety or fear of pain from the injury can lead to workers expanding their mental perception of the impact of the injury. This pain-related fear can lead to avoidance of any activity that might trigger pain, which, in turn, hinders the normal musculoskeletal rehabilitation process. This, in turn, can lead to depressive symptoms. Depressive symptoms can also reduce faith in the healing and rehabilitation process, which reduces active participation, which prolongs the injury and increases the risk of disability. Pre-existing mental health conditions can be exacerbated by disruptions in routine brought on by work injuries and continued absence from the workplace.
An employee’s perception of their workplace dynamics has a bigger influence on whether they’ll return to work after an injury than the severity of the injury. Negotiating a mental health leave can be a fraught process for all parties involved. Existing teams and colleagues often must take over some of the departing employee’s tasks. They might feel concerned for their colleague or shame about not having intervened or supported earlier. But finding the right moment and way to return to work is even more complex. Long absences from work make it even harder:
• The anxiety associated with being accepted back into the group
• The unconscious tendency of the group to exclude members during their absence
• The concern about being able to perform one’s duties at high levels of excellence
• The effect of injury on one’s self-esteem during the period of “doing nothing and not contributing.
Often, employees wish to return before it is medically advisable for them to do so. They might feel that the isolation is not contributing to their convalescence. But returning to work too early can damage the employee and the team. Roughly 20% to 30% of employees who return from work after a mental health leave need more time off. Sometimes, a leave for mental health reasons is a symptom whose root cause is an employee-workplace mismatch, but it can drag out because the mental health condition is still present. It was just never the underlying issue.
A disability settlement is often a path to poverty, and disability attorneys are incentivized to keep you broken longer. Disability attorneys for injured workers are paid based on a fixed percentage of the insurance settlement after direct medical expenses. The longer an employee is out of work, the more missed wages and the higher the attorney’s take from the case. This means that a disability attorney is incentivized not to get their clients better and back to work and normal life as soon as possible but to have them declared temporarily or permanently disabled and receive a lump sum settlement. Attorneys may encourage workers to reject offers of returning to work with restrictions or help them “doctor shop” for the most generous impairment assessments.
All the while, the injury, and the disability become a larger and larger part of the worker’s identity, further gumming up the recovery process. A big payout may seem like hitting the jackpot, but cash payouts are associated with decreased lifetime wealth, competence, and wellness. The path to return to work is obstructed, blocked, or worse, seen as a false choice between “winning a payout” and “losing the fight.” There is also a critical change in identity. The worker sees him or herself as incomplete and begins to speak as a person who is disabled or broken. The labeling becomes a self-fulfilling prophecy. The sooner the worker can start recovering at work, the better their outcomes. The more a workplace can accommodate a worker on restrictions, the more likely they will retain that worker.
Understanding the concept of hardening can help balance individual and organizational needs. Although returning to work too soon is a problem, it is not the whole story. Returning to work too late is even worse. For those who leave for 8 weeks, more than half will not return, and if it is six months or more, the likelihood of returning drops below 15%. We know work is a social determinant of health, so we must ”start the clock” when employees leave work and be cognizant of when we will likely lose them. Too often, too much time passes before the patient, and the doctor realizes how long the patient has not been working and the downstream effects that has. Too often, time away starts to add up for non-medical reasons, like administrative delays or confusion about who “owns” what part of the return-to-work process.
There needs to be a path to return to work that supports adaptation and re-identification as a worker of value. As with a broken leg, a mitral valve repair, a back injury, or recovery from a severe infection, the team must immediately begin thinking about work hardening for workplace lapses and mental health. Doctors, including psychiatrists evaluating for disability, can feel inadequate and even incompetent for at least a half dozen reasons.
Exercising preventive “care”
Sleep is central to total health, and better sleep supports better mental health. Some shiftwork is inevitable, and we should be grateful to those who engage in it to protect, feed, move, and heal us. But it comes at a great cost. One of the attractions of working from home is shorter commutes, which often translates into one more hour of sleep. Getting sleep tests and CPAP machines can be expensive, but the ROI on health and productivity is clear. Many leaders could rise in the ranks because they need less sleep than others. They need to be reminded that they are obviously exceptional and that not everyone in their chain of command has the same capacity.
Nutrition also matters to total health. The greater promise is a fundamental cultural shift that includes an atmosphere conducive to healthy lifestyle choices. There is increasing research on the connection between the gut biome and wellness, and nutrition, performance, and health in general. Yet many workplaces have only vending machines for night workers, for example. Providing better nutritional offerings, considering food as medicine, and paying for nutritional consults are certainly an investment but probably dwarfed by the cost of a company’s medical leaves. Finally, the advent of weight loss drugs like Ozempic could be a lifesaver for many employees, but its pricing is prohibitive for many.
Balance is essential, but it needs to come from the top. Worshipping on the altar of work and balancing work and meaning feels increasingly challenging. There are costs to the choices we make, even to succeed. The best-placed individuals in an organization are leaders, who have, unlike athletes, entertainers, and public figures, been very reluctant to talk about mental health issues among their ranks (even though they are over-represented in leaders and start-up founders). Making it clear to leaders that pretending to be okay does not foster trust nor reduce stigma but rather produces the opposite — this, in turn, can be used as a central point of dialogue for skilled OccMed professionals. Many leaders are so-called Type A personalities (and like many doctors), very high achieving until they or systems push too hard. Doctors are suffering from distress and mental health struggles at very high rates — and have been the canaries in the burnout coal mine. They can help others beware.
Focusing on the person in the social context
With more and more lonely people, single-family households, and religious “nones” in the workplace, responding deftly to the Surgeon General’s “loneliness epidemic” alert can positively impact the enterprise.
Work is a place where we can be seen and feel cared for. To Shakers, work was a form of prayer. The Benedictines’ mantra was “to work and to pray.” Work is fundamental to mental health; it gives us a purpose, a structure, a natural community, and usually a set of people who might notice if we don’t show up. It also gives us a group of people with whom to express common grievances. This does not mean that work should replace all the other sources of joy, structure, purpose, and community in our lives.
However, we can encourage management to think creatively about ways to ensure that their employees can partake in activities outside of the office or actively find ways to get employees to connect.
An important way of connecting at work is through race and ethnicity, sexual orientation, or caregiving ERGs, but we don’t seem to see that many employee groups are created around sources of joy or hobbies.
Remote work calls for more high-touch management.
It is very hard to tell how people are doing when they are remote — in fact, it can be hard for us without comparisons. Managers are deprived of a lot of information — just like therapists. Managers don’t have body language to read, an ability to perceive intoxication (is there alcohol on the breath?), or alarming changes in grooming and affect. Having difficult Zoom conversations such as a separation or layoff can be terrifying for compassionate managers who cannot tell how an employee is feeling nor be allowed to extend a supportive signal through body language. And such interactions can be disastrous for the organization when done by managers who are emotionally tone-deaf.
Occupational medicine practitioners can help the enterprise act on social determinants of health for its employee population.
For example, should the company reconsider its insurance policies, not just insuring by disease but by population? What else can be done that is out of the ordinary? The medical director in the New Amsterdam series queries employees on what would make their lives better. Long and uncertain commutes top the list — adding stress and reducing sleep and time with family, friends, and hobbies. The medical director calculates that renting a bus service for employees is cheaper than lost productivity.
Understanding one’s own role and context
A German proverb sums it up: “Whose bread I eat, his song I sing.” Occupational physicians (and compassionate managers) can get caught between “Hippocrates vs Plutocraties” in the need to reconcile the tension between the Hippocratic oath and fiduciary responsibility.
“Our responsibility to the whole system is to practice good medicine,” a doctor explained, “but there are a lot of judgment calls where the interests of the patient (that may be social or financial rather than purely medical, or in a medical gray zone) are in conflict with the interests of responsible financial stewardship. Our fiduciary responsibilities are actually pretty complex.” Occupational medicine practitioners could be employed directly by the employer (or hired as consultants) or by the union.
For organizational psychiatrists, the organization itself is the client, but patients are individuals, and the psychiatrists will interface with primary care doctors, psychiatrists, psychologists, and occasionally disability experts and labor attorneys.
At this intersection, these physicians can advise managers to change their practices depending on the problem they are asked to address. Collectively, these perspectives help managers construct a new workplace reality for their employees. With more perspectives comes more change.
Considering health-related trends
Occupational health is not just about managing diseases; it is also primarily about prevention and thinking ahead about what kinds of pathologies and behavioral issues employees are likely to present and what kind of health and non-personal changes will have personal impacts on workers. Here are a few questions to prime further reflection:
- How will we understand and evaluate long Covid, for example, or even the impact of normal sources of Covid on human performance?
- What will be the enduring effect of a sense of lingering grief post-Covid, especially among young adults?
- What does it mean that GenZs seem to spend so much time and money on wellness? Is it a reflection of their struggles or need for top performance and perpetual comparison on social media? How will this shape what they expect from companies regarding benefits?
- How should the organization prepare for a working population that has been fundamentally changed by Covid and working from home and in increasingly politically and socially isolated silos? How do we help or at least understand people at work in a very fractured and ideologically diverse world — but also help and understand angry workers?
- How can managers think about getting better at implementing mechanisms to discourage despondent and/or emboldened employees from committing fraud and quickly identifying when people steal, malinger, and otherwise feign symptoms to go on leave?
- Are we really fundamentally different today, and if so, what is the directionality of change? Social media is very different, but are our kids on social media because they are addicted and in pain, and we have not been able to provide secure attachment for them, or are they addicted and in pain because they are on social media? What does this mean for the future of work and health?
- In an era of progressively shortening attention spans and progressively increasing distractions, how do we manage the impact on attention and focus of institutional cultures surrounding email, slack, and other communication? How do we ensure our workplace’s digital expectations foster productivity rather than distraction and addiction?
- What does it mean to support without coddling employees, or in parental speak, tough love vs helicopter or ice breaker parenting? Is there a version of “gentle parenting” as a leadership style that still adequately enforces accountability for outcomes? Employees want to be seen and grow, which requires effort.
A therapeutic alliance to rehabilitate work
In his 1962 book, The Birth and Death of Meaning, social anthropologist Ernest Becker asks, “Where does meaning come from?” The short answer:
being a purposeful actor in a world of shared meaning where we get positive social affirmation. Many of us get this from what we do — not who we are.
We often lose the ability to be purposeful actors in a world of shared meaning because the nature of our work environment makes us either 1) unable to feel that we have a purpose or 2) feel like we have lost agency. In that situation, the ability to contribute something substantial to the world through shared work or shared meaning is lost.
In our distress, we try to find a parallel world of shared meaning online. When we escape our workplaces to scroll, we are there but not there (there); but being (there at work) ‘online’ gives an unstable and constantly changing sense of shared value (unprofitable for the companies we work for and ultimately the company we keep) because that sense of shared value is not shared by all and in many cases is so fragmented that it is a direct cause of chaos and misunderstandings in the workplace.
Occupational physicians can help leaders plan and train managers to help them design workplaces that can provide purpose and meaning and give us agency to pursue meaningful work in ways that do not compromise our health and well-being.
Compiled by Doctors Daven Morisson and Sally Hamm and the wonderful members of the Harvard Occupational & Environmental Medicine Residency program. Thank you to Doctor Michael Stanley for his insights. As always, we welcome feedback and experiences.
