Disability Evaluations and Violence Risk: Early Recognition of Mental Health Issues Can Reduce More Concerning Behaviors Later

Philip Saragoza, M.D.
Winter, 2023

An increasingly common issue I see in my consulting is organizations struggling with what to do about an employee who is exhibiting disconcerting or disruptive behavior, but that doesn’t include outright aggression, hostility or threats. These behaviors are often reflective of different types of mental health and/or substance use issues, but not yet identified as such. It is certainly appropriate in such cases to convene the organization’s threat assessment team for an initial screening and review, as well as to seek outside consultation from a mental health professional well versed in threat assessment. The consultant may be able to identify a mental health issue and if it is driving the behaviors of concern. This input then informs management’s next steps.

Frequently, however, these scenarios are left to fester until more concerning issues arise, such as open hostility, impulsivity, and threats. At some point the employer is compelled to act. They may choose to initiate a fitness for duty evaluation; or, a medical leave of absence due to a properly assessed psychiatric disability. They also could decide to just define the matter as a misconduct issue, leading to various consequences, including engaging in what we refer to as disciplinary drift: the tendency for case managers to respond with what they know – discipline and termination – assuming such actions are threat management interventions, which they are not, especially in the short term. Any of these administrative processes, once undertaken, run the risk of further aggravating the situation, increasing the employee’s stress and triggering more serious reactions. Appropriately, a threat assessment protocol should then override all other processes.

This case example demonstrates the above points:

Three months before the company convened a threat assessment of John Doe, a 10-year employee with a good performance history, he began calling off work or repeatedly arriving late. When he was present, John seemed more withdrawn and distracted; he was also falling behind on issuing time-sensitive reports and becoming uncharacteristically unresponsive to emails and work chat messages. When his manager finally addressed these issues with him, John broke down into tears and shared that his wife had asked for a divorce, that he had been living in a hotel and was drinking heavily. The manager offered support and encouraged John to consider EAP. John reported that he was already seeing a counselor and had begun taking antidepressant medication prescribed by his family doctor, but said it “wasn’t helping.” They agreed to weekly check-ins to monitor John’s progress. However, these meetings became increasingly tense over the following month. John grew more defensive about falling short on his metrics, and the manager learned that John was pressuring his supervisor, Jane, to extend deadlines for some deliverables while also falsely blaming two coworkers for not giving him information he needed to finish a particular project. When confronted during a one-on-one, John turned red and shouted at his manager, “So fire me, then! Everybody else is screwing me over; my whole damn life is falling apart. Join the party – I’ll add you and Jane to my list! For now, let’s just call it my ‘guest list’.”

One reason these situations are arising more often is increased awareness of mental health issues in the workplace, and simultaneously the continuing growth of workplace violence prevention programs and threat assessment protocols.

Managers need to better understand these situations in order to make more proactive and strategic decisions about routing cases to disability evaluations, fitness for duty evaluations or threat assessment consultation. They need to be aware of how matters can worsen due to disciplinary drift or the administrative hassles confronting employees of concern. This goal entails clearer understanding of how these scenarios often involve numerous particular risk factors for workplace violence. 

To assist with the specifics in assessing such scenarios, we may refer to the WAVR-21 V3 (Workplace Assessment of Violence Risk), noting certain risk factors and clusters of interacting factors that can develop in disability claims and fitness for duty situations.

  • Item #1: Motives for Violence; Item #2: Homicidal Ideas, Violent Preoccupations or Identifications; and Item #12: Anger Problems: When an employee is put off work due to behavioral changes and/or performance problems, numerous conflicts can arise with the employer that stimulate violent ideas and create grievances that potentially foster motives for violence. Employees who feel unfairly punished over health challenges outside of their full control may feel angry and mistreated by the employer. A common source of grievance involves employee frustration with navigating administrative processes that can be slow, tedious and imprecise. For example, some employees are penalized for failure to obtain medical documentation required for continuation of disability benefits, which may reflect lack of responsiveness by clinicians or, especially in our current healthcare climate, extreme delays in obtaining an initial appointment for mental health treatment. A considerable source of conflict, and emotionally wounding, can be medical opinions that the employee disagrees with or affects his circumstances unfavorably. The employer’s adjudication of these opinions can create highly adversarial dynamics with the employee.
  • Item # 7: Job Problems; and Item #8: Extreme Job Attachment: An employee struggling with functional impairment from mental health issues may exhibit performance problems that they themselves and/or the employer fail to recognize as resulting from a clinical condition. When this phenomenon is misunderstood, employers often pursue a disciplinary pathway with the struggling employee, who may find themselves subject to write-ups, unpaid suspensions or facing termination by the time disability and/or fitness for duty questions are raised. An ongoing condition of considerable severity may then impair the employee’s ability to find or sustain new work, and become a triggering context for an escalation in behaviors of concern. When an employee develops a psychiatric disability or is found unfit for duty, the career disruption can be severe. Psychiatric medications and/or psychotherapy do not often quickly resolve functional impairment, so leaves of absence due to these conditions are frequently substantial in duration. If an individual is highly personally invested in their work, prolonged leaves can create considerable distress. Further, in many fitness for duty scenarios the employee in question wishes to continue working, in part due to their strong job attachment, and objects to concerns raised by others. When such individuals are found unfit for duty, they may experience the opinion as a deeply personal wound. These circumstances can trigger severe reactions up through and including retaliatory hostility, threats and violence. If an employee’s career has required extensive education and professional licensing, for example in the medical professions or public safety, the devastation from being declared unfit for duty may be even more severe as it is ruinous to both one’s professional and personal identity.
  • Item #9: Loss, Personal Stressors and Negative Coping: Whatever the direct impact of an employee’s psychiatric disability, it will either contribute to, or compound their personal stressors and challenges. Financial problems are usually a given, especially in the current era of inflation and escalating cost of living. Family relations may be strained and family members may have to make their own difficult adjustments. The pressures can lead to anxiety, despair, and desperation that increase the risk for self-harm and violence to others.
  • Item #13: Suicidality and/or Depressed Mood; Item #14: Irrationally Suspicious or Bizarre Beliefs; and Item # 15: Substance Abuse and/or Dependence: Psychiatric disability and fitness for duty scenarios can involve mental health struggles co-occurring with relatively severe substance use. This combination can increase the likelihood of suicidality, psychosis and other mental health-related risk factors for violence. For example, I recently consulted on a case concerning an employee who developed paranoia induced by marijuana use. While the drug use alone was impacting the employee’s job performance, they falsely believed that others at work were targeting and harassing them by reporting work errors to management. Their paranoia blossomed into thinking the coworkers wished them physical harm. The employee, in turn, felt depressed and suicidal over being “trapped” in an unsafe situation after they spent weeks searching in vain for another job.
  • Item #19: Situational or Organizational Contributors to Violence: We remind users of the WAVR-21 that this item refers to contextual influences or systemic factors largely beyond the control of the individual of concern. In addressing issues with disabilities, risk factors may include insufficient training of managers and HR professionals in recognizing possible indicators of significant psychiatric problems or psychological distress in the workplace. Situations will invariably worsen over time. Along the way, disciplinary drift can arise. Conversely, managers in various roles may engage in denial and the inappropriate enabling of troubled employees. They may find themselves providing “unofficial accommodations” to at-risk employees through overly permissive responses to behaviors of concern. Coworkers around the individual of concern often develop considerable discomfort, fear, anger, and frustration with management, damaging to workplace morale. Inadequacies in our overworked healthcare system and the tedious process of obtaining medical documentation, mentioned earlier, are themselves systemic hassles and potential risk factors codable on Item 19 of the WAVR-21.

These observations lead to preventative recommendations:

  • Organizations would be wise to provide involved personnel with training on how fitness for duty and psychiatric disability scenarios can generate violence risk behaviors.
  • A well-attuned approach will often entail more proactive measures to address emerging problematic behaviors, and should consider consultation with mental health professionals who are both well versed in threat assessment and familiar with these evaluation formats. Disruptive and disconcerting behaviors can be put into context, including understanding how clinical conditions can manifest in job problems.
  • Consultation can also assist with strategic issues such as 1.) recognizing and overcoming the problems created by information silos (for example, between or among management, HR, leave benefits administrators, and clinicians treating the employee of concern); 2.) ensuring that independent evaluations sufficiently address any concerns for risk of harm to self or others; and 3.) informing managers on the differences among different administrative processes and directing them to appropriate, qualified resources.

By taking these factors into account, organizations may be able to resolve challenges with mental health issues in the workplace before threat assessment becomes necessary, minimizing both extra stress on the involved employee, as well as disruption in the workplace.