The Psychologically Symptomatic Employee

Not a Risk but Still Troubling:
The Psychologically Symptomatic Employee

Jolee J. Brunton, Ph.D.
Summer 2012 Newsletter

This topic was presented by Dr. Brunton at the June, 2012 meeting
of the Northern California chapter of ATAP

A common experience in our threat assessment work is to determine that an employee ­who has raised concerns about violence is ultimately evaluated as posing a very low or no risk to others or self, but remains a challenging and delicate management issue for employers.  Clinically there are two basic groups in this regard: those with major mental disorders such as schizophrenia, mood disorders, and delusional disorders; and those with personality disorders, or enduring patterns of problematic conduct and distinctly unreasonable demands – the “difficult employee” in extreme.  Not all individuals fall within these categories but many do, or manifest certain features consistent with these classifications.

In contrast to our usual newsletter features that address risk of violence issues per se, in this feature we explore understanding and managing the first group of psychologically symptomatic employees, who may display bizarre, irrational, or aggressive behaviors.  In a future edition we will address the latter group – the personality disorders.  In discussing these behaviors we are not suggesting that workplace-based practitioners should engage in diagnosing employees; but understanding the basis for some problematic behaviors is otherwise useful, as there are common errors and dos and don’ts in managing these scenarios.

Definitions of Some Disorders

First a brief review of some relevant terms and common conditions.  (In addition, please refer to previous related feature articles, posted on the home page of “The Paranoid Employee” and “The Vexatious Litigant,” as well as the WAVR-21 manual.)

Psychosis is a general term used to describe a break with outside reality and adherence to a private, idiosyncratic, and bizarre internal reality. An individual may be acutely psychotic and fairly dysfunctional, or have ongoing psychotic beliefs but otherwise be fairly functional and organized in his day-to-day behavior.  Psychosis can be a manifestation of several mental disorders, including schizophrenia, bipolar disorder, and depression, as well as organic illnesses such as brain tumors.

Schizophrenia is a mental disorder characterized by delusions (fixed and false beliefs), hallucinations (false sensory stimuli that others do not perceive, such as hearing voices), disorganized speech, deterioration in personal hygiene, and isolation.  Schizophrenia is fairly treatable with medication, although it can result in markedly impaired general functioning.

Delusional Disorders are characterized by false, fixed beliefs based on incorrect inferences about external reality despite what virtually everyone else believes.  The beliefs are firmly sustained in spite of obvious proof or evidence to the contrary and involve situations that could occur in real life (such as being followed, poisoned, loved at a distance, or deceived by a spouse or lover).  Functioning may not be markedly impaired, which speaks to the appearance of this disorder in the workplace.  For instance, an individual with a persecutory delusional disorder (the most common sub-type) may come to the attention of HR when he or she requests an investigation into their perception of harassment or malevolent treatment by coworkers.  Delusional disorders do not typically respond to medication, although there is evidence of 50% effectiveness with some of the more recently developed “second generation” anti-psychotic medications.

Mania, usually associated with bipolar disorder, is characterized by very high levels of disruptive energy, strong moods including euphoria versus extreme irritability, rapid speech, impudent actions and poor judgment, decreased need for sleep, very inflated self esteem, and grandiose ideas and schemes.  Individuals experiencing mania can be extremely intrusive, domineering and irrationally demanding, and can become quite angry if thwarted.  Employees with mania have been known to engage in torrents of sending letters, emails, and parcels to senior executives and the media proclaiming their specially felt views or “groundbreaking discoveries.”  With some there is an assault risk if physically confronted.  Mania should be considered a psychiatric emergency and is ultimately a very treatable condition with medication and psychotherapy.  An episode can last several months if untreated.  Not surprisingly, the manic individual’s sense of euphoria and grandiosity makes him or her reluctant to accept treatment.  Manic individuals with bipolar disorder suffer from periods of depression, and can pose a suicide risk.  Bipolar individuals are often very bright and many have had job and career success.  A personal stressor can at times contribute to a manic episode.

Major Depression is marked by continuing and debilitating fatigue, loss of energy, impaired concentration, and loss of interest or pleasure in normal pursuits.  Feelings of worthlessness or guilt contribute to thoughts of suicide.  Anger and chronic irritability is especially evident in men, who may appear more disgruntled than “depressed.”  This is a treatable condition and the degree of depression may vary, but it is clinically distinct from normal experiences of despondent feelings that are commonly experienced as part of life’s ups and downs.  Personality traits such as passive aggressive behavior – indirectly expressing hostile feelings via negative behavior rather than directly addressing them – can also be seen in these cases, as demonstrated in the case presented below.

Case Management Strategies

Employees with the above-described disorders can be very difficult to manage – even when assessed as posing no risk or a very low risk – especially if they view themselves as “normal.”  The problem, as they see it, is with others.  They are usually reluctant to seek treatment and frequently are non-compliant with therapy and medication.  Further complicating case management is the need to be sensitive to privacy, ADA and HIPPA concerns.  Successful case management of these employees requires a coordinated effort among management, HR/ER, and legal representatives.

The course to resolution is to identify and address problematic behavior.

An impediment for employers is misunderstanding HIPPA, privacy and ADA regulations as they apply to mental illness in the workplace.  Supervisors and managers often believe that any discussion of health or psychological issues is strictly taboo, and so they avoid addressing problematic behavior if they feel a mental problem may be involved.  They also may feel like they have failed in their job and should “stay the course” with a particularly troublesome employee; or, that they have the personal skills to lift someone out of what are in fact serious conditions.  In consultation with HR and legal, and screening for risk when prudent, the key is to focus on the behavior rather than on the cause of the behavior.  Rather than ignoring the issue, supervisors are usually best to treat it as misconduct, “disruptive to the workplace”, and follow the usual counseling steps of progressive discipline.  The employer’s respect for and concern that there may be health issues affecting performance and conduct should be communicated, along with a referral to EAP or other appropriate services.  This gives the employee an opportunity to seek evaluation and treatment on their own.

If the employee is unable or unwilling to correct problematic behavior the employer has several options.  One is a mandated fitness for duty evaluation.  Distinct from a risk assessment, fitness for duty evaluations typically assess an employee’s mental (or physical) condition in a comprehensive fashion as it relates to job duties and accommodation.  This option involves complexities that require careful legal review.  (We note that some organizations request a “fitness for duty” exam when what they want, upon clarification, is a risk assessment.)

Other options exist for employees continuing to manifest symptomatic behaviors troublesome for the workplace, as experienced HR managers are fully aware.  Employees may be counseled about expectations and then monitored going forward.  Some situations result in adversarial and legal disputes.  Ultimately the employer must often face the necessity to manage unacceptable behavior to resolution.  The following case study, a composite, demonstrates some of the human issues and one course to resolution.  The scenario is not uncommon to us and demonstrates how complicated a situation can become, including for supervisors and a work group, raising concerns about risk and its management, and the necessity for multi-disciplinary input and continuing collaboration.

Case Study

John, a 25 year-old employee of 8 months, provided internal tech support at a software company.  He had worked as a contractor for six months prior to being hired.  His job skills were exemplary and he quickly became the “go-to guy” in his department.  After a holiday break John’s supervisor, Amy, came to her manager and revealed that for the past six months she had been “trying to help John with his problems.”   John confided in her that he was very depressed and often thought of suicide.  In fact, Amy had spent numerous evenings and weekends on the phone with John talking him through suicidal crises.  Amy explained that since she was much older, John thought of her as a mother figure and felt very comfortable confiding in her.  On several occasions she found John under his desk, crying.  He left work without telling her, texting her hours later that he was “too overwhelmed by his life” to stay.   His coworkers were concerned but felt that talking to John was “too personal”, so they dealt with it by leaving the office when he appeared upset.  Over the break John had another crisis, and Amy, feeling helpless to assist, told him he needed to seek professional care.  Upset by this, John cried and angrily told Amy she was abandoning him.  He came to work that morning, was quiet, and didn’t return after lunch, texting her, “It was too painful” to see her.

Amy’s manager contacted HR, who activated the company’s threat assessment team.  Their outside professional conducted a careful and thorough face-to-face risk assessment of John and concluded he did not pose an imminent risk for suicide, and had no significant indicators as a risk to harm others.  His suicidal threats and extreme emotionality were assessed as primarily manipulative and attention seeking.  However, the situation would require careful monitoring to see it to resolution.

John agreed to voluntarily seek treatment, and took two weeks off, after which he was cleared to return to work.  The employer was very accommodating of his time needed for continuing treatment, but also presented him with a written performance plan addressing the “inappropriate behaviors” of crying, lying under his desk, leaving work without permission, and making threats of suicide (a violation of the company’s workplace violence policy).  At the same time John was to contact HR if he felt his emotional distress was such that he needed to leave work.  As the supervisory relationship between Amy and John had become psychologically complex and muddled from a workplace and management perspective, John was transferred to a new supervisor in a different building.  The new supervisor was apprised of the background of the case so as to avoid repeating the same missteps, and to maintain liaison with HR.

HR and John’s senior manager met with him on his first day back to review expectations.  John accepted and indicated he understood the behavior guidelines for his return to work.  However, hearing he was to be transferred to a new building and a new supervisor he became angry and refused the transfer.  He abruptly left the meeting.  Later he texted to his senior manager, “You won’t have to worry about me anymore.”  The threat assessment team conferred and considered that although it “felt manipulative to us,” they could not discount it as a veiled suicide threat, and decided to call the police.  The police conducted a welfare check at his home and determined John was not a threat to himself.  His behavior was considered misconduct and a careful review of the case was again conducted – from a risk, legal, and ethical perspective.  John was offered the option to resign versus being terminated, which he accepted, and his health benefits were maintained for six months.  The risk assessment professional met with John at the conclusion of his separation meeting to re-assess his status and further counsel him in a respectful manner about his coping strategies, negative and positive.  John also agreed to allow the professional to notify his therapist of the termination.  Finally, believing him to not be a current risk to harm himself, the professional advised the team to continue to monitor for any further information coming from John or anyone else.

These scenarios pose challenging monitoring issues: the goal is for the parties to disengage, for John to move on, which is best for him.  The company’s desired strategy is to “leave well enough alone”, to not have to reengage with John and address whether his communications are manipulative or legitimate cries for help and possibly life threatening.   No conscientious organization wants to ignore a possible risk of suicide communicated by a former employee.  The team and stakeholders must also be aware of and manage their own frustration and anger at John – a very human and at times hidden reaction – and not act inappropriately.  The strategy was to contact the police if John contacted his former supervisor or anyone else.  In fact he did call Amy a week later, with similar statements as before.  The company again contacted the police who intervened.  John was hospitalized involuntarily for a brief period – the hospital apparently taking no chances.  In this case his family was engaged by the hospital, according to the police, leading to John’s finally taking serious advantage of professional care.  He made no further contact with the company.  Other situations are more troublesome and may continue for the employer for various reasons.

As this case illustrates:

  1. An employee does not have to pose a risk to self or others to remain a serious behavioral and management issue;
  2. Risk screening and assessment is still important to consider before “charging ahead” with symptomatic employees;
  3. A myriad of legal and strategic issues demonstrate the need for close multi-disciplinary collaboration;
  4. Post-termination monitoring and liaison with law enforcement and outside agencies may be necessary or beneficial until a matter truly appears resolved.

A final note – The spring and summer of 2012 has been the occasion for several horrific mass murders – including Koikos University in Oakland, California; the Aurora, Colorado theater shooting; and the Oak Creek, Wisconsin Sikh temple shooting.  Media attention is high.  Among other concerns, this reminds us of the possible contribution of a copy cat effect – a shooter being “inspired” to notoriety by a previous perpetrator, and the need to carefully review the risk factors and warning signs in situations of concern.  At the same time, opinions of risk, as in the case presented above, should neither be inflated or minimized, but based on the facts as developed and understood.  The devil is in the details, and “when in doubt, confer.”