Mental Illness at Work

 

“Neurotics build castles in the sky, psychotics live in them.” My professor for a course called abnormal psychology made that statement as a way of remembering the difference between these two classes of mental illness. While the thinking around many aspects of mental illness has shifted and continues to evolve since that statement was made, that stark difference between people with neurosis who fantasize, sometimes as an escape from reality, and psychotics who can’t tell the difference between fantasy and reality remains.

While people talk about mental illness as some sort of all-encompassing disease the term mental illness is not at all precise, nor is it very useful. From the Mayo Clinic: “Mental illness refers to a wide range of mental health conditions — disorders that affect your mood, thinking and behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors. Many people have mental health concerns from time to time (emphasis added). But a mental health concern becomes a mental illness when ongoing signs and symptoms cause frequent stress and affect your ability to function (emphasis added).”

Very often when someone is labeled mentally ill, that label and the stigma it brings sticks for life. Once mentally ill, always mentally ill. Mental illness, it was thought, unlike a cold, infection, or broken bone, was not something you got over or recovered from. And mental illness is also associated in people’s minds with violence or unpredictability making people steer clear of those with the label.

The stigma of mental illness is nothing new and historically the term “insane” has been used as a weapon or as justification for brutality and slavery. In the early 1800’s entire populations of African Americans in many southern towns were classified as “insane” by the census, a classification which had nothing to do with actual mental illness. And absurdly one physician created a mental illness called drapetomania, a label given to slaves whose illness was trying to escape to freedom. According to Samuel Cartwright the physician who came up with this illness the cure was “whipping the devil out of them” and the removal of both large toes to make running impossible. This makes it very clear who the insane person was, and it was not the slaves.

Recent research implies that some mental illnesses are transient and over time people can overcome them. And certainly some of the medications now available as well as other improved treatments helps people cope better with the mental illnesses they do have.

Today, as we operate as more of a service economy, there is less tolerance for mental illness at work. In service oriented economies there is more direct interaction between individuals and if mental illness is present it is more obvious. A person laboring away on a farm could be a little “off” and no one might notice, or the illness might have little impact on their job performance. But a person with a mental illness who is cleaning your teeth or serving up your favorite coffee brew will much more noticeable.

The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) is the latest attempt by the American Psychiatric Association to classify the various mental illness to which a human can be subject. Prior versions of DSM classified mental illness into 5 categories or Axis as they were called. This new version does away with that classification as it was deemed too categorical and that many mental illnesses actually cut across these artificial boundaries. It is a big, thick book full of small print. But just because a book is big and thick doesn’t mean that it has all the answers and interrater reliability between two diagnosticians utilizing the DSM to classify a mental illness is relatively low.

One distinction I want to draw is the difference between mental illnesses and human bias and judgement errors and how math enters into the picture. We all fall victim to bias and judgement errors. One bias for instance is to give additional credence to evidence that supports your pre-existing point of view and to dismiss information that contradicts your closely held beliefs. But at some point when faced with incontrovertible proof that a closely held belief is wrong, refusing to modify your belief crosses the line from “normal” human bias to mental illness. Exactly when this occurs is defined by society and not a medical reference book or textbook. This point also shows the connection between mental illness and math, or statistics. Normal can be defined as being within 1 or 2 standard deviations from the mean on a trait. So there is a “normal’ level of fastidiousness which can cover quite a range. But if you are out a few standard deviations from the mean in either direction you would have people who would have difficulty functioning within society, for instance extreme hoarders or extreme cleanliness obsessives/compulsives, who meet the definition of mental illness by their behavior.

What is the mean score for our various human traits and characteristics? We decide that as a society. If we were all extreme obsessive/compulsives that would be the mean and would be considered normal. I am reminded of a Twilight Zone episode, #42 – “The Eye of the Beholder”, where a woman undergoes repeated plastic surgeries to her face because she was deemed hideous (of course by society). When the final bandages come off and she looks in a mirror she screams as her hideousness remains. As the camera pans out we see that by our definitions she is quite beautiful, but everyone else attending to her in the hospital room is quite hideous. Society determined the definition of beauty. And if our society becomes fractured with diametrically opposed groups, then the definition and determination of normal in each of those sub-groups can become different. Is racism, or tribalism normal or abnormal? Is xenophobia, misogyny, or a belief in some higher power directing your day-to-day actions normal or abnormal? The answer is not in a medical textbook but rather in what society defines as normal and what it defines as abnormal.

One newly emerging way of looking at mental illness is through the lens of Bayesian statistics. The Bayesian approach is one of probability. It assumes that the brain is always assigning probabilities as it is processing data based on our internal heuristics or rules-of-thumb. How likely is a certain outcome or a “thing” given past experience, assumptions I have or new incoming information? It has been shown that people with at least certain kinds of mental illness struggle to assign the correct likelihood probabilities. In schizophrenia for instance it has been shown that people have trouble connecting new incoming information to their expectations. (And hence are less susceptible to optical illusions).  And autistics don’t update their expectations regarding how the world operates, and use only incoming information rather than expectations to navigate the world. This was demonstrated in one experiment when those with autism performed just as well in remembering nonsense syllables as strings that formed complete sentences. (Science News, May 13, 2016).

While it is of course not possible to cover even a smidgen of the mental illnesses that people experience in a blog post, or the ones that occur in a work environment, there are some important points to be made.

First, some information from Harvard Medical School:

• “Low treatment rates imperil workers’ careers and companies’ productivity.
• Mental health problems affect many employees — a fact that is usually overlooked because these disorders tend to be hidden at work. Researchers analyzing results from the U.S. National Comorbidity Survey, a nationally representative study of Americans ages 15 to 54, reported that 18% of those who were employed said they experienced symptoms of a mental health disorder in the previous month.
• But the stigma attached to having a psychiatric disorder is such that employees may be reluctant to seek treatment — especially in the current economic climate — out of fear that they might jeopardize their jobs. At the same time, managers may want to help but aren’t sure how to do so. And clinicians may find themselves in unfamiliar territory, simultaneously trying to treat a patient while providing advice about dealing with the illness at work.
• As a result, mental health disorders often go unrecognized and untreated — not only damaging an individual’s health and career, but also reducing productivity at work. Adequate treatment, on the other hand, can alleviate symptoms for the employee and improve job performance. But accomplishing these aims requires a shift in attitudes about the nature of mental disorders and the recognition that such a worthwhile achievement takes effort and time.”

The most common mental illnesses manifesting themselves in the workplace include:

• Depression (estimated at 6% of the workforce at any given time)
  • Some signs: Increased irritability, much lower levels of productivity
• Anxiety (estimated at 6% of workforce at some point in career)
  • Some signs: Often require constant reassurance regarding performance and are commonly undiagnosed
• Bipolar disorder (1% of the workforce)
  • Sime signs: While the person may accomplish a lot in the manic phase, during the depressive phase will have lower productivity
• ADHD (3.5% of the adult workforce – while often thought of as a child’s issue it equally affects adults)
  • Some signs: Disorganization, failure to meet deadlines, problems with instructions and work prioritization, argumentative

While these mood disorders may be the most common mental illnesses in a large workforce, special mention needs to be made of other personality disorders, such as borderline personalities, while potentially not as widespread, but that have the ability to inflict high levels of damage to other people and to organizations, especially when they are present in management.

The Dark Triad. This is a combination of traits that often show comorbidity that is they tend to travel together and include psychopathology, narcissism, and Machiavellianism. These traits are fundamentally malevolent in nature. In other words people who express these traits are likely to cause harm to others. There is a well-researched, extensive and heavily referenced article on the Dark Triad in Wikipedia. Here is a very brief definition of each of these characteristics from that article:

“Psychopathy – Considered the most malevolent of the dark triad, individuals who score high on psychopathy show low levels of empathy combined with high levels of impulsivity and thrill-seeking. The similarity between psychopathy and antisocial personality disorder have been noted by some researchers. Psychopathy has been found to correlate with all of the Big Five personality factors…

Narcissism – Individuals who score high on narcissism display grandiosity, entitlement, dominance, and superiority… Narcissism has also been found to have a significant correlation with psychopathy.

Machiavellianism – Named after the philosophy of Niccolò Machiavelli, people who score high on this trait are cynical (in an amoral self-interest sense, not in a doubtful or skeptical sense), unprincipled, believe in interpersonal manipulation as the key for life success, and behave accordingly.”

While it can take extensive observations and assessment to determine if someone has one of these personality disorders some of the more common traits of those with these pathological issues are:

• Exploitive, opportunistic, can be successful in life, but often that success is short-lived
• They can be charismatic and persuasive
• Pay a lot of attention to their appearance, with a desire to look attractive
• Aggression, racism, bullying is often evident
• Assertiveness, dominance, self-importance
• Limited self-control, higher risk taking, short-duration marriages and multiple spouses or multiple affairs
• Low scores on honesty and humility with high scores on greediness
• Psychopaths are notorious for a lack of emotion and empathy, the ability to understand right from wrong or to understand the emotions that someone else is feeling
• And, those with these traits generally lack self-awareness – the ability to see how their behavior is perceived by others.

One study found that narcissists, people with an “overly grand view of themselves” found it difficult to impossible to apologize for any of their actions or words (Scientific American, Nov. 2011). Or as Elton John composed, “Sorry seems to be the hardest word” – especially for narcissists. Now, just because someone has a tendency to be concerned about their appearance or seems to be opportunistic does not mean that they are afflicted with the Dark Triad or a component, but a consistent pattern of behavior over time, while exhibiting many of these characteristics in combination, would be an indication that the person needs psychological care.

How does the Dark Triad affect people at work? In “Snakes in Suits”, Robert Hare, a researcher in the field of criminal psychology and developer of the Hare Psychopathy Checklist, indicates that there seems to be a higher proportion of psychopaths in management than exists in the general population. While the incidence rate is still very low (around 1%), management positions seem to fulfill at least some of the needs of a psychopath. And interesting, while many psychopaths function somewhat normally in society, about 25% of the males in federal prisons are estimated to be psychopaths.

Hare, in an article in Scientific American describes psychopaths as: “Superficially charming, psychopaths tend to make a good first impression on others and often strike observers as remarkably normal. Yet they are self-centered, dishonest and undependable, and at times they engage in irresponsible behavior for no apparent reason other than the sheer fun of it. Largely devoid of guilt, empathy and love, they have casual and callous interpersonal and romantic relationships. Psychopaths routinely offer excuses for their reckless and often outrageous actions, placing blame on others instead. They rarely learn from their mistakes or benefit from negative feedback, and they have difficulty inhibiting their impulses.”

Is there a cure or treatment for psychopaths? Many mental health experts would say no. The general feeling is that people who are psychopaths “can be treated or managed but not cured” (Dr. Nigel Blackwood, Psychiatrist at King’s College London).

So where does all this lead us? It has not been possible to cover even a fraction of the mental health issues that might show up in the workplace in this short piece. But the important point is that they are there, present in the organization. And more importantly, many people who suffer from these issues can benefit from an enlightened approach to mental health treatment. The benefits that accrue will benefit not only the individuals within the organization but the organization itself.