Strategies for Coping With OCD in the Workplace
by Donna Gillet, MA,CRC Rehabilitation Specialist and
Michael McKee, Ph.D. Clinical Psychologist
Severe obsessive-compulsive disorder can become a chronic illness for many, requiring active management. But the burden of OCD should not be a barrier to productive work.
As clinicians who provide intensive treatment for persons with severe OCD, we have had the opportunity to follow the progress of individuals through a lengthy treatment process. Treatment typically consists of medication management, exposure and response prevention, and other methods of anxiety treatment. The first steps to employment begin with tapering the intensity of treatment as symptoms and functioning improve. Clients struggle to regain their hope for the future, and begin to think of putting treatment behind them and retuning to work. In collaboration with our clients, we have given much thought to the problem of how to keep treatment going while satisfying the individual's desire to contribute to the working world. Both clients and staff have come to see the value of employment as therapy. The immediate benefit for self-esteem is clear. And the demands and structure of work challenge the individual to function in spite of the barriers palced in their way by OCD..
Ideally, when interventions have been successful, employment concerns may be limited to explaining gaps in work history and behavior at work that appears to be idiosyncratic. Employees may have anxiety about being "found out." The problem of finding time for treatment follow-up visits needs to be solved as well. Issues such as these can be problem-solved in consultation with the therapist or vocational counselor.
Many former clients may be returning to the workforce with symptoms only in partial remission, and have the added burden of learning to do their job in spite of them. They have to work for financial and self-esteem reasons, but may feel so impaired by their symptoms that it's a struggle to do so. People may be strengthened by the knowledge that working not only provides money and pride, but that it may also reduce symptoms.
Pre-employment concerns to be addressed may include reduction of morning rituals like hand washing and door or oven checking. A plan for transportation to work must be made in advance that minimizes the potential for compulsions. This is particularly true for those with obsessive fears of injuring others in auto accidents.
It is hard to find the balance between a desire to pursue a specific profession and a desire to return to a minimum level of functioning. When the obsessions revolve around contamination fears, health-related jobs may be avoided, just as counting compulsions may impede the ability to perform accounting tasks. It is difficult and painful but sometimes necessary to make the decision to abandon a beloved profession because of the potential for serious symptoms to be reactivated.
How, then, can a person with symptoms of OCD manage in the work place? Once on the job, the person must decide how to address their illness. A decision must be made as to whether or not to disclose to others, including supervisors. A prospective employee needs to assess how much extra help, if any, will be needed to learn and perform the job.
One of our clients had been a sought-after administrative assistant in a local industry before her OCD became severe. She clearly had functioned at a high level, but perfectionism made it impossible for her to complete tasks. She read and reread material that she had written to make sure it was right, often failing to submit it to her supervisor. She took a long time to complete tasks, or did not complete them at all.
When her treatment team began to discuss her return to work, our client became extremely anxious. The treatment team recommended that she first seek a volunteer job. By this means, important elements of the employment process could be practiced before she went ahead with the far more anxiety-producing test of landing a paying job. Even so, she avoided calling for interviews, ruminating about how anxious she was and how she would fail in her attempts. She would commit to making a call or going to fill out an application, and turn back. Nervous and anxious, she was convinced that she would never get the job. She was unable to take the first steps for a month, even with frequent reminders from the treatment team. The team then set a deadline of a month for completing the task of getting a volunteer job. Working with the client, they made a hierarchy detailing the steps involved in the job-seeking process and rating the capacity of each step to stimulate anxiety. The activity producing the lowest level of anxiety was thinking about making a phone call to set an appointment for a job interview. The next level involved exposure to fears associated with proceeding to the interview. Finally, the highest-rated level of the hierarchy was starting the job.
The team developed exposures focusing on her anxiety about working. Twice a day, she made phone calls that were designed to reduce her anxiety about the phone calls by gaining experience with them. Potential dialogues for the call were written, including questions to ask. The team's vocational counselor modeled how to make calls and how to carry out role plays of the interactions. Initially, our client could not make the calls on her own, but did them with her counselor. The firs actual call was made, but afterward, she ruminated at length about typically obsessive concerns and sought reassurance. She doubted whether or not she had actually made the call, given the correct information, included all relevant information, pronounced everything correctly, and sounded mature or nervous. The team empathized with her pain and discomfort, but no reassurance was given other than a reminder to use anxiety-reduction skills she had been taught. She acquired the necessary applications and filled them out, but checking for perfection was prevented (had to write in pen, not check for spelling, etc.). She received coaching to prevent long stays in the ladies room ritualizing before her interview. Such a favorable impression was made that her employer saw no need to check her references. The required physical exam caused extreme anxiety resulting from fears of exposure in a hospital gown. She overcame these fears and started the job.
Making a the decision to reveal the nature of the disorder to a potential or current employer may help relieve anxiety. This also enables the person to take advantage of the Americans With Disabilities Act (ADA), which states simply that the employer cannot discriminate against a qualified person with a disability. The ADA allows for the assumption that disabilities include illnesses that are resistant to cure and pose a lifelong management problem. Reasonable accommodations must be made as needed. These would include time off fro M.D. appointments, or adjusted work hours to accommodate special problems. Examples might include allowing time for persistent morning rituals or an altered schedule due to sedation from medication.
A job coach can be arranged through the individuals's state vocational rehabilitation office. The job coach is able to assist the person during their adjustment to the workplace by intervening with the employer or human resources office. The disclosure of the worker's illness provides an opportunity to educate job supervisors about disability. Services provided by the job coach may include educating employers or intervening with an on-site work-related exposure and response prevention exercise. The coach makes an assessment of the workplace and identifies areas where the employee may become "stuck," in an obsessive-compulsive cycle. Job coaches are also available by phone for support. The job coach alternative is particularly helpful in the context of a good, established relationship between employer and employee, and the person is retuning to work following treatment.
With sufficient support from a job coach or therapist, work may provide a distraction from obsessions and compulsions by requiring the individual to focus their attention on something else. Job tasks may not allow for compulsions. The workplace may have an OCD-unfriendly atmosphere. For example, bathroom keys may interrupt the ease with which someone may have access to un-timed hand washing. Employers and co-workers do not have the time and often do not have the patients to be "enablers," of obsessions and compulsions. Seeking reassurance may be embarrassing, and thus aversive. The increases in self-esteem and stress-reducing aspects of earning a wage enhance the impact of treatment. Furthermore, people often need the health benefits provided by companies for their own treatment. For an individual who has decided not to reveal their illness, steps can be taken to insure work adjustment. It is important in the latter case that the person choose the most appropriate job, be suited for the work, and have achieved some relief from symptoms and stabilization on medication.
A teacher who hoarded schoolroom material comes to mind. Though a highly gifted, well-respected teacher, she was unable to discard any written work her students produced. (It's no wonder they loved her!). She filled her classroom with papers, books, and projects. This posed a fire hazard, caused students to become disorganized, and embarrassed the principal. With the support of her therapist, this teacher was able to systematically discard useless items and allow the cleaning of the room during vacation. She maintained her standing at the school through ongoing management of her OCD.