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Mr. R, age 45, developed severe depression 4 years ago after his mother died. He had suffered previous major depressive episodes and was treated effiectively with fluoxetine for 15 years. This time he took a medical leave from his job as an engineer and received disability. After numerous medication trials and psychotherapy, his symptoms improved.
Mr. R is ready to think about returning to work, but he will need to refresh his skills and consider starting at a lower level than before. Headlines remind him daily about increasing unemployment and decreasing prospects of finding a job.
During his illness, Mr. R and his family depleted their savings and incurred substantial debt. His wife has not worked outside the home while caring for him and their 4 children. She is increasingly anxious and depressed. The couple argue often about money but share a common hope: that Mr. R will find a job in the next few months.
How is the recession affecting psychiatric practice? Christopher Palmer, MD, the psychiatrist who treated Mr. R, says, “We in psychiatry and psychology are well-equipped to help people who are unemployed, underemployed, and financially ruined. We do it all the time. The difference in this economy is that we’re going to be seeing a lot more people.”
Psychiatrists who read Current Psychiatry and were polled in March 2009 agree. Most were seeing an increase in patients experiencing psychological stress because of the recession, which by then had persisted 16 months. “All my patients are reporting increased stress as a result of the economic situation. The more successful my patient is, the more distress they seem to be feeling,” says a psychiatrist from Melbourne, FL.
This article on the psychological effects of the recession discusses the results of an online survey of Current Psychiatry readers, with analysis and recommendations from an interview with Dr. Palmer and colleagues Jeffrey Rediger, MD, MDiv, and Carol Kauffman, PhD, ABPP, PCC, from McLean Hospital, Belmont, MA, and the department of psychiatry, Harvard Medical School.
 | Carol Kauffman, PhD, ABPP, PCC, is director of the Institute of Coaching, McLean Hospital, Belmont, MA, and assistant clinical professor, department of psychiatry, Harvard Medical School. A veteran psychologist, she maintains an executive coaching practice in the United States and Europe. |
 | Christopher Palmer, MD, is medical director of continuing medical education, McLean Hospital. His outpatient practice focuses on substance abuse, sleep disorders, mood and anxiety disorders, psychotic disorders, and individual and family psychotherapy. |
 | Jeffrey Rediger, MD, MDiv, is medical director, adult psychiatric program, McLean Hospital SouthEast. He also is an instructor, department of psychiatry, Harvard Medical School and has a master of divinity degree. He publishes in the fields of medicine, psychiatry, and spirituality. |
Survey results
Methods. Using an e-mail questionnaire (Box), Current Psychiatry contacted 45 Reader Reactors—clinical psychiatrists who provide feedback to our editorial staff about topics being considered for publication. The 15 readers who responded practice psychiatry in the Northeast (New York and New Jersey), the South (Florida and Georgia), the West (California, Washington, and Oregon), and the Midwest (Pennsylvania, Illinois, and Missouri).
Nine of 11 readers who answered all questions in the survey said they have seen an increase in patients describing psychological reactions to the effects of the economic recession. A reader from Red Bank, NJ, reported, “I see a pattern of issues: ‘I was just laid off.’ ‘I am afraid I will be laid off.’ ‘Others have been laid off, and I’m overwhelmed with their work as well as my own.’ ‘I was planning to retire in a couple years, but now I will have to work longer than I was planning.’” Two psychiatrists reported no increase in patients with economic worries—in a prison and a state hospital with geriatric patients with cognitive impairment.
Timeline. For some survey respondents, the increase in patients with economy-related problems emerged in mid-to-late 2008—particularly in October—but others report seeing symptoms sooner. A reader from Harrisburg, PA, said, “I’ve noticed this increase for the past 4 to 5 months (dramatic), but there has been a general increase for 1 to 2 years.”
These observations mirror the rise in unemployment in the 16 months since the recession officially began in December 2007. In March 2009, the U.S. Bureau of Labor Statistics reported a national unemployment rate of 8.5% (13.2 million unemployed), which was a 25-year high. That same month, employers eliminated 663,000 jobs, for a total of 5.1 million layoffs since the recession began. Two-thirds of all layoffs occurred between November 2008 and March 2009.1
Symptoms. Depression, anxiety, or both are the most common symptoms associated with patients’ financial difficulties, survey respondents say. Other symptoms include insomnia, hopelessness, helplessness, loss of trust, anger, bitterness, resentment, suicidal ideation or attempts, numbness, desires for retaliation, increased alcohol/drug use, fear of being unable to afford medications or of losing a job, paranoia, and marital problems. Readers’ comments include:
- Augusta, GA: “Patients with depression and anxiety symptoms have increased in the emergency department.”
- Portland, OR: “I see people giving up and planning to live on unemployment as long as possible.”
- Fresno, CA: “Some married people are wishing they were single and did not have children.”
- Red Bank, NJ: “Some who have adapted are doing well, often with a low-overhead business, meeting a specialty need, or entering into a business that meets an emerging need.”
Who is affected? Overall, readers estimated that 70% to 100% of affected patients had pre-existing psychiatric disorders, whereas 20% to 30% had not sought treatment in the past. “Individuals with preexisting problems are having considerable difficulty,” one psychiatrist said.
Similarly, Dr. Jeffrey Rediger, medical director of the adult psychiatric inpatient service at McLean SouthEast, Brockton, MA, told Current Psychiatry, “For some people who were functioning marginally before the recession, this stress has pushed them over the edge. But we’re also seeing a number of young to middle-aged adults who are seeking treatment and hospitalization for the first time.”
The Current Psychiatry editorial staff conducted the survey reported in this article. The following questions were emailed to 45 Current Psychiatry Reader Reactors March 20, 2009. Fifteen responded by March 30 (response rate 33%).
Current Psychiatry is preparing an article on the psychological effects of the economic recession. We would like to know about the experiences of practicing psychiatrists. Would you please take a few minutes and answer the following questions?
- Are you seeing an increase in patients describing psychological reactions to the effects of the economic recession?
- If so, when did you notice this increase?
- What symptoms are you seeing in your patients?
- What event or events seem to be causing your patients the greatest psychological distress (loss of a job, worry about losing a job, mortgage foreclosure, loss of value in retirement savings, other)?
- What proportion of these patients has pre-existing psychiatric disorders versus persons who have not sought psychological/psychiatric treatment in the past?
- In what area of the country do you practice (city and state)?
Feel free to provide additional comments you may have.
Interview: Emerging patterns
When interviewed March 17, 2009, Dr. Rediger, Dr. Palmer, and Dr. Kauffman discussed their experiences, provided case examples, and suggested treatments they have found useful for recession-stressed psychiatric patients.
DR. PALMER: People went into panic mode in September/October. Losing a job, a retirement plan, or a home is about who we are and our worth as human beings. My sense is that most people are resilient and adaptive and will be fine despite the recession, but a portion of the population is impaired in adaptability.
DR. REDIGER: Would you explain what you mean?
DR. PALMER: A lot of people become so defiant, so angry, that they withdraw instead of adapting to a new way of life that they consider inferior. They’re humiliated; they feel complete and utter failure. For example, the contractor who owns his own business and says there’s no way he’s going to work for somebody else. He may have to go work for somebody else, get his personal finances in order for a year or two, and then start up a business again. But he has to survive in the meantime.
DR. REDIGER: People are walking around with a lot fear and self-blame. They don’t talk about this very easily; they may say things are fine, but they feel terrible. I wonder how much people are blaming themselves, perhaps for overextending their credit.
DR. PALMER: I think most of these people sensed their finances were marginal before the recession hit. They felt out of control, but their options were limited as housing prices rose beyond affordability. Clinically, I’m seeing increased rates of depression, anxiety, hopelessness. Denial is a big one; there’s a mindset that this can’t be happening.
Helplessness and dread
DR. KAUFFMAN: I resonate with the hopelessness. A lot of people tell me they are experiencing a sense of free fall, and I’ve been working with them to recalibrate a sense of empowerment. First I try some reality testing. I’ll say, “Maybe you’re feeling anxious, helpless, a little denial, fear. Is your survival in danger? Yes or no?” If the answer is no, then I’ll say, “So what can you do so you’re not living as if your survival is in danger?”
DR. REDIGER: Some people—such as the patient in the case report I submitted (Case Report 1)—are paralyzed by dread and anxiety. Two years ago their house was like an ATM machine, but now they feel trapped and worry that they can’t meet the mortgage payments.
DR. REDIGER: An economic recession is stressful because money represents power, control, and survival. The recession is not just about money. It’s about security, identity, and loss of face.
DR. KAUFFMAN: The evidence is pretty clear that financial losses are a risk factor for suicide, especially among men.2,3 You can go up and down Maslow’s hierarchy of needs and see what money means to people. I’ve also noticed that economic stress is a trigger for my clients with posttraumatic stress disorder. They feel out of control of a situation they thought they controlled.
DR. PALMER: An economic downturn can trigger learned helplessness. A construction worker has applied to 50 different construction companies, and none are hiring. He concludes, “I have to wait until the economy turns around, and then I’ll get another job in construction because that’s what I do.” He thinks he doesn’t have enough money or isn’t smart enough to get a degree, or whatever.
DR. REDIGER: And that’s another reason why someone with a history of trauma might experience a reactivation. Learned helplessness can be an aspect of chronic, repeated trauma. A person learns not to try any longer.
DR. PALMER: An inflexible perfectionist would probably have the most difficult time. A person who feels “there are rights and wrongs in the world, and the right thing is that I should be working. My family has grown accustomed to a certain lifestyle, and it’s my job to keep that up.”
DR. REDIGER: “If I work hard, this should be given to me.”
DR. PALMER: Right. A person with more flexibility might think in terms of problem-solving. “I worked in construction (or whatever), and now I can’t get a job. Therefore, I’ll go into a different field and take a lesser salary. The family will have to cut the budget, and the kids will go to a public college instead of a fancy private college.”
Mr. D, age 38, was admitted to our inpatient service in October 2008 with no psychiatric history but worsening depression and anxiety. He was thinking seriously about suicide by carbon monoxide poisoning. A paternal uncle and 2 paternal cousins died by suicide.
Mr. D reported GI complaints and chronic headaches. He had been married 11 years and had 3-year-old twins. He talked about financial problems and increasing debt at his construction business of 15 years. Instead of asking for help, Mr. D had ignored his accountant’s warnings and buried himself in work.
At admission, he was experiencing crying spells, insomnia, and hopelessness. That day he took 16 aspirins, 5 hydrocodone/acetaminophen tablets, and 4 lorazepam tablets to treat an intractable headache. He denied this was a suicide attempt but admitted to poor judgment.
During hospitalization, he received fluoxetine for depression and lorazepam for anxiety and insomnia. Prominent themes in psychotherapy included self-blame and isolation.
As his financial problems increased, Mr. D had borrowed money without completely disclosing his difficulties to the bank. He also felt ashamed because his 2 brothers were not facing financial problems. Creditors were knocking on the door of his home, demanding payment. He felt angry and humiliated that his wife and children were subjected to this. He felt certain his home would soon be in foreclosure.
After 3 weeks, Mr D was discharged to a partial hospital program with prescriptions for fluoxetine and short-term use of lorazepam. After 5 days he was re-admitted with suicidal thoughts. He had filed for personal and professional bankruptcy, but he could not imagine working for someone else after so many years of running his own business.
As treatment for his depression progressed, he began to develop greater insight into how his avoidant and isolative style of problem-solving contributed to a situation that left him vulnerable. He became more interested in cognitive-behavioral techniques for dealing with self-destructive thoughts and began to allow his stepfather (a retired corporate chief executive officer) and his wife to help him solve some of the practical problems facing him.—JEFFREY REDIGER, MD
Putting losses into perspective
DR. KAUFFMAN: Here’s where a cognitive-behavioral intervention with a goal to increase the flexibility—not just content—of thinking can help. You can ask patients, “What is most important to you? Is it money? Or is it your relationship with your family?” Or you could ask questions such as, “In the challenges you’re facing, what opportunities are there for you to do things that matter to you?”
For people who feel hopeless, I often describe this true story. A pilot was flying a jet cross-country when his engines flamed out and the plane began spinning downward. He tried everything, but nothing worked until he lowered the landing gear. This changed the vortex of forces, so that when the pilot went through his emergency procedures again he was able to pull the plane out of the death spiral.
When people become paralyzed by their problems, you can say the equivalent of “what’s your landing gear?” What small thing you could do that might create a different experience for you?
DR. REDIGER: So you’re saying, “If the big picture is too overwhelming, what’s something small you can do today?”
DR. KAUFFMAN: Yes, but not that the small thing is insignificant. As in the case report I submitted (Case Report 2), doing a small thing that makes a difference in a huge problem increases one’s internal locus of control. Feeling more empowered may lead the person to take on another thing.
DR. REDIGER: People have enormous resources that they don’t always know how to tap into. We may be experiencing a material recession but also an opportunity to recover what truly matters to us.
DR. KAUFFMAN: We’re talking about challenging people’s values and encouraging flexibility of thinking. This is a low-cost, powerful strategy that anyone can use to cope with the economic recession.
DR. PALMER: So you begin by challenging assumptions, cognitive-behavioral therapy (CBT), adaptive mechanisms, coming up with a plan, and implementing the plan, then being flexible, assessing if it’s working, and—if it’s not—coming up with another plan or revising it. That process has to be done first, before things I would recommend that are unrelated to the person’s immediate problem. If somebody tells you, “I just got laid off from work,” and you say, “Exercise could help,” he’s going to say, “Did you not hear me? I just got laid off from work.”
DR. KAUFFMAN: Evidence supports the positive psychology that 2 factors are key to sustaining hope:
- a sense of agency that you can achieve a goal
- multiple pathways planned out to reach the goal.4
Together, these 2 factors—which Snyder called “the will and the way5—are the highest predictors of performance, health, and ability to withstand adversity.
DR. PALMER: Along with CBT, I remind patients to stay connected, to see and talk to people every day. This doesn’t mean getting together to watch television; it means having real conversations. Other people can help you get unstuck. Evidence also indicates that a social network mitigates against depression and anxiety. The happier your friends are, the happier you are.6
Mr. A, age 45, is receiving executive coaching after being fired from his $1.5 million job as head of a consulting firm. He has half-time custody of his 2 children and pays hundreds of thousands of dollars per year in alimony and child support. He has a history of depression and anxiety and has been treated in the past with escitalopram.
During initial coaching sessions, Mr. A identifies himself as a victim and ruminates about how to get back at “the evil empire,” as he defines his former employer and his ex-wife. Mr. A says it seems odd not be at the top anymore. He feels stuck, depressed, and lost. We examine his role in his job and marital difficulties and identify skills he needs for a successful job search, career, and future relationships.
Early goals include becoming less chaotic and avoidant and building self-esteem. Stress management therapy is useful for his anxiety and avoidance. Cognitive-behavioral therapy and acceptance and commitment therapy help him access his strengths in new ways.
He transitions from a verbal avalanche of complaints to dialogue and self-exploration. He moves from avoiding a job search to trying to find what would “float my boat,” even if it means far lower income. He also becomes sanguine about work opportunities during the economic recession.
He creates lists of networking opportunities and reports on his successes and failures. Eventually, he works on his search at least 4 hours a day. After disappointments, we examine how he can keep himself going, increase awareness of how he is communicating, and engage in self-care to keep up motivation.
He continues to pursue opportunities and focus on the process rather than the outcome of his job search. He now sees himself as challenged by his circumstances and not as much a victim of them.—CAROL KAUFFMAN, PhD, ABPP, PCC
Addressing depression
DR. KAUFFMAN: Medication also can play a useful role for some patients.
DR. PALMER: Patients who meet criteria for major depression—in particular if they’re having suicidal thoughts—absolutely need psychotropics. Mr. R, my case patient, benefited greatly from CBT and medication. We also worked on financial planning and handling financial conflicts with his wife and children. He is exercising, doing volunteer work, and staying connected with friends and family. He is hoping to find a job in the next few months.
DR. REDIGER: For a person who’s going though a stressful period, I try to keep medication time-limited. We talk about treating symptoms, but it’s important to look at what’s causing the patient’s problems and address it.
DR. PALMER: During this recession, a lot of people are going to be down but not clinically depressed. If the depression is mild to moderate, I sometimes recommend exercise instead of medication (such as when a patient is refusing medication or has had serious side effects from medications). I recommend exercise for all my outpatients—even if they’re taking psychotropics—because exercise has been shown to be as effective as antidepressants for moderate depression.7,8
DR. REDIGER: We’ve also been encouraging people who’ve lost jobs to volunteer in the community. Having a reason to get out of the house takes the mind off one’s worries.
DR. KAUFFMAN: The “3 good things in life” exercise studied by psychologist Martin E.P. Seligman, PhD, has been shown in a 6-month, randomized, placebo-controlled study to increase happiness and decrease depressive symptoms.9 In this exercise, you look back at the end of each day and write down 3 things that went well, their causes, and an explanation for each good thing. Ask yourself, “When was I at my best today? What happened today that I feel grateful for? What did I do to make that good thing happen?”
DR. REDIGER: Remind people to talk to their children about the recession, too. If they have to move to a different home or to a different school, let their children know things are going on and how to think about that. This can help kids understand how to deal with their anxiety.
Related resources
- Getting through tough economic times. A SAMHSA guide. Substance Abuse and Mental Health Services Administration. U.S. Department of Health and Human Services. www.samhsa.gov/economy.
- Seligman MEP. Authentic happiness: using the new positive psychology to realize your potential for lasting fulfillment. New York, NY: Simon & Schuster; 2002.
- Positive Psychology Center. University of Pennsylvania, Philadelphia. www.ppc.sas.upenn.edu.
Drug brand names
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Lorazepam • Ativan
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
This article was researched and written by Current Psychiatry Editor Alice V. Luddington, ELS, and Senior Associate Editor Erica Vonderheid.
1. Employment situation summary: March 2009. Bureau of Labor Statistics. Washington, DC: U.S. Department of Labor; April 3, 2009. Available at: http://www.bls.gov/news.release/empsit.nr0.htm. Accessed April 14, 2009.
2. Stack S, Wasserman I. Economic strain and suicide risk: a qualitative analysis. Suicide Life Threat Behav. 2007;37:103-112.
3. Heikkinen M, Aro H, Lonngvist J. Recent life events, social support, and suicide. Acta Psychiatr Scand Suppl. 1994;377:65-72.
4. Snyder CR. Hope theory: rainbows of the mind. Psychological Inquiry. 2002;13:249-275.
5. Snyder CR, Harris C, Anderson JR, et al. The will and the ways: development and validation of an individual-differences measure of hope. J Pers Soc Psychol. 1991;60:570-585.
6. Fowler JH, Christakis NA. Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ. 2008;337:a2338.-
7. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007;69:587-596.
8. Craft LL, Landers DM. The effects of exercise on clinical depression and depression resulting from mental illness: a meta-analysis. JSEP. 1998;20:339-357.
9. Seligman MEP, Steen TA, Park N, et al. Positive psychology progress: empirical validation of interventions. Am Psychol. 2005;60:410-421.
Mr. R, age 45, developed severe depression 4 years ago after his mother died. He had suffered previous major depressive episodes and was treated effiectively with fluoxetine for 15 years. This time he took a medical leave from his job as an engineer and received disability. After numerous medication trials and psychotherapy, his symptoms improved.
Mr. R is ready to think about returning to work, but he will need to refresh his skills and consider starting at a lower level than before. Headlines remind him daily about increasing unemployment and decreasing prospects of finding a job.
During his illness, Mr. R and his family depleted their savings and incurred substantial debt. His wife has not worked outside the home while caring for him and their 4 children. She is increasingly anxious and depressed. The couple argue often about money but share a common hope: that Mr. R will find a job in the next few months.
How is the recession affecting psychiatric practice? Christopher Palmer, MD, the psychiatrist who treated Mr. R, says, “We in psychiatry and psychology are well-equipped to help people who are unemployed, underemployed, and financially ruined. We do it all the time. The difference in this economy is that we’re going to be seeing a lot more people.”
Psychiatrists who read Current Psychiatry and were polled in March 2009 agree. Most were seeing an increase in patients experiencing psychological stress because of the recession, which by then had persisted 16 months. “All my patients are reporting increased stress as a result of the economic situation. The more successful my patient is, the more distress they seem to be feeling,” says a psychiatrist from Melbourne, FL.
This article on the psychological effects of the recession discusses the results of an online survey of Current Psychiatry readers, with analysis and recommendations from an interview with Dr. Palmer and colleagues Jeffrey Rediger, MD, MDiv, and Carol Kauffman, PhD, ABPP, PCC, from McLean Hospital, Belmont, MA, and the department of psychiatry, Harvard Medical School.
| Carol Kauffman, PhD, ABPP, PCC, is director of the Institute of Coaching, McLean Hospital, Belmont, MA, and assistant clinical professor, department of psychiatry, Harvard Medical School. A veteran psychologist, she maintains an executive coaching practice in the United States and Europe. |
| Christopher Palmer, MD, is medical director of continuing medical education, McLean Hospital. His outpatient practice focuses on substance abuse, sleep disorders, mood and anxiety disorders, psychotic disorders, and individual and family psychotherapy. |
| Jeffrey Rediger, MD, MDiv, is medical director, adult psychiatric program, McLean Hospital SouthEast. He also is an instructor, department of psychiatry, Harvard Medical School and has a master of divinity degree. He publishes in the fields of medicine, psychiatry, and spirituality. |
Survey results
Methods. Using an e-mail questionnaire (Box), Current Psychiatry contacted 45 Reader Reactors—clinical psychiatrists who provide feedback to our editorial staff about topics being considered for publication. The 15 readers who responded practice psychiatry in the Northeast (New York and New Jersey), the South (Florida and Georgia), the West (California, Washington, and Oregon), and the Midwest (Pennsylvania, Illinois, and Missouri).
Nine of 11 readers who answered all questions in the survey said they have seen an increase in patients describing psychological reactions to the effects of the economic recession. A reader from Red Bank, NJ, reported, “I see a pattern of issues: ‘I was just laid off.’ ‘I am afraid I will be laid off.’ ‘Others have been laid off, and I’m overwhelmed with their work as well as my own.’ ‘I was planning to retire in a couple years, but now I will have to work longer than I was planning.’” Two psychiatrists reported no increase in patients with economic worries—in a prison and a state hospital with geriatric patients with cognitive impairment.
Timeline. For some survey respondents, the increase in patients with economy-related problems emerged in mid-to-late 2008—particularly in October—but others report seeing symptoms sooner. A reader from Harrisburg, PA, said, “I’ve noticed this increase for the past 4 to 5 months (dramatic), but there has been a general increase for 1 to 2 years.”
These observations mirror the rise in unemployment in the 16 months since the recession officially began in December 2007. In March 2009, the U.S. Bureau of Labor Statistics reported a national unemployment rate of 8.5% (13.2 million unemployed), which was a 25-year high. That same month, employers eliminated 663,000 jobs, for a total of 5.1 million layoffs since the recession began. Two-thirds of all layoffs occurred between November 2008 and March 2009.1
Symptoms. Depression, anxiety, or both are the most common symptoms associated with patients’ financial difficulties, survey respondents say. Other symptoms include insomnia, hopelessness, helplessness, loss of trust, anger, bitterness, resentment, suicidal ideation or attempts, numbness, desires for retaliation, increased alcohol/drug use, fear of being unable to afford medications or of losing a job, paranoia, and marital problems. Readers’ comments include:
- Augusta, GA: “Patients with depression and anxiety symptoms have increased in the emergency department.”
- Portland, OR: “I see people giving up and planning to live on unemployment as long as possible.”
- Fresno, CA: “Some married people are wishing they were single and did not have children.”
- Red Bank, NJ: “Some who have adapted are doing well, often with a low-overhead business, meeting a specialty need, or entering into a business that meets an emerging need.”
Who is affected? Overall, readers estimated that 70% to 100% of affected patients had pre-existing psychiatric disorders, whereas 20% to 30% had not sought treatment in the past. “Individuals with preexisting problems are having considerable difficulty,” one psychiatrist said.
Similarly, Dr. Jeffrey Rediger, medical director of the adult psychiatric inpatient service at McLean SouthEast, Brockton, MA, told Current Psychiatry, “For some people who were functioning marginally before the recession, this stress has pushed them over the edge. But we’re also seeing a number of young to middle-aged adults who are seeking treatment and hospitalization for the first time.”
The Current Psychiatry editorial staff conducted the survey reported in this article. The following questions were emailed to 45 Current Psychiatry Reader Reactors March 20, 2009. Fifteen responded by March 30 (response rate 33%).
Current Psychiatry is preparing an article on the psychological effects of the economic recession. We would like to know about the experiences of practicing psychiatrists. Would you please take a few minutes and answer the following questions?
- Are you seeing an increase in patients describing psychological reactions to the effects of the economic recession?
- If so, when did you notice this increase?
- What symptoms are you seeing in your patients?
- What event or events seem to be causing your patients the greatest psychological distress (loss of a job, worry about losing a job, mortgage foreclosure, loss of value in retirement savings, other)?
- What proportion of these patients has pre-existing psychiatric disorders versus persons who have not sought psychological/psychiatric treatment in the past?
- In what area of the country do you practice (city and state)?
Feel free to provide additional comments you may have.
Interview: Emerging patterns
When interviewed March 17, 2009, Dr. Rediger, Dr. Palmer, and Dr. Kauffman discussed their experiences, provided case examples, and suggested treatments they have found useful for recession-stressed psychiatric patients.
DR. PALMER: People went into panic mode in September/October. Losing a job, a retirement plan, or a home is about who we are and our worth as human beings. My sense is that most people are resilient and adaptive and will be fine despite the recession, but a portion of the population is impaired in adaptability.
DR. REDIGER: Would you explain what you mean?
DR. PALMER: A lot of people become so defiant, so angry, that they withdraw instead of adapting to a new way of life that they consider inferior. They’re humiliated; they feel complete and utter failure. For example, the contractor who owns his own business and says there’s no way he’s going to work for somebody else. He may have to go work for somebody else, get his personal finances in order for a year or two, and then start up a business again. But he has to survive in the meantime.
DR. REDIGER: People are walking around with a lot fear and self-blame. They don’t talk about this very easily; they may say things are fine, but they feel terrible. I wonder how much people are blaming themselves, perhaps for overextending their credit.
DR. PALMER: I think most of these people sensed their finances were marginal before the recession hit. They felt out of control, but their options were limited as housing prices rose beyond affordability. Clinically, I’m seeing increased rates of depression, anxiety, hopelessness. Denial is a big one; there’s a mindset that this can’t be happening.
Helplessness and dread
DR. KAUFFMAN: I resonate with the hopelessness. A lot of people tell me they are experiencing a sense of free fall, and I’ve been working with them to recalibrate a sense of empowerment. First I try some reality testing. I’ll say, “Maybe you’re feeling anxious, helpless, a little denial, fear. Is your survival in danger? Yes or no?” If the answer is no, then I’ll say, “So what can you do so you’re not living as if your survival is in danger?”
DR. REDIGER: Some people—such as the patient in the case report I submitted (Case Report 1)—are paralyzed by dread and anxiety. Two years ago their house was like an ATM machine, but now they feel trapped and worry that they can’t meet the mortgage payments.
DR. REDIGER: An economic recession is stressful because money represents power, control, and survival. The recession is not just about money. It’s about security, identity, and loss of face.
DR. KAUFFMAN: The evidence is pretty clear that financial losses are a risk factor for suicide, especially among men.2,3 You can go up and down Maslow’s hierarchy of needs and see what money means to people. I’ve also noticed that economic stress is a trigger for my clients with posttraumatic stress disorder. They feel out of control of a situation they thought they controlled.
DR. PALMER: An economic downturn can trigger learned helplessness. A construction worker has applied to 50 different construction companies, and none are hiring. He concludes, “I have to wait until the economy turns around, and then I’ll get another job in construction because that’s what I do.” He thinks he doesn’t have enough money or isn’t smart enough to get a degree, or whatever.
DR. REDIGER: And that’s another reason why someone with a history of trauma might experience a reactivation. Learned helplessness can be an aspect of chronic, repeated trauma. A person learns not to try any longer.
DR. PALMER: An inflexible perfectionist would probably have the most difficult time. A person who feels “there are rights and wrongs in the world, and the right thing is that I should be working. My family has grown accustomed to a certain lifestyle, and it’s my job to keep that up.”
DR. REDIGER: “If I work hard, this should be given to me.”
DR. PALMER: Right. A person with more flexibility might think in terms of problem-solving. “I worked in construction (or whatever), and now I can’t get a job. Therefore, I’ll go into a different field and take a lesser salary. The family will have to cut the budget, and the kids will go to a public college instead of a fancy private college.”
Mr. D, age 38, was admitted to our inpatient service in October 2008 with no psychiatric history but worsening depression and anxiety. He was thinking seriously about suicide by carbon monoxide poisoning. A paternal uncle and 2 paternal cousins died by suicide.
Mr. D reported GI complaints and chronic headaches. He had been married 11 years and had 3-year-old twins. He talked about financial problems and increasing debt at his construction business of 15 years. Instead of asking for help, Mr. D had ignored his accountant’s warnings and buried himself in work.
At admission, he was experiencing crying spells, insomnia, and hopelessness. That day he took 16 aspirins, 5 hydrocodone/acetaminophen tablets, and 4 lorazepam tablets to treat an intractable headache. He denied this was a suicide attempt but admitted to poor judgment.
During hospitalization, he received fluoxetine for depression and lorazepam for anxiety and insomnia. Prominent themes in psychotherapy included self-blame and isolation.
As his financial problems increased, Mr. D had borrowed money without completely disclosing his difficulties to the bank. He also felt ashamed because his 2 brothers were not facing financial problems. Creditors were knocking on the door of his home, demanding payment. He felt angry and humiliated that his wife and children were subjected to this. He felt certain his home would soon be in foreclosure.
After 3 weeks, Mr D was discharged to a partial hospital program with prescriptions for fluoxetine and short-term use of lorazepam. After 5 days he was re-admitted with suicidal thoughts. He had filed for personal and professional bankruptcy, but he could not imagine working for someone else after so many years of running his own business.
As treatment for his depression progressed, he began to develop greater insight into how his avoidant and isolative style of problem-solving contributed to a situation that left him vulnerable. He became more interested in cognitive-behavioral techniques for dealing with self-destructive thoughts and began to allow his stepfather (a retired corporate chief executive officer) and his wife to help him solve some of the practical problems facing him.—JEFFREY REDIGER, MD
Putting losses into perspective
DR. KAUFFMAN: Here’s where a cognitive-behavioral intervention with a goal to increase the flexibility—not just content—of thinking can help. You can ask patients, “What is most important to you? Is it money? Or is it your relationship with your family?” Or you could ask questions such as, “In the challenges you’re facing, what opportunities are there for you to do things that matter to you?”
For people who feel hopeless, I often describe this true story. A pilot was flying a jet cross-country when his engines flamed out and the plane began spinning downward. He tried everything, but nothing worked until he lowered the landing gear. This changed the vortex of forces, so that when the pilot went through his emergency procedures again he was able to pull the plane out of the death spiral.
When people become paralyzed by their problems, you can say the equivalent of “what’s your landing gear?” What small thing you could do that might create a different experience for you?
DR. REDIGER: So you’re saying, “If the big picture is too overwhelming, what’s something small you can do today?”
DR. KAUFFMAN: Yes, but not that the small thing is insignificant. As in the case report I submitted (Case Report 2), doing a small thing that makes a difference in a huge problem increases one’s internal locus of control. Feeling more empowered may lead the person to take on another thing.
DR. REDIGER: People have enormous resources that they don’t always know how to tap into. We may be experiencing a material recession but also an opportunity to recover what truly matters to us.
DR. KAUFFMAN: We’re talking about challenging people’s values and encouraging flexibility of thinking. This is a low-cost, powerful strategy that anyone can use to cope with the economic recession.
DR. PALMER: So you begin by challenging assumptions, cognitive-behavioral therapy (CBT), adaptive mechanisms, coming up with a plan, and implementing the plan, then being flexible, assessing if it’s working, and—if it’s not—coming up with another plan or revising it. That process has to be done first, before things I would recommend that are unrelated to the person’s immediate problem. If somebody tells you, “I just got laid off from work,” and you say, “Exercise could help,” he’s going to say, “Did you not hear me? I just got laid off from work.”
DR. KAUFFMAN: Evidence supports the positive psychology that 2 factors are key to sustaining hope:
- a sense of agency that you can achieve a goal
- multiple pathways planned out to reach the goal.4
Together, these 2 factors—which Snyder called “the will and the way5—are the highest predictors of performance, health, and ability to withstand adversity.
DR. PALMER: Along with CBT, I remind patients to stay connected, to see and talk to people every day. This doesn’t mean getting together to watch television; it means having real conversations. Other people can help you get unstuck. Evidence also indicates that a social network mitigates against depression and anxiety. The happier your friends are, the happier you are.6
Mr. A, age 45, is receiving executive coaching after being fired from his $1.5 million job as head of a consulting firm. He has half-time custody of his 2 children and pays hundreds of thousands of dollars per year in alimony and child support. He has a history of depression and anxiety and has been treated in the past with escitalopram.
During initial coaching sessions, Mr. A identifies himself as a victim and ruminates about how to get back at “the evil empire,” as he defines his former employer and his ex-wife. Mr. A says it seems odd not be at the top anymore. He feels stuck, depressed, and lost. We examine his role in his job and marital difficulties and identify skills he needs for a successful job search, career, and future relationships.
Early goals include becoming less chaotic and avoidant and building self-esteem. Stress management therapy is useful for his anxiety and avoidance. Cognitive-behavioral therapy and acceptance and commitment therapy help him access his strengths in new ways.
He transitions from a verbal avalanche of complaints to dialogue and self-exploration. He moves from avoiding a job search to trying to find what would “float my boat,” even if it means far lower income. He also becomes sanguine about work opportunities during the economic recession.
He creates lists of networking opportunities and reports on his successes and failures. Eventually, he works on his search at least 4 hours a day. After disappointments, we examine how he can keep himself going, increase awareness of how he is communicating, and engage in self-care to keep up motivation.
He continues to pursue opportunities and focus on the process rather than the outcome of his job search. He now sees himself as challenged by his circumstances and not as much a victim of them.—CAROL KAUFFMAN, PhD, ABPP, PCC
Addressing depression
DR. KAUFFMAN: Medication also can play a useful role for some patients.
DR. PALMER: Patients who meet criteria for major depression—in particular if they’re having suicidal thoughts—absolutely need psychotropics. Mr. R, my case patient, benefited greatly from CBT and medication. We also worked on financial planning and handling financial conflicts with his wife and children. He is exercising, doing volunteer work, and staying connected with friends and family. He is hoping to find a job in the next few months.
DR. REDIGER: For a person who’s going though a stressful period, I try to keep medication time-limited. We talk about treating symptoms, but it’s important to look at what’s causing the patient’s problems and address it.
DR. PALMER: During this recession, a lot of people are going to be down but not clinically depressed. If the depression is mild to moderate, I sometimes recommend exercise instead of medication (such as when a patient is refusing medication or has had serious side effects from medications). I recommend exercise for all my outpatients—even if they’re taking psychotropics—because exercise has been shown to be as effective as antidepressants for moderate depression.7,8
DR. REDIGER: We’ve also been encouraging people who’ve lost jobs to volunteer in the community. Having a reason to get out of the house takes the mind off one’s worries.
DR. KAUFFMAN: The “3 good things in life” exercise studied by psychologist Martin E.P. Seligman, PhD, has been shown in a 6-month, randomized, placebo-controlled study to increase happiness and decrease depressive symptoms.9 In this exercise, you look back at the end of each day and write down 3 things that went well, their causes, and an explanation for each good thing. Ask yourself, “When was I at my best today? What happened today that I feel grateful for? What did I do to make that good thing happen?”
DR. REDIGER: Remind people to talk to their children about the recession, too. If they have to move to a different home or to a different school, let their children know things are going on and how to think about that. This can help kids understand how to deal with their anxiety.
Related resources
- Getting through tough economic times. A SAMHSA guide. Substance Abuse and Mental Health Services Administration. U.S. Department of Health and Human Services. www.samhsa.gov/economy.
- Seligman MEP. Authentic happiness: using the new positive psychology to realize your potential for lasting fulfillment. New York, NY: Simon & Schuster; 2002.
- Positive Psychology Center. University of Pennsylvania, Philadelphia. www.ppc.sas.upenn.edu.
Drug brand names
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Lorazepam • Ativan
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
This article was researched and written by Current Psychiatry Editor Alice V. Luddington, ELS, and Senior Associate Editor Erica Vonderheid.
Mr. R, age 45, developed severe depression 4 years ago after his mother died. He had suffered previous major depressive episodes and was treated effiectively with fluoxetine for 15 years. This time he took a medical leave from his job as an engineer and received disability. After numerous medication trials and psychotherapy, his symptoms improved.
Mr. R is ready to think about returning to work, but he will need to refresh his skills and consider starting at a lower level than before. Headlines remind him daily about increasing unemployment and decreasing prospects of finding a job.
During his illness, Mr. R and his family depleted their savings and incurred substantial debt. His wife has not worked outside the home while caring for him and their 4 children. She is increasingly anxious and depressed. The couple argue often about money but share a common hope: that Mr. R will find a job in the next few months.
How is the recession affecting psychiatric practice? Christopher Palmer, MD, the psychiatrist who treated Mr. R, says, “We in psychiatry and psychology are well-equipped to help people who are unemployed, underemployed, and financially ruined. We do it all the time. The difference in this economy is that we’re going to be seeing a lot more people.”
Psychiatrists who read Current Psychiatry and were polled in March 2009 agree. Most were seeing an increase in patients experiencing psychological stress because of the recession, which by then had persisted 16 months. “All my patients are reporting increased stress as a result of the economic situation. The more successful my patient is, the more distress they seem to be feeling,” says a psychiatrist from Melbourne, FL.
This article on the psychological effects of the recession discusses the results of an online survey of Current Psychiatry readers, with analysis and recommendations from an interview with Dr. Palmer and colleagues Jeffrey Rediger, MD, MDiv, and Carol Kauffman, PhD, ABPP, PCC, from McLean Hospital, Belmont, MA, and the department of psychiatry, Harvard Medical School.
| Carol Kauffman, PhD, ABPP, PCC, is director of the Institute of Coaching, McLean Hospital, Belmont, MA, and assistant clinical professor, department of psychiatry, Harvard Medical School. A veteran psychologist, she maintains an executive coaching practice in the United States and Europe. |
| Christopher Palmer, MD, is medical director of continuing medical education, McLean Hospital. His outpatient practice focuses on substance abuse, sleep disorders, mood and anxiety disorders, psychotic disorders, and individual and family psychotherapy. |
| Jeffrey Rediger, MD, MDiv, is medical director, adult psychiatric program, McLean Hospital SouthEast. He also is an instructor, department of psychiatry, Harvard Medical School and has a master of divinity degree. He publishes in the fields of medicine, psychiatry, and spirituality. |
Survey results
Methods. Using an e-mail questionnaire (Box), Current Psychiatry contacted 45 Reader Reactors—clinical psychiatrists who provide feedback to our editorial staff about topics being considered for publication. The 15 readers who responded practice psychiatry in the Northeast (New York and New Jersey), the South (Florida and Georgia), the West (California, Washington, and Oregon), and the Midwest (Pennsylvania, Illinois, and Missouri).
Nine of 11 readers who answered all questions in the survey said they have seen an increase in patients describing psychological reactions to the effects of the economic recession. A reader from Red Bank, NJ, reported, “I see a pattern of issues: ‘I was just laid off.’ ‘I am afraid I will be laid off.’ ‘Others have been laid off, and I’m overwhelmed with their work as well as my own.’ ‘I was planning to retire in a couple years, but now I will have to work longer than I was planning.’” Two psychiatrists reported no increase in patients with economic worries—in a prison and a state hospital with geriatric patients with cognitive impairment.
Timeline. For some survey respondents, the increase in patients with economy-related problems emerged in mid-to-late 2008—particularly in October—but others report seeing symptoms sooner. A reader from Harrisburg, PA, said, “I’ve noticed this increase for the past 4 to 5 months (dramatic), but there has been a general increase for 1 to 2 years.”
These observations mirror the rise in unemployment in the 16 months since the recession officially began in December 2007. In March 2009, the U.S. Bureau of Labor Statistics reported a national unemployment rate of 8.5% (13.2 million unemployed), which was a 25-year high. That same month, employers eliminated 663,000 jobs, for a total of 5.1 million layoffs since the recession began. Two-thirds of all layoffs occurred between November 2008 and March 2009.1
Symptoms. Depression, anxiety, or both are the most common symptoms associated with patients’ financial difficulties, survey respondents say. Other symptoms include insomnia, hopelessness, helplessness, loss of trust, anger, bitterness, resentment, suicidal ideation or attempts, numbness, desires for retaliation, increased alcohol/drug use, fear of being unable to afford medications or of losing a job, paranoia, and marital problems. Readers’ comments include:
- Augusta, GA: “Patients with depression and anxiety symptoms have increased in the emergency department.”
- Portland, OR: “I see people giving up and planning to live on unemployment as long as possible.”
- Fresno, CA: “Some married people are wishing they were single and did not have children.”
- Red Bank, NJ: “Some who have adapted are doing well, often with a low-overhead business, meeting a specialty need, or entering into a business that meets an emerging need.”
Who is affected? Overall, readers estimated that 70% to 100% of affected patients had pre-existing psychiatric disorders, whereas 20% to 30% had not sought treatment in the past. “Individuals with preexisting problems are having considerable difficulty,” one psychiatrist said.
Similarly, Dr. Jeffrey Rediger, medical director of the adult psychiatric inpatient service at McLean SouthEast, Brockton, MA, told Current Psychiatry, “For some people who were functioning marginally before the recession, this stress has pushed them over the edge. But we’re also seeing a number of young to middle-aged adults who are seeking treatment and hospitalization for the first time.”
The Current Psychiatry editorial staff conducted the survey reported in this article. The following questions were emailed to 45 Current Psychiatry Reader Reactors March 20, 2009. Fifteen responded by March 30 (response rate 33%).
Current Psychiatry is preparing an article on the psychological effects of the economic recession. We would like to know about the experiences of practicing psychiatrists. Would you please take a few minutes and answer the following questions?
- Are you seeing an increase in patients describing psychological reactions to the effects of the economic recession?
- If so, when did you notice this increase?
- What symptoms are you seeing in your patients?
- What event or events seem to be causing your patients the greatest psychological distress (loss of a job, worry about losing a job, mortgage foreclosure, loss of value in retirement savings, other)?
- What proportion of these patients has pre-existing psychiatric disorders versus persons who have not sought psychological/psychiatric treatment in the past?
- In what area of the country do you practice (city and state)?
Feel free to provide additional comments you may have.
Interview: Emerging patterns
When interviewed March 17, 2009, Dr. Rediger, Dr. Palmer, and Dr. Kauffman discussed their experiences, provided case examples, and suggested treatments they have found useful for recession-stressed psychiatric patients.
DR. PALMER: People went into panic mode in September/October. Losing a job, a retirement plan, or a home is about who we are and our worth as human beings. My sense is that most people are resilient and adaptive and will be fine despite the recession, but a portion of the population is impaired in adaptability.
DR. REDIGER: Would you explain what you mean?
DR. PALMER: A lot of people become so defiant, so angry, that they withdraw instead of adapting to a new way of life that they consider inferior. They’re humiliated; they feel complete and utter failure. For example, the contractor who owns his own business and says there’s no way he’s going to work for somebody else. He may have to go work for somebody else, get his personal finances in order for a year or two, and then start up a business again. But he has to survive in the meantime.
DR. REDIGER: People are walking around with a lot fear and self-blame. They don’t talk about this very easily; they may say things are fine, but they feel terrible. I wonder how much people are blaming themselves, perhaps for overextending their credit.
DR. PALMER: I think most of these people sensed their finances were marginal before the recession hit. They felt out of control, but their options were limited as housing prices rose beyond affordability. Clinically, I’m seeing increased rates of depression, anxiety, hopelessness. Denial is a big one; there’s a mindset that this can’t be happening.
Helplessness and dread
DR. KAUFFMAN: I resonate with the hopelessness. A lot of people tell me they are experiencing a sense of free fall, and I’ve been working with them to recalibrate a sense of empowerment. First I try some reality testing. I’ll say, “Maybe you’re feeling anxious, helpless, a little denial, fear. Is your survival in danger? Yes or no?” If the answer is no, then I’ll say, “So what can you do so you’re not living as if your survival is in danger?”
DR. REDIGER: Some people—such as the patient in the case report I submitted (Case Report 1)—are paralyzed by dread and anxiety. Two years ago their house was like an ATM machine, but now they feel trapped and worry that they can’t meet the mortgage payments.
DR. REDIGER: An economic recession is stressful because money represents power, control, and survival. The recession is not just about money. It’s about security, identity, and loss of face.
DR. KAUFFMAN: The evidence is pretty clear that financial losses are a risk factor for suicide, especially among men.2,3 You can go up and down Maslow’s hierarchy of needs and see what money means to people. I’ve also noticed that economic stress is a trigger for my clients with posttraumatic stress disorder. They feel out of control of a situation they thought they controlled.
DR. PALMER: An economic downturn can trigger learned helplessness. A construction worker has applied to 50 different construction companies, and none are hiring. He concludes, “I have to wait until the economy turns around, and then I’ll get another job in construction because that’s what I do.” He thinks he doesn’t have enough money or isn’t smart enough to get a degree, or whatever.
DR. REDIGER: And that’s another reason why someone with a history of trauma might experience a reactivation. Learned helplessness can be an aspect of chronic, repeated trauma. A person learns not to try any longer.
DR. PALMER: An inflexible perfectionist would probably have the most difficult time. A person who feels “there are rights and wrongs in the world, and the right thing is that I should be working. My family has grown accustomed to a certain lifestyle, and it’s my job to keep that up.”
DR. REDIGER: “If I work hard, this should be given to me.”
DR. PALMER: Right. A person with more flexibility might think in terms of problem-solving. “I worked in construction (or whatever), and now I can’t get a job. Therefore, I’ll go into a different field and take a lesser salary. The family will have to cut the budget, and the kids will go to a public college instead of a fancy private college.”
Mr. D, age 38, was admitted to our inpatient service in October 2008 with no psychiatric history but worsening depression and anxiety. He was thinking seriously about suicide by carbon monoxide poisoning. A paternal uncle and 2 paternal cousins died by suicide.
Mr. D reported GI complaints and chronic headaches. He had been married 11 years and had 3-year-old twins. He talked about financial problems and increasing debt at his construction business of 15 years. Instead of asking for help, Mr. D had ignored his accountant’s warnings and buried himself in work.
At admission, he was experiencing crying spells, insomnia, and hopelessness. That day he took 16 aspirins, 5 hydrocodone/acetaminophen tablets, and 4 lorazepam tablets to treat an intractable headache. He denied this was a suicide attempt but admitted to poor judgment.
During hospitalization, he received fluoxetine for depression and lorazepam for anxiety and insomnia. Prominent themes in psychotherapy included self-blame and isolation.
As his financial problems increased, Mr. D had borrowed money without completely disclosing his difficulties to the bank. He also felt ashamed because his 2 brothers were not facing financial problems. Creditors were knocking on the door of his home, demanding payment. He felt angry and humiliated that his wife and children were subjected to this. He felt certain his home would soon be in foreclosure.
After 3 weeks, Mr D was discharged to a partial hospital program with prescriptions for fluoxetine and short-term use of lorazepam. After 5 days he was re-admitted with suicidal thoughts. He had filed for personal and professional bankruptcy, but he could not imagine working for someone else after so many years of running his own business.
As treatment for his depression progressed, he began to develop greater insight into how his avoidant and isolative style of problem-solving contributed to a situation that left him vulnerable. He became more interested in cognitive-behavioral techniques for dealing with self-destructive thoughts and began to allow his stepfather (a retired corporate chief executive officer) and his wife to help him solve some of the practical problems facing him.—JEFFREY REDIGER, MD
Putting losses into perspective
DR. KAUFFMAN: Here’s where a cognitive-behavioral intervention with a goal to increase the flexibility—not just content—of thinking can help. You can ask patients, “What is most important to you? Is it money? Or is it your relationship with your family?” Or you could ask questions such as, “In the challenges you’re facing, what opportunities are there for you to do things that matter to you?”
For people who feel hopeless, I often describe this true story. A pilot was flying a jet cross-country when his engines flamed out and the plane began spinning downward. He tried everything, but nothing worked until he lowered the landing gear. This changed the vortex of forces, so that when the pilot went through his emergency procedures again he was able to pull the plane out of the death spiral.
When people become paralyzed by their problems, you can say the equivalent of “what’s your landing gear?” What small thing you could do that might create a different experience for you?
DR. REDIGER: So you’re saying, “If the big picture is too overwhelming, what’s something small you can do today?”
DR. KAUFFMAN: Yes, but not that the small thing is insignificant. As in the case report I submitted (Case Report 2), doing a small thing that makes a difference in a huge problem increases one’s internal locus of control. Feeling more empowered may lead the person to take on another thing.
DR. REDIGER: People have enormous resources that they don’t always know how to tap into. We may be experiencing a material recession but also an opportunity to recover what truly matters to us.
DR. KAUFFMAN: We’re talking about challenging people’s values and encouraging flexibility of thinking. This is a low-cost, powerful strategy that anyone can use to cope with the economic recession.
DR. PALMER: So you begin by challenging assumptions, cognitive-behavioral therapy (CBT), adaptive mechanisms, coming up with a plan, and implementing the plan, then being flexible, assessing if it’s working, and—if it’s not—coming up with another plan or revising it. That process has to be done first, before things I would recommend that are unrelated to the person’s immediate problem. If somebody tells you, “I just got laid off from work,” and you say, “Exercise could help,” he’s going to say, “Did you not hear me? I just got laid off from work.”
DR. KAUFFMAN: Evidence supports the positive psychology that 2 factors are key to sustaining hope:
- a sense of agency that you can achieve a goal
- multiple pathways planned out to reach the goal.4
Together, these 2 factors—which Snyder called “the will and the way5—are the highest predictors of performance, health, and ability to withstand adversity.
DR. PALMER: Along with CBT, I remind patients to stay connected, to see and talk to people every day. This doesn’t mean getting together to watch television; it means having real conversations. Other people can help you get unstuck. Evidence also indicates that a social network mitigates against depression and anxiety. The happier your friends are, the happier you are.6
Mr. A, age 45, is receiving executive coaching after being fired from his $1.5 million job as head of a consulting firm. He has half-time custody of his 2 children and pays hundreds of thousands of dollars per year in alimony and child support. He has a history of depression and anxiety and has been treated in the past with escitalopram.
During initial coaching sessions, Mr. A identifies himself as a victim and ruminates about how to get back at “the evil empire,” as he defines his former employer and his ex-wife. Mr. A says it seems odd not be at the top anymore. He feels stuck, depressed, and lost. We examine his role in his job and marital difficulties and identify skills he needs for a successful job search, career, and future relationships.
Early goals include becoming less chaotic and avoidant and building self-esteem. Stress management therapy is useful for his anxiety and avoidance. Cognitive-behavioral therapy and acceptance and commitment therapy help him access his strengths in new ways.
He transitions from a verbal avalanche of complaints to dialogue and self-exploration. He moves from avoiding a job search to trying to find what would “float my boat,” even if it means far lower income. He also becomes sanguine about work opportunities during the economic recession.
He creates lists of networking opportunities and reports on his successes and failures. Eventually, he works on his search at least 4 hours a day. After disappointments, we examine how he can keep himself going, increase awareness of how he is communicating, and engage in self-care to keep up motivation.
He continues to pursue opportunities and focus on the process rather than the outcome of his job search. He now sees himself as challenged by his circumstances and not as much a victim of them.—CAROL KAUFFMAN, PhD, ABPP, PCC
Addressing depression
DR. KAUFFMAN: Medication also can play a useful role for some patients.
DR. PALMER: Patients who meet criteria for major depression—in particular if they’re having suicidal thoughts—absolutely need psychotropics. Mr. R, my case patient, benefited greatly from CBT and medication. We also worked on financial planning and handling financial conflicts with his wife and children. He is exercising, doing volunteer work, and staying connected with friends and family. He is hoping to find a job in the next few months.
DR. REDIGER: For a person who’s going though a stressful period, I try to keep medication time-limited. We talk about treating symptoms, but it’s important to look at what’s causing the patient’s problems and address it.
DR. PALMER: During this recession, a lot of people are going to be down but not clinically depressed. If the depression is mild to moderate, I sometimes recommend exercise instead of medication (such as when a patient is refusing medication or has had serious side effects from medications). I recommend exercise for all my outpatients—even if they’re taking psychotropics—because exercise has been shown to be as effective as antidepressants for moderate depression.7,8
DR. REDIGER: We’ve also been encouraging people who’ve lost jobs to volunteer in the community. Having a reason to get out of the house takes the mind off one’s worries.
DR. KAUFFMAN: The “3 good things in life” exercise studied by psychologist Martin E.P. Seligman, PhD, has been shown in a 6-month, randomized, placebo-controlled study to increase happiness and decrease depressive symptoms.9 In this exercise, you look back at the end of each day and write down 3 things that went well, their causes, and an explanation for each good thing. Ask yourself, “When was I at my best today? What happened today that I feel grateful for? What did I do to make that good thing happen?”
DR. REDIGER: Remind people to talk to their children about the recession, too. If they have to move to a different home or to a different school, let their children know things are going on and how to think about that. This can help kids understand how to deal with their anxiety.
Related resources
- Getting through tough economic times. A SAMHSA guide. Substance Abuse and Mental Health Services Administration. U.S. Department of Health and Human Services. www.samhsa.gov/economy.
- Seligman MEP. Authentic happiness: using the new positive psychology to realize your potential for lasting fulfillment. New York, NY: Simon & Schuster; 2002.
- Positive Psychology Center. University of Pennsylvania, Philadelphia. www.ppc.sas.upenn.edu.
Drug brand names
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Lorazepam • Ativan
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
This article was researched and written by Current Psychiatry Editor Alice V. Luddington, ELS, and Senior Associate Editor Erica Vonderheid.
1. Employment situation summary: March 2009. Bureau of Labor Statistics. Washington, DC: U.S. Department of Labor; April 3, 2009. Available at: http://www.bls.gov/news.release/empsit.nr0.htm. Accessed April 14, 2009.
2. Stack S, Wasserman I. Economic strain and suicide risk: a qualitative analysis. Suicide Life Threat Behav. 2007;37:103-112.
3. Heikkinen M, Aro H, Lonngvist J. Recent life events, social support, and suicide. Acta Psychiatr Scand Suppl. 1994;377:65-72.
4. Snyder CR. Hope theory: rainbows of the mind. Psychological Inquiry. 2002;13:249-275.
5. Snyder CR, Harris C, Anderson JR, et al. The will and the ways: development and validation of an individual-differences measure of hope. J Pers Soc Psychol. 1991;60:570-585.
6. Fowler JH, Christakis NA. Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ. 2008;337:a2338.-
7. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007;69:587-596.
8. Craft LL, Landers DM. The effects of exercise on clinical depression and depression resulting from mental illness: a meta-analysis. JSEP. 1998;20:339-357.
9. Seligman MEP, Steen TA, Park N, et al. Positive psychology progress: empirical validation of interventions. Am Psychol. 2005;60:410-421.
1. Employment situation summary: March 2009. Bureau of Labor Statistics. Washington, DC: U.S. Department of Labor; April 3, 2009. Available at: http://www.bls.gov/news.release/empsit.nr0.htm. Accessed April 14, 2009.
2. Stack S, Wasserman I. Economic strain and suicide risk: a qualitative analysis. Suicide Life Threat Behav. 2007;37:103-112.
3. Heikkinen M, Aro H, Lonngvist J. Recent life events, social support, and suicide. Acta Psychiatr Scand Suppl. 1994;377:65-72.
4. Snyder CR. Hope theory: rainbows of the mind. Psychological Inquiry. 2002;13:249-275.
5. Snyder CR, Harris C, Anderson JR, et al. The will and the ways: development and validation of an individual-differences measure of hope. J Pers Soc Psychol. 1991;60:570-585.
6. Fowler JH, Christakis NA. Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ. 2008;337:a2338.-
7. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007;69:587-596.
8. Craft LL, Landers DM. The effects of exercise on clinical depression and depression resulting from mental illness: a meta-analysis. JSEP. 1998;20:339-357.
9. Seligman MEP, Steen TA, Park N, et al. Positive psychology progress: empirical validation of interventions. Am Psychol. 2005;60:410-421.