No employee clocks in to work each day entirely free from personal issues and struggles. However, individuals with mental illness face an extra layer of adversity in the workplace. Simply showing up and fulfilling job responsibilities can be an uphill battle for employees who are bombarded by intrusive, obsessive or critical thoughts; trauma flashbacks; depressive episodes; anxiety triggers; and other challenges.

Adding to the issue is the friction that can arise in a workplace when a mental illness — either disclosed or not — causes an employee to struggle to keep up with their workload or to take time off frequently to go to counseling appointments or tend to their mental health. Co-workers and supervisors can be unsupportive of a teammate who falls behind, sometimes regardless of whether they’re aware of the mental illness underlying their colleague’s work performance, making the situation worse.

Professional counselors can be key allies for clients whose mental health struggles are affecting — or even derailing — their work life. Being an ally includes providing support at an individual level, such as by equipping clients with coping mechanisms and talking through career-related decisions, and at a systemic level, such as by helping clients seek accommodations from an employer or otherwise advocate for themselves.

In these situations, a supportive counselor can normalize the client’s experience, help with perspective-setting and serve as a sounding board as the client talks through decisions and emotions related to work and career, says Meredith Montgomery, a supervising professional clinical counselor in Ohio and an assistant professor of counselor education at the University of Dayton. “It’s also a counselor’s role to know what different [mental health] diagnoses might bring up in a work setting. If a clinician is working with a client who meets the criteria for obsessive-compulsive disorder (OCD), you need to really do the research to know what that can potentially mean in the workplace. But at the same time, don’t buy into clichéd old ideas; look for the newest, updated information and laws that can help support them in a work environment,” says Montgomery, a member of the American Counseling Association. “Ultimately, a counselor’s job is one of support and illumination: to illuminate [a client’s] path, not to create the path, or determine the path, or push or pull them on the path, or shove them off of it, but to equip them with all the information you can to help them make their own decisions.”

A daily struggle

Behaviors that can indicate a client’s mental health is leading to problems in the workplace include frequent absences, tardiness, difficulty motivating themselves to perform their job, or job performance issues such as struggling to meet deadlines or other work expectations, says Amanda Hembree, a licensed professional counselor (LPC) and certified employee assistance professional with a private practice in New Orleans.

Perfectionism can also be a factor, she adds. For example, a client with OCD may miss deadlines or have trouble contributing to team projects because they need extra time to prepare and complete compulsive rituals or steps until an assignment is just right. This can especially be the case in job roles that involve safety, Hembree points out. Employees with OCD may feel they need to check and recheck their equipment, tools and other safety protocols repeatedly, causing them to be late or struggle to complete other tasks.

At the same time, Hembree acknowledges that many people with mental health challenges find “workarounds” to push through the workday and keep themselves from being noticed by co-workers or supervisors.

A client’s workplace challenges may also fly under the radar in counseling sessions unless the clinician fully explores how the person’s mental illness is manifesting across their life, Hembree stresses. Clients may seek counseling for a different presenting issue, such as parenting struggles or communication problems within a marriage, and fail to recognize or acknowledge that work problems can be a contributing factor to difficulties in their personal life.

“Don’t discount work,” Hembree urges her fellow counselors. “Clients are spending 40-plus hours there each week, and it will affect what they’re bringing into the counseling office. Work plays a big role in our lives, and you [the counselor] have to figure out the intersection of why they’re in your office and what is going on at work and what can be helped in both realms. None of us lives in a vacuum. Mental illness will affect every part of a whole person’s wellness — and especially work.”

Seth Hayden, an associate professor of counseling at Wake Forest University and president of the National Career Development Association, a division of ACA, also emphasizes the importance of listening for and asking clients about job-related challenges, regardless of whether their presenting concern involves work. A comprehensive client assessment should include questions about how their presenting concern manifests throughout their life, including their physical health, relationships, ability to engage in hobbies that interest them, and views on work.

If a client identifies work as a source of stress or discomfort, a counselor should explore that further in session, says Hayden, an ACA member who specializes in career transitions with military and veteran clients. This involves uncovering the thoughts and feelings the client associates with their job and how those things tie into the person’s self-concept and align with their core beliefs.

“If work continually comes up in their conversation, let’s stop there and dive deeper, talking more about the work that they do and how they feel about it,” says Hayden, a licensed clinical mental health counselor in North Carolina and an LPC in Virginia. “Have their feelings [about work] changed over time? Do an extensive examination of aspects of career and work and how [they’re] connected to other areas of life. … If you try to artificially separate them [mental health and career], it could potentially be to the detriment of the client … because they are interconnected.”

Asking the right questions

Avoidance behaviors and other signs of distress and unhappiness at work can result from any number or combination of sources, says Montgomery, who co-presented the session “Enhance Counseling Services by Integrating Clinical and Career Counseling Strategies” at ACA’s Virtual Conference Experience in April. She emphasizes the need for clinicians to fully unpack clients’ feelings and emotions about their work situation during counseling sessions.

Montgomery urges clinicians to draw on two foundational counseling skills: asking probing questions and using empathic reflection.

“We [counselors] need to make sure we are asking the right questions. We don’t necessarily want to jump on the ‘you hate your job, let’s get you out of there’ bandwagon. When you pull it apart, it could be a toxic environment, or … a bad fit, or they could make changes to make it a better fit, but often the only option clients see is to leave,” Montgomery says. “We need to explore, explore, explore, explore [the client’s situation] before we jump to any kind of solution formulation.”

When clients talk about how hard work is for them, counselors should use empathic reflection, repeating clients’ statements back to them, to allow them to think through these thoughts, Montgomery says. It may be a knee-jerk response to agree or sympathize with client statements such as “I hate my job” or “Work has been terrible since the COVID-19 pandemic,” but counselors must be careful not to inadvertently reinforce a client’s statement with their reactions, she advises.

Instead, clinicians can probe for details and ask clients to describe the feelings underneath the statements they are making. Montgomery finds that an emotion wheel can be helpful for prompting these conversations, so she suggests counselors keep copies handy in their offices or readily available for screen-sharing during telebehavioral health sessions.

Often, individuals do not fully express their experiences because they do not have the language to do so, Montgomery says. Using tools such as an emotion wheel is a way to increase a person’s ability to better understand and communicate their experience. For example, a client may initially say, “I feel angry at work.” But after looking at the emotions listed on the wheel, they may be able to better articulate their feelings by saying, “I feel underappreciated, exhausted and disrespected at work.” That deeper and clearer understanding is far more beneficial to both the client and the clinician because the solutions to feeling underappreciated are different than the solutions to feeling angry, Montgomery says.

This exploration stage of counseling should also include a focus on identifying clients’ needs and which needs are not being met through work or are being marginalized or curtailed in the workplace, Montgomery adds. For example, a client who is social and benefits from talking through challenges with others may feel isolated and struggle to process things or complete assignments if they’re in a setting where they work alone or are physically separated from colleagues by the office layout. Identifying these needs often provides clarity and helps clients move toward either making changes in their current job situation — such as asking to be moved to a shared workspace or scheduling regular check-ins with their boss — or considering a different position or career, Montgomery explains.

Montgomery first worked in the corporate and nonprofit spheres before switching to a career in counseling. She recalls her own process of adapting to a new role as a counselor educator. After some self-reflection, she realized she craved structure to navigate the varying demands of work as a university professor, and there were some ways she could ask for help and support in this realm from her employer.

Montgomery looked for tools to create structure, such as a whiteboard to make lists and keep notes in her workspace. She also suggested her department streamline processes by creating a master calendar with due dates for evaluations and other important benchmarks. Not only did this modification keep Montgomery from feeling like she was always behind, but several colleagues mentioned that they found it helpful too, she says.

Coping mechanisms

The interconnected nature of career and mental health may cause work-related discomfort to affect clients when they are off the clock. This can manifest in many ways, including sabotaging their ability to get to work on time in the mornings or channeling feelings of frustration or unhappiness toward family members after a frustrating workday.

Amanda Barnett, an LPC who specializes in mental health and work issues with clients at her private practice in Gainesville, Georgia, helps clients who struggle to separate work stressors from their personal lives to build intentionality into their routines. She suggests clients visualize changing “hats” as they transition to and from work. For example, a client may take off their accountant hat and put on their dad hat as they leave the office. For some professions, this transition is literal because employees change into work uniforms or wear a tool belt or other work equipment, notes Barnett, an ACA member. Regardless, she urges clients to take time to center themselves, give themselves a pep talk and be mindful about setting themselves up for the workday or for their return home.

Hembree notes that offering psychoeducation regarding how anxiety manifests in the body and providing tools to lower stress and anxiety in the moment can be particularly helpful with this client population. Breathing techniques can be a useful go-to tool in the workplace, especially because some of these techniques can be used without other people noticing, she says. Hembree, who has extensive experience working with clients through employee assistance programs, often teaches clients “box breathing,” which involves inhaling for four counts, holding for four counts and exhaling for four counts. This technique can be done discretely even when an employee is sitting in a work meeting or preparing for a presentation, she points out.

Another powerful yet simple tool is helping clients realize that they can take a break — even if just for a moment — when things begin to escalate at work. Many clients get so wrapped up in the emotions they feel when they are stressed that their instinct is to dive further into the situation rather than pull back for a moment.

“Unless you’re on a heart-transplant team, you can take five minutes to have a snack, take a break, meditate or do a grounding technique,” Hembree advises. “Even if your boss is breathing down your neck and saying, ‘I need this yesterday,’ you will do a lot better if you take a couple of minutes to ground … and center yourself — and your work will be better because of it.”

Hembree also finds techniques that counter negative self-talk to be helpful with this population. Clients who struggle in the workplace can easily fall into the “comparison trap,” she says. But as is the case when people compare themselves with others based only on what they see on social media, workers see only a portion of others’ lives at work. When a client is bombarded by negative self-talk, a co-worker’s success can send them further down that spiral. It’s easy to compare themselves and catastrophize, thinking that they’ll never be as good as their co-worker, that they are a failure, or that they are about to be fired, Hembree notes.

“Perhaps a co-worker gets praise from the boss. But what [the client] didn’t see is that [the co-worker] stayed up until 2 a.m. to finish [the work assignment], missed their kid’s soccer game, got in a fight with their partner and gave themselves an ulcer to get this modicum of praise from the boss,” she says. “A counselor can offer psychoeducation that others have good and bad days, and you will have a day when you’re the superstar.”

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Disclosure

The decision to disclose one’s mental illness in a work setting can lead to the good, the bad or the ugly. In a best-case scenario, an employer will respond to disclosure in a supportive and understanding way. Employees whose mental health challenges are affecting their work life can find support in an understanding ally — whether it’s a supervisor or a trusted co-worker — who knows the reason behind their work struggles. However, disclosure in a worst-case scenario can leave an employee open to direct or indirect hostility, misunderstanding, awkwardness, retribution or discrimination from an employer.

“There should be an element of dignity in work and being able to say things without any fear. But [counselors should] recognize that there are precarious elements of work that don’t make it easy for people to do that,” says Hayden, who presented “Career Development and Mental Health in the Context of COVID” at ACA’s Virtual Conference Experience. Hayden and the other counselors interviewed agree that disclosing one’s mental illness at work is a complicated issue that must be considered carefully depending on several factors, including how supportive the overall climate is at the client’s job.

Marina Williams, an LPC in Lexington, Virginia, who specializes in helping clients with work issues, stresses that clients should think carefully about what they have to gain by disclosing a mental illness in the workplace. This issue is even more complicated for clients whose work settings can involve direct or indirect repercussions if a worker is deemed unfit. Those in law enforcement, the military or jobs with a security clearance often feel particularly vulnerable about disclosing any type of mental health issue.

“Discrimination for mental health is very common,” says Williams, who presented on workplace bullying at ACA’s 2018 conference. “I recommend that clients not tell anyone [at work], but the exception to this is if they’re having such difficulty that they need to ask for accommodation in the workplace. But even then, I would limit [disclosure] to human resources.”

Hembree has also worked with clients who were treated differently after disclosing their mental illness in the workplace. She has heard clients talk about being treated like “fragile glass,” being denied job advancement or becoming the target of bullying behaviors such as being called a “snowflake.”

“It would be amazing if we lived in a post-stigma mental health world, but we are not there yet,” Hembree says. “I generally do not suggest that people disclose unless they are in a very supportive or progressive workplace.”

When the question of disclosing comes up in counseling sessions, Barnett encourages clients to think their situation through carefully. She cautions clients about oversharing and making the assumption that co-workers are friends. And she reminds her clients that the human resources department works for their employer, not for the employees. “Everything you say to human resources could go on your permanent record,” she tells clients. “Be aware that they have a duty to the company, not to you.”

Barnett once worked with a client who had mixed results after their boss learned about their mental health struggles. The client was having frequent panic attacks at work. Because the workplace was a closed, secure environment, the client couldn’t step outside easily or bring in personal items to help them cope.

The client’s boss became aware of the situation after a workplace incident triggered a panic attack and the client became visibly upset in front of him during the workday. After that, the client received what they termed “reluctant” support from their boss. The boss wasn’t cruel, but he wasn’t overly understanding either, Barnett recalls. The client’s stress also increased when the supervisor revealed that he was leaving and cautioned the employee that the next boss might not be as understanding to their situation as he had been.

What did help, however, were the coping mechanisms that the client learned and honed in counseling with Barnett, as well as a focus on quelling negative self-talk. Barnett and the client also found small ways that the client could stay mindful and calm during the workday, such as by chewing gum.

Clients who work on-site at a job may need to seek permission to leave for therapy appointments. They may also face questions or comments from co-workers about their frequent absences. If a client feels they need to explain their mental health struggles at work, a counselor can help them figure out a way to ask for leave without fully disclosing. For example, Williams says, the person could tell their boss, “I’m going through something right now, and these appointments are helping me.” It’s also OK to simply say, “I have an appointment” and leave it at that, she asserts.

Hembree agrees that disclosure can involve a range of information and doesn’t necessarily have to include details about a client’s diagnosis. She once counseled a client with attention-deficit/hyperactivity disorder who had trouble maintaining focus when he had to sit still for long periods of time such as in trainings or meetings. His solution was to stand and move periodically or ask for breaks with the simple explanation that he was feeling “fidgety.”

Counselors can ask clients how they feel about disclosing and how receptive their workplace might be to their mental health issues and to providing potential accommodations. Most of all, clients should disclose at a level that feels safe and comfortable to them, Hembree says.

“Everyone has to advocate for themselves, individually. That’s going to be different for every person,” she says. “For some, they are desperate to remove the stigma of mental health issues and wave that flag for everyone in their office and create a better environment for [all employees]. But that’s not for everyone. You don’t have to pick up that battle. You don’t have to be the spokesperson for depression [or another diagnosis]. You just have to do the best you can on any given day, and that may be disclosing and it might not be, or [it may be] disclosing in different ways.”

Accommodations

Employees may need to disclose a mental illness in the workplace if they are seeking accommodations that would help their situation. Possible work accommodations include being able to leave work regularly for therapy appointments, reducing an employee’s hours or responsibilities, or relocating from a cubicle to an enclosed office for increased privacy and decreased distraction, Williams notes.

Although the Americans with Disabilities Act (ADA) affords protections for workers, the language in the law guarantees “reasonable accommodation,” Williams points out. Counselors and clients should keep in mind that employers can make a counteroffer or refuse an employee’s request based on how reasonable they perceive it to be.

Hembree urges counselors who are unfamiliar with ADA or the protections it affords to seek continuing education on the topic, do research or consult with colleagues (including professionals in related fields such as human resources) to better support their clients. ADA also has an information hotline (ada.gov/infoline.htm) that counselors or clients can call to ask questions, she adds.

Hayden and Montgomery both suggest that counselors whose clients plan to disclose a mental illness or seek accommodations at work role-play in sessions to help clients gather their thoughts and prepare for the conversation. Hayden advises that it can be helpful for counselors and clients to explore the following questions:

What is the client hoping to gain from the conversation?

How might the conversation go? What do they anticipate happening?

What reaction might they receive? How will they respond to it?

Montgomery encourages clinicians not to make assumptions about a client’s comfort level regarding asking for things they need. Just because a client works in management or a position of authority doesn’t mean that they will easily be able to advocate for themselves, she says. Counselors should also never make assumptions based on the client’s level of education, socialization, cultural background or other factors, she adds.

“Assume everyone is terrified about asking for what they need and go from there,” Montgomery advises. “If we assume that no one is comfortable, then we don’t have to worry about offending someone or leaving someone unprepared because they’re uncomfortable asking you [their counselor] for help with learning how to ask.”

Hembree believes accommodations can be helpful for clients whose mental health struggles at work go beyond being a “nuisance” and truly interfere with their daily ability to do their job. As with disclosure, workplace accommodations — and the process to seek them — fall on a spectrum and will vary from client to client. Hembree says the documentation she has written for accommodation requests has ranged from in-depth reports for clients in government positions to a brief letter confirming that a client left work to see her for an appointment on a certain date and time. No matter the circumstance, she always has clients review the document to ensure they are comfortable with it before she submits it to their employer. She tries to focus her documentation on the client’s needs rather than the client’s problems, Hembree says.

Counselors can also work with clients to explore coping strategies that they can use on their own without having to seek an employer’s permission. In Hembree’s experience, clients have found it helpful to have fidget devices, noise-canceling headphones or calm strips (textured stickers a person can touch to soothe or ground themselves) at their desk. Customizing a workspace by adding plants or using a lamp rather than overhead florescent lighting can also be calming, she notes.

In other cases, employees can ask for measures that would help their situation without framing it as a mental health accommodation, Hembree says. For example, a client may notice that a different workspace is available in their office and ask to be moved without giving a reason.

Making work work

What is the tipping point between struggling at a job because of an underlying mental health challenge and foundering in a position that simply is not a good fit for someone with a client’s diagnosis? There’s no easy answer to that question, Williams says, but “keep soldiering through” is not a solution.

The counselors interviewed for this article agree that finding answers to this question should involve exploration of a client’s identity and how the client feels their job aligns with their identity and personal values. It can also be helpful to talk through the timeline of when a client started to struggle at work and whether that coincided with other events in their life, Williams notes.

Barnett suggests that counselors prompt clients to think about how long they’ve pictured themselves in their current role. For example, they could ask, “Have you always wanted to be in this career? Is it your life’s passion? Or is it simply a way to get dollars in your bank account?”

“You have to get to whether [the job] fits with the core of their identity,” Barnett says. Ask the client, “Is this what you really want to do? Is it your passion? Is it meeting your needs? If not, give yourself that freedom to make a choice.”

Counselors can also offer the perspective that clients don’t have to stay in a career simply because it’s what they studied in school or have been doing for years, Barnett notes. Clients can try out other careers by taking on a side job or working part time and slowly transitioning into another position if it is a good fit for them.

Above all, the client should guide the conversation, Montgomery adds. “Work, like relationships, can be a great source of purpose and meaning and can be a place where we can grow and do really exciting things and fulfill our brain’s desire for stimulation. It also can be a place where we get a paycheck, and we go home and we get all those things in other places [outside of work],” Montgomery says. “If getting purpose from work is really important to you and you want to do that, then make the decision that supports that result. But it’s also OK to just get paid and use that money to do fantastic things in other places. … We get all kinds of messaging that you should be saving the world through work. But the reality is that it’s not true for everyone. Everyone has different needs, and we just need to explore how to get those met.”

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.