Thursday, 2 September 2010

Back to work

Returning from a blissful holiday in the sun, it seems it's not only me who's finding it hard to get back to work.

Aged 38, Penelope is single and very much alone. Her family are all abroad and she finds it hard to make close friends. She's been seeing me on and off for a few months now, presenting initially with symptoms of depression and on further occasions to request medical certificates (sick notes).

Whilst her social circumstances are making the situation worse, her major problem centres around her employment, or lack of. Whilst she has had plenty of jobs since she moved to the UK, they have largely involved working in cafes and bars which she finds incredibly stressful and hard to manage. Her love is for the arts and although she works regularly for a film production company, her work is unpaid. Should she be able to find a salaried job in this kind of work, I'm sure she would flourish, but in the current climate that's pretty tough. As it is then, her employment and social problems are making her anxious and depressed and, initially at any rate, it seemed sensible to give her a bit of time off to organise herself and recover.

However, now that she's returning monthly for repeated medical certificates, I'm finding it harder to continue to justify that decision. Her predicament is this; she cannot cope with the kind of job that she is able to get but can't get the sort of job that she'd like. Although she certainly has some symptoms of anxiety and depression, I can't honestly say that she is not fit to work, yet to force her to go back to a bar job would inevitably result in a worsening of her symptoms.

This is really more of a social problem than a medical one and I'm at a loss as to how I can help. Part of her problem lies in her personality and no amount of psychological therapy or counselling is going to change that. Dishing out repeat certificates is surely unhelpful, yet cutting them off and waiting for her to return with a true depression is not appealing either. So where do I go from here?


  1. I'm with you that repeated sick notes seems unhelpful and arguably is becoming inappropriate.

    If it's that she can work, but chooses not to, it's a grey area but really it's not as if she has a medical condition precluding her from employment. I guess within the WHO definition of health, as a state of physicla, mental and social wellbeing, and not merely the absence of disease, you could argue her social domain is impinging on health, thus sick notes are justified. But I think it's pushing the boundaries of health a tad too far.

    Personally in similar situations I've been inclined to offer choices, describing how unfortunately sick notes haven't been useful (you're no better, your situation's not changed, nothing's fixed/different) so it's not sensible to keep doing something we're not seeing as therapeutic, so let's stop doing it. But let's not be harsh, let's be helpful and generous and indeed afford you weeks to look at options and changes you'd consider/do. So although sick notes haven't seemed o help, here, have a whole month more, but that's your last one. Over the next 4 weeks, look at how you can manage best, with the seemingly bad choices laid before you, and let's see how you opting for what you can choose for yourself from these albeit unattractive options then plays out.

  2. A great dilemma, but The Shrink has nailed it. I guess there is a lot to do towards achieving that she keeps moaning about her vicious circle and she chooses how can she manage objectives ( enjoy a bar work, promote on it, or find an art work, or maybe a bit of both ). And just by making her choose you are empowering her!!

    thanks for sharing PP

  3. Yup, I'm with you on this one and that's what I've gone for. Only I've been a little more generous / soft and given her until the end of the year to sort out a job - although she still has to see me every month to assess progress! Her psychologist is of the opinion that there are still some genuine depression/anxiety symptoms at play and she seems to be engaging in treatment well. She's also actively looking for work. So, maybe I'm a walk over, but I figure she could use a bit more time.