Dealing with mental illness in the operatory

Issue 5

You’ve noticed a change in one of your most dependable employees. She’s been missing a lot of work lately, and when she does come into the office she’s usually late. Her productivity is slipping and you know her behavior change is affecting the rest of the team.

You’ve noticed a change in one of your most dependable employees. She’s been missing a lot of work lately, and when she does come into the office she’s usually late. Her productivity is slipping and you know her behavior change is affecting the rest of the team.

You suspect this employee might be struggling with a mental health disorder. About one in five working-aged Americans experience symptoms of a mental health disorder in any given month, according to the February issue of the Harvard Mental Health Letter, and is certainly something that can happen in your practice. When it does, you have to be very careful about how you handle the situation. You can’t confront the employee about the mental illness you suspect she has, or try to play counselor. You have to get outside help. If you try to handle it on your own, you’re opening yourself up for legal trouble down the road.

Having the talk

If you think a mental health issue is negatively affecting an employee’s performance, you need to talk to an outside professional before you sit down with that employee, said Dr. John Jameson of Jameson Management. Talk to an HR professional in your area and a labor law attorney to get some advice before you have that conversation.

No matter what your suspicions are-or if you know for a fact the employee has been diagnosed with depression or anxiety-this shouldn't be the focus of any conversation you have with the employee, said Tim Twigg, owner and president of Bent Ericksen and Associates. You should focus on performance issues, not what might be causing the issues. Use the job description to talk about where the employee is falling short. Don’t go down the path of assuming, accusing or labeling the employee as someone with a mental illness.

You also can turn to the office policy manual, said Penny Reed Limoli, owner of the Reed Limoli Group. While the manual shouldn’t specifically address mental illness, employee expectations should be clearly spelled out-from coming to work on time to treating other employees with respect. If the employee is struggling with these or any other job requirements, you have to address the problem. Even though this can be a difficult situation that must be handled carefully, it isn’t something you can ignore and hope will go away. Talk to the employee as his or her boss, not a friend or counselor. Remember everything you talk about should be based on performance and how not meeting expectations affects the staff, the practice and the patients.

“You have to treat mental illness like any other illness,” Limoli said. “If someone is getting strep throat and missing work, as a business owner you want the employee to be healthy, but at the same time dental offices are small. If the same person is missing work over and over it hurts the practice.”

Document everything that is said during the conversation, Limoli said. Make sure you talk to an attorney about your concerns and solicit his or her advice onhow to move forward to carefully resolve the situation. 

“In this day and age, you have to get an attorney involved beforehand, prior to deciding how to handle the situation,” Limoli said. “It’s a balance. You want to take care of your employees but you can’t be at their mercy if they can’t be there.”

When an employee approaches you

You may find yourself in a situation where an employee tells you about a recent mental health diagnosis, Dr. Jameson said. This employee might bring in a doctor’s note that indicates some restrictions, meaning he or she may not be able to perform some job duties. This could mean you need to modify the employee’s current job or re-assign the employee to another position in the practice. If this happens, remember the employee is likely to be covered under state and federal disability laws. You have to try to make accommodations, unless you want a lawsuit on your hands. But, if undue hardship to the practice is shown, you may be able to end the employment relationship if that’s what you believe is best for the practice and the rest of the staff. But don’t think that’s the end of your worries. This decision can be challenged in court, and isn’t something you can take lightly.

Just like with the other scenario, you have to document everything that is said throughout the process and you have to get a lawyer involved, Dr. Jameson said. Document based on behavior and activity, not based on the illness.

Offering assistance

While offering assistance is a nice gesture, both Dr. Jameson and Twigg agree that you should proceed cautiously when offering  mental health resources to any employees you have concerns about, even if they come to you. Americans with Disabilities Act guidelines are strict, but state laws often are more strict and constantly changing. Dr. Jameson suggests contacting Twigg’s team members at Bent Ericksen and Associations because they keep up-to-date on state laws and can guide you through these types of challenges.

“Bottom line, this is not a win/win situation for dentists if they mess up,” Dr. Jameson said. “That can be from communication with the employee or how they handle it from the beginning. Any misstep can be lots of trouble for the dentist.”

Dr. Alan Axelson, a member psychiatrist with the American Psychiatric Foundations’ Partnership for Workplace Mental Health, said it’s a good idea for bigger offices to have an employee assistance program on retainer, whether it’s something through your state dental association or a program you find on your own. These programs offer people your employees can talk to, and they look at whatever the problem is from both the employer’s and the employee’s point of view-which is good for you if the employee blames his job for his problems.

“You can get into legal difficulty if you say, ‘Look you haven’t been showing up so I’m going to fire you,” Axelson said. “This is saying ‘I’m concerned about your performance and your personal welfare.’ To refer someone to an employee assistance program, you’re doing something all sorts of employers do.”

Axelson and Limoli support providing assistance, as long as you do it the right way. Don’t tell them they have to call or visit a counselor, or that you even recommend that they do so. Give them the resources, maybe it’s just a phone number for a crisis hot line, and they can decide where to go from there. This is an option for smaller practices that may not want to pay the fee for having an assistance program on retainer, but is not something you have to do if it makes you uncomfortable.

Other team members will notice

If one employee is struggling with a mental health disorder, it will effect the rest of your staff, Axelson said. As a small staff, it’s difficult not to get involved when a co-worker starts talking about personal problems. They spend time talking it out, and that can become a distraction that leads to decreased efficiency and productivity.

Beyond that, co-workers will notice when someone repeatedly comes in late or calls in sick at the last minute, and they won’t like it. No one wants to feel like they have to pick up someone else’s slack at work. Dealing with this day after day will lower your staff’s morale, Limoli said, again resulting in efficiency and productivity problems for the practice. No matter how much the rest of the staff loves that team member, resentment will grow if one employee continues to miss work. In a small dental team, everyone has an important role, and if someone isn’t there every day or is always late, it makes it more difficult for the rest of the team members to do their jobs and meet goals.

And when the employee does show up, he’ll likely be distracted and won’t perform at his best, Axelson said.

“Precision is very important and things have to be right,” Axelson said. “If someone is depressed or anxious and having trouble concentrating, that person may not get things correct, so you’ll have mistakes that impact productivity and efficiency in the office.”

Create the right atmosphere

As dental providers you and your staff members are involved with your patients’ total health care. You’ve likely treated a patient with a mental health disorder at some point in your career. Teaching your staff to be sensitive to these issues that may come up with patients can make it easier to deal with the same issues that a staff member may deal with later.

“If a hygienist is working on a patient and that patient says my husband left and I’m depressed, the hygienist should tune into that,” Axelson said. “Staff members should know what to do with patients in distress. That sets them up to deal with employees who may have these problems.”

Making your practice one that’s sensitive to mental health disorders is key to making your employees feel like they can come to you if they are having a problem, Axelson said. If you or other staff members make jokes about anxious Mrs. Jones or that whiney patient who is going through a divorcee, staff members who are struggling with problems won’t feel comfortable telling you about what they’re experiencing. While you don’t want to play counselor, the sooner you know about a problem the sooner you can take steps toward fixing it.  

Know your role

It’s natural for you to be concerned about your employees, especially if you think they’re struggling with a mental health disorder. But you can’t get too involved, or you open yourself up for a world of trouble. You also can’t just fire someone who’s suddenly become depressed. Discrimination laws protect these employees, and you will have to fight a lawsuit if you take drastic action without taking the proper steps.

Anything you say or do can be misinterpreted and later used against you, Twigg said. That’s why it’s so important to document everything and show that, if you do have to let the employee go, you gave him or her every chance to rectify the situation. Remember if you do end up in court, the burden of proof is on the employer to prove the action took was not discriminatory or retaliatory.

Ultimately, it comes down to this: You have to protect yourself, your practice and your patients.

“It’s all about trying to be as fair as possible, but if it’s really beginning to affect the practice, you can very quickly, with the best of intentions, get yourself in a not-so-great place,” Limoli said. “I love my dental teams but we have to protect these doctors, or there’s no place for the employees to work.”

Renee Knight is a senior editor for DPR. Contact her at

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