Roland Jackson is referred to Susan, a hospital social worker, after his second visit to the Emergency Department (ED) for trouble breathing, rapid heartbeat, and panic. Tests have ruled out medical reasons for his symptoms. He is a 35-year-old married African-American with two sons, ages 10 and 13. He is employed in a manufacturing plant, one of few employers in this small town offering good wages and benefits.

At Susan’s first appointment with Mr. Jackson, she reads his hospital record and asks him to describe the experiences that led him to the ED, paying special attention to his affect as he speaks and seeking details about what happened on those occasions. She also asks him to describe a typical day, including highlights (“breakfast and dinner with my wife and boys”) and lowlights (“interactions with my boss”). Mr. J’s wife attends this session, and she provides a description of when her husband’s problems became apparent to her and how he is different now than he was before.

Noticing that Mr. Jackson becomes anxious when he talks about work, Susan asks him if there are problems there. He relates that his boss is extremely critical and disrespectful of him and other employees, frequently shouting and using racist remarks and epithets. “I worry all the time about losing my job. I can hardly sleep for wondering how I could support my family—how we would survive– if that happened. Sometimes I think about that all night.”