Holding it together at work during a crisis

Patient Guide

Sustaining high performance in public while your private life falls apart has a cost. On the tightness in the chest that doesn't go away, and when to get evaluated.

September 18, 20269 min read

Illustration for the article: Holding it together at work while your life falls apart

The meeting starts at nine.

He arrives five minutes early, as always. Greets people by name, makes the usual remark about the traffic, sits in the same chair. When his turn comes he speaks for seven minutes with complete clarity, lays out the arguments in the right order, answers the difficult question without hesitating. Someone across the table writes something down. The meeting finishes on time.

And he can barely remember a word of what he said.

That is not a figure of speech. It worked, and it worked well — the competence was intact, nobody noticed anything — but it was an automatism running on its own while his head was somewhere else. On the document that arrived yesterday. On Sunday’s conversation. On the sentence someone said that he could not find an answer to.

Then comes the corridor, the lift, the car. And it is there, in the car park, that the thing nobody saw shows up: a tightness in the middle of his chest that has been there since he woke and did not lift during the meeting or after it.

When someone arrives at the consulting room in that state, the sentence tends to come out roughly like this: I’ve got this tightness in my chest all day, I feel like I’m going to pack in any minute from the stress. Almost always said quickly, almost in passing, like someone reporting a logistical problem rather than a complaint.

Perhaps you recognized something in that scene. Or perhaps you thought of someone in your office — someone who is still delivering everything on time and about whom, even so, you have had an odd impression these past few weeks. If so, either way, it is worth saying straight away: there would be nothing wrong in that. Sustaining high-level performance in public while private life is collapsing is one of the most expensive things a person can do — and the cost shows up exactly like that, in the body, before it shows up anywhere else.

What nobody notices is precisely the problem

There is a cruel logic here, and it needs saying plainly.

People with a position, deadlines and a reputation to protect are usually exactly the people with the most resources for keeping the front intact. Years of training in speaking well under pressure. A team that depends on your steadiness. A track record of never having slipped. All of it works — and it works for far longer than would be reasonable.

The result is that the deterioration stays invisible to everyone, including to the person inside it. Nobody comments. The deadlines are still met. The work goes out. And since the only available evidence would be someone saying “you seem different”, and nobody says it, the conclusion that forms is: so it can’t be that serious.

What I tend to see is the opposite. When someone manages to keep their public performance perfectly steady through months of personal crisis, that is not a sign that everything is under control. It is a sign of how much is being spent to make it look that way.

Keeping up the front is not free

Maintaining appearances takes active work, all day, without a break.

You have to monitor your tone of voice. Choose what will not be said at lunch. Decide whether or not to answer the question about the weekend. Rehearse the short version of the story in your head, in case somebody asks. Hold the reaction when a colleague, knowing nothing, says something that lands exactly on the spot.

That effort does not appear on any workload spreadsheet, but it consumes an enormous amount. Which is why exhaustion, in this situation, bears no relation to the number of hours worked. You do what you have always done and get home as though you had done twice as much — and then you tell yourself off for it, because objectively you did nothing out of the ordinary.

You did. You did the work, and you did the upkeep of the image on top of it.

The body gives it away first

Long before your head accepts anything, the body is already flagging it. And it flags it in ways that look clinical enough to justify a trip to the cardiologist before anything else.

The constant tightness in the chest. Breathlessness without exertion. The racing heart in perfectly ordinary situations. The clenched jaw on waking. The gut that has gone off. The tension in the shoulders that has turned into a daily headache. The insomnia that is not difficulty falling asleep but waking at three in the morning with your thoughts already at full speed, and no chance of getting back off.

It is common for these people to have the full check-up. Normal tests, normal echocardiogram, everything in order. And then the usual line: “it’s stress.” What almost never comes with it is the second half — that stress sustained over months is not a passing remark, it is a condition with consequences, and that there is a point at which it deserves to be looked at with the same seriousness with which the heart was looked at.

Where it stops being a crossing

Feeling terrible during a divorce, a loss or a professional rupture is not an illness. It is the expected response of any person to a large event. None of that needs treating as a symptom, and that is not what I am saying.

What changes the nature of the conversation is the functioning. Four questions usually separate one from the other:

Has sleep settled at any point? Bad nights during a crisis are expected. Weeks on end of being awake in the small hours, month after month, are not just a reflection of what is happening — they start producing consequences of their own, on mood, attention and judgment.

Has concentration come back at any point? Not the concentration of one bad day. The sustained capacity to read a whole document and retain it, to follow a meeting from beginning to end, to write without reading the same passage four times over.

Can you still decide? This is the point that gets noticed least and matters most in people who decide for a living. Not difficult decisions — those get costly for anyone. Ordinary, everyday decisions, which start being put off or handed on without the person noticing.

Is there still any respite? A dinner where you forgot for two hours. A Saturday that went reasonably well. When the gaps disappear entirely and the state becomes continuous — same intensity, every day, regardless of what happened that day — that is a different kind of information.

If the answers point to months without sleep settling, without concentration and without respite, it is no longer about getting through a difficult stretch. It is about something that has settled on top of it and started moving on its own — and that does not lift because the proceedings ended, because the dust settled or because you took a holiday.

The objection that almost always comes up

“If I stop to deal with this, I won’t be able to keep the routine going.”

It is a legitimate objection and it deserves an honest answer: seeking an evaluation does not mean stopping anything. It does not mean time off, it does not mean a sick note, it does not mean that anyone at your work will know anything about it. A private consultation happens in a discreet setting, outside your workplace, and what is said there is protected by medical confidentiality. If you have questions about what gets recorded and how, that is a perfectly legitimate thing to ask in the very first appointment.

And there is an important inversion in this arithmetic. Risk to a career rarely comes from having sought an evaluation. It comes from months of compromised judgment, of decisions made on four hours’ sleep, of irritability wearing away professional relationships built over twenty years. That does leave a mark — and it is the kind of damage nobody notices while it is happening.

About what carries on after the phase passes

There is one last thing that usually only shows up later, once the acute crisis has resolved.

A lot of people discover, then, that the capacity to function impeccably while everything collapses was not built in that moment. It was already there. It was learned somewhere along the way, it was useful for a long time, and it became the only response available.

That does not get resolved with information or with willpower, because it is not a mistake to be corrected. It is a way of being in the world, with a history of its own. A space of analytically oriented psychotherapy is for that — not as a technique, not as training in stress management, but as a place where your own relationship with this way of functioning can be examined slowly, with someone who occupies the outside position that nobody can occupy in relation to themselves.

None of this needs deciding now.

If the tightness in your chest is there from the moment you wake, and has been for months, it might be worth just a conversation to understand what is going on. Not so that you become a patient of something. So that you know what it is.

You do not have to conclude anything today.