Encouraging disclosure of psychiatric disability: mental health consumer and service provider perspectives on what employers can do.

Once the decision to disclose a psychiatric disability to a potential or current employer is made and careful consideration has been given concerning the benefits of disclosure, care must be taken to prepare the way to assure the most favorable environment for disclosure. To assist in the creation of the open climate necessary to encourage disclosure, consumers and service providers suggest a variety of strategies for employers; in making their services available to employers, they can facilitate the development of an accepting workplace environment.

Concerns About Disclosure

Many consumers are afraid of disclosing to an employer their experience with disabling mental illness (U.S. Congress, Office of Technology Assessment, 1994). Society, through television, movies, and other media, portrays people with mental illness negatively. Often, people mistakenly believe that people with mental illness are intellectually impaired and are unable to learn new skills and knowledge or are unable to work productively and contribute to society. Consequently, consumers are often afraid that if they disclose before employment they may not be hired or that if they disclose after they might either not be promoted or may even be terminated, in spite of protection under the Americans with Disabilities Act (ADA). Also, some consumers who have disclosed have experienced difficulty in receiving positive feedback from their supervisors: either the supervisor would only provide negative feedback--because the supervisor was trying to get rid of them--or the supervisor would be hesitant to provide any constructive criticism for fear of upsetting or hurting the feelings of the employee.

In balancing these negatives against disclosing, consumers and service providers also must consider some of the benefits. After disclosure, consumers are free to be themselves, relieved of much of the stress caused by concealing a significant part of themselves from their coworkers and supervisors. Without that added stress and with a sense of being accepted for who they are, employees with psychiatric disabilities can be even more productive and better able to concentrate on their work. Finally, once the consumer has disclosed, he or she is able under ADA to request reasonable accommodations. Preliminary data from a supported employment program for people with psychiatric disabilities in Maryland indicate that consumers who disclose disability and request reasonable accommodations were employed for a longer period of time than those who did not disclose (Fabian, Waterworth & Ripke, 1993).

In deciding whether to disclose, there are several issues that consumers and providers must consider. Consumers and providers must assess the employer's attitude and openness and his/her experience employing people with psychiatric disabilities; the acceptance of coworkers; and the direct supervisor's experience with giving constructive feedback and his/her general management style. Once the decision to disclose is made, it is important to choose when and to whom to disclose. Consumers should be aware that under the law they can disclose at any time--before or during the initial interview, in followup interviews, after the job offer but before starting work, or at any time once employed. It is advised, however, that disclosure occur before serious performance problems arise on the job and also well in advance of disciplinary or termination procedures (U.S. Congress, Office of Technology Assessment, 1994). Disclosing sooner rather than later increases the opportunities for developing an open, trusting relationship with the employer and for identifying acceptable and reasonable accommodations.

Changes in Hiring

There are a number of actions employers can take to encourage disclosure of psychiatric disability in the workplace and to create the open, accepting environment where consumers feel more comfortable about making the decision to disclose.

Employers can post policies regarding hiring people with disabilities in recruitment literature, job postings, and in Equal Employment Opportunity literature.

Statements regarding the company's willingness to make reasonable accommodations for applicant's disabilities in the application, testing, and interview process can be noted (Parrish, 1991, Zuckerman, Debenham & Moore, 1993). Employers can recruit from colleges, rehabilitation agencies, mental health agencies, vocational or technical training programs for people with disabilities, or from psychosocial rehabilitation programs.

Interviewers should be trained not only in the legal and illegal interview questions under ADA guidelines but also in how to sensitively respond to an applicant who does disclose a disability, intentionally or inadvertently. Expressing appreciation for the disclosure and focusing on the performance of the job tasks may help put the applicant at ease.

Finally, describing examples of some accommodations in the hiring process, specifically some that people with psychiatric disabilities might need, such as untimed tests, interview in a private office, accompaniment by a job coach (Zuckerman, et al., 1993; Parrish, 1991; Mancuso, 1993, 1990; Howie the Harp, 1992) may indicate to people with psychiatric disabilities that the employer is sensitive to their needs.

Changes On-The-Job

In addition to the above, there are a number of strategies that employers can use in the on-the-job aspect of employment to create an accepting workplace culture.

Employers can develop or locate educational materials about reasonable accommodations, mental illness, the impact of mental illness in the workplace, and treatment and rehabilitation. Providing literature such as booklets on ADA and mental health consumers communicates an openness to employees about psychiatric disabilities (Mental Health Law Project, 1992). For example, Mt. Auburn Hospital in Cambridge, Massachusetts, has pamphlets on depression displayed outside the cafeteria alongside material on divorce, alcohol and drug abuse, and other topics. Educational materials can also be in the form of fact sheets posted in employee break rooms or available in human resource offices.

Articles can be written and published in employee newsletters. For example, Boeing Corporation has recently published an article on depression in their employee newsletter.

Some employers are now also participating in National Depression Screening Day, held each October during Mental Illness Awareness Week (Business & Health, 1994a). Employers can notify employees about their participation in National Depression Screening in a number of ways: posting notices, sending memos, or including notes in employee paychecks. In 1993, 1,300 facilities in all 50 states screened 56,000 attendees. More than 50 percent scored positive for depression and were referred for outpatient treatment or hospitalization (B. Kopans, personal communication, August 1994). Companies can conduct an onsite screening or refer employees to local screening sites in the community.

Employers can also begin education and training programs for managers and employees. Training supervisors about various types of mental illness, potential signs of mental illness, how to deal with performance problems, how to identify reasonable accommodations, and how to identify resources available to assist employees with psychiatric disabilities is crucial.

First National Bank of Chicago teaches supervisors about the pervasiveness of mental illness and how it affects healthcare costs for the corporation (Business & Health, 1994b). First National Bank of Chicago gives pointers on how to recognize the symptoms of mental illness. The bank stresses that supervisors are taught to identify symptoms of mental illness but not to draw conclusions or attempt to diagnose or treat the employee. When supervisors recognize these patterns, they refer the employee to its Employee Assistance Program (EAP). The success of First Chicago's program is evident. In the past, almost all referrals to EAP were self-referrals. Now, about 40 percent of EAP referrals are coming from supervisors (Business & Health, 1994b).

NYNEX Corporation of Lowell, Massachusetts, has had a training program for employees as part of their Wellness Programs. This training seminar highlighted the symptoms of mental illness and described reasonable accommodations and possible treatments. This seminar was in a series which included alcohol and drug abuse, as well as lectures on PMS, exercise, and other topics. The training program was given by a consumer-run center--the Mental Health Consumer Resource Center at McLean Hospital in Belmont, Massachusetts.

For employees with psychiatric disabilities who are having difficulty on the job, employers can consult with rehabilitation specialists knowledgeable about mental illness in the workplace. This employee-specific consultation can involve analyzing the technical and interpersonal demands of the job, assessing the implicit social and behavioral expectations of the specific job situation and the supervisory style used, evaluating the employee's functioning regarding these demands and skills, and recommending the skills to be developed in the employee, the supports or reasonable accommodations to be developed in the environment (physical, intellectual, and interpersonal), and the services needed to improve employee functioning. Describing the range of accommodations for psychiatric disability can best be found in other sources (Zuckerman, Debenham, & Moore, 1993; Parrish, 1991; Parrish & Mancuso, 1991; Mancuso, 1993, 1990; Parry, 1993), but often involve changes in supervisory strategies, communication, work schedules, and physical environment. Often, some of the accommodations are what any employee would want if he/she had a choice (e.g., an assigned parking space, a private office, balanced feedback from a supervisor). In these situations, the supervisor must be prepared to respond to the envious reactions of coworkers while still protecting the confidentiality of the employee with the psychiatric disability. Responses such as "We provide what our employees need in order to do their jobs well" communicates an employee-centered culture and may decrease resentment.

For employees who are returning to work from hospitalization or leave of absence after publicly "breaking down" on the job in front of other employees, employers can ease that transition back to work by arranging for a mental health or rehabilitation professional to educate the other employees and respond to any questions or concerns. This is especially important if the employee with the psychiatric disability is a supervisor or an executive. For example, in a case study prepared by Julia Lieblich (1994), a chief of structure planning was hospitalized for manic--depressive illness. Prior to his return to work, it was recommended that a psychiatrist be made available to explain this illness to the other employees, in the hope that this would ease their emotional burden as well as the executive's upon his return.

Changes in Benefits and Privileges

Employers can also demonstrate their commitment to employing people with psychiatric disabilities by making changes in the benefits and privileges aspect of employment, such as by modifying their own EAP or contracting with an EAP that specializes in psychiatric disability and rehabilitation techniques for this disability. Educating employees about the availability of EAP and the types of assistance provided (referral, consultation, career counseling, individual therapy) is useful. Some companies have structured the EAP so that the employees can use an EAP counselor as a behind-the-scenes support--someone safe to talk to when having a panic attack, someone to process angry feelings toward a coworker or supervisor, and/or someone to help employees develop skills around socializing and connecting with coworkers. Although these actual interactions may be relatively brief (15-30 minutes), they may occur periodically with the same EAP counselor and may operate contrary to the typical "consult-and-refer" approach. If this becomes too cumbersome for the EAP counselor to manage, he/she can refer the employee not only to therapy resources but also to professionals who specialize in employment and rehabilitation approaches, such as supported employment or psychiatric rehabilitation professionals. These specialists can specifically focus on the functioning-at-work aspects of the employee, rather than only on the medical or psychiatric condition and treatment.

Employers can also be careful to choose health insurance plans that provide comparable coverage for mental health as for physical health. Providing flexible, cafeteria style plans also gives employees with psychiatric disabilities a variety of options to meet their health coverage needs.

Sick leave policies can also be modified to allow the use of sick leave for mental health reasons--rather than limiting sick leave to physical health conditions; for example, sick leave or unpaid leave can be advanced for psychiatric hospitalization. Occasionally, companies have allowed other employees to contribute sick time to another employee.

Another strategy that employers can use to respond to the needs of employees with disabilities is to establish a conflict resolution panel (Zuckerman, et al., 1993). This panel might function as a resource in identifying reasonable accommodations as well as for appealing company decisions concerning them. This strategy demonstrates a commitment to involving others in decisions regarding accommodations and provides the employee with psychiatric disability with recourse should an accommodation initially be denied.

Clearly, there are a variety of things that employers can do to create an open, accepting environment that is conducive to disclosure. Employers benefit by creating a company situation which promotes diversity, recruits and retains talented employees with disabilities, and provides employees with the feeling that the company is one which is concerned about its employees and their welfare. Mental health consumers and service providers are in a unique position to assist employers in making the changes needed to create an employer open to employing people with psychiatric disabilities.

Consumer and Provider Interventions

Mental health consumers and service providers can do much to help employers promote acceptance of people with psychiatric disabilities in the workplace. The first strategy is to survey employers regarding their needs for information about mental illness, how to recruit qualified applicants with disabilities, what rehabilitation services are available to support employees and employers, effective supervisory strategies, ADA and its impact on people with psychiatric disabilities, reasonable accommodations, and other topics. One consumer organization has developed a Mental Health Resource Center based at McLean Hospital in Belmont, Massachusetts. This center has a corporate relations division which surveyed employers in the Boston area about their interest in various topics and is planning educational programs for employers.

Rehabilitation service providers and consumer--run employment programs can also refer qualified applicants to employers. Employers are looking for potential employees who are able to do the job with or without reasonable accommodations. While some employers are also interested in hiring people with disabilities for altruistic reasons, the bottom line is that the work needs to be done. It is good business to hire people with disabilities only if they are qualified to do the job. The more qualified the applicants referred by consumers and providers are, the more real is the assistance provided to employers, and the greater will be the credibility the organization has with the employer.

Service providers and consumer--run employment programs can also offer supported employment services not only to referred applicants, but also to other employees with psychiatric disabilities who may need such services. For people with psychiatric disabilities, this might involve much more offsite, discreet support than onsite technical training in job skills. It is also important for employers to be sensitive to confidentiality issues in referring the employee with the disability, especially regarding the employee's coworkers.

A related service already mentioned is employee evaluation. Service providers and/or consumer employment programs could inform employers about assessment and consultation services available for their employees with psychiatric disabilities experiencing job performance problems.

Finally, general worksite education and training programs can be implemented based on survey results. In particular, employers may be looking for experts in ADA and mental illness, effective supervisory strategies identifying reasonable accommodations, interviewing and responding to disclosure of psychiatric disability, changing the workplace culture, and a variety of other topics. This education can be offered in several different ways--as in--service training at specific worksites, at employer breakfasts, at other special events, or in publications. For example, the Manic--Depressive and Depressive Association in the Boston area and the Eli Lilly and Company sponsored an evening of panel discussions on depression in the workplace; special displays and information on networking were also provided for area employers. The Boston Federal Executive Board (representing each referral agency in the Boston area) designed their October Disability Awareness Month event in 1993 to focus on psychiatric disabilities. This event included workshops on psychiatric disability in the workplace and reasonable accommodations, as well as a luncheon and an awards ceremony for employees and supervisors of the year.

Conclusion

The strategies mentioned in this article are only a few of a range of interventions that can help employers create an open, accepting work environment. Several of the references on psychiatric disabilities in the workplace cited in this article are excellent resources for employers. Many employers are already beginning to institute culture change in their workplaces and including people with psychiatric disabilities in the work force. Rehabilitation and supported employment service providers and mental health consumers are in a unique position to facilitate the needed changes to increase the employment status and acceptance of people with psychiatric disabilities.

Bibliography

(1.)Staff (1994a). Getting help can be the biggest challenge. In Special Report: Helping employees overcome depression. Business and Health, 12(4), Supplement A, 11--15.

(2.)Staff (1994b). Employers take action in the fight against depression. In Special Report: Helping employees overcome depression. Business and Health, 12 (4), Supplement A, 17--22.

(3.)Fabian, E.S., Waterworth, A., & Ripke, B. (1993). Reasonable accommodations for workers with serious mental illness: Type, frequency and associated outcomes. Psychosocial Rehabilitation Journal, 17(2), 163--172.

(4.)Howie the Harp (1992). "A crazy folks guide to reasonable accommodation and psychiatric disability." Oakland, CA: Oakland Independence Support Center.

(5.)Lieblich, J. (1994). Managing a manic--depressive: Harvard Business School case study. Harvard Business Review, May--June, 20--32.

(6.)Mancuso, L.L. (1990). Reasonable accommodations for workers with psychiatric disabilities. Psychosocial Rehabilitation Journal, 14(2), 3--19.

(7.)Mancuso, L.L. (1993). Case studies on reasonable accommodations for workers with psychiatric disabilities. Available from: California Department of Mental Health, Attn: Publications, 1600 9th Street, Room 250, Sacramento, CA 95814. (916) 654--2678, no charge.

(8.)Mental Health Law Project (1992). Mental health consumers in the workplace: How the Americans with Disabilities Act protects you against employment discrimination. Author: Washington, D.C. 40 pages.

(9.)Parrish, J. (1991). Reasonable accommodations for people with psychiatric disabilities. Community Support Network News, 8(2), 8.

(10.)Parry, J.W. (1993). Mental disabilities under the ADA: A difficult path to follow. Mental and Physical Disability Law Reporter, 17(1), 100--112.

(11.)U.S. Congress, Office of Technology Assessment (1994). Psychiatric disabilities, employment, and the Americans with Disabilities Act OTA--BPP--BBS--124, Washington, D.C.: U.S. Government Printing Office, S/N 052--003--03166--5.

(12.)Zuckerman, D., Debenham, K., & Moore, K. (1993). The ADA and mental illness: A resource manual for employers. Washington, D.C.: American Bar Association and National Mental Health Association, 88 pages.

RELATED ARTICLE: Next Steps in Social Security Disability Process Redesign 

Moving ahead with the initiative to redesign how Social Security disability claims are processed, Shirley Chater, Commissioner of Social Security, has released Disability Process Redesign: Next Steps In Implementation. This blueprint describes how the agency will develop, test, and implement dramatic improvements in the disability process. Copies of the document can be obtained by calling 1--410--966--8255; writing to SSA, Disability Process Redesign Team, Box 17052, Baltimore, MD 21235; or via Internet (access at World Wide Web (WWW) Server (www.ssa.gov) or gopher.ssa.gov or ftp.ssa.gov).

In releasing the plan, Commissioner Chater said, "This strategy document describes the 'who, what, and where of implementation and provides a timetable and staging plan for the various features of the redesigned process.... In response to the need for urgency, we have developed a set of short-term initiatives to reduce pending workloads and processing times. These short-term initiatives will aggressively address our current disability workloads."

Calling Next Steps In Implementation an action document, Chuck Jones, recently named Director of the Social Security Disability Process Redesign Team, said, "It describes our best thinking on when specific process changes will actually occur...and...the underlying structure we have put in place to facilitate disability process change at SSA and the DDS's [Disability Determination Services in each of the states].

"Next Steps...is not a final plan. This project is too large and too complex to be fully charted or outlined at such an early stage--plus, it is to all of our advantage to continually look for opportunities to accelerate change. Due to the dynamic nature of this document, I invite your recommendations to proceed."