You Can’t Build a Ramp for a Mood Swing

Strategies for Hiring, Accommodating, and Managing Employees with Psychiatric Disorders

Don Brandon, Conrad Kuehn, and Laurie Ford

DBTAC Northwest

Center for Continuing Education in Rehabilitation

University of Washington

(800) 949-4232 (425) 774-4446

The Impact of Psychiatric Disability

An estimated 26.2 percent of Americans 18 and older suffer from a diagnosable mental disorder in a given year – about 57.7 million people. About 6% have a serious mental illness (NIMH, 2006)

The unemployment rate for people with psychiatric disabilities is 85% to 92% (Anthony et al., 2002). Few ever leave the Social Security rolls to move into full-time employment.

People with psychiatric disabilities face significant employment barriers:

  • The stigma associated with mental illness
  • The impact of long-term unemployment
  • Poverty and the fear of losing disability benefits, including health insurance
  • Lack of formal education
  • The low expectations of professionals who serve these individuals as well as the community at large

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Employers often have concerns that are specific to hiring workers with psychiatric issues. These include:

Possibility of violence

Instability, unreliability

Need to protect employee from stress

Employees need to take time off work

Strange behaviors

Difficulty in getting along with others in the workplace.

Some of these are realistic concerns about any new employee - unreliability, for example. Others, like the possibility of violence, stem from gross ignorance about mental illness and the people who experience it.

What are some common psychiatric impairments?[1]

Depression: Depressive disorders are serious illnesses that affect a person's mood, concentration, sleep, activity, appetite, social behavior, and feelings. Depressive disorders come in different forms, the most common being major depression (unipolar depression). Major depression, the leading cause of disability in the United States, affects over nine million adults in a given year. Despite the disabling effects of depression, it is highly treatable.

Bipolar disorder: Bipolar disorder (manic depression) is a brain disorder involving episodes of mania and depression. It affects more than two million American adults. Effective treatments are available that greatly reduce the symptoms of bipolar disorder and allow people to lead normal and productive lives.

Schizophrenia: Schizophrenia is a severe and chronic brain disorder that affects approximately two million Americans today. Schizophrenia impairs a person's ability to think clearly, manage his or her emotions, make decisions, and relate to others. People with schizophrenia suffer terrifying symptoms that often leave them fearful and withdrawn. However, this illness is highly treatable, and new discoveries and treatments are continually improving the outlook for people with this disorder.

Post-Traumatic Stress Disorder (PTSD): is a condition that can occur after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened.

Traumatic events that can trigger PTSD include violent personal assaults such as rape or mugging, natural or human-caused disasters, accidents, or military combat.

Many people with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. Anniversaries of the event can also trigger symptoms. People with PTSD also experience emotional numbness and sleep disturbances, depression, anxiety, and irritability or outbursts of anger. Feelings of intense guilt are also common. Most people with PTSD try to avoid any reminders or thoughts of the ordeal. PTSD is diagnosed when symptoms last more than one month.

Obsessive-Compulsive Disorder: People with obsessive-compulsive disorder (OCD) suffer intensely from recurrent unwanted thoughts (obsessions) or rituals (compulsions), which they feel they cannot control. Rituals such as hand washing, counting, checking, or cleaning are often performed in hope of preventing, obsessive thoughts or making them go away. Performing these rituals, however, provides only temporary relief, and not performing them markedly increases anxiety. Left untreated obsessions and the need to perform rituals can take over a person's life. OCD is often a chronic, relapsing illness.

Panic Disorders: Panic disorder is characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress. These sensations often mimic symptoms of a heart attack or other life-threatening medical conditions. As a result, the diagnosis of panic disorder is frequently not made until extensive and costly medical procedures fail to provide a correct diagnosis or relief.

Seasonal Affective Disorder: SAD may be an effect of this seasonal light variation in humans. As seasons change, there is a shift in our "biological internal clocks" or circadian rhythm, due partly to these changes in sunlight patterns. This can cause our biological clocks to be out of "step" with our daily schedules. The most difficult months for SAD sufferers are January and February, and younger persons and women are at higher risk. Symptoms Include: regularly occurring symptoms of depression (excessive eating and sleeping, weight gain) during the fall or winter months. Full remission from depression occurs in the spring and summer months. Symptoms have occurred in the past two years, with no non seasonal depression episodes. Seasonal episodes substantially outnumber non seasonal depression episodes (American Psychiatric Association, 1994).
Facts about Mental Illness and Work

(From a brochure by the Research and Training Center on Mental Illness and Work at Matrix Research Institute and the University of Pennsylvania; cited on the NAMI website

Fact: there are three million working-age adults with severe mental illness in the nation’s communities, of whom 70 percent to 90 percent – about 2.5 million people – are unemployed.

The NIMH estimates that there are a little more than three million adults ages 18 to 69 who have a serious mental illness. Estimates of unemployment among this group are startling: between 70 and 90 percent are unemployed, a rate higher than for any other group of people with disabilities.

Fact: A diagnosis of serious mental illness is not a reliable indicator that someone cannot work; indeed, many people are able to work successfully despite their symptoms.

Several years of study report only a small relationship between a diagnosis and work capacity, or between psychiatric symptoms and work capacity. While it is true that some of the symptoms of mental illness – its often unpredictable nature and its impact on both cognitive and interpersonal functioning – make work a real challenge, these symptoms vary from person to person.

Fact: On-the-job accommodations that make it possible for people with serious mental illness to success at work are proving relatively straightforward and inexpensive to provide.

Recent surveys indicate that job accommodations for people with disabilities of all kinds are not difficult to make or costly to implement – 68 % of all accommodations cost less than $500. the changes at work that people with serious mental illness request most often – alterations in the work schedule, modifications in job descriptions, clear communication patterns or additional training for supervisors – are generally low-cost or no-cost to employers and differ only slightly from options offered for other employees.

Fact: The great majority of people with a serious mental illness want to work. Recent surveys report that approximately 70% of those with significant psychiatric problems rank work as an important goal for themselves.

Many consumers receiving SSI or SSDI financial and medical benefits are often reluctant to give up their eligibility for what may be low-paying and low-benefit jobs. Nonetheless, about 71% of those people with serious mental illness who are asked about their future goals identify work – and the financial independence and social identity it provides – as a central and important ambition for themselves.

Fact: Innovative rehabilitation programs, which help people with the most serious mental illnesses, are placing more than 50% of their clients into paid employment.

A number of innovative programs that move clients into “real jobs for real pay” as quickly as possible – and then provide extensive supports for them either on or off the job – are reporting considerable success. An in-depth analysis of supported employment outcomes, for instance, found 52% of people still working after a year. Intensive case management and individual placement and support models that emphasize employment regularly report significant increases in wages, hours worked, work tenure, and career advancement.

Fact: Employers who have hired persons with serious mental illness in the past are generally very positive about their experiences.

Many employers throughout the country have hired people with serious mental illness. More than 70% of these employers report their willingness to continue working with rehabilitation programs that place and support people with serious mental illness. Employers who are involved with rehabilitation programs are less likely to share the public’s concerns and fears about people with mental illness, particularly with regard to violent behavior.

Fact: Although job loss continues to be a problem, those individuals with serious mental illness who are working can be helped to stay on the job if they receive the additional supports they need.

The reasons for job loss vary widely. In one study, only 12 percent of those people who left their jobs said they resigned because they didn’t want to work, and only 15% had to leave for medical reasons unrelated to their mental health. The others who became unemployed faced a variety of problems – layoffs, problems with coworkers or supervisors as well as mental health problems – that led to diminished work capacities. Many of these problems might have been resolved without job loss if ongoing support had been available.

Fact: Because people with psychiatric disabilities are the largest part of the recent increase of persons dependent upon SSI/SSDI support, the nation can’t afford to shortchange programs that help seriously mentally ill people to work.

With growing numbers of people with SMI seeking SSI/SSDI support, far more emphasis needs to be placed on vocational rehabilitation programs that can help people to work and live more independently. People with mental illness can and want to work and rehabilitation programs can be successful in getting people onto the job and keeping them employed.

The Reasonable Accommodation Interview for Employees

Purpose: The Reasonable Accommodation Interview (RAI) is designed to provide equal employment opportunity for an employee with a disability and to allow the employer a process of assessing fairly and accurately the impact of a worker’s disability on the performance of the essential functions of the job. It is assumed that the employer has accurately assessed the essential functions of an employee’s job prior to the RAI.

In addition it will serve as a demonstration of the “good faith” effort the employer is required to provide and it assures evidence of an interactive process considering the employees needs and feedback.

The dynamics of this interview are similar to a job interview. Performance issues should not be brought up in the RAI because the dynamics of a RAI are not punitive or reward based but are a fact finding problem resolution based.

I.Preliminary Tasks the Employer should Accomplish Prior to the RAI:

Review the employee’s job description to ensure that:

  1. The essential functions of the employee’s job have been identified, including:
  2. Physical requirements for performing the job, and
  3. Behavioral characteristics essential for job performance.
  4. An ADA Job Evaluation has been performed and that:
  5. The fundamental job tasks include quantity and quality requirements.
  6. The behavioral requirements of the job have been stated in measurable terms.

II.Preliminary Requests

A.Prior to a formal meeting to discuss an employee’s reasonable accommodation request, the manager or supervisor should request the following from the employee and the employee’s physician:

  1. Validation of disability from a doctor or other acceptable medical professional.
  2. Provide the medical professional with the definition of disability under the ADA.
  3. Ask the medical professional to specify what part of the definition the employee meets (see Definitions section).
  4. Provide the medical professional a copy of the employee’s job description with the essential functions listed and described in detail.
  5. An impact statement of disability from the doctor that describes the impact of disability on the employee’s ability to functionally perform each essential function of the job.
  6. Suggestions of reasonable accommodations for the performance of the essential functions affected by the employee’s disability.

B.Request that the employee bring the above information to the Reasonable Accommodation Interview.

III.The Interview

A.During the formal RAI, managers or supervisors should begin the interview by reviewing with the employee the employer’s responsibilities under the ADA and the purpose of the RAI. As your employer I am responsible to:

  1. Provide reasonable accommodation for the employee in their current job (provide reasonable accommodation examples)
  2. Provide equal employment opportunities
  3. Provide accommodation unless to so so would be an undue hardship or pose a direct threat to the employee or other employees
  4. Inform the employee of the consequences of failing to identify a reasonable accommodation:
  5. The employee will be considered not qualified for the job.
  6. Employee Benefit Program (LTD or STD).
  7. Discuss reassignment to another job position. Review with the employee that reassignment under the ADA is lateral only and is into a job for which the employee is qualified and only to a job that is open within a reasonable amount of time.

B.Ask the employee, in a documented interview setting, if he considers himself to be a person with a disability and if so, what part of the ADA definition he thinks he/she meets.

C.Ask the employee what the impact of her disability has or will have on her job performance.

D.Review the essential functions of the job and ask what impact the disability has on each specific function.

E.Brainstorm with the employee about potential accommodations.

F.Come to an agreement or resolution for providing equal employment opportunities through reasonable accommodation.

G.Research accommodation solutions and alternatives with other professionals (The Job Accommodation Network, DBTAC ADA Information Centers, etc.).

H.Keep a record of the Reasonable Accommodation Interview.

IV. Follow-Up

A.Talk to the supervisor (10 days/1 month/60 days).

B.Talk to the employee.

C.Document the follow-up.

D.Advise the Department ADA Coordinator of all progress and information obtained.

V.Formal Documentation and Record Keeping

A.Reasonable Accommodation Interview results will be filed in the employee’s confidential medical file, not their personnel file.

B.Reasonable Accommodation Follow-up documentation (including medical professional’s statements and medical evaluations) will be filed in the employee’s confidential medical file, not their personnel file.

C.Copies of both the Reasonable Accommodation Interview and the Reasonable Accommodation Follow-up will remain confidential and be provided directly to the employee if requested.

Process developed by Don Brandon, DBTAC Northwest ADA Information Center

center for continuing education in rehabilitation 1 university of washington

The Long-term Effect of Disclosure on Employment

  • Disclosure is an intense decision process that can occur anytime during the employment history of an employee. It can happen at hiring, during work, at promotion, or at year ten. As an employee it is always a nagging “should I” or “do I need to,” and as an employer it is a decision that may start several other processes at any time.

In a poll of 1,257 American adults, Louis Harris & Associates found that only 19 percent reported being "very comfortable" when meeting someone known to have a mental illness. This compared to 33 percent reportedly feeling "very comfortable" with someone who has intellectual disabilities, 47 percent with someone who is blind, and 59 percent with someone who uses a wheelchair.

  • When the National Council for Disabilities (NCD) discussed ADA implementation issues facing people with hidden disabilities, such as psychiatric disabilities, learning disabilities, epilepsy, and multiple chemical sensitivities. One participant said that the issue of whether to disclose a disability in an employment situation presents a real dilemma for people with hidden disabilities, especially if stigma is commonly associated with the disability.
  • Even when a person with a disability needs a minor reasonable accommodation, he or she sometimes fears that disclosure may result in discrimination.
  • Other participants discussed attitudinal barriers that people with hidden disabilities face, including the many inappropriate comments they may endure if their disabilities become known.(Vaughn 2007)
  • Ellison’s survey of managers stated: “A large proportion (87%) of study participants reported having disclosed their mental illness. About half of the disclosers reported unfavorable circumstances leading to disclosure while one third disclosed when they felt comfortable. Most frequently, respondents disclosed to supervisors; one third made their disability known when applying for the job. About half of the respondents had no regrets about disclosing. Multivariate analysis showed that correlates with the occurrence, timing, and choice of disclosure converge around constructs related to job confidence, empowerment, and recovery. We also describe those who chose not to disclose” Conclusion: Higher rates than previously reported and better experiences with disclosure were evident and may be related to this population’s greater recovery as well as to occupational factors. (Ellison, Russinova et al. 2003).

Disclosure Decision Points

Application or interview questions