Disability World
A bimonthly web-zine of international disability news and views • Issue no. 14 June-August 2002


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Australia: Employer Accommodations for People with Mental Health Related Disabilities
By Pat McLeod and Vicki Braidwood,
Co-Managers, Specialist (Mental Health) Services
Commonwealth Rehabilitation Service, South Australia
(This article reprinted with the authors' permission from: www.workable.org.au)
"I like work; it fascinates me. I can sit and look at it for hours."
--Jerome K. Jerome
Anyone who has tried to figure out what is really going on in a workplace knows what a fascinating and slippery phenomenon it can be. What does it really mean to expect an employer to provide a suitable workplace for someone whose disability is primarily related to their thoughts and feelings about themselves and others? Someone whose disability may be episodic and unpredictable, whose ability to concentrate and to deal with change, pressure and deadlines may be impaired, whose medication regime may cause almost as many problems as the illness itself, whose insight into their illness may be minimal, whose motivation for work could be strong or it may be ambivalent at best. Someone who may be relieved to have a diagnosis but who cannot be told whether their illness is a one-off or likely to recur and what this might mean for their capacity for work. Someone whose medical and vocational support can be patchy and unresponsive; someone whose community (including potential workmates) has so profoundly stigmatised mental illness that disclosure is extremely difficult; someone whose capacity for work, when well supported, can be as great as any of their workmates. And we want an employer to accommodate this person in the longer term, because lack of employment durability is one of the most profound handicaps faced by people with psychiatric disabilities.

Reasonable requests
Yet Australians have agreed that it is a reasonable request of an employer: Occupational Health and Disability Discrimination Laws make it clear that employers are responsible for providing workplaces which are safe and which make "reasonable" efforts to accommodate mental health related disabilities as well as physical disabilities. How best does a Vocational Rehabilitation practitioner assist an employer to meet these obligations? We know we can be successful in vocational placement, but we'd probably all agree that the challenge of job retention is far from fully met. In this paper, we'll draw from our own experience and from literature, to identify factors relevant to the issue.

Our American colleagues estimate that at least 85% of their fellow citizens who have a psychiatric disability are unemployed. That's literally millions of people denied the empowerment that employment provides and billions of dollars in lost productivity. It is reasonable to suspect that the percentages may be similar in Australia. Similarly, the costs associated with Occupational Stress are high. In the sector of Commonwealth employment in Australia, the insurable costs associated with Occupational Stress claims for 1992-1993 was expected to exceed $22 million. These costs are small compared to the uninsurable costs associated with occupational strain in the workplace.

At this point we should draw the distinction between "psychiatric disability" and "mental illness," as these terms are not interchangeable. Mental Illness is, in the majority of cases, a short term phenomenon, usually managed with medication and counseling and which is believed to affect one in five Australians. The majority of Occupational Stress cases involve a short-term mental illness. The term "Psychiatric Disability" refers to the circumstance where an individual has experienced a thought or emotional disorder which is severe and chronic and which tends to involve hospital admissions and ongoing psychiatric care.

Prevention Of Occupational Stress:
What do we know about advice to employers in terms of dealing with Occupational Stress? The literature suggests that similar strategies are required for the prevention as for the management of Occupational Stress. The major areas of prevention activity recommended are:
  1. Effective person - job matching
  2. Appropriate human resource management policies and practices.
    "Research suggests that to achieve job satisfaction and high performance all employees need consistent management that makes expectations clear, empowers workers to be responsible for their own accomplishments, allows them flexibility in the means they select to meet work goals, supports them in their efforts and reinforces their achievements" (Akabas, 1994). Hart & Wearing (1995) also conclude that in terms of prevention it is more important to develop a supportive organisational climate that helps employees to manage their work more effectively, rather than attempting to change employees' operational work demands.
  3. Early detection and intervention by:
    1. Regular Stress Audits
    2. Provision of Employee Assistance Programs
    3. Train Managers to recognise early signs of occupational strain.
    The guidelines for the Management of Occupational Stress published by Workcover (SA) 1994 states "The probability that an injured worker will ever return to work decreases with each day that a worker is off after lodging a claim."
  4. Appropriate and timely response by employers:
    1. Willingness to actively engage in rehabilitation
    2. Examine precipitating factors and aspects of the job or environment which are problematic.
    3. Modification of these factors.
    4. Provide a supportive workplace. This often requires a change in the workplace to achieve a successful return to health and productivity for individual workers (Foreman & Murphy,1995).
    5. Provide support to assist with non-work related strain, or personal characteristics likely to cause ongoing difficulties in the workplace, e.g., by referral to Employee Assistance Programs or community services.
Case Managers' Experience With Occupational Stress Cases
How do these general research findings compare with the day-to-day experience of Rehabilitation Case Managers when working with people who have lodged WorkCover claims for Occupational Stress related illnesses?

As part on an ongoing process to gain more information about what is the best practice in the area of occupational stress, a small sample of 10 case managers who are experienced in this field were interviewed. They were asked to identify the factors related to the client, the employment situation and themselves, which contributed to or were barriers to the success of the program. Case Managers were asked to consider a specific successful program but also made additional comments based on their wider experience. The major findings with respect to the employment related factors were:
  1. In 70% of programs, support in the existing or alternative workplace was nominated as an important factor. Sometimes the Case Manager, Doctor or other people provided short term positive feedback to replace or supplement workplace feedback. Due to the negative emotions that workers associated with their previous workplace, or the lack of support in the workplace, it was often necessary to seek an alternative workplace (this finding is further supported in the Foreman & Murphy research). Another option to consider is the use of support workers.
  2. In 50% of programs the flexibility of the employer to adapt an environment to the individual worker's circumstances was regarded as important in achieving a successful outcome. These included both short-term and long-term changes. Short-term accommodations included accepting reduced productivity and alternative/special duties. Long term accommodations included a willingness to examine and improve current work processes and management practices, such as improved communication flow, increased role clarity, variations in workload and establishing a new support system.
  3. In 30% of programs other factors were identified which related to the ability of an employer to "look at the big picture" and consider rehabilitation as an integral part of a wider system.
Akabas (1994) tells us that: "For anyone who has worked with those with mental illness, consistency, empowerment, flexibility, support and reinforcement have the sound of the familiar, understood and well-accepted prescription for success." Thus both in terms of prevention and management of occupational stress, the most critical factor after person/job selection is a supportive work environment. Case-managers need firstly to clearly identify the level and types of support needed for the individual worker and ensure that the workplace is prepared to provide this support. The second critical factor is the employer's willingness and flexibility to sustain the match between the work environment/demands and the worker's capacity on a short and long-term basis. This clearly requires the case manager to understand both of these factors and to assist the employer to develop strategies and resources.

The findings of this limited qualitative study of Case Managers supports the available research on appropriate organisational responses to occupational stress related illnesses. It has also given an opinion on the relative importance of the success factors and specific examples of how these were implemented in the workplace.

How Does This Relate To Psychiatric Disability?
Let's assume that the rehabilitation practitioner has done all the right things in vocational placement, optimising the person-job type fit. Much of the literature, in relation to Occupational Stress prevention and management as well as in the psychiatric disability field, argues that workplace characteristics which are required for workers in general will be relevant in the placement and employment maintenance of people with mental health related difficulties; that is to say, flexibility and support.

But what does "flexibility and support" really mean? One person's flexibility may be another's intolerable role confusion, so the need to look at this issue on an individualised basis is absolutely critical. The literature cited in the reading list suggests that recognised workplace accommodations tend to fall into these categories:
  1. Flexible recruitment and career development procedures, which assist the worker to demonstrate competencies, rather than heavy reliance on standardised (anxiety provoking) entry tests and interview formats
    (The issue of recruitment is indeed a controversial one, meriting much closer scrutiny. Hart & Wearing (1995) conclude that in developing employment policies, consideration be given to the use of personality screening during selection and placement of employees, as "stable personality characteristics" are the strongest determinants of employee's psychological outcomes. One the other hand, there is evidence to suggest that diagnosis, symptoms of psychiatric disability and standard psychological testing are not correlated with vocational outcomes for people with a psychiatric disability - see research associated with the development of the Choose-Get-Keep model.)
  2. Flexible work schedules - e.g., one which enables the worker to take longer or more frequent breaks, or to start later in the day or to allow some home based work
  3. Time off to attend therapy, either regularly and/or to recuperate after an episode of illness, (e.g. sick, recreation or unpaid leave)
  4. Reduction, rescheduling or restructuring of less important tasks/roles which pressure or distract the worker or which are unsafe due to medication side effects
  5. Changes to interpersonal communication - the way that feedback, performance management, conflict resolution, changes in workplaces or roles, training and instructions are managed: e.g. setting time aside to ensure written instructions and responsibilities are clear; arranging advocacy/support during performance appraisal
  6. Changes to the physical environment to enhance concentration and minimise anxiety.
  7. Improved disability awareness in the workplace to reduce stigma; this underpins all other accommodations.
A critical characteristic of these accommodations is that they involve sustained workplace behaviour changes; quite a challenge for the employer, a challenge for the rehabilitation practitioner to negotiate and a huge challenge for research! We know far too little about what really works here!

Psychiatric rehabilitation involves the development of knowledge and skills in the worker and the development of resources to support the worker inside and outside the workplace. The challenge outside the workplace is to develop the partnerships between the medical and vocational agencies which underpin long-term employment support.

In terms of resources/supports inside the workplace, the challenge to the rehabilitation practitioner is to identify those accommodations which will lead to better job sustainability for a particular individual. Laura Mancuso (see the reading list) makes the point that the orthodox approach is to use job analyses to identify required accommodations, but that while job analyses provide much useful information, they do not address the interpersonal and emotional aspects of workplaces, so that the "rehabilitation diagnosis" part of the "Choose-Get-Keep" approach may also be needed.

This means that the rehabilitation practitioner will need, in addition to knowledge of the worker, knowledge of the management skills and personal style of the supervisor and knowledge of what the behaviour and productivity requirements are for successful work performance in the particular workplace.

The Question Of Motivation
Motivation (or lack of it) is a thorny issue in terms of employer accommodations. Low motivation can be part of the disability itself and/or can be eroded via medication side effects and is considered to be a major barrier to employment for many people with psychiatric disabilities. On the other hand, job placement literature indicates that worker attitudes and interpersonal skills are even more important than technical skills in the hiring of employees. So asking an employer to accommodate a worker who has difficulty with motivation may be asking for the very thing an employer finds hardest to understand, let alone provide.

The Oaklands County article (see the reading list) invites us to consider the complexities of motivation. It can be undermined by a poor employment history or failure in employment, by underlying social anxieties or poor social skills which lead the individual to stay in "safe" social situations, by a fear of losing the security of their current income and medical supports, by lack of confidence in symptom management and by lack of social support. So careful assessment and nurturing of motivation needs to be a major, if not the major, component of the rehabilitation process.

When we ask an employer to accommodate a worker with motivation difficulties, what are we asking for? Our experience and the literature suggest that what we are asking of employers is a version of early intervention combined with good management practice - i.e., asking that employers actively manage motivation problems. This can be initiated by a rehabilitation process which minimises conflict between illness symptoms/medication side effects and major job roles/tasks. An educative role by the case manager, which develops a collaboration between the worker, supervisor, workmates and other relevant psychosocial supports, is likely to be critical in supporting the worker to develop or sustain motivation. The collaborating team's role is to monitor and "trouble shoot" inappropriate behaviour (worker and others), medication changes/problems, signs of relapse and supports needed for all involved.

In summary:
Finally, the bottom line is that we know far too little about the employer accommodations which best promote job maintenance. As Sheila Akabas says "we need to devote attention to the study of success." Too much research in this field has focused on the individual with the disability. "Research needs to cross the street and explore...the environment and behavior of the potential employing organisation . . ."

What we can say though is that vocational rehabilitation cannot avoid the challenge of improving job durability. In psychiatric rehabilitation, "client focus" means that the process must include detailed attention to:
  • factors which influence the worker's motivation,
  • understanding real workplace factors which support /sabotage the worker
  • developing and ensuring sustainability of resources which support the worker inside as well as outside the workplace.
Ongoing research to develop our understanding of the relationship between aspects of work environments and the psychological health and productivity of all its employees would be helpful. This would provide feedback on the effectiveness of prevention and rehabilitation strategies for reducing occupational stress as well as for placement of people with psychiatric disabilities. In particular, qualitative information from workers and employers where work performance has been affected by a mental illness would be most valuable in enhancing our knowledge of accommodations associated with sustainable employment.

The following articles are recommended because the authors have found them to be a particularly useful guide to this topic -- we are not suggesting that this is an exhaustive list:
  1. Sheila H. Akabas, "Workplace Responsiveness: Key Employer Characteristics in Support of Job Maintenance for people with Mental Illness." in Psychosocial Rehabilitation Journal, Vol 17, no 3: Jan 1994, pp 91-101
  2. Judith A. Cook, Lisa A. Razzano, D. Madison Straiton, Yvette Ross "Cultivation and Maintenance of Relationships with Employers of People with Psychiatric Disabilities" in Psychosocial Rehabilitation Journal, Vol 17, no 3: Jan 1994, pp 103-116
  3. Karen S. Danley, Ph.D. and William A. Anthony, Ph. D. "The Choose-Get-Keep Model: Serving Severely Psychiatrically Disabled People" in American Rehabilitation Oct-Nov-Dec 1987 (this is one of many articles by these authors on the Choose-Get-Keep model)
  4. Foreman, P & Murphy G "Work-Related Issues in the Design of Return-to-Work Programs for 'Stress' Claimants". In P Cotton (ed) Psychological Health In the Workplace: Understanding and Managing, Occupational Stress, 1995, (pp 135-146). Australia: the Australian Psychological Society Ltd.
  5. Hart, PM Wearing, AJ Occupational Stress and Well-Being: A Systematic Approach to Research, Policy and Practice". In P Cotton (ed) Psychological Health In the Workplace: Understanding and Managing Occupational Stress, 1995 (pp 185-216). Australia: The Australian Psychological Society Ltd.
  6. Laura L. Mancuso, "Reasonable Accommodation for Workers with Psychiatric disabilities" in Psychosocial Rehabilitation Journal, Vol 14, no. 2, Oct 1990, pp 3-19
  7. Staff of Oakland County Community Mental Health Services (Michigan) "Comparison of Barriers to Employment for Unemployed and Employed clients in a case management program," in Psychiatric Rehabilitation Journal, Summer 1995
  8. Irvin D. Rutman, "How Psychiatric Disability Expresses Itself as a Barrier to Employment" in Psychosocial Rehabilitation Journal Vol 17, No. 3: Jan 1994.
  9. Deborah Zuckerman, "Reasonable Accommodations for people with mental illness under the ADA " in MPDLR. Vol 17 No 3, pp 311-319.


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