What does research tell us about job accommodations for persons with psychiatric disabilities?

1. What does research tell us about job accommodations for persons with psychiatric disabilities? A webinar presented on April 25, 2011 by: Kim MacDonald-Wilson, Sc.D., CRC, CPRP, Assistant Professor, University of Maryland Marianne Farkas, Sc.D., Director of Training and Technical Assistance, Boston University Center for Psychiatric Rehabilitation Supported by Grant # H133B090014 from the National Institute on Disability and Rehabilitation Research and the Center for Mental Health Services to Boston University

2. Translating Knowledge to Practice: Job Accommodation • 5 year project under Research and Training Center on Improved Employment Outcomes for Individuals with Psychiatric Disabilities • Process involves: • Review and grade the research literature in terms of rigor of research and meaningfulness of research on critical topic • Synthesize identified research into one document • Develop dissemination plan (Who? How? What tools needed?) with organizations • Develop information tools

3. Background on Job Accommodations • Mandated by the Americans with Disabilities Act, 1990 and Rehabilitation Act of 1973 • Employers are required to provide ‘reasonable accommodations’ to qualified individuals with disabilities unless doing so would create an undue hardship • unreasonably high costs • significant disruption to the nature of the business.

4. Definition of Job Accommodation • Job accommodations are “any change in the work environment or in the way things are customarily done (EEOC, 2002).” • Typical modifications to: • Hiring process • Work environment or job duties • Benefits and privileges of employment • Accommodations are intended to remove the workplace barriers for individuals with disabilities (EEOC, 2002).

5. Past Research on Job Accommodations • Job Accommodations for people with various disabilities are associated with: • higher job retention rates • satisfactory work outcomes • Limited knowledge or understanding of people with psychiatric disabilities and employers about how to use the ADA and job accommodations • Deciding about disclosure of psychiatric disabilities may also interfere with requesting and using job accommodations

6. Identifying the Research to Analyze • 100 documents located using search terms • 60 documents identified by title and abstract • Screening Criteria • Focus on Job Accommodations • Sample is exclusively or mostly people with psychiatric disabilities • Approved Research Designs • Experimental; Quasi-experimental • Pre-test/Post-test; Observational cohort • Correlational; Survey Research • After screening, 19 Quantitative Studies selected for Review • 4 studies examined Outcomes of Accommodations • All Correlational or Survey Designs • Rated for rigor • 15 studies described accommodations and related factors – Process Studies • 9 Qualitative Studies on job accommodations and disclosure

7. Challenge of the Analysis: Rigor • Little rigorous research was available • Only 4 studies focused on Effectiveness of Accommodations • None of these used Experimental or Quasi-Experimental Designs • 3 out of 4 studies had sample sizes below 70 • Rigor Ratings conducted on these 4 studies revealed overall ratings of methodology were adequate • 4 studies insufficient to draw valid conclusions about the impact of accommodations on employment outcomes • Of 15 other descriptive, process-related studies • No experimental designs focused on accommodations (only 2 on disclosure) • 2 Quasi-experimental designs • 9 Survey or Correlational • Therefore, a Structured Synthesis of Research Literature conducted, including the 15 descriptive studies, and 9 additional Qualitative Studies

8. Summary of the Research Synthesis: Outcomes • There are very few well-controlled studies of the effectiveness of job accommodations for people with psychiatric disabilities. • The question of how effective job accommodations are for people with psychiatric disabilities remains open • There is no evidence from well-controlled studies that job accommodations result in improved employment outcomes. • Neither are there well controlled or rigorous studies indicating that job accommodations are ineffective.

9. Summary of the Synthesis: Outcomes Continued • There is weak evidence from uncontrolled outcomes studies that job accommodations are positively associated: • staying employed • job satisfaction • satisfactory job terminations • sense of mastery and well-being • opportunity for promotion

10. Findings: Effectiveness of Accommodations • Unsatisfactory job terminations are related to unmet accommodation needs such as flexible hours, more training, and improved supervision and support • Suggestive evidence from two uncontrolled correlational studies (Becker, Drake, Bond, Xie, Dain, & Harrison, 1998; Mak, Tsang, and Cheung, 2006) • Employment tenure was positively associated with number of job accommodations • Weak evidence due to a small sample from a single program and the use of a retrospective design (Fabian, Waterworth & Ripke, 1993) • Inadequate accommodation is associated with disability leave status and with poorer employment outcomes among individuals working, such as lower job satisfaction, lower sense of mastery and well-being, and a lack of opportunity for promotion • Suggestive evidence from one uncontrolled correlational study (Akabas & Gates, 2000)

11. Summary of the Synthesis: Process • Evidence from existing descriptive and qualitative studies suggest that most accommodations for people with psychiatric disabilities require little to nothing in direct costs • Most frequently used Accommodations • Flexible schedules • Job assistance by vocational rehabilitation service providers • Interpersonal or other support interactions provided by supervisors and coworkers • Changes in job tasks • Changes in the training process

12. Findings: Nature of Job Accommodations • Job accommodations for people with psychiatric disabilities cost little to nothing in direct costs to the employer • Consistent evidence from correlational and qualitative studies (Granger et al., 1997; MacDonald-Wilson et al., 2002; Scheid, 1999). • Employees and supervisors tend to identify different accommodations when asked about a particular job. • Employees - flexibility in schedules or other support and supervision; Supervisors - modifications in job tasks or demands, as well as flexibility in schedules (Qualitative studies: Mancuso, 1993; Secker et al., 2003) • Relationship accommodation needs were least often met in the workplace (vs. task or routine accommodation needs) • Correlational study (Akabas & Gates, 2000)

13. Summary of the Synthesis: Process Continued • The functional limitations requiring accommodation are most often cognitive or social-interpersonal in nature, less frequently emotional or physical in nature • Disclosure of psychiatric disabilities to employers is a complex process for which individuals need guidance in order to weigh both the risks and the benefits of disclosing and to make decisions about what to say, when, and to whom. • Disclosure is less complicated when employees with psychiatric disabilities are involved in supported employment (SE) services, since SE service providers often are actively involved in the disclosure and arranging of accommodations.

14. Findings: Attitudes about Accommodations • Since the ADA, employers are aware of the ADA and for people with psychiatric disabilities • Providing job accommodations (adjusting work hours, part-time jobs, restructuring jobs) • Majority are satisfied with these employees (Scheid, 1999). • Coworkers generally supportive of job accommodations for people with psychiatric disabilities (flexible work hours, banking overtime for use as sick leave, and access to counseling) • Accommodations viewed as ‘less appropriate’ - longer or more frequent breaks • Coworkers who perceived that their employer would treat people with psychiatric disabilities fairly were more likely to intend to self-disclose a mental health condition and seek treatment should they experience one in the future (Peters & Brown, 2009). • Some evidence that there remains some bias: • Psychological conditions are perceived as “questionable” disabilities (Popovich, Scherbaum, Scherbaum, & Polinko, 2003) • Accommodations for people with physical disabilities viewed as more ‘acceptable’ and ‘reasonable’ than accommodations for people with psychiatric disabilities (Dalgin & Gilbride, 2003).

15. Findings: Factors Related to Disclosure & Accommodation • People with mental health conditions (depression and substance use disorders vs. physical, sensory) are less likely to have accommodations in the workplace • (Zwerling et al., 2003). • Supervisor and coworker supportiveness are associated with disclosure of disability and successful accommodations in the workplace • (Akabas & Gates, 2000; Banks et al., 2007; Gates, 2000; Granger, 2000; Rollins et al., 2002) • Desired as accommodations by terminated employees who identified accommodations that would have made a difference in their jobs (Becker et al., 1998; Mak et al., 2006). • Over-accommodation or excessive supportiveness may result in employees leaving jobs due to feeling unchallenged and overprotected in their work • (Secker et al., 2003).

16. Findings: Functional Limitations and Job Accommodations • Functional limitations leading to the need for job accommodations primarily cognitive and social-interpersonal functioning in the workplace, such as: • Cognitive – learning job tasks, concentrating, working independently • Social-interpersonal – interacting with coworkers or customers, responding to supervisor feedback • Emotional – managing stress, adjusting to changes in the workplace, lack of confidence • Physical – maintaining stamina, adjusting to low energy levels or fatigue, experiencing physical side effects of medications • (MacDonald-Wilson et al., 2003; Mancuso, 1993; Secker et al., 2003; Symanski-Tondora, 2003) • The fewer the number of limitations that the employee has, the fewer the number of accommodations needed • (MacDonald-Wilson et al., 2003) • Cognitive limitations are associated with accommodations involving job coaching or other human assistance • (MacDonald-Wilson et al., 2003; Symanski-Tondora, 2003) • Cognitive and social-interpersonal limitations are positively associated with interpersonal accommodations • Educating coworkers , phone or other access to support personnel (Symanski-Tondora, 2003).

17. Findings: Impact of Disclosing and Requesting Accommodations • When SE Services involved: • Employees are more likely to receive accommodation (Banks et al., 2007) • Providers frequently handle disclosure and accommodation requests (Banks et al., 2007; Gioia & Brekke, 2003a; Goldberg et al., 2005; Granger 2000; Granger et al., 1997) • Disclosure helps employees with psychiatric disabilities to do their jobs better, makes work feel less stressful, and allows employees to get support • (Banks et al., 2007; Ellison et al., 2003; Gioia & Brekke, 2003b, Granger, 2000) • Disclosing may also increase stress with coworkers (Rollins et al., 2002) or being treated differently by coworkers (Granger, 2000)

18. Findings: Impact of Disclosing and Requesting Accommodations More • Self-accommodation is a successful employment strategy that helps people avoid disclosure • (Mancuso, 1993; Dalgin & Gilbride) • Using clear, assertive communication about accommodation needs and using relationship accommodations are associated with successful accommodation outcomes • (Akabas & Gates, 2000; Gates, 2000)

19. Importance of Promoting New Research on Job Accommodations High unemployment and underemployment rates among those with psychiatric disabilities: Employment = Hope. Need more rigorous research on effectiveness of job accommodations for people with psychiatric disabilities, employers, policy makers Knowledge from Supported Housing and Supported Employment shows the value of the right supports in effecting positive outcomes.