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 # H133B from the National Institute on Disability and Rehabilitation Research and the Center for Mental Health Services to Boston University

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

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.

Definition of Job Accommodation Job accommodations are “any change in the work environment or in the way things are customarily done.” 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.

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

Identifying the Research to Analyze 100 documents located using search terms 60 documents identified by title and abstract Screening Criteria for the 60 studies 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 Systematic 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

Challenge of the Analysis: Rigor Little rigorous research was available Only 4 studies focused on Effectiveness or Outcomes 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, however 4 studies insufficient to draw valid conclusions about the impact of accommodations on employment outcomes Meaning Ratings were not conducted Of 15 other descriptive studies on Process of Accommodations No experimental designs focused on accommodations (only 2 on disclosure) 2 Quasi-experimental designs 9 Survey or Correlational Therefore, instead of Systematic Review, a Structured Synthesis of Research Literature was conducted, including the 15 descriptive studies, and 9 additional Qualitative Studies

Research Synthesis Findings: Accommodations 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. Based on review of 4 Outcomes-Related Studies

Suggestive Evidence: Accommodations Outcomes Unsatisfactory job terminations related to unmet accommodation needs (i.e., flexible hours, more training, and improved supervision and support) Employment tenure positively associated with number of job accommodations for individuals in an SE program Inadequate accommodation is associated with employees placed on disability leave for mental health reasons Inadequate accommodation is associated with poorer employment outcomes among working individuals (lower job satisfaction, lower sense of mastery and well- being, and a lack of opportunity for promotion )

Summary of Research Synthesis: Accommodations Outcomes While there is little strong evidence from rigorous studies about a relationship between accommodations and employment outcomes, there is suggestive evidence from uncontrolled outcomes studies that job accommodations are positively associated with: staying employed job satisfaction satisfactory job terminations sense of mastery and well-being opportunity for promotion

Research Synthesis: Accommodations Process Accommodations Process findings from 15 descriptive and 9 qualitative studies Categories of Process Findings Nature and Process of Accommodations 5 Descriptive Studies 3 Survey/Correlational 2 Quasi-Experimental 6 Qualitative Studies 3 Individual Interview 1 Focus Group 2 Case Studies of Organizations

Research Synthesis: Accommodations Process more Categories of Process Findings (more) Attitudes about Accommodations 4 Descriptive Studies - Survey Design Disclosure and Requesting Accommodations 6 Descriptive Studies 2 Experimental on Disclosure only 4 Survey or Correlational 3 Qualitative Studies 2 Individual Interviews 1 Individual Interviews and Focus Groups Descriptive and qualitative studies suggest Promising Findings, more research needed

Promising Process Findings: Nature of Job Accommodations Job accommodations for people with psychiatric disabilities cost little to nothing in direct costs to the employer 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 Accommodated employees and supervisors tend to identify different accommodations when asked Employees - flexibility in schedules or other support and supervision; Supervisors - modifications in job tasks or demands, as well as flexibility in schedules Relationship accommodation needs were least often met in the workplace (vs. task or routine accommodation needs)

Promising Process Findings: Functional Limitations and 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 The fewer the number of limitations that the employee has, the fewer the number of accommodations needed Cognitive limitations are associated with accommodations involving job coaching or other human assistance Cognitive and social-interpersonal limitations are positively associated with interpersonal accommodations Educating coworkers, phone or other access to support personnel

Promising Process Findings: Attitudes about Accommodations Employers are aware of the ADA and accommodations for people with psychiatric disabilities Providing job accommodations (adjusting work hours, part-time jobs, restructuring jobs) and are satisfied with these employees 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) Less supportive of longer or more frequent breaks More likely to intend to self-disclose a mental health condition and seek treatment should they experience one in the future if they believe the employer treats people with mental health condition fairly Some evidence that there remains some bias : Accommodations for people with physical disabilities viewed as more ‘acceptable’ and ‘reasonable’ than accommodations for people with psychiatric disabilities Psychological conditions are perceived as “questionable” disabilities

Promising Process Findings: Disclosure & Accommodation People with mental health conditions (depression and substance use disorders vs. physical, sensory) are less likely to have accommodations in the workplace Supervisor and coworker supportiveness are associated with disclosure of disability and successful accommodations in the workplace Desired as accommodations by terminated employees who identified accommodations that would have made a difference in their jobs Over-accommodation (excessive supportiveness) may result in employees leaving jobs due to feeling unchallenged and overprotected in their work Self-accommodation is a successful employment strategy that helps people avoid disclosure

Promising Process Findings: Impact of Disclosing /Requesting Accommodations When SE Services involved: Providers frequently handle disclosure and accommodation requests Employees are more likely to receive accommodation Disclosure helps employees with psychiatric disabilities to do their jobs better, makes work feel less stressful, and allows employees to get support Disclosing may also increase stress with coworkers or being treated differently by coworkers Using clear, assertive communication about accommodation needs and using relationship accommodations are associated with successful accommodation outcomes

Summary of Research Synthesis: Accommodations Process Job accommodations for people with psychiatric disabilities are low- or no-cost, and most often involve flexible scheduling and interpersonal supports provided by job coaches, supervisors, and coworkers. The functional limitations requiring accommodation are most often cognitive or social-interpersonal in nature. Disclosure of psychiatric disabilities to employers is a complex process for which individuals need guidance in order to make decisions about whether to disclose, and what to say, when, and to whom. Disclosure and requesting accommodations are less complicated when supported employment (SE) service providers are involved with employers, since SE providers often handle these processes.

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.

Conclusions from the Synthesis of the Research on Job Accommodation While there is currently no conclusive evidence that job accommodations for people with psychiatric disabilities are effective or not, evidence suggests that accommodations are associated with positive employment outcomes. Additional research is available on the nature and process of disclosure and job accommodations, yielding several promising findings requiring further research: Most frequent accommodations are flexible scheduling and interpersonal supports Accommodations are most often needed for cognitive and interpersonal limitations. Disclosure and requesting accommodations is a complex process, especially when service providers are not involved.

Supported by Grant # H133B from the National Institute on Disability and Rehabilitation Research and the Center for Mental Health Services to Boston University