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 MarylandMarianne Farkas, Sc.D., Director of Training and Technical Assistance, Boston University Center for Psychiatric RehabilitationSupported by Grant # H133B090014 from the National Institute on Disability and Rehabilitation Research and the Center for Mental Health Services to Boston University

Translating Knowledge to Practice: Job Accommodation5 year project under Research and Training Center on Improved Employment Outcomes for Individuals with Psychiatric DisabilitiesProcess involves: Review and grade the research literature in terms of rigor of research and meaningfulness of research on critical topicSynthesize identified research into one documentDevelop dissemination plan (Who? How? What tools needed?) with organizationsDevelop information tools

Background on Job AccommodationsMandated by the Americans with Disabilities Act, 1990 and Rehabilitation Act of 1973Employers are required to provide reasonable accommodations to qualified individuals with disabilities unless doing so would create an undue hardship unreasonably high costssignificant disruption to the nature of the business.

Definition of Job AccommodationJob 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 employmentAccommodations are intended to remove the workplace barriers for individuals with disabilities.

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

Identifying the Research to Analyze100 documents located using search terms60 documents identified by title and abstractScreening Criteria for the 60 studiesFocus on Job AccommodationsSample is exclusively or mostly people with psychiatric disabilitiesApproved Research DesignsExperimental; Quasi-experimentalPre-test/Post-test; Observational cohort Correlational; Survey ResearchAfter screening, 19 Quantitative Studies selected for Systematic Review4 studies examined Outcomes of AccommodationsAll Correlational or Survey DesignsRated for rigor 15 studies described accommodations and related factors Process Studies9 Qualitative Studies on job accommodations and disclosure

Challenge of the Analysis: RigorLittle rigorous research was available Only 4 studies focused on Effectiveness or Outcomes of AccommodationsNone of these used Experimental or Quasi-Experimental Designs3 out of 4 studies had sample sizes below 70Rigor Ratings conducted on these 4 studies revealed overall ratings of methodology were adequate, however4 studies insufficient to draw valid conclusions about the impact of accommodations on employment outcomesMeaning Ratings were not conductedOf 15 other descriptive studies on Process of Accommodations No experimental designs focused on accommodations (only 2 on disclosure)2 Quasi-experimental designs9 Survey or CorrelationalTherefore, 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 OutcomesThere 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 openThere 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 OutcomesUnsatisfactory 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 programInadequate accommodation is associated with employees placed on disability leave for mental health reasonsInadequate 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 OutcomesWhile 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 employedjob satisfactionsatisfactory job terminationssense of mastery and well-beingopportunity for promotion

Research Synthesis: Accommodations ProcessAccommodations Process findings from 15 descriptive and 9 qualitative studies Categories of Process FindingsNature and Process of Accommodations5 Descriptive Studies3 Survey/Correlational2 Quasi-Experimental6 Qualitative Studies3 Individual Interview1 Focus Group2 Case Studies of Organizations

Research Synthesis: Accommodations Process moreCategories of Process Findings (more)Attitudes about Accommodations4 Descriptive Studies - Survey DesignDisclosure and Requesting Accommodations6 Descriptive Studies2 Experimental on Disclosure only4 Survey or Correlational3 Qualitative Studies2 Individual Interviews1 Individual Interviews and Focus GroupsDescriptive and qualitative studies suggest Promising Findings, more research needed

Promising Process Findings: Nature of Job AccommodationsJob accommodations for people with psychiatric disabilities cost little to nothing in direct costs to the employer Most frequently used AccommodationsFlexible 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 processAccommodated 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 AccommodationsFunctional 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 independentlySocial-interpersonal interacting with coworkers or customers, responding to supervisor feedbackEmotional managing stress, adjusting to changes in the workplace, lack of confidencePhysical maintaining stamina, adjusting to low energy levels or fatigue, experiencing physical side effects of medicationsThe 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 AccommodationsEmployers are aware of the ADA and accommodations for people with psychiatric disabilitiesProviding job accommodations (adjusting work hours, part-time jobs, restructuring jobs) and are satisfied with these employeesCoworkers 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 fairlySome 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 & AccommodationPeople 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 jobsOver-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 AccommodationsWhen SE Services involved: Providers frequently handle disclosure and accommodation requestsEmployees are more likely to receive accommodationDisclosure 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 coworkersUsing clear, assertive communication about accommodation needs and using relationship accommodations are associated with successful accommodation outcomes

Summary of Research Synthesis: Accommodations ProcessJob 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 AccommodationsHigh 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 makersKnowledge 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 AccommodationWhile 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 supportsAccommodations 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 # H133B090014 from the National Institute on Disability and Rehabilitation Research and the Center for Mental Health Services to Boston University

Reference: (EEOC, 2002)*Accom. & Work Outcomes Studies - Campolieti, 2004; Fesko, 2001; Martin, Brooks, Ortiz, & Veniegas, 2003; Rumrill, Roessler, Battersby-Longden, & Schuyler, 1998; Schartz, Hendricks, & Blanck, 2006Theory & Comprehensive literature Reviews on accommodations (cross disability) have not used Systematic Review process - (Baldridge & Veiga, 2001; Cleveland, Barnes-Farrell, & Ratz, 1997; Colella, 2001; Florey & Harrison, 2000)Limited Knowledge about ADA Psych - Banks, Novak, Mank, & Grossi, 2007; Gioia & Brekke, 2003a; Granger, 2000Disclosure - MacDonald-Wilson, Russinova, Rogers, et al., 2011

*Not Included in Analysis:Qualitative studies Process evaluations Legal guidance and case law reports Descriptive, educational, or policy documents that did not analyze data collected about people with psychiatric disabilities

*These detailed findings are based on review of the 4 outcomes studies:Unsatisfactory job terminations Based on Suggestive evidence from two uncontrolled correlational studies of people involved in supported employment programs in the US and Hong Kong (Becker, Drake, Bond, Xie, Dain, & Harrison, 1998; Mak, Tsang, and Cheung, 2006) Employment Tenure based on Weak evidence due to a small sample from a single supported employment program and the use of a retrospective design of examining past records (Fabian, Waterworth & Ripke, 1993)Inadequate Accommodation - Suggestive evidence from one uncontrolled correlational study involving workers for a healthcare organization in New York who received treatment for a mental health condition (Akabas & Gates, 2000)

*Based on the 4 outcomes related studies *

*Job Accommodation Costs - Suggestive evidence from 1 qualitative, 1 quasi-experimental, and 1 correlational studies (Granger et al., 1997; MacDonald-Wilson et al., 2002; Scheid, 1999).Most Frequently Used accommodations: Considerable and consistent evidence from quasi-experimental, correlational, survey, and qualitative studies Flexible hours and scheduling (Becker et al., 1998; Fabian et al., 1993; MacDonald-Wilson et al., 2002, 2003; Mak et al., 2006; Mancuso, 1993; Peters & Brown, 2009; Secker et al., 2003; Symanski-Tondora, 2003) Providing access to a job coach or other human assistance or support in the job (Granger et al., 1997; MacDonald-Wilson et al., 2002, 2003; Peters & Brown, 2009; Symanski-Tondora, 2003)Use of interpersonal or relationship accommodations including educating coworkers, extra support from coworkers or supervisors, or modified supervision or feedback from supervisors (Akabas & Gates, 2000; Becker et al., 1998; Fabian et al., 1993; Gates, 2000; MacDonald-Wilson et al. 2002; 2003; Mak et al., 2006; Mancuso, 1993; Peters & Brown, 2009)Modifying job duties such as restructuring the job, changing work assignments, or adjusting demands (Gates, 2000; MacDonald-Wilson et al., 2002, 2003; Scheid, 1999; Scott, 1997; Secker et al., 2003)Adjusting the training length or learning process to acquire job task skills, including self-paced work (Becker et al., 1998; Granger et al., 1997; Mancuso, 1993; Peters & Brown, 2009; Symanski-Tondora, 2003)Different Accommodations identified 2 Qualitative studies: Mancuso, 1993; Secker et al., 2003Relationship accommodations least often met - Correlational study (Akabas & Gates, 2000)

*Types of FLs and needed accommodations - (MacDonald-Wilson et al., 2003; Mancuso, 1993; Secker et al., 2003; Symanski-Tondora, 2003)Fewer FL, Fewer Accommodations - (MacDonald-Wilson et al., 2003) Cog Limitations and human assistance accommodations - (MacDonald-Wilson et al., 2003; Symanski-Tondora, 2003) Cog and Social limitations and interpersonal accommodations - (Symanski-Tondora, 2003)

*Employer Attitudes Scheid, 1999, surveyCoworkers Attitudes Peters & Brown, 2009, survey of Canadian Health Organization, randomly selected coworkersBias, acceptable disabilities Dalgin & Gilbride (2003) interviews and focus groups with people with psychiatric disabilities Bias, psychological conditions - Popovich, Scherbaum, Scherbaum, & Polinko (2003) surveys of college students

*PwMH less likely to have accommodations - (Zwerling et al., 2003). This may be due in part to fewer people with psychiatric disabilities requesting job accommodations (Scott, 1997) or believing that accommodations for psychiatric disabilities are less acceptable than for physical disabilities (Dalgin & Gilbride, 2003). Supervisor, coworker supportiveness - (Akabas & Gates, 2000; Banks et al., 2007; Gates, 2000; Granger, 2000; Rollins et al., 2002)Terminated employees desired accommodations - (Becker et al., 1998; Mak et al., 2006). Over-accommodation - (Secker et al., 2003).Self-accommodation - (Mancuso, 1993; Dalgin & Gilbride)

*SE involvement more likely to get accommodation - (Banks et al., 2007)SE Providers handle disclosure/accommodations - (Banks et al., 2007; Gioia & Brekke, 2003a; Goldberg et al., 2005; Granger 2000; Granger et al., 1997)Disclosure helps - (Banks et al., 2007; Ellison et al., 2003; Gioia & Brekke, 2003b, Granger, 2000)Disclosure may increase stress (Rollins et al., 2002), different treatment (Granger, 2000) Using assertive communication - (Akabas & Gates, 2000; Gates, 2000)*