Synthesis of the Research Literature on Job Accommodations for People with Psychiatric Disabilities 1990-2010
Conducted by the University of Maryland for the Center for Psychiatric Rehabilitation at Boston University
Table of Contents
Plain language summary
Methods and procedures
Results and conclusions
Funded in part under a grant from the National Institute on Disability and Rehabilitation Research and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Grant # H133B090014.
Job accommodations are those adjustments made by employers to a job or to the work environment that are mandated under the Americans with Disabilities Act of 1990 and the Rehabilitation Act of 1973. They are designed to level the playing field so that people with disabilities can enjoy equal opportunities in employment and become contributing members of the workforce. Most of the literature on job accommodations in the 1980s and 1990s focused on people with a range of disabilities. Very little was written about accommodations for people with psychiatric disabilities.
Results of this synthesis of the research literature on job accommodations for people with psychiatric disabilities suggest that there are very few well-controlled studies of the effectiveness of job accommodations for people with psychiatric disabilities. There are, however, numerous studies that are descriptive or qualitative in nature; use less rigorous designs; describe the nature of accommodations; identify factors related to disclosure of psychiatric disabilities and job accommodations, or describe the process of disclosing and requesting accommodations. Given how few well-controlled studies have been done in this area, the question of how effective job accommodations are for people with psychiatric disabilities remains open. There is currently no conclusive evidence from well-controlled studies that job accommodations result in improved employment outcomes. At the same time it is important to note that neither are there well-controlled or rigorous studies indicating that job accommodations are ineffective. There is weak evidence from uncontrolled studies that job accommodations are positively associated with employment outcomes such as staying employed, job satisfaction, satisfactory job terminations, sense of mastery and well-being, and opportunity for promotion.
Promising findings from descriptive and qualitative studies suggest that most accommodations for people with psychiatric disabilities require little to nothing in direct costs, and most frequently involve flexible schedules, interpersonal supports (e.g., job assistance by vocational rehabilitation service providers, interpersonal or other support interactions provided by supervisors and coworkers), and changes in job tasks or the training process. The functional limitations requiring accommodation are most often cognitive or interpersonal in nature. Results also suggest that disclosure of psychiatric disabilities to employers, while necessary in accessing job accommodations, 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. This issue 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.
Job Accommodations Study Group:
Chia Huei Lin,
Kim L. MacDonald-Wilson, Sc.D., CRC, CPRP
Assistant Professor, Rehabilitation Counseling
Counseling and Personnel Services Department
University of Maryland
3214 Benjamin Building
College Park, MD 20742
Chia Huei Lin, M.S., Doctoral Student, Research Assistant
University of Maryland
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Rationale for the Review.
Accommodations provided in the workplace are considered one of the essential components of the Americans with Disabilities Act of 1990 and the Rehabilitation Act of 1973, which level the playing field for people with disabilities and enable them to enjoy equal opportunities for employment. Mandated by law, employers are required to provide ‘reasonable accommodations’ to qualified individuals with disabilities unless doing so would create an undue hardship for the employer in terms of unreasonably high costs or significant disruption to the nature of the business. This protection under the law allows people with disabilities to perform the essential functions of the job, and to become contributing members of the workforce.
However, a limited amount is known about how the employer-provided supports such as job accommodations impact employment outcomes of people with psychiatric disabilities. While some empirical evidence exists that accommodations are associated with higher retention rates and satisfactory work outcomes for people with other disabilities (e.g., Campolieti, 2004; Fesko, 2001; Martin, Brooks, Ortiz, & Veniegas, 2003; Rumrill, Roessler, Battersby-Longden, & Schuyler, 1998; Schartz, Hendricks, & Blanck, 2006), none of these studies focused on people with psychiatric disabilities. There have been several theoretical models proposed and comprehensive literature reviews conducted regarding reasonable accommodations in the workplace for people with disabilities (Baldridge & Veiga, 2001; Cleveland, Barnes-Farrell, & Ratz, 1997; Colella, 2001; Florey & Harrison, 2000), but none of these literature reviews employed systematic review methodology. In fact, in 2006, an editorial in a special issue of the journal Work on accommodations in the workplace concluded that at that time, the existent knowledge base was insufficient to identify evidence-based practices in job accommodations for people with disabilities (Sanford & Milchus, 2006). What we do know is that people with psychiatric disabilities and employers have limited knowledge or understanding of the application of the Americans with Disabilities Act (ADA, 1990) regarding job accommodations for people with mental health conditions (Banks, Novak, Mank, & Grossi, 2007; Gioia & Brekke, 2003a; Granger, 2000). Employees or applicants with psychiatric disabilities are often hesitant to disclose disability to employers due to fears of discrimination, which may also interfere with requesting and using the accommodations that may allow them to enjoy employment opportunities often denied them (MacDonald-Wilson, Russinova, Rogers, et al., 2011).
Objectives of the Review
The primary goal of this review is to systematically analyze the job accommodation literature for individuals with psychiatric disabilities, not limited to randomized clinical trials (RCTs), using a grading scheme for rating the rigor and meaning of disability research (Farkas, Rogers, & Anthony, 2008). The underlying assumption for this review is our belief that there is important and significant research on job accommodations that has accumulated which urgently needs to be synthesized for the mental health and rehabilitation field at large. In addition, the year of this review marks the 20th anniversary of the signing of the Americans with Disabilities Act of 1990, which authorized the implementation of reasonable accommodations for qualified people with disabilities in a wide range of employment settings under Title I of the Act.
Consumers, families, employers, advocates, and service providers are searching for useful information in this critical area. More than a decade has passed since the comprehensive literature reviews on accommodations for people with other disabilities with significant advancement in the literature on outcomes of job accommodations across disability groups. It is essential to validate the research findings specific to people with psychiatric disabilities and provide the innovative technical assistance necessary to ensure the use of these research findings among employers, advocates, and people with psychiatric disabilities.
The research team for the review was guided by the definition of “reasonable accommodations” specified in the Americans with Disabilities Act (ADA) of 1990 to be any adjustments that allow people with disabilities to enjoy equal employment opportunities (US Equal Employment Opportunity Commission [EEOC], 2000) as long as the required modifications do not result in “undue hardship for the employer” (ADA, 1990; Section 101). Thus job accommodations are “any change in the work environment or in the way things are customarily done (EEOC, 2002).” Job accommodations typically include modifications to the job application process, the work environment or job duties, or to the benefits and privileges of employment. Accommodations are intended to remove the workplace barriers for individuals with disabilities (EEOC, 2002).
The goal of the review was to analyze the evidence on accommodations for people with psychiatric disabilities in the workplace. Two research questions were specified to conduct this search:
- What is the evidence on the outcomes of receiving job accommodations for people with psychiatric disabilities?
- What is the nature and process of job accommodations for people with psychiatric disabilities?
We conducted a comprehensive search of the published and the unpublished ‘grey’ literature related to the questions above using the following search terms paired with the terms psychiatric disability, mental illness, or psychiatric illness:
- Reasonable accommodations
- Job Accommodations
- Disability Disclosure
- Accommodations (in searching through the business literature, this term generated more meaningful results)
- Work or Workplace Supports
The terms ‘work supports’ or ‘workplace supports’ have been used in more recent employment literature for people with disabilities to refer to reasonable accommodations or job accommodations, among other types of supports, that people with disabilities use to be successful on the job. While these terms generally encompass any resources or supports that may be provided by practitioners, families, peers, or systems in addition to those provided by employers, we included these terms in our search since such publications may also refer to employer-provided supports such as job accommodations. We hoped, by including these additional terms, to maximize the chances of locating relevant literature on job accommodations for people with psychiatric disabilities.
The search of the published literature was conducted using a number of electronic databases, including Pubmed, PsychInfo, Google Scholar, and Business Source Complete (an upgraded version of Business Source Premier, replacing ABI/Inform). Further, we also accessed the database of cross-disability reasonable accommodations literature developed under a subcontract to a NIDRR funded project, the Mid-Atlantic ADA Center (Region III Disability and Business Technical Assistance Center) (Grant # H133A060085).
In addition to published literature, hand searches of relevant rehabilitation journals and citations contained in each located publication were also examined to identify additional relevant studies. Grey literature, including dissertations, government reports, and other unpublished studies were located through relevant websites of rehabilitation and employment-related research, training, and technical assistance centers, including such sources as:
- The Job Accommodation Network (http://askJAN.org)
- The Virginia Commonwealth University RRTC on Workplace Supports and Job Retention (http://www.worksupport.com/)
- Boston University Center for Psychiatric Rehabilitation (http://www.bu.edu/cpr/)
- National Research and Training Center (NRTC) at University of Illinois in Chicago (http://www.cmhsrp.uic.edu/nrtc/)
- The National Institute on Disability and Rehabilitation Research (NIDRR) (http://www.ed.gov/about/offices/list/osers/nidrr/)
- The Institute for Community Inclusion (http://www.communityinclusion.org/)
- Dissertation Abstracts International
A research assistant was responsible for querying the databases, locating the documents, and conducting hand searches of the relevant journals. The Senior Researcher conducted a search of the grey literature, consulted her project accommodation database, and consulted with other experts about potential sources of other studies.
These search activities resulted in 100 documents for potential inclusion. An initial screening of document titles and abstracts was conducted for relevance to the topic of job accommodations for people with psychiatric disabilities – each document had to include job accommodations and refer to people with psychiatric disabilities, resulting in 60 documents for further review. After initial screening, previously developed inclusion and exclusion criteria were used to determine which studies to include in the systematic review, using a screening form. For consideration for inclusion in the review, the document had to describe an empirical study, with the sample consisting of exclusively people with psychiatric disabilities or a significant proportion of the sample consisting of people with psychiatric disabilities with analysis of results focusing specifically on people with psychiatric disabilities. Acceptable research designs included: experimental, quasi-experimental, correlational, pre-post evaluation, observational cohort, and survey research. We excluded qualitative studies, process evaluations, legal guidance and case law reports related to the topic, or descriptive, educational, or policy documents that did not analyze data collected about people with psychiatric disabilities. We also excluded studies that primarily focused on variables and analyses unrelated to workplace accommodations for people with psychiatric disabilities. Many of these excluded documents were related to discrimination in the hiring or employment process, or to people with disabilities other than psychiatric disabilities, or to non-workplace accommodations (e.g., academic or residential accommodations). Our initial screening for the systematic review yielded 15 quantitative studies, which included four outcome-related studies and 11 process-related studies.
Ratings of the Quality of the Research
The review was conducted using a system developed at the Center for Psychiatric Rehabilitation at Boston University for rating the quality of disability research, especially those that are non-experimental in nature (e.g., evaluation, policy, survey, pre-post designs, correlational). An instrument developed for rating research quality was used to rate the rigor of the outcomes-related research studies we located (Rogers, Farkas, Anthony, & Kash, 2008). The quality standards rating scale for each of the items was based on a 4-point scale, with 4=Definitely (Above Adequate), 3= Somewhat (Adequate), 2=Minimally (Minimally Adequate), and 1=Not at all (Not at All Adequate).
The four outcome-related studies were all correlational or survey in design; no experimental, quasi-experimental, or randomized controlled trial (RCT) studies, considered more rigorous in design, were evident. Rigor ratings of the four outcome studies yielded overall ratings of methodology that were slightly less than adequate, with other components of the studies rated as minimally or not adequate. Specifically, analysis of the rigor ratings of the four studies indicates that the average scores of the introduction and rationale for the studies were 3.5 out of 4, which means that the authors were able to sufficiently describe the current related literature in the field and build the rationale for their studies. All four articles were rated for the primary methodology item (“Study/research uses rigorous or sound research methods that allow the questions of interest to be addressed”). With 3.0 on this item as cutoff, the four articles were qualified to be included in the review. The average rating of all rigor ratings in the methodology and procedures sections was 3.4, which is above Somewhat Adequate. In particular, the methodology items on the rationale of the design and the definitions of variables to be measured were often missing or inadequate. The lowest rigor ratings were of the discussion and conclusion sections. The average rating was 2.4, minimally adequate. Many authors did not sufficiently describe the limitations of their studies (including threats to validity) or provide alternative explanations of their results.
Within the grading process developed by the Center for Psychiatric Rehabilitation, the threshold for the possibility of a systematic review of the literature is five outcome studies. Although we were able to conduct rigor ratings for the four outcomes-related articles, the small number of articles available is insufficient to draw valid conclusions about the impact of accommodations on employment outcomes for people with psychiatric disabilities. Another issue is that none of these studies used experimental or quasi-experimental designs, which also limited the level of evidence needed to support the validity of their findings. The sample size of these studies was small: three out of the four studies had sample sizes below 70. Since the studies fell below the minimum in terms of overall rigor, ratings of meaningfulness were not conducted on these four studies.
Given that few high quality studies exist on the effectiveness of job accommodations for people with psychiatric disabilities, the researchers proceeded to focus on a structured synthesis of the findings of the research literature to provide a comprehensive picture of what is known about job accommodations for people with psychiatric disabilities. In addition to the 15 quantitative studies, the researchers identified nine qualitative studies that described the nature or process of requesting or accessing accommodations in the workplace. Therefore, this synthesis of the research literature includes outcomes-related and process-related quantitative studies and qualitative studies of job accommodations in order to address this important research area in which stakeholders are seeking guidance.
Time Period of the Studies and Research Covered
The Americans with Disabilities Act (ADA) was signed into law in 1990. The year 1990 was used as the starting point for the review of the literature because Title I of the ADA specifically focused on the issue of accommodations. Under Title I, employers were required to provide reasonable accommodations to qualified individuals with disabilities as long as the accommodation did not cause undue hardship on the employer. While reasonable accommodation was first mandated with the Rehabilitation Act of 1973, it covered few employers, primarily federal government employees or employers receiving federal dollars. With the signing of the ADA, the majority of employers in the United States were required to follow the law, as long as the employer had a minimum of 15 employees (as of 1994). Most of the research on accommodations for people with psychiatric disabilities was conducted after 1990. Therefore, the search was conducted on all research articles in the 20 years between 1990 and 2010.
Training of Reviewers
Two raters were used for the synthesis. One rater was an assistant professor in Rehabilitation Counseling in the Department of Counseling and Personnel Services at the University of Maryland. The other was a senior doctoral student in Counselor Education – Rehabilitation Counseling specialization at the University of Maryland. Both raters had participated in a project at UMd on a comprehensive review of the literature on job accommodations for people with disabilities and were knowledgeable about the literature base. Each rater was also knowledgeable about research methods.
Training of raters was conducted by experienced researchers affiliated with the Center for Psychiatric Rehabilitation at Boston University who had developed the rating scales and used them to conduct other systematic reviews. The training focused on rating the quality of the research and identifying acceptable indicators of quality for each of the 4 points on the rigor and meaning rating scales. Each item in the scales was reviewed and the meaning of the item and the evidence that could be considered for each indicator was discussed in detail. Sample research articles were used to test inter-rater reliability with each rater independently rating each article, and then comparing their ratings until agreement was achieved. Formal tests of inter-rater reliability yielded an 80% agreement between raters.
In the process of searching for studies to include in this review, we found a number of conceptual and educational publications that provided useful background information, laying the context for the current study. What follows is a description of the history of job accommodations.
History of Job Accommodations for People with Psychiatric Disabilities.
Job accommodations in the workplace were first mandated with the implementation of the Rehabilitation Act of 1973. This was the first law to prohibit discrimination against people with disabilities and required employers who were federal agencies, federal contractors, or organizations receiving federal dollars to provide “reasonable accommodations” to individuals with disabilities so that they could enjoy equal opportunities for employment, education, and access to public services.
During the 1970’s and 1980’s, since there was limited experience with accommodating people with disabilities, the Handbook of Reasonable Accommodations (US Office of Personnel Management, 1984) was developed by the federal government to provide information about reasonable accommodations and how to implement them. In an early study, funded by the US Department of Labor (Berkeley Planning Associates, 1982), accommodations were found to be relatively inexpensive, provided by large and small employers, to people identified as having primarily physical or sensory disabilities. Accommodations were reported to be effective in improving the productivity of workers provided them, as well as benefiting other employees in the organization.
In 1984, the Job Accommodation Network (JAN) was implemented at West Virginia University as a service of the President’s Committee on the Employment of People with Disabilities (Rochlin, 1985). By the early 1990s, information on accommodations for people with psychiatric disabilities was available at JAN. JAN is a national, confidential, and free expert technical assistance and consultation service on workplace accommodations and disability employment issues (JAN, undated). Today, JAN is funded as a service of the US Department of Labor, Office of Disability Employment Policy (ODEP) available through the internet (askJAN.org) and by phone with a toll-free number (1-800-526-7234).
In 1990, the Americans with Disabilities Act (ADA) was signed into law (ADA, 1990). Under Title I of this law, all employers with 15 or more employees (as of July, 1994) are required to provide “reasonable accommodations” to qualified individuals with disabilities unless doing so would impose an undue hardship to the employer. The U.S. Equal Employment Opportunity Commission (EEOC), which was responsible for handling discrimination complaints under Title I of the ADA, developed guidance materials about how the ADA applies to people with psychiatric disabilities (EEOC, 1997) and on reasonable accommodations (EEOC, 2002). Since the implementation of the ADA in 1990 and with the development and implementation in the 1980s and 90s of supported employment services nationwide, there has been a noticeable increase in the research on job accommodations for people with disabilities, including a focus on people with psychiatric disabilities.
In summary, while job accommodations have been in use for more than 35 years since the implementation of the Rehabilitation Act of 1973, most of what was known applied to people with physical and sensory disabilities, and very little was known about accommodations for people with psychiatric disabilities until the implementation of the Americans with Disabilities Act of 1990. Early educational and conceptual publications described the types of job accommodations that would meet the needs of people with psychiatric disabilities. Few rigorous studies on job accommodations have been conducted, especially with a focus on people with psychiatric disabilities. Indeed, we found no experimental or quasi-experimental designs related to the effectiveness of accommodations, a point that was made by Sanford and Milchus (2006) in their editorial on the difficulty in defining evidence-based practices in accommodations in the workplace. In conclusion, research is challenged by the rigor of the experimental design in investigating the effectiveness of job accommodations, when it would be unethical to withhold a legally sanctioned right to accommodation under the ADA. This is the context for a synthesis of the literature on job accommodations for people with psychiatric disabilities.
Measurement of Job Accommodation Outcomes.
Finally, the job accommodations literature dealing with people with a variety of disabilities use a number of different variables related to process or outcome findings of the provision of accommodations that may be examined. The typical process measures noted in studies of job accommodations involve attitudes toward accommodations, receipt of requested accommodations, number and types of job accommodations provided, and costs of accommodations. Typical outcomes-related measures include satisfaction with accommodations provided, improvement in job performance, maintaining the job, advancing to another position through promotion, return to work from a disability leave, benefits to the employer or organization, and benefits to other workers in the job environment. Not all of these outcome variables may be considered measures of effectiveness of the intervention involving providing accommodations, which involves primarily the impact of the accommodation on the employee’s satisfaction with the job, job performance, or job retention.
Results of the Synthesis of the Job Accommodations Literature – Outcomes Studies
Before discussing outcomes or effectiveness studies, it is important to note that the number of studies that focus on the impact or outcomes of accommodations is limited. We found no experimental or quasi-experimental studies on the effectiveness of job accommodations for people with psychiatric disabilities. Random assignment is the key design factor that defines an experimental study. The lack of experimental studies may be due to the fact that the legal right to accommodations makes it impossible to randomly assign the provision of accommodations to an experimental group and withhold it from a control group. We found four studies that examined relationships between accommodations and outcomes such as return to work, job tenure, and job terminations. These were primarily correlational studies or follow-up analyses of data in which an experimental design was used to examine a supported employment intervention. However, correlational studies only permit a description of the associations between these variables, and do not permit the inference of cause and effect relationships between accommodations and employment outcomes.
Outcomes of Accommodations – Correlational Studies.
An early correlational study exploring the effectiveness of job accommodations among individuals diagnosed with mental health conditions participating in supported employment, was conducted by Fabian and colleagues using retrospective records review and staff interviews. The study investigated the types and frequency of job accommodations and work outcomes (Fabian, Waterworth, & Ripke, 1993). The authors identified a total of 231 job modifications for the 47 jobs of the 30 participants, for an average of 5.1 accommodations per job. The most frequently identified accommodation was orientation and training of supervisors to provide necessary assistance (38.1%), followed by modifications of the non-physical work environment (16.4%), and modifications of work hours and schedules (15.6%). Using survival analysis techniques, the authors examined the relationship between job duration and number of accommodations. With the average number of accommodations (5) as the cutoff point, the authors divided the sample into two groups: accommodations of less than five (n = 19) and accommodations of five or greater (n =27). They found that five or more accommodations on a job resulted in twice the average job tenure, which indicated that job tenure was significantly associated with number of job accommodations. The major limitations of this study were that the sample size was small (n=30), and the data was collected retrospectively from a single supported employment program in a mid-Atlantic state, which limited the ability to generalize the results to other programs, or to people with psychiatric disabilities who are not involved in supported employment. In addition, the study design only indicates an association between the number of accommodations and job tenure, and cannot be used to show a causal relationship between these variables. Nonetheless, this study was important as the first study to show a relationship between accommodations and employment outcomes for people with psychiatric disabilities.
Akabas and Gates (2000) investigated the relationship between provision of job accommodations and employment outcomes among New York City workers with a diagnosis of a mental health condition. This study consisted of two phases: during the first phase, 181 insurance claimants who received reimbursement for criterion psychotropic medications for at least eleven continuous months, (89% who were employed full-time), were randomly selected to be interviewed face-to-face to determine factors related to sustaining employment. During the second phase, 43 individuals out of work and on short term disability leave with a primary or secondary psychiatric diagnoses were interviewed regarding factors needed to assist in the return to work.
The results indicated that two-thirds of Phase I participants experienced “serious and persistent” mental illness (categorized by long-term use of psychotropic medications, hospitalization history, and use of sick and disability leave in the past due to psychiatric reasons), although 79% rated themselves as slightly or not at all disabled. Regarding job accommodations, 61% of the Phase I workers reported receiving at least one accommodation, while 60% of Phase II participants on disability leave reported receiving no job accommodations prior to leave.
Another important outcome variable of this study is “accommodation adequacy,” which was created by combining both the concepts of condition stability (the extent to which functional limitations interfered with work) and workplace responsiveness (whether or not the worker was accommodated). About half of the Phase I participants (53%) who worked reported that they were inadequately accommodated. Inadequate accommodation was associated with lower job satisfaction, lower sense of mastery and well-being, and a lack of opportunity for promotion. Nearly all of the Phase II participants on disability leave (95%) reported that their conditions interfered with doing their jobs, which indicated that their accommodations were inadequate prior to leave.
Of all the types of accommodations provided to Phase 1 workers (task, routine, relationship), the need for relationship accommodations was often unmet. Seventy-six percent of the participants identified the need for relationship accommodations but did not receive it. The authors suggested from this and the finding that supervisory and coworker support was significantly related to adequate accommodation that “accommodation is a social process as much as a technical method (p. 177).” Thus, the authors concluded that work group supports were essential to developing effective accommodations for employees diagnosed with serious and persistent mental health conditions.
This study has several limitations that affect the strength of the conclusions about the effectiveness of accommodations in the workplace. First, the study design is correlational in nature, so that causal relationships between accommodations and employment outcomes cannot be reliably inferred. Accommodations were not independently manipulated. In addition, there is no control group identified, although there are comparisons between individuals who were employed and individuals who were on short term disability leave. The study is based on two samples from a population of individuals insured in one state, and it is not clear that results can be generalized to all workers with psychiatric disabilities. Evidence suggests that having adequate accommodation is associated with maintaining employment. However this conclusion is based on comparing the adequacy of accommodations given to workers who are maintaining employment to those who are out on disability leave. Variables other than accommodations could be contributing to the outcome. Despite this limitation, overall the findings suggest that the adequacy of accommodations are related to maintaining employment, and deserve further investigation.
Becker, Drake, Bond, Xie, Dain, and Harrison (1998) investigated the job terminations of 63 individuals in supported employment programs in New Hampshire who experienced a job termination within 18 months of participation in a randomized controlled trial study of supported employment. In a correlational follow-up study using the Job Termination Interview (JTI) developed for this study, data was collected from clients, employment specialists, and case managers on reasons for job terminations and accommodations that were desired. The authors classified job terminations as either satisfactory (left for another job, laid off due to elimination of the job, or left because the job was time-limited) or unsatisfactory (fired or left without another job). Desired accommodations were identified by asking raters what accommodations would have improved the job.
Approximately half (52%) of the terminations were rated as “unsatisfactory.” The most common accommodation desired by individuals who experienced unsatisfactory job terminations was flexible hours (30%), followed by idiosyncratic items (27%) such as wanting more training, more support from the employer, more feedback, or different working conditions. It is not known how many of the unsatisfactory job termination situations (out of approximately 33 individuals) had accommodations identified that were believed to have improved the job, nor do we know how many types of accommodations were identified. What is reported is that the flexible hours and miscellaneous accommodations significantly differentiated the unsatisfactory from the satisfactory termination group, although the direction of the relationship is unclear. Evidence suggests these types of accommodations are somehow related to the type of job termination.
There are a number of limitations to this study related to the effectiveness of accommodations. First, the study focused on a relatively small and select sample of Caucasian individuals with psychiatric disabilities in supported employment programs in New Hampshire during the early 1990’s, limiting the generalizability of the results to those who are employed, including those not involved in supported employment programs. In addition, this sample was a subgroup of individuals participating in a larger, randomized controlled trial of supported employment, where the employment intervention was independently manipulated but accommodation was not an independently manipulated variable. Detailed information is not provided on the accommodations data, limiting the usefulness of the findings. In addition, the data on reasons for job terminations and accommodations desired was gathered retrospectively, and therefore may be biased by recollections, although attempts were made to triangulate the data with multiple perspectives (about half of the data provided was rated from all 3 perspectives). No analysis was done however, regarding the influence of the perspectives on the data provided. Direct evidence on the effectiveness of accommodations on retaining the job is only suggested, indirectly, by asking raters about what would have improved the job.
In a similar study, Mak, Tsang, and Cheung (2006) examined job terminations among 60 individuals with mental health conditions in a supported employment program in Hong Kong. They translated and validated the Job Termination Interview (JTI; Becker et al., 1998) into Chinese. The results indicated that about half of the job terminations (53%) were unsatisfactory, which was similar to Becker and colleagues’ findings (52%). In terms of job accommodations desired to improve the job, 13 out of 60 participants reported that the accommodations that would have helped included changes in work schedule (30% or 4 individuals) and a reasonable and stable salary and better working environment (23% or 3 individuals). Other miscellaneous job changes were suggested, such as supplying spacious and air–conditioned environment, helping participants understand more about job demands, and providing sufficient supervision at work.
The limitations of this study are similar to those of the Becker et al. (1998) study. In addition, this study was conducted using a convenience sample of 60 individuals participating in supported employment in Hong Kong, and a small number of individuals (n=13) identified accommodations, further limiting generalizability of these results. Translation of the JTI interview instrument may also have affected the reliability and validity of the findings, particularly in reference to accommodations. In contrast to the US definition of accommodations as changes to an actual job to support an individual with disability, some of the reported accommodations (e.g., finding a job that matched employee’s interests and understanding the job demands better) are not typically defined as accommodations. Because of the small sample of accommodations, analyses related to type of job termination could not be determined.
Results of Synthesis of Job Accommodations Literature – Process Studies
The majority of the research literature on job accommodations for people with psychiatric disabilities involves descriptions of accommodations and other information related to providing accommodations in the workplace. While these studies do not focus on the effectiveness or outcomes of accommodations, they do provide descriptive information about job accommodations for people with psychiatric disabilities. These studies focus on attitudes about job accommodations, the nature of accommodations, and the process of requesting and accessing accommodations. Studies on disclosure of psychiatric disabilities in the workplace are included when they relate to requesting and accessing accommodations. The following synthesizes the literature on the process related to job accommodations for people with psychiatric disabilities.
Attitudes about Job Accommodations.
There were three studies examining attitudes about job accommodations provided to people with psychiatric disabilities using survey design methods to analyze relationships between variables. The first two studies surveyed businesses about policies and practices, although accommodations were not the primary focus of the studies. The third study is the most focused and most rigorous with a large sample randomly selected regarding accommodations and coworker perspectives about job accommodations.
In the first study, Jones, Gallagher, Kelley, and Massari (1991) conducted a national survey of Fortune 500 companies about their policies concerning people with psychiatric disabilities (they used the term “psychiatrically handicapped”). A total of 127 firms out of 488 included on the Fortune 500 list responded to the survey, resulting in a 26% response rate. While this study was published after the signing of the Americans with Disabilities Act, data was collected in the mid-1980’s. Only eight businesses (6.3%) provided “extra monitoring and/or support from supervisors” after hiring, although specific accommodations are not mentioned. While this survey did focus on employees with psychiatric disabilities, the information is very dated, and little detail is provided about policies related to specific accommodations, other that extra support or monitoring from supervisors. Fortune 500 employers tend to be large corporations with multiple offices and/or branches, with significant resources. Due to these factors, the generalizability of these results to the range of employers in the U.S. is limited.
Scheid (1999) conducted a telephone survey to investigate the response of employers to the Americans with Disabilities Act (ADA), with specific focus on the employment of people with psychiatric disabilities (they used the term ‘mental disabilities’). A total of 190 businesses in a southern metropolitan area were randomly selected for this survey and 117 businesses responded to the survey (a 62% response rate). While the majority of the survey focused on awareness of and compliance with the ADA, 61% of these companies reported providing specific accommodations to people with psychiatric disabilities, with the majority adjusting work hours, creating part time jobs, or restructuring jobs. Regarding the cost of the accommodations, 79.2% reported that these accommodations were not expensive at all. Only 16.7% found them somewhat expensive and 4.2% found them very expensive. While this survey involved a more rigorous survey design and indicates more awareness of and more positive attitudes about accommodations for people with psychiatric disabilities than the Gallagher et al. (1991) study, it is limited by the narrow geographic area sampled.
Peters and Brown (2009) conducted a survey to investigate the reactions of employees toward coworkers with mental health conditions and toward job accommodations. A sample of 600 employees was randomly selected from a unionized Canadian healthcare organization with approximately 6700 employees. A total of 305 employees completed the survey (51% response rate). Respondents rated each of seven accommodations regarding the extent to which they felt that the accommodation was appropriate for coworkers with mental health conditions using a 5-point scale (1 = Inappropriate to 5 = Appropriate). Job accommodations included were flexible work hours, providing a job coach, self-paced work, banking of overtime hours for use in case of illness, longer or more frequent breaks, time off for counseling, and increased supervision. Employees were less likely to view longer or more frequent work breaks as appropriate accommodations for coworkers compared to flexible hours, banking of overtime hours, and counseling. Overall, the extent of employee contact with individuals with mental health conditions had no significant effect on support for job accommodations. However, occupation type was related: employees working in occupations with limited contact with individuals with mental health conditions were more supportive of accommodations than those in occupations with daily contact. Authors interpret this finding that health care workers with more frequent contact may be in contact with people who are in more acute phases of the illness, resulting in more negative perceptions. Peters and Brown also found that employee perceptions of the likelihood that their employer would treat coworkers with mental health conditions fairly predicted the likelihood that they would self-disclose a mental health condition and seek treatment for it.
The study is limited to a sample of healthcare workers in Canada and may not be able to generalize to workers in other professions or in the U.S. Insufficient detail was provided on the types and severity of mental health conditions and contact with people with mental health conditions, particularly regarding whether the contact was with a coworker or service participant, which also makes conclusions about the relationship between positive contact and positive attitudes more complex. It is also difficult to draw any conclusions about the relationship between attitudes and behavior, although a relationship between attitudes and intention to act was found.
Nature of Accommodation.
As mentioned, much of the empirical literature on job accommodations for people with psychiatric disabilities is descriptive in nature. These studies examine the nature of accommodations such as number, type, and costs, and limitations of people with psychiatric disabilities that are associated with accommodations, as well as some information describing the process of accommodation – how accommodations are implemented. This section describes four studies focusing on the nature of accommodations: one is a secondary analysis of a large national health survey dataset that contains questions related to workplace accommodations, two studies are quasi-experimental using a time-series design, and one study is correlational in design. The quasi-experimental studies were in fact two different analyses from the same research project.
Zwerling, Whitten, Sprince, Davis, Wallace, Blanck, et al. (2003) reported a secondary analysis of data gathered from the National Health Interview Survey Disability Supplement 1994-1995, describing the nature of workplace accommodations in the American workforce and factors associated with the provision of such accommodations. Using a large, nationally representative sample of workers aged 18 to 69 years with a wide range of impairments and conditions (n=4937), 12% reported receiving workplace accommodations. The study found that people with mental health disabilities were 50% less likely to receive work accommodations compared to people with other types of disabilities. Specifically, those workers with diagnosed major depression or substance abuse disorder were significantly less likely to report accommodations.
While this study’s strengths are in its large, nationally representative sample, this study has several limitations. Types of accommodations were listed for respondents to identify whether they used them at work. Only three of those accommodations were likely to be associated with mental health conditions, so accommodations may be underreported. Information is not provided on accommodations or on employment characteristics by type of impairment or health condition, so it is not clear which accommodations were more often used by people with mental health conditions. Employer perspectives are not represented, as data is gathered by self-report of the participants.
In the first prospective empirical study of job accommodations for people with psychiatric disabilities, MacDonald-Wilson, Rogers, Massaro, Lyass, and Crean (2002) collected data about accommodations and employment on 191 individuals with psychiatric disabilities who were involved in supported employment programs in several eastern states. Researchers gathered data from employment specialists at the time of job entry and quarterly for up to one year (including through multiple jobs) using a quasi-experimental time series design.
The 191 participants in the study received a total of 322 accommodations during the year of their participation in the study. The jobs obtained by participants were primarily entry-level, unskilled jobs in the service and retail industries that participants maintained for an average of six months. The accommodations were primarily provided in one job, but 9% of the study participants had two or more jobs during the year of the study. The majority of accommodations (60%) involved the presence of a job coach, either on the job or in the hiring process. Flexible scheduling (21%) occurred frequently as well. Less common accommodations included changes in training and supervision and modified job duties. Only one of the 322 accommodations involved a direct expenditure of money amounting to $25 for a job performance test. However, employment specialists were also asked about indirect costs of accommodations, especially as they involved extra supervisor or coworker time. Over one third of the accommodations involved a reallocation of coworker or supervisor time, hours, or job duties and other indirect expenditures. Twelve percent of the accommodations required extra hours to be expended by coworkers, on average about nine hours per month. Extra supervisory hours were also reported to be involved in 28% of the accommodations with an average of five hours per month. Many of these extra time accommodations involved additional training early in the job and the supports were often reduced or eliminated as time passed.
In this study, MacDonald-Wilson et al. (2002) also reported the types of functional limitations that employment specialists identified as the basis of the need for the accommodations. The types of limitations of workers with psychiatric disabilities were primarily in interacting with others (23%), learning the job tasks (21%), and maintaining work stamina (11%). Other less frequently reported limitations were in managing symptoms or tolerating stress, working independently, attending work, and adjusting to changes in work.
Initial information about the process of accommodation was also identified in this study. Most of the time, accommodations were identified during the hiring process (63%) or once the employee was on the job (47%). Of those identified while the employee was on the job, 53% were identified during the first two months of employment. In terms of what was accommodated, accommodations were made to the hiring process 23% of the time (e.g., allowing the job coach to attend the interview, providing assistance with the application or testing process) and to the working on-the-job activities (e.g., additional training, extra supervision) 77% of the time.
While this study contains a large sample and uses a quasi-experimental design, it is limited by its focus on employees involved in supported employment programs in the Eastern U.S., limiting generalizability of results to people with psychiatric disabilities not involved with vocational services. In addition, accommodations were only reported from the service provider’s perspective, and not from employers’ or employees’ perspectives which may bias the types of accommodations reported.
In a further analysis of relationships of factors to accommodations, MacDonald-Wilson, Rogers, and Massaro (2003) conducted a multi-site, longitudinal study to investigate the relationships between functional limitations, accommodations, and demographic factors using a quasi-experimental time series design described previously. Their sample consisted of 191 workers in 22 supported employment programs from three eastern states. Data on accommodations and the functional limitations associated with the need for those accommodations were gathered prospectively from employment specialists in a structured, narrative form without preconceived categories.
Analysis indicated that the most frequent functional limitations of employed persons with psychiatric disabilities leading to the need for accommodation were cognitive limitations, followed by social, physical, and emotional/other. Accommodations were grouped into five categories: human assistance (of a job coach), flexible scheduling, extra or modified training and/or supervision, modified job duties, and other.
Demographic factors (gender, race, education level, diagnosis, substance abuse, or months of previous employment) were not associated with the number or type of reasonable accommodations. However, people diagnosed with psychotic disorders had significantly fewer cognitive limitations than people with other disorders. The strongest relationships were between limitations and accommodations: the number of functional limitations was associated with the number and type of accommodations received: the fewer limitations that were identified, the fewer number of accommodations were provided. In particular, employees with one limitation had significantly lower average total extra hours provided by coworkers and supervisors than did employees with more limitations. The types of functional limitations were also significantly related to the types of accommodations. Cognitive limitations were the strongest and most consistent predictor of accommodations provided when the accommodation type was the provision of extra supervisor and coworker hours. Individuals with functional limitations in the cognitive and social areas were more likely to receive accommodations involving human assistance (62% and 92%, respectively) while those with physical limitations were more likely to receive flexible scheduling (65%).
The limitations of this study are similar to those identified for the study by MacDonald-Wilson et al. (2002). In addition, the categorization of limitations and accommodations were coded by group consensus, and may not represent current understanding of the functional limitations that may be attributed to specific mental health conditions.
In a study with a similar focus, Symanski-Tondora (2003) conducted a dissertation using a correlational design to examine how individual characteristics (e.g., cognitive impairment, baseline work functioning, clinical symptomatology) and work site characteristics (i.e., site complexity) impact the need for reasonable accommodations among a sample of 87 participants with schizophrenia or schizoaffective disorder who were participating in a work rehabilitation study in the Veterans Administration investigating employment outcomes. Accommodations information was collected and then data from the larger study was accessed retrospectively to analyze relationships.
The most frequently used specific accommodations were allowing the worker to contact his or her therapist during the workday, accepting a longer learning period, creating an initial job match based on worker strengths and needs, establishing a flexible return to work schedule after hospitalization, and allowing the worker more time to learn job tasks. Using a factor analysis approach, the author developed an instrument to collect data on specific accommodations. The five categories of accommodations were a) supportive supervision and scheduling policies such as flexible leave and proactively addressing problems; b) use of on-site physical accommodations including physical space arrangements and allowing on-site job coaching; c) accommodations that support organization and task structure such as to-do lists, reminders, and job skill training; d) interpersonal accommodations such as coworker support, educating employers, and contact with professionals; e) modified expectation of task completion including extended learning periods and allowing for mistakes without penalty. These categories were then used for other analyses of the relationships between accommodations and individual and worksite characteristics.
Cognitive impairments, specific social domains of baseline work behavior, and site complexity all positively predicted the use of interpersonal accommodations. People with cognitive impairments were more likely than people with no cognitive impairments to use on-site physical accommodations such as job coaching although there were no differences between groups in the total number of accommodations. People with lower baseline work behavior were more likely to use onsite physical accommodations and modified expectations of task completion.
Symanski-Tondora (2003) suggested that rehabilitation professionals should consider an individual’ s personal characteristics, such as cognitive impairments, social interpersonal skills, and baseline work behavior, as well as characteristics of the job site in identifying job accommodations. Limitations of this study however focus on the generalizability of the results to people other than veterans working in rehabilitation program jobs. Participants in this study were primarily Caucasian men who were veterans participating in a work rehabilitation program in the northeast. Characteristics of the jobs may also have differed significantly from competitive jobs in the community, which may have affected the types of accommodations provided in the workplace. Accommodations information was collected at one point in time, not over a period of time on the job.
Process of Requesting and Accessing Accommodations.
This section describes four studies focusing on the process of accommodations: all four studies are survey or correlational in design. Studies involving disclosure of psychiatric disabilities in the workplace related to requesting and accessing accommodations are included.
Granger, Baron, and Robinson (1997) conducted a national mail survey of employment support practitioners working in community-based agencies in 10 states that provided employment support services to people with psychiatric disabilities. The total sample is a non-probability convenience sample of 194 respondents geographically spread throughout the U.S., with a return rate of 35%. Primary analyses are descriptive in nature.
Job coaches and job developers report that the types of job accommodations used most frequently include use of the job coach in facilitating communications, phone access to the job coach while on the job, use of positive feedback by the supervisor, the option for part-time work hours, and gradual introduction of tasks while learning the job. The costs of job accommodations for people with psychiatric disabilities were reported to be low; approximately 58% of the respondents reported no cost and 32% reported costs of less than $100. Costs were similar for initial accommodations provided on the job, as well as for accommodations maintained over time on the job.
In the process of accommodation, employment support practitioners describe themselves as very involved in facilitating communications between the employee and employer related to arranging job accommodations. Over one-third of the time, the employer was aware of the nature of the agency and types of disabilities of the individuals served or otherwise knew the individual had a mental health condition. One-fourth of the time the individual themselves disclosed to the employer, and one-fifth of the time, the individual chose not to disclose. In terms of the timing of disclosure of psychiatric disability to the employer, two-thirds of the time this occurs before the job offer (46% prior to interviews, 18% during interviews). In terms of how the accommodations are arranged, over half of the respondents indicated that they never or seldom referred to the ADA when arranging job accommodations. In addition, disclosure was a somewhat complex process, initially just revealing the fact of psychiatric disability, and later revealing more information regarding how the disability affected the job and what accommodations are needed.
While this study provided empirical evidence about the use of accommodations by people with psychiatric disabilities in supported employment programs from the perspective of employment support practitioners, the findings are limited due to the non-representative, convenience sample which makes it difficult to generalize findings nationally or to people not involved in such programs. Questions on accommodations involved pre-developed categories and specific accommodation checklists with space for practitioners to add accommodations not listed, which may have limited the range of accommodations reported. The perspectives of employers and employees with psychiatric disabilities are not included in the study, also limiting the usefulness of the findings to people not involved with service providers in the workplace.
Banks, Novak, Mank, and Grossi (2007) conducted a survey on the role of disclosing a psychiatric disability and the employment experiences of 162 people participating in ten supported employment programs across eight states (CA, IN, KS, NY, OR, PA, RI, VA) in the United States. Data for the study included demographic, disability, disclosure, employment, and support information. The disclosure study was a supplement to research on job performance and workplace supports.
They found that 82% of the employees in supported employment programs had their disability disclosed in the workplace, however disclosure was typically made by the employment agency. In general, employees had little role in disclosure once they chose to be involved in supported employment services. For those who had disability disclosed, details about the process of disclosure revealed that specifically 54% had the SE staff disclose (in 45% of the disclosures the employer was aware of the nature of the agency), and 29% of the time the employee themselves disclosed. In terms of who disclosed, women, people with a mood disorder, and people who displayed no symptoms at work were less likely to disclose. Those who did disclose most often did so during the job development and hiring process.
Most often the identified purpose of disclosure was to enlist the support of workplace personnel (80%) and negotiate accommodations (68%). Supported employees who disclosed their disability were significantly more likely to have an accommodation at the workplace than supported employees who did not disclose their disability. Fifty-two percent (n=133) of those who disclosed had workplace accommodations while only 31 percent (n= 29) of those who did not disclose had workplace accommodations. In particular, company personnel of employees who had disability disclosed were more likely to have training and were more likely to provide support compared to personnel of employees who had not disclosed. This study is one of the few studies that directly links disclosure to receiving accommodations and other employment outcomes. However, since it is a correlational study, we are unable to conclude that disclosure conclusively resulted in these outcomes. In addition, results may only be generalized to people involved in supported employment programs, and provides little insight into the role of individuals with psychiatric disabilities in the disclosure and accommodation process.
Ellison, Russinova, MacDonald-Wilson, and Lyass (2003) conducted a national survey with a large, non-representative, purposive sample of professionals and managers (n=495) who identified themselves as having psychiatric conditions. Response rate was calculated at 66% using the proportion of respondents to total number of surveys sent out, less ineligible surveys. To be eligible for the study, participants had to be working in a professional or managerial position for at least 6 months during the previous five years, and have experienced a serious mental health condition. The majority of respondents were Caucasian, female, over age 40, and well educated, with the majority (73%) reporting a mood disorder diagnosis, and most never receiving federal disability benefits, although most did report at least one hospitalization (78%) and were taking medications to treat the mental health condition (83%). This sample is clearly a different group from individuals in other studies who primarily participating in vocational rehabilitation or supported employment services.
An unexpectedly large proportion (87%) of study participants reported having disclosed their mental health condition to someone in the workplace. Most frequently, respondents disclosed to supervisors. In terms of what was disclosed, the majority (64%) tended to describe their diagnosis or that they had a psychiatric disability or mental health condition, and 31% described modifications that they needed (e.g., accommodations) or problems in keeping the job. In addition, likelihood of disclosure was positively related to confidence in the job and “having learned how to manage their psychiatric condition and have a satisfying life.”
In terms of when disclosure happened, one third made their disability known when applying for the job, another 16 percent within one year of working on the job. Investigation into the patterns of disclosure revealed that about half of the disclosers reported unfavorable circumstances leading to disclosure while one third disclosed when they felt comfortable. There was a significant relationship between when someone disclosed and under what circumstances – individuals who disclosed under unfavorable circumstances (such as a hospitalization or displaying symptoms on the job) tended to disclose at a later time (after an average of six months on the job) compared to those who disclosed under favorable circumstances (when they felt comfortable or when they felt secure in the job) who tended to disclose sooner (after about one month on the job). People with schizophrenia diagnoses, people with part time employment, and former disability benefit recipients tended to disclose earlier in their job process, suggesting that a need for accommodations may play a role in earlier disclosure patterns.
Limitations of this study include the possibility that the sampling approach may have produced a self-selection bias, positively skewing the results toward higher reported disclosure rates, and that the non-representative sample limits the generalizability of the results to all professionals and managers with psychiatric conditions or to people with more disabling psychiatric disorders who may participate in vocational support services. Information about the impact of disclosing on accessing job accommodations is not clear.
Rollins, Mueser, Bond, and Becker (2002) conducted an exploratory correlational study on social relationships at work, interviewing 104 employees with psychiatric disabilities participating in one of two different types of employment programs: one emphasizing a gradual sequence of group and individual placements in protected jobs and the other consisting of a supported employment model emphasizing individual, competitive placements. Interviewers asked participants to identify coworkers and supervisors with whom they had contact and to rate each on several aspects of their relationships, including disclosure, emotional support, and overall satisfaction.
In general, all employees in both types of employment programs disclosed more frequently to supervisors than to coworkers. However, participants in the protected jobs program had higher rates of disclosure to supervisors and coworkers than participants in the competitive jobs program. Along with the higher rates of disclosure, involvement in the protected jobs program was associated with more emotional support from supervisors and coworkers, more instrumental support on the job (instruction and information), higher overall satisfaction with supervisor relationships, but also more stressfulness in coworker relationships than those in competitive jobs. Overall, this study points to the link between disclosure in the job and having more supports, including accommodations.
One of the interesting findings is that disclosure is associated both with perceptions of more support from supervisors and coworkers, but also more stressfulness with coworkers. Implications of this finding for the impact of using job accommodations on the perceptions of employees about support and stress is also worth investigating. However, this study is limited by its focus more specifically on social relationships at work in these two distinct samples of participants. The two samples were located in different states, and were convenience samples, limiting generalizability of the results.
Results of the Synthesis of the Job Accommodation Literature – Qualitative Studies
During the search of the literature nine qualitative studies were identified that were focused on the nature and process of job accommodations for people with psychiatric disabilities. While comments about the research design are provided, no ratings of the rigor of qualitative studies were conducted. However, these studies are useful in providing rich detail about the experiences of and processes involved in requesting, accessing, and using accommodations in the workplace. Brief descriptions of these studies and findings are summarized here, supporting findings of the other studies described, and providing some breadth and context for the synthesis of the research literature on job accommodations. Of the nine studies, five are based on in-depth interviews of individuals with psychiatric disabilities (two of these also include interviews with supervisors or managers), one involves focus groups of people with psychiatric disabilities, one involves both focus groups and individual interviews with people with psychiatric disabilities, and two are case studies conducted within employment organizations.
An early qualitative study by Mancuso (1993) described the experiences of 10 workers with psychiatric disabilities including their use of job accommodations. Information was gathered through in-depth, face-to-face interviews of the workers and their supervisors. In each situation, the employer knew that the worker had a disability and each worker used at least one accommodation. Supported employment service providers were involved in 5 of the 10 work situations. Findings of this study focus on the types of functional limitations that workers experienced, the nature of job accommodations used, and the impact of accommodations.
Workers with psychiatric disabilities most frequently described having difficulty with concentration on the job. Functional limitations that could be attributed to the side effects of medications were also common. Overall however, workers viewed their functional limitations to be greater than did their supervisors. Accommodations could be agreed to by both the supervisor and worker (as in only 2 out of 10 situations, labeled explicit accommodations), or implemented by either the supervisor (in 4 out of 10 situations, labeled unilateral accommodations) or by the worker alone (in 4 out of 10 situations, labeled self-accommodations). In 5 out of 10 situations, supervisors provided ‘productivity accommodations’ that might have been provided to any employee, whether or not s/he had a disability. The types of accommodations used most frequently were flexible or part-time schedule (identified by both supervisors and employees) and modifications in work assignments or other supervisory interventions (identified by supervisors).
In terms of the impact of accommodations, supervisors reported that accommodations did not impose any undue hardship. However, some workers described negative social and personal consequences from receiving reasonable accommodations in the workplace. For example, some of the accommodations involved benefits that other workers could only accrue by attaining seniority or promotions, which may have created some resentment in coworkers. In addition, for some workers with psychiatric disabilities, receiving accommodations created a sense of indebtedness to the employer.
While this was one of the first in-depth qualitative studies on job accommodations for people with psychiatric disabilities, the validity of the findings are limited somewhat by not being peer-reviewed, and there was limited information provided about the qualitative analysis approach to judge the rigor of the study. This study does provide valuable information about some of the differences in perspectives between workers and their supervisors related to job accommodations, and highlights some of the concerns about potential negative consequences for employees related to disclosure and receiving accommodations that previously had not been addressed in research.
Secker, Membrey, Grove, and Seebohm (2003) conducted a similar qualitative study in the U.K., focused on exploring problems in work (functional limitations) and how and why related work adjustments (job accommodations) work for people with psychiatric disabilities. Semi-structured interviews were carried out with 17 employees and their workplace managers in five geographically diverse employment projects in England. Interviews were tape recorded, fully transcribed and analyzed to identify and compare emerging themes. The analysis process used was described in some detail although strategies to assure the rigor of the analysis were not described.
Problems experienced by individuals which represent functional limitations of people with psychiatric disabilities included low energy and stamina levels, lack of confidence, and psychological barriers to particular types of work, such as heightened anxiety or stress when in contact with angry customers, work on computers when the employee was unfamiliar with them, or on tasks perceived to involve a high level of responsibility. In particular, Secker et al. noted that a number of the problems appeared related to side effects of medications, and not to the psychiatric conditions themselves.
To address these problems, the adjustments to working hours or work schedules, and changes in job tasks (e.g., simplifying tasks, breaking larger tasks down into smaller ones, delaying some tasks) proved crucial for some people in enabling them to overcome these problems. Overall, many of these adjustments were found helpful by the employees, and presumably were effective. However, a few employees identified that in some cases they felt they were overprotected and not challenged in their jobs, which was itself distressing, affected work performance, and the worker’s interest in staying in the job. These situations highlighted the importance of balancing accommodation and challenge in the job, and that this balance is central to job retention. While this study makes important contributions to the literature on matching accommodations carefully to the person and the job situation, and confirms other research on the types of functional limitations and job accommodations that are effective, limited information is available on the rigor of the analysis affecting the reliability of some of the conclusions drawn.
Gioia and Brekke (2003a) reported on a qualitative study describing the impact of the Americans with Disabilities Act (ADA) on the work experience of young adults with schizophrenia. A total of 20 individuals with recent-onset schizophrenia who had worked prior to illness and returned to working after illness were interviewed about the ADA and other work-related experiences to better understand the role of the ADA in their lives. Participants were drawn from an aftercare clinic and were participating in a non-employment related study on recent-onset schizophrenia. Participants were categorized into 3 groups based on their knowledge and use of the ADA. Group 1 (n=9) had no knowledge or use of the ADA, Group 2 (n=7) had knowledge of the ADA and accommodations but did not use them, and Group 3 (n=4) had knowledge of and used ADA accommodations.
Overall, 55% (n=11) of the individuals interviewed knew about the ADA, but only 20% (the four individuals in Group 3) had disability disclosed to their employer and used accommodations. Disclosure and accommodation requests primarily happened during the hiring process, and was done by either job coaches or parents. The other 7 individuals (people in Group 2) knew about the ADA and chose not to disclose or request accommodations. Further analysis revealed differences between these groups. Group 1 participants had no knowledge or use of the ADA, but tended to have the lowest work functioning and high negative symptoms. Group 2 had ADA knowledge but chose not to disclose or use accommodations. These participants were primarily women, and had the highest level of post-illness work functioning and the lowest negative symptoms. The jobs tended to be higher than minimum wage and more career oriented. Group 3 participants were all male, had the longest post-illness job tenure, but worked in minimum wage jobs and had the highest negative symptoms. The authors conclude that educating people with psychiatric disabilities about the ADA may not necessarily result in more people requesting accommodations, given that these decisions are made regarding the person’s needs for accommodation in a particular job and their comfort with disclosure.
This study provides insight into the relationship between knowledge about the ADA, the nature of the specific job and the person’s need for accommodations, and actual use of accommodations in a group of people not primarily involved in supported employment services. However, limited information or guidance is available about accommodations or the actual process used to access them. The number of people interviewed is small, and little information is provided on the nature or rigor of the analysis, so that the findings should be interpreted with caution.
Granger (2000) conducted 20 focus groups in 10 states with persons with psychiatric disabilities, averaging about seven participants for each session. There were 78 participants in the focus groups who used job coaches and 59 participants in the focus groups who did not use job coaches for a total of 137 participants (all were of employment age 22–62 years old). The purpose of the focus groups was to obtain information from people with psychiatric disabilities about their experiences in arranging for job accommodations.
Overall, over 86% of the participants were unfamiliar with the Americans with Disabilities Act (ADA) or job accommodations, even though all of the participants using job coaches described accommodations that were provided to them. The most frequent accommodation used was flexible scheduling. Among people who used job coaches, coaches frequently facilitated communications with the employer, such as disclosing disabilities and arranging accommodations.
Employees who did not use the services of job coaches reported that they did not have anyone to help them with communications on the job. Some of the people who did not use job coaches spoke about their need for added time off to manage symptoms and recovery; but this was difficult to arrange, as they often had not disclosed their health condition or their need for accommodations. Many did not disclose their disability at all, and reported losing jobs due to the refusal to grant sick leave requests, an accommodation for returning symptoms that is dependent upon disclosure. Furthermore, those employees who did disclose their disability reported a variety of problems with employers and coworkers.
In summary, when people used job coach services, the job coach was actively involved in the process of disclosure and arranging accommodations. People who did not use job coach services were much more hesitant about disclosing and requesting accommodations, and often did not obtain accommodations when problems arose in the job. Sometimes they found jobs which were naturally more accommodating for all employees and little disclosure was required.
However, this study did not provide details about the process of arranging accommodations used, nor the effectiveness of accommodations that were provided. A limited range of accommodations were also reported, which may have been due to the focus on employee perspectives only and the limited awareness of the majority of participants about the ADA and job accommodations. Little detail was provided about the procedures used for qualitative analysis of the data or strategies used to increase the rigor of the study, suggesting caution in interpreting these findings.
Gates (2000) described a case study of an intervention piloted with 12 workers with psychiatric disabilities returning from a short-term disability leave in which a psycho-educational approach was used with the employee and the work group addressing accommodations as a social process. Key intervention components include 1) the development of a disclosure plan, 2) a systematic method for identifying the work group members, 3) a formal psycho-education training that includes the supervisor, identified work group members, and the individual in the work organization who has the authority to approve accommodations, and 4) on-going follow-up support to the supervisor and worker with disability. These workers were able to return to their jobs and remain employed with this intervention.
Analysis of the factors that related to accommodation success included the worker with the psychiatric disability using assertive and clear communications with supervisors about their need for accommodations, improved use of relationship accommodations that the work group intervention fostered, educating coworkers about disability and accommodations, and having supportive supervisors. While this study highlighted the importance of accommodation as a social process, it is limited by the small number of participants and the lack of comparison to the experiences of workers who did not participate in the work group intervention.
In another qualitative multiple case study approach focusing on employers, Scott (1997) explored how organizations are responding to the ADA mandate to fit individuals with psychiatric disabilities in the workplace. A “brute-force” case method approach (a direct, pragmatic approach gathering as much information as possible without violating ethics or company privacy) was applied to four organizations. The data sources are three organizations that allowed access to this sensitive information, and a fourth that had two disability discrimination charges filed against it involving people with psychiatric disabilities.
A number of methods of accommodations are being used by the three organizations that provided accommodations: creating a position with specific functions yet with enough flexibility to adjust demands, “carving” a position with tasks from multiple jobs that match the individual’s abilities and reassignment to a vacant position or modification of the way the job is normally done. Conclusions from the findings of the case studies focus on several factors from review across the case studies. Many workers with psychiatric disabilities are not disclosing and requesting accommodations unless the employer was involved with a mental health center assisting the person with employment. However, when accommodations do occur, there is tacit accommodation of long-standing employees in organizations. While all of the organizations were well aware of the ADA, knowledge of the intent of the ADA made a difference in the equality of treatment of the workers with psychiatric disabilities. Finally, in organizations where there is insensitivity to an employee’s privacy, adversarial situations tend to result. The main strength of this study is using the employer as the source of information. However, limited data was available about the process or effectiveness of accommodations, and little input from employees with disabilities was included.
Gioia and Brekke (2003b) reported on a qualitative study describing the impact of the Americans with Disabilities Act (ADA) on the work experience of young adults with schizophrenia. Responses of 20 individuals with recent-onset schizophrenia who had worked prior to illness and returned to working after illness were analyzed to key questions about the ADA and other work-related experiences to better understand the role of the ADA in their lives. Participants were categorized into 3 groups based on their knowledge and use of the ADA. Group 1 (n=9) had no knowledge or use of the ADA, Group 2 (n=7) had knowledge of the ADA workplace accommodations but did not use them, and Group 3 (n=4) had knowledge of and used ADA accommodations. This particular report of this study describes themes identified primarily from the experiences of people in Group 3.
These four individuals found that disclosure to their employer could be beneficial, although they recognized that the decision to disclose their health condition was a personal choice. All reported that disclosure enabled them to better perform the essential functions of their job and helped make their work environment less stressful. They each felt that by being honest with their employer they were more likely to have someone in the workplace to turn to if problems were to arise, which helped them stay in their jobs. These individuals all pointed to the effectiveness of accommodations such as not taking on more challenging or varied tasks in their work. However, findings should be interpreted with caution due to the extremely small sample, and lack of information on the rigor of the qualitative analysis.
Goldberg, Killeen, and O’Day (2005) conducted a well-designed qualitative study on the employment, ADA, and disclosure experiences of 32 people with psychiatric disabilities. All were current or former recipients of social security disability benefits, self-identified as having a mental health disorder and were recruited from one of three separate urban areas in a mid-Atlantic state. Equal numbers of employed and unemployed, and male and female participants were recruited, some who were not involved with the public mental health or vocational rehabilitation systems. Interviews were semi-structured and took place initially in 2-3 hour face-to-face meetings, and by telephone 18-24 months later for approximately an hour with 28 out of 32 of the original participants. Initial interviews included a few questions about the ADA and disclosure, and the second interview explored these in more depth. The researchers described detailed procedures for coding and analyzing the data using grounded theory strategies. Findings reported here are focused on disclosure as it relates to accommodations.
The disclosure dilemma requires a strategic analysis of a range of issues, but few participants engaged in a careful approach. Although disclosure provided the opportunity to seek ADA accommodations and invoke other legal rights, some people who disclosed indicated that disclosure had adverse consequences for them. People who disclosed on a job reported receiving harsher treatment by supervisors, feeling stigmatized by coworkers or supervisors, or receiving uncomfortable attention from others. Nondisclosure offered protection from these problems; it allowed a person to participate in the larger community without fear of prejudice or discrimination. The nondisclosure option was particularly useful for participants in later phases of recovery. However, nondisclosure posed its own challenges, such as the difficulties in explaining an uneven employment history, in obtaining job accommodations, and in keeping the diagnosis confidential.
This well-designed qualitative study describes the complexity of the disclosure process, the reasons for disclosure in addition to requesting accommodations, the interaction between the phase of recovery, involvement of service providers and their impact on deciding to disclose and request accommodations, and the impact of disclosure decisions on the person on the job. However, the nature or process of requesting and accessing accommodations was not the focus of the study, nor was the impact of receiving accommodations after a disclosure explored.
Dalgin and Gilbride (2003) conducted a well-designed qualitative study using both focus groups and individual interviews in a grounded theory approach to analysis of the data. Participants who volunteered to participate in one focus group (n=11) were recruited from a peer support center and five of those participants were selected for individual interviews. Seven of these individuals were working at the time of the focus group, six of them working full time. Although the focus was on disclosure, job accommodations concepts were reported in the results. Data collection and analysis procedures were described, including coding by an independent rater to reach consensus with the first author.
Five major themes emerged from the data: (1) disability identity; (2) the importance of job matching to eliminate the need to disclose; (3) the acceptance of the need for physical accommodations; (4) concern about a negative response; and (5) assessment process for disclosure. Regarding disability identity, although most individuals reported having a psychiatric diagnosis or label, most did not consider themselves to have a disability, raising the question about the purpose of disclosing a diagnosis or label if not to access the ADA or accommodations. Not having a disability was perceived as related to not experiencing limitations at work, either because the job closely matched their needs and skills, or otherwise they did not perceive a need for accommodations. Having a job with “natural accommodations” was seen as a successful employment strategy, eliminating the need for disclosure. Accommodations for physical disabilities were seen as more acceptable than accommodations for psychiatric disabilities, and if disclosure happened at all, people chose to disclose physical disabilities to an employer. Most people expressed concern about negative reactions to disclosure, such as discrimination or not being hired, which led them to choose not to disclose. Finally, participants described the process they used to assess whether to disclose, consider factors such as the reasons to disclose, need for accommodations, and the culture of the work environment.
This study identifies the importance of the need for accommodations for deciding about disclosure, along with whether employees consider themselves to have a disability. However, the nature of the small sample and the fact that it was a convenience sample of volunteers from one peer support center limit the generalizability of the results to other populations.
Conclusions from the Synthesis of the Literature
What follows is a detailed list of conclusions drawn from the synthesis of the research literature on job accommodations for people with psychiatric disabilities, followed by a summary of the conclusions from this synthesis.
Outcomes of Job Accommodations
- There is no evidence from a randomized controlled trial or well-controlled quasi-experimental study that provision of reasonable accommodations in the workplace results in improved employment outcomes such as job tenure, job satisfaction, satisfactoriness (job performance), or promotion for people with psychiatric disabilities. However, there is no conclusive evidence that providing accommodations is ineffective.
- There was suggestive evidence from two uncontrolled correlational studies that unsatisfactory job terminations are related to unmet accommodation needs such as flexible hours, more training, and improved supervision and support (Becker, Drake, Bond, Xie, Dain, & Harrison, 1998; Mak, Tsang, and Cheung, 2006).
- Employment tenure was positively associated with number of job accommodations (Fabian, Waterworth & Ripke, 1993), however the strength of the evidence is weak due to a small sample from a single program and the use of a retrospective design.
- There is suggestive evidence from one uncontrolled correlational study that inadequate accommodation is associated with disability leave status and 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 (Akabas and Gates, 2000).
Promising Findings from Process and Qualitative Studies
Attitudes about Job Accommodations
- Prior to the ADA, few employers had specific policies regarding hiring employees with psychiatric disabilities (Jones, Gallagher, Kelley, & Massari, 1991). However, since the ADA, employers are aware of the ADA and report providing job accommodations such as adjusting work hours, part-time jobs, and restructuring jobs for people with psychiatric disabilities, and the majority are satisfied with these employees (Scheid, 1999).
- Coworkers generally are supportive of job accommodations for people with psychiatric disabilities, in particular, flexible work hours, banking overtime for use as sick leave, and access to counseling. Accommodations viewed as ‘less appropriate’ were longer or more frequent breaks, suggesting that accommodations that might affect the coworker during the workday may be viewed less positively (Peters & Brown, 2009).
- 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).
Nature of Job Accommodations
- There is consistent evidence from correlational and qualitative studies that job accommodations for people with psychiatric disabilities cost little to nothing in direct costs to the employer (Granger et al., 1997; MacDonald-Wilson et al., 2002; Scheid, 1999).
- There is considerable and consistent evidence from quasi-experimental, correlational, survey, and qualitative studies that the types of job accommodations most frequently identified for use by people with psychiatric disabilities are:
- 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)
- 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)
- 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)
- Employees and supervisors tend to identify different accommodations when asked. Employees tend to identify flexibility in schedules or other support and supervision, while supervisors tend to identify modifications in job tasks or demands, as well as flexibility in schedules (Mancuso, 1993; Secker et al., 2003).
- Among accommodations such as task, routine, and relationship accommodations, relationship accommodation needs were least often met in the workplace (Akabas & Gates, 2000).
Functional Limitations and Job Accommodations
- The functional limitations that people with psychiatric disabilities experience leading to the need for job accommodations tend to be primarily in the areas of cognitive and social-interpersonal functioning in the workplace, although physical and emotional limitations may also be present (MacDonald-Wilson et al., 2003; Mancuso, 1993; Secker et al., 2003; Symanski-Tondora, 2003). Some examples of these functional limitations include:
- 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
- Having cognitive limitations are associated with accommodations involving job coaching or other human assistance (MacDonald-Wilson et al., 2003; Symanski-Tondora, 2003) and are associated with extra supervisor and coworker time in supporting the employee involved in supported employment services (MacDonald-Wilson et al., 2003).
- Cognitive and social-interpersonal limitations are positively associated with interpersonal accommodations such as educating coworkers and phone or other access to support personnel (Symanski-Tondora, 2003).
- Inadequate accommodation (measured by the extent to which functional limitations interfered with work performance and workplace responsiveness such as supervisor support and whether the worker was accommodated) is associated with lower job satisfaction, lower sense of mastery and well-being, and lack of opportunity for promotion (Akabas & Gates, 2000).
Process of Requesting and Accessing Job Accommodations
- Compared to people with physical and sensory conditions, people with mental health conditions (especially depression and substance use disorders) are less likely to have accommodations in the workplace (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 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) and are desired as accommodations by terminated employees with psychiatric disabilities who identified accommodations that would have made a difference in their jobs (Becker et al., 1998; Mak et al., 2006).
- Knowledge about the ADA and accommodations among people with psychiatric disabilities has been reported to be low (Gioia & Brekke, 2003a; Granger, 2000) but increasing that knowledge may not necessarily lead to an increase in the use of job accommodations given the complexity of factors involved in deciding about whether to disclose and request accommodations (Gioia & Brekke, 2003a, b).
- Using clear, assertive communication about accommodation needs and using relationship accommodations are associated with successful accommodation outcomes (Akabas & Gates, 2000; Gates, 2000).
- Service providers, when involved, handle all communications with the employer, including disclosure and arranging accommodations. Only occasionally do the employees themselves disclose (Banks et al., 2007; Gioia & Brekke, 2003a; Goldberg et al., 2005; Granger 2000; Granger et al., 1997).
- Disclosure and requesting accommodations most often happen early in the hiring process when SE or VR providers are involved (Banks et al., 2007; Gioia & Brekke, 2003; Granger et al., 1997; MacDonald-Wilson et al., 2003).
Impact of Disclosing and Requesting Accommodations
- When employees involved with (SE) services disclose their disabilities, they are more likely to receive accommodations and other employer support than people who do not disclose (Banks et al., 2007).
- Disclosure helps employees with psychiatric disabilities to do their jobs better, makes work feel less stressful, and allows employees to get support and accommodations (Banks et al., 2007; Ellison et al., 2003; Gioia & Brekke, 2003b, Granger, 2000).
- Self-accommodation or finding jobs that are naturally accommodating are considered successful employment strategies that help people avoid disclosure of psychiatric disabilities in the workplace (Mancuso, 1993).
Summary of the Conclusions.
While there is no conclusive, rigorous research evidence that job accommodations for people with psychiatric disabilities are effective or not, evidence suggests that accommodations are associated with positive employment outcomes. Given how few well-controlled studies have been done in this area, the question of how effective job accommodations are for people with psychiatric disabilities remains open. Additional studies using stronger research designs are needed to validate the effectiveness of job accommodations in improving employment outcomes.
The state of the research on job accommodations to date includes proportionately more studies that are descriptive or qualitative in nature. Some of these studies use more rigorous designs, and provide good information on the nature and process of accommodations. These studies yield some Promising Findings that require additional research. Promising findings from process-related and qualitative studies suggest that most accommodations for people with psychiatric disabilities require little to nothing in direct costs, and most frequently involve flexible schedules and interpersonal supports provided by job coaches, supervisors, and coworkers. The functional limitations requiring accommodation are most often cognitive or interpersonal in nature. Results also suggest that disclosure of psychiatric disabilities to employers, while necessary in obtaining job accommodations, is a complex process facilitated by the involvement of service providers. When service providers are not involved, it is a challenge to access accommodations when needed, but effective job matching and self-accommodation can address this. And while mostly beneficial, receiving accommodations may result in some negative personal and social consequences, and that over-accommodation may result in feeling unchallenged and less interested in the job.
It is essential to promote new research on job accommodations given the high unemployment and underemployment rates for people with psychiatric disabilities. Satisfying and meaningful employment is an important component of recovery from psychiatric disabilities. More rigorous research on the outcomes of job accommodations and effective processes for obtaining them is needed not only by people with psychiatric disabilities and service providers, but also by employers who provide accommodations and policy makers determining the effectiveness of the Americans with Disabilities Act and other legislation intended to promote equal opportunities in employment for people with disabilities.
The job accommodations study group would like to thank the staff of our funding bodies, NIDRR and SAMHSA, for their support of this undertaking including our project officer, Pimjai Sudsawad. In addition, the work of the Center for Psychiatric Rehabilitation in developing the procedures and scales for rating rigor and meaning of the research literature in previous studies supported by NIDRR were invaluable to us in conducting this review. We particularly would like to acknowledge the work of Dr. Ellen Fabian, Dr. Kim MacDonald-Wilson, Shengli Dong, Spalatin Oire, Bingqing Cui, and Terri Ferguson, for sharing their extensive database of the research literature on job accommodations for people with disabilities.
Finally, the job accommodations experts we consulted were helpful in insuring that we consulted all of the relevant literature and gave generously of their time to assist this systematic review.
The study group would also like to thank the staff of NCDDR including John Westbrook and Joann Starks for their efforts to further the use of systematic reviews by disability researchers.
Statement Concerning Conflict of Interest
No study group member has a conflict of interest in this area of job accommodations. The Center does not have a job accommodations grant at this time and no individual has a fiduciary interest in the use of accommodations in the workplace.
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