Research Brief: Mental Health, Employment, and the ADA

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Mental Health, Employment, and the ADA

An ADA Knowledge Translation Center Research Brief

Sarah Parker Harris

Rob Gould

Courtney Mullin

Department of Disability and Human Development

University of Illinois at Chicago

2019

What is the ADA?

The Americans with Disabilities Act (ADA), passed on July 26, 1990, provides a legal framework for people with disabilities to challenge discrimination. The ADA’s importance extends well beyond the court system. The ADA is also a broader symbol of bipartisan support for disability inclusion in all parts of public life. Under the ADA, disability is formally recognized as a source of discrimination. It is similar to how “race, color, religion, sex, or national origin” is recognized by the Civil Rights Act of 1964. The ADA provides a legal framework for individuals with disabilities to challenge discriminatory practices in work settings, state and local government, and places of public use. The larger goal of the law is to assure equality of opportunity, full participation, independent living, and economic self-sufficiency for all individuals with disabilities.

Mental Health and the ADA

Over 46 million adults in the United States have some kind of mental health condition, and 11.2 million adults have a significant psychiatric disability¹. Mental health conditions are the most common disability in the U.S., yet there are significant disparities in employment. Only 38.1% of adults with significant psychiatric disabilities are employed full-time compared to 61.7% of adults without disabilities². These disparities exist despite policy protections for people with disabilities, as seen in the Americans with Disabilities Act (ADA).

The ADA applies to mental health in many ways. First, the ADA specifically defines disability as “a physical or mental impairment that substantially limits one or more major life activities.” The ADA uses the term “mental impairments,” which may also refer to psychiatric disabilities, mental disabilities, and mental illness. Guidance from the Equal Employment Opportunity Commission³  (EEOC) provides examples of diagnoses that may be recognized as mental disabilities under the ADA: “major depression, bipolar disorder, anxiety disorders…, schizophrenia, and personality disorders.” It is important to note that not all diagnosed conditions are considered disabilities under the ADA, as the definition of disability states that an impairment must “substantially limit one or more major life activity.” Additionally, Congress expressly excluded certain diagnoses such as individuals currently using illegal drugs and other “conditions that are not mental disorders but for which people may seek treatment.” ³

This brief provides an overview of research regarding the implementation of the ADA as it relates to mental health considerations in the workplace including successful employer practices and real-life examples from the ADA National Network.

Research About Mental Health, Employment, and the ADA

The ADA provides protections for people with disabilities in the workforce by prohibiting employment related discrimination, as well as promoting “reasonable accommodations” in the workplace. Reasonable accommodations are adjustments or changes to a job application process or work environment so employees with disabilities can complete job tasks. Employers are expected to provide these accommodations, unless they cause an undue hardship, meaning a “significant difficulty or expense,” which is determined by a number of factors such as the size of the business and the associated costs.

Accommodations under the ADA are decided on a case by case basis. Requesting an accommodation often requires disclosing a disability status, which can be an especially complicated decision for people with mental health conditions. For example, people with invisible disabilities may fear discrimination, stigma, or retaliation. The ADA provides legal protections for people with psychiatric and other disabilities, detailed by the ADA National Network:⁴

• People with psychiatric disabilities have a choice to disclose a disability status.
• A job offer cannot be withdrawn if a medical exam reveals or an employer becomes aware of a psychiatric disability diagnosis, unless it directly interferes with essential job duties.
• If an employee discloses a disability status, such as to request an accommodation, there is a right to confidentiality and the disability status cannot be shared with others, including other employees.
• Federal contractors must ask potential and current employees to self-disclose a disability status. However, this information is too track the status of employment goals and should be kept confidential.

A review of charges filed under Title I of the ADA, maintained by the EEOC, found that almost a third (33.5%) of complaints filed by people with psychiatric disabilities from 2005-2014 were based on alleged violations of rights to reasonable accommodations.⁵ Among these cases, the most common were related to workplace flexibility and leave policies. These data align with descriptions of common accommodations found on the Job Accommodation Network (JAN), which is a resource for employees with disabilities and employers regarding workplace accommodations. Examples of common accommodations for people with mental health conditions provided by JAN⁶ include: flexible scheduling, modified break schedules, identified rest areas, identification and reduction of triggers, and allowing support animals or persons. It is important to note that not all people with mental health conditions request or need job accommodations.

In addition to the ADA, there are other policies related to mental health supports in the workplace. One of the most impactful is the Mental Health Parity and Addiction Equality Act of 2008. This policy requires similar coverage for mental health related conditions as are provided for physical health concerns⁷. There has been an evolving understanding of disability, and this Act aligns with the increasing focus on supporting mental health within the workplace.^8,9 Employers should have an understanding of the various laws related to mental health to comply with policies and to create a more inclusive work environment.

Barriers to Employment

People with mental health conditions face several barriers to employment. One of the most prevalent barriers is negative attitudes towards people with psychiatric disabilities. People with mental health conditions face higher rates of stigma as well as face potential harassment within the workplace. ^{5, 10} Removing stigma has been noted as one of the most important aspects for addressing disparities.¹¹ Despite the protections of confidentiality and reasonable accommodations under the ADA, there is a broader cultural stigma influenced by misunderstanding of people with psychiatric disabilities.¹² Experiences of mistreatment and negative attitudes have been shown to affect people’s decision to seek treatment or participate in mental health services.¹³

Due to potential discrimination, people with mental health conditions are cautious about disclosing or sharing their disability status.¹⁴ Disclosure has been linked with perceived changes in employer behavior and actions towards employees with psychiatric disabilities.⁵ Over a fifth (22.1%) of EEOC cases filed by people with psychiatric disabilities during 2005-2014 were found to include experiences of disability-specific harassment, such as being mandated to share information about a disability status beyond what is required for an accommodation request as well as enduring negative remarks or actions by coworkers or supervisors.⁵

Other researchers interviewed several people with mental health conditions and found most participants had not shared their disability status with coworkers or others at work.¹⁴ In fact, many recommended that other workers with psychiatric disabilities not to disclose their disability status. This finding was interesting since the same respondents described their lived experiences with psychiatric disabilities as a strength and asset to their career.¹⁴ The prevalence of discrimination makes it difficult for people to decide to share their disability status and contributes to disparities in employment. People with mental health conditions have complex understandings of their identities where they weigh potential costs and benefits of disclosing their mental health diagnoses.

Additionally, cultural stigma and misunderstanding of mental health conditions may affect peoples’ decision to reenter the workforce. Concern regarding potential discrimination has been shown to impact people with psychiatric disabilities’ choices to return to work after receiving treatment.¹⁵ Potential stress at work, such as mental workload in a job and interpersonal-related stress factors that accompany many workplaces, was another noted source of concern for returning to or entering the workforce^1.5 Furthermore, people with mental health conditions may be worried about types of jobs they can get and have apprehension about having to take a job that would be undervalued and underpaid.¹⁶

In a nationally representative survey of people with psychiatric disabilities, almost half of the respondents expressed concern about losing important public benefits (such as supplemental income and health care) upon returning to work.¹⁶ Income restrictions attached to these social supports and policies act as a deterrent to employment. Additionally, changes in workplace environments, such as job accommodations, alone cannot remedy employment barriers for people with mental health conditions. Addressing employment barriers should be considered from a comprehensive perspective including policy changes, workplace accommodations, and addressing negative attitudes and misconceptions.

Predictors of Success

Even though there are barriers to employment, people with psychiatric disabilities do work, and researchers have reviewed potential factors that influence successful employment outcomes. One study identified aspects that impact employment for people with mental disabilities and frame their results as “work-related” and “health-related” factors.¹⁷ The most significant job-related factors in this study were supportive work environments and jobs that had variety rather than strict routines. Supervisor and coworker support was also found as a predictive factor of successful employment.¹⁸ Other activities associated with positive employment outcomes included: disclosure, job coaching, schedule flexibility, and skill training.¹⁸ This information is somewhat contradictory to that found in a different study, where vocational services such as job coaching, accommodations, and flexibility were not significantly associated with longer job tenure.¹⁷ Employer practices and workplace culture jointly impact if people with psychiatric disabilities can obtain and maintain employment.

In terms of health-related factors, people with psychiatric disabilities have noted the importance of feeling stable and having the appropriate supports to address mental and physical concerns when choosing to return to work and for maintaining employment.¹⁶ Aligned with this, others found that lower levels of perceived stress and psychiatric symptoms were associated with sustained employment.¹⁷ The authors note that people with supports and strategies to address mental health concerns may be better able to stay employed.

Additionally, job-related and health-related factors often interact and influence each other.¹⁷ For example, workplace culture can impact employee mental health. Employees with strong skill or job fit, meaning that employees’ skills match job tasks, can lessen stress in the workplace having a positive impact on employees’ mental health.¹⁹ Influential factors for returning to work is especially relevant for people with psychiatric disabilities. Positive past work experiences and messaging from support systems, such as family and service providers, have been associated with increased likelihood of people with psychiatric disabilities reentering the workforce.¹⁶ Recognizing predictors of successful employment outcomes can help address disparities in employment for people with psychiatric disabilities.

Employer Practices

Employer practices are ways that businesses can be more inclusive of people with mental health conditions. There is increasing emphasis on supporting mental health in the workplace. However, there is limited data on best practices to support mental health of employees.⁸ One author aptly describes how businesses have been convinced to act, but they are not sure about what that action entails.

One of the most discussed employer practices is providing accommodations. Accommodations can impact the ability for people with psychiatric disabilities to participate in employment and can be used to address biases. Even though the ADA has language regarding reasonable accommodations, courts have consistently ruled against people with psychiatric disabilities in accommodation related cases.²⁰

Various factors have been shown to influence accommodations processes for people with psychiatric disabilities. Employees who disclose a disability status, meaning those who tell their employer about an impairment, are more likely to request an accommodation. ^{18, 21} Other factors associated with increased likelihood of requesting accommodations include people who have more pervasive impairments and people who have positive social relationships.²¹ As mentioned previously in this brief, disclosing a disability status is a complex decision for people with psychiatric disabilities which can affect accommodation processes.

The most common workplace supports for people with psychiatric disabilities include: feedback provided by employers and/or coworkers, assistance from key actors in the workplace, and access to a supportive work environment.¹⁸ Another study reviewed a workplace intervention for people with mental health conditions returning to work.¹⁵ The intervention yielded 280 potential practices, described as solutions to identified barriers. The authors categorized these solutions into three topics: job design, communication, and training. Example practices included adjusting job tasks, providing feedback, and support for time management. Implementation of the solutions were found to be mostly completed by employees with psychiatric disabilities, and about a third of the proposed solutions were the responsibility of supervisors. Though there were many solutions, time was shown to be a main barrier to doing many of the activities.

Providing mental health services as an employee benefit is also an employer practice shown to support inclusiveness in the workplace. Though the ADA does not require employers to provide mental health services, many employers offer mental health related benefits. A survey of employers in the U.S. and Canada found that more than 90% of those surveyed had some kind of mental health or substance usage benefits.⁷ When employers adopt disability inclusive practices like those listed, they can create inclusive workplace cultures that may positively impact all employees, not just those with disabilities.

Benefits of Employment

There are several benefits of employing people with mental health conditions. For employees with disabilities, some of the positive aspects related to having a job include a sense of independence, improved self-reported well-being, decreased symptoms of depression and anxiety, greater access to resources, and opportunities for personal development and mental health promotion.^17,22

Additionally, people with psychiatric disabilities have noted skills developed for managing mental health conditions directly translate into useful skills in the workplace.¹² One example is the ability to cope or deal with stressful situations. Some people in this study embraced mental health conditions as a positive quality and highlighted how disclosure could be used as a tool for advocacy.¹² Disclosure was described as a way to combat negative stereotypes, even though as disclosure is often accompanied by fear of discrimination.

Practices to support inclusive work environments, like providing reasonable accommodations, have also been shown to yield benefits in the workplace. Providing accommodations specifically has been shown to increase employee morale, decrease employee stress at work, increase productivity, and decrease a likelihood of turnover.²³ In addition, researchers found that providing accommodations may have a “spillover” effect, as employees with and without disabilities have more positive views and opinions of employers that grant accommodations.²³ Employers that adopt policies and practices that support employees with disabilities not only comply with the intent of the ADA but also foster inclusive workplace cultures.

Examples from the ADA National Network

Below are a few examples of how the ADA national network are addressing the issues raised in this brief. For further information on how the ADA Centers can help with issues related to the ADA, please contact the ADA National Network here.

• Documenting reasonable accommodations: An employer contacted an ADA center after receiving an email from an employee that they (the employee) had recently been diagnosed with multiple mental health conditions. The employer was unclear if the email initiated the accommodation process and what documentation the employer could require from the employee. ADA staff provided the employer with relevant EEOC guidance on reasonable accommodations and undue hardship, indicated that the employees’ email required a response, as well as information about documentation the employer may require.
• Training for workplace culture: One ADA center conducted a training on, “The ADA and Fostering an Inclusive Work Culture for Employees with Psychiatric Disabilities” at the APSE (Association of People Supporting Employment First) 2019 Annual Conference. The training highlighted how supported employment professionals can support an inclusive workplace, and education for employers and employees about the ADA. Feedback from the participants indicated that they enjoyed the “real life” aspects of the presentation, appreciated the information, and planned to share it with employees and employers.

References

1. Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/
2. Luciano, A., & Meara, E. (2014). Employment status of people with mental illness: National survey data from 2009 and 2010. Psychiatric Services, 65(10), 1201-1209.
3. Equal Employment Opportunity Commission (1997). EEOC Enforcement Guidance on the Americans with Disabilities Act and Psychiatric Disabilities (EEOC Notice no. 915.002). Retrieved from https://www.eeoc.gov/policy/docs/psych.html
4. ADA National Network (2018). Mental health conditions in the workplace and the ADA. Retrieved from https://adata.org/factsheet/health
5. von Schrader, S. (2017). The patterns and context of ADA discrimination charges filed by individuals with psychiatric disabilities. Ithaca, NY: Yang-Tan Institute on Employment and Disability. Retrieved from https://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1375&context=edicollect
6. Job Accommodation Network (JAN), Office of Disability Employment Policy (n.d.). Accommodation and compliance series: Employees with mental health impairments. Retrieved from https://askjan.org/disabilities/Mental-Health-Impairments.cfm
7. Held, J. (2017). Mental health and substance abuse benefits benchmarked. Benefits quarterly, 33(1), 68-70.
8. Kelloway, E. K. (2017). Mental health in the workplace: Towards evidence-based practice. Canadian Psychology/psychologie canadienne, 58(1), 1.
9. Wylonis, L., Wylonis, N. T., & Sadoff, R. (2017). Navigating the rolling hills of justice: Mental disabilities, employment and the evolving jurisprudence of the Americans with Disabilities Act. Behavioral Sciences & the Law, 35(2), 178-185.
10. Baldwin, M. L., & Marcus, S. C. (2011). Stigma, discrimination, and employment outcomes among persons with mental health disabilities. In Work accommodation and retention in mental health (pp. 53-69). Springer, New York, NY.
11. Levy, B., Celen-Demirtas, S., Surguladze, T., & Sweeney, K. K. (2014). Stigma and discrimination: A socio-cultural etiology of mental illness. Humanistic Psychologist, 42(2), 199-214. doi:10.1080/08873267.2014.893513
12. Elraz, H. (2018). Identity, mental health and work: How employees with mental health conditions recount stigma and the pejorative discourse of mental illness. Human Relations, 71(5), 722-741.
13. Vogt, D., Fox, A. B., & Di Leone, B. A. (2014). Mental health beliefs and their relationship with treatment seeking among US OEF/OIF veterans. Journal of Traumatic Stress, 27(3), 307-313.
14. Boyd, J. E., Zeiss, A., Reddy, S., & Skinner, S. (2016). Accomplishments of 77 VA mental health professionals with a lived experience of mental illness. American Journal of Orthopsychiatry, 86(6), 610-619.
15. van Oostrom, S. H., van Mechelen, W., Terluin, B., de Vet, H. C., & Anema, J. R. (2009). A participatory workplace intervention for employees with distress and lost time: a feasibility evaluation within a randomized controlled trial. Journal of Occupational Rehabilitation, 19(2), 212-222.
16. Millner, U. C., Rogers, E. S., Bloch, P., Costa, W., Pritchett, S., & Woods, T. (2015). Exploring the work lives of adults with serious mental illness from a vocational psychology perspective. Journal of Counseling Psychology, 62(4), 642.
17. Russinova, Z., Bloch, P., Wewiorski, N., Shappell, H., & Rogers, E. S. (2018). Predictors of sustained employment among individuals with serious mental illness: Findings from a 5-year naturalistic longitudinal study. Journal of Nervous and Mental Disease, 206(9), 669-679.
18. Corbière, M., Villotti, P., Lecomte, T., Bond, G. R., Lesage, A., & Goldner, E. M. (2014). Work accommodations and natural supports for maintaining employment. Psychiatric Rehabilitation Journal, 37(2), 90-98.
19. Velez, B. L., Cox Jr, R., Polihronakis, C. J., & Moradi, B. (2018). Discrimination, work outcomes, and mental health among women of color: The protective role of womanist attitudes. Journal of Counseling Psychology, 65(2), 178.
20. Hickox, S. A., & Hall, A. (2018). Atypical Accommodations for employees with psychiatric disabilities. American Business Law Journal, 55(3), 537–594.
21. Chow, C. M., & Cichocki, B. (2016). Predictors of job accommodations for individuals with psychiatric disabilities. Rehabilitation Counseling Bulletin, 59(3), 172-184.
22. Modini, M., Joyce, S., Mykletun, A., Christensen, H., Bryant, R. A., Mitchell, P. B., & Harvey, S. B. (2016). The mental health benefits of employment: Results of a systematic meta-review. Australasian Psychiatry, 24(4), 331-336.
23. Schur, L., Nishii, L., Adya, M., Kruse, D., Bruyère, S. M., & Blanck, P. (2014). Accommodating employees with and without disabilities. Human Resource Management, 53(4), 593-621.

For More Information, Please Contact:

Sarah Parker Harris (skparker@uic.edu) and Rob Gould (rgould3@uic.edu)

Department of Disability and Human Development

University of Illinois at Chicago

1640 W. Roosevelt Road (MC 626)

Chicago, IL 60608

Phone: (312) 413-1647

Fax: (312) 413-1630

TTY: (312) 413-0453

http://www.ahs.uic.edu/dhd/

SUGGESTED CITATION: Parker Harris, S., Gould, R., and Mullin, C. (2019). ADA research brief: Mental health, employment and the ADA (pp. 1-6). Chicago, IL: ADA National Network Knowledge Translation Center.