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Functional Limitations Experienced by Some Workers With Psychiatric Disabilities

To be honest, that is part of the reason this company has held on to me - because they do think I do a good job. I am dependable. My health isn't dependable, but I am, in terms of trying to do the best I can and be there when I'm supposed to be there.

- Judy, Associate Editor

The ADA's employment regulations describe the development of accommodations as "a process in which the employer and employee identify the precise limitations imposed by the disability and explore potential accommodations that would overcome those limitations."⁷ While the ADA, ingeneral, emphasizes the strengths and capabilities of people with disabilities, any discussion of accommodations is necessarily focused on limitations associated with a physical or mental impairment. If the need for the accommodation is not related to a worker's disability, the law does not apply.

A basic tenet of rehabilitation is a distinction between "impairment' 'and "disability." Anthony and Liberman (1986) presented a conceptual model which defined "impairments" as symptoms, and "disabilities" as limitations in performing certain skills and activities.⁸

The ADA also distinguishes between impairment and disability. The employment regulations define mental impairment as "any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities."⁹  For example, a DSM-111-R diagnosis may be used as evidence of an impairment (i.e. a mental illness).

In contrast, the ADA defines "disability' as "a physical or mental impairment that substantially limits the performance of one or more major life activities of such individual."¹⁰ In addition to those whose functioning is actually limited by the impairment, the ADA also protects individuals with 'a record of such an impairment' ' and those who are "regarded as having such an impairment.¹¹ The Appendix to the regulations goes further to emphasize that the presence of a disability is not based solely on a diagnostic label (which indicates the presence of an impairment), but rather "on the effect of that impairment on the life of the individual," and reiterates that the extent of functional limitations may vary across individuals with similar impairments. ¹² In other words, a psychiatric diagnosis alone does not qualify a person for coverage as an "individual with a disability" under the ADA; rather the determination is based on the extent to which the mental illness limits his or her functioning. The law is also intended to cover disabilities imposed by treatments related to the disorder, such as the side effects of psychotropic medications.

The distinction between impairment and disability is also important to the implementation of accommodations. According to the DSM-III-R, psychiatric diagnostic categories are provided in order to "enable clinicians and investigators to diagnose, communicate about, study and treat the various mental disorders."¹³ In practice they are also used to facilitate record-keeping and reimbursement practices. While one element of a complete DSM-III-R diagnosis indicates the severity of psychosocial stressors" in the individual's life over the preceding year, and another depicts the clinician's judgment of the individual's overall "psychological, social and occupational functioning," the ratings are not intended to predict functioning (such as prospective job performance).¹⁴

A psychiatric diagnostic label, then, is not especially useful in developing accommodations. Knowing that a worker is diagnosed as having "schizophrenia" versus "bipolar disorder" says little about his or her functioning on the job. More useful is an understanding of the individual's work experience, education, and skills, as well as any functional limitations he or she experiences in performing a particular job in a certain work setting.

Prior to the interviews, I identified a set of functional limitations sometimes experienced by workers with psychiatric disabilities. The following examples are based on my own observations as an employment service provider, as well as my discussions with mental health consumers and service providers nationally.

Examples of Functional Limitations Experienced by Some Workers with Psychiatric Disabilities

Difficulty in:

• maintaining concentration over time
  
• screening out external stimuli
  
• maintaining stamina throughout the work day
  
• managing time pressure and deadlines
  
• initiating interpersonal contact
  
• focusing on multiple tasks simultaneously
  
• responding to negative feedback

This study examined the impact of mental illness on job functioning from the perspectives of both the worker and his or her supervisor. I asked each worker: "How does your mental illness affect your functioning on the job?"

I also asked each supervisor, "From your perspective, how does the worker's mental illness impact on his/her functioning on the job?"

Although the question was posed in an open-ended way (allowing for either benefits or limitations to be identified), eight workers responded with examples of functional limitations, while two felt that the illness did not impact their job functioning. My findings were as follows:

1.   The most commonly described functional limitation was difficulty with concentration. This problem was reported by five of the eight interviewees listing any limitations.

2.   Among those identifying functional limitations resulting from mental illness, five attributed at least one limitation to side effects of psychotropic medications. In three instances, problems resulting from medication side effects were the only functional limitations cited.

3.   Several workers commented on the interplay between stress and their job functioning.

4.   Workers and their supervisors sometimes had divergent opinions on how the worker's mental illness affected his/her job functioning.

Each of these findings is discussed in greater detail below.

FINDING #1: Difficulty with concentration was the most frequently described functional limitation.

Difficulties with concentration were the functional limitation most frequently described by workers with psychiatric disabilities in this study. Some respondents offered detailed examples of their experiences.

Judy is an associate editor with a large publishing company. She said, "If it's a problem, it takes the form of extreme difficulty with concentration and disassociating, whether I'm into another personality or just into sort of empty space...I find myself just gazing out the window or staring off into space, not being able to... get back on track...My brain just kind of grinds to a halt."

Joe is a senior executive at a hospital. He said that when he is having extreme difficulty with concentration, "It might take me 20 minutes to get through something that should take two minutes."

Linda works as a recreation aide in a senior day program. She says, "It's hard to describe. I'm doing this or that...and all of a sudden sometimes you're blanked out, and it's like for a minute you're not there and then you're back "

FINDING #2: Functional limitations resulting from psychotropic medications were also common.

Five workers described functional limitations associated with the side effects of psychotropic medications. For three workers, medication side effects were the only functional difficulties mentioned.

Vince is a driver for a pizza delivery unit of a national corporation. When he's not driving, he assists with preparation and clean up in the store. He said, "The side effects from medications would sometimes cause hand-shaking. This would slow me down a bit when I was working in the store, but it didn't affect my driving at all. I had started on a new medication, and I had pretty bad hand-shaking for about three months. I got off the medication, and it went away."

Bill worked as a peer counselor at a social rehabilitation agency. He commented on his need to use medications, despite the side effects." You know, I take a lot of medication. It makes the throat dry, I sleep a lot. Of course, with working, I don't have time, but it makes me feel medicated, and it makes me feel kind of dopey some of the time. But it helps control my symptoms, and I'll take it because I need it to stay sane..."

Steve works as a stock clerk in a department store. He has a bachelor's degree and began work toward a law degree. He feels substantially underemployed Steve has been able to arrange an afternoon schedule, even though all other stock personnel are required to report to work at 6:00 a.m. His job coach encourages him to consider morning work hours, and poses the hypothetical question, "What if you were told you had to be in at 6:00a.m.? Would you quit your job? "Steve feels that he might, although he's not certain whether it's a matter of pride or an obstacle posed by the medications. He commented on the side effects of medications: "I have a hell of a lot of trouble getting up in the morning. And the medication hurts that a lot I feel like I'm very slow moving in the morning. It takes me until about 10 or 11 or 12 to get going."

Joe takes Halcion, which can cause memory problems. He described a highly visible event that occurred at a previous job while he and a superior presided over a public meeting. He made a statement that contradicted what she had said only minutes earlier. The superior countered by correcting his statement, which he proceeded to repeat shortly thereafter. She rebuked him in front of the group saying, "I already overruled you on that one." Joe described the situation: "I had repeated myself because I just forgot. It wasn't like I was being warlike. I wasn't defying her. Then, about a month later, I got called into a big heavy duty meeting with her and her staff and my boss about this incident. It was a really heavy duty thing." He had not yet told anyone at work that he had a psychiatric disability, so he just absorbed the criticism, wagering that disclosure would be even more damaging to his career." What was I going to do? I wasn't then going to start talking about my memory lapses with her and her staff and my boss, who doesn't know anything about this stuff. It infuriated me like hell. Why can't I just say what it was that happened?"

FINDING #3: The interplay of workplace stress and job functioning.

Based on my experience as a job developer, it seems that a primary concern among prospective employers of workers with psychiatric disabilities is their perceived inability to handle stress. Many employers described the high levels of stress in their work environments as reasons why they would not be suitable for persons with psychiatric disabilities. But the workers interviewed here explicated much more complex relationships between stress and work. Most had found ways to manage stress effectively.

Among the 10 workers interviewed for this study, two made no comments about stress, four made only minor or tangential comments about stress, and four spoke at length about the interplay of stress, work, and their psychiatric disabilities. Examples of worker comments about stress are summarized below.

Ben commented that he increases his medication dosage when he experiences heightened stress from work or other aspects of his life.

Linda feels that stress is her biggest challenge with respect to work. When I asked how her mental illness affected her functioning on the job, she said, "I don't see any problems as far as being mentally ill. The only thing I could picture would be stress...I have a lot of problems with stress, and I have problems with people, sometimes dealing with the people. I have to really be careful because sometimes I get confused."

In hindsight, Bill feels that he probably lost an earlier job as a bank teller because his psychiatric disability made it difficult to handle the stress."It was a very high stress job, and I really think that the mental illness was what caused me to finally lose it. I quit, I wasn't fired, but I left after about five months just because of the pressure. See I didn't know I had a mental illness. I just thought that I was some guy who had a breakdown, who was taking medication. So I would find out towards the end of the day the room would start to spin. I would start to get disoriented, and I had to keep a lid on it. It was real confusing."

Brian works on the warehouse crew in an industrial materials recovery facility. He's currently taking courses at a community college, but feels he must choose a career carefully to avoid stress. He has previous work experience in a discount variety store, which he found highly stressful. However, he feels confident that he would do well in slower paced retail settings, such as men's clothing. He feels that professions such as banking, public relations, or insurance would be too stressful. Ideally, he would like to work in an artistic environment.

Thomas works as a utility clerk in a large grocery store. He would like to advance from bagging groceries to operating the cash register but is concerned that the new position would be too hectic, too stressful.

Several workers commented that "structure" in the work environment reduces stress. But one felt that too much structure generated additional stress; he works best with a clear objective and lots of freedom.

Although she can work at home, Judy prefers the structure of working at the office: "Working at home is a problem because...I can go days without saying a word to anybody and that tends to make things more stressful. [Working at the office] tends to provide a certain amount of structure. It keeps me from falling apart."

Rosanna has learned from experimentation that she can best control stress by avoiding overtime and maintaining a regular schedule, which includes proper sleep, diet, and exercise."I'm responsible to make sure I get enough sleep, I eat right, I get proper exercise. I have to control my stress. That's the most important thing I can do for myself. That means working a 40-hour week and that's it.” When stress does accumulate, she finds it difficult to sleep, and as a consequence, her concentration is diminished.  At these times, she takes more medication before bed, which usually breaks the cycle. She also reported that stress can make her forgetful."My senses are directly affected by the level of stress I'm under." She concluded, "My illness is exacerbated by stress."

Joe feels that the common description of stress "triggering" increased symptoms is oversimplified.  He recalled a period leading up to a deadline for hospital accreditation in which he and his colleagues worked 80 hours each week "It was constant intense hours, not just being therefor 80 hours. It was really intense...One day I remember, we worked from 7 in the morning until 3 o'clock in the morning, and were right back at 7:00 the next morning. And I didn't get any more symptomatic because I was purposeful, and I was getting somewhere, had a sense of accomplishment. I got much more symptomatic when I had a lot of time on my hands [in a previous job]." Overall, he finds that too much or too little structure is problematic."If I have fairly open stuff and a lot to do, that's when I do best. I don't think that's true of a lot of people.”

Most people need structure and the right amount to do. I need very little structure and lots to do.

Because only workers with psychiatric disabilities were interviewed for this report, it is difficult to determine to what extent the interplay between stress and work functioning among the interviewees was attributable to their disabilities or whether the effects of stress were exacerbated by their disabilities. This study also did not distinguish between personal and job-related stressors. The interviews did indicate that many workers with psychiatric disabilities feel that they have to monitor and manage stress in order to perform well on the job. The sources of stress and methods for controlling stress varied from person to person. However, similar findings would likely result from interviews with any group of workers.

FINDING #4: Workers and their supervisors sometimes had divergent opinions on how the worker's mental illness affected his/her job functioning.

As noted above, this study gathered information from two perspectives on how an individual's mental illness affects his or her functioning on the job - both the worker's and the supervisor's viewpoints. In some cases the opinions were quite similar, but in other instances, they diverged. Where there were differences, the workers generally perceived themselves to have greater functional limitations than did the supervisors. This may reflect the workers' success in developing and employing strategies to compensate for their disabilities so that they do not interfere with job performance.

While it is curious that the workers' and supervisors' opinions were so often different, it is possible that such differences occur within many employer/employee relationships, regardless of the presence of a psychiatric disability. With that caution in mind, the comments are illustrated below.

Examples of agreement between worker and supervisor

Part of Ben's function is to serve as a role model to members of the social rehabilitation agency where he is now the head assistant counselor. Regarding his mental illness, Ben said, "I'm pretty well stabilized, so it doesn't really affect me on the job." His supervisor is the program coordinator. She said, "Generally, Ben has been very stable through the entire employment period. He does have some minor remissions. He's aware of what his symptoms are and shares them with us. We're pretty aware of what they are now, and he will usually say, 'I'm having a bad day' or 'I'm having a bad time.'If he hasn't said that and we've noticed it, we can confront him with it. He's very comfortable with that.

Thomas works as a utility clerk in a grocery store. Neither Thomas nor his supervisor commented on any difficulties in job functioning due to mental illness.

Rosanna noted difficulties with concentration, distractibility, and forgetfulness, which sometimes interfere with her productivity. Her supervisor had similar remarks: "I think there are probably two areas. There are days when she is up and days when she is down. When she's up, it interferes with some of her ability to settle down and be as productive as she can be. And likewise when she's down...There are just times when she's more productive and less productive, and there are times when she's more distractible and not as productive as she could be. Although...she doesn't fall terribly outside the normal range for many of the people I see."

Examples of different opinions expressed by workers and supervisors

Steve cited only intermittent problems with concentration. His supervisor didn't notice that: "The impression I have is that sometimes he keeps telling me things twice, three, four, five times, even though I've told him the right answer already, told him not to worry. But he's always making sure...He does an excellent job always, or pretty close to it. I would say that his problem doesn't reflect on his work Like I say, he's very reliable, he's very work efficient, I'm very happy with him."

Joe discussed difficulties with concentration and memory. But he also described methods he uses to "cover himself" for these problems. When asked how Joe's mental illness affected his job functioning, the supervisor stated that Joe worried a lot. He said they sometimes discussed how to deal with other people who weren't cooperating or doing their best. But overall, his supervisor commented that he could never tell that Joe was having any "inner problems."

Both Linda and her supervisor view stress as the major difficulty for her. In addition, the supervisor says that Linda is gradually developing the confidence she needs to lead groups and otherwise act independently."I think probably the way her illness may affect her is just her ability to handle stress and the level of self-confidence that she's actually doing well...Taking that first step in being able to actually lead an activity in front of a group, for instance, is probably her biggest challenge. One on one she does great. She can go up to any senior and carry on a great conversation with them. She's got a real pleasant demeanor."

Judy felt that her psychiatric disability makes it difficult to concentrate. She described periods in which she blanked out, or could only do "nitty gritty " but not "creative " work.  Her supervisor commented, "It doesn't really seem to affect her performance at all, except that she's frequently absent.”

Conclusion

Most of the workers I interviewed felt that their mental illness affected their job performance in some way. For some it was manifested in difficulty handling stress or in problems with concentra­tion. Some felt that they did better with more structure, some with less. When workers felt that their mental illness did not affect their job functioning, the supervisor usually concurred. However, among those workers who noticed an impact, some supervisors concurred, while others didn't notice any effect or observed a different effect

Given the natural human propensity to stress, particularly in the work environment, these findings should be interpreted cautiously. It is unclear to what extent the functional limitations cited were due to mental illness. In addition, the study did not elicit any discussion of the unique assets that workers with psychiatric disabilities may bring to their work. The most significant conclusion is that, as with all aspects of ADA implementation, the assessment of an applicant's or employee's skills and functional limitations should be individualized, not generalized from a diagnostic label.

Ile findings suggest the following areas for future investigation or research:

• How can functional limitations associated with mental illness be more accurately assessed or measured? How could the findings be applied to improve the job success of workers with psychiatric disabilities?
  
  
• Do individuals with psychiatric disabilities differ from individuals without psychiatric disabilities in terms of their response to stressors on the job? If so, in what ways?
  
  
• Which stressors are particularly problematic, and what coping mechanisms have individuals with psychiatric disabilities developed? How might workers in the general population apply these techniques to their own situations?
  
  
• How divergent, in general, is a worker's opinion of his/her performance from the opinion of his/her supervisor?
  
  
• Which supervisory techniques might help a worker and supervisor develop a congruent image of the worker's job performance? What would be the benefits of doing so?
  
  
• Among workers with psychiatric disabilities who use psychotropic medications, how common are functional limitations associated with medication side effects? How often do prescribing physicians inquire about and adjust for the work-related problems resulting from medication side effects? For those who use psychotropic medications, what are the most effective strategies mental health consumers can employ to reduce or eliminate side effects (including techniques for communicating with their physicians)?
  
  
• What unique strengths or experiences do people with psychiatric disabilities bring to the workplace?

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