Mental Health and Employment — Challenging Social Work’s Paternalism
By Lynn K. Jones, DSW
Social Work Today
Vol. 6 No. 6 P. 38

Are some social workers too protective of their employed clients with mental health conditions? Some say yes and tell us why this needs to change.

As a social worker, I don’t like to hear that some of us may be making it more difficult for people with mental illness to find jobs and exercise their rights under the Americans with Disabilities Act (ADA). But that’s what David Morris, CEO and cofounder of Habitat International, Inc., believes.

At his carpet production company in Tennessee, 70% to 80% of the staff is people with disabilities, including, among others, people with schizophrenia, Down syndrome, cerebral palsy, and autism as well as people who are homeless and former prisoners.

“I’ll put them up against any so-called able-bodied, able-minded, normal person—however you define the word normal,” says Morris about his workforce. Unfortunately, he has found that most social workers would not.

“We’ve done this so long that we usually stay away from social workers,” says Morris. He believes many social workers assume that individuals with mental illness cannot manage a job and that their benefits will be jeopardized if they find employment.

Sheila H. Akabas, MBA, PhD, shares Morris’ experience with social workers. “Social workers have a knee-jerk reaction to be paternalistic in protecting people and their benefits and don’t make sufficient use of the opportunities that people with mental health conditions have for employment. They don’t challenge the potential of the ADA to protect people,” says Akabas. She is a faculty member of the Columbia University School of Social Work and is director of the Center of Social Policy and Practice in the Workplace.

ADA 101
So are social workers’ fears well-founded? How much protection does the ADA really afford those with mental illness? According to Paul Appelbaum, MD, professor of psychiatry at Columbia University, past president of the American Psychiatric Association, and chair of the APA’s Council on Psychiatry and Law, a person must be impaired and “substantially limited” in one or more life activities to qualify for the ADA. This sometimes makes demonstrating that a person is covered by the ADA challenging. For most people with mental illness, there are times they can do certain things and times they cannot. “And although a broad interpretation of the ADA could encompass those kinds of disabilities, in practice, the courts tend not to. They are inclined to adopt a model that is more consistent with physical disabilities, which change less,” adds Appelbaum.

The other confounding factor is that the courts have ruled that if someone has a condition that would otherwise be disabling but is being successfully treated, that person no longer qualifies for protection under the ADA. Appelbaum explains, “So a person with a bipolar disorder who may be subject to periodic bouts of depression or mania but most of the time has the disorder well-controlled would have a very difficult time making a claim to be covered by the statute in the first place because the treatment is largely effective most of the time. Of course, exactly when it’s not effective is when that person needs protections, but that turns out to be a difficult point to get across.”

But the legislative intent was to provide coverage for those cases. Akabas speaks with authority about this because she was on the committee that worked on the original language for the regulation. “We were very insistent that even people who were asymptomatic because medication was effective are still covered by ADA if they have serious mental health conditions that could impair their activities.”

The solution is to get the ADA working for people with mental illness long before cases go to court. “The most effective advocacy usually does not occur in court. It is a result of education and negotiations with employers to help them recognize the problem and identify reasonable accommodations that will not be unduly burdensome to the organization but can significantly help the employee,” says Appelbaum.

Changing Mental Models
Social workers need to change some powerful mental models before they can effectively advocate and negotiate appropriate accommodations for their clients with mental illness who are entitled under the ADA, suggests Akabas. She provides evidence-based training and education to both employers and social workers on the ADA and accommodations at the WORC (Work Opportunities for Rewarding Careers) Project.

“These mental models are filled with misassumptions and myths. They are not evidence-based.” So what are these mental models? Akabas reels off a list that social workers commonly hold.

Mental model: People get worse when they are forced to go to work.

Reality: “There is absolutely no research evidence to prove that people with mental health conditions will decompensate because they work. There is none. On the contrary, there is significant research evidence that suggests that people improve and recovery is promoted by employment.”

Mental model: People don’t want to work.

Reality: Seventy percent of people with a severe mental illness want to work.1

Mental model: Individuals must have their benefits protected because you can’t get back on benefits once you’re off them; they will face a long waiting period to get back on benefits.

Reality: “It is not true that once you are working that you can’t get back on benefits [SSI (supplemental security income) and SSDI (Social Security Disability Insurance)]. It also is not true that there is a long waiting period to get back on benefits once you are off them. In fact, there is no waiting period at all. Another misconception is that if you are working you will lose your health benefits.”

Mental model: People on medications do not have the energy to work.

Reality: Medications can be adjusted to support working people. Morris has found that often medications do have to be adjusted because families have preferred that their family member with a mental health condition is sedated, which makes it easier for them but creates problems in the workplace.

Our language reflects our mental models. Akabas instructs social workers to shift from referring to individuals as “people with a mental illness” to “people with a mental health condition.” “Employers are not going to hire someone who is ill. Why would they? But just as employers hire people who have cardiac conditions and diabetic conditions, they can hire someone with mental health conditions if that person is seen as not ill and functional.”

Social workers typically conduct assessments that identify problems and solutions, but Akabas and her colleagues train social workers to identify strengths and aspirations. They train social workers to ask, What are your plans for returning to work, if you’re not working now? “That casts the whole assessment process in a different light because what it says to the individual is, I am going to be well enough to work and I can be part of the mainstream of America.” Akabas firmly advocates that taking a strengths-based approach rather than a problem-solving approach is empowering. Both the social worker and the person with a mental health condition move toward thinking about work rather than disability.

Morris doesn’t have much respect for social work assessments and evaluations. “We don’t even look at them anymore.” He is also not interested in the past. “Social workers love to talk about their clients’ pasts.” What interests Morris is their aspirations. “With each member of our company, we basically ask, ‘What are your dreams if you would like to tell us, and what would be your goals or dreams at work?’”

Disclosure
A social worker can be an important intermediary between the worker receiving services and the employer. One key issue for social workers is that the ADA does not apply until an individual discloses a mental health condition. A social worker can help with that.

Akabas explains that social workers can help people figure out what has to be disclosed, to whom, when it has to be disclosed, and how it is going to be disclosed. Sometimes, it must be disclosed at the interview. Otherwise, it can be disclosed after employment, but before people go on the job. For example, a client may be coached to say, “Oh, and by the way, I have a weekly doctor’s appointment at 4:00, and I’m claiming accommodation under the ADA. I’m prepared to come in early or to return to work afterward.” Akabas cautions, “The social worker has to help because the person with the mental health condition is fragile, probably hasn’t had this experience before and needs the support and a knowledge base. If the social worker doesn’t provide that knowledge base, who will?”

Accommodation
The ADA can assist people with mental health conditions gain accommodations that make it feasible for them to work. Ramona Poetzel, JD, professor in the department of management at Texas A & M, researches discrimination law. Poetzel has firsthand experience—she has bipolar disorder.

“From my own experience, I needed one extended leave of absence and I needed an accommodation during one semester because I needed to reduce my teaching load, so that there was less stress and less contact time with a lot of other people. Those accommodations have been essential for me to maintain my job and attain stability when I’ve had a serious problem. Medication doesn’t always work to keep you stable.”

Sandra Perry, JD, is a labor attorney in Indianapolis who deals with employment discrimination issues. She explains that determining appropriate accommodation between a person with a mental health condition and an employer is an interactive and ideally a creative process where the social worker can be an asset. “One thing that is important for social workers to realize is that the individual does not have to be the one to ask for an accommodation,” says Perry. A social worker can play an important role by discussing with the employer what kind of accommodation may be helpful for a person with a mental health condition and can even provide helpful information about the mental health condition to the employer.

Perry asserts that most employers want to do what’s right, but often they don’t know what that is. When employers learn that there are some fairly straightforward accommodations that can be made to support an employee, they usually want to do that.

As more and more people work with mental health conditions, employers and coworkers will probably learn to deal with the vagaries of mental illness behavior. We learned to deal with pregnancy because of the Family and Medical Leave Act, and that wasn’t comfortable at first, either. Poetzel suggests that there are many people with personality problems that we learn to deal with in the workplace. “Well, if we can learn to tolerate people that we think are generally unpleasant and difficult to deal with, we certainly can learn to tolerate people who have a mental illness, who can’t control their behavior, and we know it’s not intentional. It’s not like they’re doing this because they want to be doing this.”

Employment Ability = Expertise With Hope and Heart
Becoming cynical is a professional hazard for social workers. It is understandable because we often see clients with mental health conditions at their worst. It can be hard to see beyond their present reality. And we do feel protective. We don’t want to put them under undue stress. We know what may result.

“Usually the biggest disability is you and me,” says Morris. “You have to go beyond that person that you think is unreachable because there is someone inside waiting to blossom. You have to have hope and open your eyes and hearts more. The biggest accommodation is sometimes thinking more from your heart than your mind. And I think that if you think from your heart, then you’re going to have a little more patience.”

Morris’ only regret is that he doesn’t have more business so he can hire more people with disabilities. He knows their alternative. Akabas has the same concern. “What I feel strongly is that people with mental health conditions are sitting in the same day treatment seat year in and year out with nobody trying to move them out of that seat.”

Social workers can be part of the solution instead of the problem. The formula seems to be going beyond our expertise and into our hearts with hope. Morris says, “When you do it, it’s like a closed flower bud that just pops open and blooms.”

— Lynn K. Jones, DSW, is a freelance writer and an executive coach and organizational consultant in Santa Barbara, CA. As a specialist in organizational culture, she supports leaders and organizations in developing mission-driven cultures.

Reference
1. The Substance Abuse and Mental Health Services Administration’s National Mental Health Information Center. Available at: http://mentalhealth.samhsa.gov

— Source: http://mentalhealth.samhsa.gov