Understanding the vocational impact of mental health disorders.

8/22/2019 Understanding the vocational impact of mental health disorders.

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Impact of Mental Health

or erTexas Community Rehabilitation

Program Conferences

May 13, June 17, June 24, July 8, 2010

Gary L. Fischler, Ph.D., L.P.

1Copyright 2010 All rights reserved


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8:00 10am - Overview: Relationships between mental health disorders and

vocational functionin

-Video presentations and discussion: Symptoms & functionalimpairment of Axis I mental health disorders

10:00 10:15 - Break / Networking

10:15 - noon - Personality disorders: Functional impairments &rehabilitation strategies

-Problem-solving approaches; Partnering with mental

health service providers, employers, & consumers

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Some Facts and Fi uresAbout 20% of adults have a diagnosable

Surgeon Genera s Report,

1999)

48% lifetime revalence Kessler et al. 1994

Mental disorders are the second leadingcause of disabilit after cardiovasculardisease (Surgeon Generals Report, 1999)

Mental disorders account for 20% rimarto 65% (secondary) of all disability claims(Wagner et al., 2000)

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Genera emp oyment rate o SPMI s on y

10-30% (Anthony, 1994)


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Clients Seeking Rehab ServicesBy Diagnosis*

Mental illness 32%

Ortho edic 20%

Learning disability 12%

Mental retardation 10%

Chemical dependency 7%

Deafness 5%

Brain injury 4%

Other 9%

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*Minnesota Dept. of Rehab Services (1999)


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Relationship Between Psychiatricsor ers an o u es

Ps chiatric EssentialDisorders

Dutiessyc o og ca

Factors

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ESSENTIAL PSYCHOLOGICAL FACTORS

IN JOB PERFORMANCE (Fischler & Booth, 1999)PSYCHOLOGICAL

FACTORS

EFFECTS ON JOB

PERFORMANCE

DIAGNOSTIC

EXAMPLES

Cognition

Intelligence, memory,

academic skills, and theability to use these skills

Depression, anxiety, bipolar,

schizophrenia, dementia, chronicchemical abuse

Pace

e a y o per orm as s a

a reasonable speed.

epress on, o sess ve-compu s ve

disorder, passive-aggressive personality

disorder

Persistence

until it is complete.

,

deficit hyperactivity disorder, histrionic

personality disorder, somatization

disorder, schizophrenia.

Reliability

Coming to work every day inspite of personal or emotional

problems.

Agoraphobia, somatization disorder,mood disorders, avoidant personality

disorder, chemical abuse

onsc en ousness

and Motivation

an ng an ry ng o o a

good job; persisting until it is

accomplished.

a or epress on, persona y sor ers,

chemical abuse


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PSYCHOLOGICAL EFFECTS ON JOB DIAGNOSTIC

FACTORS PERFORMANCE EXAMPLES

Interpersonal

Functioning

The ability to accept

supervision, to get along with

Bipolar disorder manic phase,

post-traumatic stress disorder,

cowor ers or e pu c. many persona y sor ers,

chemical abuse.

Honesty, The ability to be truthful, Anti-social personality disorder,

trustworthiness direct, and straightforward, to

refrain from such things as

lying and theft at work.

borderline personality disorder,

chemical dependency.

Stress tolerance

The ability to withstand job

pressures such as deadlines or

working with difficult people.

Schizophrenia, post-traumatic

stress disorder, somatization

disorder, agoraphobia, major

de ression chemical abuse

Job-specific

requirements

e.g., Typing speed, conflict

resolutions skills, people

Any

skills.


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Overview of PsychiatricDiagnosis (DSM-IV)

Depression, anxiety, schizophrenia

Somatoform disorders

Learning disorders

Axis II: Personality traits & disorders; mentalretardation

Axis III: Physical problems

Axis IV: Psychosocial stressors

Axis V: Global assessment of functioning (0-100)

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Most commonly has progressive onset

-

Affects about 1% of population

Often intermittent symptoms

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Characteristics of Schizophrenia Compromised reality operations

Hallucinations and delusions; illogical thinking; mayshow denial or oor insi ht ma show oor ud ment

Communication problems Unusual or illogical language; disorganized thought and

speec

Negative symptoms

Flat affect low ener slee disturbance amotivationaland anhedonic

Cognitive problems

decision-making skills

Interpersonal problems

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Suspicious; frightened or argumentative; social

withdrawal, indifference; unusual appearance or behavior


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Schizophrenias Effecton Work

,

Distrusts coworkers and supervisors; may be fearful orargumentative; criticism is viewed as attack; difficult towork in a team

Coworkers may become rejecting or hostile in return,

Interested in achievement or promotions may bediminished by negative symptoms; passive or avoidant in

response to performance demands Easily distracted; cognitively inefficient; increased error

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Symptoms increase under stress; reliability problems


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Schizo hrenias Effect onEssential Psychological Factors

Level of Impairment:

1. No impairment.

2. Mild -- minimal impairment with little or no effect on

.

3. Moderate -- some impairment which limits ability to

function fully.

4. Serious -- major impairment which may at timespreclude ability to function.

12

. .


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Understanding and Memory 1 2 3 4 5

Remembers locations and basic workprocedures

x

Understands and remembers short, simple

instructions

x

instructions.

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Concentration and Persistence 1 2 3 4 5

Carries out short, simple instructions. x

.

Maintains attention and concentration for xexten e per o s o t me.

,

attendance, and be punctual.

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Concentration and Persistence (Cont) 1 2 3 4 5

Sustains ordinary routine without special

su ervision.

x

Can work with or close to others withoutbeing distracted by them

x

Makes simple work-related decisions x

or s qu c y an e c ent y, meets

deadlines, even under stressful conditions.

x

Comp etes norma wor ay an wor weewithout interruptions due to symptoms

x

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Works at consistent pace without an

unreasonable number or length of breaks.

x


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Social Interaction 1 2 3 4 5

Interacts appropriately with the general x

.

Asks simple questions or requestsassistance when necessary.

x

Accepts instructions and responds

appropriately to criticism from supervisors.

x

Gets along with coworkers without

distracting them

x

Maintains socially appropriate behavior x

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a n a ns as c s an ar s o c ean ness

and grooming

x


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Adaptive Behavior 1 2 3 4 5

Responds appropriately to changes at work. x

Is aware of normal work hazards and takes

necessar recautions.

x

Can get around in unfamiliar places, can xuse public transportation.

e s rea s c goa s, ma es p ansindependently.

x

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Management Strategies with Schizophrenia

Refer for treatment; encourage compliance

Flexible scheduling

ee s g egree o s ruc ure an rou ne; avo

occupations with less structure where misinterpretationsare more likely (e.g. human services)

Avoid high-speed or cognitively complex assignments

Allow solitary work; avoidance of team participation;-

Tangible and frequent incentives (e.g., piecework, break-times, cigarettes)

Dress and behavior codes may need to be clarified Open and direct communication; discuss upcoming

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Consider debriefing coworkers regarding oversensitivityand need for benign environment


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psychotic symptoms

ea y-or en e psyc o erapy s use u or

education, identify symptom precipitants,

,

hallucinations and delusions

eu t erapy e p u or soc adysfunction and negative symptoms

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Family psycho-educational therapy may

also be useful


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Affects up to 25% of females; 12% of malesnd =

Chance of 3rdepisode = 70%

Chance of 4th e isode = 80-90%

Usually begins in mid twenties

D sth mia is milder more chronic and

predisposes individual to major depression

U to 15% die of suicide

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Characteristics of Majorepression

, ,

Lack of interest in life; low motivation

oor s eep; poor appe e; a gue

Pessimism; low self-confidence; feelings ofwor essness; gu

Poor concentration, memory, & decision-

ma ng pseu o emen aHopelessness; preoccupation with dying;

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su c a ea on

Sometimes irritable


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Ma or De ressions Effecton Work

Low motivation, energyLow initiative for independent activity

Poor persistence, endurance

Hypersensitive to criticism or rejection

Poor ability to deal with stress, pressure,deadlines

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Irritable with, or withdrawn from, coworkers


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Mana ement Strate ies forMajor Depression u e wor se ng

Avoidspeed-dependent tasks

Max m zepre cta ty n wor ass gnments;

improve self-confidence for new tasks

ons er wr en gu e nes, pro oco s

Flexible scheduling, including breaks

Max m ze soc a support; wor on team; max m zepositive feedback

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vo o s w su c e r s s


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Anti-depressant medication is usually very

effective, especially for physical symptoms (e.g.,fatigue, sleep disturbance, concentration)

ogn ve- e av ora psyc o erapy can a so every effective, especially for mood disturbance,

relationshi issues etc. Combination often produces long-term relief from

symptoms

Shock therapy (ECT) may be effective for severecases that are resistant to other treatments but

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often interferes with ability to work


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,

Occurs in .4% to 1.6% of population

75% will return to full functioning

u c e may occur n - o cases

Onset is later than schizophrenia twenties to

Equally common among men and women

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n erm en ep so es an symp oms


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Characteristics ofMania/Hypomania

, ,

Grandiosity

Re uce nee or s eep

Increased sociability, flamboyancePressured speech, hyperactivity, racing

thou hts fli ht of ideas

Mood-congruent hallucinations and

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-

Excessive energy, but inefficient &

Reduced social judgment; irritable or

Distractibility; distracts coworkers

Work quality decreases under stress and

27Can be very creative and productive


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Management Strategieswith Mania

Encourage a structured, predictable lifestyle

Clear deadlines

A ro riate outlets for creativit socializinFlexible scheduling

,necessary

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ons er e r e ng cowor ers; u y can

help with organizational tasks


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stabilize mood

n -psyc o c me ca on may a so e

helpful if psychotic symptoms are present

Rea ty-or ente psyc ot erapy can e

useful to improve judgment and identify

esty e prec p tants

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Accommodations forPsychiatric Disorders

EEOC recommendations for non-obvious disabilities

(Also see American Bar Association, 1997):

9 Determine essential functions of job

9 Assess functional limitations re: essentialpsychological factors)

9 Employee and employer mutually identify

accommo at ons9 Accommodations implemented by employer, taking

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Mutual accommodations require

disclosure of psychiatric problems to

employer:

9 Likely to result in better fit betweenfunctional limitations and accommodations.

9 Employees can be coached to make adjustments

for themselves.

9 Employee may be coached in asking for

work lace ad ustments without disclosure.

9 Indirect suggestions by employee may result in

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accommodate.


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T es o Accommodationse. . Mancuso 1993

:9 Most frequent schedule flexibility or changes

(e.g., part-time, flex time, more frequent breaks,

9 Formal or informal job coaches during difficulttimes

9 Change of supervisory methods (e.g., written,

verbal, frequency)9 Rearranging job duties with other employees

9 Reassignment to less stressful work

9 Private or solitary work space

9 Telecommuting

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9 Additional supervisory support


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Em lo er can re uire treatment as accommodation:

[a] qualified individual with a disability is not requiredto accept an accommodation, aid, service, opportunity or

accept. However, if such individual rejects a reasonableaccommodation, aid, service, opportunity or benefit that

essential functions of the position held or desired, andcannot, as a result of that rejection, perform the essential

,considered a qualified individual with a disability. (U.S.Dept. of Labor, 41 CFR 60-741.21).

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plaintiffs depression should not affect hiswork erformance. Several of his su ervisorsurged him to seek treatment, which he

refused to do for more than fourteen months.P a nt s re usa to see t e recommen eand available treatment precludes him from

disability under the ADA (Roberts v. County

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considered to have a voluntary disability.Employers duty to accommodate ends if

employee is non-compliant with treatment:

An employee with bipolar disorder had problemswith attendance and performance was not

otherwise qualified because of med

. . ,

Inc.,No. 96-4072, 1997, U.S. App., LEXIS

12232, 10th Cir.)

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Debrief Coworkers

or uperv sors

has a mental health problem (disability ifaccommodation is sou ht

Educational in nature

factors that are external rather than volitional:

Cognitively slow vs. unmotivated (lazy)

Concentration difficulties vs. not capable (stupid)

Interpersonally sensitive vs. rude (snobbish)

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Consider within the context of team building


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Disclosure of Mental Health

ro ems - vantages

Receive support from colleagues

Therapeutic affirmation

Becomin a consumer advocateMost have no regrets (Ellison et al., 2003)

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Disclosure of Mental Health

ro ems - sa vantages

Shame & embarrassment

Stigma

Discrimination

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Encoura e Treatment Com lianceReasons for noncompliance:

Side effects Need to remember and or anize

Expense & inconvenience

Denial

Involve family & social supports

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General Vocational Facts About(SPMI)

employment, especially when they are integratedwith mental health treatment programs (Drake et al.,1996)

Longer involvementbetter outcomes (Bond, 1998)

OTJ training produces outcomes equal to or better

than extended unpaid pretraining (Bond, 1998)

or s ncent ves e.g., can e s gn cantnegative predictors (e.g., Edelson, 1993; Ford, 1995)

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P iti P h i l P di t


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Positive Psychosocial Predictors

o o ace e o(Alforson et al., 1998)

Close relationships with family and friends

Values competitive employment as

Strong desire for financial independence

Ready transportation to and from workShows stron ob-seekin initiative

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independent of VR system


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Axis II: Personality Traits andDisorders

enduring patterns of perceiving, relating to, andthinking about the environment and oneself,and are exhibited in a wide range of social and

personal contexts

ersona ty sor ers are ex reme var an sof these traits, which lead to either:

mpa rmen n soc a or occupa onafunctioning;

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Clinically significant distress


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cognitive confusion are strongest negative,

Agreeable andConscientiouspersonality

outcomes (Costa & Widiger, 1994)

nterpersona pro ems are t e mostfrequent cause of unsatisfactory

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term nat ons (Becker, et al. 1998)


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-

47-90% incidence in those diagnosed withx s sor ers

PDs tend to improve with age

Compulsive and histrionic traits (not

disorders) improve functioning; all others

worsen functioningPDs more likel in those with abuse histories

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Onset by early adulthood


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-

Insight tends to be poor Self-ratin s and eer ratin s are onl

modestly related:

r= .36 (Klonsky, Oltmanns, & Turkheimer, 2002)Diagnosis is more difficult than Axis I,

requiring:

Extensive history-taking, Review of records

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Personality testing


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Treatment outcomes are uneven: Lon -term s chothera or rou thera is

treatment of choice

Dialectic Behavior Therapy (DBT) is especially

Medication often ineffective

Impossible to change without motivation

Subjective distress improves prognosisPositive RTW outcomes are also difficult

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PDs b Cluster

Cluster A Odd

Idiosyncratic thinking, suspiciousness, social withdrawal

Paranoid, Schizoid, & Schizotypal

Cluster B Dramatic

Intense emotional expression, mood instability, poor

Antisocial, Borderline, Histrionic, Narcissistic

Anxious, worried, emotionally constricted, poor decision-

making, risk-adverse, cowardly

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Avoidant, Dependent, Compulsive, Passive-Aggressive

Dramatic Cluster Characteristics


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Dramatic Cluster Characteristics

Grandiose Sense of entitlement; Self-centered

Reacts to criticism or rejection with rage, shame Disregard for rules and ethics

Irresponsible and unreliable

Impulsive; seeks immediate gratification; self-centered;

Often argumentative, hostile, and aggressive

Oppositional relationships with authority

High co-occurrence of substance abuse Unstable mood; often have co-occurring mood disorder

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-

Impulsive, irresponsible, unreliable

Self-destructive behavior, often manipulative motive

Dramatic Cluster Effects on Work


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Dramatic Cluster Effects on Work

Overestimates skills, accomplishments; underestimatesweaknesses

, ,

Resents coworkers and supervisors who make demandsand dont recognize specialness

Takes direction or criticism poorly

Can be talented, charming, entertaining

uper c a , con c ua re a ons ps w cowor ers

Chafes under supervisory direction

Shows poor judgment

Violates workplace rules, including safety procedures

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Potentially violent

Can be superficially charming and persuasive

Management Strategies with


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ra a c u er

Set clear expectations, boundaries, & consequences Maximize ob ectivit of erformance review standards

Allow opportunity to feel important and valued, but

monitor for exploitation of others

Maximize strengths such as superficial charm and a desire

to be noticed, such as in some customer service work

must be firm, street smart, but not thin-skinned

Standards for performance and attendance must be set and

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maintained; manipulation resisted

Random drug testing may be valuable



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Dramatic Cluster (cont) ons er occupa on w g ac v y eve an c ange o

scenery Avoid jobs that are detail-oriented

Closely monitor adherence to safety procedures; avoiddangerous work

-behavior

Flexible scheduling to accommodate mood swings

Can develop close relationships with coworkers, butboundaries should be clarified and monitored

Consider debriefin coworkers re ardin boundar issues

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and employees need to avoid hostile situations

Ps h l i l E l ti :


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Psychological Evaluation:

Recommended Practices

Training and experience in forensic and/or

Is preferably not the treating clinician:

(Greenberg & Shuman, 1997):

Who is the client/patient?

Competency ssues

Interference with therapeutic relationship

Evaluation procedures

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avoid agreeing toperform an evaluation ofhis patient for legal purposes because his

forensic evaluation usually requires that

other people be interviewed and testimony

may a verse y a ect t e t erapeut c

relationship. (American Academy of

,

for the Practice of Forensic Psychiatry,1995

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Procedures Confidentialit

Distribution of information

Conse uences of coo eratin or declininReview relevant collateral information,

includin :

Medical records VR records

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School or employment records



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Personality (e.g. MMPI-2) Co nitive intelli ence and memor

Academic

Structured interview: Mental health, chemical dependency, employment,

education, legal, medical, social, family histories

serve e av or

Reported symptoms

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-



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Summary of personal history, symptoms, andtest results

DSM-IV diagnoses

Functional strengths and limitations Treatment recommendations

Individual, group, or family therapy

e cat on eva uat on

Environmental recommendations for successful

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Ethical Issues: Interpretation


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Ethical Issues: Interpretation

of Results F.1.a. RCs:

Will take reasonable steps to ensure that appropriateexplanations are given to the client.

. .a. sc osure to c ents. s

Take steps to ensure that clients understand the

im lications o dia nosis, the intended use o tests andreports

B.3.1. Records. RCs:

rovi e access to recor s an copies o recor s w enrequested by clientsIn instances where the recordscontain information that may be sensitive or detrimental

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to t e c ient, t e RC as a responsi i ity to a equate yinterpret such information to the client.

Guidelines for Interpreting


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Exam Results to Clients

Abilities, strengths, & weaknesses Personalit & emotional fit with VR lan

Briefly describe the tests and test results:

Describe intellectual and academic strengths Explain how identified weaknesses can be dealt with

What implications do the diagnoses have for functional

mpa rmen s an p an

Helps insure that VR plan is consistent with the

abilities and circumstances o the client. see A.1.b.

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Client Welfare)



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Exam Results to Clients

Allow client to vent feelings, but keepclients focus on understandin self with

regards to developing a:

realistic lan that isconsistent with the abilities and

circumstances o the client. see A.1.b.

Client Welfare)

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S SS

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REFERENCES


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competitive employment among people with severe mental illness. PsychiatricRehabilitation Journal, 22, 34-45.

mer can ar ssoc a on . enta sa t es an t e mer cans w t sa ty ct (2ndEd.). Washington, DC: Author.

American Ps chiatric Association 1995 . Dia nostic and statistical manual o mentaldisorders (4thEd.). Washington, DC: Author.

Anthony, W.A. (1994). The vocational rehabilitation of people with severe mental illness.ssues an my s. nnova ons an esearc , , - .

Becker, D.R., Drake, R.E., Bond, G.E., Xie, H. Daine, B.J., & Harrision, K. (1998). Jobterminations amon eo le with severe mental illness artici atin in su ortedemployment. Community Mental Health Journal, 34, 71-82.

Bond, G.R. (1998). Principles of the individual placement and support model: Empiricalsuppor . syc a r c e a a on ourna , , -

Costa, P.T., & Widiger, T.A. (1994). Personality disorders and the five-factor model ofpersonality. Washington, DC: American Psychological Association


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ra e, . ., c ugo, . ., ec er, . ., n ony, . ., ar , . . . e ew amps restudy of supported employment for people with severe mental illness. Journal of Consulting andClinical Psychology, 62. 391-399.

Edelson D.S. 1993 . Prediction o vocational rehabilitation outcome: A com arison o the redictivevalidity of demographic variables, MMPI-2, WRK, TRT. Unpublished doctoral thesis. Minneapolis,MN: Minnesota School of Professional Psychology

Ellison, M. L., Russinova, Z., MacDonald-Wilson, K.L., & Lyass, A. (2003). Patterns and correlates ofwor p ace sc osure among pro ess ona s an managers w psyc a r c con ons. ourna oVocational Rehabilitation, 18, 3-14.

Fischler, G.L. & Booth, N.E. (1999). Vocational impact of psychiatric disorders: A guide for

rehabilitation ro essionals. Gaithersbur MD: As en Publishers

Ford, L.H. (1995). Providing employment support for people with long-term mental illness. Baltimore,MD: Paul Brookes Publishing Co.

Greenberg, S.A. & Shuman, D.W. (1997). Irreconcilable conflict between therapeutic and forensic

roles. Professional Psychology: Research and Practice, 28, 50-57.

Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S, Wittchen, H-U, &K dl K S (1994) Lif ti d 12 th l f DSM III R hi t i di d i th


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Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in then e a es: esu s rom e a ona omor y urvey. rc ves o enera syc a ry, ,

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Kessler, R.C. & Frank, R.G. (1997). The impact of psychiatric disorders on work loss days.syc o og ca e c ne, , - .

Klonsky, E.D., Oltmanns, T.F., & Turkheimer, E. (2002). Informant reports of personality disorder:Relation to self-report, and future research directions. Clinical Psychology: Science and Practice, 9,

- .

Mancuso, l. (1993). Case studies on reasonable accommodation for workers with psychologicaldisorders. Washington, DC: Washington Business Group on Health.

U.S. Department of Health and Human Services (1999). Mental health: A report of the SurgeonGeneral. Rockville, MD: National Institute of Mental Health.

Wagner, C.C., Danczyk Hawley, C.E., & Reid, C.A. The progression of employees with mental

disorders through disability benefits systems. Journal of Vocational Rehabilitation, 15, 17-29.


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Gary L. Fischler, Ph.D.icense syc o ogist

Diplomate, American Board Psychological Specialties, Forensic Clinical

PsychologyDiplomate, American Board of Disability Analysts

p oma e, mer can oar o aw n orcemen xper s

Dr. Fischler earned his doctorate in Clinical Psychology from theUniversity of Minnesota in 1984. He is an adjunct assistant professoro psyc o ogy a e n vers y o nneso a an an a unc acu y aArgosy University, the Minnesota School of ProfessionalPsychology. He is also a court appointed psychologist and aconsultant to vocational rehabilitation, disability determination, and

pu c sa e y agenc es. r. sc er s spec a n eres s re a e o e

interface between mental health, legal issues, and workplace concerns,and he offers independent medical exams (IMEs), pre-employment,promotional, and fitness-for-duty exams to private and public

65

organ za ons. e as wr en severa pu ca ons on ese op cs, ancoauthored a book, Vocational Impact of Psychiatric Disorders: AGuide For Rehabilitation Professionals. He can be reached [email protected].

Understanding the vocational impact of mental health disorders.

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