Behavioral health/workers’ comp/disability management

CMs open doors for psych patients

How to educate employers about accommodation

Most problems case managers face when handling disability claims for psychiatric disorders emerge from communication gaps between employers and staff and a general lack of understanding about psychiatric disability. In most cases, the case manager is the person best-suited to be an objective third party who heals the employer/ employee relationship and facilitates the accommodations that keep the employee on the job.

"In many cases that involve mental illness, the relationship between the employer or supervisor and the employee creates internal stress for the employee and exacerbates the situation," says Mark Raderstorf, CCM, CRC, a licensed psychologist and president of Behavioral Management in Minneapolis. "Stress in the work environment often tips the scale that sends the employee over the edge. The case manager can be instrumental in rebuilding relationships and fashioning return-to-work plans that keep the employee on the job."

Mediation helps at work

However, managing psychiatric disabilities takes special skills that may not come naturally to many case managers. "You must be a person that is comfortable going into the work environment and addressing touchy issues in an objective way," he says. " Many of the same skills that apply to traditional medical case management apply here as well, but in addition you must be able to mediate workplace conflict."

Raderstorf recalls a head injury client with major depression. "Both sides were very distrustful of each other. The patient had memory problems and difficulty managing multiple tasks, but the real issue was long standing bad blood between the employee and his supervisor and coworkers." With his client’s permission, he set up a meeting for the client, his wife, the company personnel director, and the client’s supervisor. "We called it a return-to-work planning session. It was really a mediation. Unless both sides, employee and employer, trust each other, any plan the case manager develops for return-to-work falls apart."

Employers often have little knowledge or experience with mental illness, he adds. "Supervisors and co-workers both have misconceptions about the employee with a psychiatric disability. The disability manifests itself in the workplace in ways that impact co-workers." Workplace behaviors common in employees with psychiatric disabilities include reduced productivity, absenteeism, and lethargy.

"Other employees have to pick up the slack, and they begin to resent the employee with the psychiatric disability. If a co-worker has cancer and is tired due to chemotherapy, co-workers feel a great deal of empathy and willingly help the employee," Raderstorf says. "However, employees with psychiatric disabilities are often seen as lazy people who just want a free ride."

Case managers may have to educate co-workers before an employee with a psychiatric disability can successfully return to work. Brown-bag lunch-and-learn sessions work very well, he says, enabling case managers to provide general information about a psychiatric disability such as depression. "The sessions usually evolve into a vehicle for co-workers to vent their resentments about the disabled employee. The sessions also help co-workers understand that the employee has a medical condition that was fueling the performance problems and help them look at the person in a more supportive light."

The one mistake employers always should try to avoid is spending too many resources simply trying to prove a psychiatric disability exists, says Carol Miaskoff, BA, JD, assistant legal counsel for coordination in the Office of Legal Counsel for the Equal Employment Opportunity Commission in Washington, DC. "Establishing psychiatric disability may be necessary to some degree, but it is also often counterproductive," she says. "There are legal consequences for employers who go through a long back-and-forth process to establish a psychiatric disability without focusing on effective accommodation under the Americans with Disability Act [ADA] to get their employees back into the workplace."

Getting back to work, properly

Miaskoff says case managers should advise employers to follow a more moderate approach that moves employees with psychiatric disorders back to work more quickly. She suggests the following steps:

• Ask the employee’s health care provider to confirm the employee is under treatment for a psychiatric disorder covered under ADA. (See box on p. 29 for psychiatric conditions that merit accommodation under ADA.)

• Ask the health care provider to provide a summary of the employee’s condition and an evaluation of its seriousness.

• Talk to the employee and receive consent to discuss the employee’s mental health status and possible accommodations with the employer.

• Request a good job description from the employer and begin to discuss possible work adjustments.

It’s important that in trying to accommodate the employee’s disability, supervisors don’t change the standards of the job, Raderstorf says. "The approach has to be, These are the standards of the job. How can we help the employee meet them?’ If employees are allowed to meet lower productivity quotas, the case manager should make sure that it’s only for a temporary period."

Raderstorf and Miaskoff say reasonable accommodations for psychiatric disabilities include paid or unpaid time off, part-time work to start, or a later start time. An employee may have a medication that takes time to adequately control symptoms first thing in the morning. In those cases, a later start time may be the only necessary accommodation, Miaskoff observes. Here are five other accommodations to consider:

1. Flexible hours to accommodate treatment.

An employee may need an expanded lunch hour once a week for therapy or medical appointments. "An employee with major depression may ask to work at home one day a week to help cut their stress levels. That is also a fairly easy and reasonable accommodation for an employer to make," says Miaskoff.

2. Physical changes to the environment.

Physical accommodations might include room dividers, partitions, or soundproofing. "We had a case where an employer ran a small printing plant. The noise in the plant exacerbated the employee’s mental disability. The employer argued that keeping the plant quiet for the benefit of one employee with a mental disability would create an undue hardship, and we agreed," says Miaskoff.

"In that case, perhaps the employee could wear ear plugs. The key is to remain flexible and seek creative solutions which don’t place an undue burden on the employer," she says.

In another case, the employee worked in a large room with many people answering telephones. "The ringing of the phones distracted the employee with the psychiatric disability," she says. The employer turned down the volume and pitch of the telephone ring. You just have to give someone a fighting change. You don’t have change the entire workplace to comply with ADA."

Remember, many individuals with psychiatric disorders are easily distracted. "Case managers should assess the workplace," she says. "Is the client’s desk directly across from the water cooler? Is the client’s work station next to the fax machine? For a person with acute concentration difficulties, external distractions are very difficult to handle."

3. More regular supervision and feedback.

"This may help an employee who has difficulty structuring their workload and staying on track," she notes. "Case managers can educate supervisors about special needs, such as giving employees only one deadline at a time." Employ ees with concentration problems may need to be given assignments on a daily basis, Raderstorf adds. "I also suggest that supervisors provide written as well as verbal instructions for these clients."

4. Job coach for technical assistance.

Job coaches actually go to work with the employee to observe and smooth the way. "I had a client with anxiety and paranoia who needed a great deal of handholding to help her through daily stresses when she first returned to work," Raderstorf says.

"She was convinced her co-workers were out to get her.’ She needed a sounding board to give her a more balanced perspective of what was happening in the workplace."

Another client with major depression was receiving electroconvulsive therapy, which created short-term memory loss, he notes. The client was a computer analyst whose work was very technical. Raderstorf arranged for the employer to hire a computer consultant to meet with his client an hour a week for about three months to review the client’s work.

"The consultant was someone on the sidelines to coach him along. It not only reassured the client that he could still do his job, but where the client did make mistakes the consultant helped him correct them. The supervisor simply didn’t have the time for that type of micromanagement and remedial training," he says.

5. Rehabilitation case manager.

Sometimes, hiring a case manager is considered an accommodation, says Raderstorf.

"One thing I’d love case managers help more employers to understand is that an employee with a psychiatric disability isn’t going to come in and ask for help under ADA," Miaskoff says. "The employer has to listen to what the employee is saying. If they hear a request for help, they can’t ignore it. They have to respond. If employers wait until an employee makes a formal request for accommodation, it’s often too late to avoid legal trouble."

The EEOC publishes its policy documents or "guidances" for ADA accommodation on its Web site at, Miaskoff says. She encourages case managers to download the information and use it to help navigate the tricky waters of ADA accommodation for psychiatric disabilities.