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Assessing Fitness-For-Duty and Return-to-Work Readiness
for People With Mental Health Problems


Gary L. Fischler, Ph.D
Minneapolis, MN

This article originally appeared in the Minnesota Career Development Association Newsletter, The MCDA Communique, Summer, 2000. Reprinted here with permission.


Employees with mental health problems can present complex issues for human resource departments, administrators, supervisors, and disability claims representatives. In some situations, such as police and fire departments, mass transit companies, nuclear power facilities, or construction projects involving dangerous equipment, mental health problems can pose a direct threat to the safety of the employee or the public. In other cases, the stakes may not be as high, but employees with mental health problems can have a profound effect on organizational effectiveness, productivity and staff morale.

Therefore, it is not surprising that an employee with a mental health problem that is affecting the workplace, can create a good deal of consternation and confusion for human resource departments and related parties. Usually more questions arise than can be answered. Can the employee work safely? Can he or her work safely under high levels of stress? If I discipline the employee for poor performance or conflicts with other workers, is that a violation of ADA? Should I refer him or her for treatment?

Well-meaning but vague or inaccurate statements from the employee’s psychotherapist or psychiatrist can exacerbate the confusion. For example, when a therapist opines that an employee cannot work for 60 days due to “stress,” what should an administrator do? When an employee has been out on sick leave or administrative leave due to mental health problems how can an administrator determine when the employee is ready to return? Should a note from the therapist suffice, or should the administrator insist on an independent examination from a third party?

To answer these questions we first need to understand how mental health disorders affect the employee’s workplace behavior.

How Mental Health Disorders Affect the Workplace

Recently, we (Fischler & Booth, 1999) described methods for evaluating the impact of psychological disorders on vocational functioning, and offered methods for helping people with psychiatric disorders find and keep satisfactory competitive-level work. These factors include cognition, pace, persistence, reliability, conscientiousness, motivation, interpersonal skills, stress tolerance, and honesty and trustworthiness, and are summarized in table 1. When an employee’s disorder significantly affects these psychological dimensions, it can have major implications for all involved in the workplace, including supervisors, coworkers, and troubled employees themselves. Understanding a disorder’s expression helps drive decisions about an employee’s fitness-for-duty (FFD), and allows for effective case management and a positive outcome in the return-to-work (RTW) process.

Table 1: Essential Psychological Factors in Job Performance

Psychological Factors Effects on Job Performance Diagnostic Examples
Cognition Intelligence, memory, academic skills, and the ability to use these skills. Mental Retardation, brain injuries, schizophrenia, depression, anxiety.
Pace The ability to perform tasks at a reasonable speed. Depression, obsessive-compulsive disorder, passive-aggressive personality disorder.
Persistence The ability to stay with a task until it is complete. Bipolar disorder manic phase, attention deficit hyperactivity disorder, histrionic personality disorder, somatization disorder, schizophrenia.
Reliability Coming to work every day in spite of personal or emotional problems. Agoraphobia, somatization disorder, avoidant, antisocial and borderline personality disorders, major depression, bipolar disorder manic phase.
Conscientiousness and motivation Wanting and trying to do a good job; persisting until it is accomplished. Antisocial, schizoid, and passive aggressive personality disorders, major depression.
Interpersonal functioning The ability to accept supervision, to get along with coworkers or the public. Bipolar disorder manic phase, post-traumatic stress disorder, antisocial, passive aggressive, schizoid, borderline, and narcissistic personality disorders.
Honesty, trustworthiness The ability to be truthful, direct, and straightforward, to refrain from such things as lying and theft at work. Anti-social personality disorder, 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 depression.
Job-specific requirements e.g., typing speed, conflict resolution skills, “people skills.” Depends on requirement.

The relationship among the professionals involved in a particular case is illustrated in Figure 1. The “expert” in each domain has a different professional role: psychiatrist or psychotherapist (i.e. treating clinician), supervisor / employer, and the occupational health psychologist. These professionals have a responsibility to make a “paradigm shift” from their own specialty perspective in order to understand how mental health factors and job performance interact with each other. However, it is the primary role of the occupational health psychologist to insure that this shift is made, resulting in an accurate assessment in FFD and RTW issues.



The Comprehensive Psychological Assessment

Research suggests that interpersonal functioning, severity and type of psychiatric problem, job satisfaction, work history, cognitive functioning, family support, substance abuse, level of motivation, and dependability, are all linked to satisfactory employment outcomes for people with mental health problems (Becker, Drake, Bond, Xie, Dain, & Harrison, 1998; Tsang, Lam, Ng, & Leung, 2000). These domains, in turn, are affected in various ways by an individual’s personality, values, experiences, and symptoms. Therefore, individual assessment, provided by occupational health psychologists who understand how psychiatric and vocational paradigms work together to produce vocational problems and solutions, is critical for effective vocational intervention.

Because mental health disorders tend to be less easily understood than physical illness, and because the criteria for diagnosing them may appear to be more subjective, the administrator may believe that the best information would come from the treatment provider. After all, shouldn’t the treating clinician know the employee better than anyone else? Wouldn’t the provider be privy to a great deal of private information to which nobody else would have access? And if the employee were asked to take an independent examination, wouldn’t the evaluator rely primarily on the subjective report of the employee anyway?

Unfortunately, one of the biggest mistakes possible in the evaluation of mental health RTW issues is the exclusive reliance on the employee’s treatment provider (i.e., a psychologist, psychiatrist, or psychotherapist) as the primary source of this information. First, it is generally accepted, even among treating professionals, that patients who have “secondary gains” (e.g., financial compensation) for their illnesses, such as personal injury plaintiffs or employees receiving long-term disability benefits, present themselves in very different ways than patients who are not seeking compensation (e.g., Weissman, 1990; Williams, Lees-Haley, & Djanogly, 1999). Such patients may tend to exaggerate or overreport their problems and minimize their ability to cope. They may consciously or unconsciously resist treatment efforts.

Second, treating clinicians generally rely much more extensively on patient self-report than do independent evaluators. Indeed, psychotherapists have traditionally been trained to uncritically accept patients’ self-views. Rogers (1957) originally identified four “facilitative” therapist attitudes: empathy, warmth, congruence, and unconditional positive regard. Thus, treating clinicians’ perceptions of their patients tend to be biased in favor of the patient’s self views and agenda. To do otherwise would be to jeopardize the therapeutic relationship itself. Among others, Greenberg and Shuman (1997) argued that therapeutic and forensic clinical roles for mental health professionals are incompatible.

Finally, many treating clinicians do not routinely use objective psychological test data. Often, such testing is viewed as a needless expense by managed care companies. Moreover, clinicians tend to overestimate their ability to use clinical data accurately, in spite of substantial research indicating that actuarial methods of prediction (i.e., test data combined in mechanical ways) outperform clinical prediction in the long run (e.g., Grove, Zald, Lebow, Snitz, & Nelson, 2000).

Psychological FFD and RTW Evaluations: Best Practices

Background Information. Prior to conducting the evaluation, the psychologist should have access to as much information about the work history of the employee as possible. Such information may include length of employment, job description, disciplinary history, performance reviews and absenteeism. In addition to employment data, the psychologist needs to obtain as much prior medical and/or mental health data as is relevant to the case at hand. Such information may yield critical clues such as prior episodes of illness or disability, treatment recommendations, prognosis, and relevance to the employee’s work situation, past and present.

The In-Depth Personal Interview. Because the employee’s perception of the problems is likely to be quite complex, the interview tends to be lengthy. In our practice, we typically schedule 2 hours for the initial appointment, with additional time scheduled if necessary. The interview is composed of 5 broad areas:

1. Employee’s description of work problems, if any;

2. Employee’s social history including education, family, legal, psychiatric, substance use, aggression, medical, and activities of daily living;

3. Employee’s work history prior to the current problems, including previous employers;

4. Current symptoms, mental status, and behavioral observations;

5. Employee’s perception of ability to return to work, including suggesting modifications to improve work performance.

Because work adjustment is related to long-term personality adjustment as well as acute mental health symptoms, the interview needs to take a longitudinal approach to personal history as well as a thorough description of current clinical problems.

Psychological Testing. As described above, objective, actuarially-based information is critical in forensic examinations, including those involving FFD and RTW issues. The tests used commonly fall into 4 categories:

1. Cognitive: Measures intelligence, concentration, and memory.

2. Personality: Measures personality and emotional characteristics, which may be involved in mental health problems such as depression or personality disorders.

3. Effort and motivation: Measures the extent to which the employee is putting forth appropriate effort and is motivated to present in an accurate manner. Ideally, employees who are either minimizing or malingering their symptoms will be identified with these tests.

4. Organizational behavior: Measures personality characteristics that help determine the suitability of an employee for his or her specific job. For example, managers, police officers, and sales people tend to have certain personality characteristics in common.

Recommendations. The evaluation is not complete without specific recommendations that try to address the best interests of both the employee and employer. Such recommendations usually fall in one of three categories:

1. Fit to return to work – no restrictions. The employee has fully recovered from whatever problems he or she had been experiencing and is now ready to return to work.

2. Fit to return – with restrictions or modifications. The employee may return, but only with some provisions. These may range from initiating or continuing in mental health treatment to making modifications to their workplace environment.

3. Unfit to return. The employee cannot return to work because he or she would be unable to do the job due to an ongoing mental health problem, or would be a threat to the safety of self or others.


Workplace Modifications

When employees with mental health problems can benefit from modifications to the workplace, they may be entitled to “reasonable accommodations” under the Americans With Disabilities Act (ADA; Bruyère & O’Keeffe, 1994). To what extent such an accommodation is “reasonable” is based on business necessity, and therefore depends on the judgment of the employer, not the psychologist. The most frequent accommodations for mental health problems, however, are fairly simple and inexpensive, and are therefore usually worth consideration.

For example, in the case of major depression, the following strategies may be helpful (Fischler & Booth, 1999):

1. Giving the employee simple, straightforward tasks to aid memory and concentration and help him or her develop a sense of mastery over their job.

2. Promoting as much predictability as possible in the employee’s daily tasks.

3. Providing clear guidelines and instructions, possibly in writing.
4. Allowing for flexibility with regard to pace of work and timing of breaks.

5. Working as part of a team to decrease the employee’s sense of loneliness or isolation.

Disclosure of Disability

Many workers with psychiatric disabilities see disclosure of it to their employers or coworkers as undesirable, embarrassing, or inevitably leading to stigmatization on the job. Others, however, see it as a useful strategy to promote long-term positive adjustment at the worksite. Since every situation is different, the pros and cons of disclosure must be assessed in each. Mancuso (1993) described several potential benefits of disclosure, including enabling a worker to involve a third party, such as a vocational rehabilitation professional, in the development of accommodations, making it easier to come to work during a periods of heightened symptoms, and allowing coworkers and supervisors opportunities to provide support. Our observation has been that for many individuals the most effective way to improve long-term job retention is by creating a partnership with an employer who values diversity in the workplace, and who is willing to take a little extra time to understand the unique needs of a potentially effective and productive employee.

Follow-up

After returning to work, the occupational health psychologist should follow-up with the employee, the employee’s treatment provider, and the employer to make sure that the recommended strategies are on track. At follow-up the psychologist can quickly assess the employee’s current mental status, level of improvement, and work status. Treatment records can be checked to verify that the employee has indeed followed through with obtaining the agreed-upon treatment, that the treatment plan seems appropriate, and that the treatment is proceeding adequately. The employer should also be contacted to see if the employee is successfully reintegrating into the workplace and if the modifications that were implemented seem to be effective. Any problems evident at this point should be aggressively evaluated and appropriate changes in the RTW plan be made.

“Red Flags.” During the follow-up, a number of warning signs could signal a potentially unsuccessful RTW outcome. The employee may report continued problems with symptoms such as sleep disturbance, poor concentration, reduced appetite, or suicidal thinking. Other issues such as lack of family support, treatment non-compliance, negative attitudes towards work, or obvious denial that a problem exists, may all affect the RTW outcome.

Conclusions and Recommendations

Successful RTW requires an orchestrated effort between the employee, the employer, the employee’s mental health treatment provider, and the occupational health psychologist. A psychological evaluation that is thorough and objective, and that makes a paradigm shift from clinical to employment issues, is critical to a positive outcome and to avoid lingering problems such as excessive disability leave, poor interpersonal adjustment, chronic poor work performance, or unsafe working conditions for the employee and/or coworkers. This paradigm shift must translate psychiatric symptoms and job duties into a common language that details the essential psychological factors of a job.

Best practices for FFD and RTW evaluations include providing both general and specific recommendations regarding employees’ ability to return to work, their mental health treatment needs, and their needs for workplace modifications. Follow-up with the employee, his or her treatment providers, and the employer can help insure that the RTW strategies are appropriate and useful, and may facilitate intervention if the process becomes derailed.

References

Becker, D.R., Drake, R.E., Bond, G.E., Xie, H., Dain, B.J., & Harrison, K. (1998). Job Terminations Among People with Severe Mental Illness Participating in Supported Employment. Community Mental Health Journal, 34 (1).

Bruyère, S.M. & O’Keeffe, J. (Eds.) (1994). Implications of the Americans with Disabilities Act for Psychology. Washington, D.C.: American Psychological Association

Fischler, G., Booth, N. (1999). Vocational Impact of Psychiatric Disorders. Gaithersburg, MD: Aspen Publishers, Inc.

Grove, W.M., Zald, D.H., Lebow, B.S., Snitz, B.E., & Nelson, C. (2000). Clinical versus mechanical prediction: A meta-analysis. Psychological Assessment, 12, 19-30.

Greenberg, S.A. & Shuman, D.W. (1997). Irreconcilable conflict between therapeutic and forensic roles. Professional Psychology: Research and Practice, 28, 50-57.

Mancuso, L.L. (1993). Case Studies on Reasonable Accommodations for Workers with

Psychiatric Disabilities. Washington, D.C.: Washington Business Group on Health.

Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103.

Tsang, H, Lam, P, Ng, B., & Leung, O. (2000). Predictors of employment outcome for people with psychiatric disabilities: A review of the literature since the mid ‘80s. The Journal of Rehabilitation, 66, 19-31.

Weissman, H.B. (1990). Distortions and deceptions in self-presentation: Effects of protracted personal injury cases. Behavioral Sciences and the Law, 8, 67-74.

Williams, C.W., Lees-Haley, P.R., & Djanogly, S.E. (1999). Clinical scrutiny of litigants’ self-reports. Professional Psychology: Research and Practice, 30, 361-36.

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