Predicting and Maximizing Return-to-Work Outcomes
for People with Mental Health Disorders

Dr. Fischler earned his doctorate in Clinical Psychology from the University of Minnesota in 1983. He is a clinical assistant professor at the University of Minnesota and the Minnesota School of Professional Psychology. He is also a court appointed psychologist and a consultant to vocational rehabilitation and public safety agencies. Dr. Fischler’s special interests relate to the interface between mental health and workplace issues, and he provides preemployment, promotional, and fitness exams to private and public organizations. He has written several articles on these topics, and has recently coauthored a book, Vocational Impact of Psychiatric Disorders: A Guide For Rehabilitation Professionals (Aspen Publishers).

INTRODUCTION

HOW DO PSYCHIATRIC DISORDERS BECOME DISABLING?

When psychiatric dysfunction is severe and chronic, it is easy to understand how work can be negatively affected. Indeed, a number of writers^1-5 have described vocational challenges in this group. Others^6-8 have described detailed supported programs for improving vocational outcomes, often in noncompetitive work settings. Lowman^9.10 attempted to describe how psychological factors might affect career choice and success, and psychotherapeutic methods for helping people with work problems resulting from psychological dysfunction. Recently, we 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. ¹¹

Fischler and Booth¹¹ provided a summary of essential psychological factors that may affect job performance and vocational rehabilitation outcomes, and examples of how they can be manifested in different psychiatric disorders (Diagnostic and Statistical Manual of Mental Disorder, fourth edition (DSM-IV)¹². These factors include cognition, pace, persistence, reliability, conscientiousness, motivation, interpersonal skills, stress tolerance, honesty, and trustworthiness. Understanding a disorder’s expression allows for effective case management and a positive outcome in the RTW process.

The relationship between essential psychological factors, psychiatric disorders, and job duties 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 ensure that this shift is made, resulting in an accurate assessment of the RTW issues.

PREDICTING RTW OUTCOMES:
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 employment outcomes for people with mental health problems.^13.14 These domains, in turn, are affected in various ways by an individual’s personality, values, experiences, and symptoms.

A thorough psychological assessment recognizes that personality traits, or, in their extreme, personality disorders, often constitute a significant part of the diagnostic picture, and may in themselves account for the differences in vocational outcomes in different individuals with similar clinical (i.e., DSM-IV, Axis I) psychopathology. Personality disorders in nonselected “normal” community samples tends to be higher than most people believe, at about 10%. In samples that already have been diagnosed with Axis I disorders, the estimates are considerably higher, from 23% to 90%.¹⁵ Moreover, the presence of a personality disorder tends to bring with it substantial functional impairments, including those in the vocational domain.¹⁶

The personality characteristics “agreeableness” and “conscientiousness”¹⁷ seem to be the best predictors of occupational success. Further support for this position was found in research performed with data from our own practice. Edelson¹⁸ followed 88 urban VR clients over a period of two and a half years. Although the overall rehabilitation rate for competitive employment was rather low (5.7%), the Psychopathic Deviance (Pd) scale of the MMPI-2 (Minnesota Multiphasic Personality Inventory, 2nd ed.) was consistently and significantly related to vocational success. Specifically, clients who were more impulsive, rebellious, or antagonistic, as measured by the Pd scale, had a significantly poorer VR outcome than those who were more conventional, agreeable, and thoughtful in their actions.

Because mental health disorders tend to be less easily understood than physical illness, and because the criteria for them may appear to be more subjective, a belief may arise on the part of an administrator, employer, claims manager, or lawyer that disability information is best obtained 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 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.^19.20 Such patients may tend to exaggerate or over-report their problems and minimize their ability to cope. They may consciously or unconsciously resist treatment efforts. For example, Fee and Rutherford²¹ estimated that, after controlling for the severity of an initial head injury, litigating patients were twice as likely to report symptoms (e.g., depression, anxiety, headache) as nonlitigating ones. Patients who intentionally fake or significantly exaggerate their psychological symptoms to achieve financial gains have been estimated as high as 47% for workers compensation cases²², and over 50% for personal injury plaintiffs.²³

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. For example, Rogers²⁴ originally proposed that there were 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.

Greenberg and Shuman²⁵ have concisely articulated 10 principles that differentiate therapy from forensic clinical roles. These include identifying whose client is the examination subject, what is considered privileged information, the attitude of the examiner, the competence of the examiner, the nature of the hypotheses generated by the examiner, the level of scrutiny applied to the information gathered and the conclusions offered, the amount of control that the subject has in each relationship, the degree of “adversarialness” in each relationship, the goal of the professional in each relationship, and the impact on the critical judgment by the examiner. Greenberg and Shuman conclude that because of these differences there is an “irreconcilable conflict” between the roles of therapist and forensic examiner. To the extent that decisions related to the disability or RTW status of an individual are considered forensic rather than therapeutic endeavors, a treating clinician would find him or herself in exactly such a conflict when attempting to provide such information for an administrative or legal purpose.

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.²⁶

In the insurance industry, physical injury claimants are often asked to submit to an Independent Medical Examination (IME). In the personal injury arena, plaintiffs are often asked to take an “adverse” exam. The SSA and the VA have their own panels of “consultants” that perform such examinations for disability determination purposes. Employers need to have a similar approach to evaluating disability and RTW claims at work.

A comprehensive psychological examination, therefore, should include objective personality assessment which has scales to detect exaggeration, such as the MMPI-2²⁷ as an essential part of any examination that seeks to make decisions about disability status. In addition, such an examination should include review of all available records (such as psychiatric or medical treatment, legal status, personnel records, etc.) in order to provide corroboration of the patient’s self-report.

PSYCHOLOGICAL 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. This might come in the form of copies of the personnel file, a summary letter from the human resources (HR) director, or a verbal communication with the HR director of the employee’s supervisor. The information covered should generally fall in three broad areas:

1. Basic information such as length of employment, job description, disciplinary history, performance reviews, and absenteeism;

2. Job performance issues such as error rate, productivity, when or if problems began to emerge; and

3. Essential psychological factors for the job in question, such as ability to get along with coworkers, supervisors, and customers; the ability to tolerate supervisory deadlines and other stressors; and the need for sustained concentration.

Data privacy laws may differ from state to state, and the information generated by the psychological exam may or may not be considered to be “medical data” by state statute. For this reason, the psychologist should ask the employee to give written consent prior to initiating the examination process, and decline to conduct the exam if the employee refuses to do so. When in doubt, consult a legal consultant knowledgeable in both employment and data practices law.

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 information such as prior episodes of illness or disability, treatment recommendations, prognosis, and relevance to the employee’s work situation—past and present. In addition, these clinicians may have their own opinions about the employee’s ability to return to work and should be consulted for their input. Finally, since the employee may be inclined to give different information in a treatment vs. forensic examination, inspecting the treatment records is likely to yield useful information on the reliability of the employee’s self-report. Since most employers do not (and probably should not) have extensive information related to the employee’s mental or physical health, the psychologist would usually need to obtain it directly from the treatment or forensic sources, with the permission of the employee. While many employees are understandably reluctant to release this information, issuing final RTW recommendations without it may significantly limit the level of certainty that can be placed in the evaluation.

The In-Depth Personal Interview

Because the employee’s perception of the problems is likely to be quite complex, the RTW interview tends to be lengthy. The interview is composed of five 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 before, objective, actuarially based information is critical in forensic examinations, including those involving RTW issues. The tests used commonly fall into four 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 RTW evaluation is not complete without making specific recommendations that try to address the best interests of both the employee and employer. Recommendations tend to 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 the workplace environment. Workplace modifications and accommodations will be more fully discussed below.

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 because the individual would be a threat to the safety of self or others.

WORKPLACE MODIFICATION

When an employee with a mental health problem can benefit from modifications to the workplace, he or she may be entitled to “reasonable accommodations” under the Americans with Disabilities Act (ADA).²⁸ To what extent such an accommodation is “reasonable” is based on business necessity, and, therefore, depends on the judgment of the employer. However, if an employer’s attorney or insurance claims representative does not know that certain modifications would allow the employee to more successfully return to work, the employer could be held liable later.

The most frequent accommodations for mental health problems are fairly simple and inexpensive, and, therefore, are usually worth consideration. Mancuso²⁹ presented 10 case studies of competitively employed workers with psychiatric disabilities. She found that workers rarely discussed their disabilities directly with their supervisors and thus created difficulties in providing appropriate accommodations. Employees who do disclose their disability, however, allow for “explicit accommodations.” These include such modifications as flexible scheduling, extended periods of absence to accommodate periods of symptom increases, and short-term rather than long-term projects that require less regular attendance.

Importantly, the most common accommodation cited by both supervisors and employees in Mancuso’s study was flexible or part-time scheduling. Supervisors also described a willingness to modify work assignments according to the employee’s fluctuation of symptom severity. Other modifications that are often useful include providing a quiet workplace to maximize sustained concentration, using formal or informal job “coaches” to help the employee maximize organization strategies, rearranging job duties with other employees, and obtaining additional supervisory support (e.g., more frequent meetings or performance reviews).

In addition to formal modifications, the occupational health psychologist can make general recommendations to help the employer understand the likely impact of the employee’s problems and how to deal with them. For example, in the case of major depression, the following strategies may be helpful:

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.

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 RTW strategies are on track. Generally, 30 days is a good time to gather this information, and a return appointment for the employee to meet with the psychologist can be scheduled at the end of the RTW evaluation. At that time, the psychologist can quickly assess the employee’s current mental status, level of improvement, and work status. The employee would be asked to give his or her consent for the psychologist to obtain the most current treatment records to be sure 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. It might be useful to have a telephone conversation with the treatment provider to get his or her input on RTW issues. The employer also should 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 arise that signal a potentially unsuccessful RTW outcome. These could include an appearance of poor grooming, decreased alertness, or depressed affect. The employee may also report continued problems with symptoms such as sleep disturbance, poor concentration, reduced appetite, or suicidal thinking. Little or no family support may be available to help the employee return to baseline functioning.

Unilateral changes in medication or treatment noncompliance can be especially troublesome. Similarly, a negative attitude toward the psychotherapist or missing therapy appointments often can presage a negative RTW outcome. If the employee is unusually guarded or defensive, or seems to have a “Pollyanna” attitude towards his or her problems, this can indicate a tendency to quit treatment prematurely after the immediate crisis has passed.

Finally, the employee’s attitude toward returning to work (either excessive “workaholism” or a lackadaisical attitude) is an important consideration. Does he or she accept work modifications, reject them, or see them as inadequate? Does the employee seem to solicit excessive help from coworkers or supervisors? He or she may not really want to return to work or may have underlying fears about adjusting successfully to the return.

TEAMWORK

It should be clear by now that successful RTW is most likely to occur when the employee and all of the experts involved are invested in a positive outcome. To maximize the chances of this, everyone needs to be communicating effectively and be “on the same page.” It is possible that one member of the team could consciously or unconsciously sabotage the process if they are not in agreement with it. Figure 2 illustrates the relationships between the team members. The employee and occupational health psychologist need to have a partnership that accepts input from the employee’s psychiatrist or psychotherapist, as well as his or her supervisor or employer. It is the occupational health psychologist’s role to ensure that effective communication transpires, and to serve as the case manager until the employee has successfully returned to work.



CONCLUSION

Attorneys and claims managers often struggle with mental health disability and RTW cases because the issues can be vague and mired in clinical rather than job-relatedness issues. 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 which makes a paradigm shift between clinical and 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 RTW evaluations include providing both general and specific recommendations regarding the employee’s ability to return to work, his or her mental health treatment needs, and his or her needs for workplace modifications. Follow-up with the employee, their treatment providers, and employer can help insure that the RTW strategies are appropriate and useful, and may facilitate intervention if the process becomes derailed.

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