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Health Equity | Population Health
What Happens When Workers Disclose A Mental Illness Like Bipolar Disorder At Work
Workers Fear the Stigma But Disclosure Can Increase Support For Their Job, A New LDI Study Finds
Work is a consequential place where people strive for personal growth, financial stability, and a sense of purpose. It can be a highly challenging environment for anyone, but particularly so for individuals with serious mental illness (SMI), who experience some of the most unfavorable outcomes among workers with disabilities. Furthermore, the decision to disclose their condition at work can be complex and consequential, since research suggests that stigma and discrimination related to mental disorders contribute to the labor market disadvantage that individuals with SMI face.
In collaboration with Marjorie Baldwin, PhD, professor and health economist at Arizona State University, LDI Senior Fellow Steven Marcus, PhD, conducted the first-ever systematic analysis of factors associated with disclosure of SMI at work and the association between disclosure and the probability of gainful employment (earnings above the cutoff for federal disability benefits). The analyses were conducted among workers with schizophrenia, bipolar disorder, or major depressive disorder who were engaged in regular jobs (those paying at least minimum wage, not set aside for persons with disabilities, and not obtained with mental health services assistance).
In their recent Journal of Mental Health Policy and Economics study, they found that workers who disclose are younger and report lower levels of self-stigma, on average. Compared to workers with a diagnosis of schizophrenia, workers with bipolar disorder are more likely to disclose, while workers who have major depression are less likely. Workers who have disclosed report more support and tolerance at work and are more likely to have worked at least three years in their job.
The authors also found that, when individual and work-related characteristics are held constant, disclosing mental illness may increase a worker’s chances of maintaining gainful employment. Some possible explanations are that disclosure could lead the employer to provide work accommodations, or that disclosure could reduce the stress of keeping the mental illness a secret.
We spoke to Professors Marcus and Baldwin about their research and how to catalyze change around mental illness in the workplace.
Can you summarize what’s known about workplace disclosure and how your study differs?
Marjorie: First, it’s important to define disclosure:we mean a point in time when an individual with a serious mental illness tells their supervisor or employer something about their mental illness. It may be that they disclose their diagnosis or their full history of mental illness, but it’s more likely to be partial information. Disclosure often happens in the context of requesting job accommodations, but not always.
There’s a lot in the literature on workplace disclosure of mental illness, but much of it is anecdotal. This literature shows that workers perceive several dangers from disclosure, primarily driven by stigma against mental illness. Workers’ concerns range from being harassed to being fired.
Most of the literature on workplace disclosure of SMI focuses on workers who receive assistance from mental health vocational services. This “supported employment” is important for people who are still dealing with some of the most acute symptoms of mental illness, whose illness does not allow them to work in gainful employment. Our study is unique in that we focus exclusively on workers with SMI who are independently employed in regular jobs.
Steven: By partnering with Marjorie, a renowned expert in the economics of disability and employment, and with pilot funding from LDI and the University of Pennsylvania Research Foundation, we were able to conduct a large national survey of 821 people with SMI who were capable of employment in a regular job. This is critically important because we know that many people with SMI are working in well-paying jobs in the community – like accountants, clerks, medical professionals, retail staff, and tradespeople. For the first time we looked at disclosure and employment systemically – not just anecdotally – to understand how disclosure promotes or impedes successful work outcomes.
What inspired you to investigate the association between workplace disclosure of serious mental illness and gainful employment?
Marjorie: Since the late 1980s I’ve coauthored numerous studies of stigma and discrimination against workers with physical disabilities to understand how that discrimination affects outcomes in the labor market. Then in 1999, my own son was diagnosed with schizophrenia, and suddenly I was plunged into this world of mental illness that I really didn’t know much about. His experience made me realize how important employment is for people with mental illness.
Steven: As an epidemiologist, statistician, and computer scientist, my research agenda focuses on how mental health services affect the lives of people with a broad range of psychiatric disorders including nonfatal suicidal behavior and deaths by suicide. In my work with Marjorie, we focused on an understudied population namely, people with SMI who are employed in regular jobs. It was the opportunity to study this hidden population that most excited me about this research.
Why don’t people disclose and what should they know about the protections and laws/policies in place to inform their decision?
Steven: Disclosure is a difficult decision for the worker because on the one hand, it is the means to access job accommodations, but on the other hand, it may subject the worker to stigma and discrimination. For example, to schedule sessions for treatment, employees may need time off from work or other accommodations which may require disclosure of their mental illness to their employer.
In a part of a related study where we listened to workers’ narratives about the decision to disclose, some participants mentioned being harassed after they disclosed – for example, a supervisor trying to get rid of them. Some said that they were afraid of being treated differently after disclosure, such as not being given important projects or not being promoted. Some workers who chose not to disclose their mental illness said that it’s simply private information and not something that people need to know.
Marjorie: The legal protections for workers with mental illness are spelled out in the Americans with Disabilities Act (ADA, 1990) and its Amendments (ADAAA, 2008). Employees and employers should know that workers are not required to disclose a psychiatric disability unless requesting a job accommodation. If a worker does disclose, employers must treat that information as confidential. Additionally, employers are required to provide requested accommodations, unless they can demonstrate that an accommodation imposes “undue hardship” on the firm.
What policies and actions can employers implement to reduce the stigma surrounding mental illness and create a more inclusive environment?
Marjorie: Employers should cultivate a supportive workplace culture. We found that workers were more likely to disclose and had better outcomes when the culture of the workplace was supportive of people with differences, including people with disabilities. The American Psychiatric Association’s antistigma program called ICU (“I See You”) is designed to establish a culture in which all employees recognize that mental illness is an illness and that people with mental illness can be capable and productive employees.
Employers should also establish policies and procedures for responding to disclosure of SMI that are consistent with the ADA, including training of supervisors in the mandates of the law. The Job Accommodation Network can assist employers in supporting and providing reasonable accommodations for workers with all different kinds of disabilities.
Finally, employers should sensitize all employees to respond with compassion to coworkers with mental illness. One of the best ways for individuals to develop compassion and understanding for persons with SMI is to interact with them. The National Alliance for Mental Illness has a program called In Our Own Voice, which provides a personal perspective on mental illness from individuals with lived experience of SMI.
How might your study be relevant to workers with other disabilities or health conditions?
Steven: The results of our study gave us a broad range of insights into how employers can effectively integrate persons with serious mental illness into the workforce. Across all types of disabilities and illnesses, it is important for employers to respond to disclosure with compassion, efforts to reduce stigma, and training for supervisors and coworkers.
Other conditions which elicit relatively intense stigma include epilepsy, AIDS, substance use disorders, and suicidal behavior. The mandates of the ADA and the resources of the Job Accommodation Network are applicable to all types of physical and mental disabilities.
Marjorie: A diagnosis of SMI doesn’t have to mean a loss of hope. Many people with serious mental illness can recover, achieve, and succeed in the competitive workforce.
The study, “Workplace Disclosure of Serious Mental Illness and Gainful Employment: Theory and Evidence,” was published in March 2023 in the Journal of Mental Health Policy and Economics. The authors are Marjorie Baldwin, Allan DeSerpa, and Steven Marcus.
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