The International Journal of Psychosocial Rehabilitation

Disclosure of a Psychiatric Disability in Supported Employment:
An Exploratory Study

Becky R. Banks, M.A., L.S.W.
Research Associate/Coordinator
Center on Community Living and Careers
Indiana Institute on Disability and Community

Indiana University,2853 East 10th Street, Bloomington, Indiana 47408-2696
bebanks@indiana.edu


Jeanne Novak, Ph.D.
Assistant Professor
School of Intervention Services

428 Education Building
Bowling Green State University
Bowling Green, Ohio  43403
jnovak@bgnet.bgsu.edu


David M. Mank, Ph.D.

Director
Indiana Institute on Disability and Community
Indiana University

2853 East 10th Street, Bloomington, Indiana 47408-2696
dmank@indiana.edu


Teresa Grossi, Ph.D.

Center Director
Center on Community Living and Careers
Indiana Institute on Disability and Community
Indiana University

2853 East 10th Street, Bloomington, Indiana 47408-2696
tgrossi@indiana.edu



  Citation:
Banks B.R., Novak J., Mank D.M., & Grossi T (2007) Disclosure of a psychiatric disability in supported
employment: An exploratory study. 
International Journal of Psychosocial Rehabilitation. 11 (1) 69-84.



Abstract
People with psychiatric disabilities entering the workplace and their supported employment providers frequently contemplate whether to disclose the supported employee’s disability and their support needs to employers and workplace personnel.  This study examined the role of disclosing a psychiatric disability and the employment experiences of 162 people participating in ten supported employment programs in the United States.  Results indicate that 82% of the supported employees had their disability disclosed in the workplace; however disclosure was typically made by the employment agency.  The relation between who disclosed the disability, what was disclosed and the effect on employment outcomes (including typical employment experiences, job adjustment and workplace accommodations) are examined.  Practical suggestions are identified for supporting individuals regarding disclosure.  

Keywords:
Psychiatric disabilities, supported employment, disclosure, employment outcomes


Introduction
Individuals with psychiatric disabilities entering the workforce often contemplate whether to disclose their disability to employers or coworkers.  Because mental illness is commonly described as a “hidden” disability, the general public is not likely to notice the disability unless perceptible psychiatric symptoms or difficulties resulting from the disability occur.  For people with mental illness entering the workforce and their employment providers, determining the scope and nature of supports provided by employment specialists at the workplace may depend on a variety of factors, including the supported employee’s choices and comfort level with disclosing their disability at work.  

The Americans with Disabilities Act (ADA) (PL 101-336) prohibits discrimination based on disability, yet individuals with may feel reservations about the ramifications of disclosing their disability to workplace personnel due to a fear of vocational stigma, not being accepted by workplace personnel or being viewed as “different”, inadequate or incompetent.  In a qualitative study, Allen and Carlson (2003) indicated that individuals chose to conceal their disability to preserve self-concept and avoid negative stereotypes.  Because of public perceptions about mental illness, many individuals with psychiatric disabilities express fears of disclosing the disability to prospective or current employers. 

In addition to the dilemma of possible stigma, in order to be eligible for legal protection under the ADA, an individual must disclose his or her disability to the employer and state the need for accommodations.  Drake, Becker, and Bond (2003) note that accommodations for people with psychiatric disabilities rarely require direct expenditures on the part of the employer, rather, the accommodations involve extra supervision, or reallocation of time (such as scheduling adjustments or additional breaks).  In another study of relationships between employers and people with psychiatric disabilities, Cook, Razzano, Straiton & Ross (1994) indicated that when individuals disclosed their mental illness, employers were able to provide additional support in the areas of job training, job performance, and supervision.  However, Granger, Baron and Robinson (1997), found that less than half of the respondents with mental illness referred to the ADA when disclosing their disability to employers.  In a study of disclosure and support provided by psychiatric rehabilitation practitioners in helping supported employees understand how to assert their rights under the ADA, 86% of the participants were unfamiliar with their rights under the ADA and job accommodations, and that they relied on their job coach or job developer to arrange job accommodations (Granger, 2000).  Another qualitative study by Giola and Brekke (2003) involving 20 individuals diagnosed with schizophrenia revealed that only four of the participants had knowledge of ADA accommodations and referred to these when disclosing their disability.  For these individuals, disclosure enabled them to better perform essential functions of their job and access support at the workplace when symptoms arose.  Ellison, M. L., Russinova, Z., MacDonald, K. L., & Lyass, A. (2003) found that over 87% of study participants working in business, technical and educational settings disclosed their psychiatric disability to employers.  The issue of disclosure is not often discussed in the context of multicultural issues (Weston, 2002).  It is possible that patterns of disclosure could be related to diversity issues in relation to social and personal contexts.

Often, employment specialists also struggle with the matter of disclosure.   Without careful consideration, employment specialists may reveal unnecessary information about the individual and his/her mental illness, increasing the supported employee’s issues with stigma.  In contrast, the employment specialist may be too vague in describing the supported employee and the reasons the individual is involved in supported employment services, which may subsequently lead to unanswered questions and potential suspicions on the part of workplace personnel.  Employment specialists need more information about the ramifications of when, how, who and why disclosure is necessary.  This study takes a first step toward addressing these issues.  
 
This study explored the role disclosure of mental illness plays in the employment experiences of people with psychiatric disabilities. Several research questions guided the investigation:
1.    Are there demographic and disability characteristics that make it more likely that a supported employee’s psychiatric disability will be disclosed to workplace personnel?

2.    Under what conditions (when, why, and how) is a psychiatric disability disclosed in the supported employment workplace?

3.    Does a disclosure of disability, or the source of that disclosure, relate to how typical a supported employee’s employment experiences will be in terms of job acquisition and hiring, job features, human resources management processes, and social aspects?

4.    Is disclosure of disability associated with the provision of workplace accommodations and coworker supports at the supported job site?

5.    Is disclosure status related to the overall job adjustment of supported employees with psychiatric disabilities?

A number of hypotheses about the relationship between disclosure and employment features and outcomes were set forth.  It was predicted that disclosure of a mental illness would be associated with lower levels of functioning, a less typical employment situation, and a greater likelihood of workplace accommodation and coworker support.  A non-directional hypothesis was postulated regarding the relationship between overall job adjustment and disclosure status.

Method
This multi-site study utilized a survey design to assess the relation between mental illness disclosure for supported employees and associated employment features and outcomes.  Data for the study included demographic, disability, disclosure, employment and support information for 162 supported employees served by 10 mental health vocational programs across 8 states (CA, IN, KS, NY, OR, PA, RI, VA).  This disclosure study was a supplement to quantitative research on workplace supports and integration outcomes for people with psychiatric disabilities (Banks, Charleston, Grossi & Mank, 2001) which analyzed job performance, psychiatric symptoms, workplace supports and integration outcomes of 243 individuals with psychiatric disabilities.  The workplace supports study indicated that higher levels of social integration correspond with higher wages of supported employees.

Procedures
Administrators of 10 vocational programs for people with mental illness were initially contacted by telephone and invited to participate in the research project.  Programs were selected based on nominations from national experts in the field of psychiatric rehabilitation.  All programs were described as having successful employment outcomes and were considered to be using “natural supports” approaches to employment service delivery.  Natural supports are defined as “any assistance, relationships, or interactions that allow a person to secure or maintain a community job . . . in ways that correspond to the typical work routines and social interactions of other employees” (Rogan, Hagner, and Murphy, 1993).  

Information was provided to agencies about the study purpose, survey content, and data collection procedures.  Agencies were asked to complete survey forms for all supported employees working in community-based jobs.  The program staff person with the most knowledge of each supported employee and his or her job situation was asked to fill out the survey form.  Financial remuneration of $15.00 was offered for each completed survey.

Confidentiality requirements for submitting data were explained prior to data collection.  Reference numbers were assigned to each survey to protect the anonymity of individuals included in the study.  
Administrators of the participating agencies were re-contacted approximately one year later and asked to complete a follow-up data form for each of the 243 supported employees included in the original study.  This one-page supplemental data form consisted of questions about the disclosure of the supported employee’s disability to workplace personnel.  All of the 10 agencies agreed to complete the disclosure supplements.  Supplemental data forms were returned for 162 of the 243 supported employees.  The 33 percent attrition rate is due, in part, to the fact that some staff who had completed the original surveys reported that the supported employees were no longer working or receiving services from the participating agencies.

Participants
The majority of the sample was male (61.7%) and Caucasian (85.8%), and nearly half of the participants (43.2%) were between the ages of 31 and 40.  Greater than half of the sample (58.7%) lived independently while 27 percent resided with parents or other family members and 14 percent lived in a supervised or supported residential setting such as a group home, supervised apartment or supported living setting.

The most prevalent primary disability diagnoses were schizophrenia and other psychotic disorders (47.2%) and affective disorders (36.5%).  The mean Global Assessment of Functioning (GAF) score for participants was 59.42 (SD = 9.3).  GAF is a rating of overall psychological functioning on a scale of 0-100. According to the DSM-IV, a GAF score between 51 and 60 indicates moderate symptoms or moderate difficulty in social or occupational settings (American Psychiatric Association, 1994).  GAF scores were obtained from the participants’ most recent clinical record.  Nearly 20 percent of the sample (n = 32) had GAF scores indicating serious symptoms or impairment in functioning while 40 percent (n = 65) had GAF scores indicating minimal to mild symptoms.  Demographic and disability characteristics of the subset of 162 persons for whom disclosure supplements were returned were similar to those of the original sample of 243. 

Instruments
Natural Supports Survey.  The natural supports survey for employees with mental illness was adapted from an earlier 62-item survey designed for participants with developmental disabilities.  A detailed description of the design and development of this previous survey instrument is provided in Mank, Cioffi, and Yovanoff (1997).  A panel of experts was consulted to help tailor the survey instrument for use with employees with psychiatric disabilities.  Modifications to the original survey included changes to items about disability diagnosis and the addition of items about level of functioning, workplace accommodations, level of indirect employment support, service delivery model type, and community connections and supports.  The natural supports survey for employees with mental illness was pilot tested with four community mental health agencies to assess item content, scope, and clarity.  The final version of the survey included 85 items covering five general areas: demographics, disability information, employment features and outcomes, company personnel, and community connections and supports.  Further description of survey content is provided in Banks et. al., (2001).

Disclosure Supplement.  The Disclosure Supplement was developed as a follow-up questionnaire to the Natural Supports Survey.  The primary purpose of the supplement was to determine which supported employment participants from the original sample disclosed their disability to workplace personnel.  The 5-item supplement also requested information about the circumstances surrounding disclosure.  Response categories for each question were developed based on a review of the relevant literature and suggestions from the expert panel.

Measures
Of particular interest in the present study were variables related to (a) disability disclosure, (b) level of functioning, (c) typicalness of employment features, (d) workplace accommodations and coworker support, and (e) overall job adjustment.

Disability disclosure.  Disability disclosure status was measured as a dichotomous variable (disclosure/no disclosure).  For supported employees whose disability was disclosed to workplace personnel, respondents were asked to indicate when, why, and how the disclosure was made.  In addition to the predetermined response categories for each question, an “other” category was included to allow for additional responses.

Level of functioning.  Level of functioning was assessed in two ways: Global Assessment of Functioning (GAF) scores and a measure of severity of psychiatric symptoms at the worksite.  GAF scores were gleaned from the supported employee’s most recent clinical record.  Severity of psychiatric symptoms at the worksite was rated on a 4-point scale (none, mild, moderate, severe).  

Typicalness of Employment Features.  Respondents were asked how “typical” the employment experiences of the person with a disability were compared to those of employees without disabilities in the same work setting.  A 7-point scale (1 = not typical, 7 = quite typical) was used to rate the typicalness of 24 features of employment.  For example, respondents were asked to rate “how typical” the individual’s job application process was compared to that of other job applicants.  If the individual with a disability was required to submit the same formal job application that other prospective employees are required to submit, then this would be quite typical.  If, however, other prospective employees are required to fill out a formal job application while the person with a disability was not required to do so, then the application process would be considered atypical.  The 24 typicalness items were organized into four item clusters: job acquisition and hiring (e.g., recruitment, job application, interviewing), job features (e.g., work schedule, hourly pay, break times and location), human resources management processes (e.g., initial job training, supervision, opportunities for promotion), and social aspects (e.g., participation in non-work and at-work social activities).  The scale was not designed as a value judgment but, rather, a comparison between the typical experiences of employees with and without disabilities.

Factor analysis was used to analyze the correlational structure of the typicalness items.  This was done in order to reduce the total number of variables required to describe the underlying dimensions of typicalness (Tabachnick & Fidell, 1996).  A maximum likelihood solution with varimax rotation indicated the presence of four distinct factors with eigenvalues greater than 1.0, capturing 71 percent of the total variance in scores.  The factor solution was somewhat satisfactory, although a simple structure was not attained as some variables loaded onto more than one factor.  Criterion for loading was .45. One item (i.e., transportation) was dropped due failure to load on a factor.  The factor structure closely mirrored the section breaks in the survey itself.  A principal components analysis yielded similar results.

Following factor analysis, Cronbach’s alpha coefficients were calculated for each of the four resultant subscales.  Coefficient alphas for the subscales ranged from .86 to .95 and suggested a high degree of internal consistency.  One item (i.e., amount of task-related interaction with coworkers) was dropped from the Social Aspect subscale because it did not add to internal consistency alpha.  Table 1 presents item loadings of the rotated 4-factor solution and internal consistency coefficients for each subscale.

Table 1  Factorial Structure of Typicalness of Employment Items

 

Items

Factor

Job Acquisition

Job Features

Management Processes

Social Aspects

 

Interviewing

.89

.12

.22

.15

Job application

.76

.24

.12

.04

Recruiting

.73

.16

.34

.24

Role in choosing job

.64

.19

.44

.30

 

 

 

 

 

Company benefits

.10

.83

.08

.20

Break location and schedule

.20

.72

.19

.22

Hourly pay

.14

.58

.41

.11

Others do similar work

.21

.55

.35

.14

Opportunity for job variety

.29

.49

.41

.41

Work schedule

.16

.45

.41

.27

 

 

 

 

 

Disciplinary process

.24

.27

.81

.26

Layoff conditions

.23

.34

.74

.25

Support in time of crisis

.23

.10

.71

.36

Supervision

.27

.20

.70

.25

Work rules and expectations

.24

.30

.66

.39

Performance evaluation

.26

.45

.66

.14

Orientation or induction

.39

.26

.57

.33

Opportunity for promotions

.26

.44

.57

.31

Initial job training

.45

.16

.48

.37

 

 

 

 

 

Participation in at-work social activities

.17

.23

.16

.94

Participation in non-work social activities

.11

.26

.32

.79

Behaves within accepted social norms

.19

.07

.42

.58

 

 

 

 

 

Cronbach’s coefficient alpha

.90

.86

.95

.89

 

Factor scores were computed using items identified with factor analysis and Cronbach’s alpha coefficients.  Participant responses to items comprising each typicalness factor were averaged to compute four separate factor scores for each participant.  Calculating an average rather than a sum of item responses maintained the 1 (not typical) to 7 (quite typical) scale, simplifies interpretation of factor scores.        

Workplace accommodations and coworker support.  Respondents were asked if workplace accommodations were in place for supported employees.  They were also asked to identify the specific accommodations by using a checklist.  Examples of accommodations include job restructuring, flex time, self-management tools, physical changes to the immediate work environment, and additional supervisor feedback.  Coworker support was operationalized by two questions: (a) was training and support provided to company personnel? (yes/no), and (b) did company personnel provide support to the employee with a disability? (yes/no).  Examples of support provided to company personnel include general disability awareness training or training specific to the support needs of the employee with a disability.  Examples of support provided by company personnel include helping the supported employee learn new tasks, meet productivity standards, maintain socially appropriate behavior, participate in social activities at work, or manage job-related stressors.

Overall job adjustment.  Job adjustment was defined as the extent to which the supported employee has adjusted to the job following initial training.  Six items measuring job adjustment (e.g., work rate is comparable, relationships with coworkers are positive, employee seems satisfied with job) were scored on a scale of 1 (a little) to 7 (a great deal).  Responses to items were averaged to compute a composite score on overall job adjustment for each participant (Cronbach’s alpha = .91).

Data Analysis
Two sets of analyses were performed to investigate the disclosure of psychiatric disability and associated employment features and outcomes.  In the first set of analyses, univariate tests of group differences were used to examine differences between the characteristics of supported employees whose disabilities were disclosed and characteristics of supported employees whose disabilities were not disclosed.  Following a significant 2, standardized residuals were examined to determine which cells contributed most to the significant 2 value. Descriptive statistics regarding how, when, and why a disability were disclosed were also calculated.

The second set of analyses examined whether disability disclosure variables were associated with differential employment features and outcomes.  This set of analyses was performed in three steps.  First, t-tests were conducted to study the relation between disclosure variables (disclosure status and disclosure source) and typicalness of employment variables (job acquisition, job features, management processes, and social aspects). Second, multiple response crosstabs were examined to determine whether company personnel variables differed by disclosure status.  Third, a univariate analysis of variance was conducted to determine if overall job adjustment was related to disclosure status.  With regard to ethnic diversity, there was a small number of non-caucasian participants (N=17), which is less than 15% of the sample of participants.

Results

Initial findings of the Natural Supports Study focusing on the relationships between mental health diagnosis, workplace supports, and supported employment outcomes have been reported previously by Banks, Charleston, Grossi, and Mank (2001).  The results reported here examine disability disclosure in the supported employment workplace and its relation to employment features and outcomes.  

Disability Disclosure
Which supported employees disclosed?  A disclosure of disability was made for 82 percent of the supported employees in the present study.  Employees who disclosed differed from those who did not disclose on a number of demographic and disability characteristics (see Table 2).  Employees were significantly less likely to have disclosed their disability if they were women, had a mood disorder, or displayed no psychiatric symptoms at work.  Employees who disclosed did not differ significantly from those who did not disclose in terms of ethnicity, age, living arrangements, or Global Assessment of Functioning (GAF) score.

Table 2  Sample Characteristics


DISCLOSUREa

(N=133)

NO DISCLOSURE

(N=29)

 

 

Variable

n

%

n

%

Statistic (df)

p-value

Gender

        Female

        Male

 

 

45

88

 

 

33.8%

66.2%

 

17

12

 

58.6%

41.4%

c2 (1) = 6.19

.013

Ethnicity

         Caucasian

         Other

 

 

116

17

 

87.2%

12.8%

 

 

23

6

 

79.3%

20.7%

Fisher’s exact p = .255

ns

Age

         18-30

         31-40

         >40

 

 

27

54

52

 

20.3%

40.6%

39.1%

 

 

3

16

10

 

10.3%

55.2%

34.5%

c2 (2) = 2.58

ns

Living Arrangement

         Parents/family

         Independent

         Supervised/supported

        

 

37

70

19

 

29.4%

55.6%

15.1%

 

5

21

3

 

17.2%

72.4%

10.3%

c2 (2) = 2.79

ns

Primary Diagnosis

         Schizophrenia

         Mood Disorder

         Other

 

 

64

41

25

 

 

49.2%

31.5%

19.2%

 

11

17

1

 

37.9%

58.6%

 3.4%

c2 (2) = 9.02

.011

Severity of Symptoms at Work

          None

          Mild

          Moderate/Severe

 

 

15

86

32

 

11.3%

64.7%

24.1%

 

8

13

8

 

27.6%

44.8%

27.6%

c2 (2) = 6.11

.047

Global Assessment of Functioning (0-100)

M(SD) = 59.41(9.6)

M(SD) = 59.48(8.0)

t (160) = .04

ns

aDue to missing data, sample size ranged from 126 to 133 for the Disclosure group.


What was the context of disability disclosure?  Table 3 displays the how, when, and why of disability disclosure.  An individual’s disability was most often disclosed to workplace personnel by supported employee staff.  In nearly half the cases of disclosure, the employer was already familiar with the nature of the services provided by the supported employment agency. For nearly three quarters of those whose disability was disclosed, the disclosure was first made during the job development phase. The top three reasons cited for disclosure of disability were to (a) enlist or facilitate the support of workplace personnel, (b) negotiate accommodations, or (c) address symptoms or crisis issues.

Table 3  <>Circumstances Surrounding Disclosure of Mental Illness to Workplace Personnel (N = 133) 

Contextual Variable

n

%

 

How was the disclosure made?a

       Supported employment staff disclosed to workplace personnel

       Employer already familiar with nature of services provided by 

            supported employment agency

       Supported employee disclosed to employer

 

 

 

72

 

60

 

 

 

39

 

 

 

54.1

 

45.1

 

 

 

29.3

 

When was disclosure first made? (n = 127)

       During job development

       During job acquisition and hiring

       During employee orientation and training

       During ongoing support to the employee

       Other

 

 

 

91

 

16

 

2

 

10

 

8

 

 

 

71.7

 

12.6

 

1.6

 

7.9

 

6.3

 

What was the purpose of disclosure?b

       Enlist or facilitate support of workplace personnel

       Negotiate accommodations

       Address symptoms or crisis issues

       Take advantage of tax credits

       Respond to request for information from Social Security

       Invoke ADA protections

       Other

 

 

 

106

 

91

 

82

 

19

 

15

 

8

 

10

 

 

 

79.7

 

68.4

 

61.7

 

14.3

 

11.3

 

6

 

7.5

a30% of respondents endorsed more than one statement.  b74% of respondents endorsed more than one statement.

Employment Features and Outcomes

Typicalness of employment features.  The hypothesis that disclosure of a mental illness would be associated with a less typical employment situation was only partially supported. Univariate tests were conducted to compare the group that did not disclose to the group that disclosed on the four typicalness subscales. Cell size for the group that disclosed (n= 133) was substantially greater than the cell size for the group that did not disclose (n = 29). However, Levene’s test for equality of variances was not significant for any of the four typicalness subscales. The mean typicalness score for the group that did not disclose was significantly higher than the mean typicalness score for the group that disclosed on the job acquisition and management processes subscales.  In other words, those who did not disclose acquired their jobs in a more typical fashion and were managed in a more typical manner.  There were no mean differences between groups on the Job Features and Social Aspects subscales. Similar results were obtained when severity of symptoms was entered into the model as the covariate. The covariate analyses enabled us to determine whether any significant relations were found after the effects of severity of symptoms were taken into account.

Table 4

Means, Standard Deviations, and t-test Results for Effects of Disclosure on Four Typicalness of Employment Features

isclosure

 

No Disclosure

 

t-test

 

Typicalness Subscale

 

M

 

 

SD

 

 

M

 

SD

 

 

df

 

t

partial

h2

 

Job Acquisition

 

 

5.49

 

1.37

 

 

6.21

 

1.42

 

 

155

 

2.48*

 

.04

Job Features

 

6.02

1.02

 

6.24

1.00

 

159

1.08

.01

Management Processes

 

5.97

1.04

 

6.46

.93

 

159

2.31*

.03

Social Aspects

5.20

1.46

 

5.21

1.82

 

133

.024

.00

 

 

 

 

 

 

 

 

 

 

Note.  Partial h2 = effect size.

*p < .05. 

A second set of analyses was performed to determine if the source of disability disclosure (individual v. agency staff) related to the typicalness of the employment situation.  Individuals who self-disclosed had more typical job acquisition experiences (M = 6.2, SD = 1.30) than individuals whose disabilities were disclosed by agency staff (M = 5.24, SD = 1.32), t (109) = 3.42, p = 001.  No significant differences were found for job features, management processes, or social aspects subscales.

Workplace accommodations and coworker support.  Multiple response crosstabs revealed that supported employees who disclosed their disability were significantly more likely to have an accommodation in place at the workplace than supported employees who did not disclose their disability, 2 (1) = 4.14, p = .042.  Fifty-two percent (n=133) of those who disclosed had workplace accommodations while only 31 percent (n= 29) of those who did not disclose had workplace accommodations.  Company personnel were more likely to have received training if the supported employee’s disability was disclosed (63%) than if it was not disclosed (31%).  Company personnel were more likely to provide support to employees who disclosed their disability (78%) than to employees who did not disclose their disability (45%).     Overall job adjustment.  The t-test results indicate that, although the mean score for the nondisclosure group (M = 5.9, SD = 1.51) was higher than the mean score for the disclosure group (M = 5.62, SD = 1.17), overall job adjustment was not significantly related to disability disclosure status, t = 1.092 (159), p = .277.  This finding held even after severity of symptoms was entered as a covariate.

Discussion
This study provides an analysis of disclosure of the psychiatric disability in the workplace and associated outcomes of 162 individuals with psychiatric disabilities in supported employment jobs.  The finding that 82 percent of study participants had their disabilities disclosed to workplace personnel is in line with other studies of disclosure among individuals with psychiatric disabilities who use vocational rehabilitation services or job coaches (e.g., Granger, 2000).  This high rate of disclosure is not surprising given the fact that often times the employment service provider will contact an employer about a job prior to the individual with a disability ever submitting an application for employment.  For almost half the participants in this study de facto disclosure was made because the employer was familiar with the nature of the services provided by the supported employment agency from which the participant received services.  In these instances, the applicants or employees themselves had little role in disclosing their disability once they chose to receive supported employment services.  Clearly individuals with psychiatric disabilities who choose to receive supported employment services have unique considerations with respect to disclosure.

In this study we found differences in whether an individual had their psychiatric disability disclosed based on gender, type of psychiatric disability and the presence of symptoms at work.  We found that in most situations, the disability was disclosed to workplace personnel, and disclosure of the disability primarily occurred to facilitate accommodations and to provide training and information to the workplace personnel to in turn support the individual. 

We hypothesized that disclosure of the mental illness would be associated with lower global assessment of functioning, less typical employment conditions, presence of accommodations at the workplace and increased support by workplace personnel.  These data indicated that Global Assessment of Functioning had no relationship to disclosure of the mental illness.  Therefore, individuals with high or low GAF scores had their disability disclosed.  Regarding typical employment features, those individuals whose disability was not disclosed to the employer had more typical experiences in acquiring the job, however, results indicate individuals have more typical experiences in job acquisition and hiring if they disclosed the disability themselves rather than disclosure by their employment consultant.  From the results of this study, it appears that whether or not an individual disclosed had no bearing on how well the individual adjusted to the job.  Individuals who did have their disability disclosed had accommodations arranged at the workplace.  Additionally, company personnel received training (such as disability awareness training or other instructions specific to the needs of the individual in the supported employment job).  Company personnel in turn supported the individual whose disability was disclosed in their jobs.

These findings indicate that supported employees and the employment specialists should be sensitive to who discloses information about the supported employee’s psychiatric disability, how this information is relayed to the workplace personnel, when to share the information, what information to disclose, and the primary purpose for disclosing information about the mental illness.  It is likely necessary for employment specialists and individual supported employees to consider these factors and make sound decisions based on the work culture and individual’s preferences when discussing the type and amount of support needed for the individual to have successful outcomes in employment.  While disclosure is a sensitive issue that should be discussed with the individual, it may also involve personal understanding of the implications for the supported employee.  Employment service providers should explore the following practical suggestions when arranging workplace supports with individuals diagnosed with psychiatric disabilities:
•    Help the individual understand his/her rights through the ADA, and the reasonable accommodations allowed for individuals with psychiatric disabilities.  Explore any accommodations that may be needed on the job with the supported employee and develop a plan to discuss with the employer any needed accommodations and supports.

•    Discuss with the supported employee his/her comfort level and preferences with disclosing the disability at the start of employment services. Realize in some circumstances, disclosure may be necessary in facilitating workplace supports and negotiating accommodations, especially if individuals may experience psychiatric symptoms at work.  In other instances, individuals who may not exhibit symptoms that interfere with job performance may not find it necessary to disclose their disability.

•    Prepare the individual in answering questions about his/her disability.  The individual’s choice of disclosing the disability may involve examining personal attitudes and beliefs, and coming to terms with the disability and its chronicity, yet still viewing oneself as a competent, contributing member of the workplace.  It is best for the individual to have a comfort level with his/her disability and recognize that the psychiatric disability label is NOT the individual.  Rather, the individual may have unique characteristics that require support and accommodations.  Help the individual learn to focus on strengths rather than limitations when discussing his/her disability.

•    Plan the type and amount of employment support and intervention that is most effective and least intrusive for the supported employee (on-site support, off-site, or support to workplace personnel).
 
•    Examine the workplace culture to understand if it is a work environment that is supportive of diversity, and supports all employees and their various differences. 

•    If disclosure results from the role of the employment consultant’s involvement, use “common language” terms to describe the individual’s basic support needs.  Never describe the individual in clinical or medical terms, or in ways that draw attention to their limitations.  Rather, accentuate the individual’s strengths, and his/her skills. 

•    Develop specific plans for supports from workplace personnel.  Identify with the supported employee what kind of support is needed, when the support is needed, who at the workplace can be a mentor, and what issues may trigger stressors (for example, changes to the work environment or increase in productivity demands) that may require support from coworkers and/or the employment specialist.

•    Realize that employment specialists can be ambassadors for the individuals they serve through effective communication to educate and alleviate concerns of employers who hire people with disabilities. 

Whenever possible, avoid professional interference at the workplace.  Use discretion and confidentiality.
Using these suggestions can help the employment specialist and the supported employee adequately discuss and agree upon the decisions around disclosure.  Through incorporating these strategies, both the employment specialist and the supported employee can be best prepared to negotiate accommodations and access workplace supports.    

Limitations
There are several limitations to this study.  These data with a sample of 162 individuals provide only a synopsis of disclosure and associated outcomes.  The sample was not randomly chosen and may not be representative of all people with psychiatric disabilities in supported employment.  In most situations, the employment provider provided the data, and no inter-rater reliability was used for the natural supports survey or the disclosure supplement.  Therefore, some bias may be suspected where employment staff members provided the data.  To control in part for this bias in the data, test–retest information was collected on 15% of the natural supports survey sample. In addition, in this study, disclosure results did not relate to age, ethnicity and living arrangements. A larger sample may discover relationships in such data regarding these variables. Future research is needed that investigates the relationship of employment, disability, age, and multicultural issues.

Implications
This study poses several implications for further research.  Further research is needed about the effects of the employment specialist in supporting individuals in the hiring, recruitment, orientation, and training process.  How does disclosure affect integration outcomes?  Are individuals with psychiatric disabilities more or less integrated socially with coworkers if they disclose their psychiatric diagnoses?  Additionally, a better understanding is needed of how individuals adjust to their jobs in lieu of the disability.  What is the effect of the employment specialist support on job adjustment?  Issues of supported employment, and outcomes are in need of studies related to gender, ethnicity, and multicultural issues. These issues have been rarely studied (e.g., Olson, Cioffi, Yovanoff, & Mank, 2001).  In addition, the Association for Business Communication (2005) and Hawley-McWhirter (1999) note the lack of information regarding disability, employment, and multicultural issues.
The above implications are critical in understanding workplace supports and integration.  Further research is needed to understand strategies to support individuals with psychiatric disabilities in typical and natural ways in their workplaces and communities.


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