Work 30 (2008) 311–316 IOS Press

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Disclosure of mental health
Kathy Hatchard∗
Hatchard Rehabilitation, Penticton, British Columbia, Canada

Abstract. As today’s workplaces strive toward a climate of inclusiveness for persons with disabilities, much work remains for employers in developing a process to achieve this ideal. While survivors of mental illness are encouraged to disclose related concerns to their employer, such sharing of personal information remains daunting. Similarly, employers attempting to assist the process are often awed by the extent of collaborations involved in integrating employees with mental health issues back to work as well as concern about compliance with human rights legislation. Needed accommodations in terms of approach to the work itself are often simple; however substantiating the need for adjustments is more complex. This case study introduces a model to support the development of shared goals and shared understandings for return to work (RTW) among workers with mental health concerns, employers, co-workers and therapists. The model of occupational competence is used as a basis to guide dialogue, identify challenges and generate solutions that take into consideration a worker’s preferences, sensitivities, culture and capacities in relationship to the occupational demands in a given workplace environment. A case study is used to demonstrate the potential utility of the model in assisting stakeholders to strengthen collaborations and partnering to achieve a shared understanding of worker and workplace needs.

1. Introduction Disclosure of mental health issues in the workplace is influenced by multiple factors including intrinsic and extrinsic issues. While there is legislation that protects a worker’s right not to disclose health information in the workplace, some workers may want to share aspects of their challenges. Literature offering guidance to workers regarding disclosure in the workplace is geared to assist the worker and to inform his actions in disclosing. However, this information portrays a complex picture that requires considerable judgment in its application to real life situations. Often, the literature divides recommendations for action about when and how to disclose information into distinct time periods i.e. when writing a resume, before a job interview, during the interview, prior to starting a job and while underway in the workplace [2]. This linear approach as far as when to share pertinent information about the consequences and needs of working with a mental health problem is not adequate for workers. The remainder of the lit∗ Address

erature available to workers is intended for particular populations. For example, individuals with a visible disability or those working as part of a supported work program where some level of disability is inherent in the participation. Guides for employers in addressing disclosure by their prospective and current employees [1] underscore the need for ongoing learning on the part of the employer. Employers require training about awareness of attitudes, legislation, disabilities and issues impacting disclosure and accommodation. There is a need to explore the potential of a framework or model to assist both the worker and the employer in developing a shared vision. Subsequent identification of goals relating to return to work factors and required planning for strategies and workplace accommodations can then follow. A model worthy of consideration in bringing cohesiveness to these challenges is the occupation competence model.

2. Background on the occupation competence model The occupation competence model [11] was introduced at a time when Canadian occupational therapists were seeking clarification of their unique contributions

for correspondence: K. Hatchard, 405 Valiant Drive, Penicton, BC, Canada V2A 8Y1. Tel.: +1 250 490 9162; E-mail: hatchardspec@telus.net.

1051-9815/08/$17.00  2008 – IOS Press and the authors. All rights reserved

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to rehabilitation. The author saw a need for occupational therapists to ‘name and frame’ the language of their role to provide clarity. In doing so, however, the author did not envision the profession as working in isolation but noted the importance of utilizing terms having a shared meaning by many disciplines. For example, the chosen domains of the ‘individual’ dimension of the model, i.e. cognitive, affective and physical, were drawn from the field of educational psychology. The dimensions of ‘environment’ and ‘occupation’ rounded out this three dimensional perspective. In 2002, Shaw and Polatajko [15] identified the need for a model to address the specific challenge of analyzing factors relating to the process of return to work (RTW) for disabled workers. They selected the occupation competence model [11] to build from, based on its ability to frame in components of an occupational perspective, its visual demonstration of the multidimensional interaction of factors and its illustration of the potential for variation in the combination of factors that may impact upon work outcomes. Seemingly complex, the model actually offered a tool to give order to return to work scenarios, through the visualization of a familiar Rubik’s cube. From this starting point, the authors expanded upon the three dimensions to reflect common factors cited in studies of return to work. These factors were then placed within the three dimensions of the occupation competence model. Key factors identified in the person (worker) dimension naturally included physical and cognitive domains as well as affective aspects of the individual such as motivation, coping skills, job satisfaction and commitment. Key factors identified in the occupation (work) dimension included the nature of the work, level of autonomy, ability to self-pace etc. The environment dimension was considered in two realms: the macro environment and the micro environment. The macro environment included factors outside the work environment such as the unemployment rate, disability incentives, family living arrangements, etc. The microenvironment included factors such as: position status, union status, peer relations, supervisory relations and the availability of light work. In 2004, Drummond and Hatchard applied the model to guide the development of a case management process for return to work when working with employers [4]. The model offered a structure for identifying the complex needs and challenges of individuals and helped to guide the actions employers need to take in supporting optimal return to work. The authors postulated that the common goal of all stakeholders involved in a return to

work process was the improving occupational competence of the worker. The model was used to encourage each stakeholder to visualize the worker engaged competently. This common vision provided the anchor for collaborative visioning by the stakeholder mix. Each stakeholder considers both strengths and barriers related to the worker, the work and the work environment in formulating his perspective in supporting progress toward occupational competence. A simplified graphic that depicts this process is presented below. The diagram breaks down the three axes including the worker, the work and the worker’s environment. It then illustrates both the complexity and the dynamic nature of the interactions possible in the analysis of occupational competence. The establishment of shared understandings will be enhanced through the worker’s disclosure of specific functional difficulties. Regardless of the level of disclosure, the model encourages the respectful development of perspective and collaborative problem solving by all of the stakeholders. Even when disclosure is declined, the model offers a visual tool for stakeholders to assemble a vision of return to work options based on known factors relating to the worker, the work and the worker’s environments. In this way, information required from the employee or his representative can be requested in a respectful and concise manner. This is particularly important when dealing with mental health return to work plans. RTW is complex given that the onset has often been insidious, multifactorial and usually not attributable to an isolated medical issue. Potential alienation from the workplace compounds the issue. Intervention, therefore, needs to engage the workers at their unique level of recovery and circumstance. 3. Case study The following case study draws upon the lived experiences of a therapist and a client in managing disclosure about mental health challenges in a workplace. The case is presented as the experience transpired, using short vignettes followed by an interpretation of the experience and interactions of worker – employer, worker – co-workers, employer – co-workers and worker – occupational therapist. This case study also draws attention to the potential of the occupation competence model that may be of assistance in helping workers and employers in handling the disclosure of mental health challenges in the workplace. Pseudonyms are used to refer to the worker, the workplace and the employer to respect the confidentiality of the stakeholders in this process.

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Fig. 1. A process for establishing a shared understanding of challenges and strategies for return to work.

3.1. Joan – Considering the need for disclosure Joan is a forty-eight year old investment services representative. She is divorced and lives alone. Joan has been employed at a unionized bank in a small town for the past eight years. Prior to this, she had always worked in banking and has an excellent work record marred only by frequent absences due to stress related illness. Four months ago, Joan experienced a period of mania and was diagnosed with bipolar mood disorder. Previously misdiagnosed with a myriad of related conditions, Joan had never had the opportunity to take a firm approach to managing her mood disorder until now. During her time off work, she was often seen in town by her co-workers as she worked painstakingly toward resuming her usual activities. Through the grapevine, she was aware that rumours were spreading at the bank about her apparent wellness and continued time away from her job. Joan discussed her concerns with her occupational therapist, resulting in a dialogue around the complexities of disclosure. This scenario depicts a worker with much strength, including maturity, self-awareness and motivation to return to work. The work of an investment representative is fast paced and highly detailed, conducted in a workplace with multiple stimuli including the relentless scrutiny of the customer himself. The social nature of the micro-environment of the workplace is both potentially supportive and potentially intrusive. The worker’s dialogue with the occupational therapist regarding concerns in relation to disclosure of her illness is key to engaging the complex collaborative process required for a successful outcome. This supportive di-

alogue underscored the widespread incidence of issues of disclosure in today’s workplaces thus engaging Joan in the process of exploration. All stakeholders need to be aware of their potential role in assisting to engage the process of disclosure, depending on the interplay of worker, work and work environment factors at the time. 3.2. Taking steps toward disclosure Encouraged by her growing awareness that she was not alone in feeling somewhat daunted by the pathway leading back to work, Joan sought the advice of the bank’s human resources officer. Joan’s many years of living with a mental health challenge had lowered her tolerance for ignorance around the realities of recovery in these situations. Financially, she could not afford to leave her position and start over, even if there were any opportunities in the small town. The human resources representative was non-judgmental and straightforward as Joan considered her options on what to say to all involved. Given the new diagnosis and significant changes to lifestyle balance needed, Joan felt empowered, yet hesitant, requiring time to deliberate regarding how to proceed. She elected to disclose her diagnosis to her employer. She decided her employer’s awareness of her health challenges and new routines was essential to maintain wellness during the transition back to work and beyond due to the high paced nature of the work and the ongoing high level of stimulation. She considered the stress associated with ongoing misconceptions of herself as a worker and elected to partially disclose her health challenges to her co-workers.

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Despite her efforts, she wondered if she would ever find acceptance back at work. The worker demonstrates an awareness of her vulnerable stage of recovery, yet is also empowered by a growing awareness of rights and options regarding disclosure. She considers the importance of understanding on the part of her coworkers, and the need for their awareness of the efforts involved in regaining her health and ability to work. Microenvironment (workplace) factors such as the presence of supportive coworkers and the lack of availability of lighter jobs impact planning for return to work. The limitations of alternate work in the macroenviroment, a small town in this situation, are another key consideration. As the interplay among worker, work and environmental factors is considered, the need for a synthesis of decision-making regarding disclosure on many levels becomes clear. In their recent study of workplace disclosure among professionals and managers with psychiatric conditions, Ellison et al. [5] found that disclosure is not an all or nothing phenomenon. In addition, factors such as “confidence in the job, capacity to regulate one’s condition on the job, having learned how to manage one’s illness, knowledge of the ADA (rights) and feeling socially connected” p. 12 had significant impact on the individual’s decision making. 3.3. Gaining co-worker support and understanding At a staff meeting prior to Joan’s return to work, the human resources representative took some time to discuss the prevalence of depression and to do some general teaching about wellness strategies with the staff. Joan was not in attendance by choice. Several staff members identified direct and indirect experiences with mood disorders. Following Joan’s wishes, the representative then explained that these were some of the challenges currently facing their co-worker. Later, Joan was reassured by reports of the positive tone of the session. The worker’s courage in initiating actions that will allow her to function in her chosen workplace is admirable. However, the work environment has the power to make or break the outcome no matter how clearly the issues are stated. The power of a progressive workplace environment that seeks to collaborate with workers and co-workers toward managing mental health issues in the workplace is demonstrated. Research also suggests that high levels of communication are required to support successful return to work outcomes [6]. With mental health claims now the number one reason for disability claims in the developed world [17], such responses are deemed necessary for a business’s fiscal survival.

3.4. A plan for handling ongoing challenges in the workplace The challenges were not yet over. During her time off work, Joan was able to identify some longstanding challenges. Lacking clear diagnostics, she had never fully understood nor felt empowered to disclose the barriers that previously affected her. A stimulating work environment with rigidly structured break times hampered both her endurance and concentration, often contributing to extreme fatigue by the end of the day. When she needed a break, she needed a break, but this was frowned upon in the bank setting even though her current role did not impact others’ schedules. In discussing these challenges with her occupational therapist, she felt petty, always having been a team player in the past. When her concerns were framed in as common to the illness vs. personal weakness, she was empowered to disclose this to human resources. A request for accommodation in terms of a flexible break schedule was presented to the employer. The employer agreed to this trial. Bolstered by this backing, Joan was able to assertively respond to the inevitable questions from her co-workers regarding her flexible breaks. The worker’s progress following diagnostic clarification and subsequent personal reflection propels a growing awareness of the impact of stressors on both work performance and overall wellness. In turn, selfawareness leads to a growing self-efficacy. Working with the employer to disclose the challenges of functional problems that arise in the workplace that can impact upon work performance also helped increase the awareness of barriers inherent in the workplace that make it difficult for a person with a mental illness to work competently. Increased communication assisted in overcoming barriers such as a rigid work schedule and coworker misconceptions. When underway in the workplace, development of a personal strategy for disclosure appears a positive attribute. Ellison et al. [5] describe positive, but not clearly predictable outcomes regarding disclosure patterns of survivors in the workplace, indicating the very individual and personal nature of this challenge. Joan’s request for accommodation in terms of pacing her work/break schedule, while seemingly a small request, is often the single most important accommodation [17] for workers with mental health issues. A mindful approach such as this is cited as key in promoting ‘best fit’ in terms of activity selection in individuals with bipolar mood disorder [7]. The current literature is rich with commentary regarding the nature of environments

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required to foster the needed relationships to support such collaborations. Kirsh [9] examined the desirable qualities of workplace culture and climate and the interplay with person-environment fit. Secker and Membrey [14] also report on the direct relationship between a supportive and educated workplace on the consumer’s performance at work. 3.5. Taking steps to manage work-life balance Still, the challenges of maintaining a stable mood through the transition back to work and beyond were daunting. Joan recognized the need to maximize her skills in maintaining her health. Her occupational therapist recommended taking the time to integrate her new learning regarding mindfulness in daily living. The concepts of pacing activity, attention to relationships and boundaries and proactiveness in stress management strategies, while logical, would require some effort to integrate. Joan was supported by her employer to attend eight sessions of a weekly education class. Attendance during the workday was initially questioned by a few curious co-workers, but Joan’s growing assertiveness and sense of support from her employer enabled her to proceed with her plan for continued recovery. At this stage, the worker shows an awareness of the ongoing nature of defining and expressing her needs. The demands of the work itself are high and dictate the need for the worker’s further education and practice to ensure integration of needed health management concepts. The availability of the educational group resource within the macroenvironment is a strength. The worker’s disclosure of needs is becoming more focused and succinct as the specific need for action is guided by the analysis of all factors. The resulting accommodation is approval for the education by the employer. The co-workers are able to support the plan through the specific level of disclosure guided by the worker. Jacobson and Greenley [8] described recovery as referring both to internal conditions experienced by persons who describe themselves as being in recovery and external conditions that facilitate recovery. Externally, they described the importance of a “positive culture of healing. . . applied to a human services organization. . . an environment characterized by tolerance, listening, empathy, compassion, respect, safety, trust, diversity, and cultural competence.” p. 484. Such affirming environments [12] make it possible for consumers to begin to engage in the work of recovery and to be able to voice their needs in the context of the stage of their personal

journey. Progressing forward in recovery is intertwined with the enabling of self-direction. Shaw [16] suggested that newer expectations for consumers of rehabilitation services include having greater control over managing the steps in the rehabilitation or care processes. While, the optimal participation of consumers in guiding their own rehabilitation is receiving much attention [10,16], the required skills are not clearly defined. The individual’s ability to disclose issues of concern to key supports on his team would appear to be key in driving a self-directed rehabilitation process involving collaborative partnerships. Rebeiro [13] examined the recovery paradigm in mental health services as a point of convergence of vision. Highlighting the model as a value system that supports “right to self-determination, recognizes the critical importance of social support to an individual’s recovery, and stresses the importance of process and the continuum nature of recovery over time” p.98. However, it is very difficult for any stakeholder to assist the worker in question if the worker does not feel empowered to selectively disclose their functional challenges.

4. Discussion Drawing upon the occupation competence model and engaging in a process to establish a shared understanding as proposed in Fig. 1 can provide a frame of reference for all stakeholders to collaboratively understand and develop solid return to work plans. This process invites knowledge sharing and exchange as well as consideration of the interrelated variables impacting the worker, the work and the environments of the worker. All players are challenged to participate within their roles in the dynamic step-wise planning that naturally stems from defining barriers and strengths in this three dimensional manner. Needed accommodations are highlighted and more likely to be valued at all levels in spite of their seeming simplicity. Understanding of the complex nature of disclosure and its variations from each stakeholder viewpoint is invited. Above all, this multidimensional approach values the worker as a whole person, fosters his self-awareness and provides a vehicle for the continued journey that is recovery. A truly client centred approach to return to work results in a unique stakeholder mix for each client’s treatment team. The variations in skill, education and experience across the stakeholder spectrum and within each stakeholder category further colour each unique team. In each situation, the development of common purpose

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K. Hatchard / Disclosure of mental health Lyass, Patterns and correlates of workplace disclosure among professionals and managers with psychiatric conditions, Journal of Vocational Rehabilitation 18 (2003), 3–13. E. MacEachen, J. Clarke, R, Franche and E. Irvin, The process of return to work after injury: Findings of a systematic review of qualitative studies, Working Paper #299, Toronto:ON: Institute for Work and Health. K. Hatchard, An occupational therapist’s journey through bipolar affective disorder, Occupational Therapy in Mental Health 19 (2003), 1–17. N. Jacobson and D. Greenley, What is recovery? A conceptual model and explication, Psychiatric Services 52 (2001), 482– 485. B. Kirsh, Organizational culture, climate and personenvironment fit: Relationships with employment outcomes for mental health consumers, Work 14 (2000), 109–122. M. Mancini, E. Hardiman and H. Lawson, Making sense of it all: Consumer providers’ theories about factors facilitating and impeding recovery from psychiatric disabilities, Psychiatric Rehabilitation Journal 29 (2005), 48–55. H. Polatajko, Naming and Framing Occupational Therapy: A lecture dedicated to the life of Nancy B., Canadian Journal of Occupational Therapy 59 (1992), 189–200. K. Rebeiro, Enabling occupation: The importance of an affirming environment, Canadian Journal of Occupational Therapy 68 (2001, 80–89. K.L. Rebeiro-Gruhl, Reflections on. . . The recovery paradigm: Should occupational therapists be interested? Canadian Journal of Occupational Therapy 72 (2005), 96–102. J. Secker and H. Membrey, Promoting mental health through employment and developing healthy workplaces: The potential of natural supports at work, Health Education Research 18 (2003), 207–215. L. Shaw and H. Polatajko, An application of the Occupation Competence Model to organizing factors associated with return to work, Canadian Journal of Occupational Therapy 69 (2002), 158–167. L. Shaw, C. McWilliam, T. Sumsion and J. Mackinnon, Optimizing environments for consumer participation and selfdirection in finding employment, OTJR: Occupation, Participation and Health 27 (2007), 59–70. A. Vandergang, Working Well: An employer’s guide to hiring and retaining people with mental illness, Canadian Mental Health Association, Toronto, ON. 2002.

is paramount in guiding the cohesion needed to support the worker’s progression. The collaborative process underscored in this case provides a common base for analyzing impacting factors regardless of the specific discipline involved. The resultant common vision relates to the worker’s progression toward regaining occupational competence in his chosen workplace. The process is strengthened by the selective, yet forthright disclosure by the worker of relevant functional concerns. Stakeholders involved in return to work for mental health consumers must clearly challenge themselves to move beyond the complex web of impacting factors and viewpoints. A view of the process as a dynamic one, occurring within environments that support disclosure and basic human understanding is needed. If stakeholders can vision together, the complexity will yield to focused collaboration. Most importantly, if consumers are empowered to be heard, their place in guiding the pathway back to work will become clear.

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