This guide provides information about supporting people with complex co-existing (co-occurring) disorders. This combination of conditions is often called complex co-morbid disorders or dual diagnosis. Throughout this document we will use the less confusing term of complex co-existing disorders. It is a starting point for understanding some of the important issues involved when providing employment assistance to job seekers with complex co-existing disorders.
Understanding complex co-existing disorders and impacts on job performance
People with health conditions and people with mental illness in particular, often have more than one health condition at any time. This is important to recognise because each health condition may impact on a person's employment. Often only the most visible condition attracts treatment and workplace accommodations, while the least visible condition can cause greater impacts at work. Common examples are:
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any clinical psychiatric disorder and substance dependencies (Becker, Drake and Naughton 2005)
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mood disorders (bipolar affective disorder, major depression) and anxiety disorders
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any clinical psychiatric disability and personality disorders
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any health condition involving chronic pain and substance abuse
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musculoskeletal disorders and major depression
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musculoskeletal disorders, depression, anxiety disorders, substance abuse, and sometimes all four disorders
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any clinical psychiatric disabilities and developmental or other disorders, for example, intellectual disability, attention deficit and hyperactivity disorder.
It is important that you have an appreciation of the impact of complex co-existing disorders on the job seeker, in addition to being aware of individual treatment arrangements. The most appropriate way to achieve this is to work in partnership with treating health professionals wherever possible. This will greatly assist in delivering co-ordinated and individualised employment-related support that can respond to the person’s needs should they change over time.
The Workplace Adjustment Tool contains further information on disability and the conditions referred to in this guide. The Workplace Adjustment Tool is a searchable database that allows you to search for ideas for workplace adjustments and solutions based on a particular disability and the type of job being undertaken.
How complex co-existing disorders impact on employment
Complex co-existing disorders impact on employment differently from single disorders, for example:
- optimal treatment and care may not have been obtained for all relevant health conditions
- although the final impact on the person is not usually a sum of the parts, it can be more difficult to identify employment restrictions, and identify whether these are associated with a treatable disorder
- even if all conditions have been optimally treated, it is more difficult to obtain and coordinate information from multiple treatment professionals than it is from a single treatment professional
- the person's work history since onset of the relevant conditions, and the person's perceptions of what they can manage, is an important source of information—sometimes there is no direct link between a disorder and an employment restriction
- the person's perceived ability to perform an activity (self-efficacy for specific tasks) can be the most important factor despite the presence of multiple health conditions.
Pre-employment strategies
Like other people with psychiatric disability and mental illness your job seekers will benefit from a person-centred and strengths-based approach, where the focus is on individual motives, goals, preferences and needs. Assistance can then be individually tailored in consultation with the job seeker. An assertive strength-based approach helps maintain a focus on individual resources and strengths while avoiding a focus on the disorder and personal limitations and past failures.
Working closely with treating health professionals wherever possible to develop a coordinated approach to understanding the person's conditions and monitoring their wellbeing is also recommended. A valuable first step is to help the person obtain suitable treatment and care for each condition that is likely to have impacts on employment.
You can assist people with complex co-existing disorders to find suitable employment by creating an individualised pre-employment plan. When developing the plan with the job seeker, you may like to consider the following:
- talk to each job seeker and their treatment professionals about what they can manage, and the type and intensity of assistance that may be needed
- be aware of any untreated health conditions that could impact on work, for instance, a person with a musculoskeletal disorder and untreated depression may be at greater risk of job loss than someone with adequately treated co-existing depression (Becker and Drake 2003)
- discuss the combination of conditions with the person and one or more of their treatment professionals—try to ascertain the limits of comfortable performance, suitable duties, and suitable working hours and identify jobs that are both most preferred and most likely to be sustainable.
Job search strategies
The following strategies may also be of assistance when supporting job seekers with complex co-existing disorders:
- for people with substance related disorders, avoid workplaces that serve alcohol, even for those people who have been successful in recovery from substance abuse
- provide links to support services that can assist the job seeker in managing potential earnings, for example, shopping on payday, use of a trustee, auto credits and debits, and use of any income for goals that reduce the availability of cash for substances.
Neither the person nor the treating professionals may anticipate all of the ways in which co-existing conditions impact on the person's preferred employment. To reduce the risk of discouraging employment options which the person may in time be able to manage, work experience through the Work Experience Placement Programme or ‘job tryouts’ on casual pay or short-term contract could be used to identify job preferences and work activities for which assistance, aids and equipment, or workplace accommodations, are needed.
Disclosure issues
There is no single answer to the question of disability disclosure for people with complex co-existing disorders. Many people with complex co-existing disorders may not show visible signs of their condition. There is also much social stigma still surrounding public perceptions of any mental illness. Consequently it is absolutely essential that the pros and cons of disclosure be thoroughly discussed with job seekers.
People with complex co-existing disorders will often not want to disclose information about their disability to an employer. You may consider discussing with the job seeker limiting the degree of disclosure and only releasing sufficient information to ensure appropriate supports are put in place.
It is important to canvass with job seekers the benefits of disclosure, whether full or partial disclosure, in terms of workplace integration and job maintenance. For example, if a job seeker requires adjustments to working hours or routines and or flexibility with leave and return to work arrangements, then disclosure is vital.
Similarly if a job seeker requires modifications to physical work space to establish a less distracting or noisy environment and/or support strategies (like time out if anxious or being able to phone someone external to work if experiencing stress) then disclosure is clearly advisable. There are also questions of timing (when to disclose) and selectivity (who needs to know).
Post placement support strategies
Ongoing Support
Once a person who has complex co-existing disorders has commenced work give consideration to what strategies may assist them in maintaining their employment. Ongoing support requirements and the way this is delivered should be discussed with the worker. Ongoing support may include:
- using an integrated team approach to problem solving and to celebrate success—the team may include employment specialists, mental health professionals, drug and alcohol counsellors and medical practitioners
- if such a team is not available, create a virtual team by establishing and maintaining contact with all interested treatment professionals
- assisting workers in preparing for possible exacerbations of their health conditions in the workplace
- developing contingency plans for health deterioration, for example, temporary replacements, additional unpaid leave, and gradual return to work
- viewing job difficulties related to health conditions as learning opportunities to improve work performance and worker reliability—discuss best approaches to providing ongoing assistance as a team
- asking rehabilitation specialists and treatment professionals to help address any work performance issues and to identify the forms of assistance that may be required to improve work performance
- pointing out the person's accomplishments along the way
- viewing health and performance setbacks as learning experiences and offering ongoing assistance with employment goals
- talking to workers about long-term goals including career development plans when you have a clear idea of their strengths and the type of activities for which they need assistance.
While not common for people experiencing mental illness, consider the Supported Wage System if on site training and job redesign does not enhance the person's productivity levels to the level required by the employer.
More information
For information and step by step instructions on the financial help available to employers of people with disability, including the application process, visit:
The following fact sheets, developed for service providers, are also a useful resource:
- Disclosure of disability
- Mental Health First Aid – General Helping Skills for all Mental Health Problems (see related links on this page)
References
Becker D.R and Drake R.E 2003, ‘A working life for people with severe mental illness’ Oxford Press, New York.
Becker D.R, Drake R.E and Naughton W.J 2005, ‘Supported employment for people with co-occurring disorders’, Psychiatric Rehabilitation Journal, 28(4), 332-336.