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Should You Tell?
For People With a Mental Illness, There's No Easy Answer

By Amy Joyce
Washington Post Staff Writer
Sunday, February 18, 2007

If you have depression or some other mental illness, what do you do about work? Hope no one notices? Disclose your illness early on and trust that your boss will understand?

Should You Tell is a complicated question. There is no right answer, and there are some risks to consider.

I discovered this years ago after watching a movie at home with two friends. One of them looked up, scared. She hesitated. And then she let it out: "Do you hear them? The helicopters. They're coming for me, guys."

This sweet, gentle friend was scrunched up in the corner of the couch, shaking. Her Ivy League graduate degree and over-the-top intelligence couldn't get her out of this situation. We had to get her to the hospital.

The next day, after she'd spent a night in the emergency room, I called her boss to say she had the flu. Another friend and I took turns calling in the flu excuse while she huddled in her room. It wasn't convincing.

This friend had a prized internship that should have turned into a good job. It did not. From the boss's point of view, something peculiar was going on. My friend appeared unreliable. Her boss never knew why her performance so suddenly dropped. Not only was my friend soon out of a job, but she also knew she couldn't even ask for a reference.

One in four people has depression or mental illness, and many of those who are affected face the same dilemma: Tell your boss, and you may be ostracized, penalized or not hired. Don't tell, and your boss might lose confidence in you. Despite the long way we've come -- public figures such as former Montgomery County executive Douglas Duncan, Pittsburgh Steelers superstar Terry Bradshaw, and writer and political adviser Robert Boorstin have announced that they, too, have depression or other related illnesses -- a strong stigma is still attached to these diseases.

After the experience I had with my friend, I was inclined to think that the best thing to do is tell. But then I spoke with Sarah.

She works for a Washington area aid organization and often goes on month-long trips to war zones, where she works seven days a week. She has depression, treated with therapy and medication. Until recently, it didn't interfere with work, so she kept silent.

But stress had been accumulating during three years in the job. When a trip to a war-torn nation in Africa came up recently, she worried she wouldn't survive it. The stress had "put me in a place where I just couldn't function," she told me. "I thought I might truly kill myself if I had to go out to the field again."

The only way to stay home and get treatment was to tell her boss.

But she soon felt as if she was being punished for being ill. "I was forced to do work I had never been asked to do before. I was not seen as the go-to person to be relied on anymore," said Sarah, who is soon moving on to a new humanitarian job.

"If I had diabetes or cancer, they wouldn't expect me to suck it up and keep going," she said.

She will never tell an employer again. "I just saw the repercussions."

There is more to consider than pure emotion when considering disclosure, however. A drug test or security clearance -- or the law -- might raise the issue. It is important to know what is required and what isn't.

While working in public relations for a Baltimore mayor, the Visiting Nurse Association and other groups, Sheryl Williams hid her bipolar disease and anorexia. "I just feared not being credible. I knew how 'mental patients' were treated," she said. The effort it took for her to hide her illness every day at work left her exhausted, but she managed.

But when she took another job and encountered the inevitable drug test, she knew it would come back positive because of her medications. So she decided to tell. It helped that she had gained the boss's trust after years of doing work on contract for him, she said.

"My boss said, 'Okay, so what?' " Williams said. The human resources director concurred. "I could have just hugged both of them. Now I don't feel as if I am limited at all."

Another reason for disclosure: It allows legal coverage. If a person has a mental illness and does not disclose it to a boss or other official entity at work, the employee can't benefit from the Americans With Disabilities Act.

About 14 percent of all charges filed under the ADA involve mental illness. But an employee who does not disclose a condition loses that legal protection, said Chris Kuczynski, director of the ADA policy division at the Equal Employment Opportunity Commission.

Employers cannot ask in interviews whether someone has a mental illness. They are permitted, however, to ask once a conditional job offer is made, according to Peggy Mastroianni, associate legal counsel with the EEOC. If the offer is withdrawn after an admission is made and the illness does not directly relate to the job, the company can be held liable for violating the ADA. (This is the only law the EEOC enforces that prohibits something being asked in an interview.)

Companies have rights, too. In fact, if an employee creates a problem by doing poor work, the company can take action against that worker if it has not been informed of a mental illness as a potential problem, Mastroianni said. But if an employee's conduct or performance is hindered because he was denied accommodation allowed by the ADA -- a flexible schedule or time off to see a doctor, for instance -- the company might not have the same leeway.

Sometimes, the health-care system reinforces the stigma, allowing endless treatments for a broken leg but a limited number of visits to a therapist.

Legislation was introduced in the Senate last week by Edward M. Kennedy (D-Mass.), Pete V. Domenici (R-N.M.) and Mike Enzi (R-Wyo.) that would allow anyone with health insurance to have equitable coverage for both mental and physical illness. A bill is expected to be introduced in the House soon. So far, 40 states have passed similar laws, including Maryland and Virginia. The District does not have one, according to Andrew Sperling, director of legislative advocacy with the National Alliance on Mental Illness. The organization is lobbying for the Senate bill, he said. "Placing arbitrary limits on treatment for mental illness is just wrong," he said.

Putting mental-health problems on the same footing as physical illnesses may help more people make the disclosure because it might encourage treatment. It also might help blunt the stigma that surrounds the diseases.

That stigma might have kept Kay Redfield Jamison, a professor of psychiatry at Johns Hopkins University, from disclosing her bipolar disorder years ago, but she had no choice. As a medical student seeking hospital privileges, she had to inform her employer.

The chairman at the University of California at Los Angeles, where she was working when her illness became apparent, "never suggested I not compete or leave academic medicine," she said.

"He said learn from it, teach from it, write from it," Jamison said. "But I do not offer these up as typical examples. They are exemplary."

One study conducted by the Boston University Center for Psychiatric Rehabilitation showed the difficulty of deciding what to disclose. Some study participants said it was empowering to go to work, feel like everyone else, and not tell anybody they had a mental illness, said Zlatka Russinova, one of the study's authors. But other people who were initially afraid to disclose but later told a supervisor "felt really empowered to be open," she said. "It's a personal choice."

Some like that they educate or help others when they disclose. Those are powerful incentives, up to a point.

"The vast majority are saying to themselves, 'Why would I ever disclose? Everybody's afraid of people with mental illness,' " said Stephen Hinshaw, chairman of the psychology department at the University of California at Berkeley and author of "The Mark of Shame: Stigma of Mental Illness and an Agenda for Change." "But that only perpetuates shame, ignorance and an inability to proactively take steps to ease the situation."

Employers have a different incentive to encourage disclosure. They can save money when they help employees get treatment because though they may pay more for insurance, they may get a more productive and loyal worker in return.

The National Institute of Mental Health recently released a study showing that slightly increasing the care for a worker's depression would actually save employers money.

Most of the savings come from increased productivity when employees are able to get treatment, said author Philip Wang, director of the division of services and intervention research at NIMH, who conducted the study while researching at Harvard University. Companies often "think of health benefits as dumping resources into an endless black hole, and they get nothing back," he said. "But here's an area that's currently untapped."

In the study, a hypothetical group of 40-year-old workers with depression were referred to treatment. Savings from reduced absenteeism and employee turnover due to the intervention began to exceed costs of the program by the second year.

Mastroianni, the EEOC attorney, suggests that employers put policies in place that explain the ADA rules and outline what the company offers someone who might have a mental illness. This should help create a comfortable atmosphere in which workers can be honest.

But the consensus remains: There is no one right answer on disclosure.

"It is completely personal," said Williams, the public relations employee. "People have to feel it's the right time and right place. I could never say in a thousand years that you should or shouldn't. This was not easy for me. I came to this decision gradually and only did it at work because I was made to feel extremely comfortable."

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