Creating an Inclusive Workplace

Although people with psychiatric disabilities express a desire to work, their efforts to find and keep a job are not always successful. Many factors contribute to lack of success, but one important factor is too often overlooked: negative attitudes in the workplace. The broad term used to describe these negative attitudes is “stigma,” but the USPRA Language Policy Guidelines (2003) recommends the more specific terms of “prejudice” and “discrimination.” Prejudice refers to negative stereotypes applied to a group, such as people who are diagnosed with a mental illness. Discrimination refers to prejudiced acts, including person-to-person disrespect and broad policies that work to exclude people from housing, jobs, and the opportunity to become an integrated member of a community. When internalized by a person with a psychiatric disability, negative stereotypes contribute to a sense of shame, creating a barrier to self-esteem and recovery, as described in the December 2008 Recovery & Rehabilitation newsletter.

While U.S. society has made great strides in reducing some forms of prejudice and discrimination, negative attitudes towards people with psychiatric disabilities remain a serious problem. Widespread ignorance and fear contribute to discrimination against individuals with psychiatric disabilities, which is more common than discrimination against people with intellectual or physical disabilities, and is often seen as more acceptable than discrimination against other groups.

Fears and negative stereotypes that result in discrimination are often based in the shared assumptions of a culture or society—such as assumptions about a person’s traits or abilities based on group membership or beliefs about a person’s “proper” role in society. Employment discrimination affects people of color, cultural and linguistic minorities, people with disabilities, and women (Balcazar, Suarez-Balcazar, Taylor-Ritzler & Keys, 2010). The concept of a “hostile work environment” comes from efforts to reduce sexual harassment, where the phrase is used to indicate an overall work climate that tolerates harassment, not just overt harassing behaviors from a particular individual. Researchers on race and culture use the term “microaggression” to refer to “brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color” (Sue et al., 2007; p. 271). Legislation exists to prosecute discrimination and harassment; however, although legislation has helped, it does not by itself prevent prejudice, discrimination, harassing behavior, or microaggressions. To minimize discrimination and maximize inclusion, the workplace needs to address broad organizational factors (policies, procedures, and daily practices; O’Leary-Kelly, Bowes-Sperry, Bates & Lean, 2009) as well create a climate that will not tolerate discrimination.

Organizational climate refers to the shared perceptions of employees about the practices, procedures, and behaviors that get rewarded, punished, or ignored (Schneider, 1990), including organizational tolerance of harassing or discriminatory behavior. Creating respectful organizational climates is a critical element in protecting women against discrimination and sexual harassment in the workplace (O’Leary-Kelly et al., 2009). For example, employees may perceive weak consequences for sexual harassment and strong consequences for complaints, such as backlash or career limitations (Brooks & Perot, 1991). When policies and practices decrease tolerance for discrimination, they increase the chance that stigmatizing behaviors will be reported, while also improving both wellbeing and work behavior for the individual who is the target of the discrimination or harassment (Offerman & Malamut, 2002). Approaches that are effective in reducing sexual discrimination and sexual harassment may provide guidance for developing policies, procedures, and practices that will help create work environments that are welcoming and respectful towards individuals with psychiatric disabilities.

Understanding stigma

Through studies on the vocational recovery of persons with psychiatric disabilities, Zlatka Russinova and her colleagues at the Boston University Center for Psychiatric Rehabilitation are seeking to understand the many forms of stigma and how they affect a person at work. While the majority of people in these studies experienced stigma on the job, that experience did not affect everyone in the same way. Those who had disclosed their psychiatric condition at work experienced negative personal effects, such as heightened anxiety and sensitivity about co-workers’ attitudes and opinions, and feared that co-workers might use their psychiatric background to gain some advantage. Feelings of suspicion, shame, and guilt were reported, as were feeling insecure, vulnerable, and disempowered. Those who had not disclosed their psychiatric condition expressed different fears—fears of being found out, of losing the job, of potential relapse and subsequent humiliation—and described emotional pressures and moral conflicts related to keeping a “secret.”

“We were surprised by the widespread effect of stigmatizing language,” says Russinova, “and to realize how important it is to be sensitive to verbal exchanges that could be experienced as stigmatization.” The subtle manifestations of stigma, similar to the experience of racial microaggressions, have a powerful effect over the long term. In an effort to better understand these effects, Russinova and her colleagues are developing a “stigma taxonomy” that clusters negative attitudes and discriminatory behaviors directed towards people with psychiatric disabilities into several categories (Russinova, Griffin, Bloch, Wewiorski & Rosoklija, 2006):

With funding from the national institute on Disability and Rehabilitation Research and the Center for Mental health services, Boston University’s Center for Psychiatric Rehabilitation has developed a technical assistance guide for anyone providing consultation to employers with the goal of proactively eliminating prejudice and discrimination against employees with psychiatric disabilities.

If you are an employer interested in promoting zero tolerance of prejudice and discrimination in the workplace, the following is a summary of the process offered to employers to develop and implement these processes. if you would like to receive a copy of the technical assistance guide, please contact Associate Director of training Rick Forbess at

From A Technical Assistance Process Guide Enhancing Workplace Inclusion for Employees with Psychiatric Disabilities:

Technical Assistance Process Steps

Step 1. Engaging the Employer
Conduct an overview of the workplace inclusion program for senior management.

Step 2. Targeting Discriminatory behaviors
Assist the workgroup to identify the types of discriminatory behaviors employees with psychiatric disabilities experience in their work setting.

Step 3. Developing Policies
Facilitate participatory process to develop/modify policies designed to eliminate workplace discrimination.

Step 4. Establishing benchmarks
Define indicators for evaluating the extent to which policies are effective.

Step 5. Designing benchmark Evaluation
Develop process and tools to evaluate benchmarks.

Step 6. Educating Employees
Design and implement an educational campaign.

Step 7. addressing Problems
Assist the workgroup to design and implement strategies to increase effectiveness of policies.

Negative impact on work performance

Supervisors may express very low expectations, assuming a lack of capacity. “A manager who views a new employee as disabled may feel extra motivation to help that person learn the job’s tasks, yet may also reveal an expectation of low competence. Such a patronizing response could not be more different from the outright antipathy traditionally associated with prejudice, yet it can be just as harmful in the workplace” (Morris & Fiske, 2009). Alternatively, a supervisor may have expectations that are too high, neglecting to take into account a person’s need for accommodation. Other examples include discrediting the person by challenging his/her professional competence, being treated differently from colleagues, or using a person’s psychiatric condition as a form of leverage or coercion. For example, one study participant reported, “My boss will say ‘Don’t you need more medication?’ when he disagrees with me.” More blatant forms of discrimination fall into this category as well, such as being denied advancement or being fired because of one’s psychiatric condition. Study participants reported having lost their positions when they requested a work accommodation, and one person stated, “When I brought the director a doctor’s letter requesting I be given a leave of absence, she actually refused it and called police to have me escorted out of the building.”

Negative social interactions with colleagues

A lack of knowledge about psychiatric conditions may cause a co-worker to make false assumptions about a person’s behavior or to make over-generalizations, resulting in uncomfortable interactions. Participants reported that ordinary behavior and reactions often were automatically attributed to their psychiatric condition. For example when one participant was grieving over the death of a family member, a co-worker suggested hospitalization. Language that is insulting, including offensive humor, may be the result of ignorance or insensitivity, but is also evident in settings where the workers should know better, such as among mental health service providers. Co-workers may appear patronizing and condescending, or their efforts at light-heartedness may come off badly. More significantly, many workers with psychiatric disabilities report being systematically excluded from work projects and social events, or ridiculed and demeaned, as in the situations reported by the study participants who said, “They pretend to be scared because I was issued a sharp knife in order to do my job,” and “They all expected me to be violent and my boss said, ‘Let me know if you’re going to blow us all away.’”

Addressing Stereotypes and Discrimination

In 2003, the federal Center for Mental Health Services launched an anti-stigma campaign, the Elimination of Barriers Initiative (EBI, 2003), designed to change the workplace environment through the development of “zero tolerance of stigma” policies. Although materials were developed specifically to target businesses and human resources personnel, and the initial responses were positive, project funding limitations prevented thorough testing and long-term follow-up (Bell, Colangelo & Pillen, 2005). Several states have since followed up with their own initiatives, and SAMHSA continues to maintain a website, What a Difference a Friend Makes, with materials to extend the campaign:

The Center for Psychiatric Rehabilitation at Boston University has recently completed a study involving the development and evaluation of a seven-step anti-discrimination technical assistance process for the workplace (see box). The technical assistance process actively involves the employer in assessing the degree of discrimination within the organization, as recommended by studies to address other forms of discrimination. “We wish we could change attitudes,” said Russinova, who has worked on this project, “but at least we can start changing behavior—like with sexual harassment.” Identifying and understanding both the attitudes and the actions that create a disrespectful, uncomfortable, or hostile organizational climate are the first steps toward planning and implementing change.

Strategies for improving the organizational climate primarily include policy development, evaluation of policy effectiveness, and education. The technical assistance process begins with an exploration of organizational priorities and obtaining buy-in from senior management. A task force of middle managers and other stakeholders is formed to set goals for what stigmatizing behaviors to address, develop relevant policies, define the indicators of progress, and identify clear benchmarks for measuring success. As part of the goal-setting process, the technical assistance consultant provides information to the task force about the types of stigma commonly experienced by people with psychiatric disabilities.

Policy development focuses on articulating an expected standard of behavior relative to people with psychiatric disabilities. Any plan for policy development or revision should take into account employees’ current awareness of existing policies and the success of any previous efforts to increase employee awareness. Familiarity with the many types of discriminatory behavior helps the policy workgroup ensure that the final policies cover all of the issues of concern. For example, an organization may have clear and effective policies that prevent discrimination in hiring and promotion, but may lack policies, training, and supervisory guidance about the use of respectful language.

In addition to developing policies, the organization task force, with the guidance of the technical assistance consultant, identifies strategies for change. For example, an educational campaign might be used to inform staff of new policies and to provide training to address problematic behaviors. Organization-wide education would include training, but also might draw on broadcast mechanisms such as the use of posters and/or email reminders. Material on sensitive language use, for example, could be posted, distributed, and used in orientation and training sessions. Readymade materials can be used, such as the USPRA Language Guidelines, or the Language Matters flier developed by On Our Own of Maryland; or an agency may prefer to create its own.

Evaluating the effectiveness of the changes implemented identifies specific indicators for improvement. Guiding questions help specify the indicators by asking, “What would we see or hear if policies intended to eliminate workplace discrimination and stigmatization were effective?” and “What measure would we use to determine whether action is needed to improve policy effectiveness?” Once the indicators are identified, the task force can pinpoint benchmarks—which are the target level of an indicator that would define success—and the method to evaluate the agency’s performance on the indicators. Selecting an evaluation method should consider the organization’s resources and make use of existing evaluation mechanisms when possible to minimize costs.

The technical assistance process was developed with a mental health agency in the greater Boston area. Rick Forbess, who has many years of experience providing technical assistance and program change consultation in psychiatric rehabilitation, worked with agency management to support the organization’s change process. He describes technical assistance as similar, in some ways, to working with an individual: “It is so important to invest time in gaining a thorough understanding of the organization, how the management and staff see any problems, and what efforts have been put in place to resolve the problems that have been identified.” The change process must be tailored to the organization and, as Forbess says, “Ownership of the problem and solutions must rest with the employer and employees in order for the technical assistance to be successful. One way to build ownership is through a work group of other employees in planning and carrying out each step of the process.” The result of this project is the new publication: A Technical Assistance Process Guide for Eliminating Workplace Stigma/Discrimination for Employees with Psychiatric Disabilities.


Over the past few decades, the role of employment in recovery has been recognized, and effective approaches have been developed that help people with psychiatric disabilities get and keep competitive employment. Undoubtedly, the field of psychiatric rehabilitation will continue to research and refine processes to support individuals in job placement and career development. However, changes in employment services will go only so far if there are no changes in the workplace. Understanding stigma, prejudice, and discrimination is a first step toward designing interventions to improve the workplace climate, and to make it possible for people with psychiatric disabilities to experience full inclusion and integration in the workforce.

Resources and References

Americans with Disabilities act:

Balcazar, F. E., Suarez-Balcazar, y., Taylor-Ritzler, T. & Keys, C. B. (2010). Race, Culture, and Disability: Rehabilitation Science and Practice. Sudbury, Ma: Jones and Bartlett.

Bell, J., Colangelo, a. & Pillen, M. (2005). Final report of the evaluation of the elimination of barriers initiative. Available from:

Brooks, L. & Perot, A. R. (1991). reporting sexual harassment: exploring a predictive model. Psychology of Women Quarterly, 15, 31–57.

Morris, M. & Fiske, S. (2009). “the new Face of Workplace Discrimination.” Forbes (online), november 12, 2009:

Offermann, L.R.. & Malamut, A.B.. (2002). “When leaders harass: the impact of target perceptions of organizational leadership and climate on harassment reporting and outcomes.” Journal of Applied Psychology, 87, 885–893.

O’Leary-Kelly, A. M., Bowes-Sperry, L., Bates, C. A. & Lean, E. R. (2009). “sexual harassment at work: a decade (plus) of progress.” Journal of Management, 35(3), 503–536.

Russinova, Z., Bloch, P., Wewiorski, N. & Rosoklija, I. (2006). “Manifestations of psychiatric stigma at the workplace.” Paper presented at the international Work, stress, and health Conference, Miami, Florida, March 2–4, 2006.

Schneider, B. (ed.) (1990). Organizational Climate and Culture. San Francisco: Jossey-Bass.

Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L. & Esquilin, M. (2007). “racial microaggressions in everyday life: implications for clinical practice.” American Psychologist, 62 (4), 271–286.

Office of Disability employment Policy (2006). “accommodations for people with psychiatric disabilities (written for employers)”:

On our own of Maryland “stigma: language Matters” flier:

Research and training Center on independent living at the University of Kansas poster on language guidelines for writing and reporting about people with disabilities:,%20our%20image%20poster.pdf

Substance abuse and Mental health services administration (2006). Developing a Stigma Reduction Initiative. SAMSHA Pub no. SMA-4176. Rockville, MD: Center for Mental health services, SAMHSA. available from: 4176/Developing_a_stigma_reduction.pdf

SAMHSA resource Center to Promote acceptance, Dignity and social inclusion associated with Mental health (ADS Center) resources focused on a mentally healthy workplace:

SAMHSA elimination of barriers initiative:

USPRA (2003). Language Policy Guidelines. available from: