Hidden Wounds

“The rocket hit the ground in front of me, and it blew off both of his legs,” Martin recalls.

It’s one of many horrifying experiences the National Guardsman endured in Iraq—and one he can’t forget. Martin estimates that he saw at least one soldier die every week he was stationed there in 2005.

He wasn’t visibly injured like those bleeding all around him. He didn’t seek treatment. He thought he could handle the stress. Unlike most others in his unit, he had seen combat before. He had commanded a tank company for the U.S. Army during the first Gulf War.

“I attributed my disorientation, my inability to clearly think, to exhaustion,” Martin recalls. “But as time went on, I knew something was wrong.”

It wasn’t until he returned to the United States that a nurse at Fort Lewis in Washington state recognized his symptoms as post-traumatic stress disorder (PTSD) and traumatic brain injury from three concussions he sustained in a four-month period.

He had flashbacks. His mind replayed scenes of fellow soldiers dying. He had trouble staying focused. He couldn’t sleep. And, there was the constant fear. “For some reason, when I came back, I would drive and I was always worried that a car bomb was going to get me,” Martin says.

Martin is one of an estimated 17 percent of soldiers returning from Iraq and Afghanistan with PTSD. After 10 months in rehabilitation, Martin is employed as a systems engineer at Northrop Grumman Corp. in Clearfield, Utah.

However, many returning veterans are unable to find employment. Their average jobless rate in 2010 was 11.5 percent compared with 9.4 percent for nonveterans. The unemployment figures for young veterans ages 18 to 24 were worse—20.9 percent compared with 17.3 percent for nonveterans.

Some veteran advocates blame the high unemployment numbers on the stigma of PTSD, at least in part. “Hollywood is great at dramatizing the crazy veteran—the veteran who is a loose cannon, who is perhaps unreliable or a substance abuser. That’s probably the furthest thing from the truth,” says Brock A. McNabb, a readjustment counseling specialist with the U.S Department of Veterans Affairs (VA).

Although combat veterans commonly come to mind as vulnerable to PTSD, they aren’t the only ones. Others include victims of rape; survivors of plane crashes, industrial accidents and natural disasters; and emergency medical personnel and law enforcement officers who routinely deal with crime and accidents. Among rescue and recovery workers at the World Trade Center after the Sept. 11, 2001, terrorist attacks, 12.4 percent have symptoms of PTSD, according to a 2007 study published in the American Journal of Psychiatry. An estimated 6.8 percent of Americans will experience PTSD at some point in their lives. About 3.6 percent of U.S. adults, 5.2 million people, have PTSD during a given year, according to the U.S. Department of Veterans Affairs National Center for PTSD.

HR professionals can help supervisors understand that these invisible injuries are just as real as physical wounds and are treatable. Flexibility and compassion can go a long way to retaining a productive and loyal employee, say advocates for people with PTSD. If that’s not enough motivation, employers should be aware that federal regulations effective in May, which implement the 2008 amendments to the Americans with Disabilities Act (ADA), make it easier for employees with PTSD and other mental health disabilities to pursue discrimination claims.

Employers’ Attitudes

Many employers express uncertainty about hiring someone with PTSD. They worry that the individual will pose a safety threat to other workers. They are concerned that employees with PTSD would require costly accommodations and take too much of their managers’ time.

In a June 2010 poll, the Society for Human Resource Management (SHRM) found that 46 percent of the HR professionals responding said post-traumatic stress and other mental health issues pose hiring challenges. Just 22 percent said the same about combat-related physical disabilities.

Another poll indicates that employers are concerned about the potential for violence but aren’t sure if that concern is valid, says Hannah H. Rudstam, a member of the senior extension faculty at the DBTAC-Northeast ADA Center in the School of Industrial and Labor Relations at Cornell University in Ithaca, N.Y. Cornell and SHRM researchers collaborated on the January poll to gauge employers’ views on hiring veterans.

In that poll, 53 percent of the HR professionals responding said they didn’t know if workers with PTSD are more likely to commit violence in the workplace. Rudstam says she suspects that those expressing uncertainty were masking concerns they weren’t comfortable expressing directly, even in an anonymous survey. Eight percent said employees with PTSD would be more violent, while 39 percent said they wouldn’t be.

In addition, 61 percent of the respondents said that accommodating workers with PTSD or traumatic brain injury requires more effort for the employer, while 52 percent reported that they didn’t know if accommodations would be costly. Only 6 percent had accommodated a worker with PTSD.

“They were really struggling with understanding ‘What do accommodations in this area look like? What are the possibilities? What do we do?’ ” Rudstam says. “They have very, very little experience with these types of accommodations.”

What Is PTSD?

In World War I, they called it “shell shock.” In World War II, it was dubbed “combat fatigue.”

It wasn’t until after the Vietnam War that “post-traumatic stress disorder” became an official diagnosis accepted by the American Psychiatric Association.

Symptoms include severe anxiety, sleeplessness, nightmares, social isolation, emotional numbness, irritability and a feeling of being on guard. A key symptom: The individual relives a traumatic event when confronted with reminders or thinks about it when trying to do something else.

While the majority of people exposed to a traumatic event don’t have ongoing psychiatric problems that require clinical intervention, some do to varying degrees.

Matthew J. Friedman, a psychiatrist and executive director of the VA’s National Center for PTSD, wants employers to know two facts: “PTSD is easy to recognize … and it’s very treatable.”

Yet some individuals don’t recognize they need help, or they don’t seek help right away because they believe doing so shows weakness, which their military training and society discourages. Sometimes, symptoms don’t appear until months, or even years, after the traumatic event when a chance encounter, remark, sound or smell triggers a memory.

Before getting treatment, some may turn to alcohol or drugs to relieve their pain.

Army Staff Sgt. Meg Krause was a medic in Afghanistan and Iraq who returned home in 2006 to enroll at Penn State University. Two years later, she began having nightmares and flashbacks. She couldn’t sleep. She started drinking. The turning point came one night when she was out with friends. “We heard a car backfire. I thought insurgents were chasing me,” Krause recalls. She called the police, telling them insurgents were waiting for her. Her roommate drove her to a VA hospital, where she went through detox and counseling and was diagnosed with PTSD.

With therapy and the help of her professors, Krause finished college in December 2008 as scheduled and landed a job. “Have a support system in place that’s going to help you,” she advises. Her first employer gave her a flexible work schedule so that after sleepless nights, she could start work later the next morning. She now works as associate

Concerns of Violence

While news coverage involving atrocities committed by people with mental illnesses reinforce the public perception that they are prone to violence, studies have shown otherwise, researchers say.

“Violence is exceedingly rare among people with mental illness, and the rare instances that do occur are associated with other factors, such as active substance abuse or refusing to take medications,” testified Dr. Gary R. Bond, a professor of psychiatry at Dartmouth Medical School, before the U.S. Equal Employment Opportunity Commission (EEOC) at a March hearing on the employment of people with mental disabilities. “Being employed significantly reduces the possibility of violence even further.”

Workers with PTSD, particularly those who have sought treatment, shouldn’t be cause for alarm, Friedman says.

“Most people with PTSD are ‘over-controlled.’ They don’t want to lose their temper. They don’t want to be aggressive. They tend to avoid situations that might evoke such feelings or behavior,” Friedman says. “Most veterans with PTSD are quite able to accommodate to the workplace.”

Individuals with PTSD have shown significant improvement from therapy that teaches them to face the memories they’ve been avoiding and find ways to cope. Medication may be prescribed to reduce anxiety, Friedman says.

In one long-term study of female rape victims completed in 2005, 76 of 110 women contacted five to 10 years after treatment had recovered. The research was conducted by Patricia A. Resick, now director of the women’s health sciences division of the VA’s National Center for PTSD.

Legally Speaking

With a greater understanding of what PTSD is—and isn’t—employers can help ensure that workers with the disorder are productive, advocates say. And, there’s legal risk if they don’t try. Federal regulations implementing the 2008 ADA amendments make it easier for employees to get their discrimination claims heard in court.

Congress expanded the definition of who is disabled and now requires the primary focus in ADA cases to be on whether discrimination has occurred, according to Jeanne Goldberg, senior attorney advisor with the EEOC’s Office of Legal Counsel.

“It’s going to be far less often now that employers are able to get court cases thrown out on summary judgment on the ground that the individual is simply not covered under the ADA,” Goldberg says. “We have stressed to employers that this is a very important point in time to revisit the training of their front-line managers and supervisors to make sure they know how to recognize a request for accommodation when they receive it and what to do to make sure they meet their obligations to provide accommodations to individuals with disabilities where it would not be an undue hardship on the business.”

Medical conditions that are episodic or in remission, such as PTSD or cancer, are now considered disabilities if they substantially limit a major life activity when active.

It was more difficult to prove PTSD was a covered disability when Donna Malone was fired by her employer, Land Air Express of New England, while she was hospitalized for treatment of PTSD. Her condition stemmed from physical and sexual abuse she endured as a child.

Malone’s manager said he fired her because of his “gut feeling”—based on news stories about employees “going postal”—that she was a danger to other employees. The manager never spoke to Malone’s doctors or took time to understand the illness before firing her, EEOC senior trial attorney Markus Penzel told the commission in March. The company settled for $360,000 in 2003.

Don’t Ask, Don’t Tell

During the hiring process, employers are prohibited by law from asking any disability-related questions in interviews or on job applications, Goldberg says. If applicants volunteer information about disabilities, employers can only ask what accommodations they will require. If applicants ask for accommodations in pre-hire testing, employers can ask for reasonable medical information if the disabilities are hidden.

For privacy reasons, managers and HR professionals can't ask questions even if they suspect someone has PTSD.

After a job offer has been made, the employer can ask the individual to submit to a medical exam or provide a medical history, if the request is made of all entering employees in the same job category, she says.

“There are very valid reasons that a person with a hidden disability, particularly with mental health disabilities, do not tell their employers,” says Kathe Stark, SPHR, employment litigation specialist with Carrill Law Firm PC in Las Cruces, N.M. “The stigma and the discrimination is very real.”

Stark was diagnosed with PTSD years ago after she was raped as a teen. Early on, she had symptoms at work. Someone would raise his voice in a meeting, and she’d feel something building inside of her. She’d excuse herself from the meeting until it subsided. Eventually, she learned to cope.

For privacy reasons, managers and HR professionals can’t ask questions even if they suspect someone has PTSD. But if the worker volunteers the information, she suggests talking to them to help them determine what their triggers are.

She had one employee whose work would noticeably suffer each November. “The third year, I sat down with the employee and asked if there was anything I could do to help. It was only then that I learned the employee had PTSD and that November was the anniversary of something bad that had happened,” says Stark, who teaches disability awareness workshops.

As an HR professional, she tells supervisors: “Don’t call me up and tell me you have an employee who is depressed or who is bipolar, because you don’t have a medical degree. Tell me what you’re seeing … and then we can have a conversation with this employee.”

When there is a behavioral problem, HR professionals can refer the employee to an employee assistance program (EAP), says Richard Kunz, human resources manager with the City of Pasadena.

“We can’t necessarily require professional treatment. We can require they attend the EAP first session and can require whatever sessions that the EAP recommends,” Kunz says.

Like Stark, Kunz has PTSD. The former security officer has seen several fatal accidents, including one where he witnessed two pedestrians hit by a drunk driver. That scene and others came flooding back when, during the course of his HR duties, he investigated e-mail content of some employees, including a video of a person being struck by a helicopter rotor blade. “Immediately upon seeing that, I go through a whole series of flashbacks of all the things I’ve seen on TV, video and real-life experiences,” he explains. When such episodes happen, he shuts his door until it passes.

He and his staff are aware that a crisis at work can trigger PTSD in some employees who may or may not have experienced traumatic events in the past. When there’s a death in the office, for example, they call in an EAP crisis team to help employees deal with their emotions.

“Support and encouragement from supervisors and managers of the employee go a long way to providing a safe environment for the person to deal with their PTSD issues instead of hiding from them or treating them with unhealthy means,” Kunz says.

How does your organization address the needs of employees with PTSD? What challenges have you faced? How did you resolve them?