What Can Be Done

This situation is not hopeless. Among the steps we can take:

• Employment outcomes should be expected from mental health systems as a whole, not just from employment programs within them.

• Consumer and family groups must make employment a priority for advocacy.

• All clinical staff, even those in nonrehabilitation roles, should be educated about the dangers of long-term unemployment, as well as the benefits of employment.

• Individuals unemployed for more than three months should have employment as a mandated element of treatment planning, just as crisis planning is required.

• People unemployed at entry into mental health systems should be engaged in employment services concurrently with treatment services.

• Mental health systems need to fund employment services independently of public vocational rehabilitation services, in addition to using braided funding streams.

• Mental health funders should require that mental health programs actively recruit and hire people with mental illness in positions other than just consumer-designated roles, such as peer counselors.

• Helping people get off benefits such as SSA or welfare through acquisition of good jobs should become an explicit goal for mental health and rehabilitation systems. Benefits planning should include a positive disposition toward employment rather than present a neutral array of options.

What Is Working

One organization making progress on a local level is Columbia River Mental Health Services, a comprehensive community mental health center in Clark County, Washington. Its employment arm, Clearview Employment Services (CES), operates a multiplicity of programs with a staff of 25 FTEs (including several consumers in various roles), and it is funded through a variety of federal and state sources. CES aims to meet the needs of diverse constituencies facing multiple barriers to employment and life success, including a history of mental illness, substance abuse, homelessness, incarceration, domestic abuse, low educational attainment, and receipt of public assistance.

CES is an integrated part of the mental health system. It uses individual job development based on the consumer's expressed desires and capabilities, not general job prospecting. Once a job type is identified, the job-matching process, which incorporates a person-environment fit strategy, ensures that the job meets the criteria identified through the planning process. After specific vocational areas are targeted, a marketing plan, as well as individual placement and support plans, are developed by the individual and project staff.

CEs' service design uses a supported employment model to respond to the multiple needs of the people it serves by:

• using no “pre” or “readiness” screening;

• using a person-centered employment and career planning approach;

• focusing on the importance of hope and relationship building in engaging and motivating people;

• emphasizing rapid job entry;

• directly recruiting consumers to the program rather than relying on clinical staff's referrals for employment services;

• using peer and natural supports (peer support groups and personal networking for job acquisition);

• using a personal (transtheoretical) change model10 to assist people in taking control of their employment options;

• accessing resources from a program that assists consumers with co-occurring disorders; and

• creating entrepreneurial/self-employment options for people with disabilities.

In the previous fiscal year, CES served 742 people through open orientation sessions in the community; 337 developed career profiles; and 160 found employment with 196 separate jobs obtained. Consumers' average weekly wage was $238.42. Through a federal grant, CES also has helped consumers develop 17 entrepreneurial microenterprises (table).

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Table. Small businesses developed through CES's assistance

Conclusion

Employment should be seen as part of the social contract of recovery and citizenship. The civil rights movement for people with psychiatric disabilities has not made employment a priority in the way earlier civil rights movements have positioned it. Nevertheless, the answers do not lie solely within consumers' control. Treatment provider staff and systems must improve their capacity to inspire, support, and advocate for employment outcomes as one measure of their success.

Professional personnel and administrators must hold themselves accountable for building their own system and personal competencies to support consumers' achievement of meaningful employment results. They must not accept unemployment as justifiable because of the “severity of the disability” or “system disincentives.” As noted mental health advocate Patricia Deegan eloquently stated in Oslo, Norway, in 2004, “It is nearly impossible to make your own future if you are not part of the economic fabric of the culture you live in.”11