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Left out of the economy

June 1, 2007
by JOE MARRONE
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Much more must be done to help consumers enter the workforce

The argument that people with psychiatric disabilities cannot work is an empty one, as anecdotal and research data have shown. Early in the community mental health movement, the ability of people with mental illness to work was first highlighted through the development of transitional employment at Fountain House in New York City in the 1950s. Recently, there has been even more information on successful supported employment, prominently connected with the research on the individual placement and support model associated with Drake and colleagues at Dartmouth College.1

Yet overall employment outcomes for people with serious mental illness have not increased significantly. This is true even with the recent emphases on recovery and system change/transformation and attempts to solve Medicaid disincentive issues. Nationally less than 25% of adult public mental health consumers are employed at any level.2 More disturbingly, the number of people who even attempt or get access to employment through public mental health programs remains quite low.3

Unemployment leads directly to poverty—a situation that people with mental illness are three times more likely to be in than people without disabilities. Cornell University researchers reported in 2005 that people with psychiatric disabilities had a poverty rate of 30% compared to 24% for people with any disability and 9.1% for people without disabilities.4

Few things are more harmful to a person's physical and mental health than long-term unemployment. Numerous studies within the past two decades show significant correlations between long-term unemployment and negative personal results, such as increased hospitalizations, increased substance abuse, greater incidence of depression, lower self-esteem, and increased anxiety.5-9 So it is quite surprising that so much discussion centers around the possible negative effects of stressors associated with entering employment (with little evidence supporting this view). There is almost no discussion on the need to avoid long-term unemployment.

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);

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