Meeting of March 15, 2011 - Employment of People with Mental Disabilities
Commissioner Feldblum and members of the panel, I am Gary Bond, Ph.D., Professor of Psychiatry, Dartmouth Medical School, is a mental health services researcher who has studied employment services for people with serious mental illness for over 30 years. He joined the faculty at the Dartmouth Psychiatric Research Center in 2009 after 26 years as a professor of psychology at Indiana University Purdue University Indianapolis.
The Dartmouth Psychiatric Research Center (PRC), under the direction of Robert E. Drake, M.D., Ph.D., was established in 1987 with initial research in New Hampshire focused on integrating vocational and mental health services and on integrating case management and substance abuse services. The PRC has expanded both geographically to research sites throughout the U.S. and in focus of mental health services research. The PRC is currently staffed with over 50 faculty, postdoctoral and predoctoral students, and research associates and assistants.
What is Serious Mental Illness?
This testimony concerns the population of people with serious mental illness, defined by three criteria: (a) Diagnosis: a psychiatric diagnosis of schizophrenia, bipolar disorder, or other major psychiatric disorder; (b) Disability: significant role impairment, in areas such as independent living, interpersonal functioning, and employment; (c) Duration: extended involvement with the mental health system (such as admission to psychiatric hospitals, supervised group homes, and mental health case management services) (Schinnar, Rothbard, Kanter, & Jung, 1990). This is a large segment of the disability population. For example, over one-third of people of the Social Security disability roles have a serious mental illness (McAlpine & Warner, 2000).
People with serious mental illness are a very heterogeneous group that has included Nobel Prize winners, American Presidents, artists, and other famous persons, as well as many who live in poverty and isolation (Draine, Salzer, Culhane, & Hadley, 2002). You cannot judge a person by their diagnosis. While the public has many negative stereotypes about this group, the take-home message from this testimony is that the research strongly demonstrates that full recovery from mental illness is possible. Working is a crucial element in this recovery process.
Employment of People with Serious Mental Illness
Employment rates for people with serious mental illness are very low. Surveys have found that only 10% - 15% of people with serious mental illness receiving community treatment are competitively employed (Henry, 1990; Lindamer et al., 2003; Pandiani & Leno, 2011; Rosenheck et al., 2006; Salkever et al., 2007). Rates are even lower, typically less than 5%, in follow-up surveys of people discharged from psychiatric hospitals (Farkas, Rogers, & Thurer, 1987; Honkonen, Stengård, Virtanen, & Salokangas, 2007). National and international surveys of community samples, which include respondents with less serious disorders, have reported employment rates of 20% - 25% for people with schizophrenia and related disorders (Marwaha et al., 2007; Mechanic, Bilder, & McAlpine, 2002).
The employment rate for people with serious mental illness is less than half the 33% rate for other disability groups (Anthony, Cohen, Farkas, & Gagne, 2002). Both rates are of course much lower than for the general population. Even during the height of the current recession, the national employment rate for adults in the general population was 72%, according to U.S. Bureau of Labor statistics (Fogg, Harrington, & McMahon, 2010).
Moreover, people with serious mental illness who are working are often underemployed. Nearly twice as many workers with mental illness earn at or near minimum wage as workers without disabilities (Cook, 2006). Non-standard jobs (such as temporary employment, independent contracting, and part-time employment) are common among workers with serious mental illness. Such jobs pay lower wages with fewer benefits (Schur, 2002). Among those employed, people with serious mental illness are overrepresented in unskilled occupations, such as in the service industries and as laborers (Mechanic et al., 2002).
Most People with Serious Mental Illness Want to Work
Despite these dismal employment statistics, most people with severe mental illness want to work. Studies indicate that approximately 2 out of every 3 people with mental illness are interested in competitive employment (Frounfelker, Wilkniss, Bond, Drake, & Devitt, in press; McQuilken et al., 2003; Mueser, Salyers, & Mueser, 2001; Ramsay et al., submitted; Rogers, Walsh, Masotta, & Danley, 1991). Moreover, these rates may understate the interest in working in this population, because many mental health professionals discourage clients from pursuing employment goals.
Barriers to Getting and Keeping Jobs
Why, then, is there a wide disparity between employment rates and desire to work? The reason is not that people with serious mental illness cannot work. People with serious mental illness are capable of working if they are matched to appropriate jobs and receive appropriate supports. But attitudinal, service, and system barriers are challenges to their employment. According to a national survey (Hall, Graf, Fitzpatrick, Lane, & Birkel, 2003), persons with serious mental illness reported the primary barriers to employment to be stigma and discrimination (45%); fear of losing benefits (40%); inadequate treatment of disability (28%); and lack of vocational services (23%).
Regarding attitudinal barriers, psychiatric disability is the most stigmatizing of all disabilities (Corrigan, Larson, & Kuwabara, 2007). One national survey reported that only 19% of those polled were “very comfortable with people with mental illness,” compared to triple than rate for people with a physical disability (National Organization on Disability, 1991). People with serious mental illness experience discrimination and negative attitudes constantly in everyday life (Corrigan et al., 2003; Wahl, 1997). Employers are less likely to hire someone whom they believe has a mental illness (Berven & Driscoll, 1981; Tsang et al., 2007).
One major attitudinal barrier is the perception that people with mental illness are violent. News stories involving atrocities committed by people with mental illness reinforce this perception. Based on extensive epidemiological research over the past two decades, we have a much better understanding of the risk factors for violence in the psychiatric population (Elbogen & Johnson, 2009). 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 use or refusing to take medications (Swartz et al., 1998). Being employed significantly reduces the possibility of violence even further (Elbogen & Johnson, 2009). In sum, a very low proportion of people with mental illness have a history of violence and overall people with mental illness are no more likely to behave violently than people without mental illness.
Another barrier is the fear of losing Social Security disability benefits (MacDonald-Wilson, Rogers, Ellison, & Lyass, 2003) Many of these apprehensions are based on lack of information and misconceptions. In one survey, 85% of Social Security disability beneficiaries incorrectly believed that Medicaid benefits would be terminated if they went to work (MacDonald-Wilson, Rogers, Ellison et al., 2003). Fortunately, when provided accurate information about the impact of employment, beneficiaries substantially increase their employment earnings (Tremblay, Smith, Xie, & Drake, 2006).
Another set of barriers relate to inadequate support and encouragement from mental health professionals. Most people with serious mental illness have the same goals as the rest of society – to work, to have friends, to have a decent place to live, and to contribute to society. But many professionals do not believe that clients with serious mental illness can work (Braitman et al., 1995; West et al., 2005). Even though most clients say they want to work and list employment as a top priority, clinicians typically give highest prior to symptom control and stabilization, often disregarding client preferences (Lehman, Steinwachs, & PORT Co-Investigators, 1998). Clinicians make referrals to supported employment for only about half the clients who ask for it (Casper & Carloni, 2007).
In many states, most treatment options are in protected settings that do not embody the goal of community integration. As Mike Hogan, the chair of the New Freedom Commission on Mental Health (New Freedom Commission on Mental Health, 2003) and current director of the New York state mental health authority has said: “The poster child for (generally) ineffective day programs in the state of New York is Continued Day Treatment. In 2008, just over $150 million was spent to serve about 21,000 individuals. The program model is what it says...some programs deliver relatively short term acute services that have value, but mostly it’s clinically oriented day care. It keeps people off the streets (not unimportant in cities like New York City), but that may be the only real value” (Hogan, 2011).
Once employed, people with serious mental illness often need ongoing support and accommodations to succeed. But employers are far less willing to accommodate people with psychiatric disabilities than those with physical conditions (Hazer & Bedell, 2000). Workers with mental health conditions are half as likely to receive accommodations as those with other disabilities (Zwerling et al., 2003). This is true even though most accommodations for psychiatric disabilities cost very little or nothing, in contrast to technological and architectural changes required for other disabilities (Mancuso, 1995). According to one employer survey, the kinds of functional limitations they most commonly observe in workers with psychiatric disabilities are cognitive (e.g., following instructions, concentrating) and social (e.g., interacting, reading social cues), and to a lesser extent emotional (e.g., managing symptoms, tolerating stress) and physical (e.g., stamina) (MacDonald-Wilson, Rogers, & Massaro, 2003).
The onset of serious mental illness often occurs in early adulthood, interfering with the completion of education. Over 30% of people with severe mental illness have not completed high school (Cornell University Disability Statistics, 2007). Low educational attainment contributes to the underemployment of people with serious mental illness. The median annual income of the U.S. population without a high school diploma or equivalent is less than $20,000 (U. S. Bureau of the Census, 2007). Median income increases 33% with completion of high school and more than triples with the completion of a bachelor’s degree.
Strategies for Overcoming Barriers to Employment
Fortunately, there is a form of vocational assistance that is highly effective in overcoming these and other barriers to employment. It is called evidence-based supported employment and entails a specific, well-researched approach: a team of employment specialists and mental health workers helps individual clients identify what kind of work they would like to do, find a job as quickly as possible, and succeed on the job or move to another job, and when appropriate, working closely with employers to develop support plans for ensuring success at the job site (Becker & Drake, 2003). Employment specialists are trained to employ strategies to overcome functional limitations, for example, through teaching workers coping strategies, making accommodations, and carving out jobs that assign duties to fit capabilities (McGurk & Mueser, 2006; McGurk & Wykes, 2008; Swanson & Becker, 2010). Benefits counseling is another core component of the model.
Although developed only twenty years ago, evidence-based supported employment has demonstrated high rates of competitive employment in 15 controlled studies. All 15 of these studies showed significant results strongly favoring supported employment. Enrollment in evidence-based supported employment more than doubles the probability that a person will work, compared to usual services (Bond, Drake, & Becker, 2008). In U.S. studies, the overall success rate in achieving competitive employment is about 70%. Long-term outcomes show that about half of all clients who enroll in evidence-based supported employment become steady workers over the decade after enrolling (Becker, Whitley, Bailey, & Drake, 2007; Salyers, Becker, Drake, Torrey, & Wyzik, 2004). The benefits of employment extend to improved quality of life, greater integration into society, and less burden on the mental health system (Bond, Drake, & Becker, 2010).
Evidence-based supported employment recently has been found effective in a 23-site study of over 2000 SSDI beneficiaries with serious mental illness (Frey et al., 2011). This study demonstrates that supported employment can overcome fears about losing benefits in a group that had long received disability benefits and was not previously engaged in treatment.
Evidence-based supported employment has spread widely across the U.S. For example, a Dartmouth-led learning collaborative includes a network of state and local leaders in 13 states (Becker, Drake, & Bond, in press; Becker, Drake, Bond et al., in press). Because evidence-based supported employment is very flexible, it has been successfully implemented around the world. It has been successful in both large and small communities (Haslett, Bond, Drake, Becker, & McHugo, in press) and in a variety of ethnic and racial groups (Bond et al., 2010). It is effective with young adults, older adults, and across the spectrum of society (Campbell, Bond, & Drake, 2011).
Many lay people are surprised to learn that disability-related characteristics, such as psychiatric symptoms, cognitive impairment, and co-occurring alcohol and drug use, exert little or no influence on the capacity of an individual with serious mental illness to work, provided they are enrolled in evidence-based supported employment (Campbell, Bond, Drake, McHugo, & Xie, 2010; McGurk & Mueser, 2004).
What Can Employers Do?
The role for employers in the employment of people with serious mental illness is straightforward. Employment practices that promote the employment of this group are consistent with good employment practices and include the hiring of people on the basis of qualifications and not on the basis of stereotypes, providing consistent and supportive supervision, ensuring that the work place is not a hostile environment for any employee. The types of reasonable accommodations that an employer might be expected to make for a person with serious mental illness follow from the specific functional limitations for an individual employee. If an employee has trouble following instructions, then written instructions may be in order. Reducing complexity and ambiguity of job duties may be helpful for some employees. If an employee has interpersonal challenges, then assigning job duties that minimize these limitations might be an appropriate strategy. To maintain Social Security benefits, an employee may request part-time employment.
The dismal rate of employment among people with serious mental illness is a formidable challenge. Nonetheless, we have compelling reasons to be optimistic that people with serious mental health problems can work and that working helps them to recover from mental illness. The major barriers to employment are not immutable clinical or cognitive characteristics but rather attitudes and lack of access to support services and accommodations. The research on evidence-based supported employment is stronger than for any other mental health intervention; it is far more consistent than the evidence for medications, psychotherapy, or skills training. Access to supported employment is the key to unlocking the employment potential for this population. Supported employment services are important resources for employers, who can be more confident that their employees have behind-the-scenes help to deal with job stresses. Even in the absence of professional support, employers can play a pivotal role promoting the employment of people with serious mental illness by approaching applicants and workers as individuals and applying sound employment practices. Work accommodations typically involve pragmatic and inexpensive modifications. Employment is a win-win for people with serious mental illness, for employers, and for society at large.
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