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Work as a Priority: A Resource for Employing People who have Serious Mental Illnesses and are Homeless

What Do We Know about Employment for People who Have Serious Mental Illnesses and Are Homeless?^[1]

The vast majority of people with mental illnesses, including those with a history of homelessness, want to work and need to work. For many, work is an adjunct to their recovery from serious mental illness. Further, income from work may help them maintain residential stability. Though the United States enjoyed its longest period of economic growth throughout the 1990s, nearly 90% of people with serious mental illnesses were unemployed. This chapter provides a brief overview of what is known about employment services for individuals who are both homeless and have a serious mental illness.

Background

A renewed emphasis on employment services for people with serious mental illness, including those with a history of homelessness, is occurring throughout the United States. This reflects both the national agenda to help people who receive public assistance find work, and the call for increased job opportunities for people with mental illness by mental health advocates, homeless services advocates, and families. The experiences of mental health consumers who have been homeless reveal that even people with significant barriers can be employed successfully with the right blend of respect, encouragement, opportunity, and support.

Homelessness remains one of America’s most serious problems, particularly for people with mental illnesses. On a given day, an estimated 600,000 people are homeless^[2], approximately one-third have a serious mental illness^[3], and about one-sixth suffer from co-occurring mental illness and substance use disorders.^[4]

Racial and ethnic minorities are dramatically over-represented and often are underserved in homeless populations.

Homeless individuals frequently face numerous other barriers to achieving lives of personal, social, and economic fulfillment, among them:

• Lack of decent, affordable housing;
• Chronic poverty and unemployment;
• Fragmented, underfunded, and unresponsive service systems;
• Disabling consequences of mental health and substance use issues;
• Discouragement from recurrent homelessness;
• Impact of health-related disabilities and chronic health conditions;
• Barriers resulting from involvement with the criminal justice system; and
• Emotional effects of histories of physical or sexual abuse.

Unemployment for people with serious mental illnesses has been estimated at approximately 80-90%.^[5] Housing instability, coupled with insufficient education, job skills and employment opportunities, contributes further to the problem for these individuals. According to a recent survey, only 8% of people who are homeless, including those with serious mental illnesses, reported working at a job that they expected to last at least three months^[6]. People who were homeless indicated that insufficient income and lack of employment were among the most important factors preventing them from exiting homelessness.

In terms of income, the same survey found that those who are both homeless and experiencing a mental health and/or substance use disorder reported receiving less in total income over the previous 30 days ($337) than homeless individuals without mental illness and substance use issues alone ($427). Furthermore, 42% rated the need for assistance to find work as highest among their service needs.

It is clear that employment services must be coordinated with additional services to address these complex issues. Each day, despite obstacles, thousands of homeless and formerly homeless people with serious mental illnesses demonstrate their resilience, re-kindle their hope, seize opportunities, and achieve success in their housing, social, and work lives. However, much remains to be accomplished to make a wider audience aware of the needs, issues, and triumphs of people with mental illnesses who are or have been homeless and successfully employed.

What We Know So Far

Given the dearth of empirical studies regarding employment of people who are homeless and have serious mental illnesses, the effectiveness of programs throughout the country that provide vocational services to this population is difficult to ascertain.

What little research does exist consists primarily of vocational rehabilitation studies of homeless people that include sub-samples of individuals who also suffer from mental illnesses. In addition, the literature concerning employment services for people with mental illnesses, and the experience of providers who have adapted these services for individuals with mental illness who also are homeless, provides valuable insight into what is different about having a mental illness and being homeless when it comes to employment. This literature also can be used to help identify the kinds of services and supports that can help people with mental illnesses find and maintain employment. Throughout this guidebook, the elements and philosophies of existing employment programs for people with mental illnesses are discussed with suggested modifications for those who also are homeless.

Effective Services and Supports

Given the dearth of empirical studies regarding employment of people who are homeless and have serious mental illnesses, the effectiveness of programs throughout the country that provide vocational services to this population is difficult to ascertain.

What little research does exist consists primarily of vocational rehabilitation studies of homeless people that include sub-samples of individuals who also suffer from mental illnesses. In addition, the literature concerning employment services for people with mental illnesses, and the experience of providers who have adapted these services for individuals with mental illness who also are homeless, provides valuable insight into what is different about having a mental illness and being homeless when it comes to employment. This literature also can be used to help identify the kinds of services and supports that can help people with mental illnesses find and maintain employment. Throughout this guidebook, the elements and philosophies of existing employment programs for people with mental illnesses are discussed with suggested modifications for those who also are homeless.

Effective Services and Supports

Several authors have identified critical elements for successful employment programs. Ridgeway and Rapp^[7], Whiting^[8], and White and Wagner^[9] point to a number of program-level factors that affect employment outcomes for people with mental illnesses, including:

• Integration of employment services with other mental health rehabilitation services;
• Emphasis on consumer preference and practical assistance with finding jobs;
• Limited reliance on vocational assessments;
• Ongoing assessment and support based on individual needs and preferences; and
• Services that are flexible, and consistent with individual preferences and long-term vocational goals.

Employment Outcomes

Several recent studies provide useful information regarding the employment histories and needs of individuals who are homeless and have serious mental illness, as well as the factors that contribute to employment success. It is worth noting that the bulk of funding for these demonstration programs comes from sources other than the traditional employment sector.

Job Training for the Homeless Demonstration Program (JTHDP). From 1988 to 1995, this U.S. Department of Justice program examined the effects of providing flexible funding to nonprofit organizations offering employment, job training, and support services to homeless individuals^[10]. These programs were based on the premise that job training and placement programs work best when combined with the additional services homeless people need to overcome obstacles to employment. JTHDP sites were required to provide an array of employment services including job assessment, training, development, placement services, and post-placement/follow-up services. In addition, sites were required to provide outreach, case management, substance abuse/mental health assessment and treatment, and housing services, along with child care, transportation, and life skills training. Three of the 63 demonstration sites provided services exclusively to homeless people with serious mental illnesses.

Overall, participants with mental illnesses (60%) were more likely than other participants (49%) to report they had not been employed in the six months prior to enrollment into JTHDP. They also were more likely (56% versus 46%) to report no earnings in the six months prior to intake. Despite these disadvantages at the outset, those with mental illnesses were just as likely to be placed in a job (33% versus 36%) as were other participants and were more likely to remain employed 13 weeks later (60% versus 50%).

The Next Step – Jobs (NSJ) Initiative. This three-year demonstration program began as a partnership among the Corporation for Supportive Housing, the Rockefeller Foundation, and 20 non-profit supportive housing providers in San Francisco, New York, and Chicago, to enhance employment opportunities for their tenants.^[11],[12] All programs served homeless or recently homeless people, and were established within urban community-based organizations with strong links to other agencies in their communities.^[13]

More than one-third of the 3,200 supportive housing residents involved in NSJ were identified as needing mental health services. These programs stressed that job training and placement programs worked best when combined with the additional services homeless people need to overcome obstacles to employment.

Results indicated that 8% to 21% of participants with mental illnesses were employed at intake. Although most participants with mental illnesses worked at least once during the initiative, they were more likely to hold part-time positions and hold fewer jobs overall. Moreover, NSJ participants with mental illnesses appeared to be more likely to have jobs within the participating organization.^[14],[15] Further, the supportive housing industry has proven to be a rich source of jobs; and individual employment appears to be most effective when access to work is combined with raised expectations, flexible opportunities, and encouragement.^[16]

ACCESS Demonstration Project. This Federally funded study examined the effect of service system integration in helping homeless people with serious mental illnesses exit homelessness and improve their health status, service use, and quality of life.^[17] Over the four-year study period, more than 7,000 homeless people with serious mental illnesses received intensive outreach and case management services for up to one year.

In examining ACCESS consumers’ perception of service needs, Rosenheck and Lam^[18] found that employment was ranked relatively low among people who were homeless at the time, although 56% indicated that help with job training or finding a job was an important service need. However, only 15% of these participants reported receiving job assistance services in the 60 days prior to contact with ACCESS outreach staff. Given these findings, Cook and her colleagues further examined client-level data from the ACCESS project to determine whether participants experienced improved employment outcomes as a result of the services received through the ACCESS program.^[19]

They found that just under one-third (30%) of ACCESS participants never had held a full-time job at any time in their lives before entering the ACCESS program. Alternatively, in the twelve-month period prior to ACCESS participation, over a third (36%) reported some type of work for pay, indicating motivation to secure gainful employment among this group. ACCESS clients who were employed were more likely to be young men with some college education and shorter histories of homelessness. They also tended to have diagnoses of depression and never to have been hospitalized for a mental problem.

Overall, ACCESS participants’ vocational outcomes steadily improved during their first year after entering ACCESS services. The proportion who had worked in the past 30 days rose from 18% at baseline to 22% at one year. Among those who worked, the proportion employed full-time rose from 24% to 32%. The mean hourly wage also increased from $5.56 at baseline to $5.94 at 12 months. Likewise, the average number of hours worked per week rose from 20 to 26 hours. Estimated mean monthly earnings rose significantly, from $259/month to $469/month at twelve-month follow-up.

Despite the fact that more than three-quarters (78%) were not in the labor force at baseline, 12 months after entering the ACCESS program, only 8% were receiving job training or education services, and 9% were receiving job development. In comparison, 71% reported receiving mental health services, 29% substance abuse services, 23% benefits and entitlements assistance, 19% housing assistance, and 15% legal services.

Outcomes for those receiving employment-related services were instructive. Individuals who reported receiving job training services were two-and-a-half times more likely to be working, while those who reported receiving assistance with finding a job were two-and-one-third-times more likely to be working for pay at 12-month follow-up. Vocational services were associated with positive outcomes regardless of severity of mental impairment or substance abuse difficulties. ACCESS participants faced an array of disadvantages including histories of homelessness, mental illness, and in many cases, substance abuse problems. Like participants in similar studies, ACCESS participants’ poor work histories and lack of post-secondary education were additional barriers to employment. Further, relatively few received any vocational or educational services in their first year after becoming homeless.

At the same time, the ACCESS cohort showed modest, steady improvement in employment status, achievement of full-time employment, hourly wage, hours worked per week, and estimated monthly earnings, indicating the enhanced employment potential of this group after only one year of coordinated service delivery.

Another noteworthy finding was the association between receipt of vocational services and greater likelihood of employment at 12 months. This link remained significant even when controlling for diagnosis, mental illness and substance abuse status, and demographics, suggesting that formerly homeless people with serious mental illnesses may benefit significantly from vocational rehabilitation efforts. At the same time, the results indicated the need for rehabilitation outreach to this population.

Employment Intervention Demonstration Program (EIDP). This SAMHSA program revealed a positive association between receipt of services and employment for people with mental illnesses.

Preliminary findings of the eight-site study indicated that 51% of individuals who received services for 12 months were employed, compared to 28% of those who received services for three months.^[20] Of the study’s 1,648 participants, 100 (6%) reported being homeless at any interview; 17 of those reported being homeless at two interviews.

Though EIDP program participants had significant levels of disability and impairment, 86% of all jobs held were at the minimum wage or above; the average amount earned per employed client was $4,894.

Researchers tested a number of vocational models, including supported employment, Individual Placement and Support (IPS), and the Program for Assertive Community Treatment (PACT) vocational model, each of which is described in Chapter Three of this guidebook.

Urban vs. Rural Employment Program Considerations

While best practices for employing homeless people with mental illnesses in urban settings are just beginning to be identified, even less is known about what works in rural settings. Rural-based employment programs have a number of special impediments to overcome:

• Consumers often must travel long distances from their homes to their places of employment; public transportation often is insufficient or non-existent.

• Opportunities for employment may be fewer if small businesses are the major source of employment.

• The development of supported or transitional employment programs may be difficult, since the number of enrollees often is insufficient to recoup the costs of hiring job developers, job coaches, etc.

• Because small employers generally do not want a high turnover rate, job development on behalf of consumers who are homeless becomes more difficult.

A report summarizing work and education programs for people with serious mental illnesses in seven Western states identified common themes relevant to both rural communities and urban settings:^[21]

• Interagency collaboration is essential.

• Social Security benefits management, information, and advocacy are important considerations to address consumers’ fear about loss of benefits while working.

• A "fast track" to work often is more effective and preferable than are pre-vocational training and sheltered work.

• Data systems to track service costs and outcomes are critical for evaluation.

• Many communities need public education about consumer employability.

• Programs often have limited resources for employment.

These findings also were supported in a 10-site research study examining competitive employment outcomes among people with serious mental illnesses in both rural and urban settings in New Hampshire. The SAMHSA-funded Employment Intervention Demonstration Projects (EIDP)^[22] found that positive vocational outcomes were associated with the presence of a number of factors including the amount of resources a program was provided, the importance of a program among the agency’s priorities, and the emphasis on helping people to obtain competitive employment other than reliance on pre-vocational programs. The study suggests that the presence of these factors was more important to achieving positive employment outcomes for consumers than were local economic factors, difference in case mixes among programs, or differences in providers’ relationships with the State Department of Vocational Rehabilitation.

Another recent study of one of the eight EIDP programs described implementation issues in delivering a combined Program for Assertive Community Treatment (PACT)/Individual Placement and Support (IPS) approach in a rural community in South Carolina.^[23] Among the many obstacles encountered were problems in recruiting, training, and retaining qualified staff, and adhering to the fidelity standards of each approach within a combined program structure. Despite these difficulties, 60% of program enrollees held at least one job after they entered the program and the employment rate fluctuated between 25%-40% over the two-year study period.

Clearly, employment programs designed for rural communities must be flexible, mobile, and able to withstand the higher costs that may be associated with serving relatively low numbers of enrollees. As discussed in more detail in Chapter Three, social enterprises and self-employment approaches increasingly are being viewed as effective program responses to meet the needs of consumers in rural communities. Furthermore, the development of social enterprises adds to the number of jobs in the local marketplace and may be a way of addressing chronic unemployment in rural communities.^[24]

Chapter Summary

Employment is an important, but often neglected, goal for people who are homeless and have serious mental illnesses. The remedies to employing this population do not lie in formulaic solutions, but rather require existing service programs to make employment as high a priority as are housing or treatment. By receiving vocational services within a comprehensive system of care, homeless people with serious mental illnesses may attain the resources they need to remain permanently housed.

When designing vocational programs for homeless people with serious mental illnesses, their limited or intermittent work histories, as well as their significant and continuing mental health, substance abuse, and housing assistance needs are important factors to keep in mind. With safe, affordable housing, support services (e.g., case management, medication, social skills training), and employment services, these individuals can achieve job stability.^[25]

To assist people with multiple needs, services targeted at goals other than employment (e.g., clinical symptom control, receipt of benefits and entitlements, acceptable housing) are necessary but not sufficient to further consumers’ vocational achievement. The adaptation of currently popular vocational rehabilitation models such as supported employment—particularly variants designed for people with mental illnesses (e.g., individual placement and support, and clubhouse models)—need to be considered for people with severe mental illnesses. These programs, which have demonstrated improved vocational outcomes for people with serious mental illnesses,^[26] may provide people with the work skills and job supports needed to secure and retain paid employment.

Chapter 1 Notes

^[1] This Chapter contains material adapted from: Cook, J.A., Pickett-Schenk, S.A., Grey, D., Banghart, M., Rosenheck, R., and Randolph, F. Vocational outcomes among formerly homeless individuals with severe mental illness in the ACCESS program. Psychiatric Services 52(8):1075-1080, 2001; and Kaufman, C.L. "Employment of people who are mentally ill and homeless: A review of trends and practices." Paper prepared for the CMHS Sponsored Employment and Vocational Rehabilitation for Homeless People with Serious Mental Illnesses Workshop, Washington, DC, September 1999.

^[2] Interagency Council on the Homeless. Priority: Home! The Federal Plan to Break the Cycle of Homelessness. Washington, DC: U.S. Department of Housing and Urban Development, 1994.

^[3] Federal Task Force on Homelessness and Severe Mental Illness. Outcasts on Main Street: Report of the Federal Task Force on Homelessness and Severe Mental Illness. Washington, DC: Interagency Council on the Homeless, 1992.

^[4] Fischer, P.J., and Breaky, W.R. The epidemiology of alcohol, drug, and mental disorders among homeless people. American Psychologist 46(11): 1115-1128, 1991.

^[5] Anthony, W.A., and Blanch, A. Supported employment for people who are psychiatrically disabled: An historical and conceptual perspective. Psychosocial Rehabilitation Journal 11(2): 5-19, 1987.

^[6] Burt, M.R., Aron, L.Y., Douglas, T., et al. Homelessness: Programs and the People They Serve. Washington, DC: Interagency Council on the Homeless, 1999.

^[7] Ridgeway, P., and Rapp, C. The Active Ingredients in Achieving Competitive Employment for People with Serious Mental Illness: A Research Synthesis. Lawrence, KS: University of Kansas School of Social Welfare, 1998.

^[8] Whiting, B. Employing the Formerly Homeless: Adding Employment to the Mix of Housing and Services. New York, NY: Corporation for Supportive Housing, 1994.

^[9] White, A., and Wagner, S. "Effective strategies: Employment for homeless people with serious mental illness." Paper prepared for the CMHS Sponsored Employment and Vocational Rehabilitation for Homeless People with Serious Mental Illnesses Workshop, Washington, DC, September 1999.

^[10] Trutko, J.W., Barnow, B.S., Kessler-Beck, S., et al. Employment and Training for America’s Homeless: Final Report of the Job Training for the Homeless Demonstration Program. Washington, DC: U.S. Department of Labor, 1997.

^[11] Dressner, J., Fleischer, W., and Sherwood, K.E. Next Door: A Concept Paper for Place-Based Employment Initiatives. New York, NY: Corporation for Supportive Housing, 1998.

^[12] Rog, D., Holupka, C.S., Brito, M.C., et al. Next Steps: Jobs Second Evaluation/Documentation Report. Washington, DC: Vanderbilt Institute for Public Policy Studies, Center for Mental Health Policy, 1998.

^[13] Long, D. A., Doyle, H., and Amendolia, J.M. The Next Step: Jobs Initiative Cost-Effectiveness Analysis. New York, NY: Corporation for Supportive Housing, 1999.

^[14] Rog, Holupka, Brito, et al., op.cit., p. 8.

^[15] Parkhill, P. Vocationalizing the Homefront: Promising Practices in Place-Based Employment. New York, NY: Corporation for Supportive Housing, 2000; and Fleischer, W. and Sherwood, K.E. The Next Wave: Employing People with Multiple Barriers to Work: Policy Lessons from the Next Step: Jobs Initiative and Next Wave Symposium. New York, NY: Corporation for Supportive Housing, 2000.

^[16] Rog, Holupka, Brito, et al., op.cit., p. 8.

^[17] Randolph, F., Blasinsky, M., Leginski, W., et al. Creating integrated service systems for homeless people with mental illness: The ACCESS program. Psychiatric Services 48: 369-373, 1997.

^[18] Rosenheck, R., Lam, J.A. Homeless mentally ill clients and providers: Perceptions of service needs and clients’ use of services. Psychiatric Services 48(3): 381-86, 1997.

^[19] Cook, Pickett-Schenk, Grey, et al., op.cit. p. 7.

^[20] Preliminary findings of the Employment Intervention Demonstration Program. Center for Mental Health Services. Available at http://www.psych.uic.edu/EIDP.

^[21] Kaley-Isley, L. Work in the West: Work and education programs for people with serious mental illness. The West Link, 18(2), June 1997.

^[22] Drake, R. E., Fox, T.S., Leather, P.K., Becker, D.R., Musumeci, J.S., Ingram, W.F., and McHugo, G.J. Regional variation in competitive employment for people with severe mental illness. Administration and Policy in Mental Health, 25(5): 493-504, 1998.

^[23] Meisler, N. and Williams, O. Replicating effective supported employment models for adults with serious mental illness. Psychiatric Services, 49(11):1419-1421, 1998.

^[24] Raveloot, C., and Seekins, T. Rehabilitation counselors’ attitudes toward self-employment as a rehabilitation strategy. Rehabilitation Counseling Bulletin 39(3): 189-201, 1994.

^[25] Whiting, op.cit., p. 8.

^[26] Ridgeway and Rapp, op.cit., p. 7.

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