Employment: A Workable Option Despite Mental Illness

Dr. Judith Cook

"Very few people with serious mental health disabilities are working, and yet employers consistently tell us that workers with these disabilities do a good job, that their needs are very similar to those of other workers, and that they are a productive segment of the labor force," said Judith A. Cook, Ph.D., a professor in the Department of Psychiatry at the University of Illinois at Chicago.

Dr. Cook spoke at SAMHSA's conference this past fall, "Hand in Hand: It's Worth the Investment! A National Summit on Best Practices for Mental Health in the Workplace." (See SAMHSA News, Summit Promotes Mental Health in the Workplace.)

"The lack of employment among consumers of mental health services reflects a tremendous loss of productivity and potential for these individuals personally and for our society economically," Dr. Cook added.

This sentiment is shared by many stakeholders and advocates in the mental health field. In 1995, SAMHSA's Center for Mental Health Services(CMHS) launched a study, the Employment Intervention Demonstration Program (EIDP), that seeks to answer the question: What do people with psychiatric disabilities need so that they can successfully obtain and retain employment?

Finding answers is a national priority as reflected by related Federal efforts including the Ticket to Work and Work Incentives Act of 1999 and the New Freedom Initiative. (See SAMHSA News, Fall 2001.)

For 5 years the EIDP tested a host of innovative interventions at eight sites, and now the early results are starting to yield significant findings.

"When CMHS launched this study, there was a school of thought that if you just offer people more clinical services, they will get well and go to work," said CMHS project officer Crystal Blyler, Ph.D. "But what the investigators found was very different."

One of the study's most salient findings is that both clinical and vocational services are necessary for people to find and keep employment; and further, that people who receive well-integrated and coordinated vocational and clinical services have greatly improved outcomes compared to those receiving nonintegrated services.

In fact, says EIDP's principal investigator Dr. Cook, such integration and coordination are "vital to success."

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The Study

More than 90 percent of the EIDP participants had a diagnosis in the schizophrenia spectrum, major depression, or bipolar disorder, generally considered among the most serious mental illnesses. Two-thirds of the participants had at some point in their lives experienced a substance abuse disorder. More than 90 percent were taking prescription medications.

Each of the eight demonstration sites designed its own intervention using a variety of innovative approaches. (See SAMHSA News, Vocational Models Tested). Most of the approaches were a variation of supported employment and offered a combination of clinical and vocational services, Dr. Cook said. A common protocol allowed data about outcomes to be compared despite differences across sites.

Dr. Blyler emphasized that the study focused on "competitive employment. Previous studies included volunteer jobs, sheltered workshops, and housework. It creates a much higher bar to surmount when a job pays at least minimum wage, is open to anyone, and is in a mainstream setting," she explained.

Participants were followed for 2 years and assessed on an ongoing basis.

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Results

In the first eight quarters of their EIDP participation, more than 1,600 participants held 2,230 jobs (an average of 2.2 jobs per worker), earned $4.7 million, and worked 820,293 hours.

At the end of the 2-year period, 64 percent of those receiving EIDP services had worked while participating in the program. "For most participants," Dr. Cook said, "subsequent jobs lasted longer than their first job."

Eighty-six percent of all jobs held were at minimum wage or above, paying an average of $5.91 per hour. Participants worked an average of nearly 20 hours per week.

These results demonstrate that given the proper services, people with mental illnesses "will enter the labor force and they will stay there," Dr. Cook said.

The successes documented by the program were tempered by certain other findings: Most of the jobs were for lower-skilled positions that were not very interesting or fulfilling and did not offer a path to upward mobility. Less than one-third of the full-time jobs held by participants carried any sick leave, vacation, or health insurance benefits.

The latter is particularly serious because people with mental illness often face the loss of Supplemental Security Income, Social Security Disability Insurance, and Medicaid if they earn money beyond the ceiling at which these benefits pay.

"Consumers of mental health services need jobs that offer more than just a survival wage," Dr. Cook said. "They need to be able to replace the income that is threatened by the loss of financial and medical benefits as they experience employment success."

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Recommendations

Drs. Cook and Blyler indicated that the results suggest several recommendations for efforts to encourage employment among people with mental illnesses:

• Vocational rehabilitation services should be offered in settings that integrate them with clinical services and require employment for minimum wage or above.

• When needed and desired, vocational support should be ongoing.

• Vocational supports must be combined with educational services so that jobs will be more interesting, higher paying, and more conducive to upward mobility.

• People should be matched to jobs they prefer.

• Vocational rehabilitation must provide information and support regarding Government entitlements and must include financial planning.

• Vocational service providers should assist in negotiating reasonable accommodations with employers and help to address workplace stigma and discrimination.

"We now have research to support these recommendations and the data to back them up," said Dr. Cook. "We can use these to work for a better service system."

Dr. Cook observed that "there was not that much difference in outcomes between the different enhanced vocational approaches. What made the most difference to participants was getting a lot of vocational services over a long period of time."

She concluded, "In this program, we were able to move people into the level of the working poor. What remains is to refine and disseminate the methods and remove the barriers and disincentives so that they will move into the working, thriving population."

For more information on the EIDP and resources, see Employment Program Resources.

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