Establishing employment services as a priority for persons with long-term mental illness.
At the personal level, each individual must have the opportunity to develop and act on his or her interest in employment. There is a prevailing assumption among many who work with persons with mental illness that employment is at best a secondary concern. Indeed, many consumers of mental health services remember all too well when they were first told they could never work and when, more recently, they were told they could not work yet.
At the programmatic level, many community mental health centers, psychosocial rehabilitation programs, and private psychiatric settings must begin to re--examine the ways in which they can make the goal of employment an important focus of their services.
At the policy level, a wide range of federal, state, and local agencies need to explore ways in which funding priorities, regulatory strictures, and staffing patterns can promote, rather than inhibit, the hope of most consumers to find work.
Because those with serious mental illness are today a younger and less institutionalized group with more peerappropriate life goals than ever before, it is irresponsible to continue to offer programming for them that does not have at its core a recognition of the role that employment must play in their lives.
It should be noted that the employment needs of this group have not gone entirely unnoticed, and indeed there have been a number of initiatives over the past several years to prioritize work. Psychosocial rehabilitation programs, for instance, have frequently developed transitional and supported employment programs that help people to work. The principles of these programs--reasonably rapid placement into a real job for real pay, intensive initial support on and off the job, and persistent ongoing support thereafter--have demonstrated considerable effectiveness in helping people to establish themselves as workers rather than as patients. In addition, both the Rehabilitation Services Administration (RSA) and the National Institute on Disability and Rehabilitation Research (NIDRR) have funded a variety of professional training and services research projects to help establish the importance of employment programming for this group. Also, at the Center for Mental Health Services (within the Department of Health and Human Services) there has recently been a major commitment of research and demonstration dollars to promote and assess vocational interventions for those with long-term mental illness.
NIDRR has funded three Rehabilitation Research and Training Centers (at Boston University, the Thresholds Programs in Chicago, and at Matrix Research Institute) to explore varying aspects of this issue, and each of the three participated in an NIDRR-sponsored Consensus Conference in September 1992 to examine past research findings and future research needs in this area.
Nonetheless, nearly everyone with a long-term mental illness remains unemployed. In the process of prioritizing employment, advocates, providers, and policymakers will need to address a number of central concerns about work for persons with long-term mental illness. This paper attempts to summarize those concerns, for many of them will serve as benchmarks for our progress over the next decade.
Work itself must be redefined. Often enough, discussions about the work potential of people with long-term mental illness begin with a question about whether or not the majority of those who want to work can indeed do so. This question is more readily answered positively if the term "work" is redefined, and redefined so that it corresponds to the broader society's changing conception of employment. The older paradigm of work--a 9 to 5 job, 5 days a week, year in and year out, with progress steadily made up the organizational and financial ladder--no longer serves in our society as the only definition of employment. Indeed, work patterns have altered dramatically over the past few decades and now embrace a wider array of work styles. Many people do not work 7 or 8 hours a day, Monday through Friday, either because of personal choice or limited job opportunities. Increasing numbers of workers do not stay in a single job or company or career their whole lives; there is broader recognition of the importance of job mobility, time off, and educational programs to the individual's sense of personal fulfillment; and employers are more willing to allow the supports that some people may need (e.g., child care, leaves of absence, employee assistance program counseling, etc.) in order to make their best contribution to the work force.
It is somewhat anachronistic, it would follow, to only look for work potential in those with long-term mental illness who can survive a 40-hour week for a year or more, although there are many persons with disabilities for whom such a job is just right. Many others, however, will want part-time work, periodic work, or work where they can receive the supports they need to succeed at the job. When work itself is redefined, we can say with confidence that the vast majority of people with long-term mental illness can indeed work.
Educating many constituencies about the work potential of people with mental illness must be an ongoing responsibility. Despite a wealth of research and anecdotal evidence about the work potential of people with long-term mental illness, many of the constituencies that should be promoting work opportunities fail to do so. A concerted effort to build a broad consensus around the importance of work is needed. Thus:
* Mental health professionals--therapists and counselors, case managers and housing specialists, etc.--need to pay greater attention to their clients' employment aspirations.
* Consumers of services--after years of accepting their counselors' assertions that they can't work--need to be more assertive in exploring their vocational options.
* Family members--who are often quite ambivalent about the challenges of employment--need an exposure to both the possibilities and the rewards of work for their relatives.
* VR counselors--who remain dubious about the vocational potential of those with mental illness--need more experience with success.
* Employers--who are only recently coming to terms with the Americans with Disabilities Act--need education on how to integrate this group into the work force.
* Policymakers--who shape budget priorities and program regulations--need to reassess the impact of their decisions on client work incentives.
A broad review of the work potential of people with long-term mental illness should also include a frank discussion of whether or not those with mental illness should work. In addition to offering rehabilitation opportunities, how strongly should counselors, family members, and others encourage work, regardless of the financial or social disincentives that may apply?
Employment issues should be raised early in the overall rehabilitation process. Little progress will be made in encouraging clients to pursue vocational options if work opportunities are held in abeyance while therapists and counselors, case managers, and families work on related issues; the nature of long-term mental illness is such that there are almost always therapeutic hurdles to be faced, medication issues to be resolved, and housing or financial or social challenges to be met. It has been the habit of the field to insist that all of these problems be solved before work issues are addressed. This, of course, has tended to interminably delay both rehabilitation and employment and has only served to intensify the perception (of the client as well as the family and the counselors involved) that the client cannot work. The earlier that work is presented as a priority issue and employment is promoted as an immediate goal, the more likely it will be that the individual will be able to establish a primary identity as a worker. Only in a few cases would such an effort be contra-indicated.
Individuals who are dually diagnosed--with mental illness and a secondary disabling condition--must also be encouraged to work. Although there is growing awareness of the numbers of people with psychiatric disabilities who have secondary diagnoses--particularly drug and alcohol abuse problems--the expanding number of programs designed for those with dual diagnoses rarely include a vocational element. One can examine the current literature on mental health/substance abuse cooccurrence and only occasionally see a reference to employment programming. There is an urgent need to insure that the emerging programs for this population also make employment goals central to their operations.
Employment services that emphasize integration into the workplace should become the standard for replication. Although the research literature on rehabilitation interventions for people with long-term mental illness is still limited, there is growing evidence that integrated employment, i.e., programs that shift the locus of rehabilitation programming from the sheltered environment of the workshop to the more demanding hurly-burly of actual work environments, succeeds best. Transitional and supported employment programs have risen from the realm of exciting experiments to become proven approaches; yet, these are relatively scarce across the country. While the terms "transitional" and "supported" have very broad meanings, the principles that underlie the best of these programs--rapid movement into a real job, intensive support for stabilization, and ongoing assistance thereafter--are the critical components.
Consumers should be playing a broader role within the service delivery community. There are a number of ways in which the human services sector, and particularly the mental health and VR professions, can shape roles for people with mental illness. First, there must be a concerted effort to insure that jobs within the mental health and VR sectors are available. While not everyone who has had a major mental illness makes a wonderful counselor, job coach, or case manager, many of those who have received services have both the knowledge base and the positive empathy which can be invaluable in assisting others to make the leap to employment. Programs need to examine the formal policies and informal discouragements that have kept them from hiring persons with mental illness into their agencies, and they must insure that the training, supervision, and supports these new hires will require are in place. At the same time, the nation has a number of outstanding consumer-operated and consumer-staffed agencies that offer a wide range of rehabilitation services, and these deserve evergrowing support.
The disincentives to employment embodied in social welfare and healthcare policies must be removed. Certainly one of the most widely felt disincentives to employment has been the way in which the Social Security Administration's policies have interacted with the absence of a national healthcare program. Most people dependent upon Social Security Insurance (SSI) or Supplemental Security Disability Income (SSDI) are afraid that if they are successfully employed they will lose their access to the medical services (including behavioral healthcare) essential to their lives in the community. For the most part, the work incentive provisions of the Social Security Act have made these fears unrealistic (most of those with long-term mental illness can retain their Medicaid eligibility long after the financial benefits run out), but the complex rules that govern the system are little understood and far more needs to be done to insure that consumers, families, counselors, and therapists have a more complete understanding of these rules.
Vocational programs must begin to place clients in better jobs. Fully three-fourths of the jobs found through transitional and supported employment programs are entry level, often at minimum wage rates and with few healthcare or other benefits. This is unsatisfactory; for employment programming to be successful in the long run, the array of jobs available to people with long-term mental illness must mirror the types of jobs available to the general population. While a strong argument can be made that many clients can utilize entry level positions as steppingstones to more demanding work, it is unclear how many people could (and should) move directly into more intellectually or physically demanding positions. What is clear is that there is a growing consumer constituency dissatisfied with their options and wary that far too many clients are being steered into dead end jobs.
Advocates for those with mental disabilities should play a stronger role in local economic development activities. All across the country, communities are focusing upon jobs. From the federal level, where job creation strategies are a priority of the current administration, to the state level, where the taxing strategies of one state to attract business vie with economic incentives in another state, the nation is concerned about putting its people to work. Advocates for those with psychiatric disabilities should be a part of these larger discussions about the economy, seeking to insure that the jobs developed are equally or competitively available to people with mental illness.
Federal and state policies must begin to frame appropriate financial strategies to fund long-term supports for the working client. Those with long-term disabilities require long-term supports. Although this would seem a prerequisite for the success of programs serving people with periodic and episodic recurrences of mental illness, current policies nonetheless have not been able to assure those who do work will have the ongoing supports they may need. The rate of job loss among those with long-term mental illness is high, and the loss of one job typically results in a decision to either drop out of the job market or to re-enter the VR system.
There are alternatives: It may be possible for ongoing support to help the individual avoid job loss altogether; or, for those who do lose jobs, short-term help in finding another job may permit the individual to quickly re-enter the job market, rather than to re-enter the VR system. The goal of the vocational programs is not so much to help the individual to keep a single job as it is to help the worker with psychiatric disability to establish a long-term attachment to the labor market, to insure that those with long-term mental illness have a growing and strengthening sense of themselves as workers.
Unfortunately, there is little consistent financial support for the kind of job coaching (on or off the job) that many people will need in order to form that attachment, and many agencies are hard pressed to find fiscal support for long-term services. In a very fundamental way, we continue to make employment a second class priority.
The agenda is, as usual, a crowded one: professional and consumer education, the removal of financial disincentives, the restructuring of programs and policies, and the development of the financial resources for long-term support are all critical aspects of a genuine effort to assist persons with long-term mental illness to work. The growing emphasis within both the mental health and vocational rehabilitation professions on the importance of consumer-directed services will remain little but a phrase unless those systems become more responsive to the most pressing and fundamental requests from consumers for jobs.
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|Date:||Mar 22, 1995|
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