Research on Employment for Persons with Severe Mental Illness: Volume 13

That opportunities for gainfully employing persons with severe mental illness should be maximized is a position around which there is virtual unanimity. But identifying obstacles to this goal and ways to overcome them is another matter – one that, in different forms, has engaged members of a number of disciplines. In this volume we bring together diverse disciplinary perspectives from psychology, psychiatry, statistics, occupational therapy and psychiatric rehabilitation research, sociology and labor economics to discuss a range of topics related to employment and mental illness. The papers included here span a range of domains, from “person – level” questions of person-environment fit to the broad societal effects of labor markets. Evaluative perspectives on various approaches that the mental health community has taken in seeking to advance the employment of persons with serious mental illness are also examined. While we will not claim to have represented every perspective currently in play in research on employment for persons with mental illness, we feel this volume represents the multi-disciplinary flavor of the small but growing research establishment in this area.

The last several decades have brought about a paradigm shift in the conceptualization of disability (Fougeyrollas & Beauregard, 2001; Williams, 2001). The traditional medical model considers disability to be a characteristic of the person, situated within the body. In the medical model view, disability, or difficulty functioning in major life domains, results from bodily impairments associated with a medical diagnosis or disorder, and a medical intervention or treatment is required to “correct” the problem of the individual. Alternatively, contemporary social models argue that disability is a social construction. In the social model view, disability is created by social policies, stigma and other barriers within the social and physical environment. Changes in attitudes and policies and the removal of barriers are needed to “correct” these environmental problems.

Significant unemployment among adults with serious mental illness (SMI) is a well-documented problem. Estimates suggest that as many as 85% of adults with SMI are unemployed at any one time (Anthony & Blanch, 1987; Milazzo-Sayre, Henderson & Manderscheid, 1997; Rogers, Walsh, Masotta & Danley, 1991). Recent years have seen advances in the development and dissemination of a variety of supported employment services for adults with disabilities. When people with SMI are enrolled in services with a specific employment focus, they achieve employment outcomes (e.g. job placement rates, job tenure) superior to those achieved by people receiving standard mental health services such as day treatment (Bond et al., 2001; Cook, 2003). Supported employment is now considered an “evidenced-based” practice (Bond et al., 2001). Although supported employment approaches vary, evidence-based services share common principles, including (1) prioritizing client preferences for type and timing of work; (2) providing in-vivo and follow-along supports as long as needed; (3) viewing work attempts as part of a learning opportunity; (4) having a commitment to “competitive” employment as an attainable goal; and (5) not relying on pre-vocational training, day treatment or sheltered workshops (Bond et al., 2001; Mowbray, Leff, Warren, McCrohan et al., 1997; Ridgeway & Rapp, 1998).

Employment has been identified as a significant goal for many homeless persons with mental illness. However, treatment plans for this population typically focus on housing and mental health needs, and neglect to assess individuals’ desires and abilities to achieve and maintain paid employment. This chapter describes the work experiences of the Chicago cohort of the Access to Community Care and Effective Services and Supports (ACCESS) project.

The relationship between employment services and employment outcomes has been the subject of research for a number of years (Bond et al., 2001; Drake et al., 1996). More recently, the competitive employment of service recipients has become an important indicator of community mental health program and service system performance. The National Association of State Mental Health Program Directors’ President’s Task Force on Performance Measures, for instance, recognized the importance of monitoring employment rates for adults with serious mental illness: “For payers, this is the payoff…Monitoring this outcome for populations with mental illness…is critical. This was considered a critical outcome to track.” For similar reasons, the new federal Performance Partnership (Block) Grant program (Federal Register, 2002) requires annual reporting by all states of employment rates for recipients of publicly funded mental health services.

Mental disorders are common and associated with substantial levels of work disability. Relative to persons with most types of physical impairments, persons with mental disorders have lower employment rates and lower mean wages, and experience greater discrimination in the workplace (Baldwin, 1999, 2000; Baldwin & Johnson, 1995, 2000). Persons with mental disorders have lower socioeconomic status, on average, and greater risk of living in poverty, than persons with physical disorders (Dohrenwend et al., 1992). By 1999, mental disorders had supplanted back cases as the health condition most frequently cited in employment discrimination charges filed under the Americans with Disabilities Act of 1990 (Moss et al., 1999).