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Position Statement 31: Employment Development of Services for Adults in Recovery for Mental Illness

Policy Position

To have and hold a job at the highest level is a crucial source of dignity and purpose for many people. For individuals with mental and substance use conditions it is also a key supporting factor in their recovery. Stemming from support for the Americans with Disabilities Act of 1990 1 and its mandate to eliminate unfair treatment of and discrimination against qualified workers with disabilities, Mental Health America asserts that individuals with mental and substance use conditions who have an aspiration and a need to work should have access to employment resources that provide needed supports in order to seek, obtain, and maintain employment in their community.

Background

Most people want to work and identify themselves by their work. Most people who have mental health and substance use conditions also want to work. The ability to work and contribute to society is often an integral part of recovery for people with mental illnesses and addictions. Employment services can help people to achieve recovery, but only if they lead to a job. Individuals with mental health and substance use conditions have a long history of exclusion from employment opportunities and of employment preparation that rarely concluded with a real job. For decades, people with behavioral health disabilities were discouraged from working, fearing that deadlines and other stresses might overwhelm them. To the contrary, most people who work show improvement in their mental health and greater satisfaction with their lives.2

Yet all too often, people with mental health and substance use conditions are unable to access employment services and gain employment. The national unemployment rate for persons with serious mental illnesses hovers at 90 percent, and less than 25 percent of people with schizophrenia receive any form of vocational assistance3. Of the more than six million people served by state mental health authorities across the nation, only 21 percent are employed. Despite this exceptionally low rate, only ten percent of the people employed received evidence-based supported employment services.4

Education is closely linked to opportunities for work, yet individuals with mental and substance use disorders have the lowest educational attainment level of any disability group. Mental illnesses often begin when young adults are completing high school and looking at future opportunities and career plans, and education suffers accordingly.5

For individuals with serious mental illness, obstacles to gaining and keeping a job include the fear of losing healthcare insurance by losing eligibility for the SSI or SSDI programs, stigma and discrimination at the job site, lack of housing and diminished self-confidence. Traditional vocational rehabilitation services do not provide the appropriate level of support that individuals with a mental illness or addiction need in order to overcome these barriers to employment. For those recovering from substance use conditions, vocational histories may vary, ranging from being chronically or permanently unemployed to being continuously employed. Unemployed clients in substance abuse treatment programs face many challenges and obstacles in obtaining and keeping jobs. Employed clients may need help with finding more satisfying work or with identifying and resolving stresses in the work environment that may exacerbate ongoing substance abuse or precipitate a relapse.

The barriers consumers face may exist within themselves, in interpersonal relations with others, or in coexisting medical and psychological conditions. Barriers also stem from society, scarcity of lower level jobs, and prejudice against employing people with mental health and substance abuse disorders and a criminal history. 6

According to a recent survey, 90 percent of companies use criminal background checks in making hiring decisions.7Another study found that a criminal record reduces the likelihood of a job callback or offer by nearly 50 percent. Considering that more than 30% of youths have an arrest record by the time they turn 23,8 the implications of barring people with criminal histories from employment are staggering. Many jurisdictions around the nation have begun reforming their hiring practices to reduce these negative consequences.

Principals for Employment Services

  • Programs should center on a supporting and maintaining the consumer's individual preferences for the jobs she or he wants, with job development tailored to her or his own career interests and capabilities.
  • Psychosocial rehabilitative services should be built upon a consumer's strengths and abilities while de-emphasizing illnesses and disabilities.
  • Developing confidence and competency toward employment should be an integral part of recovery programs for individuals with mental and substance use conditions.
  • Employment programs should focus on moving consumers out of the category of "working poor" and into economic self-sufficiency.9
  • Personalized benefits planning should be provided. It is particularly important that persons with mental health and substance abuse condition understand the effect of work on their benefits and not be discouraged from working by "myths". 10

Evidence-Based, Best and
Promising Practices

  • Programs should follow the ten Research-Based Principles of Successful Vocational Rehabilitation Strategies outlined in Research-Based Principles of Successful Vocational Rehabilitation Strategies by the National Research and Training Center on Psychiatric Disability, University of Illinois at Chicago.11
  • Core components of employment services should include continuing vocational assessment, job development, job placement, and ongoing job support, that emphasize opportunities for career growth.
  • Job placement should provide an opportunity for advancement rather than skills training that isolates individuals from the rest of society.12
  • Supported employment is a well-defined, evidence-based approach to helping people with mental health and substance use conditions to find and keep competitive employment within their communities. Supported employment programs are staffed by employment specialists, who have frequent meetings with treatment providers to integrate supported employment with treatment services.13
  • Supported employment programs that help people with the most serious mental illnesses place more than 50 percent of their clients in paid employment.14
  • Programs should be rigorously tested to evaluate how different approaches work, for whom they work, and under what conditions.15
  • Employment services should be integrated with provider service models. A fully integrated service model will necessarily include supported employment and assistance in gaining competitive employment, since both of these are essential to real recovery. Many funding sources do not allow this breadth of service, so cooperative agreements should be developed by mental health service providers with the Department of Rehabilitation and/or the Employment Development Department in the jurisdiction. 16
  • Employment training and placement should be culturally competent.
  • One viable path to employment for people in recovery is to start one’s own business.17

Action Steps

Federal Action

  • The Centers for Medicare and Medicaid Services (CMS) should revise Medicaid regulations to broaden the Medicaid Rehabilitation Option to cover vocational and employment support services. Currently, only psychosocial services are covered. Alternatively, other federal funding should be provided to insure the availability of these cost-effective programs.
  • Supported-employment services should be available to veterans with mental health and substance use conditions who are under Veterans Administration care. The Veterans Administration should be granted the authority to provide these veterans the employment-supports they need to enter the workforce.
  • The federal regulations governing the Protection and Advocacy for Beneficiaries of Social Security (PABSS) program should be made more flexible so that it can more effectively serve persons with mental health and substance use conditions. Specific provisions should be made for the continuation of health care benefits for persons participating in these programs so that employment does not entail a loss of essential health support.
  • SAMHSA should redouble its efforts to meet its Strategic Initiative Goal 4.3: Increase gainful employment and educational opportunities, while decreasing legal and policy barriers, for individuals in recovery with mental and substance use disorders.
  • This requires that SAMHSA “implement evidence-based practices related to employment and education for individuals with mental and/or substance use disorders throughout all service systems.”18

State, Local, Provider and Employer Action

  • States should take advantage of the full range of federal resources available for employment programs and initiatives. This includes opportunities for state Medicaid agencies to broaden their scope and become more involved in employment issues. 19
  • States, providers and employers should take full advantage of options available through the federally funded Protection and Advocacy for Beneficiaries of Social Security (PABSS) program designed to serve SSI beneficiaries who want to work even though they have continuing disabilities.20
  • State regulations should be evaluated and changed as needed to ensure that employment services are provided in the most appropriate way for individuals with mental health and substance use disorders.
  • State agencies responsible for employment services should receive training to improve their skills in building and sustaining rapport with people with mental health conditions so that consumers can successfully choose, get, and keep employment opportunities.
  • State agencies responsible for employment services should receive training to improve their skills in building and sustaining rapport with people with mental health and substance use conditions so that consumers can successfully choose, get, and keep employment opportunities.
  • Interagency partnerships should be created in order to provide a seamless service process so that the consumer can move easily between providers as needed to successfully obtain, retain, and advance in employment.
  • States, local communities and providers should pursue innovative funding and service models in order to expand access to employment. For example, in Chicago the award- winning Thresholds program engaged more than 130 employers, including both large national corporations and local businesses in its program. Funding for this program has come from the state, corporate donors and foundations. Thresholds has partnered with Dartmouth University to conduct ongoing effectiveness research. The goal is to have a rapid translation of the science into changes in services.21
  • State and local governments should require and employers should adopt “ban the box” programs that remove any questions about the applicant’s criminal history from initial employment applications. When background checks are deferred until later in the interview process, job applicants have a better chance of being evaluated based on their qualifications for the job. To date, at least six states and 30 local jurisdictions have implemented some form of a “ban the box” policy.22 States should also liberalize their standards and procedures for expunging criminal records.

Effective Period

This policy was approved by the Mental Health America Board of Directors on December 8, 2012. It is reviewed as required by the Mental Health America Public Policy Committee.

Expiration: December 31, 2017

  1. Americans with Disabilities Act of 1990 http://www.usdoj.gov/crt/ada/pubs/ada.txt
  2. Supported Employment for People with Co-occurring Disorders. Deborah R Becker; Robert E Drake; William J Naughton Jr. Psychiatric Rehabilitation Journal; Spring 2005; 28, 4; Health Module. pg. 332
  3. Lehman et al., 1998; Hollingsworth et al., 1997; Leff et al., 1995 as cited in Bond et al., 2001
  4. Source: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Uniform Reporting System Outcome Tables (2009), http://www.samhsa.gov/dataoutcomes/urs/urs2009.aspx
  5. Source: Substance Abuse and Mental Health Services Administration, Leading Change: A Plan for SAMHSA’s Roles and Actions 2011–2014, HHS Publication No. SMA 11-4629, Rockville, MD: U.S. Department of Health and Human Services (2011), http://store.samhsa.gov/product/Leading-Change-A-Plan-for-SAMHSA-s-Roles-and-Actions-2011-2014/SMA11-4629
  6. Center for Substance Abuse Treatment, Integrating Substance Abuse Treatment and Vocational Services, Treatment Improvement Protocol (TIP) Number 38. Rockville, MD: Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services (2000)http://store.samhsa.gov/product/TIP-38-Integrating-Substance-Abuse-Treatment-and-Vocational-Services/SMA06-4216
  7. Rodriguez, M. N., Farid, E. & Porter, N., December, 2011 Legislative Update, “State Reforms Promoting Employment of People with Criminal Records,” a joint publication of the National Employment Law Project, the Sentencing Project, and the National H.I.R.E. Network (2011)http://www.nelp.org/page/-/SCLP/2011/PromotingEmploymentofPeoplewithCriminalRecords.pdf?nocdn=1
  8. "Cumulative Prevalence of Arrest from Ages 8 to 23 in a National Sample"Brame, et al., 129 Pediatrics 21 (January 2102)
  9. See Mental Health America Position Statement 12, Evidence Based Healthcare: http://www.mentalhealthamerica.net/go/position-statements/p-60
  10. Hale, et al., "The Mental Health Treatment Study: Designs, Outcomes, Policy Implications and Next Steps," Mental Health America webinar (July 19, 2012) http://www.mentalhealthamerica.net/go/action/policy-issues-a-z/recorded-presentations/webinars-and-presentations
  11. www.psych.uic.edu/eidp/EIDP-Principles.pdf
  12. Core Components of Employment Services, National Supported Employment Consortium: Supported employment is usually defined as: (1) a work setting which includes people without disablities; (2) jobs pay at least minimum wage; (3) service agency provides ongoing support; (4) intended for people with severe disabilities. Hale, et al., op. cit., n. 5 supra.
  13. Supported Employment: Evidence-based Practice Toolkit. Rockville, MD: This document was produced for the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS) by the New Hampshire Dartmouth Psychiatric Research Center and Westat, DHHS Publication No. SMA-08-4364 (2009), http://store.samhsa.gov/product/Supported-Employment-Evidence-Based-Practices-EBP-KIT/SMA08-4365
  14. Cook, J. A., Leff, H. S., Blyler, C. R., et al., “Results of a Multisite Randomized Trial of Supported Employment Interventions for Individuals With Severe Mental Illness,” Archives of General Psychiatry 62:505–512 (2005).
  15. CMHS Employment Intervention Demonstration Program (EIDP), www.psych.uic.edu/eidp
  16. Massachusetts Medicaid Infrastructure and Comprehensive Employment Opportunities (MI-CEO), http://www.mi-ceo.org/
  17. Hill, T. & Taylor, P. Working Papers from Road to Recovery Multimedia Advisory Committee (unpublished) (August 2011) http://www.recoverymonth.gov/~/media/Images/Files/Webcast%20Transcript/R2R2012July_EMPLOYMENT_DG.ashx
  18. Source: Substance Abuse and Mental Health Services Administration, Leading Change: A Plan for SAMHSA’s Roles and Actions, 2011–2014, op. cit.
  19. Jennifer Sullivan Sulewski, Dana Scott Gilmore, & Susan Foley, Medicaid Involvement in Employment-Related Programs, Findings from the National Survey of State Systems and Employment for People with Disabilities. a publication of the Center on State Systems and Employment (RRTC) at the Institute for Community Inclusion (2003), http://www.communityinclusion.org/article.php?article_id=122
  20. http://www.ssa.gov/work/ServiceProviders/pafactsheet.html
  21. "2009 APA Gold Award--Supported Employment: Helping Members Achieve Recovery and Economic Independence," 60 Psychiatric Services 1392 (Oct. 2009); Becker, et al., "Strategies for State-wide Implementation of Supported Employment," 31 Psychiatric Rehabilitation Journal 296 (2008).
  22. Rodriguez, M. N., Farid, E. & Porter, N., December, 2011 Legislative Update, "State Reforms Promoting Employment of People with Criminal Records," op. cit./sup>

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