Tuesday, June 17, 2014

Employment Challenges for Persons with Serious Mental Illness

This post is comprised of excerpts from testimony by Dr. Gary Bond, Professor of Psychiatry, Dartmouth Psychiatric Research Center to the EEOC at a March 15, 2011 hearing on employment of persons with disabilities. Please click on this link for the complete written version of the testimony, together with all references.

There are many benefits of employment—work enhances skills such as communication, socialization, academics, physical health, and community skills; it factors into how one is perceived by society; it promotes economic well-being; it leads to greater opportunity for upward mobility; and it contributes to greater self-esteem. Yet only 15 percent of those with a mental disability are in the labor market
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People with serious mental illness are a very heterogeneous group that has included Nobel Prize winners, American Presidents, artists, and other famous persons, as well as many who live in poverty and isolation. You cannot judge a person by their diagnosis. While the public has many negative stereotypes about this group, the take-home message from this testimony is that the research strongly demonstrates that full recovery from mental illness is possible. Working is a crucial element in this recovery process.

What is Serious Mental Illness?
This testimony concerns the population of people with serious mental illness, defined by three criteria: 
(a) Diagnosis: a psychiatric diagnosis of schizophrenia, bipolar disorder, or other major psychiatric disorder;
(b)Disability: significant role impairment, in areas such as independent living, interpersonal functioning, and employment;
(c) Duration: extended involvement with the mental health system (such as admission to psychiatric hospitals, supervised group homes, and mental health case management services). 
This is a large segment of the disability population. For example, over one-third of people of the Social Security disability roles have a serious mental illness.
Employment of People with Serious Mental Illness
Employment rates for people with serious mental illness are very low. Surveys have found that only 10% - 15% of people with serious mental illness receiving community treatment are competitively employed. Rates are even lower, typically less than 5%, in follow-up surveys of people discharged from psychiatric hospitals National and international surveys of community samples, which include respondents with less serious disorders, have reported employment rates of 20% - 25% for people with schizophrenia and related disorders.
The employment rate for people with serious mental illness is less than half the 33% rate for other disability groups Both rates are of course much lower than for the general population. Even during the height of the current recession, the national employment rate for adults in the general population was 72%, according to U.S. Bureau of Labor statistics.
Moreover, people with serious mental illness who are working are often underemployed. Nearly twice as many workers with mental illness earn at or near minimum wage as workers without disabilities. Non-standard jobs (such as temporary employment, independent contracting, and part-time employment) are common among workers with serious mental illness. Such jobs pay lower wages with fewer benefits. Among those employed, people with serious mental illness are overrepresented in unskilled occupations, such as in the service industries and as laborers.
Most People with Serious Mental Illness Want to Work
Despite these dismal employment statistics, most people with severe mental illness want to work. Studies indicate that approximately 2 out of every 3 people with mental illness are interested in competitive employment Moreover, these rates may understate the interest in working in this population, because many mental health professionals discourage clients from pursuing employment goals.
Barriers to Getting and Keeping Jobs
Why, then, is there a wide disparity between employment rates and desire to work? The reason is not that people with serious mental illness cannot work. People with serious mental illness are capable of working if they are matched to appropriate jobs and receive appropriate supports. But attitudinal, service, and system barriers are challenges to their employment. According to a national survey, persons with serious mental illness reported the primary barriers to employment to be:
  • stigma and discrimination (45%); 
  • fear of losing benefits (40%);
  • inadequate treatment of disability (28%);
  • lack of vocational services (23%).

Regarding attitudinal barriers, psychiatric disability is the most stigmatizing of all disabilities. One national survey reported that only 19% of those polled were “very comfortable with people with mental illness,” compared to triple than rate for people with a physical disability (National Organization on Disability, 1991). People with serious mental illness experience discrimination and negative attitudes constantly in everyday life. Employers are less likely to hire someone whom they believe has a mental illness.
One major attitudinal barrier is the perception that people with mental illness are violent. News stories involving atrocities committed by people with mental illness reinforce this perception. Based on extensive epidemiological research over the past two decades, we have a much better understanding of the risk factors for violence in the psychiatric population. Violence is exceedingly rare among people with mental illness, and the rare instances that do occur are associated with other factors, such as active substance use or refusing to take medications. Being employed significantly reduces the possibility of violence even further. In sum, a very low proportion of people with mental illness have a history of violence and overall people with mental illness are no more likely to behave violently than people without mental illness.
Another barrier is the fear of losing Social Security disability benefits (MacDonald-Wilson, Rogers, Ellison, & Lyass, 2003) Many of these apprehensions are based on lack of information and misconceptions. In one survey, 85% of Social Security disability beneficiaries incorrectly believed that Medicaid benefits would be terminated if they went to work (MacDonald-Wilson, Rogers, Ellison et al., 2003). Fortunately, when provided accurate information about the impact of employment, beneficiaries substantially increase their employment earnings (Tremblay, Smith, Xie, & Drake, 2006).
Once employed, people with serious mental illness often need ongoing support and accommodations to succeed. But employers are far less willing to accommodate people with psychiatric disabilities than those with physical conditions. Workers with mental health conditions are half as likely to receive accommodations as those with other disabilities. This is true even though most accommodations for psychiatric disabilities cost very little or nothing, in contrast to technological and architectural changes required for other disabilities. According to one employer survey, the kinds of functional limitations they most commonly observe in workers with psychiatric disabilities are cognitive (e.g., following instructions, concentrating) and social (e.g., interacting, reading social cues), and to a lesser extent emotional (e.g., managing symptoms, tolerating stress) and physical (e.g., stamina).
The onset of serious mental illness often occurs in early adulthood, interfering with the completion of education. Over 30% of people with severe mental illness have not completed high school. Low educational attainment contributes to the underemployment of people with serious mental illness. The median annual income of the U.S. population without a high school diploma or equivalent is less than $20,000. Median income increases 33% with completion of high school and more than triples with the completion of a bachelor’s degree.
The dismal rate of employment among people with serious mental illness is a formidable challenge. Nonetheless, we have compelling reasons to be optimistic that people with serious mental health problems can work and that working helps them to recover from mental illness. The major barriers to employment are not immutable clinical or cognitive characteristics but rather attitudes and lack of access to support services and accommodations.
Even in the absence of professional support, employers can play a pivotal role promoting the employment of people with serious mental illness by approaching applicants and workers as individuals and applying sound employment practices. Work accommodations typically involve pragmatic and inexpensive modifications. Employment is a win-win for people with serious mental illness, for employers, and for society at large.

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