Editors Note: This article is based on interviews with a number of experts in the fields of welfare reform, mental health and employment. The interviews focused on the impact of welfare reform on employment opportunities of persons with psychiatric disabilities. They also explored ways that mental health agencies and advocates can prepare for changes in welfare policy at the state and local levels. Finally, they addressed some of the most effective programs and strategies for helping people with psychiatric disabilities find and maintain employment.
Work is a key component of a full and healthy life. This is just as true for persons with psychiatric disabilities as it is for others. Consumer surveys reveal that the vast majority of people with psychiatric disabilities want to work. A recent study at the Connecticut Veteran's Hospital confirmed that work improves the psychological status of persons with psychiatric disabilities, reduces their overall medical expenses and provides opportunities for them to grow and establish a place in the larger community.1
By focusing on the importance of work and training, the current national experiment in welfare reform has the potential to expand employment opportunities for people with psychiatric disabilities. However, many mental health experts express both concern and optimism about the impact of welfare reform on employment prospects for people with psychiatric disabilities. Among the reasons cited for concern are:
Despite these concerns, a number of mental health advocates express optimism that welfare reform will prompt state and local mental health agencies to adopt more innovative and effective strategies to help people with psychiatric disabilities enter or reenter the workforce. Proponents hope that welfare reform will create an environment that encourages state and local agencies to work together in new ways to address the issue of employment and training. In addition, mental health officials point out that welfare reform offers an opportunity for the mental health system to contribute its considerable expertise and experience in promoting and supporting employment in the effort to assist welfare recipients to enter the world of work.
Effect on Welfare Benefits and Other Benefits
Welfare reform can affect the financial and other supports available to people with psychiatric disabilities in several ways. Those who now qualify for welfare could lose both their welfare and Medicaid benefits either because they have exceeded the two-year eligibility period allowed for benefits under the federal welfare reform law or because they have failed to meet the work requirements that will be established in each state. Some states may set the eligibility period for welfare benefits at less than two years. Individuals who are no longer eligible for welfare automatically lose their Medicaid benefits, although they may reapply separately for Medicaid.
In addition, persons with a primary diagnosis of substance abuse will no longer be eligible to receive Supplemental Security Income (SSI). However, they may reapply for SSI with another primary diagnosis. For example, individuals with co-occurring mental health and substance use disorders may reapply based on the mental health disorder. In a number of states, those who lose their SSI eligibility must also relinquish Medicaid benefits.
Persons with psychiatric disabilities who are no longer eligible for welfare benefits may apply for SSI. However, this can be a long and complex process, and many people may be unable or unwilling to attempt it. Individuals who have no fixed address, including many persons who are homeless, are not eligible for SSI.
Differing Views on the Impact of Welfare Reform
Despite its emphasis on employment and training, welfare reform is unlikely to have a "positive impact on people with psychiatric disabilities," predicts Howard Goldman, M.D., Ph.D., director of the Research Infrastructure Support Program (RISP) at the National Association of State Mental Health Program Directors (NASMHPD) Research Institute. According to Dr. Goldman, persons with psychiatric disabilities already find it hard to obtain employment and training opportunities, and increased competition for jobs by welfare recipients will only make things more difficult. He predicts that overburdened health, employment and social services agencies will be overwhelmed by the influx of new job seekers and that people with psychiatric disabilities could lose access to needed medical and other benefits as a result of stringent new work and eligibility requirements in the federal welfare reform law. Richard Baron of Matrix Research Institute in Philadelphia concurs that having large numbers of welfare recipients enter the labor force will make it harder for people with psychiatric disabilities to find jobs and obtain training while lowering wage rates for entry-level and part-time jobs. "This will make it that much more difficult for people to live and receive the medical benefits they need," he says.
Both Dr. Goldman and Mr. Baron express concern that employment initiatives stemming from welfare reform will rely on traditional approaches to vocational rehabilitation that have proven ineffective for people with psychiatric disabilities. They question whether the new welfare requirements will allow for the long-term, multidisciplinary strategies that are effective for this population. "The real issue is whether welfare reform will provide access to innovative, effective employment programs," Dr. Goldman says.
John Allen, director of the Office of Consumer Affairs, Maryland Department of Mental Hygiene, hopes that increased competition for entry-level jobs resulting from welfare reform will lead to a burgeoning of agency- and consumer-run businesses that provide jobs for people with psychiatric disabilities, people who will find it increasingly difficult to compete in the regular economy. Mr. Allen predicts that persons with psychiatric disabilities will be insulated to some degree, although not indefinitely, from the loss of welfare benefits because of special provisions in the welfare reform law. He also makes note of provisions in the SSI program that enable persons with psychiatric disabilities to maintain needed Medicaid and other benefits for a time after returning to work. Nonetheless, Mr. Allen laments that society has yet to understand that people with even the most serious mental illnesses can work and progress toward recovery. "Unfortunately we're not at the point where most people can imagine how to provide the accommodations that make work possible," he points out.
However, Sinikka McCabe, director of the Wisconsin Bureau of Community Mental Health, predicts that welfare reform will have little impact on adults with psychiatric disabilities in her state. This is, in part, because few people with psychiatric disabilities in the state are enrolled in the federal Aid to Families with Dependent Children (AFDC) program, the program that is affected most directly by the welfare reform law. Ms. McCabe emphasizes that the Wisconsin mental health system attempts to provide comprehensive and highly individualized services that seek to identify the best job match for an individual based on the person's particular career interests, skills and experience rather than simply placing individuals in entry-level jobs. [See "Focus on the States" on page 5.] Persons with psychiatric disabilities may go through a series of agency-financed job "tryouts" or on-the-job training experiences before obtaining permanent full- or part-time employment. Thus she anticipates little competition between people with psychiatric disabilities and welfare recipients for entry-level jobs.
According to A. Kathryn Power, director of the Rhode Island Department of Mental Health, Mental Retardation and Hospitals, the "welfare reform revolution" offers an opportunity for people who are dependent on government benefits, including many with psychiatric disabilities, to move toward independence and to take a more active role in their own lives. Although she acknowledges that welfare reform will make the state's job market more competitive, Ms. Power maintains that mental health agencies and advocates can use welfare reform as a springboard for improving employment opportunities and outcomes for people with psychiatric disabilities. "As the welfare reform discussion goes forward, those of us who are responsible for making sure that people with psychiatric disabilities are treated fairly have to make it a priority to participate as fully as possible in the decisionmaking framework," she says.
Ms. Power also points out that within the broad requirements of the federal welfare reform law, states have room to take a "fluid, flexible and responsive" approach to establishing their own welfare reform policies and programs. She notes that Rhode Island has requested a waiver from the federal government to extend the state's food stamp program beyond the planned termination date to avoid placing unnecessary hardships on low-income families. She points out that for states such as Rhode Island that have already established their own welfare reform programs, there will be a process of adapting the state program to meet the federal requirements.
State-Level Collaboration and Cooperation
Joseph Bevilacqua, Ph.D., of the Judge David L. Bazelon Center for Mental Health Law, a former State Mental Health Commissioner in several states, says that the focus of welfare reform has now shifted to the states and, in some cases, to county and other local jurisdictions. "Mental health agencies, consumer organizations and other mental health advocates must speak with a unified voice to gain the attention of governors, legislators and other officials who will make decisions about welfare reform at the state and local levels," he emphasizes. Dr. Bevilacqua also notes that the Bazelon Center has provided training in developing effective mental health coalitions in a number of states and plans to expand state-level training efforts this year.
In addition to advocating for mental health concerns in the state welfare reform planning process, state mental health officials must forge partnerships with welfare and other human service agencies to ensure that services are delivered in the most coordinated and effective manner, according to Steven M. Fishbein of the New Jersey Division of Mental Health Services. Mr. Fishbein says that mental health officials need to understand the new rules of welfare reform and, at the same time, serve as a resource to state welfare agencies. He notes that some mental health providers in the state have begun to offer vocational rehabilitation services to welfare recipients. He believes that this trend will not undermine services to people with psychiatric disabilities but instead will strengthen the position of mental health systems by highlighting their expertise and establishing a central role for them in welfare reform.
Effective Strategies
Despite differing views on the potential impact of welfare reform on job opportunities for persons with psychiatric disabilities, many mental health experts agree that employment initiatives must be based on innovative and effective strategies. Research and experience during the past several decades have identified a number of strategies for promoting employment of people with psychiatric disabilities. These include:
Mental health officials and advocates emphasize that the traditional approach to vocational rehabilitation has not been effective for people with psychiatric disabilities. One of the key reasons, they say, is that this approach requires a person to spend long periods of time preparing for work rather than simply getting a job. However, the major challenges encountered by people with psychiatric disabilities have less to do with performing actual work tasks than with handling work-related stress, criticism from supervisors and interpersonal relationships. Thus many mental health experts believe that the most effective employment strategy is to get people on the job quickly and then to provide a wide range of supports such as job coaching, job accommodations, counseling, peer support groups and job clubs.
Many research studies and demonstration efforts focusing on the employment of people with psychiatric disabilities during the past decade have also established the effectiveness of a multi-disciplinary approach that combines case managers, psychologists, vocational rehabilitation counselors and other specialists. The multidisciplinary approach reinforces the importance of employment as a critical factor in the recovery process. [See "Focus on the States" on page 5.]
Although experts in mental health and employment believe that most people with psychiatric disabilities can work, they point out that not all individuals are ready for regular full-time jobs. Therefore, it is important to provide a range of employment opportunities that include job "tryouts," on-the-job training and part-time employment. In addition, being able to work does not preclude the need for long-term services and supports such as counseling and, perhaps, medication. Those who work part time, and even many with full-time jobs, may not be able to obtain adequate insurance through their employers to cover their ongoing medical needs. In addition, because of the long-term and fluctuating nature of some mental illnesses, people with psychiatric disabilities may continue to go through periods when they are unable to work, thus requiring the continuation of medical and other benefits.
Widening the Range of Work Options
A number of mental health experts emphasize that an expanded view of work is needed to ensure that people with psychiatric disabilities have the fullest opportunities for employment. Mr. Baron points out that full-time competitive employment without any government supports should not be the only goal for people with psychiatric disabilities, some of whom may never attain complete economic and medical independence. He contends that persons with psychiatric disabilities should have the option to engage in a range of work patterns and that government benefit programs should be flexible enough to continue to provide needed supports even after a person returns to work. "Many people with serious illness could be working half-time or in on-again, off-again patterns," he points out. "Our laws, regulations and supports should make that possible."
Others point out that persons with psychiatric disabilities, as with other people, are likely to have a number of different jobs throughout their lives. Thus it may be unrealistic to expect any single program or strategy to result in permanent employment. Instead, perhaps the most appropriate goal is to assist individuals to find points of entry, or perhaps reentry, into the workplace and then to provide ongoing supports when they are needed and wanted.
1 Bell, M. D., Lysaker, P. H., and Milstein, R. (1996). "Clinical Benefits of Paid Work Activity in Schizophrenia," Schizophrenia Bulletin 22:51-67.
Bell, M.D. and Lysaker, P. H. (Winter 1996). "Levels of Expectations for Work Activity in Schizophrenia Clinical and Rehabilitation Outcomes," Psychiatric Rehabilitation Journal 19(3).
The House of Representatives appears unlikely to propose major changes in the Federal Rehabilitation Act during the upcoming reauthorization of the law, a House Education and Workforce Committee staff member told participants at a recent meeting of the Income Security and Employment Subcommittee of the Mental Health Liaison Group.
Todd Jones, staff to the Education and Workforce Committee, emphasized that most Committee members believe that the nation's vocational rehabilitation system needs major repairs. However, he pointed out that the upcoming reauthorization of the Higher Education Act and the planned consolidation of federal job training programs will be extremely time consuming, competing with the desire to make fundamental changes in the rehabilitation law this year. Consequently, any significant changes will more likely have to be initiated in the Senate. The House Committee had scheduled a hearing on the Rehabilitation Act for February 27, which is likely to be the Committee's only hearing on the issue this year.
Jones noted that he still expects some changes to be made during the Rehabilitation Act reauthorization process, which must be completed by September 1997, particularly in promoting greater implementation of key elements of the Act's 1992 amendments. These amendments are widely considered to have provided a major strengthening of the law by: establishing a "presumption of employability" for people with disabilities; emphasizing consumer choice; mandating the development of Individualized Written Rehabilitation Programs (IWRPs) in conjunction with and approved by the client; and strengthening priorities for serving minorities and those with the most severe disabilities.
However, mental health experts point out that these provisions have yet to be widely incorporated into practice at the state and local levels.
A number of mental health advocates and organizations, including the National Association of State Mental Health Program Directors (NASMHPD), have expressed concern about the lack of services provided to persons with psychiatric disabilities by vocational rehabilitation agencies. [See NASMHPD Position Statement on page 9.] The vocational rehabilitation system, with its background in working with persons with physical disabilities and its emphasis on closing cases as quickly as possible, is viewed by some as having failed to provide the long-term, individualized services that are most effective for persons with psychiatric disabilities.
Ruth Hughes, Executive Director of the International Association of Psychosocial Rehabilitation Services (IAPSRS), emphasized that the current "cobbled together" system of benefits and supports for people with psychiatric disabilities is both ineffective and costly. Pointing to a pilot program in California that enables mental health agencies to consolidate funding streams from various programs to provide more flexible and individualized services, she called for increased coordination among the vocational rehabilitation system, the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs, Medicaid, welfare and other programs that serve people with disabilities. These and similar programs around the nation demonstrate that effective services can be provided at lower cost than programs that operate under the existing fragmented service system.
In addition to the reauthorization of the Rehabilitation Act, Congress this year will also consider two bills that would provide more flexibility in the SSI and SSDI programs in serving people with disabilities. The Rehabilitation and Return to Work Opportunity Act (H.R. 4230) introduced by Rep. Jim Bunning (R-KY), chairman of the House Ways and Means Social Security Subcommittee, proposes to reward private-sector rehabilitation providers for successful rehabilitation outcomes. Currently only state vocational rehabilitation agencies receive such reimbursement. Another bill introduced by Rep. James Jeffords (R-VT) would create work incentives in SSDI and Medicare programs similar to those already found in Medicaid. Many advocates maintain that these bills would remove some of the long-standing work disincentives in these programs for people with psychiatric disabilities.
Employment is central to all of our lives. It rewards us financially and emotionally. It helps define us and our place in the world, in our own eyes and in the eyes of others. The absence of meaningful employment is detrimental to our mental health. We know that employment increases the level of independence and speeds the recovery of individuals with a psychiatric disability—people who want to make their own way in the community just like everyone else. In this issue of networks, we address employment from a number of different perspectives.
As the masthead on this newsletter indicates, the objective of the National Technical Assistance Center for State Mental Health Planning (NTAC) is to provide "practical tools for a changing environment." Few changes in the current environment present as intriguing a set of questions and challenges as welfare reform, especially with respect to its impact on employment opportunities for persons with psychiatric disabilities.
Research suggests that fewer than 15 percent of individuals with serious mental illness are employed. Hopefully, this issue's lead story exploring the thinking of a number of mental health officials and advocates will encourage all of us to consider for ourselves whether that situation is likely to improve or worsen with welfare reform and why.
In December 1996 the National Association of State Mental Health Program Directors (NASMHPD) revised its "Position Statement on Employment and Rehabilitation for Persons with Serious Psychiatric Disabilities" to reflect the current perspective of state directors on the role of employment and rehabilitation in consumers' recovery. The statement, reprinted in this issue, encourages state and community leaders to strengthen their partnerships to develop a full range of employment opportunities for adults with serious mental illness. [See Position Statement ]
For its part, NTAC is providing support to these state and community-based efforts through the identification, development and broad dissemination of information regarding innovative programs and practices in employment. The "Technical Assistance and Training" page on NTAC's web site includes a number of brief descriptions of model employment and rehabilitation programs that have been shared with us from around the country. We encourage readers to let us know of other programs that could be added to the site.
NTAC is also facilitating an Employment Work Group to examine ways in which the interests of persons with psychiatric disabilities in employment and rehabilitation can be advanced. A report will be presented in a future issue of networks, on the web site and to the next meeting of the NASMHPD Board of Directors.
As always, we welcome your comments and suggestions about our work.
— Bruce D. Emery, M.S.W.
WELFARE
The term welfare covers several different state-administered programs
including the federally funded Aid to Families with Dependent
Children (AFDC) program and general welfare, which is funded by
states. These programs provide funds for food, clothing, shelter
and other necessities. The welfare reform law transforms AFDC
into the Temporary Assistance for Needy Families (TANF) state
block grant program. States will receive block grant funds from
the federal government but will establish their own eligibility
criteria and priorities within broad parameters set by the law.
SUPPLEMENTAL SECURITY INCOME
Administered by the Social Security Administration, this program
provides financial support for people with disabilities, including
those with psychiatric disabilities. The federal welfare reform
act prohibits people from receiving SSI benefits if their eligibility
for the program is based on a substance abuse diagnosis; however,
people in this category may reapply with another diagnosis (e.g.,
mental health disorder).
MEDICAID
This federally funded medical benefits program is automatically
available to individuals who qualify for AFDC and, in a number
of states, to persons covered by SSI. However, once a person no
longer qualifies for AFDC, they lose their automatic Medicaid
eligibility and must reapply separately.
Wisconsin Initiates Pilot Employment Programs
Through an innovative partnership between the State Mental Health and Vocational Rehabilitation systems, the Wisconsin Bureau of Community Mental Health has initiated pilot programs in 10 predominantly rural counties to promote employment for people with psychiatric disabilities. By contributing $100,000 in matching funds, the Bureau was able to leverage an additional amount of nearly $370,000 in federal funds through the state Division of Vocational Rehabilitation (DVR) to support these pilot programs.
After several years of discussions between the Bureau and DVR about potential joint projects, the opportunity for this arrangement came about in 1996 when DVR was unable to provide adequate matching funds to obtain the state's full allotment of federal vocational rehabilitation funding. These funds are allocated to states by formula, contingent on a roughly 20 percent/80 percent match between the state and the federal government. State vocational rehabilitation funding has not kept pace in recent years with federal funding available to support vocational rehabilitation services. Thus DVR faced the dilemma of being eligible for federal funds that it could not obtain because it was unable to provide the full state match required.
In a series of meetings involving representatives of the Bureau, DVR and the Wisconsin Alliance for the Mentally Ill, an arrangement was reached in which the Bureau contributed $100,000 in state mental health funds to DVR to obtain additional matching federal funding. The total amount of about $470,000 was used to hire vocational rehabilitation staff and place intensive focus on employment issues in the selected pilot program sites. The matching funds arrangement will continue at the same funding level for at least three years.
In addition to making it possible to hire vocational rehabilitation staff for each of the pilot program sites, the matching funds have enabled Bureau representatives to make monthly visits to consult with staff at the sites. The funds also support quarterly training sessions attended by Bureau central office staff, pilot program staff, and local and regional DVR staff.
Patricia Rutkowski, lead clinical consultant with the state Bureau of Community Mental Health, pointed out that the matching grant arrangement made it possible to combine the financial resources of the vocational rehabilitation system with the specialized expertise and resources available through the mental health system. She noted that the state vocational rehabilitation agency has not been able to devote the time and staff needed to provide the long-term and individualized services and supports that are most effective in assisting people with psychiatric disabilities to succeed in employment. On the other hand, she pointed out that the mental health agency has this expertise and flexibility but lacks adequate funding.
Ms. Rutkowski emphasized that a key element in convincing DVR officials and the state legislature to approve the third-party funds was the Bureau's record of success in promoting employment for people with psychiatric disabilities. In several of Wisconsin's rural counties, the employment rate for people with psychiatric disabilities ranges from 40 to 60 percent.
Ms. Rutkowski attributed this success to the pioneering Program for Assertive Community Treatment (PACT) developed in Wisconsin in the early 1970's and now used throughout the state and in other states to promote employment for people with psychiatric disabilities. The PACT concept promotes a comprehensive and individualized approach to employment services and supports. One of the primary tenets of this concept is that work is a key element of treatment and recovery.
The PACT model has been successful in addressing the unique challenges and opportunities of promoting employment for persons with psychiatric disabilities in rural areas. On one hand, there are fewer jobs available in rural communities. However, rural communities also have a strong work ethic and a tradition of helping each other. There is a natural network in rural communities of employers, mental health service providers and job seekers.
Ms. Rutkowski noted that mental health programs are highly visible in rural communities, where people can see the impact of the programs on people they know. When communities see that a program is well-run and effective, they offer support in various ways including providing job opportunities. "Everyone knows if you're doing a good job," she emphasized. "We can be our own best public relations tools."
For more information about the pilot programs or PACT, contact Patricia Rutkowski, Wisconsin Bureau of Community Mental Health, Department of Health and Family Services, P.O. Box 7851, Madison, Wisconsin 53707. Telephone: 608-266-9331, Fax: 608-267-7793.
Anthony, W. (1995). The Relationship Between Symptomatology, Work Skills, and Future Vocational Performance. Boston, MA: Center for Psychiatric Rehabilitation. (Cost: $3.00; contact the CPR at 617-353-3550.)
Center for Mental Health Services. (1995). People with Psychiatric Disabilities, Employment and the Americans with Disabilities Act: Turning Policy Into Practice. Rockville, MD. (No cost; contact the Knowledge Exchange Network at 800-789-2647.)
Danley, K. and Ellison, M. (1996). Involving People with Psychiatric Disabilities as Consumer Advocates in Vocational Rehabilitation: Executive Summary. Boston, MA: Center for Psychiatric Rehabilitation. (Cost: $4.20; contact the CPR at 617-353-3550.)
Ford, L. (1995). Providing Employment Support for People with Long-Term Mental Illness: Choices, Resources and Practical Strategies. Baltimore, MD: Paul Brookes Publishing Co. (Cost: $29.95; call 800-638-3775.)
Judge David L. Bazelon Center for Mental Health Law. (1992). Mental Health Consumers in the Workplace. Washington, D.C. (Cost: $6.95; contact the Bazelon Center at 202-467-5730.)
National Mental Health Association and the American Bar Association. (1994). The ADA and People with Mental Illness: A Resource Manual for Employers. Alexandria, VA. (Cost: $35; contact NMHA at 703-684-7722.)
Noble, J., Honberg, J., Hall, L., and Flynn, L. (1997). A Legacy of Failure: The Inability of the Federal-State Vocational Rehabilitation System to Serve People with Severe Mental Illness. Arlington, VA: National Alliance for the Mentally Ill. (Cost: $5.00; contact NAMI at 800-950-6264.)
Shafer, M., Middaugh, A., Rubin, M., and Jones, R. (1995). Best Practices in the Vocational Rehabilitation of Persons with Serious Mental Illness. Tucson, AZ: University of Arizona, Community Rehabilitation Division. (Cost: $15.00; contact the Division at 520-626-2400.)
U.S. Department of Education, Rehabilitation Services Administration. (Spring 1995). American Rehabilitation, Special Issues on Severe Mental Illness, 21(1). Washington, D.C. (Cost: $3.75; contact 202-205-8296.)
Viccora, E., Perry, J., and Mancuso, L. (1994). Exemplary Practices in Employment Services for People with Psychiatric Disabilities. Alexandria, VA: National Association of State Mental Health Program Directors. (Cost: $6.00; contact NASMHPD at 703-739-9333.)
http://www.welfareinfo.org - Welfare Information Network. Offers an electronic clearinghouse for information, policy analysis and technical assistance on welfare reform.
http://www.samhsa.gov - Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Provides information on welfare reform, managed care, current activities and publications.
http://www.tmn.com/cdf/index.html - Children's Defense Fund. Provides updates on the 1996 welfare reform law and other welfare-related legislation.
http://www.handsnet.org/cwla - Child Welfare League of America. Discusses issues related to implementation of welfare reform.
http://www.os.dhhs.gov/104con.html - U.S. Department of Health and Human Services. Summary of recent federal legislation in areas including welfare reform and health insurance.
http://www.apse.org - Association for Persons in Supported Employment. Provides information about supported employment services offered by APSE, special products and services, ethical guidelines and hyperlinks to sites focusing on supported employment activities.
http://members.aol.com/workmri/home3.htm - Matrix Research Institue University of Pennsylvania Research and Training Center. Provides information on the impact of managed behavioral healthcare on rehabilitation services for persons with serious mental illness and on the organization's current activities and publications.
http://www.pcepd.org - President's Committee on the Employment of People with Disabilities. Includes a directory of state liaisons who provide information and assistance on employment of persons with disabilities.
http://web.bu.edu/SARPSYCH - Center for Psychiatric Rehabilitation. Provides information, resources and hyperlinks related to psychiatric and vocational rehabilitation.
The National Association of State Mental Health Program Directors (NASMHPD) recognizes the fundamental importance of competitive, integrated, paid, and meaningful employment to the quality of life for persons with psychiatric disabilities. Chronic unemployment can lead to isolation, poverty, and a diminishing self-worth in any adult, hindering efforts at recovery. In addition, one residual effect of chronic unemployment for persons with psychiatric disabilities is the perpetuation of homelessness. The current high rate of unemployment among people with psychiatric disabilities—estimated at 85 percent or more—must be lowered. The focus should not only be on employment opportunities, but also on habilitation and rehabilitation, including integrated supported competitive employment to better enable individuals with mental illness to participate in the workforce.
The lack of jobs that provide flexibility for adults with serious mental illness is a major barrier to successful community living, a personal loss to people who wish to work, a societal loss to employers and taxpayers, and a barrier to successful recovery for those with mental illness. State mental health authorities (SMHAs) should assume a leadership role in significantly increasing the rate of employment among individuals with psychiatric disabilities. Vocational Rehabilitation (VR) agencies and SMHAs should collaborate and design program linkages and develop a range of employment options to increase rehabilitation opportunities for individuals requiring mental health services. Mental health policymakers should work to maximize the availability of community supports and case management efforts that focus on employment issues early in the rehabilitation process.
NASMHPD supports the goals of the Americans with Disabilities Act of 1990 to: eliminate unfair treatment of and discrimination against qualified workers with disabilities, improve access to mainstream resources, and mandate the assessment of disabled applicants' qualifications with consideration of accommodations and support services. However, we believe the Rehabilitation Act has failed to serve adequately the habilitation and rehabilitation needs of individuals with psychiatric disabilities, and should be amended accordingly. We acknowledge employment as an important route to recovery, economic empowerment and independence for consumers of mental health services. We will work to increase their opportunities to become productive members of American society.
NASMHPD encourages the development of community-based employment services and vocational rehabilitation services that are tailored to meet the needs of persons with psychiatric disabilities and that are governed by individual skills, knowledge, abilities and preferences. Employment support and rehabilitation standards must be flexible to accommodate the episodic nature of mental illnesses. Effective employment services should offer long-term support both on and off the job in all phases of employment including, but not limited to: career planning; job goal selection; job placement; self-presentation in writing and in person during pre-employment screening; negotiating reasonable accommodations; acquiring specific job skills; obtaining transportation and clothing appropriate to the work setting; estimating how earnings will impact entitlements such as SSI, SSDI, Medicaid and Medicare; education in using existing Social Security Administration work incentive programs to their greatest advantage; establishing positive relationships with co-workers and supervisors; assistance in changing jobs; job retention assistance; supported education; and consumer-run enterprises.
Effective rehabilitation services must view successful rehabilitation for individuals with mental illness differently than for others. While vocational rehabilitation agencies frequently define successful rehabilitation as leading to full-time competitive employment, the VR system should adapt to the needs of all individuals with psychiatric disabilities, whether or not they are in a stage of recovery that enables them to engage in full-time employment. The VR system should acknowledge the different needs and preferences of individuals with varying degrees of psychiatric disability. These individuals should have access to the full range of choices, including volunteer and part-time work, full-time competitive employment and advanced training and education. Rehabilitation policies should provide incentives for rehabilitation agencies to coordinate their efforts with SMHAs and effectively serve individuals with psychiatric disabilities. While the focus of mental health has grown from removing and controlling symptoms to building active life roles and activities in institutional and community settings, state vocational rehabilitation systems must be encouraged to keep pace with this change.
Employment support must be an integral component of comprehensive community support programs. State mental health agencies should collaborate with state vocational rehabilitation agencies, consumers, family members, mental health professionals, private businesses, taxpayer groups, and other advocates to: focus existing public and private resources (such as the state/federal vocational rehabilitation program and state services for unemployed citizens) to better serve persons with psychiatric disabilities; expand supported employment opportunities; redirect public funds away from segregated day programs and toward community-based employment programs; and reduce the disincentives still present in SSI/SSDI policies for recipients returning to work. Employers must be educated about the potential of persons with psychiatric disabilities to become valued workers. NASMHPD recognizes the disincentive to work created by flaws in the benefit structures of the SSI and SSDI programs and the risk posed by the potential loss of Medicaid benefits for those entering the workforce. Ultimately, the structure and availability of such benefits and the availability of adequate and appropriate private mental health insurance coverage will significantly impact many individuals' prospects for recovery and successful integrated, competitive employment.
NASMHPD believes that the growth of managed care both makes it necessary and provides an opportunity to more fully integrate employment and recovery goals with service delivery. State mental health agencies should work to develop tools for appropriate evaluation of the success of managed care plans in moving covered individuals into employment or partial employment settings. In addition, SMHAs and other appropriate state agencies should examine the potential for cost effective cooperative agreements with managed care organizations to coordinate treatment, rehabilitation and vocational services.
The National Technical Assistance Center for State Mental Health Planning (NTAC) is funded under a Cooperative Agreement between the Center for Mental Health Services (CMHS) and the National Association of State Mental Health Program Directors (NASMHPD). NTAC's mission is to provide focused, state-of-the-art technical assistance to State Mental Health Agencies (SMHAs), consumers, families, and members of State Mental Health Planning and Advisory Councils to: bring about long-lasting improvements in the design, delivery and evaluation of mental health services; foster consumer recovery and independence through consumer-centered services; and prepare for the future of public mental health care.
Guided by input from its Steering Committee, NTAC staff continually scan the environment to identify key trends and issues that impact mental health services delivery. Below are the highlights of recent NTAC technical assistance-related activities:
On-site Technical Assistance to States
Alabama. The Alabama Department of Mental Health has been engaged in a long-term systems reform process. NTAC will provide on-site consultation to assist the state in reviewing the strengths and weaknesses of the process to date and in identifying potential future steps.
Georgia. A dramatic decline in funding for the state's inpatient hospital system due, in part, to a shift to community-based services has led NTAC to approve a technical assistance award to the Georgia Department of Mental Health. NTAC consultants will assist the state in developing a plan to unify the existing state hospitals into a facility-based system and identifying strategies to further shift services into the community.
Iowa. NTAC staff are working with the Iowa Division of Mental Health and Developmental Disabilities and the Mental Health Consumer Resource Project to plan a statewide conference to promote consumer and family-member participation in mental health services planning, delivery and evaluation.
Regional and National Meetings
Consumer-initiated Programs. NTAC staff have been working with the National Consumer/Survivor Exchange Network, representatives from CMHS and others to plan a two-day conference that will focus on identifying successful strategies for developing consumer-run programs on limited budgets.
Cultural Competence. The Departments of Mental Health in South Carolina and Ohio joined with NASMHPD and others to co-sponsor a national conference in cultural competence held February 22-26 in Myrtle Beach, S.C. NTAC will provide financial assistance and staff support to produce a report based on the conference that identifies exemplary practices and innovative approaches to develop and maintain culturally-competent mental health services.
Employment. A small group of state mental health executives, facilitated by NTAC, has begun to explore ways in which NASMHPD's recently-revised Employment and Rehabilitation Position Statement can be implemented in the public mental health system. [See page 9.] A report is expected in early April.
Housing. NTAC has played an active role in partnership with the members of the NASMHPD President's Task Force on Housing and Supports and other organizations to plan a national executive training institute. The goal of the institute is to develop state-level partnerships between state mental health agencies and state housing finance and development agencies that will result in increased access to affordable housing for persons with psychiatric disabilities. The meeting is planned for this Fall.
Managed Care. The State/County Managed Care Dialogue Group met in Washington, D.C., in January. Supported by the CMHS Office of Survey Analysis, the meeting identified areas of common needs requiring further attention from SMHAs and County Mental Health Authorities, including issues of authority and risk, performance indicators and outcome measures and decisionmaking and quality improvement. NTAC is currently developing a report and recommendations.
Performance and Outcomes Measures. NTAC continues to assist in the work of the NASMHPD President's Task Force on Performance Indicators and Outcome Measures. The task force meets regularly by teleconference and has recently issued a press release reflecting priorities for future action. This document is available from NASMHPD or NTAC.
Women with serious mental illness and histories of physical/sexual trauma. NTAC is collaborating with CMHS, NASMHPD, the NASMHPD Research Institute, Inc., and other partners to identify ways in which SMHAs can more appropriately respond to the mental health-related needs of women with serious mental illnesses and histories of trauma. Preliminary plans are underway to co-sponsor a national experts workshop to identify the scope of the problem, innovative responses and next steps.
For additional information on these and other NTAC activities, visit our web site at http://www.nasmhpd.org/ntac or contact Bruce Emery, M.S.W., Director, at 703-739-9333, ext. 28, or e-mail: bruce.emery@nasmhpd.org
March 16-18: National Community Mental Healthcare Council (NCMHC) and National Association of Psychiatric Health Systems (NAPHS). 1997 Training Conference, Creating and Sustaining Healthy Communities: Integrating Behavioral Healthcare, San Francisco, CA. Contact Gayle Jamison at 301-984-6200.
March 18-22: California State University at Northridge (CSUN). 12th Annual International Conference: Technology and Persons with Disabilities, Northridge, CA. Contact Dr. Harry Murphy at 818-677-2578.
March 19-22: National Empowerment Center (NEC). Learning from Us Conference, Albuquerque, NM. Contact Rae Unzicker at 605-338-1088.
March 22-25: Commission on Accreditation for Rehabilitation Services (CARF). Creating Quality Services in the Era of Accountability: 1997 National Behavioral Health/Employment and Community Support Services Conference, Tucson, AZ. Contact Bette McMuldren or Mary Wells at 520-325-1044.
June 9-13: International Association of Psychosocial Rehabilitation Services (IAPSRS) Conference. Beyond Boundaries: Broadening Horizons, Vancouver, B.C. Contact David Issler at 410-730-7190.
June 20-23: United States Conference of Mayors. Annual Conference, San Francisco, CA. Contact Carol Edwards at 202-293-7330.
July 9-13: National Alliance for the Mentally Ill (NAMI). 1997 National Convention, Albuquerque, NM. Contact Janet Dinkens at 800-950-6264 or 703-524-7600.
July 15-18: Association for Persons in Supported Employment (APSE). Eighth Annual Conference, Orlando, FL. Contact Mary Callender at 804-278-9187.
July 27-30: National Association for Welfare Research and Statistics (NAWRS). 37th Annual Workshop, New Horizons: New Realities Moving Toward Self-Sufficiency, Atlanta, GA. Contact Sandra Brown at 404-656-3768.
Experts in the fields of mental health and housing have responded enthusiastically to Housing for Persons with Psychiatric Disabilities: Best Practices for a Changing Environment. Published by NTAC in Fall 1996, this technical assistance Tool Kit describes effective strategies for meeting the housing and related support needs of people with psychiatric disabilities. The Tool Kit synthesizes models and best practices in the context of rapidly changing federal and state environments and includes a number of useful appendices.
A broad audience of clinicians, consumers, family members, housing developers, advocates and technical assistance providers report finding the Tool Kit useful in designing, financing and advocating for housing and supports for people with psychiatric disabilities. Copies of the Tool Kit are available from NTAC for $20; call 703-739-9333, ext. 30.
networks is published quarterly by the National Technical Assistance Center (NTAC) for State Mental Health Planning (NTAC) and is supported under a Cooperative Agreement between the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration CMHS/SAMHSA) and the National Association of State Mental Health Program Directors (NASMHPD).
Winter 1997 Issue -
Bruce D. Emery, M.S.W., director
Gail P. Hutchings, M.P.A., associate director
John D. Kotler, M.S.J., senior writer/editor
Andrea Sheerin, information specialist
Rebecca Crocker, meeting/design specialist
Christine Diaz, administrative assistant
Cited reproductions, comments, and suggestions are encouraged. You may also be added to the mailing list for networks. Contact Christine Diaz at 703/739-9333, ext. 30, or send e-mail to: christine.diaz@nasmhpd.org. [Please include your name and return mailing address, email address and/or telephone number in the body of your message so we may respond to your inquiry].