Employment: A Workable Option Despite Mental Illness
Dr. Judith Cook
"Very few people with serious mental health disabilities are
working, and yet employers consistently tell us that workers with
these disabilities do a good job, that their needs are very similar
to those of other workers, and that they are a productive segment
of the labor force," said Judith A. Cook, Ph.D., a professor
in the Department of Psychiatry at the University of Illinois at
Dr. Cook spoke at SAMHSA's conference this past fall, "Hand
in Hand: It's Worth the Investment! A National Summit on Best Practices
for Mental Health in the Workplace." (See SAMHSA News,
Summit Promotes Mental Health in the Workplace.)
"The lack of employment among consumers of mental health
services reflects a tremendous loss of productivity and potential
for these individuals personally and for our society economically,"
Dr. Cook added.
This sentiment is shared by many stakeholders and advocates in
the mental health field. In 1995, SAMHSA's Center for Mental Health
Services(CMHS) launched a study, the Employment Intervention Demonstration
Program (EIDP), that seeks to answer the question: What do people
with psychiatric disabilities need so that they can successfully
obtain and retain employment?
Finding answers is a national priority as reflected by related
Federal efforts including the Ticket to Work and Work Incentives
Act of 1999 and the New Freedom Initiative. (See SAMHSA News,
For 5 years the EIDP tested a host of innovative interventions
at eight sites, and now the early results are starting to yield
"When CMHS launched this study, there was a school of thought
that if you just offer people more clinical services, they will
get well and go to work," said CMHS project officer Crystal
Blyler, Ph.D. "But what the investigators found was very different."
One of the study's most salient findings is that both
clinical and vocational services are necessary for people
to find and keep employment; and further, that people who receive
well-integrated and coordinated vocational and clinical services
have greatly improved outcomes compared to those receiving nonintegrated
In fact, says EIDP's principal investigator Dr. Cook, such integration
and coordination are "vital to success."
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More than 90 percent of the EIDP participants had a diagnosis
in the schizophrenia spectrum, major depression, or bipolar disorder,
generally considered among the most serious mental illnesses. Two-thirds
of the participants had at some point in their lives experienced
a substance abuse disorder. More than 90 percent were taking prescription
Each of the eight demonstration sites designed its own intervention
using a variety of innovative approaches. (See SAMHSA News,
Vocational Models Tested). Most of the
approaches were a variation of supported employment and offered
a combination of clinical and vocational services, Dr. Cook said.
A common protocol allowed data about outcomes to be compared despite
differences across sites.
Dr. Blyler emphasized that the study focused on "competitive
employment. Previous studies included volunteer jobs, sheltered
workshops, and housework. It creates a much higher bar to surmount
when a job pays at least minimum wage, is open to anyone, and is
in a mainstream setting," she explained.
Participants were followed for 2 years and assessed on an ongoing
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In the first eight quarters of their EIDP participation, more
than 1,600 participants held 2,230 jobs (an average of 2.2 jobs
per worker), earned $4.7 million, and worked 820,293 hours.
the end of the 2-year period, 64 percent of those receiving EIDP
services had worked while participating in the program. "For
most participants," Dr. Cook said, "subsequent jobs lasted
longer than their first job."
Eighty-six percent of all jobs held were at minimum wage or above,
paying an average of $5.91 per hour. Participants worked an average
of nearly 20 hours per week.
These results demonstrate that given the proper services, people
with mental illnesses "will enter the labor force
and they will stay there," Dr. Cook said.
The successes documented by the program were tempered by certain
other findings: Most of the jobs were for lower-skilled positions
that were not very interesting or fulfilling and did not offer a
path to upward mobility. Less than one-third of the full-time jobs
held by participants carried any sick leave, vacation, or health
The latter is particularly serious because people with mental
illness often face the loss of Supplemental Security Income, Social
Security Disability Insurance, and Medicaid if they earn money beyond
the ceiling at which these benefits pay.
"Consumers of mental health services need jobs that offer
more than just a survival wage," Dr. Cook said. "They
need to be able to replace the income that is threatened by the
loss of financial and medical benefits as they experience employment
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Drs. Cook and Blyler indicated that the results suggest several
recommendations for efforts to encourage employment among people
with mental illnesses:
- Vocational rehabilitation services should be offered in
settings that integrate them with clinical services and require
employment for minimum wage or above.
- When needed and desired, vocational support should be ongoing.
- Vocational supports must be combined with educational services
so that jobs will be more interesting, higher paying, and more conducive
to upward mobility.
- People should be matched to jobs they prefer.
- Vocational rehabilitation must provide information and support
regarding Government entitlements and must include financial planning.
- Vocational service providers should assist in negotiating
reasonable accommodations with employers and help to address workplace
stigma and discrimination.
"We now have research to support these recommendations and
the data to back them up," said Dr. Cook. "We can use
these to work for a better service system."
Cook observed that "there was not that much difference in outcomes
between the different enhanced vocational approaches. What made
the most difference to participants was getting a lot of vocational
services over a long period of time."
She concluded, "In this program, we were able to move people
into the level of the working poor. What remains is to refine and
disseminate the methods and remove the barriers and disincentives
so that they will move into the working, thriving population."
For more information on the EIDP and resources, see Employment
See AlsoRelated ContentVocational Models Tested »
See AlsoRelated ContentEmployment Program Resources »
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