Over two-thirds of individuals with serious mental illness (SMI) want to work and indicate that finding appropriate employment opportunities is a top priority.1 In addition to providing income, the opportunity to work facilitates social inclusion and influences many aspects of health status.2 For people with disabilities, employment can serve to increase self-esteem, social integration, and participation in community activities. Employment is viewed as a primary treatment goal for people with a psychiatric disability. For these reasons, the employment of individuals with SMI is being measured as part of the Healthy People 2020 objectives, a set of scientific objectives for improving the health of Americans, which are measured over a 10-year period.3
Despite the widespread recognition that employment is a crucial component of recovery, prevalence estimates from the National Survey on Drug Use and Health indicate that the proportion of individuals with SMI (i.e., those surveyed who live in households and met criteria for a diagnosable mental illness with substantial impairment) who were employed fell from 56.0 percent in 2008 to 48.5 percent in 2013.4 This decline is in contrast to substantial improvement in the overall U.S. employment rate during the same period.5 Employment rates are found to be even lower among individuals receiving public mental health services, ranging from 17.9 percent to 39.0 percent depending on the definition of the sample.6 Many people with a psychiatric disability want to work and could be successful in achieving competitive employment with the help of an evidence-based supported employment service known as Individual Placement and Support (hereafter referred to as supported employment).2,7
Supported employment is an important intervention that can enable people with SMI to succeed in finding and maintaining jobs.2 Supported employment services differ from traditional vocational rehabilitation services.2 Supported employment focuses on achieving outcomes by matching individuals to jobs best suited for their skills, strengths, interests, and capacities, and by providing continuous support during employment. Vocational rehabilitation focuses on career counseling, job-seeking skills, training, and assistance navigating job markets. More specifically, supported employment uses eight guiding principles,8 which distinguishes it from other vocational support programs:
Along with psychotherapy, medication, family support and education, and case management, supported employment can play a key role in successful recovery.9 Moreover, supported employment in itself can be the main motivating factor for which an individual with SMI seeks treatment; individuals may not be ready to admit that they have an illness, but if they are struggling with employment they may accept help from programs that offer supported employment.9 However, despite the strong evidence base supporting this type of intervention, recent surveys of state mental health authorities indicate that only about 2 percent of adults with SMI have access to supported employment.2,10
Specialty mental health treatment facilities provide an ideal setting for individuals with SMI to receive supported employment services. Using data from the most recent national survey, the goal of this report is to describe the number and characteristics of specialty mental health treatment facilities that offered supported employment in the United States.
The National Mental Health Services Survey (N-MHSS) is an annual survey conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) of all known mental health treatment facilities in the United States, both public and private.11 The survey is the only source of national and state-level data on the mental health services reported by publicly and privately operated specialty mental health treatment facilities. The N-MHSS is designed to collect data on the number, location, services, and characteristics of mental health treatment facilities throughout the 50 states, the District of Columbia, and the U.S. territories.12 The N-MHSS is a point-prevalence survey, meaning that it provides a picture of facilities' activities on a given day during the year but may not represent the full scope of facility characteristics or services in a given year.
The 2014 N-MHSS data, which are the most recent analytic data, are used for this report.13 There were 14,706 eligible mental health treatment facilities that responded to the survey (the overall response rate was 88.1 percent). Of the 14,706 facilities in the 2014 N-MHSS, basic facility information, service characteristics, and client counts were reported for 13,176 facilities. The remaining 1,530 facilities were excluded from analyses because their service characteristics were not reported, or they were subsequently found to be out-of-scope.
This report focuses on the availability of supported employment.14 In addition, facilities reported separately whether they offered vocational rehabilitation services.15 This report examines whether the percentage of facilities offering supported employment differed based on facility characteristics: service delivery setting, facility operation, and religious affiliation. In addition, the report examines whether facilities offering mental health treatment programs or groups designed exclusively for persons with SMI offered supported employment and whether the types of payments or funding accepted were related to offering supported employment. Item response rates were high for basic facility characteristics and services offered (98.1 to 100 percent); response rates for funding sources were slightly lower (75.0 to 97.6 percent). For calculating percentages, facilities with missing responses were considered to not have the characteristic or service specified.
Because the N-MHSS is considered a census of facilities and provides actual counts rather than estimates, statistical significance and confidence intervals are not applicable. The differences between proportions mentioned in this report were assessed using Cohen's h. The results described in the text have a Cohen's h effect size ≥ 0.20, which indicates that there are meaningful differences between the groups.
The majority of mental health treatment facilities offered neither supported employment nor vocational rehabilitation services. In 2014, just 19.6 percent of facilities offered supported employment (i.e., 2,586 facilities out of 13,176), and 15.9 percent offered vocational rehabilitation services (i.e., 2,093 facilities). However, the delivery of these two services overlapped in most facilities that offered them: 1,435 facilities offered supported employment and vocational rehabilitation services, 1,151 facilities offered supported employment only, and 658 facilities offered vocational rehabilitation only (Figure 1). Therefore, 75.4 percent of facilities offered no employment services.
Figure 1. Employment services offered in mental health treatment facilities: 2014
This report examines whether the percentage of facilities offering supported employment differed by service delivery setting, facility operation, and affiliation with a religious organization (Table 1). Facilities that delivered services in a 24-hour hospital inpatient setting were less likely to offer supported employment (12.4 percent) than facilities that delivered services in residential (23.1 percent) or outpatient settings (21.6 percent). Private facilities (for-profit and non-profit) were less likely to offer supported employment (10.3 and 19.4 percent, respectively) than facilities operated by public agencies or departments (29.1 percent). Approximately half of facilities operated by the U.S. Department of Veterans Affairs (VA) offered supported employment (47.5 percent). Facilities that were affiliated with a religious organization were less likely to offer supported employment than those that were not affiliated with a religious organization (10.0 vs. 20.4 percent).
Table 1. Number and percentage of mental health treatment facilities that offered supported employment by facility characteristics: 2014
Most mental health treatment facilities (58.5 percent) offered a mental health treatment program or group designed exclusively for persons with SMI. Among these facilities, 27.4 percent offered supported employment; in contrast, only 8.6 percent of facilities that did not offer mental health treatment programs or groups designed exclusively for persons with SMI offered supported employment.
Figure 2. Percentage of mental health treatment facilities that offered supported employment by type of payment and funding accepted: 2014
As shown in Figure 2, the only funding sources associated with greater percentages of facilities offering supported employment were Community Services Block Grants (29.4 vs. 17.0 percent), Community Mental Health Services Block Grants (29.4 vs. 15.7 percent), and Indian Health Service/638 contract care funds (28.4 vs. 19.2 percent). The percentages of facilities offering supported employment across two additional funding sources—state mental health agency funds (22.8 vs. 15.3 percent) and VA funds (25.8 vs. 18.0 percent)—were close to the criteria for a meaningful difference (Cohen's h = 0.19).
Table 2 presents the percentages of specialty mental health treatment facilities that offered supported employment in each state. In 2014, these percentages ranged from 7.2 percent (Arkansas) to 44.6 percent (New Hampshire).
Table 2. Supported employment in mental health treatment facilities: 2014
Despite widespread evidence and attention that supported employment is effective and beneficial, it was offered in relatively few specialty mental health treatment facilities. These data suggest that there is a clear gap in the availability of an evidence-based practice that can increase and sustain employment among adults with SMI and that can aid in their recovery.
Unsurprisingly, facilities offering inpatient services were less likely to offer supported employment services because inpatient settings tend to serve patients with more functional impairment than patients served in outpatient settings. Moreover, the goals of inpatient care are different from those of care delivered in residential and outpatient settings: the latter are more focused on recovery and rehabilitation.
The percentage of publicly operated or funded facilities that offered supported employment was higher than the percentage of privately operated facilities; yet because most mental health treatment facilities in the United States are privately operated, there were more private facilities that offered supported employment. Nonetheless, public operation and funding were associated with supported employment; for example, the higher rate of supported employment offered in facilities operated by the VA is a part of its programs to help veterans become integrated into their communities.
These data allow us to see a snapshot of services offered across the United States in public and private specialty mental health treatment facilities, but the data have some limitations and important considerations. The data, which are the most recent release, were collected in 2014, and the number of facilities offering supported employment may have changed in the last 2 years. In 2014, SAMHSA awarded seven 5-year grants to states (Alabama, Connecticut, Illinois, Ohio, Kansas, Utah, and Washington) to establish two site locations offering supported employment and to make policy and financial changes with the goal of sustainability and scalability under the Transforming Lives Through Supported Employment program. Further, because the N-MHSS is a survey of facilities and their characteristics, it cannot be determined whether or how many clients used supported employment services, the characteristics of clients who used these services, or the nature and quality of the services offered. Additionally, although facilities that accepted funding from federal government grants were more likely to offer supported employment, it cannot be stated from these data whether the federal funds were used to finance the supported employment services. It is also not known whether and how facilities distinguished the difference between vocational rehabilitation services and supported employment even if they used the provided survey definitions.14,15
A main barrier to facilities offering supported employment is the financing and reimbursement of services.2 Some states have made supported employment available under Medicaid, but states vary widely in their use of financing practices for the service. In 2011, the Office of the Assistant Secretary for Planning and Evaluation published Federal Financing of Supported Employment and Customized Employment for People with Mental Illnesses: Final Report, which describes ways that states can draw on multiple funding streams to offer supported employment,16 but funding challenges still remain.2 Policy implications of the Social Security Administration's Mental Health Treatment Study suggest ways to increase funding, implementation, and approaches to improve access to supported employment services.17
Facilities can use SAMHSA's Supported Employment Evidence-Based Practices Kit to integrate services into their treatment programs.18
Given that most adults with SMI can and want to work, employers can help support and accommodate employees with mental illness in the workplace. Most accommodations can be provided with little or no cost to the employer (e.g., by offering flexible schedules or opportunities to telework).19
Individuals with SMI may also be able to obtain employment and vocational services from other settings beyond specialty mental health treatment facilities. For example, at the national, state, or local level, departments of labor, vocational rehabilitation offices, departments of education, and disability services may serve the population of adults with SMI and psychiatric disabilities. However, these types of agencies and organizations often have broader missions, focus on different populations, and provide more traditional vocational rehabilitation services rather than evidence-based supported employment.2
To find specialty mental health treatment facilities that offer supported employment, use SAMHSA's Behavioral Health Treatment Locator: https://findtreatment.samhsa.gov/.
Sherman, L.J., Lynch, S.E., Teich, J. and Hudock, W.J. Availability of supported employment in specialty mental health treatment facilities and facility characteristics: 2014. The CBHSQ Report: June 15, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD.