Mental Illness and Employment
Individuals with disabilities who want to be involved in the world of work have difficulties entering and remaining in the workforce (Baron & Salzer, 2002). Those who live with mental disabilities have higher levels of unemployment than those living with physical disabilities. These individuals continue to face many barriers to successful entry into the workplace. Although many psychosocial and medical methods are part of the current treatment regimen for those with mental illness, they continue to have difficulties with employment (Rutman, 1994).
The purpose of this paper is to examine the needs and interventions for those with serious mental illness who want to enter and remain in the workforce. The first section presents data on those with serious mental illness, statistics related to their participation in the workforce, and some societal issues. Next to be addressed will be the impact of the illness both on the individual and his or her family. The different treatment interventions that have been utilized by professionals in working with those who live with mental disorder will then be described. Finally, this paper addresses how accommodations in the workplace can provide viable means to maintaining employment.
Individuals with Disability and Employment
Individuals with disabilities experience difficulties transitioning into and remaining in the workplace (MacDonald-Wilson, Rogers, & Anthony, 2001). Included among those who are categorized as disabled are a group of persons with psychiatric disabilities. Studies have shown that these persons have greater difficulties than their peers with other disabilities in finding and maintaining employment due to difficulties in social, emotional, and cognitive functioning (MacDonald-Wilson et al., 2001) and remain “underemployed and unemployed” at higher rates than individuals who do not have a disability (Fabian, 1999).
According to Baron & Salzer, (2002) there are 51 million persons with known disabilities. Among those with disabilities who are not institutionalized between the ages of 21 to 64 there is a 30% employment rate. Only 16.4% of those are able to work year-round, full time (Baron & Salzer, 2002). Of the 5.9 million persons diagnosed with a mental illness, 4-5 million are diagnosed with serious mental illnesses (SMI). These persons who are diagnosed with serious or significant disabilities have a reduced possibility that they will achieve employment (Hayward & Schmidt-Davis, 2003). Persons without a disability in the general population have an 82.1% employment rate, but the employment rate among those with a mental disability is only 41.3% (Stoddard, Jans, Ripple, & Kraus, 1998, p. 10).
Even though persons with psychiatric disabilities desire to enter the workforce, many are unable due to system barriers, stigma, and reduced functionality (Hayward & Schmidt-Davis, 2003). System barriers include time-limited services, poor response of the system to the cyclical nature of mental disorders, and poor cooperation between community-based agencies and vocational rehabilitation counselors.
Stigma towards persons with disabilities is reflected in hiring practices and is a major obstacle towards successful vocational outcomes for persons with severe mental illness (Garske & Stewart, 1999). The very nature of psychiatric disability results in reduction of a person’s ability to interact with others socially, maintain appropriate cognitive and affective functioning, and perform necessary daily basic functions. The Social Security Administration and the Rehabilitation Services Administration are addressing the relevant issues aimed at reducing the dependency on governmental cash benefits by persons with disabilities while helping them to find employment.
Low Skill Work
Persons with disabilities often times find themselves at the unskilled end of the work spectrum with 25% of persons with disabilities working as machine operators, food preparers, service jobs, or sales (Rutman, 1994). Rarely are these individuals seen working as teachers, physicians, computer programmers, or police and firefighters (Rutman, 1994). With such a significant percentage of persons with disabilities working in low wage labor market jobs it will be difficult for them to enter occupations with the largest projected growth rates: systems analysts, general managers and top executives, registered nurses, computer support specialists, and teacher assistants (Fabian, 2000). This is problematic because growth in employment areas such as administrative support functions, fabricators and laborers is expected to be very slow as American industry continues to experience a shift from manufacturing to more computer and systems management (Fabian, 2000).
Persons with disabilities may not get opportunities to work in a broad range of industries with a broad range of co-workers further limiting their expectations for future employment (Fabian, 2000). Researchers are using Social Cognitive Career Theory (SCCT) to explore how persons with severe mental illness view themselves and the environment in which they function, the relationships they have, and the behaviors they engage in to help them learn how to explore careers rather than settling for any job (Kravetz, Dellario, Granger, & Salzer, 2003). Fabian (1999) proposes that focusing on persons’ strengths and careers will lessen the dependence on low-skill jobs by persons in this disability group.
The Value of Work for Persons with Disabilities
Neff (1988) noted that work is not just an end in itself but rather that “work is an instrumental activity carried out by human beings, the object of which is to preserve and maintain life, which is directed at a planned alteration of certain features of our environment” (p. 6). Vocational rehabilitation (VR) and other support programs have had little success in helping persons who have psychiatric disabilities become part of this endeavor called work (MacDonald-Wilson et al., 2001). Some of the reasons put forward in the literature include: ungainly bureaucratic systems, societal stigmatization, slow and poor support from VR and other support systems, the cyclic nature of the illness, and the early onset of the illness that results in lost social and work skill acquisition (Freedman & Fesko, 1996). Work is an important facet of life for all people and those who are living with psychiatric illnesses are no exception.
Freedman and Fesko (1996) questioned family members and persons with significant disabilities about the meaning and value of work in their lives. When asked to describe different aspects of work, families and persons offered differing opinions: persons were most concerned about work productivity, compensation and benefits, and overcoming stigma and discrimination, while family members voiced concern over psychological functioning, self-esteem and socialization (Freedman & Fesko, 1996). Both persons and family members also addressed the importance of how persons were treated at work, the support they received from supervisors and providers (job coaches), whether or not to disclose their illness, and being placed in menial jobs (Freedman & Fesko, 1996). Even though it has been reported that persons with severe mental illness and other disabilities usually are placed in low-skill jobs (Fabian, 1999), other researchers reported that persons and their families paid more attention to being placed in menial jobs because of the persons’ level of education and job experience before being diagnosed with the illnesses (Freedman & Fesko, 1999).
Persons with long-term mental illness thus do not seem to have realistic expectations about the relationship between work and compensation. While in the Freedman and Fesko study (1996) persons expected to be paid more because of their prior experience and education, in another study (Becker, Bebout, & Drake, 1998) persons expected to be paid more based on an inaccurate understanding of the relationship between type of work and compensation. In the latter study researchers suggested that lack of work experience and having others manage their finances might have led the persons in the study to have such unrealistic expectations even though they were able to get jobs based on their preferences (Becker et al., 1998).
A commonly held view is that when persons have the opportunity to work in their preferred jobs their self-esteem increases. However, when work is used as the outcome measure there seems to be a weak association between work and self-esteem (Torrey, Mueser, McHugo, & Drake, 2000). In their sample of persons with serious mental illness (SMI), Torrey et al. (2000) noted that increased self-esteem was reported by those persons who worked the longest period of time. Persons who reported high self-esteem experienced few symptoms of suicidality, depression, anxiety, and guilt (Torrey et al., 2000).
It has been shown that individuals with disabilities can achieve competitive employment via supported employment. The Rehabilitation Act of 1973 (amended) has as one of its tenets that persons with disabilities be able to enter competitive employment in an integrated setting. Persons diagnosed with severe disabilities now have the supports that could enable them to manage their lives better and to enter and maintain employment (Wehman, 1988). Those diagnosed with severe mental illnesses like bipolar disorder need special supports in order to be able to enter the labor market and to work competitively.
Stigma and the Public Response
Individuals with disabilities have to deal not only with the immediate and long lasting effects of their illnesses and conditions, but they must also must deal with the negative stigma society has attached to these disabilities. Community attitudes have long been negative toward persons with disabilities (Brown & Bradley, 2002; McLaughlin, Bell, & Stringer, 2004). Attitudes persist that people with SMI are unpredictable, destructive, have diseases that others may catch, cannot be habilitated, and should be seen and not heard. These negative attitudes seem to be even stronger towards persons who have long-term mental illnesses compared to those that have a physical disability, and these negative attitudes drive how people in the community as well as employers respond to their social and work needs (Brown & Bradley, 2002). These negative attitudes may also determine the support available and utilized in the workplace and in the daily life events of the individual with the illness (Brown & Bradley, 2002). Thus researchers call for focused intervention strategies at three levels: the individual’s peers and supervisors, the work group, and the entire business (Fabian et al., 1999).
Since employers are no less prone to these negative stereotypes of those who have mental illnesses, they must be educated to help promote more positive perceptions about those with SMI. McLaughlin, Bell, and Stringer (2004) researched a sample of 600 subjects who were disabled and working. They reported that co-workers’ perceptions of the job performance of the person with the disability were the most cogent factor in determining acceptance, suggesting an ongoing need for further employer/employee education on disabilities in general and for specific disabilities (McLaughlin et al., 2004). Stigmatic beliefs are held even by supporting professionals and family members. Persons debate about disclosing their illness and treatment to family members and employers as a result of their own subjective feelings about the stigma or having experienced overt discrimination and even violence (McLaughlin et al., 2004).
Garske and Stewart (1999) suggested that it is the stigma of the illness rather than the physical limitations that keep the person from satisfying his or her life goals. Rutman (1994) reported that barriers to employment and community integration also include problems caused in the following areas – the person’s instability, prescribed medication issues, persons’ lack of interest in the value of work and social impassiveness, service systems that persons find it difficult to maneuver in, and work disincentives created by social security. Persons’ instability is usually attributed to the cyclic nature of the illness’ episodes and their not wanting to take medications based on their prior experience with medications (they can be harmful and produce disruptive side effects) create natural barriers to employment (Rutman, 1994).
Even though this population is an untapped resource of workers that our society could use, the stigma associated with having a mental illness is very strong in our society and predicting work readiness, vocational outcomes, and readiness for change can be difficult (Rutman, 1994).
Intervention Models Focusing on Employment for Individuals with BP
There are many community-based models that enable persons with severe disability to enter the workforce. These models include supported employment, sheltered workshop programs, community rehabilitation programs, assertive community treatment, clubhouse, projects with industry, individual placement, and transitional employment (Barker, 1994). Researchers have found that some programs incorporate components of various models as they seek to adjust to the needs of their persons (Barker, 1994). This “responsive service system” attends to the individualized needs of local persons, offering them only the services they require while providing them an array of choices from which to choose (Barker, 1994).
Persons living with severe and persistent mental illness require ongoing support due to the cyclical and encompassing nature of the illness (Anthony, Cohen, Farkas, & Cohen, 2000). Case management is a means to answer the many needs of both the treatment team and the person (Anthony, Cohen, Farkas, & Cohen, 2000). Case management is described as the tool to address the various goals of persons while helping them to navigate the community of service providers (Anthony et al., 2000). According to Anthony et al. (2000) case management involves “connecting with clients, planning for services, linking clients to services, and advocating for service improvements.”
Supported employment (SE) was originally designed to enable persons with mental retardation to enter the workforce. The principles of SE have been generalized for use with persons who have other severe disabilities, helping them gain entrance into competitive employment (Wehman, 1988). Decades of research have shown that SE helps persons with developmental and mental disabilities to find a way to enter the world of work (Wehman, 1988). Competitive employment resulting from supported employment programs benefits individuals with disabilities because it provides not only benefits and higher incomes, but it also provides persons with disabilities opportunities to work alongside non-disabled coworkers, thus improving their community integration (Wehman, 1988).
Even though the value of sheltered workshops in the lives of those with severe disabilities have been called into question, research still shows that it is a valuable option for those with severe disabilities (Black, 1992). Sheltered work was initiated to serve as a form of transitional employment, but few persons employed in these settings enter competitive work settings (Black, 1992). Reasons given for the poor competitive vocational outcomes of those in sheltered work include the need for high numbers of staff to serve this population, their slow return to normal productive capacity due to the nature of their illness, and being part of a system that wants to keep their industrious and productive workers in order to continue being financially productive (Black, 1992). Black (1992) also noted that persons who are productive in these settings are not usually the ones moved into competitive employment, and these persons tend to be paid below the minimum wage.
Predictors of Entering Competitive Work and Long-Term Medical Stability
Researchers have failed to agree on a set of predictable variables that result in higher workforce participation for persons with SMI. The many variables mentioned in the literature seem to depend on the narrow definition of functionality (e.g., post-hospital employment, competitive employment, history of hospitalizations, being ready to work, remaining on the job) employed by various researchers. Focusing on post-hospital employment, Anthony et al. (2000) reported that research had shown five demographic variables to be significant – number of previous hospitalizations, length of the last hospitalization, employment history, marital status, and diagnosis, while race, occupational level, age, educational level, and sex were either tentative or not significant. Anthony et al. (2000) noted that diagnosis, current symptoms, ability to function in one environment, demographic variables such as age, gender, ethnicity, and intelligence, aptitude, and personality largely failed to predict whether a person benefits from vocational rehabilitation and finds a job.
Recent studies have both agreed and disagreed with these results. For instance, in a retrospective study of 4, 603 persons who had been successfully closed as rehabilitated, Bolton et al. (2000) considered all three phases of the rehabilitation process (taking personal history, functional assessment and limitations profile, and services annotated in the rehabilitation plan) and reported that job placement services, getting a good personal history, providing training and restorative services, and the amount of time in rehabilitation predicted competitive employment and salary at closure. Even though functional limitations displayed minimal relationships with employment outcomes in this sample of persons, counselors are encouraged to use it in combination with other data in planning services.
Macias, DeCarlo, Wang, Frey, and Barreira (2001) for example, explored the issue of work interest as a predictor of competitive employment. One hundred and sixty-six persons who had been enrolled in either a Clubhouse program or an Assertive Community Treatment program were followed for 2.4 years. Those who expressed a work interest were able to find competitive work compared to those who did not (51.3% versus 28.6%). When the persons in this study who had expressed no interest in work were given vocational support, 29% of them did engage in competitive employment (Macias et al., 2001, p. 287). This emphasizes the role the service team can play in providing ongoing support.
Individuals who live with the effects of a SMI need accommodations in order to enter the workforce and maintain their jobs (Becker et al., 1998). The passage of the ADA (1990) changed the accommodation landscape. Research just prior to the passage of the ADA with 127 Fortune 500 companies, found that only 23 had either formal or informal policies regarding the employment of persons with disabilities and that these policies were mostly driven by affirmative action (Jones, Gallagher, Kelly, & Massari, 1991). According to the Americans with Disabilities Act of 1990 (ADA), Title ?, employers are prohibited from discriminating against qualified individuals with disabilities in job application procedures, hiring, firing, advancement, compensation, job training, and other terms and conditions of employment (MacDonald-Wilson et al., 2002).
According to the ADA (1990) a “qualified individual” is a person with a disability who can, with or without reasonable accommodation, perform the essential functions of the job. Reasonable accommodations may include leaves of absence, flexible work schedules, changes in leave policy, physical workplace modifications, access to special equipment, adjusting supervisory interactions, provision of a job coach, job reassignment, counseling, peer and employer training (MacDonald-Wilson, Rogers, Massaro, Lyass, & Crean, 2002).
Employers who have had more contact with persons with disabilities tend to be more flexible in their hiring and accommodations for those who are SMI (MacDonald-Wilson et al., 2002). One of the roles of the ACT and other support teams is advocacy by means of ongoing relationships with industry (Diksa & Rogers, 1996). These contacts will help foster positive relationships and trust among the various stakeholders. Industries who have past experiences with persons who have SMI also relate fewer fears about persons’ symptoms, notably violence and poor productivity (Diksa & Rogers, 1996).
This is a positive step in reducing community and especially employers’ negative stigma about persons who live with SMI. One of the surprising results from a sample of SE programs was that 12% to 17% of individuals and programs were not being monitored as to how successful the individuals with disabilities were on the job (Diksa & Rogers, 1996, p. 6). This highlights the need for better contact to ensure that both employer and person goals are being met. In this sample, job coaches and case managers were providing the necessary contact with families and businesses.
The paper focused on the issues surrounding the relationship between having a diagnosis of bipolar disorder and being able to work and function in the community. Research findings were shown related to enabling persons diagnosed with SMI and specifically bipolar disorder enter and remain in the workforce. The issues discussed included Social Security disincentives, symtomology issues, medication issues, medical and psychosocial interventions, predictors of entering the workforce, and accommodations.
Persons diagnosed with this disorder face many obstacles to maintaining employment. Fortunately, individuals who live with severe and/or persistent mental illness now have tools to enable them to enter and remain in the workforce (Wehman, 1998). Research has shown many areas in which both they and their support system can utilize in this endeavor. Most researchers have examined case management, medication management, and supported employment as singular issues but there appears to be a need to explore how combing these interventions together could increase persons’ ability to being employed. There is need to attend to as many intervention modalities as possible in many avenues.
It has been shown that families must be closely involved as they seem to be most able, at times, to be the sole link between the person and the community. To this end service providers must be accessible to provide the needed education and other supports required. Service providers must be adequately trained in current delivery models that are shown to provide the needed outcomes. Supported employment and case management methods have been shown to provide the necessary path to work for those with serious mental disorders. Research has also shown that persons with severe mental illness need non-time limited support because the illness is ongoing and cyclical.
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