Monday, March 28, 2005

Reshaping Work Incentives for People with Serious Mental Illnesses

Choose work is the inspirational slogan of APSE, the Employment Network (formerly known as Association for Persons in Supported Employment). Yes, going to work is an easy choice for most of us based on our need for income and the other positive things a job brings to our lives. However, the decision to work is often a confusing choice for people with disabilities to make due to contradictory forces at work. To illustrate my point, let’s explore some of the challenges faced by adults diagnosed with serious mental illnesses (SMI).
The Social Security Administration (SSA) is our nation’s principle provider of cash benefits for unemployed Americans with SMI. Under SSA’s Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) programs, formal disability testing is used to measure the capacities of individuals to become self-supporting. For decades, Americans with symptoms of SMI have undergone psychological testing and evaluation to document their ability to engage in competitive employment. Historically speaking, eligibility for SSA benefits meant acknowledging the permanency of one’s disability and incapacity to work.
Despite noble intentions, disability entitlement programs are often identified as major reasons for a lack of progress made by adults with SMI in going to work. For example, the President’s New Freedom Commission on Mental Health issued a report in 2002 concerning the need for national reforms to improve public mental health services in the United States. In a summary of its findings, the Commission reported "...undetected, untreated, and poorly treated mental disorders interrupts careers, leading many into lives of disability, poverty, and long term dependence. Our review finds a shocking 90 percent unemployment rate among adults with serious mental illness–the worst level of employment for any group of people with disabilities. People with mental illness live in a kind of disability welfare system that badly needs reform."
In 1999, Congress passed the Ticket-to-Work and Work Incentives Improvement Act with the objective of increasing employment and self-sufficiency for beneficiaries with disabilities enrolled in SSI and SSDI programs. Most people agree that SSA’s Ticket-to-Work Program has been disappointing. It has not resulted in any significant increase in employment participation by eligible beneficiaries because its design does not go far enough in addressing fundamental fears nor motivational needs of SSA beneficiaries, Employment Networks offering job placement services to beneficiaries, nor prospective employers who might choose to hire beneficiaries with long unemployment histories.
Instead, our nation’s disability benefits programs continue to promote dependency because of: (1) a sense of public entitlement by existing beneficiary groups; (2) entrenchment due to fears about losing cash and health care security by going to work; (3) a "learned helplessness" due to attitudes of disability permanency and inability to work; and (4) perceived rewards vs. risks in pursuing goals of self-sufficiency.
The fears associated with possible loss of public entitlements are not only held by mental health consumers themselves, but also by family members, mental health professionals, and rehabilitation practitioners who support them. This fact is evidenced by the low percentage of beneficiaries who choose to go to work as well as high percentage of working beneficiaries who intentionally limit their hours worked and wages earned to avoid the loss of public benefits.
Dispelling Myths & Misunderstandings
The unemployment and underemployment problems of adults with SMI are not grounded in facts, but rather in a number of commonly held myths. These include false assumptions that people with SMI: (1) don’t want to work; (2) can’t work because of their illness symptoms; (3) can’t work because they will lose their basic living supports; and (4) can only work in low-paying jobs that require minimal stress and skill sets. None of these stubbornly held myths can stand the test of objective scrutiny.
For example, studies conducted with mental health consumers continue to support the fact that a majority prefer to be working and self-supporting. Contrary to reported unemployment rates, the desire to find a good job continues to be rated as one of the highest areas of need by consumers regardless of where they live in the United States.
Also, many people believe that adults with SMI need to recover from their illness before they can go to work. However, scientific evidence is now documenting the reverse tends to be true. Most adults recover from illness BECAUSE they go to work, have structure in their lives, earn money, have opportunities to connect with others, and gain a sense of self-respect through personal achievement. Supported employment programs throughout the country are proving that people with SMI can work if they choose to, develop a customized employment plan, find an interested employer, and have access to the mental health treatment and supported employment they need to be successful.
The potential loss of cash and health care benefits is an understandable fear of many mental health consumers who are considering entering the workforce. However, a majority of these individuals are eligible for SSA’s work incentives that will enable them to go to work and protect basic living needs. Most of these individuals can go to work and make a smooth transition from disability benefits if they receive expert guidance to measure the impact of working and insure daily living expenses are addressed.
In Minnesota, for example, the Minnesota Work Connection, a disability benefits planning outreach program funded by SSA, educates beneficiaries about work incentives and offers individualized guidance about plans for self-support. The State of Minnesota also offers a progressive Medicaid Buy-in Program called Medical Assistance for Employed People with Disabilities (MA-EPD). MA-EPD offers affordable health care and medications for adults with SMI who want to work but have extraordinary medical care expenses. MA-EPD provides health care protections at a low monthly premium for qualified, employed individuals with disabilities.
Finally, customized employment demonstrations are showing that people with SMI need not be limited to unskilled jobs or menial labor positions. My employer, Rise, Incorporated, runs a program called Career Trek that encourages people with SMI to use their post-secondary education, training, and skills to gain access to well paying jobs in the range of $10.00-$16.00 per hour for all trial sites. Career Trek, a national demonstration program funded by the federal Rehabilitation Services Administration (RSA), is proving that the underemployment of people with SMI is not rooted in a lack of job skills, but rather in public attitudes and restrictive policies that limit creativity and discourage risk-taking. Career Trek helps adults with SMI market and use their talents in customized jobs of their choosing including professional, para-professional, self-employment, and occupational trades.
Without a doubt, the high unemployment of adults with SMI is driven by a blend of unfounded fears, misinformation, ambiguous public policies, and ineffective service delivery designs. As the facts continue to accumulate, we have a moral obligation to use current and reliable information to improve our system of mental health services. One fact is now clear--working is fundamental to mental health recovery.
If this is true, then the principle public policy question is this: What steps should government and community mental health agencies be taking to increase the job placement and economic stability of people with SMI?
Making a Compelling Business Case
Achieving any substantial level of change in the employment and self-sufficiency of adults with SMI will require new strategies for attacking presenting barriers and the reasons for inertia among the principle stakeholders.
For adults with SMI and their loved ones, it means introducing compelling reasons to go to work. Educating consumers about the importance of work to their recovery is only a beginning. Breaking decades of traditional thinking and non-work habits is quite another matter. The only true way to break through a consumer’s cycle of fears about losing disability entitlements is to build a strong business case for going to work. More adults with SMI will act on their expressed choices about employment if they know that going to work offers clear financial rewards and health care protections.
For community mental health and rehabilitation professionals, it means offering compelling reasons to abandon traditional service practices and introduce strategies proven most effective to mental health recovery. In short, community mental health and rehabilitation programs must abandon current practices such as adult day treatment in favor of supported employment. The goal of working is within reach of most individuals, but the evidence is clear that most beneficiaries will need customized support to find, keep, and grow in a job of their choosing.
For employers, it means offering compelling reasons to hire and retain SSA beneficiaries as their employees. Educating employers about the job abilities of people with SMI is just a beginning. Most businesses will need knowledge and technical support about the symptoms of mental illnesses, learning how to customize job functions to match the abilities of applicants, and implementing job accommodations that are needed for retention success. Employers need a compelling business case to hire, train, and support people with long histories of chronic unemployment and economic dependency. These actions will happen by way of wishful thinking or a continuation of existing mental health practices.
Our nation’s current system of Social Security is not sustainable without a major infusion of new taxes or a restructuring in regards to how benefits are paid in the long run. Since Social Security is largely a "pay-as-you-go" system for retirement and disability benefits, Congress is looking for fresh ideas and approaches. The rapid depletion of resources in the Social Security Trust Fund, and growing deficits for public services at the federal, state, and local levels has created a national crisis that requires our immediate attention. When budget deficits are factored with a growing body of evidence about the value of working to mental health recovery, it offers a compelling argument for structural and sustainable changes.
If working is truly fundamental to mental health recovery, then our only real choice is to pursue aggressive changes in public policies, funding strategies, use of public disability entitlements, and direct service approaches that increase job placement and self-sufficiency outcomes. Of course, the size and dimensions of this task will require time, federal and state cooperation, and a sharing of expertise and resources by the public and private sectors. In 2005, a convergence of human and economic factors has created a strong argument for introducing changes in our conceptual vision and mental health strategies. Are we ready to take on these formidable challenges? After a long history of neglect, Americans who live with SMI deserve no less than our very best effort.


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