**[Promoting Work Among SSI/DI Beneficiaries]{.smallcaps}**

**[with Serious Mental Illness]{.smallcaps}**

*[Prepared for the:]{.smallcaps}*

![](media/image1.wmf){width="0.6666666666666666in"
height="0.6930555555555555in"}**[Ticket to Work and Work Incentives
Advisory Panel]{.smallcaps}**

*[Prepared by:]{.smallcaps}*

**[Martha R. Burt]{.smallcaps}**

**[Laudan Y. Aron]{.smallcaps}**

**[The Urban Institute]{.smallcaps}**

**[2100 M Street, NW]{.smallcaps}**

**[Washington, DC 20037]{.smallcaps}**

**[www.Urban.org]{.smallcaps}**

# October 17, 2003 {#october-17-2003 .unnumbered}

This paper was prepared for the Ticket to Work and Work Incentives
Advisory Panel under a Social Security Administration contract to the
Urban Institute. It has benefited from the helpful comments of Elaine
Maag of the Urban Institute. The opinions and conclusions in this report
are the sole responsibility of the authors, and do not represent the
official views of the Social Security Administration, the Ticket to Work
and Work Incentives Advisory Panel, the Urban Institute, or its funders
or trustees.

[Promoting Satisfactory Work Experiences Among SSI/DI Beneficiaries with
Serious Mental Illness]{.smallcaps}

One long-range goal of the Ticket to Work and Work Incentives
Improvement Act of 1999 (hereafter, TTW) is to save public costs by
increasing the proportion of Supplemental Security Income (SSI) and
Social Security Disability Insurance (DI) beneficiaries who work, and
ultimately the proportion who leave the rolls because they achieve the
level of substantial gainful activity (SGA). Related goals include
increasing work activity even for beneficiaries who would not be
expected to earn their way off the rolls. The Social Security Act and
the TTW facilitate the transition to work by providing employment
support resources and work incentives for beneficiaries.

This paper focuses on the substantial proportion of people who are
SSI/DI beneficiaries by reason of serious mental illness (SMI)---34
percent for SSI and 27 percent for DI.[^1] It discusses options for
helping people with SMI on the SSI/DI rolls work more. It describes
strategies and techniques that are being used to promote employment
among people with SMI, as well as the issues and challenges involved in
achieving this objective. It ultimately addresses the question of what
some realistic goals might be for Social Security programs with respect
to promoting work among beneficiaries with SMI.

As we detail in this paper, many people with SMI work, and many others,
including some on the SSI/DI rolls, want to work. We start from two
premises---(1) that promoting work among people with SMI who want to
work is a good thing to do, and (2) that mental illness is poorly
understood and managed, both within and beyond the workplace, which
contributes in part to its costs to society. Employment is an important
route to recovery, economic empowerment, and independence for people
with mental illness. But a number of challenges exist, including the
nature of SMI, the SSI/DI application process, the appropriateness of
available incentives, and the expectation of sustained long-term
competitive employment.

We first present background information on the characteristics of people
with SMI who receive SSI and DI, the work activity level of people with
SMI both on and off the SSI/DI rolls, and Congress' pre-Ticket efforts
to increase work participation through incentive provisions such as
1619a, 1619b, and other provisions governing continuing eligibility for
benefits and rapid reinstatement if working does not prove viable. We
rely for this information on many papers and reports prepared for the
Ticket to Work Advisory Panel (Rupp and Bell 2003), which we briefly
summarize.

We then review the various techniques and strategies for promoting work
that have been the subject of demonstration programs sponsored by the
Social Security Administration and the Substance Abuse and Mental Health
Services Administration (SAMHSA) before Ticket to Work. We also examine
how people with SMI, and their employers, handle their employment---what
is being called in some places "managing disability." We describe
techniques and approaches available to employers, intermediaries such as
Ticket to Work's employment network (EN) providers, and people with
disabilities themselves that increase the odds of successful engagement
in work. Competent management of disability may help people with
disabilities find and keep work by changing attitudes, skills, and
expectations; modifying the work environment and workplace interactions;
and increasing skills in handling potentially sensitive situations. On
the general public policy assumption that workforce participation is
good for people with disabilities just as it is for others in our
society, whether or not it leads to self-sufficiency, it is important
that techniques for managing disability become more widely known in the
workplace and applied when SSI/DI beneficiaries with SMI venture into
employment.

# background

## The SSI and DI Programs

Supplemental Security Income and Social Security Disability Insurance
are federal programs providing financial support to adults who have a
medically determinable physical or mental impairment that prevents them
from engaging in substantial gainful activity.[^2] The impairment must
be one that can be expected to result in death or that has lasted, or
can be expected to last, for a continuous period of not less than 12
months. DI provides benefits to disabled and blind people who have
participated in employment covered by Social Security for 20 of the most
recent 40 calendar quarters before applying for DI. DI payment amounts
are based on contributions made through FICA taxes on earnings.
Qualified recipients must wait five months from the onset of their
disability before receiving cash benefits. Determinants of disability
under SSI are similar to those under DI. But unlike DI, SSI is a
means-tested program that does not require recipients to have a prior
work history. SSI provides cash payments to aged, blind, and people with
disabilities who have limited income and resources (usually no higher
than 75 percent of poverty). Once a person qualifies for SSI, cash
benefits start immediately, without the waiting period required under
DI.

Given that both SSI and DI beneficiaries have one or more disabilities,
the need for health care is likely to be great. As many SSI/DI
beneficiaries are unlikely to have the resources to pay for the health
care they need, eligibility for public health insurance is a very
important aspect of the SSI/DI package. Most DI recipients are
ultimately eligible for Medicare, but benefits start only after a lag of
24 months and do not (yet) cover prescription drugs. Most SSI recipients
are categorically eligible for Medicaid, and most ultimately receive it.
But state application practices vary in the extent to which they
facilitate the Medicaid application process.

## People with Serious Mental Illness in the SSI/DI Programs

Over the past 20 years, persons with SMI have been the fastest growing
populations in the SSI and DI caseloads. A mental illness is the primary
impairment for approximately 34 percent of adult non-elderly SSI
beneficiaries (about 1.24 million people) and 27 percent of adult
non-elderly DI beneficiaries (about 1.50 million people).[^3] Some of
these people are concurrent beneficiaries of both programs. SSI/DI
beneficiaries with SMI are younger and in better physical health than
most SSI and DI participants. As a result, they tend to have longer
projected durations on these programs and are likely to be more costly
to the programs relative to beneficiaries with other conditions.
Promoting employment among these beneficiaries is clearly good public
policy---for both financial and other reasons---but the nature of SMI
presents particular challenges to an affected person's ability to
sustain employment.

Salkever (2003) describes employment prospects with respect to the three
SMI diagnoses affecting the greatest proportion of SSI/DI beneficiaries
between the ages of 18 and 64---major depression and bipolar disorder
(both affective disorders which together account for about 15 to 18
percent of beneficiaries), and schizophrenia (about 7 to 10 percent of
beneficiaries, including schizaffective disorders). For our purposes,
his basic points are that these illnesses wax and wane, leaving people
who have them able to function adequately for stretches of time only to
deteriorate periodically when the symptoms of their illness return.[^4]
These patterns can substantially reduce their long-term prospects for
stable work, and for work at the SGA level, as reflected in national
survey data as well as in SSA program data described below.

Salkever (2003) has summarized findings from national surveys on
employment among adults with mental disorders (other than mental
retardation). Researchers using National Health Interview Survey data
from 1982-91 (Yellin and Cisternas 1996) analyzed work activity among
people with a self-reported disability, which could be of any type.
Results consistently showed the lowest employment rates for people with
reported mental disorders, who were employed only about half as often as
people with other disabilities but no mental illness. Further, people
with psychotic disorders such as schizophrenia had employment rates
about half (21 percent) those of all persons with mental disorders (43
percent). Analyses of four national surveys (Mechanic, Bilder, and
McAlpine 2002) showed employment rates for persons with serious mental
disorders (not including mental retardation) to be between 32 and 61
percent, but for people with schizophrenia the rates were between 22 and
40 percent. Women with major depression are significantly less likely to
work than those without this disorder, although having bipolar disorder
or dysthemia did not have the same effects on employment. Similar
analyses for men did not show negative effects for any of these
affective disorders on employment, but dysthemia seemed to have a
negative effect on income (Marcotte, Wilcox-Gok, and Redmon 2000).
Finally, evidence from a national study of people with schizophrenia
(Slade and Salkever 2001) found an employment rate of about 22 percent,
but only half of the jobs were in competitive employment without
supports. The remaining job situations either had ongoing job coaching
or were in noncompetitive work environments.

Low rates of working and earnings among SSI/DI beneficiaries with SMI
parallel those for people with SMI in the general population. Relatively
few SSI/DI beneficiaries have any earned income. Only about 15 percent
of all SSI/DI beneficiaries have any earnings in a 12 month period---a
proportion that remains the same regardless of whether beneficiaries do
or do not have SMI or which benefits (SSI or DI) they receive. Further,
12-month earnings among those with any earnings are low overall and only
half as much for those with SMI (\$2,400) as for those with other
disabilities (\$5,400), regardless of program. Working fewer hours, on
average (about one-third time vs. one-half time), and earning a lower
hourly wage both contribute to these differences (Salkever 2003).

It is quite possible that Social Security's employment supports and TTW
programs may help achieve part of the goal of promoting more work
activity among SSI/DI beneficiaries, especially given that a substantial
share of current beneficiaries want to work. About 10 percent
volunteered for Project NetWork (described below) including those with a
primary diagnosis of SMI. Interest in working is even more widespread
among people with SMI in the general population. In a recent survey for
the National Alliance for the Mentally Ill (Hall et al. 2003),
two-thirds of respondents who report a mental illness were not working
and over half relied on public programs for cash assistance, health
care, and other benefits (37 percent reported receiving SSDI and 35
percent reported receiving SSI income). Nevertheless, among the 86
percent of respondents aged 18 to 54, a majority reported a strong
interest in working.

However, achieving full self-sufficiency---that is, reducing the SSI/DI
rolls by helping people become self-sufficient---is much less certain
for people with SMI. The same is probably true for other beneficiaries
as well. The nature of the population of individuals on disability
benefits under the SSI and DI programs and the process they have gone
through to establish eligibility raise these concerns. As other writers
have noted (Batavia 2003), people receiving SSI and/or DI:

> "...are among those with the most substantial disabilities in our
> country. They have already been subject to a process whereby they have
> been found to be so disabled that they cannot work at any job in the
> economy. Some of them have had to subject themselves to a prolonged
> process, sometimes involving legal appeals, in which they have had to
> argue that they are too disabled to work and in which 'the system'
> ultimately agreed with this conclusion."

That even some of them do try to work, despite their disability, is a
reflection of the importance of work to these beneficiaries, as it is to
the U.S. population in general. However, work is one thing and
employment at a level that will more than simply compensate a disabled
person for the loss of SSI/DI cash assistance and health care coverage
is another. Techniques for helping people find and keep jobs and for
managing disability in the workplace can increase labor force
participation, at least for a time. Although they are no guarantee that
a substantial proportion of people with SMI currently receiving SSI/DI
will achieve self-sufficiency, they are likely to increase work activity
among those who value working and would work as much as they could, with
proper supports and incentives.

Some socioeconomic characteristics known to affect workforce
participation differ substantially between SSI and DI beneficiaries with
SMI and those with other disabilities, indicating that it may be
particularly difficult to design structures to increase work
participation among beneficiaries with SMI. Beneficiaries with SMI have
only about 60 percent of the lifetime work experience of other
beneficiaries, measured in mean years of work (for SSI, 5.9 years for
those with SMI vs. 9.7 years for others; for DI, 10.9 years for those
with SMI vs. 17.5 years for others). Further, among those with SMI, SSI
beneficiaries have worked only about half as many years as DI
beneficiaries. Education levels do not differ between SMI and other
beneficiaries, but neither group has a mean education level equivalent
to high school completion (about 10 years for SSI and 11 years for DI
beneficiaries).

In a review of over 30 controlled studies conducted between 1985 and
1997 that attempt to identify strong predictors of vocational outcomes
for people with psychiatric disabilities, Tsang and colleagues find that
functioning prior to disability onset, work history, and social skills
are strong and significant predictors of employment, while the results
for symptomatology (i.e., abnormalities in moods, thoughts and behaviors
resulting from mental illness) and actual diagnosis are much more mixed.
Newer research suggests that how well one can think and process
information (cognitive functioning) and how supportive one's family is
of one's work-related efforts can also improve vocational outcomes
significantly (Tsang et al. 2000). A consistent finding among studies
looking at supported employment programs specifically is the absence of
client-level factors predicting better employment outcomes: diagnosis,
symptoms, age, gender, disability status, prior hospitalization,
education, and even co-occurring substance abuse are all poor predictors
of employment outcomes. While a strong work history does predict better
outcomes, even individuals with poor work histories have better
employment outcomes when they receive supported employment services
compared to traditional vocational services (Bond et al. 2001).

## Pre-Ticket SSI/DI Work Incentives and Demonstrations

The TTW incentive structure builds on earlier efforts to promote work
among SSI/DI beneficiaries through legislative and regulatory provisions
that expand rehabilitation opportunities, as well as allow beneficiaries
to work without risking loss of cash assistance and/or health benefits.
The work incentives for SSI and DI participants vary. In general, after
certain income disregards, SSI recipients lose \$1 of benefits for every
\$2 of earnings. In addition to these work rules, other incentives
designed to promote work for SSI recipients include:

-   Extended cash benefits while working (Section 1619a);

-   Continued Medicaid eligibility even after one would no longer be
    eligible for SSI cash payments (after exceeding the SSI break-even
    point), up to some state-specific income threshold (Section 1619b);
    and

-   A disregard of certain impairment related work expenses (IRWEs), or
    the disregard of certain income for a specified Plan for Achieving
    Self-Support (PASS).

DI beneficiaries suffer no reduction in benefits until their earnings
reach the level of substantial gainful activity, but those who do reach
that level for long enough could lose both their DI and Medicare
eligibility. In general, DI beneficiaries have the opportunity to work
during a trial period lasting up to nine months, during which
eligibility and benefits continue in case the beneficiary is not able to
sustain work.

These incentive provisions, structured by Congress, assume an ultimate
payoff for Social Security programs in reduced SSI/DI benefit payouts
because beneficiaries will eventually work enough to become
self-sufficient and leave the rolls. Even with these incentive
provisions, however, few beneficiaries, whether with SMI or other
disabilities, have any earned income, as we just noted, those with any
income do not earn more than a few thousand dollars a year, on average,
and even fewer (less than 1 percent) leave the rolls each year due to
earned income exceeding eligibility criteria (Rupp and Scott 1998).

# Experience with promoting work for people with SMI, both on and off the SSI/DI rolls, and their implications

## Findings of Demonstrations to Increase Work Among People with SMI

### Project NetWork

In the early 1990s the Social Security Administration mounted a special
demonstration program to increase work participation by SSI/DI
beneficiaries. This field experiment, Project NetWork, incorporated
extensive outreach to beneficiaries and increased their access to
return-to-work services. The project identified eligible individuals
and, through intensive outreach, invited them to apply. Applicants who
qualified (about 60 percent, on average) were designated "participants."
They were divided into treatment and control groups, with only the
former receiving the enhanced access. Evaluation results (Rupp and Bell
2003) showed that participants earned much more during the intervention
period than nonparticipants. Two caveats are especially important to
note, however. First, there were no differences between treatment and
control participants---virtually the entire "impact" was due to
self-selection, with beneficiaries having characteristics more
predictive of work success choosing to apply and being selected at
higher rates than beneficiaries with less promising characteristics. So
the actual intervention had only the most marginal effects. Second, and
at least as important from the point of view of TTW's eventual ability
to bring about the goal of reducing the SSI/DI rolls, average annual
earnings of participants, including those with zero earnings, were in
the \$3,200-\$3,500 range. Even after eliminating participants who had
zero earnings in all of the six follow-up years (36 percent for the
treatment group), average annual earnings increase only to about
\$5,800---still well below the level that would be needed for
self-sufficiency. The only aspects of the Project NetWork evaluation
results that hold some promise for the goal of helping beneficiaries
with SMI leave the SSI/DI rolls were that beneficiaries with SMI were at
least as likely as those with other disabilities to apply for the
enhanced work supports and to be selected as participants, and that
outcomes for participants with SMI did not differ in any substantial way
from the average for all participants, regardless of disability type.
These results suggest that beneficiaries with SMI are as interested in
working and as capable of predicting their own employment success as
beneficiaries with other disabilities.

#### Essential Project NetWork Findings

-   People with SMI did not fare any differently than people with other
    diagnoses---they were actually slightly more interested in working
    (more applied), and more were selected as participants (considered
    acceptable).

-   People with SMI earned as much, on average, as the sample as a
    whole, and more than some other disability categories.

-   People with SMI were just as good as those with other diagnoses at
    predicting their own success.

-   BUT, only 10 percent of all eligible individuals applied, only 64
    percent had earnings in at least one of the six follow-up years, and
    these job-holders still earned only about \$5,800 a year, on
    average, during the six year follow-up period (\$3,500 a year if one
    includes everyone with zero earnings).

-   So, the motivation to work exists for some, although earnings
    potential does not appear to be high.

### Employment Intervention Demonstration Program

SAMHSA's Center for Mental Health Services (CMHS) sponsored the
Employment Intervention Demonstration Program (EIDP) beginning in 1995.
Its goals were to identify the complex factors involved in securing and
maintaining satisfying employment among mental health consumers, and
understand how different types of service interventions might improve
clients' chances of working. Eight sites tested nine service models,
with two models included at each site. Some models were considered
"enhanced" (i.e., the treatment conditions) while others were considered
the comparison models. Data were collected on 1,648 EIDP participants
from 1996 through 2000.

All participants were mental health consumers. Although 97 percent had
held a paying job at some time in their lives, one-third had not done so
in the five years before the study began, and only one-fourth had worked
25 or more months out of the prior 60 months. When they did work, most
jobs were at minimum wage. At baseline, 12 percent received both SSI and
DI, 35 percent received SSI only, 25 percent received DI only, and 28
percent did not receive either benefit.

During the first 24 months of EIDP, participants in the enhanced
conditions were more likely than comparison group participants to have
done any work for pay, to have worked each month in competitive
employment, and to have worked 40 or more hours per month. However, jobs
for all working participants tended to be at minimum wage, and to be
part-time (19 hours per week, on average). Controlling for many
participant characteristics, regression analyses found that people's
employment outcomes improved over time in both enhanced and comparison
conditions, but the enhanced group had better outcomes overall and their
outcomes increased more over time. As has been found in other studies of
individual factors affecting employment (Mechanic et al. 2002; Slade and
Salkever 2001), better work histories, fewer symptoms, lower levels of
functional impairment (ability to carry out activities of daily living),
no other health problems, and diagnoses other than schizophrenia led to
better employment outcomes, over and above the effects of enhanced
services. Younger people and those not receiving disability income
(which we can take as a proxy for being less disabled) also had better
employment outcomes.

Looking at the effects of services, those receiving more total hours of
clinical services had poorer vocational outcomes (possibly reflecting
poorer mental health status), those receiving more total hours of
vocational services had better employment outcomes, and those receiving
integrated employment and clinical services had the best outcomes of
all. In this final condition, employment services staff could identify
situations in which mental health status was interfering with work
performance and bring clinical resources into play quickly and
appropriately (because the services were integrated) to prevent the
situation deteriorating to the point of losing the job.

Vocational services associated with better outcomes included job
development, on-site job support, collaboration with employers,
vocational assessment, vocational treatment planning, vocational
counseling, and transportation. EIDP defined employment and clinical
services as high on integration when they were delivered by the same
agency, at the same location, using a single case record, and with
regularly scheduled and frequent (not less than three times a week)
meetings of the vocational and clinical providers (Cook 2003).

Nevertheless, there are some important caveats in the EIDP results.
First, more people were on SSI/DI at the 24-month follow-up than had
been recipients at baseline. About one-third of the people who began
with no benefits were receiving them at follow-up, leaving only 19
percent who do not receive either DI or SSI. The proportion receiving
both DI and SSI increased the most. Second, no more than 3 percent of
employed participants who received only SSI ever achieved monthly
earnings at or above SGA; corresponding proportions for recipients of
SSDI only and both DI and SSI are about 4 or 5 percent. Nor did
participants reach even these levels until about 18 months into their
period of service receipt.

Further, EIDP participants and programs encountered the basic stumbling
block that people with SMI had a lot of trouble keeping jobs once they
had them. EIDP interventions did improve on the average length of time
people with SMI were able to hold their jobs, which is reported in the
literature to be about three to four months and rarely longer than six
months. But even EIDP interventions could not keep many of the people
with initial job placements employed at their first job (although many
people were helped to return to employment). In the Maryland site,
Lehman and colleagues (2002) reported that over time, enhanced program
participants' initial employment levels of about 20 percent declined to
the 10 percent experienced by the comparison sample.

Thus despite the investment made in them, even the most successful
employment support programs for people with SMI, which do help more
people to work for at least some time, do not appear able to help people
in ways that might lead to large reductions in the SSI/DI rolls. They
can successfully place many clients and can help them extend their job
tenure and get new jobs when old ones are lost. But they cannot control
the factors that keep their participants operating at or below poverty
incomes, or the course of the mental illnesses that affect job tenure.
Being casework programs whose obligation is to help their clients access
the best supports available, they also help mental health consumers
obtain SSA benefits. So work increases, but does not have the effect of
reducing the benefits rolls. And client need persists, leading to
increased proportions becoming SSI/DI beneficiaries.

#### Essential EIDP Findings

-   During each month starting about nine months into the period of
    receiving work-related services and continuing through month 24,
    about 30-35 percent of participants in EIDP's enhanced models had
    done at least some work for pay.

-   During the same follow-up period, even the participants in EIDP's
    comparison groups---who received "usual" employment-related
    services---achieved a monthly employment rate of 25 to 30 percent.

-   Thus both the enhanced and "usual" employment-related services are
    considerable improvements over current employment rates for SSI/DI
    beneficiaries.

-   The more vocational services people receive, the better their
    employment outcomes.

-   People who receive a relatively balanced amount of well-integrated
    and coordinated vocational and clinical services have much better
    employment outcomes than those who receive non-integrated services.

-   EIDP participants earned enough, on average, to save SSI/DI about
    \$1,800 in benefits per person over a two-year period (about \$74 a
    month), based on a \$1 reduction in benefits for each \$2 earned,
    after accounting for disregards.

-   While employment outcomes are significant accomplishments for EIDP
    participants, they remain low overall. With all the help that EIDP
    offered its participants, and all the jobs that people held, they
    were not able to get jobs that paid enough to lift them out of
    poverty, and hence off the SSI/DI rolls. Nor were most able to
    sustain employment in one job for much beyond six months, and
    significant gaps (of about 80-100 days) were common between jobs
    before people went back to work.

-   The cost of achieving this level of results is not trivial. Clark
    and colleagues (1998) estimate that these programs cost about
    \$3,600-\$3,700 a year per participant, which is more than most of
    the participants earn, and double the savings realized by the SSI/DI
    programs.

## Program and Policy Options for Increasing Participation in Employment

Major advances in science and service delivery over the past two decades
have led to a virtual revolution in how mental health and illness are
understood and managed (Mueser et al. 2002; Drake et al. 2001; Torrey et
al. 2001; Goldman et al. 2001). A range of effective, well-documented
treatments are available, yet the Surgeon General's 1999 report on
mental health (U.S. DHHS 1999) notes that less than one-third of adults
with a diagnosable mental disorder receive treatment in any given year.
Further, the President's New Freedom Commission on Mental Health cites,
as part of its Goal 2, the appropriateness of helping people with major
mental illnesses to achieve as extensive an involvement in productive
work as possible, and as they desire (President's New Freedom Commission
on Mental Health 2003).

A variety of programs and practical strategies have been developed and
proposed to support the employment of people with psychiatric
disabilities (Crowther et al. 2003; Bond et al. 2001; Drake et al.
2001). Some have been stimulated by changing views of what people with
disabilities can accomplish, and some by the legal requirements of the
Americans with Disabilities Act (ADA).[^5] New ways of thinking about
the interactions between mental illness and different aspects of
workplace culture and environment, as well as how specific
characteristics of a job may contribute to stress and mental illness,
are also leading to changes in how employers think about mental wellness
and work more generally.

Workers with serious mental illnesses may experience any of a wide
variety of symptoms that could interfere with productivity at work.
These include problems with judgment, attention, concentration, memory,
decisionmaking, psychomotor functioning, cognitive processing, and
social interactions and communications. To address these difficulties, a
strong focus has been on creating accommodations that workers with
mental illness may need to succeed at work. Examples of such
accommodations include adjustments needed to help workers maintain
stamina and concentration, stay organized and meet deadlines, cope with
memory deficits, work effectively with supervisors, interact with
coworkers, handle stress and emotions, deal with change, and manage
attendance issues.

As serious mental illnesses affect many people who do not receive SSI/DI
benefits as well as many who do, we start with approaches that operate
at the broadest level of prevention/ accommodation for people already in
the workforce, then with approaches that are more directly focused on
people whose disability has kept them out of the workforce, and finally
with approaches for facilitating workforce participation other than
specific programs.

### Proactive Approaches for Managing Mental Health in the Workplace

Providing employees with mental illnesses with various accommodations is
important, but like most traditional approaches to workplace
disability-related issues it is reactive rather than proactive. New
developments in human resource management have led to a virtual paradigm
shift in how disability in the workplace is viewed and treated. As part
of what is now known as disability or absence "management," employers,
insurers, health care providers, and human resource professionals have
come together and developed a variety of approaches designed to prevent
mental illness (by reducing workplace factors that may actually
contribute to mental illness) and promote mental wellness among workers
generally. This shift from a reactive to a proactive stance toward
health and disability has primarily focused on physical wellness and
safety, but is gradually being extended to mental health issues as well.
One consulting firm that specializes in psychiatric disability
management suggest four specific tasks that companies should undertake
to directly address mental wellness in their workplace (O'Connor
Associates undated):

> First, generate employee and supervisory feedback about employer
> practices and work culture traits that contribute to stress or
> depression. This process provides HRM \[human resource management\]
> with ratings on its disability management practices, mental
> health-related resources such as EAP \[Employer Assistance Program\]
> and Work/Life, and HRM ADA/FMLA \[Americans with Disabilities
> Act/Family and Medical Leave Act\] policies. Second, conduct 'audits'
> of your training and HRM consultant resources to assess their ability
> to reduce work culture variables that contribute to mental
> health-related disability. Third, analyze various medical and EAP
> vendor data to assess their expertise to manage disability (versus
> just injury or symptoms) and improve mental wellness in your
> workforce. This will provide HRM the knowledge to create employee
> management and environmental changes to reduce these costs.
> Understanding the uses of these data reinforces the value of HRM in
> the disability management team dynamic (alongside risk management,
> benefits administration, etc). Fourth, implement a strategic plan for
> changing work culture and employee management protocols in response to
> your overall assessment. Such a plan would include staff training,
> behavioral performance standards for supervisors, and proactive (vs.
> response-oriented) strategies for reducing disability-related events
> or behavior in the workplace.

With its focus on prevention and early intervention, the main
beneficiaries of workplace disability management practices clearly
extend far beyond those with serious mental illnesses (the focus of this
review). Yet employers who are aware of and committed to supporting the
mental well-being of all employees are also likely to be the ones best
able to accommodate those with more serious mental disorders. Research
has mapped out the many domains of work that can contribute to stress
among workers (Table 1), creating a useful list to work with and
consider with respect to making accommodations for people with serious
or persistent mental health problems. These same factors that are
stressful for workers generally can be detrimental to people with SMI,
and may even affect the recurrence of mental disorders that are episodic
by nature, such as major depression.

\[Table 1 about here\]

### Employment-Related Accommodations for Mental Health Disabilities

Because mental illness is often "hidden," it can be difficult for
employers to distinguish between behaviors that are manifestations of a
disability and ones that simply require disciplinary actions. Employers
report psychiatric disability to be among the most difficult to
identify, accommodate, and manage. They have specific concerns about how
to handle performance problems among employees with a mental illness,
and many have a variety of misconceptions about the ability of people
with mental illness to work with others, the inevitability of employee
relations problems resulting from negative co-worker reactions, and the
ease with which physical disabilities can be accommodated relative to
mental ones (Handrich 2000).

It is important to remember that the functional limitations (abilities
to perform various tasks) stemming from mental illness vary from one
individual to another, and even over time for the same individual. In
some cases employment-related accommodations are needed to address
limitations imposed by the mental condition itself, and in other cases
to handle the effects of medications. Also, while DI and SSI
beneficiaries clearly have work-limiting conditions, many other people
with psychiatric disabilities may not need any accommodations to perform
their job and others may need only a few.

Some very practical tools and strategies are now available for employers
and others who are involved in helping accommodate people with mental
illness. They include such recent publications as the Hogg Foundation
for Mental Health's (2000) *Managing Mental Illness in the Workplace: A
Practical Guide for Supervisors*, and another by the Job Accommodation
Network within the Office of Disability Employment Policy of the U.S.
Department of Labor (undated) *Work-Site Accommodation Ideas for Persons
with Psychiatric Disabilities* (see Appendix B for specific examples of
such accommodations). New websites also offer extensive materials such
as the Canadian Mental Health Association's *Working Well: An
Employer\'s Guide to Hiring and Retaining People with Mental Illnesses*
(Vandergang 2002), one publication among several available at the
association's website, "Routes to Work: Helping People with Mental
Illness Secure Mainstream Employment."

Effectively accommodating psychiatric disabilities can require changes
in a variety of domains including:

-   **Schedule adjustments** such as more breaks, flexible scheduling, a
    compressed workweek, or part-time work (often these are done to
    accommodate the side effects of medications).

-   **Benefit adjustments** such as using sick leave for therapeutic and
    other mental health treatments.

-   **Support system adjustments** such as training co-workers how to be
    more supportive and helpful to a given employee.

-   **Environmental adjustments** such as changing the location,
    organization, or noise or lighting level where someone works, or
    allowing for work to be done off-site.

-   **Supervisory style adjustments** such as increasing access and
    frequency of contact with supervisors, more training of supervisors,
    and changes in communication style.

-   **Assignment adjustments** such as allowing for self-paced work,
    flexible hours, job sharing, or reduction of tasks.

-   **Interpersonal communication adjustments** such as written or
    recorded communications, rather then verbal only.

-   **Assistive devices** such as alarms that can signal appointments,
    tape recorders, portable computers, light boxes, etc.

-   **Job description adjustments** can include reducing less important
    job responsibilities so that the employee can focus on their primary
    tasks (Handrich 2000).

In the case of people with SMI, such as those on the SSI/DI rolls, even
greater accommodations may be needed in the form of job coaches,
counselors, and other support staff from the employer or an independent
employment promotion program such as EIDP.

When assessing the need for, adopting, and evaluating accommodations, a
variety of issues should be considered: what limitation (or pattern of
limitations) the individual with the psychiatric disability is
experiencing, how and to what degree the limitation(s) affect the person
and his or her job performance, what specific job tasks are being
affected, whether the individual with the disability has been asked
about his or her needs for accommodation, what accommodations can reduce
or eliminate the problems (and whether all resources that can help
identify possible accommodations have been used), and the need for
regular meetings with the person with a psychiatric disability to
evaluate the effectiveness of existing accommodations (Duckworth
undated).

Who can make these assessments, suggest accommodations, and implement
and evaluate them? Certainly individual employers and employees
themselves, and EAP staff whose focus has moved beyond the traditional
ones of substance abuse and later physical disabilities. But a host of
other individuals and organizations (both formal and informal) can and
do provide important supports alongside clinical treatments and
interventions. These include case managers, job coaches, job developers,
consultants, staff of various employment networks, and others.

### Program Options Other Than Permanent Competitive Employment 

It is clear from the many research and demonstration programs reviewed
above that not all people with SMI who want to work will be able to
sustain a permanent competitive job, with or without accommodations or
ongoing supports. A variety of other options are available, including
supported employment programs and programs that offer employment
experiences, work-skill development, or prevocational training. These
include hospital-based training and work integration programs, sheltered
workshops, transitional employment (working in a job that is \"owned\"
by a rehabilitation agency), work crews, skills training, training in
community living, and programs providing assertive community treatment
(or ACT). While participation in many of these prevocational types of
programs has been shown to have a number of positive outcomes (reducing
the length of hospital stays, increasing independent living, preparing
people for more intensive work, etc.), they have generally not been
found to be effective at leading to permanent employment. Supported
employment does better than the other programs at helping people get and
keep jobs, but even these more effective programs do not move people to
the level of self-sufficiency. Both types of programs increase the time
participants spend working, which has implications for SSI/DI program
costs. Yet other options that fall in between permanent competitive
employment and prevocational programs are innovative approaches such as
work integration contracts and social firms/enterprises and
cooperatives.

Supported employment programs are an important option for people with
SMI. The Rehabilitation Act Amendments of 1986 and 1992 (PL 99-506),
define supported employment as:

"Competitive employment in an integrated setting with ongoing-support
services for individuals with the most severe disabilities:

-   for whom competitive employment has not traditionally occurred or
    for whom competitive employment has been interrupted or intermittent
    as a result of a severe disability;

-   who, because of the nature and severity of their disabilities, need
    intensive supported employment services from the designated state
    unit (Division of Vocational Rehabilitation) and extended services
    after transition in order to perform this work; or,

-   transitional employment for individuals with the most severe
    disabilities due to mental illness."

A major review of studies examining different ways of helping people
with SMI return to work has found supported employment to be more
effective than prevocational training (Crowther et al. 2001; Bond et al.
2001). Supported employment programs place clients directly into
competitive jobs but provide on-the-job support from trained "job
coaches" or other employment specialists. Crowther and colleagues
identify the core principles of supported employment as: (a) the goal is
competitive employment in work settings integrated into a community\'s
economy, (b) clients are expected to obtain jobs directly, rather than
after lengthy pre-employment training, (c) rehabilitation is an integral
component of mental health treatment rather than a separate service, (d)
services are based on clients' preferences and choices, (e) assessment
is continuous and based on real work experiences, and (f ) follow-on
support is continued indefinitely. The advantage of supported employment
was found in a variety of employment outcomes (not just securing a
permanent competitive job), but data on clinical and social functioning,
as well as costs, revealed no major differences between supported
employment and prevocational training. Interestingly, the studies
reviewed included fairly large shares of women, people from ethnic
minorities, and people with schizophrenia. The main findings, therefore,
are likely to apply to the general population of patients with SMI who
would like to work.

Another innovative approach to promoting work among people with SMI is
work integration contracts. These contracts, which tend to be used by
small to medium-sized businesses as well as community-based agencies,
rely on government support that gradually decreases over time (Gaston
and Gabriel 2000). In Quebec, for example, employers can receive
government grants to cover as much as 85 percent of a worker's salary in
the first year and up to 75 percent in later years. The grants can also
be used to cover "special needs" including workplace access,
accompaniment, assessments, and medical treatment. In one particular
program, 10 percent of the 3,000 people with these "work integration"
contracts have a serious mental illness and after several years the
province contributes 40 percent of their salaries.

Yet other approaches include social firms or enterprises and
cooperatives. Social firms are small or medium sized enterprises
developed with the primary focus of employing people with disabilities
in an environment that is basically similar to a "regular" firm but with
appropriate supports offered to anyone who needs them. In these firms,
people with disabilities work alongside people without disabilities,
have regular work contracts, are paid regular wages, and enjoy the same
rights and responsibilities as their nondisabled counterparts: "the
balance between commerce and care is the single most critical issue
\[facing\] social firms, and this balance is achieved differently
according to the origins of the firm and the orientation of its
founders" (Grove et al. 2000). Social firms can be in the service (e.g.,
office work, recycling, restaurant, catering, landscaping) or
manufacturing sectors (e.g., textiles, computer hardware, furniture);
most receive some sort of initial public funding. In some cases they can
be required to develop a market analysis and business plan before
receiving final government approval. Once established, however, they can
be as much as 85 percent self-financing. These efforts are especially
popular in Europe where 2,000 social firms and cooperatives (broadly
defined) employ as many 47,000 people with disabilities, including many
with SMI (Table 2). While the majority of the workers are permanent
employees, as many as one-quarter may be engaged in transitional work,
and another 10 to 15 percent may be receiving "qualifying training."

\[Table 2 about here\]

The case of Italy is especially interesting. Progressive metal health
legislation beginning in 1978 stopped admissions to psychiatric
hospitals and promoted equal rights, full citizenship, and community
integration of people with mental illness, including the right of access
to work. A 1991 law established "type B" social cooperatives
specifically designed to provide job opportunities for people with
disabilities. The cooperatives are eligible for government grants as
long as 30 percent or more of their employees are people with
disabilities.

### Other Options for Increasing Employment Among People with SMI

States have a variety of options open to them to increase employment
among people with serious mental illness. First, they can tailor
assistance for various public assistance populations they are already
serving, including recipients of Temporary Assistance to Needy Families
(TANF),[^6] youth with mental illness, and transitional populations such
as people leaving community-based treatment facilities. Services should
include basic screening, needs assessments, and referrals for treatment,
as well as guidance about benefits, early intervention services, and
education, training, and other employment services. A second option
states have is to expand and modify vocational rehabilitation (VR)
services to accommodate the special needs of people with mental illness
(the program has traditionally served people with physical and
developmental disabilities).

Another important policy option is available through Medicaid
regulations---most states have now adopted an option in the Medicaid
program called the "psychiatric rehabilitation option" (or "rehab
option") that allows states to offer certain "medically necessary"
services (e.g., assistance with daily living skills, social skills, and
even training and employment services) to persons with mental illness
and have Medicaid share the cost. The employment-related services are
limited to prevocational or rehabilitative services that address the
symptoms of mental illness in relation to a job, and cannot focus on
services or training on how to perform a given job. Only one state,
Georgia, has successfully incorporated employment-related services into
its Medicaid program; the state even provides for billable peer support
in which people with mental illness counsel others who have similar
conditions. Through its commitment to move 20 percent of its day
treatment clients into supported employment, Georgia has learned two
important things: it costs less to provide rehabilitative services to
people with mental illness than for persons with developmental
disabilities, and workers in supported employment need flexible
schedules and ongoing, readily accessible anxiety counseling (NGA Center
of Best Practices 2003).

Finally, states should make the investments needed to expand
professional and non-professional supports for people with mental
illness, especially support following employment. A variety of
demonstrations have shown the importance of initial and ongoing
education, training, and counseling support for the successful
employment of people with mental illness. There is a clear need for
increasing the numbers and types of professional and nonprofessional
supports available to people with mental illness. Professional supports
include physicians, clinicians, counselors, and employment specialists,
while nonprofessional supports can include employers and coworkers,
family, friends, teachers, and clergy. The resources needed to make
these investments are costly, but it can be done.

Ten European countries have gone as far as using quota systems when it
comes to employing people with disabilities although this approach is
becoming less popular over time. Firms that fail to employ a
pre-specified percentage of people with disabilities as part of their
workforce must pay a "levy" into a pooled fund that is used to promote
the employment of people with disabilities. Although this is unlikely to
be adopted in the United States, where quotas are generally viewed with
suspicion, more positive employer incentives could be used to reward
those who are at the forefront of employing people with disabilities.
Positive incentives might include public subsidies for disabled
employees' salaries, subsidies for job coaches and other supportive
personnel supplied by the employer, allowing employers to deduct the
costs of accommodations from tax liabilities, or other forms of tax
credits.

# Implications for Social Security Administration Programs and Other Policy Stakeholders

This paper has summarized results of demonstration programs designed to
help people with serious mental illness find and keep jobs, workplace
accommodations that may help sustain employment, structured employment
opportunities that support people with SMI, and other public policies
that reduce some of the barriers that may inhibit interest in working
among SSI/DI beneficiaries with SMI. From this review we may conclude
that it will be quite difficult to reach the goal of moving substantial
numbers of SSI/DI beneficiaries with SMI off the rolls through sustained
competitive employment. It will be much less difficult, however, to help
many beneficiaries participate in paid work to some degree, and with
some reductions in benefit amounts. Thus it may be in the interests of
both the Social Security Administration's disability programs and the
beneficiaries themselves to make supports available that would help
beneficiaries work as much as they want and as much as they are able.

## Implications Related to the Nature of Serious Mental Illness

As we have seen, the nature of serious mental illness has important
implications for what one might reasonably expect to achieve with TTW
for this population, and the incentives that are likely to be necessary
to promote more employment among this group of SSI/DI beneficiaries.
Specifically,

-   Serious mental illness often involves periods of less intensive
    symptoms, but severe symptoms often recur periodically. This means
    it is very unlikely that many beneficiaries with these conditions
    will move to steady employment, although they may be able to sustain
    a series of shorter-term jobs.

-   Among SSI/DI beneficiaries with SMI, we may assume that various
    medications have been tried but have not been able to control their
    condition enough to permit steady work---otherwise they would not
    have qualified for benefits.

-   SMI symptoms are such that they may interfere with a person's
    ability to perform many jobs, especially if no workplace
    accommodations are made.

-   In addition to difficulties inherent in the nature of SMI, SSI/DI
    beneficiaries with these conditions have other characteristics that
    limit their ultimate capacity for earnings at the level that would
    signal no further need for benefits---poor educational attainment,
    poor work histories, and few skills.

Nevertheless, we have also seen (from Project NetWork) that some SSI/DI
beneficiaries with SMI want to work, and that those who are most likely
to be able to work are also those that volunteer for programs such as
Project NetWork. EIDP results have also shown that some programs
designed to help people with SMI get and keep jobs have had some
success, especially when they offer integrated clinical services and
employment supports. Further, models tested by EIDP that used an
approach involving immediate job placement (without much effort to get
participants "employment ready") were indeed able to help many people
obtain and keep employment, at least for the short term.

## What Level of Employment Can One Reasonably Expect to Achieve for Beneficiaries with SMI?

We summarize known employment rates for current SSI/DI beneficiaries
with SMI plus the results of demonstration programs, and then draw
several implications.

-   Currently, 15 percent of SSI/DI beneficiaries with SMI have nonzero
    earnings in any 12-month period. Although we do not have actual data
    on the proportion working at any given time, given the intermittent
    nature of work for this population that proportion is likely to be
    very low---perhaps as low as 5 percent.

-   The average annual amount earned by SSI/DI beneficiaries with SMI
    who have any earnings is very low\--\$2,400, and no more than 1
    percent earn their way completely off the SSI/DI rolls each year.

-   EIDP's enhanced models were more successful than "services as usual"
    in helping clients with SMI earn some income from employment.
    Beginning the demonstration with people who mostly had not worked at
    all during the five years before the demonstration, interventions
    were able to increase the odds that the people receiving the
    treatment conditions would get jobs, keep them longer, and return to
    work more quickly after losing a job.

-   With programs and services more closely resembling EIDP's treatment
    conditions than Project NetWork's, policymakers could aspire to
    increasing both the proportion of people with any earned income and
    the level of earned income, as follows:

    -   Increase the proportion with any earned income in a 12-month
        period, from its current 15 percent to between 20 and 30
        percent. This would be an increase of between 33 and 100
        percent.

    -   Increase the proportion working at any given time, from what is
        probably around 5 percent to 10 percent or more.

    -   Increase job tenure.

    -   Reduce the lag between one job and another if a beneficiary has
        to leave a job.

    -   Increase earnings (by helping participants get jobs with higher
        pay and/or work more total hours in a year).

-   These achievements could save SSA disability programs money in cash
    benefits, but---

    -   It is not realistic to expect that even these efforts will
        result in many SSI/DI beneficiaries with SMI completely leaving
        the rolls and not returning,

    -   Earnings are not likely to enable participants to get the health
        and mental health care they need without Medicaid, and

    -   The investment in clinical and employment services might or
        might not be offset by savings in cash benefits.

Assuming that one or more of the goals just described are ones that the
Congress can embrace, even in the absence of complete departure from the
beneficiary rolls, SSA should explore four aspects of how to accomplish
them. These are reviewing and potentially revising the incentive
structures for ENs with respect to beneficiaries with SMI, doing the
same for the incentive structures facing beneficiaries, exploring
options for types of work and work settings that might promote more
employment, and exploring options for employment supports and the
funding structures that would make them more available.

## Appropriate Incentive Structures

### Incentive Structures for Employment Networks

For the SSI/DI programs to achieve any of the outcomes just described,
two sets of actors have to have the right incentives---Employment
Networks (ENs), and current SSI/DI beneficiaries with SMI. ENs are
gatekeepers for TTW. Although the beneficiaries themselves ostensibly
have a "Ticket" and can take it to any EN they choose, the ENs also have
the right to refuse to serve particular beneficiaries. The obvious
reason to do this would be because an EN believes that taking on clients
with poor prospects of success is not in its best interests. The design
work for SSA's Adequacy of Incentives Study has focused a good deal on
the incentive structure for ENs, but not with specific reference to
serving people with severe mental illness. Employers and Employment
Networks alike, including traditional vocational rehabilitation
programs, have tended to avoid people with SMI because success can be
elusive and temporary. Given limited resources for community-based
employment services, they more often select those with less severe
impairments, especially with current policy emphasizing quick results
and competitive employment outcomes. Stigma and ignorance associated
with mental illness present other challenges, predisposing employers and
ENs toward believing that people with SMI will be difficult to supervise
and work with, and because employers report that they in fact have had
such difficulties with employees who have a serious mental illness.

The EN incentive structure in TTW is mostly based on the assumption that
people will obtain and sustain employment. We have seen that this is
probably not a realistic assumption for beneficiaries with SMI. As Cook
(2003) concludes on the basis of the EIDP results, hardly any EIDP
participants would have met Ticket criteria under which the ENs would
get paid, while the supports to assist them even to the relatively low
level of work they achieved would have to be expended regardless of
results.

For ENs to be willing to serve SSI/DI beneficiaries with SMI, they will
probably need an incentive structure that allows payment even though the
beneficiaries never leave the rolls. Milestones for people with SMI are
more reasonably couched in terms of working "about half-time" for "about
six out of twelve months," and "returning to work after job loss,"
rather than increased pay at steady work. If ENs could get paid for
meeting such simplified goals, and get paid annually for each year they
help their clients achieve each milestone, Tickets from people with SMI
might be more attractive to them.

It may also be interesting to explore the possibilities of constructing
some index or formula that pays ENs on the basis of achieving the
intermediate goals just described---increasing the number of people with
any earned income, the proportion of time working, hourly wages, and
hours per week worked, and reducing the down time between jobs---all of
these lead to increases in average annual income. Each of these elements
of a formula would have to be specific about what SSA would pay for, in
terms of percentage increases and other changes. The metric would have
to give ENs credit for effort that is under their control, while
allowing some leeway for the effects of disease patterns that are not
under anyone's control. Allowances would also be needed for ENs to
achieve the modified goals through a variety of supported work
settings---that is, not strictly in competitive employment without
supports. If the EN incentives were right, some ENs might become
interested in working with employers and clinical professionals to help
create these settings.

Further, the TTW legislation says that to remain in the program,
participants have to show "timely progress." If this means progress
"toward self-sufficiency," we have seen that most SSI/DI beneficiaries
with SMI are not likely to reach, or even approach, that goal. So the
legislative requirement works against them and discourages ENs from
taking them as clients. Requirements for client progress would have to
be altered before most beneficiaries with SMI were a reasonable gamble
for ENs. It is not clear whether SSI/DI beneficiaries with other
disabilities face circumstances that are as discouraging to work as
those faced by people with SMI. The simple fact of mental illnesses'
instability---the periodic increases and decreases in symptoms and
problems---makes employment more difficult to sustain than holding a job
when one has some physical disabilities. If the needs of beneficiaries
are indeed different with respect to promoting work, the Social Security
Administration may need to consider modified rules and guidelines for
including people with SMI in the Ticket program.

### Incentive Structures for Beneficiaries

It is important to recognize some of the major issues that affect the
employment decisions of SSI/DI beneficiaries in general, and that apply
at least as strongly for those with SMI. If one goal is go have more
SSI/DI beneficiaries use their Tickets, program administrators will have
to develop ways to overcome the significant disincentives to work that
exist. Myriad factors have been identified that reduce the likelihood
that beneficiaries will seek to work, although no definitive empirical
evidence is available to estimate their relative importance (Wittenburg
et al. 2002). We note the ones that policymakers and program
administrators are most likely to be able to affect, which include:

-   **Strong work disincentives created by SSI/DI rules:** While the
    work incentives for SSI and DI vary, both programs include high
    potential marginal tax rates on benefits (Burkhauser and Wittenburg
    1996). For SSI, recipients generally lose \$.50 of benefits for
    every \$1 in earnings. DI beneficiaries risk losing all benefits if
    their earnings exceed a certain threshold (defined as substantial
    gainful activity) for an extended period of time. The high implicit
    tax rates on benefits probably discourage some recipients in these
    programs from working. Another important issue is the potential for
    retroactive repayment demands. The Social Security Administration
    may need to make these demands because the system is slow to
    register earnings and thus may overpay benefits for some period
    while beneficiaries are working. Stories circulate among
    beneficiaries of people who have been required to repay excess
    benefits as much as a year after the overpayments were made, and who
    do not have the funds to do so. However often or infrequently this
    happens, the stories persist and offer a serious disincentive to the
    much larger number of people who hear them and learn to fear being
    caught in this situation.

-   **Fear of losing health care benefits:** Repeated surveys show that
    for many people with disabilities, the possibility that they could
    lose Medicaid as their health insurance without having a replacement
    is a major obstacle to employment. Because SSI and DI beneficiaries
    are generally eligible for Medicaid and Medicare, respectively, the
    potential loss of these benefits through excess earnings represents
    an important potential disincentive. This is especially true as they
    are unlikely to be replaced by any employment-linked health
    benefits, or by benefits offering the level of protection that
    Medicaid and Medicare give. Stapleton and Tucker (2000) provide the
    strongest findings to date on this issue, showing that many SSI
    recipients who do work restrain their earnings to stay below the
    1619(b) threshold.

-   **Transportation:** While this barrier exists for many people with
    disabilities, SSI beneficiaries are especially affected because of
    financial constraints that restrict automobile ownership.

-   **Consumer Choice and Control:** Individuals who are forced into
    available jobs without considering their preferences and needs tend
    to quit sooner or perform at a level that leads to termination.

A beneficiary's decision to try to work will depend not only on his or
her interest in working, but also on a belief that no significant losses
will be associated with the attempt and a belief that supports will be
available that actually work. The former concern is especially important
if, as will likely be the case, working does not succeed in sustained
earnings at the level of self-sufficiency. For an incentive structure to
succeed in attracting SSI/DI beneficiaries to try employment, it
therefore must overcome fears related to loss of benefits, and offer
employment-related services that actually help.

-   **Assurances that needed benefits will continue:** Most SSI/DI
    beneficiaries with SMI are likely to need some level of continued
    cash assistance, and are virtually certain to need ongoing heath
    insurance coverage.

    -   The Social Security Administration should clarify, and if
        necessary change, disregard and other incentive structures to
        make them more compatible with promoting work among people whose
        incomes are unlikely ever to exceed the poverty level, even if
        they work. In addition, accounting mechanisms should be improved
        to avoid as much as possible any significant lag time in
        adjusting benefits to income levels. If lag times are
        unavoidable, the attitude in handling repayment situations needs
        to be one of good faith and respect rather than an assumption of
        fraud and abuse. This attitude needs to permeate throughout the
        disability program when dealing with beneficiaries in these
        situations, including the line workers with whom the
        beneficiaries and their caseworkers actually interact.

    -   Assurance of continued health care coverage (and coverage of
        medications for Medicare beneficiaries) could probably do more
        to attract beneficiaries to employment than any other single
        modification of current procedures. DI beneficiaries with SMI
        will also need prescription drug benefits if psychotropic
        medications play a significant role in enabling them to work.
        Health insurance coverage through Medicaid or Medicare should
        never be withdrawn, regardless of earnings, unless it is clearly
        being replaced by equivalent private employer-based health
        insurance in a job that people have a reasonable expectation of
        being able to keep working at for a long time.

    -   Policy options to increase working need to assure beneficiaries
        that they are not jeopardizing their access to SSI/DI and
        Medicaid when they need it. Despite all the incentive structures
        that are in place to this effect, their practical administration
        still leaves many beneficiaries and their caseworkers in doubt
        that their benefits will be secure if they try working. Both
        beneficiaries and their mental health providers and/or case
        managers have to understand and believe the incentives and
        safeguards, or they will not participate in activities that
        promote work.

-   **Providing services that succeed.** Earlier in the paper we
    described the characteristics of employment-related services that
    seem to have the greatest success with this population---integrated
    employment and clinical services available on a sustained basis. To
    induce SSI/DI beneficiaries with SMI to use a Ticket, they will have
    to know a good deal about the types of work-related supports that
    the Ticket will buy. Given the sources of anxiety about benefits
    loss that are common for many in this population, the Social
    Security Administration will need to:

    -   Create work-related support systems that truly are appropriate,
        sustained, and persistent, as well as being easily accessible
        and available in sufficient volume that those who want to use
        them can do so (through modifying EN offerings and incentives),
        and

    -   Make sure that beneficiaries and the people closest to them
        (families and/or caseworkers) know that this is true. Knowledge
        of and faith in employment-related services spreads through
        outreach and education, but above all by having a track record
        of follow-through and commitment that beneficiaries and their
        families can hear about and be convinced by word of mouth.

## Options for Types of Work and Work Settings

TTW's goal for SSI/DI beneficiaries is to help them obtain and retain a
job in competitive employment, ultimately without formal supports, that
produces income sufficient to allow the beneficiaries to leave the
SSI/DI rolls, thereby saving the government money. The goal of
competitive employment is shared by many other stakeholders interested
in increasing opportunities for those with SMI.

The Rehabilitation Act defines supported employment as competitive work
in an integrated setting, where "competitive work" refers to work that
pays at the same rates as those paid to persons with no disabilities who
have similar job functions, and "an integrated setting" is a natural
work setting where people without disabilities are also employed. EIDP's
goal was to help participants obtain and keep competitive employment,
defined as a job that paid minimum wage or higher; was located in a
mainstream, integrated setting; was not set aside for mental health
consumers; and was consumer owned (the person can keep working at the
job as long as desired). Note that each of these definitions focuses on
job characteristics, not on the presence or absence of supports. Both
accept that a job can meet the "competitive" criterion and still offer
its occupant a wide variety of supports to sustain employment.

Thus "competitive employment" as the term is commonly used in the
rehabilitation world includes a wide range of options with respect to
both accommodations/supports for individual workers and general
workplace characteristics that promote mental well-being and prevent (or
minimize the recurrence of) mental illness. The figure below illustrates
the independence of these two dimensions, although it is clear that a
workplace that manages (mental) disabilities well would also do a good
job of accommodating individual workers with mental illnesses, including
SMI. It would be interesting to explore whether disabled workers in work
settings that do a good job of "managing disability" require fewer
individual supports than those holding jobs in less accommodating
environments.

+------+------------------------------------------------------------+---+
|      |                                                            |   |
+------+------------------------------------------------------------+---+
|      | *Individual*                                               |   |
|      |                                                            |   |
|      | *Accommodations/*                                          |   |
|      |                                                            |   |
|      | #### Supports {#supports .ES-Heading-4 .unnumbered}        |   |
|      |                                                            |   |
|      | **Competitive**                                            |   |
|      |                                                            |   |
|      | **Employment**                                             |   |
|      |                                                            |   |
|      | *Workplace*                                                |   |
|      |                                                            |   |
|      | *Disability*                                               |   |
|      |                                                            |   |
|      | *Management*                                               |   |
+------+------------------------------------------------------------+---+
|      |                                                            |   |
+------+------------------------------------------------------------+---+

In general, supported employment aims to promote social integration and
productivity as well as an individual person's skills and abilities. The
"support" parts of supported employment include individualized supports
such as transportation, job site training, family support, or any
service necessary for the worker to perform the job. These are generally
provided at least twice a month, and last for the duration of
employment. A wide variety of models of supported employment have been
developed over the last decade within this general framework, as
illustrated in the following figure and described briefly below.

![](media/image2.wmf)

# Individual Placement Model 

> A community-based job in an integrated work setting for a specific
> individual with a disability. Initial training and on-going support
> services may be facilitated by a job coach/employment specialist as
> well as natural workplace supports.

# Group Placement Model 

> Use of a full-time supervisor and a small group of individuals with
> disabilities to work in an integrated setting at an industry or
> corporation. The supervisor and/or group of individuals may be
> employed by the place of business itself or by a supported employment
> service provider.

# Mobile Work Crew 

> Use of a full-time supervisor and a small group of supported
> employees, who travel together to multiple work sites in the community
> to engage in contracted work.

# Small Business Enterprise 

> A private business, typically a small subcontracting, retail, or prime
> manufacturing operation, that employs individuals with disabilities.
> It provides community integration by including people without
> disabilities as coworkers, and/or through regular, ongoing contact
> with the general public (New Jersey Department of Human Services
> 2001).

It is also important to understand that there are many other employment
options that fall outside this broad spectrum of (unsupported)
competitive employment and supported (competitive) employment. Indeed it
can be useful to think of a "continuum of employment" with the various
unsupported and supported competitive options at one end, and other
forms of work and work-related training at another.

But is competitive employment (meaning full-time, sustained employment)
a reasonable goal for many people with SMI, whether SSI/DI
beneficiaries? The evidence we summarized above suggests that while many
people with SMI want to work and are able to do some work, they are not
likely to reach the level of self-sufficiency. Given that most people
with SMI on SSI/DI are unlikely ever to become self-sufficient again,
might we not want to rethink this goal and whether it should have top
priority. There is evidence that work levels can be increased even among
this severely disabled population, and those with somewhat lesser levels
of mental disability have worked in a variety of settings and done well,
even if they never become completely self-sufficient.

It is important to recognize that people with SMI fall along a broad
continuum of disability levels, that conditions are likely to fluctuate
over time, and that people with SMI may have periods during which work
is realistic and desirable, and periods during which it is not feasible.
Both programs and benefits will need to be designed to accept and
accommodate those fluctuations.

It is useful to think about employment options for people with SMI along
a continuum that has (unsupported) competitive employment at the top,
followed by supported (competitive) employment, followed by enclave
situations and sheltered workshops, and so on. Each works well for some
group of people with SMI. The closer one gets to the
independent-competitive end of this continuum, the smaller the
proportion of people with SMI that will be able to sustain
participation. Since our basic conclusion is that promoting work among
people with SMI is still worth doing, even though it may not lead to
self-sufficiency, we need to consider other options.

## Collaborating with Other Agencies

Some of the options for supporting SSI/DI beneficiaries with SMI in
employment will likely require the Social Security Administration to
work with a variety of agencies and programs. At the level of direct
service delivery to beneficiaries, both employment services and clinical
services will need to be involved. But there are also many things that
can be done collaboratively with other agencies and organizations to
affect the general climate in which people with SMI, including SSI/DI
beneficiaries, try to find and keep jobs.

At the broadest societal level, strong stigma and misunderstanding still
exist surrounding the nature of mental illnesses and what should be
expected of people who suffer from them. Only modest and somewhat mixed
changes have been reported in the attitudes and practices of employers,
despite the changing political landscape. In general, more negative
attitudes and concerns are expressed about employing people with mental
or emotional disabilities, particularly in regard to their social skills
and ability to function as a part of a team. Salkever (2002) reports
findings that the negative symptoms of many people with severe mental
illness (e.g., low affect, poor social skills, inability to handle
interpersonal situations, depressive demeanor) have a stronger negative
effect on employment success than even florid positive symptoms of
mental illness (e.g., hearing voices, talking to invisible people).

It would ultimately be in everyone's interest to see reduced levels of
misunderstanding, fear, and resistance on the part of employers and the
general public to working with people with SMI. Increased public
awareness and education about mental illnesses in general is sorely
needed, as is information about the strengths and abilities of people
with SMI in relation to work and other aspects of life. This increased
awareness would help all people with SMI who want to work.

The Social Security Administration could participate in such an
educational campaign, both internally with its own employees and
externally in conjunction with other public and private entities. Within
DHHS the Center for Mental Health Services is an obvious potential
collaborator. The Department of Labor's office of Disability Employment
Policy, which runs the Job Accommodation Network, is another, as is the
National Institute on Disability and Rehabilitation Research (NIDRR)
within the Department of Education. Each is likely to have state
equivalents, as well as national associations such as the National
Association of State Mental Health Program Directors, that could
participate in public and employer education campaigns. Outside the
government arena, the National Alliance for the Mentally Ill and other
advocacy groups are also possibilities for joining a collaborative
educational effort.

Also at the broad societal level, people with SMI, as well as people
with less severe types of mental illness and emotional problems, need
far better access to mental health treatment. As the Surgeon General's
1999 report and the recent President's New Freedom Commission on Mental
Health both note, only about half of the people with serious mental
illness in this country get the care they need. State and local mental
health systems are not able to serve all the people with SMI who need
treatment, let alone other people with mental health needs. Many face
severe budgetary constraints and have experienced funding reductions in
recent years that have left them even more strapped for resources. Most
see their role as limited to mental health treatment; few are actively
engaged in the type of cross-agency work (e.g., with employment
networks, workforce development agencies, or vocational rehabilitation
agencies) that is needed if people with SMI are to be assisted into work
opportunities.

The Social Security Administration could set an example in this regard
by engaging in more cross-agency work at the federal level to develop
federal policies that support realistic expectations for working among
people with SMI---including mobilization of the employment and clinical
service resources that it will take to increase labor force
participation among SSI/DI beneficiaries with SMI. Through its upcoming
Mental Health Treatment Study, it could extend the work of EIDP to
demonstrate the most useful combinations of treatment and work supports
for SSI/DI beneficiaries with SMI. The expectations presented above are
best guesses based on combining the information from several already
completed studies. The MHTS will be able to verify or modify our guesses
as to the potential increases in numbers employed annually and at a
point in time, and what investment in employment and clinical supports
will be required to achieve those increases.

A genuine commitment to increasing employment among people with SMI
involves recognizing the full continuum of employment options (not just
competitive employment with or without supports), and encouraging
entry---and rewarding progress---anywhere along this continuum. Acting
on such a commitment would involve changing policies and practices to
increase funding for supported employment and developing the
infrastructure needed to bolster a vibrant supported employment sector
within local and regional economies. Too few supported employment
programs are now available and their continued existence depends on a
patchwork of uncertain funding. Greater program availability would
translate into greater access for those who might benefit from them. The
experience of Italy and other countries suggests that this is not only
feasible but economically sensible. For those unable or unwilling to
engage in supported employment, other employment-related programs and
activities should be made available, including community-based sheltered
workshops and other work activities. Doing so affirms the role of work
as "a defining feature of human existence. It is the means of sustaining
life and of meeting basic needs. But it is also an activity through
which individuals affirm their own identity, both to themselves and to
those around them. It is crucial to individual choice, to the welfare of
families, and to the stability of societies" (Juan Somavia, ILO Director
General, June 2001, as quoted in O'Reilly 2003).

# References

Batavia, Andrew I. 2003. Sure, I Want to Work---That's the Ticket:
Disability, Human Nature, and the Ticket to Work Program. In *Paying for
Results in Vocational Rehabilitation*, edited by Kalman Rupp and Stephen
H. Bell (400-407). Washington, DC: Urban Institute Press.

Bond, Gary B., Deborah R. Becker et al. 2001. Implementing Supported
Employment as an Evidence-Based Practice, Psychiatric Services, 52(3)
313-322.

Burkhauser, Richard and David Wittenburg. 1996. How Current Disability
Transfer Policies Discourage Work: Analysis from the 1990 SIPP. *Journal
of Vocational Rehabilitation*, 7(1/2)(August): pp. 9-27.

Clark, Robin E., Haiyi Xie, Deborah R. Becker, and Robert E. Drake.
1998. Benefits and Costs of Supported Employment from Three
Perspectives. *The Journal of Behavioral and Health Services Research,
25*(1), 22-34.

Cook, Judith A. 2003. Results of a Multi-Site Clinical Trials Study of
Employment Models for Mental Health Consumers. Chicago, IL: University
of Illinois at Chicago, Department of Psychiatry, EIDP Coordinating
Center. Available at <http://www.psych.uic.edu/eidp>, click on "Latest
EIDP Findings" (accessed September 8, 2003).

Crowther, Ruth E., Max Marshall, Gary R. Bond, and Peter Huxley. 2003.
Vocational Rehabilitation for People with Severe Mental Illness.
Cochrane Review (Issue 3), The Cochrane Library, Oxford, England: Update
Software

Crowther, Ruth E., Max Marshall, Gary R Bond, and Peter Huxley. 2001.
Helping People with Severe Mental Illness to Obtain Work: Systematic
Review. *British Medical Journal*, *322*(7280), 204-8, (January 27).

Drake, Robert E., Howard H. Goldman et al. 2001. Implementing
Evidence-Based Practices in Routine Mental Health Service Settings,
Psychiatric Services 52(2), 179-182.

Duckworth, Kandra M. Undated. *Work-Site Accommodation Ideas for Persons
with Psychiatric Disabilities*. Washington, DC: Job Accommodation
Network, Office of Disability Employment Policy, U.S. Department of
Labor. Available at <http://janweb.icdi.wvu.edu/media/Psychiatric.html>
(accessed September 5, 2003).

Gaston, Harnois and Phyllis Gabriel. 2000. *Mental Health and Work:
Impact, Issues and Good Practices*, document WHO/MSD/MPS/00.2, World
Health Organization and International Labor Organization, Geneva,
Switzerland.

Goldman, Howard H., Vijay Ganju et al. 2001. Policy Implications for
Implementing Evidence-Based Practices, Psychiatric Services 52(12),
1591-1597.

Grove B et al. 2000. *The Social Firm Handbook.* South Hampton, England:
Ashford Press.

Hall, Laura Lee, Abigail C. Graf, Michael J. Fitzpatrick, Tom Lane, and
Richard C. Birkel. 2003. *Shattered Lives: Results of a National Survey
of NAMI Members Living with Mental Illnesses and Their Families*,
Treatment/Recovery Information and Advocacy Database (TRIAD), National
Alliance for the Mentally Ill, Arlington, VA, July 2003

Handrich, Rita R. 2000. *Managing Mental Illness in the Workplace, A
Practical Guide for Supervisors.* Austin, TX: Hogg Foundation for Mental
Health, University of Texas at Austin.

Lehman, Anthony F., Richard Goldberg, Lisa B. Dixon, Scot McNary,
Leticia Postrado, Ann Hackman, and Karen McDonnell. 2002. Improving
Employment Outcomes for Persons with Severe Mental Illness. *Archives of
General Psychiatry 59*, 165-72.

Marcotte, Dave E., Virginia Wilcox-Gok, and D. Patrick Redmon. 2000. The
Labor Market Effects of Mental Illness: The Case of Affective Disorders.
In *The Economics of Disability*, edited by David S. Salkever and Alan
Sorkin (181-210). Stamford, CT: JAI Press.

McGrew, John H., Gary R. Bond, Laura Dietzen, and Michelle Salyers.
1994. Measuring the Fidelity of Implementation of a Mental Health
Program Model. *Journal of Consulting and Clinical Psychology, 62*(4),
670-78.

Mechanic, David, Scott Bilder, and Donna McAlpine. 2002. Employing
Persons with Serious Mental Illness. New Brunswick, NJ: Rutgers
University, Institute for Health, Health Care Policy, and Aging
Research.

Mueser, Kim T., Pattrick W. Corrigan et al. 2002. Illness Management and
Recovery: A Review of the Research, Psychiatric Services 53(10),
1272-1284.

NGA Center for Best Practices. 2003. Strategies States Can Use to Employ
Persons with Mental Illness. Washington, DC: National Governors
Association Center for Best Practices, Issue Brief, Health Policy
Studies Division (HPSD).

Newcomb, Chad, Suzanne Payne, and Mikki D. Wald. 2003. What Do We Know
About Disability Beneficiaries' Work and Use of Work Incentives Prior to
Ticket? In *Paying for Results in Vocational Rehabilitation*, edited by
Kalman Rupp and Stephen H. Bell (31-70). Washington, DC: Urban Institute
Press.

New Jersey Department of Human Services. 2001. Supported Employment and
Day Program Manual. Trenton, NJ: Division of Developmental Disabilities.

O'Connor Associates, LLC. Undated. Managing the Mental Wellness of Your
Workforce in the New Millenium---The Emerging Role of Human Resource
Management. White paper produced for the Society for Human Resource
Management." Available at
<http://www.oconnorassociates.net/featured2.html> (accessed September 5,
2003).

O'Reilly, Arthur. 2003. "The Right to Decent Work of Persons with
Disabilities," IFP/Skills Working Paper No. 14, Geneva, Switzerland:
International Labor Office.

President's New Freedom Commission on Mental Health. 2003. *Achieving
the Promise: Transforming Mental Health Care in America.* Washington,
DC.

Rupp, Kalman and Stephen H. Bell. 2003. Provider Incentives and Access
in the Ticket to Work Program: Implications of Simulations Based on the
Project NetWork Field Experiment. In *Paying for Results in Vocational
Rehabilitation*, edited by Kalman Rupp and Stephen H. Bell (261-326).
Washington, DC: Urban Institute Press.

Rupp, Kalman and Charles G. Scott. 1998. Determinants of Duration on the
Disability Rolls and Program Trends. In *Growth in Disability Benefits:
Explanations and Policy Implications*, edited by Kalman Rupp and David
Stapleton (129-175). Kalamazoo, MI: The W. E. Upjohn Institute for
Employment Research.

Salkever, David. 2003. Tickets Without Takers: Potential Economic
Barriers to the Supply of Rehabilitation Services to Beneficiaries with
Mental Disorders. In *Paying for Results in Vocational Rehabilitation*,
edited by Kalman Rupp and Stephen H. Bell (327-354). Washington, DC:
Urban Institute Press.

Salkever, David S., Marisa Elena Domino, Barbara J. Burns, Alberto B.
Santos, Paul A. Deci, James Dias, H. Ryan Wagner, Richard A. Faldowski,
and Jan Paolone. 1999. Assertive Community Treatment for people with
Severe Mental Illness: The Effect on Hospital Use and Costs. *Health
Services Research, 34*, 577-601.

Slade, Eric and David Salkever. 2001. Symptom Effects on Employment in a
Structural Model of Mental Illness and Treatment: Analysis of Patients
with Schizophrenia. *Journal of Mental Health Policy and Economics, 4*,
25-34.

Stapleton, David and A. Tucker. 2000. Will Expanding Health Care
Coverage for People with Disabilities Increase Their Employment and
Earnings? Evidence from an Analysis of the SSI Work Incentive Program.
In *Research in Human Capital and Development*, Vol. 13, pages 133-180,
Stamford, CT: JAI Press.

Torrey, William C., Robert E. Drake et al. 2001. Implementing
Evidence-Based Practices for Persons with Severe Mental Illness,
Psychiatric Services 52(1), 45-50.

Tsang, Hector, Paul Lam, Bacon Ng, and Odelia Leung. 2000. Predictors of
Employment Outcome for People with Psychiatric Disabilities: A Review of
the Literature Since the Mid '80s, *Journal of Rehabilitation* 66(2),
19-29.

U. S. Department of Health and Human Services. 1999*. Mental Health: A
Report of the Surgeon General*. Rockville, MD:
DHHS/SAMHSA/CMHS/NIH/NIMH.

Vandergang, Agnes. J. 2002. *Working Well: An Employer\'s Guide to
Hiring and Retaining People with Mental Illnesses.* Toronto, Ontario:
Canadian Mental Health Association.

Yellin, Edward H. and Miriam G. Cisternas. 1996. Employment Patterns
among Persons with and without Mental Conditions. In *Mental Disorder,
Work Disability, and the Law,* edited by Richard J. Bonnie and John
Monahan (25-54). Chicago: University of Chicago Press.

**APPENDIX A**

**Nature of Disorders, Their Treatment, and Employability
Implications**[^7]

Two-thirds or more of all DI and SSI beneficiaries with mental disorders
\[have\] diagnoses that \[fall\] in the categories of either affective
disorders or schizophrenia-related disorders. The specific diagnoses for
most of these individuals are serious chronic illnesses, such as major
depressive disorder, bipolar disorder (manic depression), and
schizophrenia. To better understand the obstacles that these illnesses
pose to employment, it is useful to briefly highlight the salient
features of their symptomatology, natural history, and susceptibility to
treatment.

*Major depressive disorder* is characterized by depressed mood and loss
of interest or capacity to experience pleasure over an extended period
of time. While other symptoms vary widely, several that commonly occur
may result in substantial reductions in productivity or ability to work.
These symptoms include fatigue or lack of energy, diminished ability to
think or concentrate, inability to make decisions, and psychomotor
retardation. Untreated episodes of major depression last an average of 9
months; one half or more of patients will experience at least one
recurrence of episodes and, for a substantial number of patients, a
regular pattern of recurrence will occur over a long period of time.
Studies of the etiology of major depression have identified a number of
predictive factors including genetic endowment, personality type, and
gender. Another important factor identified by both statistical and
biological evidence is the occurrence of stressful life events and
situations. To the extent that workplace experiences may be a source of
stress, return to work following the onset of a major depressive episode
may increase the risk of recurrence.

Treatment of major depressive disorder has been described as a
three-phase process: acute, continuation, and maintenance. The most
commonly used treatment modalities in all phases are pharmacotherapy and
psychotherapy. Substantial scientific evidence supports the
effectiveness of both modalities, separately and in combination, in the
acute and continuation treatment phases, though the evidence on
psychotherapy pertains mainly to several newer, time-limited
depression-specific treatment approaches (cognitive behavioral therapy
and interpersonal therapy). Since acute-phase drug and psychotherapy
treatments typically require 6 to 8 weeks to produce substantial
reductions in symptoms, in cases where a faster response is critical
(e.g., because of psychotic or delusional symptoms and/or intense
unremitting suicidality), electroconvulsive therapy (ECT) is an
effective alternative. Because of expense, patient discomfort, and risk
of side effects, however, ECT is not a widely used front-line therapy.
All three therapy modes may also be used in the continuation and
maintenance treatment phases; ECT is, of course, rarely used, and
evidence of psychotherapy effectiveness in the maintenance phase of
treatment is weak.

Several aspects of the treatment process are particularly relevant for
considering the long-term employment prospects of a person with a
chronic major depressive disorder. First, while appropriate treatment is
often effective and for most patients could be expected to lead to a
return to full or nearly full functioning, patient behavior in care
seeking and compliance with treatment is a major problem. Patients
experiencing severe symptoms may be unwilling to seek treatment promptly
as a consequence of these very same symptoms. Medication side effects
also often result in patients failing to take medication as prescribed.
Limits on insurance coverage may also contribute to these behaviors.
Second, empirical evidence reveals that much of the treatment provided
is not appropriate, with problems in drug therapies being particularly
common. Third, the many patients at a high risk of episode recurrence
need long-term treatment and active monitoring of their status and
symptoms.

Type I *bipolar disorder* is characterized by alternating manic and
depressed states. In the manic phase of the disorder, patients manifest
hyperactivity, extreme distractibility, and impaired judgment; psychotic
symptoms (e.g., delusions) and paranoia may also occur in this phase. In
a less common form of bipolar disorder (Type II), depressive phases are
preceded by subsyndromal manic phases (hypomania), which may actually
result in increased productivity and creative energy. For Type I bipolar
disorder patients, however, occupational role functioning is usually
severely impaired during manic states. In addition, patients
experiencing subsyndromal manic phases often transition to the more
typical (and severe) episodes of mania.

Treatment of bipolar disorders is similar to treatment of major
depression but with the addition of mood-stabilizing drugs to prevent
recurrence of manic episodes. ECT may also be useful for treating mania,
and some drugs developed for other indications (e.g., anticonvulsants,
antipsychotics, and calcium channel blockers) have also shown beneficial
effects. Hard scientific evidence on treatment effectiveness appears
more limited for bipolar patients than for patients with major
depression, but available evidence generally suggests a somewhat poorer
prognosis for bipolar patients. Compliance is a particularly difficult
problem for these patients (especially in their manic phases) and may
help to explain the lower rates of relapse prevention.

*Schizophrenia* is a profoundly disabling chronic disorder that most
commonly begins in early adulthood. Symptoms are generally divided into
two categories: positive and negative. Positive symptoms include
delusions, hallucinations, disorganized speech and thought, difficulty
in carrying out goal-directed behavior, unpredictable and bizarre social
behaviors, and catatonic behavior. Negative symptoms include flattened
affect, lessening of fluency and productivity of speech, and apparent
disinterest in goal-directed behaviors. Problems in cognitive
functioning (e.g., information processing, abstract categorization,
cognitive flexibility, attention, memory, and visual processing) have
also been frequently noted in persons with schizophrenia, although
cognitive difficulties have not been specifically classified as symptoms
of the disorder. Variations over time in symptom levels are common,
particularly for positive symptoms; negative symptoms tend to be more
persistent and less cyclical. The long-term course of illness varies
from person to person, though the majority of patients do not return to
the level of mental functioning they enjoyed before they got sick, and
approximately 10 percent remain severely ill over long periods of time.
On the other hand, in long-term follow-up studies, one-half or more of
all patients have shown significant improvement in functioning, probably
resulting from both improvements in patients' coping skills and social
supports over time and biological factors that bring about reduced
symptom levels.

Recommended treatment interventions for schizophrenia are linked to a
sequence of four phases in the course of the illness: acute,
stabilizing, maintenance, and recovery. Key components of treatment are
pharmacotherapy with antipsychotic medications and a variety of
psychosocial interventions (supportive psychotherapy, family
psychoeducational programming, and psychosocial and vocational
rehabilitation). Because the volume and variety of services used by
patients is often substantial, coordination and continuity of services
is a major concern. The gap between recommended treatment and treatment
actually received is also very large; empirical evidence suggests that
the rate of conformance of actual treatment with treatment guidelines is
less than 50 percent. Specific reasons for this gap include deviations
of physician prescribing practices in terms of antipsychotic dosage
levels and the lack of access to recommended psychosocial services.
Treatment effectiveness in actual practice is also compromised by
patient noncompliance with drug regimens, due at least in part to side
effects of antipsychotic medications. For this reason, the superior
side-effect profiles of the newer "atypical" antipsychotics may be
important for achieving better patient outcomes. Models of service
delivery, such as assertive case management (ACM) and assertive
community treatment (ACT), can be effective at coordinating the wide
range of services needed by many patients and achieving reductions in
hospitalization and increases in patient integration in the broader
community. These models are resource intensive however, requiring
relatively low client-staff ratios and participation of multiple
disciplines in the treatment team; replications that deviate from these
staffing patterns to satisfy program budget constraints may lead to less
successful outcomes (McGrew et al. 1994; Salkever et al. 1999).

As has already been suggested, these serious and chronic mental
disorders typically have substantial negative impacts on patients' labor
market productivity. Deficits in judgment, attention, decisionmaking,
psychomotor functioning, and cognitive processing affect patients'
abilities to carry out and complete even relatively simple job tasks and
physical labors. Problems in social interactions and communications with
fellow workers and supervisors further compromise their job performance.
While these deficits and problems can be ameliorated by treatment
interventions, recurrence of acute symptomatic episodes is common and
can be brought on by stressful workplace events or by the failure of
patients to comply with their treatment regimen. Moreover, side effects
of efficacious drug treatments may also impair the patient's
productivity at work.

The negative productivity effects of these major disorders can, of
course, be magnified by the presence of comorbidities, such as alcohol
or substance abuse, that are common among persons with serious mental
disorders. The self-reported diagnosis information from the 1994--95
NHIS-D surveys suggests that these comorbidities are in fact a more
widespread problem among beneficiaries with mental disorders. In
particular, almost 10 percent of beneficiaries reporting *any* mental
disorder (excluding retardation) also reported alcohol or substance
abuse problems; in comparison, only about 2 percent of other
beneficiaries reported such problems. Data from the EIDP indicate that
64percent had co-occurring substance abuse (Cook 2003).

**APPENDIX B**

**Examples of Workplace Accommodations**

**for People with Psychiatric Disabilities**

**Maintaining Stamina during the Workday**

-   Flexible scheduling

-   Allow longer or more frequent work breaks

-   Provide additional time to learn new responsibilities

-   Provide self-paced workload

-   Provide backup coverage for when the employee needs to take breaks

-   Allow for time off for counseling

-   Allow for use of supported employment and job coaches

-   Allow employee to work from home during part of the day, or week

-   Part-time work schedules

**Maintaining Concentration**

-   Reduce distractions in the work area

-   Provide space enclosures or a private office

-   Allow for use of white noise or environmental sound machines

-   Allow the employee to play soothing music using a cassette player
    and headset

-   Increase natural lighting or provide full spectrum lighting

-   Allow the employee to work from home and provide necessary equipment

-   Plan for uninterrupted work time

-   Allow for frequent breaks

-   Divide large assignments into smaller tasks and goals

-   Restructure job to include only essential functions

**Difficulty Staying Organized and Meeting Deadlines**

-   Make daily TO-DO lists and check items off as they are completed

-   Use several calendars to mark meetings and deadlines

-   Remind employee of important deadlines

-   Use electronic organizers

-   Divide large assignments into smaller tasks and goals

**Memory Deficits**

-   Allow the employee to tape record meetings

-   Provide type written minutes of each meeting

-   Provide written instructions

-   Allow additional training time

-   Provide written checklists

**Working Effectively with Supervisors**

-   Provide positive praise and reinforcement

-   Provide written job instructions

-   Develop written work agreements that include the agreed upon
    accommodations, clear expectations of responsibilities and the
    consequences of not meeting performance standards

-   Allow for open communication to managers and supervisors

-   Establish written long term and short term goals

-   Develop strategies to deal with problems before they arise

-   Develop a procedure to evaluate the effectiveness of the
    accommodation

**Interacting with Coworkers**

-   Educate all employees on their right to accommodations

-   Provide sensitivity training to coworkers and supervisors

-   Do not mandate employees attend work related social functions

-   Encourage all employees to move non-work related conversations out
    of work areas

**Difficulty Handling Stress and Emotions**

-   Provide praise and positive reinforcement

-   Refer to counseling and employee assistance programs

-   Allow telephone calls during work hours to doctors and others for
    needed support

-   Allow the presence of a support animal

-   Allow the employee to take breaks as needed

**Attendance Issues**

-   Provide flexible leave for health problems

-   Provide a self-paced work load and flexible hours

-   Allow employee to work from home

-   Provide part-time work schedule

-   Allow employee to make up time

**Issues of Change**

-   Recognize that a change in the office environment or of supervisors
    may be difficult for a person with a psychiatric disability

-   Maintain open channels of communication between the employee and the
    new and old supervisor in order to ensure an effective transition

-   Provide weekly or monthly meetings with the employee to discuss
    workplace issues and productions levels

**Source**: Kandra M. Duckworth, *Work-Site Accommodation Ideas for
Persons with Psychiatric Disabilities*, Job Accommodation Network,
Office of Disability Employment Policy, U.S. Department of Labor,
Washington, DC, undated. Available online at
<http://janweb.icdi.wvu.edu/media/Psychiatric.html>

[^1]: Mental illnesses are disorders such as *schizophrenia,
    schizoaffective disorder, bipolar disorder, major depressive
    disorder*, obsessive-compulsive disorder, *panic and other severe
    anxiety disorders*, autism and pervasive developmental disorders,
    attention deficit/hyperactivity disorder, borderline personality
    disorder, and other severe and persistent mental illnesses that
    affect the brain. The italicized disorders represent the largest
    groups within the SSI/DI population with mental disorder (excluding
    mental retardation) as a primary diagnosis. Of these, schizophrenia
    and schizoaffective disorder are considered psychoses, bipolar and
    major depressive disorders are considered affective disorders, and
    the others fall into other psychiatric categories.

[^2]: This summary relies heavily on Newcomb, Payne, and Wald (2003).

[^3]: This summary relies heavily on Salkever (2003).

[^4]: We reproduce his full discussion as Appendix A.

[^5]: The legal aspects of employing people with mental health
    disabilities are an important and growing area of interest but are
    *not* the focus of this review.

[^6]: In 1998, the Presidential Task Force on the Employment of Adults
    with Disabilities reported that 28 percent of TANF recipients have
    mental disorders that may interfere with successful employment, but
    some states report much higher rates. Oregon, for example, estimates
    that three-quarters of its welfare population has some type of
    mental disorder (NGA Center of Best Practices 2003).

[^7]: This appendix is reproduced from Salkever (2003), pages 333-335,
    who, in turn, largely took it from the Surgeon General's Report on
    Mental Health (1999).