An Individualized Job Engagement Approach for Persons with Severe Mental Illness

Work is highly valued and is considered a socially integrating force in Western culture; however, many individuals with psychiatric disabilities are excluded from the world of work. The National Institute of Mental Health estimates employment rates of between 10% and 30% for persons with severe and persistent mental illness (as cited in NAMI, electronic data www.nami.org/helpline/factsheet.htm). Studies reported by Anthony, Cohen, and Danley (1988) suggest employment rates for persons with severe and persistent mental illness of between 0% and 15% for full- or part-time competitive employment, indicating that a majority of persons with mental illnesses have minimal or no earned income and rely heavily on entitlement programs. The economic burden of mental illness to society is further increased by loss of tax revenue and the cost of care for persons with severe and persistent psychiatric disabilities, resulting in an immense overall cost to society (Rupp & Keith, 1993; Wyatt, 1995). In the context of psychiatric rehabilitation, work can be seen both as an outcome and as a highly effective treatment modality in enhancing meaningful community integration (Frey and Godfrey, 1991; Mueser, Becker, Torrey, Xie, Bond, Drake, & Dain, 1997; Russert and Frey, 1991). For the individual with a mental illness, inability to find or maintain employment can lead to marginalization within society, lack of financial resources (Robins & Regier, 1991), social isolation, and stigmatization (Berven & Driscoll, 1981; Farina & Felner, 1973; Trauer, Duckmanton, & Chiu, 1998). Many authors acknowledge the positive impact of employment on self-esteem and the socially integrating function of work (Anthony & Blanch, 1987; Neff, 1988; Perese, 1997; Trotter, Minkhoff, Harrison, & Hoops, 1988; Van Dongen, 1996; Wart, 1983). Conversely, unemployment among persons with mental illness has been associated with lower self-esteem and higher levels of psychiatric symptoms (Bell, Lysaker, & Milstein, 1996; Bell, Milstein, & Lysaker, 1993; Perese, 1997; Westermeyer & Harrow, 1987). Despite extensive legislative efforts to improve vocational rehabilitation services to persons with psychiatric disabilities, employment rates for persons with a history of mental illness have remained low. In 1979, the National Institute of Handicapped Research (NIHR) reported that clients with mental illnesses constituted the largest target population for vocational rehabilitation services, yet they had the lowest probability of success. Based on a review of 1,000 cases at the Pennsylvania Office of Vocational Rehabilitation, Marshak, Bostick and Turton (1990) concluded that persons with psychiatric disabilities were only half as likely to achieve positive vocational outcomes as persons with physical disabilities. On a national level, Rutman, McGurrin, and Manderscheid (1994) reported successful rehabilitation rates of 56% for persons with mental illness between 1984 and 1988 versus 69% for persons with other disabilities. Noble (1998) reported that the federal-state vocational rehabilitation system currently spends an estimated $490 million annually on time-limited services to consumers with mental illness, without producing long-term employment outcomes. He suggested that the same amount of money spent on more appropriate, integrated service models could provide stable annual rehabilitation funding for 62,000 to 90,000 consumers. Supported employment is one of the models of vocational rehabilitation that has demonstrated success in securing competitive employment for people with severe and persistent mental illness. Based on a review of the supported employment literature, Bond, Drake, Mueser, & Becker (1997), concluded that in experimental studies, a mean of 58% of clients participating in supported employment achieved competitive employment, compared to 21% of controls. Furthermore, their review found support for the integration of mental health and vocational services within one service system, but not for preplacement training (Bond et al, 1997). …