Provider perspectives on employment for people with serious mental illness

Introduction

The Recovery Movement has established that persons with serious mental illnesses (SMI) can lead productive lives (Davidson, 2016). Within this context, employment is seen as a primary means of participation in society, enabling such persons to meet many of their material and social needs (Marrone, Hoff, & Gold, 1999). Employment also has been associated with reduced psychiatric symptoms and use of mental health services, as well as improved self-esteem (Drake, Bond, Goldman, Hogan, & Karakus, 2016; Mueser, Drake, & Bond, 2016). Among individuals receiving mental health services, 66% of them express an interest in being employed. However, only approximately 15% of these individuals are employed at any given time (Drake et al., 2016). Bridging this gap has become an important policy issue. The Individual Placement and Support (IPS) model of supported employment (SE) has been proposed as one effective strategy for helping persons with SMI to obtain and maintain competitive jobs. Far from being embraced as a solution, however, it has been difficult to secure funding for IPS programs and, in systems that have been able to secure such funding, sometimes it has been difficult to generate a sufficient number of referrals to fill available openings. In an initial study of the resulting underutilization of SE services, Casper and Carloni (2007) attributed the low number of referrals to the beliefs and attitudes of mental health providers, who act as gatekeepers to SE. This article reports on a new survey of providers about their perspective on the issue of employment for persons with SMI, hoping to add to this growing literature.

Background

Since the 1980s, the Recovery Movement has advocated for the rights of individuals with SMI to have access to the same opportunities and responsibilities as anyone else (Davidson, Rakfeldt, & Strauss, 2010). Independence, gaining control of one’s own life and active participation in society by contributing to the communities of their choice are some of the basic rights advocated (Davidson, 2016; Davidson, Bellamy, Guy, & Miller, 2012; Deegan, 1992; Frese, Knight, & Saks, 2009). This advocacy has been necessary to overcome the discrimination historically faced by persons with SMI, whose rights to access these opportunities have been denied both inside and outside of institutions (Davidson et al., 2010). Thus far, the movement has demonstrated that many such persons can exercise self-determination and achieve full membership in society even when continuing to experience symptoms of mental illness (Rowe, 2015).

With respect to employment opportunities specifically, the most effective strategy developed to date to improve the low rate of employment among persons with SMI is the IPS model of SE (Bond, 2016; Drake et al., 2016; Mueser et al., 2016; Mueser & McGurk, 2014). The effectiveness of IPS in improving employment outcomes for people with SMI is well established (Bond, 2016). In the IPS model, clients work with employment specialists to attain competitive employment based on their personal interests (Bond, 2016; Mueser & McGurk, 2014). The IPS model has eight practice principles: (1) competitive employment is the goal, (2) employment support is integrated with clinical care, (3) eligibility is based solely on client choice (as opposed to clinical status or symptoms), (4) attention is paid to client preferences, (5) personalized benefits counseling is important, (6) rapid job search, (7) systematic job development and (8) time-unlimited support (Bond, 2016). The second practice principle calls attention to the importance of clinicians in helping people with SMI to gain and maintain employment, with Cook and colleagues (2005) having demonstrated that SE models in which psychiatric and vocational service delivery are highly integrated produce better employment outcomes when compared to those with low levels of service integration.

Despite the need for service integration, there have been few other studies focusing on the role of providers in the employment of persons with SMI. But there may be a good deal of variation in how mental health providers understand their role in supporting their clients’ quest for work, and this variation may have impact on the success of IPS programs to attract and support clients in securing employment. There is evidence, for example, that client–provider relationships can enhance recovery through various hope-inspiring and empowering practices such as supporting clients’ spirituality or helping clients accept and value themselves (Russinova, Rogers, Ellison, & Lyass, 2011). Seeing clients as persons apart from their diagnosis and believing in clients’ potential to recover are also highlighted as important (Ashcraft & Anthony, 2008; Davidson et al., 2010). Yet Ashcraft and Anthony (2008) point out that there is still resistance among some providers when it comes to the concept of recovery as informing clinical care. While some clinicians have reported that helping clients with SMI to work is a core part of their role, they also have reported being unaware of the employment services available in their local community (Marwaha, Balachandra, & Johnson, 2009). In this case, the researchers involved suggested that limits in expertise or amount of time available to dedicate to employment could be factors limiting clinicians’ effectiveness in this role.

Hamilton and colleagues (2013) found that when SE programs were well implemented, staff generally viewed clients’ capacity for employment in a positive, optimistic way. Where there was no experience with employment programs or where this experience was of little success, provider attitudes regarding employment were neutral or pessimistic. Pogoda, Cramer, Rosenheck, and Resnick (2011) have suggested that providers could be a barrier to the implementation of SE programs. In this vein, some providers have been found to be uninformed and/or uneducated about SE (Marwaha et al., 2009; Pogoda et al., 2011), concerned about their clients’ capacities for employment, and concerned about the detrimental effects of work-related stress and its potential for precipitating relapses (Hamilton et al., 2013; Marwaha et al., 2009; Pogoda et al., 2011; Sommer, Lunt, Rogers, Poole, & Singham, 2012). Some providers have expressed concern that clients would lose their benefits if they worked and suggested that clients who receive benefits may not need any additional income from employment (Pogoda et al., 2011).

Since 2002, when it became the first state in the United States to adopt a commissioner’s policy on the development of a recovery-oriented system of care (Davidson et al., 2007), the State of Connecticut has recognized that gainful employment may be essential to individuals’ health and well-being. Employment has been fully embraced as an integral part of the Connecticut Department of Mental Health and Addiction Services’ (DMHAS) mission. DMHAS has adopted the IPS model as its main strategy for offering SE services to clients and has consistently expanded its SE services over the last decade. Currently, DMHAS is able to offer SE services to approximately 8% of its clients with SMI, which is roughly four times the 2012 national average of 2% (Bruns et al., 2016). In an effort to further expand these services, DMHAS received a grant from the US Substance Abuse and Mental Health Services Administration in 2015 to extend supports to persons of Latino origin and those with histories of criminal justice involvement. Increasing the integration of mental health providers with the available SE programs is viewed as key to the success of this expansion.

The Provider Survey reported here was developed as part of this effort to expand Connecticut’s SE services. Adding new slots to the existing SE openings highlighted for stakeholders that there was an underutilization of IPS in Connecticut, even after 15 years of recovery transformation efforts. The survey was developed to better understand what DMHAS providers do, what they think is important for their clients’ recovery and what they think is important for their clients to obtain and sustain employment. The intent is to use this information to guide the development of new strategies to increase the referral base for SE services, so that more of the 66% of clients who want to work are enabled to do so.

Methods

The instrument

The Provider Survey was developed to capture providers’ views regarding the relationship between employment and recovery for their clients. Four main aspects of their views were addressed: (1) the important aspects of their work with clients with SMI, (2) factors that enable persons with SMI to obtain and maintain employment, (3) factors that promote the recovery of persons with SMI and (4) barriers that providers may face in making referrals to SE services. The fourth aspect of the survey was addressed only to providers who stated that employment was important for their clients but at the same time also said that they did not refer clients to SE services. Each of these four main aspects was assessed through a series of statements for providers to rate in terms of their importance. Providers were asked to rate each statement from 1 (not at all important) to 5 (very important). The first main question was addressed by 25 statements, the second by 17, the third by 23 and the fourth by 20. The highest and the lowest rated statements can be seen in Tables 1 to 4. For the complete survey, see Appendix 1.

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Table 1.

Five most important and five least important activities providers do in working with clients with serious mental illness.

Most important activities	Mean	Least important activities	Mean
Promoting client self-care and wellness	4.71	Prescribing and/or administering medications	3.85
Referring clients for alcohol or substance use treatment	4.62	Deciding on diagnostic formulations	4.21
Addressing domestic violence or other trauma	4.57	Providing advocacy and legal support	4.27
Referring clients for medical care	4.55	Taking extensive personal and family histories	4.28
Identifying and addressing stigma and discrimination	4.55	Providing employment support	4.31

Paired comparison between most important and least important statements to determine significance of difference was performed using Wilcoxon signed-rank test and all comparisons presented a p < .01.

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Table 2.

Five most important and five least important components in enabling clients with serious mental illness to obtain and maintain employment, according to providers.

Most important components	Mean	Least important components	Mean
Identifying and addressing internalized negative views of themselves that lead people to believe they are not capable of working	4.59	Viewing employment as a source of stress that should be avoided	2.67
Providing encouragement for the person to seek employment	4.56	Viewing employment as increasing a person’s risk of relapse	2.89
Paying attention to client preferences with respect to employment	4.52	Viewing employment as something that needs to wait until the person has achieved other recovery goals (e.g. clinical stability)	3.48
Viewing employment as offering the person a valued social role or as an important source of a positive sense of identity	4.52	Conducting a rapid job search as soon as the person expresses interest in working	3.96
Viewing employment as an important step in recovery	4.44	Providing time unlimited and individualized job search	4.06

Paired comparison between most important and least important statements to determine significance of difference was performed using Wilcoxon signed-rank test and all comparisons presented a p < .01.

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Table 3.

Five most important and five least important factors in the recovery of persons with serious mental illness, according to providers.

Most important factors	Mean	Least important factors	Mean
Having a sense of hope	4.85	Eliminating all psychiatric symptoms	3.38
Having sense of purpose and meaning in life	4.81	Being employed in competitive job	3.96
Believing in oneself as a capable person	4.81	Being financially independent	4.21
Being stably housed	4.79	Having friends and/or romantic partners	4.24
Having good quality medical care	4.77	Being connected to something larger than oneself (e.g. sense of spirituality)	4.40

Paired comparison between most important and least important statements to determine significance of difference was performed using Wilcoxon signed-rank test and all comparisons presented a p < .01.

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Table 4.

Five most important and five least important barriers to making referrals for employment support, according to providers who think employment is important for people with serious mental illness, but don’t make referrals.

Most important barriers	Mean	Least important barriers	Mean
My clients are not interested in working	3.24	There is too much paperwork required in making referrals	1.99
Persons with mental illnesses are discriminated against in the workplace	3.13	I used to make referrals but they never worked out	2.04
My clients have internalized negative views of themselves that keep them from working	3.03	I don’t have the time it would take to make referrals	2.10
My clients’ families do not support their working	2.92	My clients are too dangerous to work; employers would be afraid of them	2.46
My clients don’t have the skills they would need to work	2.88	Working might precipitate a relapse	2.55

Paired comparison between most important and least important statements to determine significance of difference was performed using Wilcoxon signed-rank test and all comparisons presented a p < .01.

Results

A total of 1,306 providers from 47 different agencies participated in the survey (1,131 completed the whole survey, 157 partially completed it and 18 began reading the survey but chose not to respond to any items). Providers self-identified as 142 team supervisors and 175 directors, CEOs and administrators; 21 physicians, 70 nurses and 238 other clinicians; 234 case managers; 94 employment specialists, 64 peer specialists and 175 mental health workers; and 30 more were grouped as others. A total of 275 responders have been working in their current role less than 1 year, 301 from 1 to 2 years, 246 from 3 to 5 years, 161 from 6 to 9 years and 323 for 10 or more years.

For all four main questions, the mean of each of the five highest ranked statements was significantly different from the mean of each of the five lowest ranked statements. Table 1 presents the five highest and five lowest ranked statements for main question 1 – Please indicate the degree to which each of the following activities is an important component of what you do in working with clients with SMI.

Table 2 presents the five highest and five lowest ranked statements for main question 2 – Please indicate the degree to which each of the following components are important in enabling clients with SMI to obtain and maintain employment.

Table 3 presents the five highest and five lowest ranked statements for main question 3 – Please indicate the degree to which you think each of the following items are important factors in the recovery of persons with SMI.

Table 4 presents the five highest and five lowest ranked statements for main question 4 – Please rate the degree to which the following factors are barriers to making referrals for employment support.

Perhaps as a result of system transformation efforts, DMHAS providers rated promoting client self-care and wellness as the most important activity, addressing domestic violence or other trauma as the third most important, and identifying and addressing stigma and discrimination as the fifth most important. The fact that much of community-based practice occurs outside of clinical settings may help to account for why prescribing and/or administering medications, deciding on diagnostic formulations, and taking extensive personal and family histories were rated as least important in what providers do. Providing employment support was also endorsed as one of the least important activities in which participants engage; a finding that is consistent with the low level of importance participants accorded to employment in general.

On the other hand, participants seem to be less concerned with employment as a source of stress, as something that increases the chance of relapse, or as something that should come only after clinical stability is achieved, pointing to another possible shift toward recovery-oriented practice from 20 years ago (when the earlier survey was conducted). When it comes to what is important for people with SMI to obtain and retain employment, the eight core principles of the IPS model (Bond, 2016) were not rated that highly. Two of them – conducting rapid job search and providing time unlimited and individualized job search – were ranked as least important. Only one of the core principles was ranked among the five most important: paying attention to clients’ preferences with respect to employment (ranked third). This low rating of IPS principles suggests either that providers need to be educated about the utility of these IPS principles or that they have themselves experienced the principles as ineffective. It also helps us understand why there may be an underutilization of SE services.

Addressing internalized negative views of themselves and encouragement were rated as the most important components in enabling employment for persons with SMI as opposed to identifying and addressing instances of employment discrimination (ranked as the eighth most important component), suggesting that providers might view most of the burden of the high rates of unemployment for people with SMI being due more to the person than to employers or to the lack of accommodations in the work setting. Employment as offering a valued social role or important source of a positive identity and as an important step in recovery are viewed as important components for people to obtain employment. At the same time, though, being employed in a competitive job and being financially independent are not seen as important for people to recover. This apparent contradiction suggests that employment may be seen differently for persons with SMI from how it is traditionally viewed for others, for whom it is seen as an unequivocally desirable source of meaning and purpose as well as a source of material support. Of the factors in the recovery of persons with SMI, having a sense of hope was viewed as the most important factor in promoting recovery and highest rated statement of all. Having a sense of purpose and meaning in life and believing in oneself as a capable person were ranked as second and third most important factors in recovery. Eliminating all psychiatric symptoms was viewed as the least important factor. Surprisingly, employment in a competitive job, being financially independent, having friends and/or romantic partners, and being connected to something larger were ranked as least important factors for the recovery of persons with SMI.

The reasons for not making referrals among providers who viewed employment as important included their perceptions that their clients are not interested in working, that they face discrimination in the workplace, that they have internalized negative views of themselves that keep them from working, that their clients are not supported by their families and that their clients are not skilled enough to work. It is perhaps not surprising, then, that providers rated identifying and addressing the internalized negative views of themselves as most important in enabling clients to obtain and maintain employment. Providers might also emphasize the need for education and training over rapid job placement. This might reflect a questioning of the capacity of people with SMI to work, with less questioning of the possible lack of accommodations for people with SMI in the jobs that are available. The referral process to SE seems not to be an issue for the providers surveyed.

Discussion

These findings suggest that providers view encouragement and overcoming internalized negative views of oneself as the most enabling factors when it comes to employment among persons with SMI. But how likely are clients to be encouraged to work by providers who view employment and financial self-sufficiency as of little relevance to their recovery? And how are clients to internalize a more functional sense of self first, without obtaining and maintaining employment? Especially in American culture, work provides a fundamental source of positive self-esteem and personal identity (Davidson & Strauss, 1995). It is extremely difficult in such a productivity and performance-oriented society – in which the first question people are often asked is ‘What do you do?’ – to develop and preserve a positive sense of identity in the absence of a paid role. Beyond a positive identity, employment can also be used as a powerful social tool for clients. More than half of people with SMI describe problems with loneliness in comparison to one-third of the general population (Killeen, 1998; Lauder, Sharkey, & Mummery, 2004). In the literature, this elevated rate of loneliness is related to difficulty making and keeping friends, lack of opportunity to participate in social activities and stigma associated with mental illness that can prevent people with SMI from feeling a sense of belonging in their communities (Perese & Wolf, 2005). It is also well documented that social support can enhance the quality of life for persons with SMI, reducing social isolation, facilitating integration into society and adopting socially valued roles, thus encouraging their process of recovery (Davidson et al., 2012). The structure of employment offers the resources to gain social support from colleagues and social interactions at the workplace.

It is likely that providers understand how employment could reinforce a positive sense of identity and social interactions implicitly in their own lives and work roles, but they do not appear to transfer this understanding to their clients. This might come with the implicit assumption that employment and the access to material resources and social status that it confers are somehow not as important to clients as to other human beings. If so, then this might be a subtle form of manifestation of the stigma and discrimination that mental health providers have been found to demonstrate toward their clients (Davidson, Miller, & Flanagan, 2008).

Countering this interpretation is the fact that, in terms of the importance of what they do, providers rated ‘promoting self-care and wellness’ as the most important component of their work. The fact that this statement was rated as most important, however, may reflect that the items comprising this factor have been promoted by system leaders, managers and persons in recovery and family members themselves over the previous 15 years of efforts to transform the Connecticut system to a recovery orientation (Davidson et al., 2007); an orientation that emphasizes self-care, addressing discrimination, offering trauma-informed care and increasing the use of recovery supports. In this respect, providers appear to be viewing the system as having made some progress in these areas.

These same system transformation efforts may help to account for why some provider responses in this survey differ from other surveys conducted previously, especially in relation to the risks and barriers to employment. These surveys suggested that providers had negative views of their clients’ capacities to become employed, viewed employment as a potential source of stress that might precipitate a relapse or otherwise negatively affect clients’ well-being (Hamilton et al., 2013; Marwaha et al., 2009; Mueser & McGurk, 2014; Pogoda et al., 2011; Sommer et al., 2012), and thought that clients needed to wait until they were clinically stable – that is, free of symptoms and/or substance use – prior to attempting employment (Mueser & McGurk, 2014; Pogoda et al., 2011). One difference between the present survey and these prior ones, however, is prior surveys asked about whether or not providers thought clients should work. Rather, the present survey only asked about what providers thought would enable their clients to obtain and maintain employment, assuming that this was a valued goal. While it is possible that there would have been similar responses had we not assumed that work was a valued goal for clients to pursue, and had asked instead about whether providers viewed their clients as ‘ready’ to work, it remains worth noting that viewing employment ‘as a source of stress to be avoided’, ‘as increasing a person’s risk of relapse’ and ‘as something that needs to wait until the person has achieved stability’ were the lowest rated items in terms of importance by all providers.

Limitations

Those who completed the survey may not be representative of all public sector mental health providers in Connecticut. In fact, most people who responded to the survey were not clinicians. There may be differences between providers who decided to participate and those who chose not to. We need also to consider that as with any self-report measure, there may be a difference between what people report and how they actually behave, with a bias toward reporting what they feel would be the favorable response.

Conclusion

The IPS model of SE has been shown to be effective in helping many persons with SMI obtain competitive employment (Drake et al., 2016; Mueser et al., 2016; Mueser & McGurk, 2014). Employment of such persons has been shown to be beneficial to their recovery (Bond et al., 2001; Drake et al., 2016; Marwaha & Johnson, 2005; Mueser et al., 2016), and the majority of such persons who are not employed would like to be (Drake et al., 2016). This survey suggests that one reason that more clients may not be referred to IPS programs is that clinicians do not view employment or financial self-sufficiency as important factors in recovery, further compounding the historical view that these persons are unable to, and uninterested in, working. Such findings call for a provider education campaign to highlight the fact that most persons with SMI – like most persons in general – do want to work and, with supports, most are capable of doing so. Future research will be needed to determine whether such a campaign will be successful in addressing the current underutilization of this recovery-oriented support.