Qualitative and Quantitative Data about Obstacles to Employment
There is an increasing recognition that individuals with serious and persistent mental illness can not only find employment but also benefit positively from it Research consistently shows that a significant majority of people facing mental health challenges express a desire to work Numerous studies highlight that for those with serious mental health conditions, gaining employment can lead to improved well-being and quality of life.
In 2008, only 21% of individuals within state mental health systems were employed, highlighting a significant opportunity for improvement Employment not only promotes recovery and enhances mental health but also improves financial stability, boosts self-esteem, and fosters positive attitudes towards the future Additionally, gaining employment can empower individuals, fostering self-sufficiency and potentially reducing their reliance on mental health services.
This section outlines the challenges faced by individuals with severe and persistent mental illness in securing and retaining employment Each identified obstacle is supported by documented qualitative and quantitative research, highlighting its significance as a barrier to employment for this population.
Stigma and discrimination significantly hinder individuals with serious and persistent mental illness from securing competitive employment Many employers mistakenly perceive that hiring people with disabilities is unsuitable or may fear the accommodations required for their integration into the workplace.
A 2007 study by Planning Decisions, funded by the Maine DHHS federal CHOICES CEO grant, highlights the critical need to change employer attitudes towards individuals with disabilities The report, based on qualitative research from focus groups and surveys, concludes that the persistent high unemployment rates among people with disabilities are largely due to the belief held by over half of employers that these individuals cannot perform effectively in the workplace.
Mental health services providers’ attitudes
Employers often harbor concerns about hiring individuals with mental illnesses, but studies indicate that mental health consumers also face challenges within the mental health service system, which is characterized by low expectations, minimal guidance regarding employment, and a predominant focus on medical issues A notable report from August 2009, commissioned by Maine Medical Center's Department of Vocational Services and conducted by Hornby Zeller, highlights these systemic shortcomings.
The article "Improving Employment Outcomes for Adult Mental Health Consumers" highlights the often-overlooked desire of mental health consumers to work, as noted by Casper and Carloni A report from Maine confirms that this issue is prevalent in the state, indicating a need for practitioners to recognize and support the employment aspirations of these individuals.
“the majority of staff in one of the [mental health] agencies was still operating under the theory that work is something you do after you get well.” 14
The Hornby Zeller report highlights that Maine practitioners traditionally directed consumers to employment services based on mental health assessments However, research in supported employment indicates that the key determinants of successful job outcomes are the consumer's motivation to work and their previous work experience, rather than their mental health status.
Research indicates that 50% to 75% of individuals with mental illness express a desire to work, yet many are not actively seeking employment due to personal fears and attitudes that hinder their job search The Hornby Zeller Report on Maine’s new CSN Employment Services Program supports this finding, revealing that a common reaction among consumers was the belief that “We thought we weren’t allowed to work,” highlighting the misconceptions surrounding employment opportunities for those with mental health challenges.
The disincentives associated with the Social Security Administration benefit system can be major barriers to work for a person with a disability 19 A person’s income supports through Social
Employment income can significantly impact Security Disability Insurance (SSDI), Supplemental Security Income (SSI), and health insurance, typically Medicaid, creating barriers for consumers seeking jobs Common concerns include the fear of losing benefits and health coverage, uncertainty about reliable benefit advice, and anxiety over the potential need for reinstating benefits in the future However, research indicates that access to benefits counseling helps recipients understand how work affects their income and health benefits, increasing their likelihood of gaining employment.
Lack of work experience/confidence
A significant barrier to employment for many individuals is the lack of a consistent work history, with some having not worked for years or facing substantial gaps in their employment records Additionally, those who have engaged in "under the table" work find it challenging to accurately report their experience on job applications or resumes According to the Coordinator of Maine’s CSN Employment Services Program, clients who have been out of work for five years or more have, on average, been unemployed for thirteen years This prolonged absence from the workforce creates substantial obstacles to securing successful employment.
A mismatch between an individual's interests and the jobs available can hinder employment, particularly for those with serious mental illnesses Many are placed in low-paying positions like dishwashing and janitorial work due to high demand for unskilled labor, rather than personal preference In Maine, early results from the CSN Employment Services Program indicate a trend toward securing predominantly low-skilled jobs Therefore, aligning job development with individual consumer choices is crucial for a successful supported employment program.
Concern about mental health symptoms
Many individuals fear that working may worsen their mental illness symptoms However, a 2007 study by Becker et al revealed that over 80% of clients who received suitable employment support successfully managed their symptoms and utilized coping skills to maintain their jobs Becker noted, “The successful management of symptoms and the deployment of appropriate coping skills appeared to play an important role in finding and maintaining work.” Additionally, the study indicated that high-fidelity supported employment programs significantly contribute to achieving positive employment outcomes for consumers.
Individuals with serious and persistent mental illness may require structured long-term vocational support for varying durations based on their employment needs Research consistently shows that employment programs adhering closely to the evidence-based Supported Employment model are significantly more effective for these individuals compared to alternative support options or the absence of support.
Improvement's fidelity review of Maine's Long Term Supported Employment Program (LTSE) utilized both quantitative and qualitative data analysis to assess adherence to evidence-based supported employment services The findings revealed that high fidelity programs in Maine achieved an impressive employment rate of 77%, compared to just 23% for low fidelity programs This significant disparity indicates that low fidelity programs can hinder employment opportunities for individuals seeking support.
The Need for Employment Services
To determine the array of employment services needed, this report looked at Consent Decree
Standards related to employment as well as other measures of need for employment services The October 2006 Consent Decree Plan set the following standards for compliance to the Consent
Decree with regard to employment for Class Members.
10% or fewer consumers identified as having ISP identified unmet vocational support needs
13% or more consumers employed in competitive employment in the community 33
† Although these standards apply only to class members, this report looks at how these standards would apply if used for all persons with SPMI in OAMHS services.
The latest State Unmet Needs Report for FY 2010 reveals that only 2.1% of individuals with Severe and Persistent Mental Illness (SPMI) receiving services from the Office of Adult Mental Health Services (OAMHS) have an unmet need for vocational services, indicating a positive outcome for the first measure.
According to the 10% Consent Decree Standard, there are 199 individuals across the state with unmet needs for various vocational services Notably, the majority of these reported unmet resource needs pertain specifically to Vocational Rehabilitation Services.
Statewide Reports of Unmet Needs for Vocational Services Quarter 1 FY ’10 §
Type of Vocational Service Reports of Unmet Needs
Benefits counseling related to employment 15
Club house and/or peer vocational support 2
Total reports of unmet needs for vocational services 240**
* Most „other needs‟ are goals, client descriptions, needs (not resource needs), needs listed a
’none’ or ‘other’ and resource needs that fit within an existing category
**The total number of reported unmet needs is more than 199, since some persons reported multiple unmet needs within the category of employment services 35
To meet the requirements of the Consent Decree, it is essential that 13% of class members secure employment However, the established standard within the Consent Decree mandates that 15% of class members achieve competitive employment, with an overall target of 20% for either competitive or supported employment opportunities.
‡ Data is compiled through the Maine DHHS Enterprise System (EIS) for individuals who indicate a need on their ISP
An individualized support plan is essential for addressing resources that are unavailable within designated timeframes While some needs may initially be classified as unmet, they could be fulfilled before the quarter concludes The compiled data considers factors such as client zip code and completed Resource Data Summary (RDS) reports by case managers, including both class members and non-class members.
Enrollment and RDS data is entered by providers into APS Healthcare’s CareConnection at the time of the initial Prior
Authorization (PA) request and at all continuing stay reviews. § See footnote above for how the data is compiled.
The CSN Employment Services Program initiative, outlined in the report "Improving Employment Outcomes for Adult Mental Health Consumers," reveals a significant unmet need for employment services, with 230 individuals currently awaiting assistance from seven employment specialists Despite the limitations of each measure, these figures indicate that at various times, the number of people in need of support ranges from 199 to 230.
SP M I have some t ype of unm et resourc e need for empl o ym ent se rvices.
Many individuals with Serious and Persistent Mental Illness (SPMI) are actively seeking employment, yet they often go unrecognized as having unmet needs for employment services As of December 31, 2009, data from the Individual Service Plans (ISPs) revealed that 1,641 people with SPMI in OAMHS services were in search of work While some are actively pursuing job opportunities, others may be utilizing mainstream employment resources or Vocational Rehabilitation services designed for individuals with disabilities Additionally, there are those who adopt a more passive approach but would consider employment if suitable opportunities arise Further details regarding the employment status of persons enrolled in Assertive Community Treatment (ACT) can be found in the accompanying table.
CI, ICI or PNMI services: services that are only provided for those with SPMI 38
Not employed - not looking for work 5,993
Not employed - looking for work 1,641
Part-time (less than 32 hrs per week) 619
Full-time (32 or more hrs per week) 107
Note: The total exceeds 100% as a few persons checked multiple categories
Based on this information, the percentage of people with SPMI who are working is currently below the 13% compliance standard This table shows that 767 p e rson s with SPMI receiving
OAMHS services are proving effective, with enrollment data from APS indicating that 96% of individuals with Serious and Persistent Mental Illness (SPMI) receiving these services are aged 18 to 64 This percentage translates to an estimated 8,787 individuals benefiting from OAMHS support.
As of December 31, 2009, data from the EIS system reveals the employment status of individuals receiving CI, ACT, and ICI services, with 96% of the 9,153 participants being of working age The employment rate for working-age adults with Serious and Persistent Mental Illness (SPMI) in OAMHS services stands at approximately 9%, equating to 767 out of 8,787 individuals.
Determining the array of employment services needed:
To meet the 13% employment standard for individuals with Serious and Persistent Mental Illness (SPMI) receiving services from the Office of Adult Mental Health Services (OAMHS), an estimated 375 additional individuals with SPMI who are currently unemployed must secure and sustain employment.
The calculations overlook the high turnover rate of individuals utilizing OAMHS services, which is estimated to be around 25% within a six-month timeframe Additionally, the challenge of job retention is not considered, as individuals with Serious and Persistent Mental Illness (SPMI) often hold jobs for less than a year on average.
How many people would need to enter either the VR employment services or the CSN
The Employment Services Program collaborates with ACT team employment specialists to help individuals with Serious and Persistent Mental Illness (SPMI) achieve their employment goals, although this process can be uncertain Many individuals benefit from informal supports or mainstream resources like CareerCenters Key factors influencing success include the time taken to reach a successful employment outcome and the job placement rate, which vary among the three employment service programs.
The Maine Bureau of Rehabilitation, through its Division of Vocational Rehabilitation (VR), offers long-term services to clients, who typically engage for an average of 39 months from application to case closure under an employment plan that includes education and training A case is deemed successfully closed when an individual maintains at least 90 days of employment in a competitive, integrated setting In fiscal 2008, 174 individuals with mental illness achieved successful closures, with recent assessments indicating that 39% of those enrolled in Maine VR services successfully complete their programs.
In its first year of operation, the CSN Employment Services Program achieved a placement rate of
Out of 336 individuals who participated in the CSN Employment Services Program, 46 secured employment, resulting in a success rate of 14% The program measures success by the number of individuals who find jobs, rather than tracking long-term employment retention Many participants from the previous year continue to engage with the program, and as it evolves, those completing education and training are increasingly likely to gain employment For instance, 15 individuals achieved job placements in the quarter ending December 31, 2009, highlighting the program's ongoing impact in supporting clients' employment goals.
Vocational Services OAMHS has established a number of performance targets, including that
Out of a population of 8,787 individuals, 13% equates to 1,142 persons, of which 767 are currently employed, leaving 375 persons still seeking work To reach a 15% employment rate, we need to account for the 767 already working, resulting in a requirement of 551 additional workers Furthermore, to achieve a 20% employment rate within the working-age population, we would need to employ 990 persons, which means an increase of 223 workers from the current employment figures.
OAMHS does not track turnover as a statistic According to APS reports for the period from July to December 2009, a total of 12,563 individuals were enrolled in services This data is derived from the information entered into APS during that timeframe.
Overview of Employment Resources Currently Available
This section highlights resources designed to assist individuals with serious and persistent mental illness in achieving success in competitive employment While some services are offered statewide, others are geographically limited, with funding sourced from OAMHS and various other agencies or programs Employment resources can be found in traditional mental health agencies as well as in specialized employment services catering to individuals with diverse disabilities A detailed list of these employment resources is organized by the seven geographic areas, aligning with the specific needs of each region.
Community Service Networks (CSNs) is available in the appendix The CSN Employment
Services Program will be publishing a Guide to Employment Resources by CSN within the next six months This resource will identify available employment services at the local level.
Navigating the mental health service system can be challenging for consumers due to its complexity and varying regulations The OAMHS plays a crucial role in helping individuals access and comprehend available services while addressing disparities by collaborating with both consumers and service providers within seven local Community Service Networks (CSNs) These CSNs aim to streamline service coordination, ensuring that individuals with serious mental illnesses receive comprehensive mental health and vocational services within their community Additionally, a competitive job is defined by OAMHS as one that pays at least minimum wage and allows for full integration with employees without disabilities.
OAMHS provides comprehensive support for clients with Serious and Persistent Mental Illness (SPMI) throughout their employment journey Initially, community integration workers assist clients as they explore employment options Once clients are ready to pursue their employment goals, employment specialists guide them in taking actionable steps Finally, after securing a job, long-term supported employment staff offer ongoing assistance as needed The accompanying graphic outlines the essential stages and key personnel involved in helping individuals with mental illness achieve successful employment, highlighting the available services and support tailored to their needs.
Overview of Employment Support Services: Key Activities and Staff
Graphic created by Vanessa Bell, Muskie School *CWICs are funded jointly, see page 16
OAMHS acquires employment support services via its contract with Maine Medical Center for CSN Employment Services, along with agreements with community mental health agencies featuring ACT teams and Community Rehabilitation Providers that offer long-term employment support to clients Additionally, OAMHS employs employment specialists directly at Riverview Psychiatric Center to enhance these services.
Specialists play a crucial role in ACT Teams, working alongside mental health agencies as part of the CSN Employment Services Program The table below illustrates the staff dedicated to supporting employment objectives and the individuals they assist Further details about the services provided and the specific roles of the staff are outlined in the following sections.
Community Integration (CI) Staff on 12/1/09 7722 349 FTE*
ACT Employment Specialists on 12/1/09 830 15 FTE
CSN Employment Specialists on 6/30/09 172 7 positions
Benefits Counselors (CWIC) on 9/30/09 94 5 positions
Long Term Supported Employment (LTES)
Community Rehabilitation Providers on 12/31/09 210 27 contracts**
FTE, or full-time equivalent, represents a measurement of work hours that equates to full-time positions For instance, an agency might hire four part-time employees to cover two full-time roles The provided table for CI and ACT illustrates the number of FTEs employed on a specific day, rather than indicating the total number of positions available if all roles were fully staffed.
**Some Community Rehabilitation Providers have not encumbered any funds in six months or more Others employ multiple full time staff
The CI staff in mental health agencies across the state play a crucial role in helping clients view employment as a key aspiration for recovery They engage in ongoing discussions about the significance of work in the recovery process and assist clients in identifying their employment goals, which can be incorporated into their individual service plans (ISPs) Additionally, CI workers may refer clients to employment specialists, benefits specialists, BRS vocational rehabilitation services, and other resources like Career Centers Through this support, CI workers guide clients on their journeys toward recovery and meaningful employment.
CSN Employment Services Program and the Employment Service Networks (ESNs)
In February 2008, Maine Medical Center’s Department of Vocational Services was awarded a
The Ohio Department of Mental Health and Addiction Services (OAMHS) has entered into a $675,000 contract to hire and retain employment specialists across seven Community Service Networks, along with two statewide program coordinators This initiative marks OAMHS's largest investment in vocational services since the October 2006 Consent Decree Plan, aimed at enhancing employment support for individuals with severe and persistent mental illness By placing employment specialists within mental health agencies, OAMHS ensures that clients have direct access to employment services integrated with their mental health treatment Research indicates that supported employment programs yield better outcomes when employment services are part of the mental health team In a collaborative effort, each agency will provide office space and jointly oversee the employment specialists alongside regional project coordinators from Maine Medical Center.
CSN employment specialists offer a range of services including job development, career exploration, and job search assistance They primarily receive referrals from CI staff at host agencies or directly from consumers According to their contract, these specialists can manage caseloads of up to 25 individuals.
CSN employment specialists also serve as facilitators for the Employment Service Networks
Employment Service Networks (ESNs) play a crucial role in each Community Service Network (CSN) by fostering local partnerships among essential stakeholders in employment services These networks consist of various members, including a CSN employment specialist, an ACT Team employment specialist, a Vocational Rehabilitation Counselor, a Disability Program Navigator, and a Community Work Incentives Coordinator.
Incentives Coordinator (CWIC, also known as a benefits specialist), a Community Rehabilitation Provider (CRP) and a consumer, if designated, from the Consumer Council System of Maine
While employers are not members, they are encouraged to engage with CSN employment specialists, who also deliver presentations on employment services to various agencies beyond their own These presentations serve to disseminate up-to-date information about employment services and emphasize the critical role of employment in supporting consumers' recovery Recently, five local agencies benefited from these informative sessions.
An employment specialist plays a crucial role in guiding clients and mental health practitioners to view employment as an achievable objective The CSN Employment Services emphasizes the importance of fostering a realistic perspective on work, paving the way for successful job placements.
Program uses the Need for Change Scale to do this This scale was developed by Casper and
In a study conducted by Carloni in 2006, the Need for Change Scale was utilized to evaluate the employment aspirations of individuals with psychiatric disabilities This initiative aimed to engage all consumers of Community Integration (CI) who expressed a desire to alter their employment situation From April 1, 2008, to June 30, 2009, a total of 1,075 individuals in Maine completed the scale, with 566 respondents reporting a strong or urgent need for employment change Out of these, 336 participants enrolled in individualized employment specialist services provided by host agencies within each Community Support Network (CSN), where they collaborated with specialists to address their employment goals.
Post-Employment Support Post-Education Support
Hornby Zeller's report highlights that four out of seven Community Support Networks (CSNs) met the OAMHS goal of 15% employment for program enrollees in their first year Among the 46 individuals who secured jobs, only five obtained full-time positions, while the remainder found part-time, seasonal, or situational assessment roles The most prevalent job was cleaning, with eleven individuals working as janitors or cleaners Other notable employment included general helpers (4), store clerks (3), customer service representatives (3), and data entry specialists (3), along with various other roles such as artists, office clerks, support workers, certified nursing assistants, dietary aides, dishwashers, harvesters, and stock room clerks, each held by two or more individuals.
Among the 40 positions analyzed, the median hourly wage was $8.00, with over half of the participants earning above the minimum wage of $7.25 The highest regular employment wage recorded was $14.00 per hour, while one individual earned $50.00 per hour for a weekly piano performance Notably, 20% of the respondents reported earnings of $10.00 per hour or more On average, participants worked 18 hours per week, with hours ranging from a seasonal high of 50 hours in crop harvesting to a low of just one hour for piano performances.
Assertive Community Treatment (ACT) Employment Specialists
Steps Taken to Overcome Obstacles
OAMHS has implemented a series of strategic steps to enhance the employment service system for adults with Serious and Persistent Mental Illness (SPMI), aiming to boost their employment outcomes These initiatives are organized into three primary categories, with each individual activity playing a unique role while collectively contributing to the overall improvement of the system.
The OAMHS has conducted multiple studies to identify the challenges faced by individuals with psychiatric disabilities seeking employment, as outlined in this report These efforts are part of the DHHS's commitment to improving workplace accessibility and support for this population.
The OAMHS has actively engaged in focus groups and interviews to collect qualitative data on employment barriers as part of the CHOICES grant initiative Furthermore, the Vocational Workgroup of the State Rehabilitation Council analyzed data from multiple sources and has produced a draft report addressing these challenges.
In 2008, findings from various sources have shaped the training initiatives of OAMHS and will continue to guide its future efforts The success of OAMHS relies significantly on fostering strong, committed, and sustained partnerships with key stakeholders, including clients, community service providers, and the Department of Labor Bureau.
The DHHS Office of Quality Improvement, in collaboration with the Office of Consumer Affairs, the State Rehabilitation Council, and the Muskie School, conducted a report titled “Competitive Employment Interview” to gather insights directly from consumers Sixteen individuals, employed either part-time or full-time, shared their experiences regarding how their work history, benefits counseling, mental health management, and personal motivations impacted their employment status.
Benefits counseling plays a vital role in enhancing vocational services, significantly improving employment rates for individuals with disabilities, as evidenced by numerous studies.
Vocational Workgroup in 2007 drew upon the work of a 2006 study in Vermont that found that
Participants who received specialized benefits counseling experienced notable improvements in their earnings, with the counseling group reporting an increase of $1,256 per year compared to two control groups.
Report noted above, all of the Maine consumers interviewed stated that the benefits information received was helpful 65
A skilled and well-supported workforce is essential for effective service delivery Since 2006, OAMHS has implemented various initiatives to train staff in mental health and employment services, aiming to improve their knowledge and skills in employment practices.
Community Integration workers play a vital role in connecting individuals to the mental health system, maintaining regular contact with those served by public mental health services To ensure quality support, all Community Integration staff must possess the MHRT/C certification, which was updated in January 2009 to enhance its vocational component This emphasis on vocational aspects underscores the importance of integrating employment opportunities into mental health recovery.
A minimum 30-hour course on "Disability" is now mandatory for certification, emphasizing the essential competencies needed for all staff involved in community support This change, which elevates the course from optional to required, reflects the growing recognition of the importance of disability awareness Since the implementation of this new requirement, around 100 individuals have completed the course.
In February 2007, over 550 workers from various CI organizations, including ACT, CI, ICI, and ICM, participated in a three-hour workshop titled "Work and Recovery: Vocational Training," conducted by experts from the University of Massachusetts Institute for Community Inclusion The workshop aimed to educate attendees on the importance of work in the recovery process and provided them with practical strategies to support their clients' vocational aspirations This comprehensive training initiative for case management staff took place in Portland, Augusta, and Bangor.
Providers who work in residential programs also receive some training in supported employment as part of their certification requirements This content was added to the
Mental Health Support Specialist (MHSS) curriculum in 2005 A total of 1,145 people have taken the MHSS courses since 2006.
A fidelity review conducted in January 2008 assessed Maine's ACT Teams and identified varying adherence to the evidence-based model In response, all ten teams received technical assistance from MMC's Vocational Services Program to enhance employment support for clients Starting in October 2009, OAMHS implemented contract requirements mandating that ACT team employment specialists dedicate at least 90% of their time to employment-related activities, with a goal of having at least 15% of clients employed at any given time In the initial quarter following this policy implementation, four out of ten ACT employment specialists achieved the 90% activity threshold.
Long Term Employment Support (LTES) staff
OAMHS working closely with the Office of Quality Improvement conducted a fidelity review of these services against the evidence-based supported employment model In
In January 2008, OAMHS convened a meeting with all LTES providers to discuss the outcomes of a review, which highlighted the necessity for policy changes based on provider feedback As a result, new policies were implemented to enhance collaboration by enabling reimbursement for participation in team meetings and ensuring swift access to related services for individuals at risk of losing their jobs while receiving LTES.
Certified Intentional Peer Support Specialist Training Program (CIPSS)
The Office of Consumer Affairs provides a free nine-day course for consumers interested in peer support programs across various settings This training emphasizes the importance of peers assisting each other in achieving their goals Completing the CIPSS course enables participants to obtain paid positions as peer support specialists in Warmline programs and hospital emergency services.
Departments and ACT Teams A total of 53 people have graduated from this program over the past 3 years.
Community Support Specialist Program (CSSP)
The College Supported Services Program (CSSP), funded by OAMHS for over a decade and developed in partnership with the University of Maine at Augusta, offers a college-level educational experience for individuals recovering from mental health and substance abuse disorders Students in the CSSP complete five college courses to obtain the Provisional Mental Health Rehabilitation Technician/Community (MHRT/C) certification, which serves as a foundational credential for entering the mental health field Graduates can pursue further education to achieve full certification or obtain a college degree, with the program typically graduating 10-12 students each year.