|
|
|
|||||||||||||||||
| Employment
Programs Help Patients With Mental Illnesses Succeed by Richard A. Sheerer Psychiatric Times December 2003 Vol. XX Issue 13 |
||||||||||||||||||
| "What
mental health practitioners need to hear," Zlatka Russinova, Ph.D.,
told Psychiatric Times, "is that people with serious mental illness
do have the capacity to go back to work." Russinova is senior research
associate at Boston University's Center for Psychiatric Rehabilitation
and has specialized in researching the connections between mental
illness and employment. "I'll give you one example. I had a colleague
who is a postdoctoral fellow and who has been conducting interviews
for our study. She has been so amazed that, as a clinician, she never
believed that people with serious mental illness could do this or
think clearly about serious economic decision making. She said to
me, 'There probably are so many other mental health professionals
out there who think the way I thought.'" Where occupational therapy
was once seen as a treatment tool, the ability to work and earn a
living is now recognized as a realistic outcome for many patients.
In one study of workers with serious mental illness, Russinova and her colleagues found that 74% of the 687 participants had held the same job for 24 months or longer. In that group, 28% suffered from major depression, 17% had schizophrenia or schizoaffective disorder, 42% had been diagnosed with bipolar disorder, and 11% had posttraumatic stress disorder or other dissociative disorder. Across the country, programs are going beyond just training people with mental illnesses for jobs and helping them find employment opportunities. They are creating businesses in which workers who are mentally ill take an active part in running the enterprise, dealing with customers and sharing in the economic fruits of their labor. "We've seen this happening around the country," said Ron Honberg, J.D., national director for policy and legal affairs at the National Alliance for the Mentally Ill. He told PT, "A lot of times they are food establishments. That's a successful model, but it's not widespread. It's a very cool approach, involving people in all aspects of the enterprise, giving them a stake in how it does. It's a progressive approach to addressing a need that is very profound for people with mental illness." Examples can be seen in the Table. Eloise Newell runs Restoration Project Inc., a vocational rehabilitation program that trains people who are mentally ill in furniture upholstery and refinishing in Acton, Mass. "We do an annual survey of our graduates," she told PT. "Over the 10 years we've been in existence, more than 70% of them remain employed. Their recovery appears to be permanent." Newell was a university-level physics instructor when her own son was diagnosed with schizophrenia as a college sophomore. "Sixteen years ago, programs weren't geared toward recovery," she said. "He was always ambitious and had a strong work ethic. He said he knew if he could work he would be better." She founded Restoration Project on the Montessori model. "My mother started the first Montessori school in North Carolina. Our work here is based on Montessori principles and on constructionism. Stations are set up, and people choose where they want to work. We have a facilitator who looks after the different stations." As part of their training, participants work on jobs brought in by consumers. Other upholstery businesses in the area don't resent the competition, according to Newell. "The other businesses have reacted very well," she said. "At first they didn't think we were any competition, but now they realize that we are. But we're different: We don't work that fast, our product is our people. "We charge less than the going rate. I think that's required as part of nonprofit status, but we're only about 10% less. But we're not that much competition. The fact that we take longer to do the job makes a difference. Our customers are loyal, and they're also our supporters, the source of much of our funding." Participants attend the project two days a week and are supposed to spend some of the time away from the work environment preparing to look for outside work. "A person absorbs what they've learned after they do an exercise, which is why you need three days away after working," Newell explained. "Everything we do here is normal vocational training, skills built on top of skills, problem-solving. It is empowering if you want a person to go forward." While participants learn a useful trade and are helped to find a real-world job, Newell said that the project's focus includes a broader agenda. "Our participants go through the normal stages of recovery. First they work on acquiring transportation, getting a driver's license, and then a car. Then they work on housing. They learn to advocate for themselves on medications. In about six months, they're usually ready to get a job." Newell added that a consulting psychiatrist monitors patients' progress, but, "Our program is really based on educational models rather than psychiatric models. We don't treat our participants like 'people with mental illness,' whatever that means. We don't treat them as patients. The first thing I discovered was that they understood my jokes; they're not really much different than my students in my physics classes. "I reject completely the idea that people with mental illness don't excel. Many of them are smart and talented people. If you treat them like great people, pretty soon they start feeling like great people." Russinova is more emphatic in extolling the abilities of people with mental illness. "One of the old myths was that people with serious mental illness could only do low-level jobs--the so-called F jobs: flowers, filing, food. We have done studies that have documented capacity of the mentally ill to be successful. "For example, in the late 1990s, I did a study with Marsha Langer Ellison [Ph.D., M.S.W.] looking at professional and managerial careers. We studied 495 participants around the country who were able to maintain a high-level job successfully for at least six months. Many of these were people who held jobs for years and years, despite their mental illnesses. "Some of them were in technical jobs, some in sales, some in middle or upper management," she added. "These were definitely not in low-level, menial jobs. Forty-eight percent were in professional specialties. Forty-six percent were in executive positions or were program directors. Only 3% were in clerical and sales jobs, and 2% in low-level technical positions." Russinova said the group "had a very interesting distribution: 75% of the whole sample was employed full time; 62% had held their position for more than two years; 28% had held the same job for more than five years. What was most interesting was that they had the capacity to keep such high-level jobs for a long time. Thirty-three percent of this sample were working in non-helping professions; 16% were working in health and social services other than mental health--we separated the health services. Thirty percent were in mental health; 21% in self-help advocacy jobs. All in all, it was a very surprising, very positive picture." Many of the study participants were dependent on continuing treatment to maintain their positions, Russinova said. "These people haven't been cured. Eighty-eight percent of the study participants were taking psychotropic medications at the time of study. They had well-maintained, well-managed illness. Seventy-three percent were in some kind of psychotherapy at the time of study. "These people made heavy use of the mental health system to maintain their working capacity," she added. "We asked these folks about the things that helped them succeed vocationally. The most important was consistent use of medications. Number two was the support of a spouse or significant other. Third was the support of a therapist. The list varies somewhat per diagnosis. The group with bipolar disorder had a higher percentage of people who were married or in a relationship. In other groups, medications and the support of a therapist were the most important factors contributing to success." Last May, the Boston University research team presented baseline findings from a five-year study of sustained employment. Of the 696 individuals who met the study criteria of both a serious psychiatric condition and sustained employment in the two years prior to enrolling in the study: 74% were continuously employed for the entire two years; 17% were employed for 18 of the 24 months; 9% were employed for 12 to 18 of the 24 months; 80% had at least one psychiatric hospitalization in the past; 95% were taking psychotropic medications at the time of the study; 74% were working 35 hours or more a week; 53% had professional or technical jobs and 24% had managerial or administrative jobs; 32% had total annual income of more than $40,000 and 38% had incomes of between $20,000 and $40,000; 43% owned their own home; and 42% lived with a spouse or significant other. The researchers noted, "Psychiatric diagnosis was not associated with participants' ability to sustain employment during the two years prior to entering the study. However, diagnosis was associated with participants' occupational status, the number of hours they worked per week, and the salary they earned per hour. On average, the group of participants who reported a diagnosis of bipolar disorder had a higher occupational status, worked more hours per week, and earned a higher salary per hour than the other diagnostic groups. At the same time, the group of participants who reported a diagnosis of schizophrenia or schizoaffective disorder, on average, had a lower occupational status, worked fewer hours per week, and earned a lower salary per hour than the other diagnostic groups." "The bottom line is that people with mental illness are able to sustain employment," Russinova said. "They can succeed both over time and by moving up in higher level positions. The other thing we found was the importance of education. It makes a difference in peoples' capacity to get and to sustain better jobs. People will do better if they acquire a better education prior to getting sick or acquire schooling through vocational rehabilitation programs." |
||||||||||||||||||
| NASMPHD Position Paper on Peer Services | ||||||||||||||||||
|
The NASMPHD
issued this position paper in 1989. South Carolina currently has
no nonprofit peer services, no assistance for clients wishing to
start up employment, housing, support services or drop in centers
with services hubs. It's about time the mental health system and
advocacy agencies in this state started to put their money where
their mouths are to lower the costs of mental health care both in
terms of human potential and taxpayer dollars. So state and
national taxes are directed at the acute care revolving door syndrome,
which only serves to retraumatize and intimidate persons in crisis,
often backed by police force and involuntary measures like stunning
drug combinations (chemical strait jackets) and police force. This
is literally overkill, considering that most patients fed onto the
assembly in this manner are not criminals, not violent and not dangerous
to themselves or anyone else. Mental health care in this state and
this nation are largely punitive, portraying false images of mental
patients to perpetuate the use of force and convince taxpayers systemic
coercions are necessary to protect the public from this vulnerable
population. The drug industry drives much of the medical model reductionism
that keeps mental patients dependent and hopeless, pumping out new
"miracle drugs for mental illness" and getting reimbursed
through Medicaid, thus commercializing the pain, suffering and isolations
that accompany mental illness labels. While drugs as an adjunct
to therapy and ancillary services are sometimes necessary, the practices
of polypharmacy (drug cocktails) and stun drugging hospitalized
patients is wasteful and shameful in terms of human lives ruined
and tax dollars poured into Medicaid for these dubious standard
treatments. It is only common
sense to require mental health system directors to abide finally
by their own policies and begin diverting acute care dollars into
startups for client operated nonprofit services that might salvage
lives while saving millions in taxpayer dollars currently funding
Medicaid, Medicare and state salaries for mental health professionals
who receive their paychecks without being accountable for the bad
outcomes coercion and disrespectful, abusive treatment keep generating. |
||||||||||||||||||
| Preface | ||||||||||||||||||
|
Unemployment rates for persons with mental health disability in South Carolina and nationwide are running around 90 percent. The work rules for persons on SSDI are confusing and often frightening, as every attempt at even part-time work results in a new psychological evaluation that could mean a complete loss of benefits for persons already living in extreme want. The statistics suggest a waste of talent and ability, an untapped resource...related to the stigma associated with a psychiatric diagnosis, the unwillingness of employers to hire persons with known histories of involvement with mental health services. While the great majority of persons on disability would like to work, their isolation within their own communities, fear of losing what small benefits they receive and lack of supported work initiatives to help them reintegrate takes a huge toll in human resources, dignity and economic well-being of both the government and the individuals for whom services are sparse or non-existent. Most persons with mental illness diagnoses who apply to Vocational Rehabilitation for help usually end up even more isolated in VR sheltered workshops laboring on industry contracts that bring in profits to substantially enhance VR's operating budget. Or VR refers them to Goodwill Industries Inc., an organization geared to finding menial work situations for persons with low skills or little education or both. Goodwill does an excellent job of assisting persons with few skills in finding food industry, custodial or sales floor work but has no component for helping educated or technically skilled disabled persons rejoin the workforce in ways that are meaningful and lead to retention. VR has historically lacked supported work components, including job placements commensurate with client abilities or job coaching combined with case management that have been proven in demonstration grants and research models to increase retention and attract psychiatrically disabled persons back into the workforce. The losses in terms of tax dollars, Medicaid and Medicare payments and re-hospitalizations are extreme. Most persons on disability with qualifications for skilled or technical work find themselves without services that would help them reintegrate into their communities, perform meaningful and satisfying work in a context of support and contribute to the state and national tax bases. |
||||||||||||||||||
| Barriers Created by Vocational Rehabilitation Services:Solutions | ||||||||||||||||||
| Barriers Encountered by People with Mental Illness
Presented by: Richard Baron Matrix Research Institute Respondent: Paul Marchand The Arc Consortium for Citizens with Disabilities STRENGTHENING THE WORK INCENTIVE PROVISIONS OF THE SOCIAL SECURITY ACT TO ENCOURAGE PERSONS WITH SERIOUS MENTAL ILLNESS TO WORK AT THEIR POTENTIAL by Richard C. Baron, M.A., Executive Director Daniel J. Raudenbush, Ph.D., Director of Training Kathleen Wilson, M.S., MAP Supervisor Joanne E. Marinelli, Work Incentives Advocate Matrix Research Institute Abstract This paper is based on a presentation made to policy makers within the Social Security Administration, at the request of the SSA Office of Disability, as part of a series of seminars to provide current information on the disability field to inform SSA policy. The presentation stressed three broad points: first, that persons with serious mental illness, despite epidemic unemployment, can and want to work; second, that a variety of external factors keep people with serious mental illness from working at their potential; and, third, that the Work Incentive Provisions of the Social Security Act require modification if those with serious mental illness are to develop a long-term attachment to the labor market. The article stresses that social policy goals should not emphasize reducing the number of people on the SSA roles but, rather, should seek innovative means to encourage those with serious disabilities to work to their capacity without fear of abandonment of the supports they may need in the future. Introduction The last decade has witnessed a dramatic refashioning of our understanding of the capacity of people with serious mental illness to work: although employment has long been ignored as a significant treatment or rehabilitation goal for those struggling with the most disabling forms of mental illness, there is a growing consensus among service consumers and provider personnel, advocates and policy-makers, that our suppositions about the relationship between mental illness and work ~ and the social policies that result from those suppositions -- bear re-examination. This article seeks to look again at some of the realities of mental illness and work: it reviews the current research literature on the topic, discusses the broad social factors that help to keep people with serious mental illness from employment, and reviews a series of a dozen changes to the Work Incentive Provisions of the Social Security Act that would help more people with serious mental illness to work more often. Although the materials presented here focus on these issues from the perspective of serious mental illness, it is likely that many of the same issues -- and suggested policy changes -- apply as well to a wide array of other individuals with other disabilities: one of the central concerns emerging in the disability community is the degree to which both disability and employment are lifetime issues, requiring social policy responses that recognize the long-term implications of rehabilitation and income supports. Serious Mental Illness and Employment A considerable amount of research now supports the propositions that people with serious mental illness can work, want to work, and can be substantially assisted to work by innovative rehabilitation programs. Despite prejudices to the contrary, we now know: Fact One: there are three million working-age adults with serious mental illness in the nation, of whom 70% to 90% - about two and a half million people -are unemployed. This is a staggering figure. Among the general population of people with disabilities, approximately 67% are unemployed a statistic that has remained static for nearly a generation. Disheartening as this is, conditions are still worse for people with serious mental illness, where unemployment is the predominant fact of life. Fact Two: a diagnosis of serious mental illness is not a reliable indicator that someone cannot work. Current research makes clear that mental illness does not predict work capacity in any meaningful way. While it is true that most forms of serious mental illness certainly create significant barriers to successful employment, symptoms and severity vary considerably, as do job requirements and employer acceptance. Further, the individual's disability will vary over time: a diminished work capacity today may not predict tomorrow's competence. The experience of rehabilitation workers in the field suggest keeping an open mind about any individual's work potential. Fact Three: the great majority of people with mental illness want to work, with nearly 70% identifying work as a key life goal for themselves. Despite the tendency to "blame the victim" (i.e., the client is unmotivated the family members are fearful the employer believes the work requirements will be too stressful etc.), it is best to look at what those with serious mental illness want to achieve for themselves, and work is central to their vision of recovery. Most consumers of mental health services can remember clearly both the first time they were told by a mental health counselor that their illness meant that they "would never work" and the most recent time it was suggested that they "couldn't really work yet:" nonetheless, survey research indicates that employment remains a primary goal. Fact Four: people with serious mental illness who do work are likely to use fewer community mental health and emergency psychiatric services. A growing body of research suggests that those who are working are less likely to be heavy users of day programs and clinical care services, and are less likely to find themselves in psychiatric emergency rooms. There is a growing understanding that work competes with symptoms for the client's attention, with the demands of work ~ and the rewards of work-receiving priority. Fact Five: innovative rehabilitation programs - particularly transitional and supported employment- are increasingly successful in helping people to find and hold jobs. It is now clear that the principles that drive TE/SE program models -- e g., rapid placement into a real job with real pay, intensive on-the job and off-the job support from job coaches to help the client to stabilize his or her work performance; and ongoing support to help sustain employment-- can be relied upon to help a substantial number of those now unemployed to find and hold jobs. Fact Six: employers who are involved in these TE/SE programs report satisfaction with the work of their new hires and the effectiveness of the programs. In one survey, for instance, 70% of employers report that the TE/SE programs have been very responsive to their concerns, and that those with disabilities that they have hired have been excellent employees. While employers have many reasons for responding the TEISE program opportunities, both "bottom-line" inducements and "altruistic" encouragements prove effective. Fact Seven: go-the-job accommodations for people with serious mental illness are both inexpensive and straightforward. Several research studies indicate that the majority of job accommodations requested by people with serious mental illness are for changes in schedule or for modest modifications in work requirements-with the costs of such changes averaging less than $500. Fact Eight: people with mental illness work at all kinds of jobs in the labor market, although 75% of placements are in entry-level (low-pay/low benefit) positions. While it is important to recognize that entry-level employment may be appropriate long-term placements for some people with serious disabilities and may be useful 'first-job' placements for others who plan to move their careers forward more gradually, a sizable number of persons could readily succeed at more demanding positions-with better pay and more generous health benefits-if more was done to identify 'better jobs' for them at the outset. Fact Nine: although job loss continues to be a significant problems for people with serious mental illness, long-term job supports can help people remain employed. Many studies report that people with serious mental illness who do go to work are more likely than others to lose those jobs-whether through resignations or dismissals-in the first year following placement. Those same studies, however, report that too little is done to help people who are working to remain employed, either by providing additional supports to help them keep their current job or by assisting the individual in moving to a new position in a timely manner. Fact Ten: if more people with serious mental illness worked more often, the Social Security Administration could reduce its support expenditures. SSA currently expends approximately $60 billion annual in SSI and SSDI support payments to persons with disabilities, a significant portion of which is directed towards persons with serious mental illness. If more people were working and if more of those working were able to sustain their careers over a lifetime, SSA cash payments would decline substantially. If it is true that persons with serious mental illness want to work and can work-and should work -it is reasonable to ask why unemployment rates are so dramatically high. Part of the answer lies in an examination of the external barriers to employment-the barriers that are not related to the impact of the disability itself -- that have served as additional handicaps to those who are eager for jobs. The Barriers to Employment Three broad social preconceptions underlie the staggering rates of unemployment among those with serious disabilities: first, the belief that people with serious mental illness simply can't work; second, the way in which define a deceptively simple word like "work" and, third, the social policies perspectives of the Social Security Administration. Changes in each of these areas is necessary if people are to develop careers for themselves. The Culture of Mental Illness The current culture of serious mental illness continues to accept that unemployment is a fact of life-an acceptable and understandable condition. It is still true that many mental health professionals see the individual with a serious mental illness as too fragile to sustain employment (or to sustain employment yet), and are most likely to prescribe either those clinical treatments or rehabilitation programs that seek to stabilize the individual's emotional status, residential circumstances, financial supports, and symptom controls-and to do so before employment issues are addressed in order to insure that psychiatric crises ( and with them the costs of emergency room visits or short-term hospitalizations) are minimized. Family members also often seek stabilization, in part to give them a chance to go on with their own lives and in part to avoid what they believe will inevitably be another painful failure experience for the individual they care about. Vocational rehabilitation counselors often reconfirm for the clients they see the fears of the clinicians and family members. As a consequence, the consumer is often overwhelmed by such consistently negative advice, and rarely seek out either rehabilitation programming or employment opportunities on their own. They are unlikely to meet other people with serious disabilities who have gone to work, and in this process employment becomes a "second-order" priority, to be addressed when everything else in their lives is on a very even keel. In fact, innovative programs are demonstrating that the sooner the individual is engaged in work, the more likely he or she will be able to sustain work: but the culture of mental illness has made unemployment the norm. The Meaning of 'Work.' Our preconceptions of what it means to 'work' are often based on an older and singular understanding of what it means to work, a once predominant understanding that is less relevant to the general non-disabled population today than it was two decades ago. For most of us, the ability to work still tends to imply a work pattern of several dimensions: a) a nine-to-five job five days a week; b) ongoing employment, with few gaps (of months or years) in one's resume; c) successive successes at work, with one never resigning peremptorily or being fired by one's employer; d) employment without accommodations from the employer for one's special needs; and e) employment without support from family, friends, or human service agencies. If, however, we broaden our understanding of what it means to work to include more varied work patterns -- patterns that have become more evident as women have entered the workforce, or as economic restructuring has made traditionally solid jobs now insecure temporary positions -- it is possible to better perceive the enormous work potential of persons with serious mental illness, or with other seriously disabling conditions. It is true that the work patterns of people with serious disabilities are likely to be more varied, but still important to structure 'work' as an opportunity for anyone with special needs to demonstrate their capacity for productive labor. Suppose our understanding of what it means to work included the following possibilities: a) part-time employment, for portions of each day, or a few days each week b) periodic employment, so that working six months or nine months or eighteen months before the disability might force one out of a job would not be seen as a failure but would be seen as important steps to lengthening job tenure of the span of a lifetime; c) both successful and unsuccessful employment, in which people with disabilities could fail at or become dissatisfied with jobs at much the same pace as the rest of the workforce without becoming identified as someone who cannot work at all; d) employment that makes appropriate use of the 'reasonable accommodations' of the Americans with Disabilities Act; and e) employment that relies upon ongoing supports-sometimes intensive, sometimes not -from job coaches and employment counselors whenever over a lifetime career they are needed. Work--once redefined in this way--becomes a significant and realizable opportunity for people with serious disabilities. What is suggested here is that social policy needs to see work as a lifetime endeavor that may require-particularly for people with serious disabilities-a lifetime perspective. The success of rehabilitation programs can no longer be based on initial placement rates, but on their ability to help people with long-term disabilities to sustain a long-term engagement in the labor force. The success of the individual is not stabilization on a particular job, but the development of a perception of themselves as a person who works, whatever the pattern of employment may turn out to be. The focus of social policy, it would follow, must be to assist those individuals who can work at whatever pattern is possible-to be fully engaged in the labor market. The Problem with Social Security The problem--from the perspective of the individual with a serious disability who is currently receiving either SSI (Supplemental Security Income) or SSDI (Social Security Disability Insurance) payments--is that SSA policies are often seen to discourage work, as redefined here. On the one hand, it must be recognized that while the Work Incentive Provisions of the Social Security Act do make it more possible and more financially rewarding for people receiving SSI or SSDI payments to go to work, most people either do not know about, do not understand. or do not utilize the Work Incentives. The myths surrounding the operations of the Social Security Administration are pervasive: people with serious mental illness believe that SSA policies discourage employment, and that either one will be cut off from benefits the minute one goes to work or that the loss of benefits-and particularly the loss of medical coverage-is only a matter of time. As a matter of fact, much of this is not a true reflection of SSA policies, but the myth persists. On the other hand, there is a great deal more that can be done to improve the incentives of the program, encouraging people who want to go to work--but are fearful of losing benefits because their needs (that is, their individual patterns of employment)-do not match the model that SSI and SSDI policies are build around. Because people with serious lifetime disabilities are more likely to have varied work patterns, the SSI and SSDI regulations as they currently stand continue to discourage significant numbers of people from working-or from working up to their potential -because of the ways in which SSA policy does indeed penalize them for working. Both the myths and the realities of the SSA Work Incentives need to be addressed in the years ahead. Much of what we know about the impact of SSA myths and realities comes from hard experience: from counselors in vocational rehabilitation programs who discover that the 'lack of motivation' among clients is really a rational response to perceived or real financial disincentives to employment; from Social Security data which indicates that only one-half of one percent of SSI/SSDI recipients/beneficiaries leave the SSA roles; from projects like the one at Matrix Research Institute that provide education, counseling and advocacy to persons with serious mental and physical disabilities that is specifically focused on the SSA Work Incentives; and from consumer surveys that indicate how strongly people feel constrained to stay idle. It is widely understood that an 'underground economy' exists, in which people receiving SSI or SSDI payments may not report modest income in order to avoid SSA scrutiny. It is less widely understood that clients and counselors often review the impact of work together, only to conclude that it would be wisest for the client either to avoid employment entirely or to depress his or her earnings--by working less hours at less pay--in order to remain SSA eligible. Addressing both problems-the myths and the realities-is critically important in the years ahead. If the Social Security Administration can be seen as a 'work-friendly' system, in which the policies and procedures recognized the realities of employment for people with serious disabilities, then far more people are likely to go to work, and far more of those are likely to keep working over their lifetime. Strengthening the SSA Work Incentives The recommendations made here begin with a challenging proposition: it should not be the goal of the Social Security Administration to reduce the numbers of people who remain on the SSA roles; rather, the most effective goal is to significantly increase the number of SSA recipients who are working and the consistency of their employment over their lifetime, even while remaining SSA eligible. Increases in the numbers of people who are working and the consistency of their employment over their lifetimes will reduce-perhaps dramatically-SSA income support expenditures: estimates of expenditure reductions in the 20% - 40% range are not unrealistic if people are genuinely encouraged to work and supported in their return to work over their lifetime. Such reductions will translate into millions of dollars saved, but only if those with serious long-term disabilities can be assured that SSA's assistance will be there when it is genuinely needed. What can be done in this regard? More people with serious mental illness would work if SSA would improve the responsiveness of its Claims Representatives. The myths surrounding the current policies of the Social Security Administration persist in part because SSA Claims representatives are often uninformed about the Work Incentive Provisions of their own system, and in part because the complexity of the regulations make it difficult for even the best-intentioned Claims Representative to keep them straight. Work Incentive Advocacy specialists -- like the ones at Matrix Research Institute -- consistently find that the Claims Representatives are confused, inaccurate, and unconcerned about these issues and the impact they have on the individual who wants to work. 1. Greater Training and Support for Claims Representatives. SSA could invest in better training for its Claims Representatives and could provide additional supports -- in-house work incentive specialists, access to 1-800 number expertise, use of fact sheets and/or computer-generated work incentive work sheets (for PASS Plans, for example) -- that would transform the Claims Representative from a barrier to a support. 2. SSA Support for External Work Incentives Advocacy. SSA could provide grant support to regional or state wide external work incentive advocacy programs that would provide information to clients, vocational counselors, family members, and casemanagers to insure both that people understand and are able to utilize the work incentives. More people with serious mental illness would work if SSA would increase the financial inducements within the Work Incentives. There are two key concerns here: the first is that the benefits of the SSI work incentives are considerably more attractive than the SSDI benefits, in part because the more gradual SSI program gives people an opportunity to enter the world of work and the slowly grapple with its implications: the more all-or-nothing nature of the SSDI 'trial work period' permitting only 9 months of employment before ineligibility, is a major concern; the second is that the SGA level-which impacts on SSDI recipients also-is far too low, having remained at the same level for several years. 3. Revise the SSDI Work Incentives to an SSI Approach. The more gradual approach of SSI holds less risk and fear for most people with serious disabilities, and better acknowledges that for many people they will be struggling with disability issues and employment throughout their lives. 4. Increase the Substantial Gainful Activity Level. SGA should be revised upwards, beyond the $750/month level, and should be pegged to a standard of living index for the future. More people with serious mental illness would work if SSA would grapple with the need for extended medical coverage. For most of those with serious disabilities, the greatest concern they have is the loss of medical coverage. While many can readily understand and deal with the reduction or loss of direct financial support, the loss of medical support is often catastrophic. For most people, medical support provides not only for their physical health care needs, but also for their mental health treatment and rehabilitation services and their psychotropic medications-all critical to their ability to remain successfully employed. Even the current 1619b extension of medical care expires at the point that the individual reaches the "threshold level" - an annual income limit that is established by each state but that generally hovers at approximately $18,000 a year. However, because in today's economy even an $18,000/year job may well have either no medical coverage or medical coverage with no substantial mental health benefits, the individual who wants to work feels enormously threatened: they expect to be ill again, and expect to need that medical coverage. 5. Extend Medical Coverage to Disabled Persons in Need. The Social Security Administration should develop innovative ways to extend medicaid coverage beyond the 1619b limits, perhaps offering to pay for those medical costs not otherwise covered by employer plans or other work incentive initiatives, and insuring that medical coverage will continue to be available to each person with a serious disability with need. 6. Utilize PASS Plans and Earned Income Tax Credits. Innovative policies should be developed that help people with serious disabilities to utilize Pass Plans and Earned Income Tax Credits to insure that their medically necessary expenses -- and especially those that permit continued employment-will be met. More people with serious mental illness would work if SSA would make it easier to apply for and re-enter the active SSA roles. One of the continuing barriers is the '`black-and-white" nature of eligibility. SSA makes is difficult for one to become eligible: a complex process and extended application procedures result in delays of a year or more before one is determined eligible. This serves as a barrier to the individual who may wish to return to work and become ineligible, but who believes that the recurring nature of the disability may force unemployment and re-application to SSA. 7. Streamline the SSA Application Process. Streamlining the process of application, and easing the process for re-application, would encourage many people who are afraid of working if it means either permanent ineligibility or arduous reapplication every time they need support, to engage in the labor market on an ongoing basis. 8. Consider Permanent SSA Eligibility. SSA may want to re-orient itself around the concept of permanent eligibility for persons with serious disabilities, which will permit the individual with a lifetime disability to establish a lifetime commitment to employment, but within the framework of work patterns that they can successfully support without losing SSA eligibility if they need it. More people with serious mental illness would work if SSA would insure that ongoing long-term employment supports are available. One of the underlying propositions for this new perspective on employment and mental illness is the concept that persons with long-term psychiatric disabilities are likely to require long-term employment supports (of varying intensities over time) if they are to retain a long-term attachment to the labor market. SSA could do a great deal more to financially underwrite those long-term support services, which are often unavailable to people who return to work. 9. Encourage Greater Use of PASS and IRWE Plans for Long-Term Support. To avoid job loss, people with serious mental illness often need the temporary assistance of job coaches and casemanagers, who will resolve conflicts with employers, negotiate for job accommodations, help them seek new employment opportunities, or respond to personal crises in ways that do not threaten their employment status. PASS Plans and IRWEs can be used -- if supported by regulations and the training of Claims Representatives-to fund these supports. 10. Include Long-Term Supports as Subsidies. Because these long-term supports are often best provided by rehabilitation agencies, the Work Incentives ought to include a way for the services provided by agencies to be considered subsidies to the client. More people with serious mental illness would work if SSA would invest its dollars in innovative rehabilitation programs. The demands on the state/federal vocational rehabilitation system often mean that inadequate levels of support are available in many communities to provide effective rehabilitation programming for persons with the most severe disabilities. At the same time, the move toward managed behavioral health care by the state mental health authorities may diminish the capacities of the states to direct their dollars toward vocational rehabilitation programming. Because such programs are essential to providing pre-vocational preparation, job training and job coach, and long-term supports, SSA can play a vital role in keeping such agencies vitally engaged in employment related services. 11. Utilize the SSA Payments to State VR Agencies for Programs. Each year the Social Security Administration returns millions of dollars to state VR agencies to repay them for their work in successfully placing people with disabilities onto jobs. These dollars should be targeted-either for expanded TE/SE programming, or specifically for the long-term support services that those who have been placed on jobs are likely to need to retain their employment. 12. Expand the "Direct Payment" Plans to Contract with Agencies. SSA's current plans to directly contract with rehabilitation provider agencies should be expanded, but should be revised in ways that make the agencies more able to participate without assuming all of the risks of the enterprise. Conclusion The nation cannot afford to keep people from employment: SSA expenditures have begun to reach disproportionate levels, one that a growing segment of the public will not easily see increased. It is a "penny-wise/pound-foolish" approach to pursue policies that seek to either fully support someone or not support them at all: what we need are policies that go further in recognizing that those with the most seriously disabling conditions can work, but in career patterns that challenge both our understanding of "work" and our policies of support. More effective policies can both save the nation considerable dollars and give those with serious disabilities the opportunity to establish the careers they seek. |
||||||||||||||||||
| Peer
Delivered Services:Saving Lives, Saving Costs by Sue Poole |
||||||||||||||||||
|
Systems consultant Deborah Reidy published research 10 years ago citing negative impacts of stigma within the system itself on service recipients who spoke to her of feeling degraded, dehumanized and deprived of choices by mental health professionals who focused on deficits rather than strengths and assets. (See Stigma Is Social Death). Although the
paradigm is slowly changing, many mental health systems today still
rely on the acute care revolving door approach to delivering treatment
instead of attending to the holistics of people's circumstances
and life paths. In its recent TRIAD report (http://www.nami.org/),
NAMI deplored the "shameful lack of consumer operated service
programs", which are defined as nonprofit support, recovery
and active advocacy initiatives in the areas of housing, social
networking and jobs. As the Ohio
Department of Mental Health Pine Valley mental health center notes
in its site's recovery section at http://www.pvadamh.org/recoveryinfo.htm,
a sense of hopelessness is often inculcated by mental health professionals
who do not understand or promote recovery because they do not believe
their patients are capable of independent thought or self-determination.
This attitude trickles down into the client culture itself, erecting
roadblocks to hope for a brighter future, so that many clients become
dependent on the system for lack of a psychosocial infrastructure
enabling decent standards of living and freedom from fear and discrimination
in their own communities. Low expectations often become self-fulfilling
prophecies, and mental health clients are engaged in a nationwide
struggle to overcome the barriers to inclusion. Perhaps, Reidy suggests,
society itself suffers by rejecting the gifts, compassion and solid
work ethics clients can offer. In the words of Douglas DeVoe, executive director of Ohio Advocates for Mental Health: "We find peer support programs much better able to assist people in their recovery in a non-stigmatizing way, as well as providing a forum for people being treated for a mental illness to see their peers working and achieving and possibly catch a bit of hope that there is a potentially better life for themselves." And Devoe also minces no words on the most significant unmet need...and the reason it is unmet. He says, "Employment, employment, employment. The 90% unemployment rate among people diagnosed with severe mental illness in Ohio is abysmal . We need to see escape from the public mental health system as a priority. Many of the crisis issues around housing and transportation would be greatly eased if more people had a reasonable income could effectively have more choices with their own money. Some of this goes to Sue's point about stigmatizing attitudes within the public mental health system and the concurrent need to keep us dependent." For many mental health clients, it comes down to respect for their professionalism, their dedication to helping their peers find safe spaces for recovery and a way out of the acute care revolving door dilemma. The collaborative work of vibrant researchers and advocates like Jean Campbell, Debi Reidy, Mark Salzer and the advocacy of organizations like Ohio Advocates for Mental Health and the Mental Health Association of Southeastern Pennsylvania are slowly but surely chipping away at the barriers psychiatrically labeled persons experience in trying to live with self-determination, dignity and...above all...hope for a better future.
|
||||||||||||||||||
| Missing Link:Psychosis in an Accepting Environment Can Lead to Growth and Creativity | ||||||||||||||||||
| Biological
Basis for Creativity Linked to Mental Illness: Creative people more open to stimuli from environment Journal of Personality and Social Psychology September, 2003 Psychologists from U of T and Harvard University have identified one of the biological bases of creativity. The study in the September issue of the Journal of Personality and Social Psychology says the brains of creative people appear to be more open to incoming stimuli from the surrounding environment. Other people's brains might shut out this same information through a process called "latent inhibition" - defined as an animal's unconscious capacity to ignore stimuli that experience has shown are irrelevant to its needs. Through psychological testing, the researchers showed that creative individuals are much more likely to have low levels of latent inhibition. "This means that creative individuals remain in contact with the extra information constantly streaming in from the environment," says co-author and U of T psychology professor Jordan Peterson. "The normal person classifies an object, and then forgets about it, even though that object is much more complex and interesting than he or she thinks. The creative person, by contrast, is always open to new possibilities." Previously, scientists have associated failure to screen out stimuli with psychosis. However, Peterson and his co-researchers - lead author and psychology lecturer Shelley Carson of Harvard University's Faculty of Arts and Sciences and Harvard PhD candidate Daniel Higgins - hypothesized that it might also contribute to original thinking, especially when combined with high IQ. They administered tests of latent inhibition to Harvard undergraduates. Those classified as eminent creative achievers - participants under age 21 who reported unusually high scores in a single area of creative achievement - were seven times more likely to have low latent inhibition scores. The authors hypothesize that latent inhibition may be positive when combined with high intelligence and good working memory - the capacity to think about many things at once - but negative otherwise. Peterson states: "If you are open to new information, new ideas, you better be able to intelligently and carefully edit and choose. If you have 50 ideas, only two or three are likely to be good. You have to be able to discriminate or you'll get swamped." "Scientists have wondered for a long time why madness and creativity seem linked," says Carson. "It appears likely that low levels of latent inhibition and exceptional flexibility in thought might predispose to mental illness under some conditions and to creative accomplishment under others." For example, during the early stages of diseases such as schizophrenia, which are often accompanied by feelings of deep insight, mystical knowledge and religious experience, chemical changes take place in which latent inhibition disappears. "We are very excited by the results of these studies," says Peterson. "It appears that we have not only identified one of the biological bases of creativity but have moved towards cracking an age-old mystery: the relationship between genius, madness and the doors of perception." This research was funded by the Stimson Fund and the Clark Fund at Harvard University and by the Connaught Fund at U of T. University of Toronto |
||||||||||||||||||
