A strong commitment to community inclusion must have at its center an array of programs and practices that help people with psychiatric disabilities to attain and maintain competitive employment: few issues are more critical to having the opportunity to ‘live like everyone else’ as the ability to succeed in holding down a job. Despite the still prevalent conviction among clinicians, family members, rehabilitation professionals and some consumers themselves that people with psychiatric disabilities are either unready, unmotivated or unable to work, there is a growing body of research evidence to the contrary: people with mental illnesses should, would, and could work – if the appropriate policies, programs and practices provided the supports they need to succeed in the competitive labor market.
It is important, of course, to define what we mean by competitive work – jobs that are available to anyone (disabled or not disabled); jobs that offer wages and benefits that are comparable to industry standards; and jobs that provide opportunities for work alongside non-disabled coworkers. This definition excludes some types of jobs: steady work in an agency-based workshop or on an agency run work crew, volunteer work in the community, or long-term jobs in an agency sponsored business all may offer some benefits on the pathway to competitive jobs, but for many should not be considered an appropriate ‘end goal.’ But the definition of competitive work offered above does allow for different patterns of work: some people will do best working full-time, others part-time; some people will occasionally get fired while others settle in to a long-term job for years; some will seek out entry-level jobs, others semi-skilled or skilled positions, others executive or professional roles.
But in each case, there is wide agreement on the benefits of competitive work: a paycheck, a sense of participation in the normal life of the community; the chance to make new friends; an escape from one’s own problems; and the reassurance of routines. Freud said that life is all about love and work, and yet unemployment among people with psychiatric disabilities is regularly reported to be in the staggering 75% – 85% range. We can do better.
Four Generations of Employment Programs and Practices
Part of what we know about what does and doesn’t work in helping people with psychiatric disabilities to succeed in the competitive labor market comes from years of – generations of – work with various models.
- Sheltered Work Programs. The field was dominated for quite a while by ‘sheltered workshops’ – in both hospital and community settings, providing a safe and supportive environment in which people could learn both the specific skills and interpersonal styles required for work: a good deal of research has shown that while such programs can be helpful, the longer people spend in them, the less likely they are to leave these sheltered settings for competitive work in the real world – and the less likely staff are to believe they can succeed anywhere else.
- Community-Based Programs. A variety of programs offering more ‘real world’ work opportunities emerged in the 60s and 70s: Transitional Employment (with short-term job placements in entry-level positions in the community); Enclaves (in which a group of consumers with staff operated a portion of a community business – a stockroom or mailroom, for instance); and Agency-Operated Businesses (in which the agency operated a restaurant or copy center or grounds crew, with consumer staff having the opportunity and responsibility to learn new skills). These programs have been useful for many, but many others have had difficulty making the transition to competitive employment afterward.
- Supported Employment. A third generation of programming – Supported Employment – is considered the field’s ‘best practice’ model: it’s key elements are a rapid movement of individuals into fully competitive jobs in community settings and a commitment to provide the supports consumers need to develop the skills and capacities required by the job while on the job; a strong commitment to helping consumers obtain the types of jobs they prefer rather than the types of jobs available from the agency; a strong commitment to provide long-term supports that can help the consumer both succeed at the first job and potentially move on to better jobs over time; and a recognition of the importance of benefits counseling – so that consumers are aware of and able to use both the work incentive provisions of the Social Security system and the availability of low-cost Medicaid coverage for workers with disabilities to their advantage.
- Next. A new generation of employment programs are probably on the horizon, with the growing recognition that more attention has to be paid to: a) integrating supported employment with supported education programs, so that more consumers can move beyond entry-level jobs; b) helping consumers better prepare for disclosure of their disability to their colleagues and their supervisors in a way that insures reasonable accommodations and minimizes lingering feelings of prejudice; and c) the use of Certified Peer Specialists as vocational supporters.