Employment Programs Help Patients With Mental Illnesses Succeed

"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."