1. Fighting for our livelihoods:
Developing good and sustainable job opportunities for economic self-sufficiency
Fighting for our livelihoods: Developing good job opportunities for economic self-sufficiency…
Jonathan Delman, PhD, JD, MPH
NYAPRS Conference, Kerhonkson, NY, 9/13/17

2. Employment and mental illness: the backstory
“They don’t want to work”
“The can’t work”
“They can work when we control the jobs”
“They CAN work competitively… but not sure they can hold jobs for long.”
But who are “They”?
People today receiving mental health services
The universe of people who have received mental health services
“Serious mental illness is used to distinguish mental disorders that cause disability from mental disorders that do not result in disability.”

3. Work is good Emotional Functional Income Basic needs
Independent community living
Emotional- structure, fulfilling
Functional- independence (TAY), responsibility

4. Low work rates for people diagnosed with serious mental illnesses
Labor force participation %
Ill
Disability insurance
Give up looking
Unemployment %
Underemployment
70% of people with SMI who have college degrees making less than $10/hr.
The labor force participation rate is the percentage of the population that is either employed or unemployed (that is, either working or actively seeking work) In the past dozen years, the labor force participation rate for adults of working age (21–65) fell by 3.3%, to 75%2 —meaning that fewer adults are working or actively looking for jobs

5. Do these rates have to be this low?
Yes No
If they can be higher, then by how much?
Can we do something about this?
Should we spend time doing something about it?
Like looking down a ant colony (Tail wagging the dog)
DO WE NEED THIS SLIDE

6. EBPing it: Supported employment
-Competitive employment is the goal Eligibility is based on consumer choice Consumer preferences are important Job search starts soon after consumers express interest in working
-Services are integrated with comprehensive mental health treatment.
-Personalized benefits counseling is important Follow-along supports are continuous Employment specialists systematically develop relationships with employers based upon their client's preferences
Evidence based practice for helping people get part-time, low paying jobs that typically last months*
Whom does it work for?
A great advance from very long term preparation and sheltered work
Minimal impact on the rate of competitive employment among the population served by state mental health authorities
Could it be better if funded more intensively and more widely.
There is relatively little effort on promoting community sustainable jobs and long-term prospects
E.g., careers for young adults
*Not meaning to be sarcastic here. It’s just that people often want to get going on an EBP but they don’t know what the probable outcomes are, just that it “works”.

7. Barriers to sustained work
Personal challenges, such as anxiety & learning disabilities… fears about losing benefits (SSI)
Family pressures
Nature of the position
Match
Clarity
Complexity
Workplace culture and practice [Organizational social capital]
Supervision
Other workers
Stigma, discrimination
Wellness, promoting psychological capital
Health and health care access
External employment supports
Lack of work experience
Education disruptions
Recent criminal justice involvement
Single parent with young children
Service transitions
“Aging out” process
Adult system not meeting developmental needs nor prepared to do

8. Are we aiming too low?
Are aiming in the wrong direction?

9. aiming too low: What is the goal… or intended outcome?
Working
Competitive working
“Sustainable jobs”
Decent paying
Full time
Benefits
Working and developing
Internships
Entrepreneurship
Self-employment
Careers
Education

10. Aiming in the right direction: Capital theory, A more holistic perspective
Psychological
Workplace Social
Cultural
Human
Personal Social
Human
Cultural
Psychological
Resilience
Persistence
Confidence
Social- personal
Social- workplace
Supervision
Other staff
Delman, J., & Klodnick, V. V. (2016). Factors Supporting the Employment of Young Adult Peer Providers: Perspectives of Peers and Supervisors. Community mental health journal, 1-12.
Yes- position match

11. Social capital
Collective value of one’s social network connections and resources that generate instrumental, informational, and emotional support
Personal social capital includes ties with “natural supports” and “formal supports”
Dis/encouragement,
Advice
Professional connections
Organizational-social capital: Social relations within the organization-
Staff
Employment practices that stabilize employee relationships and clarify roles and policies, such as reasonable pay and clear job descriptions.
Significant predictor of job satisfaction and productivity
and its success
(e.g., close family, signiicant others, and friends) (e.g., social service agencies and providers).
Positive organizational social capital is most critical for people just starting a job, when job conditions feel most uncertain and anxiety is at its highest

13. Demand side, employer-based strategies
Focus on the interests, attitudes, and capacities of organizations that employ people with SMI
Strategies
Incentives

14. Key best practices categories
Job description
Supervision
Health promoting
Addressing stigma/discrimination
Employees as individuals, flexibility
Disclosure and reasonable accommodations
Human Resources
Transparency

15. Existing best practices laws and programs not fully leveraged
FMLA
Employment Assistance Plans (EAPs) and the like
ADA and state related laws
Short term disability insurance (STDI) and
Return to Work (RTW) strategies
Addressing Stigma-person/person, education, training
Health care- Peer jobs, Recovery coaches
A confidential counseling and referral service for employees with behavioral health problems
EAPs are available in various forms at over 40% of mid- to large-sized employers nationally, though employee eligibility criteria vary significantly
Improves presentism and retention rates for people with SMI when the EAP assists them to access evidence-based services shortly after “onset”.
EAP should access/coordinate services network to support employees with SMI
CBT
Peer support
Occupational therapy
Are employees aware of this resource?
Will they use this resource
STDI pays a portion of the salary of a worker who becomes disabled.
Allows the employee to fully focus on his/her recovery and retain the position for the long-term.
Approximately one-third of US private industry employees have access to (STDI)
Concerns about mis/over-use
RTW services
Evidence supported and focused care (e.g., cognitive behavioral therapy, collaborative care)
Can significantly reduce work days missed for people with SMI and be cost-effective regardless of whether or not person is on STDI
Employer Resource Networks (ERNs), a lower cost alternative to EAPs, are multi-employer collaborations designed to link and leverage vocational support resources, are emerging nationally (Hollenbeck, 2015). Some ERNs have been developed by groups of businesses that pay a fee to participate, while others are based on government subsidies, such as Massachusetts’ five “Regional Employment Collaboratives.” These collaboratives help organizations to hire and retain people with disabilities (Henry, Laszlo, & Nicholson, 2015).
orientation

16. How are these programs underutilized in terms of people with SMHC

17. ADA- Discrimination Hiring
All aspects of employment, including social events
Includes hostile workplace
Reasonable Accommodations
Hostile workplace
Addressing stigma and discrimination
Contact
Education

18. Accommodations
Reasonable Accommodations: Modifications or adjustments to ordinary business operations toward supporting a qualified employee with a disability perform essential job functions.
Mental Disability
Impairment that substantially limits one or more major life activities of an individual.
assessed without regard to mitigating measures, including medications
A record of such an impairment.
Being regarded as having such an impairment
Common accommodations for people with
psychiatric disabilities include:
• Flexible scheduling in order to attend
counseling or support meetings
• Enhanced job training and coaching
• Training and coaching for co-workers on
diversity and stigma
• More intensive individualized supervision
• Provide praise and positive reinforcement
• Divide large assignments into smaller tasks
and steps
• Reduce distractions in the workplace
ļļ Moving workplace to quieter area
ļļ Provide space enclosures or a private
office
• Unpaid leave

19. Key aspects of RAs When to take action: RA Threshold Standards
Request or other notice of needing help
No particular communication method required of employee
“Other obvious”
RA Threshold Standards
Reasonableness: Is the suggested accommodation reasonable?
Undue Hardship: Will the suggested accommodation put undue hardship on the organization (productivity, quality, impact on other staff)?
Interactive process

21. Accommodations are PREPARATION and PROCESS!
Interactive dialogue between YA TPM, supervisor, & 3rd party
One size does not fit all
Generate multiple solutions
Agreement is established & written down
Questions to Foster Discussion:
What is the likelihood that the accommodation(s) will be effective? How will we know they are effective?
How long will the accommodation(s) last? When will the impact be reviewed?
What will the short- & long-term impact of the accommodation(s) be?
What accommodation(s) are less burdensome & likely to be effective?
What has worked here in the past for ?
What has worked in the past for this employee?
Why is a accommodation being requested? Or suggested?
Undue hardship?
*Working Well software
The employer should acknowledge receipt of an employee’s RA request immediately. The supervisor should meet with the employee as soon as possible, or if not available, delegate the task;
The initial discussion should ALWAYS begin with the employee’s job tasks and functions. Do not start by discussing illness, etc.;
Not always fully addressed in a single session.
The employer should not condition the granting of an RA on the employee’s promise of improved performance,
The employer must engage in a “flexible give-and-take,” including:
Being active in seeking information as needed from the employee or designees (e.g., doctors);
If rejecting an RA proposal, communicate the specific reasons to the employee, which allows the employee to make a reasonable counter-proposal. Pg

22. Infrastructure for employing people with SMI
Top management to endorse and actively participate in the development of a corporate culture that supports the employment of people with SMI
Communications, e.g., Champions HR
Training, orientation
Toolkits that organize instructional materials for businesses to support employees
Prominent disability/inclusion offices
(Rudstam, Hittleman, Pi, & Gower, 2013).

23. Technical Assistance for employing people with disabilities
DOL, Office of Disability Employment Policy (ODEP)
WOIA, Implementation, Program guides
Work-based learning opportunities- Apprenticeships
One-stops
JAN (Job Accommodation Network)
ADA centers
Source America- Pathways to Careers
SAMHSA/NIDILRR TA centers- Transitions RTC, BUCPR
Toolkits (e.g., yemployingyoungadultpeerproviders_a_toolkit.pdf)
Technical Assistance Collaborative- JD
The US Workforce Innovation and Opportunity Act (WIOA), effective July 1, 2015, requires state-run Vocational Rehabilitation agencies to work with employers to assess their labor needs and coordinate the development of work-based learning opportunities, such as apprenticeships (Stapleton et al., 2015; U.S. DOL, 2014). WIOA is also providing $400 million in pilot funding for studying innovative workforce retention strategies, including best practices described above
Identifies each intern’s skills and interests using an in-depth “discovery” process, supporting the selection of paid internships or customized self-employment
Source America
Exposes interns to a wide range of jobs and work settings through 8-12 week paid internships, providing experiential learning opportunities to participants
Creates a resource for employers to provide any necessary ongoing employment supports through reimbursement of the employer tax
Incentivizes employers to provide integrated community employment
Promotes informed employment decisions made by participants

24. Incentives (beyond the pure business case)
Tax Credits
Apprenticeships
ADA and state anti-discrimination laws
Regulatory provisions released in 2013 require federal contractors to set a seven percent workforce utilization goal for the employment of individuals with disabilities, though direct incentives have yet to be developed
encourages employers to set strategic goals, including the development of tools to track the number of employees with disabilities.
Talent maximization
The US Workforce Innovation and Opportunity Act (WIOA), effective July 1, 2015, requires state-run Vocational Rehabilitation agencies to work with employers to assess their labor needs and coordinate the development of work-based learning opportunities, such as apprenticeships (Stapleton et al., 2015; U.S. DOL, 2014). WIOA is also providing $400 million in pilot funding for studying innovative workforce retention strategies, including best practices described above (Stapleton et al., 2015).
Work Opportunity Tax Credit
Disabled Access Credit:
Support for Modifications and Accommodation
Architectural and Transportation Barrier Financial Deduction
Veterans with Disabilities
States:
See generally IRS-
Small businesses-
Financial tax credits
To motivate employers, several commentators have recommended the creation of tax credits for hiring and supporting people with significant disabilities (Hollenbeck, 2015). (Tax credits have proven very effective in shaping housing policy for people with disabilities.) One suggestion has been for tax credits to cover the cost of accommodations that would otherwise impose an “undue hardship” on business operations (Hollenbeck, 2015). In addition, the U.S. AbilityOne Commission, an independent federal agency, is working with SourceAmerica’s Pathways to Careers model to pilot the Employer Payroll Tax Incentive. In this model, a company that employs a person who is receiving or likely to receive SSDI is entitled to a credit against its payroll tax (Bardos, Burak, & Ben-Shalom, 2015). Emerging research indicates that employer tax credits can enhance employment among people with mental impairments (Heaton, 2012).

25. Emerging players for employing people with SMHC
Employers of all sizes and types HR
Disability diversity department
State Disability Rehabilitation offices

26. References
Bond, G. R., & Drake, R. E. (2014). Making the case for IPS supported employment. Administration and Policy in Mental Health and Mental Health Services Research, 41(1),
Corbière, M., Villotti, P., Lecomte, T., Bond, G. R., Lesage, A., & Goldner, E. M. (2014). Work accommodations and natural supports for maintaining employment. Psychiatric Rehabilitation Journal, 37(2), 90.
J. Delman, L. Kovich, S. Burke & K. Martone (2017). The Promise of Demand-side Employer-based Strategies to Increase Employment Rates for People with Serious Mental Illness, Psychiatric Rehabilitation Journal, 40(2), 179.
J. Delman & V. Klodnick (2017). Factors Supporting the Success of Young Adults as Peer Support Workers, Community Mental Health Journal
J. Delman, & V. Klodnick (2017). Effectively employing young adult peer specialists: A toolkit. Worcester, MA: University of Massachusetts Medical School
Dewa, C. S., & Hoch, J. S. (2014). Estimating the net benefit of a specialized return-to-work program for workers on short-term disability related to a mental disorder: An example exploring investment in collaborative care. Journal of Occupational and Environmental Medicine, 56(6),
Lutterman, T. (2013) Uniform Reporting System Results and National Outcome Measures (NOMs) Trends. Retrieved from
O'Day, B., Blyler, C., Fischer, B., Gill, C., Honeycutt, T., Kleinman, R., ... & Wishon-Siegwarth, A. (2014). Improving Employment Outcomes for People with Psychiatric Disorders and Other Disabilities (No. b4fe9ac23df949f09c8dab4a c). Mathematica Policy Research. Retrieved from
Richmond, M. K., Pampel, F. C., Wood, R. C., & Nunes, A. P. (2016). Impact of employee assistance services on depression, anxiety, and risky alcohol use: a quasi-experimental study. Journal of Occupational and Environmental Medicine, 58(7),
Schultz, I. Z., Milner, R. A., Hanson, D. B., & Winter, A. (2011). Employer attitudes towards accommodations in mental health disability. In I. Z. Schultz & E. S. Rogers (Eds.), Work Accommodation and Retention in Mental Health (pp ): Springer New York.