This Web site is a component of the SAMHSA Health Information Network

Enter Keywords Choose Website This Site Mental Health at HHS All Mental Health

Online Publications Order Publications National Library of Medicine National Academies Press Publications Homepage

printer friendly page e-mail this page bookmark this page shopping cart  current or new account

This Web site is a component of the SAMHSA Health Information Network.

Work as a Priority: A Resource for Employing People who have Serious Mental Illnesses and are Homeless

The Impact of Homelessness on People with Serious Mental Illnesses who Are Seeking Employment^[1]

Addressing homelessness requires more than securing housing and access to treatment. Employment often becomes a priority for individuals once they are housed. Yet, many housing and other service programs are not equipped to address the need for job training and assistance. Moreover, vocational approaches developed for individuals in the mental health service system often are insufficient to address the specific needs of people who are both homeless and have serious mental illnesses.

The same factors that place people with mental illnesses at increased risk for homelessness are challenges to employment as well.^[2] The lack of safe, affordable housing for individuals with mental illnesses, income levels that are below the Federal poverty level, and fragmented and under-funded service systems that often do not provide the full array of needed community supports, all make successful employment more difficult. In addition, despite statutes protecting the rights of people with disabilities, the effects of stigma and discrimination make it difficult for people with mental illnesses to find housing and jobs, maintain social networks, and gain acceptance in their communities. People with serious mental illnesses who become homeless also are less likely to have contact with family members and, therefore, lack this essential resource for support. Finally, problems related to untreated mental symptoms and/or drug and alcohol abuse make it difficult to maintain stable housing and employment.

Stand-alone services that fail to take these factors into account will not be able to prevent homelessness and break the cycle of unemployment for people who have serious mental illnesses. This chapter addresses personal, program, and system-level challenges to employment for people who are homeless and also have serious mental illnesses.

Personal-Level Challenges

People who are homeless and have serious mental illnesses often face major obstacles to employment. Table 4.1 provides an overview of some of the factors related to homelessness and mental illness that affect employment and potential service strategies for addressing these issues.

These and other barriers to employment in many cases can be addressed through the key program elements identified in Chapter 5, as well as through some of the strategies noted here.

It also is important to remember that in addition to barriers, people with serious mental illnesses, especially those who have been homeless, have significant strengths on which providers and employers can build (see Figure 2.1 in Chapter Two). Individuals who have negotiated life on the streets and the mental health system have resiliency, strength, patience, courage, and humility. They can tolerate anxiety, negotiate systems, and adapt to adverse conditions. Some of their skills can transfer directly to the workplace, while others will help them handle the significant changes inherent in worker role recovery.

Table 4.1 Addressing Personal Challenges to Employment

Challenge	Impact Upon Work	Service Strategy
Lack of permanent address and telephone number, lack of bathing and laundry facilities	Potential employers or employment specialists cannot contact the applicant. Applicant prefers not to leave shelter phone number with the employer. Personal hygiene more difficult.	Establish community voice mailboxes. Establish times when applicant can pick up messages or make calls from the program site. Offer showers and laundry services in shelters or local drop-in programs.
Lack of personal documentation	Without identification, social security number, or birth certificate, employers cannot hire.	Case management and advocacy services to acquire the personal documentation needed.
Poor self-esteem, confidence	Reluctance or fear of trying employment.	Vocational counseling, providing work at the shelter or residence with job coaching services that endorse successes, no matter how small.
Undeveloped vocational goals	"Impulse shopping for jobs," unclear knowledge of personal skills relevant to available jobs.	Use involvement in part-time, transitional, or volunteer work to develop/reinforce goals.
Skills mismatch	Skills needed for survival on the streets not necessarily those needed for work.	Skills identification and sorting to assess skills needed for success at a particular job.
Mobility	The "hook," or possibility of employment is not discussed prior to the individual’s departure from the shelter. Once employed, the person breaks contact with the employment specialist.	Introduce the possibility of work at the earliest possible contact. Respond to consumers’ expressed desire to work with rapid placement and follow-along. Arrange times and places to meet away from the employment office.
Functional illiteracy and educational deficits	Individual cannot meet basic hiring requirements.	Include both formal (GED, classroom) and informal (on-the-job), educational (reading, math, etc.) opportunities as part of the employment service package.
Functional disabilities caused by psychiatric symptoms or other physical health conditions	Individual cannot meet the physical or cognitive demands of work or manage work-related inter-personal relationships, including those with supervisor.	Ensure access to integrated treatment and rehabilitation that includes medications, mental health counseling and support services, and case management. Cognitive remediation services and physical therapy may also be needed.
Alcohol or drug dependency	Alcohol/drug use violates drug-free workplace rules, increases absences from work, impairs physical and cognitive functioning, and increases the likelihood of criminal charges, errors or injury on the job. Provides just cause for termination from employment.	Ensure access to alcohol/drug treatment, recovery/motivation support groups and peer and family support networks. Include case management support as part of an integrated planning strategy that addresses an individual’s needs at various stages of recovery.
Criminal justice system involvement	Criminal record can exclude eligibility for some jobs and questions regarding past criminal involvement in the hiring process are not precluded under the ADA.	Vocational case management that builds motivation for change, addresses worker role recovery, and focuses on acquiring or retaining work to rebuild an acceptable work history. Enrollment in job training or educational programs that provide credentials which employers need and indicate the person’s motivation to succeed.
Fear of losing entitlements	Decision not to work, or to limit hours worked per week, or reluctance to accept wage increases for fear of losing entitlements.	Work incentives benefits management counseling on an ongoing basis. Utilize/advocate for options that ensure retention of health care benefits.

To help people at risk for homelessness overcome barriers, recognize their strengths, and become successfully employed, employment services must be offered as part of a larger set of services that address the housing and support needs of individuals with serious mental illnesses. This "three-legged stool" approach suggests that agencies focus on three critical elements to maximize the well-being of consumers and reduce their risk of recurrent homelessness:^[3]

• Housing that is safe and affordable, consistent with individual preferences, and with support services as needed;

• Coordinated and integrated mental health/substance abuse treatment and other support services that are based on consumer needs and preferences, and are recovery and outcome-focused; and

• Growth-oriented jobs that are consistent with consumer goals, growth-oriented, and provided in integrated community settings, with other support services, including ongoing job support, as needed.

Substance abuse deserves special mention because it is a common barrier to employment for people regardless of whether or not they also have serious mental illnesses. It can have a negative impact on job performance, timeliness, and attendance. The stigma of co-occurring mental and substance abuse disorders also is a powerful barrier to employment. It is present not only in the way society views people with co-occurring disorders, but also in the negative views an individual may have about his or her place in the workforce and as a member of society.^[4]

Employment programs must be designed with recognition and consideration that ongoing treatment for both mental and substance use disorders is an essential component of any program serving individuals with mental illnesses who are, or have been, homeless. In addition to ensuring ongoing treatment and support for substance abuse, employment programs should incorporate early assessment so behaviors associated with substance abuse that create obstacles to sustained employment can be addressed. Because employment may contribute to sobriety for some individuals, sobriety should not be a necessary prerequisite to receive employment services.

Program and Services Provider-Level Challenges

Consumers may encounter a number of service provider level barriers to employment. Table 4.2 highlights some of these program-level challenges. When creating employment programs, providers should begin by taking an inventory to determine their own readiness and capacity to make employment an organizational priority. Agencies may begin by assessing the staff’s ability to challenge traditional concepts of work readiness for its clientele, and identifying and acquiring the resources and technical assistance to help them firmly establish and sustain vocational programs. This may require a fundamental shift in agency priorities.

Agencies also must develop clear and reasonable expectations for both staff and clients about the services offered and the people they are able to help. If an agency cannot "keep the promise" it makes to its clients, both staff and client morale will suffer. Individuals with serious mental illnesses, especially those who also have been homeless, have suffered numerous setbacks and losses. An agency must ensure a good fit between the services it offers, and the clients it accepts, if participants are going to experience the success that is so critical to their recovery.

Table 4.2 Addressing Program-Level Challenges

Challenge	Impact Upon Work	Strategy
Lack of knowledge and experience	Unclear goals, expectations, funding sources, strategies to use to meet the employment needs of their constituency.	Build awareness through training, visits to other programs, program development consultations.
Staff "paradigm paralysis"	Generally held belief among staff that consumers are too disabled to work, work is too stressful, and lack of prior success impedes future success.	Develop new assessment tools that provide a wider measure of inherent skills and competencies, incorporate consumers who achieved work success as trainers.
Stringent readiness prerequisites	Assessments screen out rather than include, requirements that people are abstinent or symptom-free conflict with consumers’ wish to work.	"Meet the person where they are" with jobs that they can do safely and wish to do, with case management support. Replace preoccupation with the disability with a new purpose and build motivation for treatment and advanced employment.
Failure to acknowledge cultural and ethnic needs	Employment services conflict with the consumers’ cultural orientation.	Include culturally competent, multi-lingual staff (including consumer staff) on the team. Familiarize families with services, provide staff cultural sensitivity training, review and adapt program outcomes to meet individual needs.
Milestone disparity	Success (and funding) is determined by achieving outcomes that fail to endorse small steps and successes.	Adopt milestone-based outcome system that included flexibility, rapid re-placement, and short-term goal attainment.
Compartmentalization	Employment seen as the responsibility of the vocational staff only.	Adopt a "jobs are everybody’s business" approach that includes roles for housing staff, facility support staff, treatment staff, etc., to contribute to the employment process.
Funding inadequacy or fragmentation	Funding sources serve "one slice" of the population with different requirements, funding is short-term, out of step with consumer need.	Cast a "wide funding net", utilizing HUD, MH, VR, Substance Abuse, earned business revenue, DOL, and private sources with strategic planning process that covers all of the needs.
Lack of coordination between employment services, case management, and treatment services	Clash of priorities viewed from different staff perspectives, broken links between work and non-work issues and services.	Adopt an integrated team approach to coordinate the full range of work and non-work services to meet consumers’ comprehensive needs.
"Keeping the promise"	Lack of success for clients promised more than staff can deliver affects both client and staff morale.	Specify clearly what the program can and can’t provide; be realistic and deliver what you promise to those you accept in the program.

The Corporation for Supportive Housing was established in 1991 to support the individual efforts of local nonprofit pioneers developing service-supported housing for those most in need: people coping with homelessness and extreme poverty, as well as chronic health conditions such as mental illness, addiction, or HIV/AIDS. They have identified three strategies to help develop effective employment programs: (1) establish employment goals as integral to the agency’s mission; (2) make significant internal changes; and (3) integrate those changes into the existing system of agency services.^[5] To make work a priority, agencies can:

• Build collaborations. Housing, employment, treatment, and support service providers need to develop linkages with one another. Mental health and homeless services providers can work as members of neighborhood-based initiatives to identify people in their communities who need jobs and housing, and to find ways to increase their access to those services. Working with Business Improvement Districts and police departments may be another way to link agency-sponsored jobs with outreach and jail diversion programs. Another way providers and mental health authorities can promote and develop comprehensive, wrap-around services that link work with economic security and health insurance for their constituents, is to encourage collaborations among state vocational rehabilitation, Medicaid authorities, and the Social Security Administration.

• Avoid over-reliance on formal settings and approaches. People who have been homeless often are resistant and distrustful of office-based services. Providing employment services in more informal settings can be a critical program modification. For example, meeting at a restaurant or a park instead of at the office to discuss work options, is just one of the many ways staff can help diminish the consumer’s fear and increase trust.

• Utilize non-traditional approaches. When is the possibility of work an option? Where should employment services be delivered? What staff is responsible for employment programs? Challenging traditional assumptions in each of these areas can result in the creativity and flexibility needed to adopt effective employment strategies. For some, it may mean that people are engaged in some form of work—even for an hour or two—shortly after street engagement. For others, it may mean that housing staff are trained in employment assessment and supervision of job crews. Committing to work as an agency priority means jobs are the business of everyone.

• Think creatively about funding. Agencies sometimes need to blend funds from multiple sources to support employment programs. State and local mental health and alcohol/substance abuse agencies often include employment as one of their priority funding areas. HUD Supportive Housing funds, as approved and submitted through the local continuum of care process, may be another source for employment services funding. Investment by businesses and consortiums of businesses, including Business Improvement Districts, can be matched with other dollars to support employment services, specifically work crews and small businesses. State VR funds may help pay for situational assessments, on-the-job training, job coaches, and, in many cases, assist those interested in self-employment. HUD Community Development Block Grants (CDBG), usually administered through municipalities and often used for economic and business development, can be another funding source for small business start-ups. Public housing authorities with access to HUD funds for housing development also can seek service dollars to increase self-sufficiency among tenants. Private foundations that support self-sufficiency for people with disabilities can be identified using online or published foundation directories. Foundations may be a good source of support for vehicles, equipment, and other program costs.

• Hire consumers in staff positions. Consumer perspectives are invaluable in developing employment services. As staff members with responsibility for developing and/or evaluating programs, they can help determine the relevance of proposed services. In addition, they can articulate the benefits of employment, how they addressed their own feelings of learned helplessness and disillusionment, and what staff supports were important to them.

Addressing Challenges In Service Systems

Individuals who are homeless and have mental illnesses face numerous service system barriers to employment; they often receive mixed or conflicting messages. For example, when seeking public assistance, they must portray themselves as needy and unable to live without assistance. Yet, when applying for work, they must portray themselves as motivated, skillful, and self-reliant. Role ambiguity is just one system-related barrier that consumers face when seeking employment. Other common service system barriers to employment and suggested ways to address them are found in Table 4.3.

Table 4.3 Addressing Service System Challenges

Challenge	Impact Upon Work	Strategy
Services fragmentation	Multiple funding sources, priorities, roles, reporting requirements, and regulations increase ambiguity and create overlaps and gaps in employment services for consumers.	Utilize HUD Continuum of Care process to integrate work in the community for homeless people. Advocate for agreements between State VR, Mental Health, and Substance Abuse agencies for blended funding.
Welfare-to-Work changes fail to meet the needs of people with persistent, multiple barriers including homelessness, mental illness, and substance abuse	Inability to meet stringent work requirements for those without disability exemptions results in sanctions/loss of benefits. Emerging Ticket to Work plans reward providers who move customers into employment and off benefits. People with chronic recurrent needs may not be well served.	Homeless services agencies should advocate for representation on Workforce Investment Boards and solicit contracts for employment services for their constituencies. Develop vendorship with State VR, contracts with Departments of Social Services and Labor for hard-to-serve individuals.
Stigma	Results in fear and misconceptions regarding the nature of mental illness. Leads to wrong assumptions regarding their capabilities to perform work, limits job opportunities.	Develop Business Advisory Councils whose members provide written endorsements of the employment program, and advocacy and public information programs. Familiarize staff and community members with ADA provisions. Develop educational programs for businesses on the benefits of hiring underutilized workers.
Lack of provider agency coordination and collaboration.	Shelters, housing providers, crisis services, and employment service providers have differing views regarding employment, resulting in fragmented services and mixed messages to the consumer.	Engage shelters, housing providers, and employment services providers in a strategies planning process that offers consumers work with agencies that receive funding and technical assistance support.

Chapter Summary

People with serious mental illnesses who also are homeless face numerous challenges to achieving employment success, including the personal barriers resulting from the consequences of mental illness and/or co-occurring substance use disorders, and recurrent homelessness. Added to these barriers are program structures that may not address their needs, service system fragmentation, and societal factors such as stigma and discrimination. Breaking these barriers requires recognition of the various and often interconnected individual, organizational, and environmental factors that may impede employment.

Chapter 4 Notes

^[1] This Chapter contains material adapted from: White, A., and Wagner, S. "Effective strategies: Employment for homeless people with serious mental illness" and Shaheen, G., Bianco, C., Falco, A. "Employing people with mental illness who are homeless: Surveying the field." Papers prepared for the CMHS Sponsored Employment and Vocational Rehabilitation for Homeless People with Serious Mental Illnesses Workshop, Washington, DC, September 1999; and Bianco, C., and Shaheen, G. Employing Homeless People with Mental Illness: Principles, Practices and Possibilities. Unpublished draft prepared for the CMHS PATH Program. Albany, NY: Advocates for Human Potential, July 1999.

^[2] Lezak, A.D., and Edgar, E. Preventing Homelessness Among People with Serious Mental Illness: A Guide for States. Rockville, MD: Center for Mental Health Services, 1998.

^[3] Whiting, B. Employing the Formerly Homeless: Adding Employment to the Mix of Housing and Services. New York, NY: Corporation for Supportive Housing, 1994.

^[4] Ludet, A.B., Magura, S., Vogel, H., and Knight, E. Recovery challenges among dually diagnosed individuals. Journal of Substance Abuse Treatment, 18: 321-329, 2000.

^[5] Corporation for Supportive Housing. Work in Progress: An Interim Report of the Next Step: Jobs Initiative. New York, NY: Corporation for Supportive Housing, 1997.

^[6] Rog, D., Holupka, C.S., Brito, M.C., et al. Next Steps: Jobs Second Evaluation/Documentation Report. Washington, DC: Vanderbilt Institute for Public Policy Studies, Center for Mental Health Policy, 1998.

Table of Contents | Previous | Next