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

Working with the State Vocational Rehabilitation Agency^[1]

The Federal/state vocational rehabilitation (VR) system has been in existence since 1920. The Federal Rehabilitation Act mandates funding for vocational and other state-administered rehabilitation. The VR program originally was designed to serve people with physical disabilities until the Federal statute was amended in 1943, allowing services for people with mental illnesses and developmental disabilities. However, the structure and guidelines of the current VR system remain better suited to the needs of people with stable, non-declining physical disabilities than to those with relapsing disabilities such as long-term mental illness.^[2],[3]

While people with mental illnesses present challenges that state VR agencies sometimes are unprepared to address, the current VR system is even less suited to meet the needs of people with mental illnesses who also are homeless. This chapter provides an overview of VR services available to help people with disabilities obtain employment, discusses its effectiveness in meeting the employment needs of people with mental illnesses, and suggests a number of considerations in the creation of effective collaborations between mental health and VR systems.

Purpose and Scope of VR Services

The Federal Rehabilitation Act defines a disability as any mental or physical condition that substantially interferes with a major life function. Areas of functioning identified in the statute include mobility, communication, the ability to set and pursue goals, work endurance, the ability to acquire and express work skills, and the ability to form and support interpersonal relationships.

At the Federal level, the VR program is administered by the Rehabilitation Services Administration (RSA), which awards annual matching grants to each state to operate its own VR program. In each state and territory a designated state unit administers the VR program, with considerable latitude in how these services are operated. State-employed vocational rehabilitation counselors determine eligibility for VR services based on Federal guidelines, provide vocational and supportive counseling and job placement services, purchase or locate alternative sources of funding for services to help people achieve vocational goals, monitor and coordinate the delivery of these services, and monitor individuals’ progress. Among the services funded by state VR agencies are:

• Situational, on-the-job assessments of work performance;
• Personal adjustment training to assess and build the "soft skills" (e.g. co-worker relationships) needed for job success;
• Work adjustment training to build stamina, attendance, etc.;
• On-the-job training that pays the employee’s salary for a limited time after job placement; and

• Time-limited job coaching to provide employee/employer support on and off-site.

In addition, supported employment, allocated to states on a formula grant basis, has been incorporated into the VR program as a supplement to services provided under the standard VR program. Supported employment closure is achieved when the person with the disability maintains employment for 90 days or more under Federal criteria. The key benchmark by which the Federal government judges the success of the state VR programs is the number of successful closures generated each year.

Since all categories of people with severe mentally or physically disabling conditions potentially are eligible for VR services, state rehabilitation counselor caseloads often are large and may include individuals with a wide range of disabilities. These include individuals with traumatic brain injuries, spinal cord injuries, HIV, histories of alcohol and substance abuse, neurological disorders, musculoskeletal disorders, cancer, heart disease, mental illnesses, developmental disabilities, those who are deaf and/or blind, among other disabling conditions. In addition, state rehabilitation counselors are expected to be conversant with a daunting array of technologies and with the professions that employ them.

According to Albrecht, the short-term goals of the national rehabilitation program are to "enable people with impairments to function at their highest possible physical, social, and psychological level."^[4] The longer-term goals have to do with society’s desire to increase an individual’s ability to work or otherwise function independently, thereby decreasing public expenditures. Thus, rehabilitation counselors often face competing priorities in terms of furthering the social mission of the program within the context of the agency’s competing political concerns and fiscal limitations.^[5]

Effectiveness of the VR System for People with Mental Illnesses

VR often has been criticized as ill-prepared to cope with employment support strategies to help people with mental illnesses obtain and maintain jobs. Some suggest that the VR system’s training programs have done people with mental illness a disservice resulting in pessimistic notions of mental illness.^[6] Consumers and their families increasingly have become vocal in their dissatisfaction and disillusionment with the VR system, suggesting that it keeps people with disabilities trapped in lives of poverty.^[7] Much of this criticism was summarized in a survey issued by the National Alliance for the Mentally Ill.^[8] Based on reviews of earlier studies examining the effectiveness of the national VR program and current state VR plans, the NAMI report concluded:

• The time-limited nature of VR services, predicated upon the perception that, once employed, VR customers no longer needed vocational services, was inconsistent with the realities of the fluctuating nature of severe mental illness;
• The emphasis on case closures provides incentive for state VR counselors to work with the easiest-to-place individuals as opposed to individuals with more complicated, long-term needs;
• oo many resources were devoted to the eligibility determination process, frequently using assessment methodologies such as paper-and-pencil tests that may not consider the cognitive and/or literacy skills deficits of some people with mental illnesses;
• State VR counselors and administrators lacked knowledge of the needs of people with severe mental illnesses, and too few opportunities existed to acquire this knowledge;
• Despite evidence that specialization produced better outcomes, most states had not designated VR counselors as mental health specialists;
• Little evidence was found of effective coordination between state VR and state mental health agencies; and
• The time-limited nature of VR funding served as disincentives for community mental health providers to contract with those agencies.

In response, the Rehabilitation Act Amendments of 1998 included a number of new provisions in accordance with advocates’ recommendations:^[9]

• Purchase of rehabilitation technology to assist people in compensating for physical disabilities that would otherwise preclude them from performing job tasks;
• Requiring trial work periods to determine eligibility before an individual is judged to be too severely disabled to benefit from VR services;
• Strengthening education and training for VR staff;
• Increasing the role of individuals in developing their own rehabilitation plans;
• Requiring agencies to report on the employment status of individuals six- and 12-months post-case closure; and
• Self-employment business planning and start-up funds, although this is not widely available.

In the past, the VR system has been slow to adapt and change. Factors inhibiting change include limited knowledge of mental health issues and effective employment approaches for people with mental illnesses, the inability to provide long-term supports, and natural resistance to change.^[10] While the NAMI report does cite major improvements in the VR system that are better meeting the needs of people with mental illnesses, challenges still remain.

The results of a 32-state survey of VR programs conducted in 2000 revealed that a number of these programs have taken steps to address some of these challenges.^[11] Sixteen states reported they had mental health specialist VR counselors. Six of those states indicated that they had a large number of these specialists, and three that they had some level of co-location of state VR staff in mental health agency settings. Fifteen of the states had agency-sponsored training on mental health rehabilitation available to their VR staff. Nine states reported that the training was in-depth. In four of the states, VR counselors underwent this training with their mental health counterparts.

Sixteen of the states in the survey had blended funding arrangements with the state mental health agency, with eight of those states describing highly integrated budget arrangements. In two of the states, these arrangements were mandated by statute and, in one state, by court order.

Similarly, 14 of the states reported a joint planning process between the state VR and mental health agencies, described by eight states as highly integrated. Six of the states reported they had made some effort to promote mental health consumer leadership, and five states described a significant effort to promote a recovery philosophy.

Despite remaining concern regarding the effectiveness of VR services for people with serious mental illnesses, intrinsic advantages that can be expanded exist within the VR system. First, and most obvious, VR can be an important source of funding for employment services where other resources are scarce or non-existent. Second, a wide range of potential services exist that can offer flexibility in meeting individual needs, including initial job testing and access to integrated work through situational assessments. In some states, VR will even fund business plans or provide business start-up capital for people with disabilities whose goal is self-employment.

Individual Employment Plans (IEPs) require active involvement of individuals and significant others and allow individuals to choose their vocational goals, the services needed to achieve them, and their preferred service provider. Since VR establishes contracts with private vendors, it can connect individuals with agencies offering specialized services. Linkages with mental health and/or homeless services providers familiar with their clients’ specialized needs, could represent an effective investment of VR resources by increasing the likelihood for employment success. Furthermore, IEPs represent an effective way to ensure that services are appropriate to meeting personal employment goals and can be modified to incorporate new and improved vocational rehabilitation services.

Individualized VR services can be the basis of continuing system improvement.^[12] Private community rehabilitation programs, in competing for VR funds, have a stronger incentive to seek more efficient and effective methods of helping consumers find jobs. VR counselors, impelled by limited budgets, are likely to select providers that offer the greatest chance for successful closures. This may make it difficult for providers of mental health services to access and utilize VR contracts to provide services to people with mental illnesses, given its cyclical nature.

Another VR attribute can be utilized to better address the work-related needs of people with mental illnesses, particularly those who are homeless. As the only government agency whose prime focus is employment for people with disabilities, including people with mental illnesses and histories of homelessness, VR has a singleness of purpose not shared by other Federal and state agencies. VR employment services can cut across disability groups and can be provided to individual agencies serving a diverse clientele with a range of disabilities. Its value cannot be overestimated as a potential partner with other Federal and state agencies (Substance Abuse and Mental Health Services Administration, Housing and Urban Development, Department of Labor, State Mental Health, and Alcoholism and Substance Abuse authorities, etc.) in reducing systems fragmentation and overlap in providing vocational rehabilitation services. For people with mental illness who are homeless and need to negotiate multiple social, mental health, substance abuse, and housing services, VR has the potential to be a common thread for employment supports throughout the individual’s service planning process. However, significant systems integration needs to occur at the Federal, state, and local levels for these benefits to be fully realized.

Best Practices for People with Serious Mental Illnesses who are Homeless

As a group, people with serious mental illnesses who are also homeless present some of the greatest challenges to the VR service system. The VR system can better meet the employment needs of individuals who are, or have been, homeless, by making them a priority group, recognizing their specialized needs, combined with cross-agency/discipline collaboration in the development and delivery of innovative services.

Making People with Serious Mental Illnesses a Priority

The 32-state survey of VR agencies^[13] indicated that people with mental illnesses were a priority population in most of those states, comprising from 18% to more than 70% of caseloads. The value of specialty caseloads is highlighted by the experience of one state that eliminated specialty caseloads in favor of a generalist approach. Within two years of making this change, this state experienced an estimated 20% decrease in the number of new cases and the number of successful outcomes involving people with mental illnesses.

Staff Training

The same survey found that some generalist VR staff were skeptical about working with people with serious mental illnesses, indicating that education and staff training is essential. The availability of training for VR staff on mental illness and psychiatric rehabilitation was found to range from ongoing coursework offered on a statewide basis to no available training at all. When offered, training reportedly was sporadic and, in most cases, did not include a focus on the needs of people who are homeless and who also have serious mental illnesses.

Of those surveyed, California was the exception. The State VR and Mental Health Authority (MHA) provided a total of $1.5 million in interagency support for training and technical assistance, program reviews, research, and Building Employment Service Teams (BEST) Network support. BEST Networks are county-based coordinating bodies that provide support in areas such as training, networking with employers, support services (e.g., housing and transportation), and with special populations (e.g. youth, homeless individuals) to county teams comprised of VR and MHA staff. Some Networks employ a BEST technician—a person with a history of mental illness who provides coordination and support services (e.g., training, event/meeting coordination, research, clerical support) to Network teams.

To enhance the services provided by VR practitioners, the Center for Psychiatric Rehabilitation at Boston University offers a part-time, one-year Certificate Program in Psychiatric Vocational Rehabilitation, funded by a grant from the Federal Rehabilitation Services Administration (RSA). Using training materials that include the "choose-get-keep" approach and other psychiatric rehabilitation technologies, the certificate program is offered as a series of six, two-day institutes. Program topics include partnering competencies; identifying vocational needs; facilitating vocational rehabilitation readiness; personalizing vocational assessment; achieving vocational placements; developing essential skills, supports, and accommodations; and meeting the needs of culturally diverse service recipients.

Federal Collaboration

A good working relationship between state VR and mental health agencies is key. State Mental Heath Authorities (SMHAs) that emphasize vocational services have been successful in finding ways to blend funds to create opportunities for individuals with mental illnesses. For instance, in California, several county mental health agencies and local VR offices have developed cooperative contracts to blend public mental health and vocational rehabilitation funds, resulting in significant positive outcomes.

The effectiveness of partnerships at the Federal, state, and local levels is further demonstrated in Illinois, in which the state VR and mental health agencies entered into regional agreements negotiated by consumers and specialist staff of state and community agencies. The agreements covered the responsibilities of all stakeholders regarding the scope of services, methods of referral, role of consumer leadership, and the process of dispute resolution. The participants to the agreement are surveyed and the agreements revised annually. Through Federal funding by the Social Security Administration, the VR program mental health specialists and some of their counterparts in community mental health agencies received 24 months of training and technical assistance in best practices in psychiatric rehabilitation from two training and research institutes. The grant also funded the development of two Internet sites, one that will feature interactive training software.

In addition, the Illinois State VR program provided 12 months of training in psychiatric rehabilitation philosophy and practices to 25 psychiatric residents of one of the major state medical schools. The VR program specialists are forming teams with these psychiatrists, with consumers, and with staff of the state mental health agency to provide outreach training in psychiatric rehabilitation to community physicians and other community leaders throughout the state. A major emphasis of this training will be the needs of people who are homeless and have serious mental illnesses. These teams will also support initiatives to link people with mental illnesses who are exiting the corrections system to community support and vocational services.

The Illinois VR program currently is working with the state mental health agency and the National Empowerment Center to develop consumer leadership training and consumer staffed outreach teams. Through its four-year co-sponsorship of a consumer advisory committee, the VR program has facilitated the development of a consumer-produced video series on work, recovery philosophy, and consumer rights.

Linking Supportive Housing and Vocational Rehabilitation Systems

Partnerships among various disciplines with differing philosophies can be an effective way to increase employment success for individuals with mental illnesses who also are homeless. In an effort to improve access to VR services and increase employment outcomes for tenants of supportive housing, the Corporation for Supportive Housing and the New York State Office of Vocational and Educational Services for Individuals with Disabilities (VESID) entered into a partnership with several non-profit providers of supportive housing between 1996 and 1999 to implement the Linking Supportive Housing and Vocational Rehabilitation Systems Project.^[14] The Project, funded by the U.S. Department of Education, Rehabilitation Services Administration, sought to improve systems integration and establish collaborative relationships between the VR and supportive housing services sectors. The project increased VR eligibility and employment rates of tenants with mental illnesses who had histories of homelessness.

An important factor in the Project’s success was its inclusion of an intermediary between the supportive housing providers and VESID that facilitated joint training, meetings, and problem solving. Another key element was the use of an on-line VR application system, which resulted in nearly three times the number of tenants being referred to VESID than before, as well as a nearly 50% decrease in length of time between application and eligibility determination.^[15] Other strategies emerging from the project included:

• New referral relationships between VR and supportive housing agencies to coordinate and expedite VR eligibility determinations;
• Expansion of local electronic training resources to include VR-funded programs and resources;
• Development of an electronic job bank enabling supportive housing agencies to access job leads for their tenants within the supportive housing industry; and
• Expanding and upgrading vocational and employment services provided by supportive housing agencies.^[16]

Future Challenges in Building Successful VR/MH Partnerships

Despite evidence of the effective partnerships and strategies that have emerged, a number of changes can be implemented to enhance the ability of people with mental illnesses, particularly those who are homeless, to take full advantage of VR services.

Increased Collaboration

Interagency collaboration at the state level can help overcome systems integration barriers, clarify roles, and plan innovative service delivery approaches:

• Designing and implementing VR/MH systems integration efforts. VR counselors and mental health/homeless services providers need to be familiar with their respective policies and practices before dialogue and collaboration can occur. Use of the "Linking Supportive Housing and Vocational Rehabilitation Systems" project as a template for services integration could be a starting point. Utilizing the state budgets to blend VR/MH funding resources to support both intensive, time-limited supported employment services as well as extended, long-term post-placement supports also can help meet the long-term support needs of the population.

• Establishing VR/MH agreements clarifying agency roles. A number of states have developed interagency memoranda of understanding that underscore compatibility of mission, vision, and values in designing and delivering consumer-responsive supported employment services. They can include: (1) responsibilities of the state agencies involved in supported employment and the agreed upon definitions of terms and models of service delivery; (2) principles and operating guidelines intended to promote access to integrated employment, including supported employment; and (3) quality indicators for supported employment that serve as a guide for self-evaluation, quality assurance, and generally accepted best practices.

• Joint planning to explore non-traditional approaches. Non-traditional approaches may delineate: (1) supportive housing staff to complete some initial VR eligibility paperwork, and electronically transferring the data to reduce the time it takes to determine eligibility; (2) automatic VR eligibility when a consumer has established SSI eligibility due to disability; (3) mechanisms to support self-employment, including funds for business planning, equipment purchase, lease, etc; and (4) eligibility for VR on-the-job training funds or other employer work incentives for those involved with career-level competitive employment. In addition, social enterprises or affirmative businesses might consider becoming VR vendors for training and out-placement into other community competitive jobs.

Staff Training and Incentives

A number of strategies may increase VR staff understanding and desire to meet the special needs of individuals who are homeless and have serious mental illnesses. These include opportunities for training and specialization, and incentives for serving this particular population:

• Facilitating statewide cross-systems training initiatives. Training for VR counselors should include orientation, not only to the functional implications of mental illness, but also to the psychological and physical implications of homelessness. It also should include an appreciation of the effects of co-occurring substance abuse and mental illness, as well as compounding factors affecting employment, including criminal justice system involvement. Since many mental health consumers with histories of homelessness possess a combination of these disadvantages, VR counselors should be aware that traditional employment services may not work, and that new approaches may be necessary. In the emerging workforce development system, VR counselors and administrators who are aware of the needs of people who are mentally ill and also homeless could act on behalf of homeless services agencies seeking contracts from the Workforce Investment Boards, and ensure that consumers’ needs are met through the one-stop system.

• Establishing VR mental health specialists. VR counselors who also are specialists in mental illness and psychiatric rehabilitation can help improve employment outcomes for consumers. This approach has proven to be effective, and when withdrawn, leads to a drop in successful outcomes among people with serious mental illnesses.

• Providing incentives for serving people with serious mental illnesses who are homeless. Acknowledging that these individuals require intensive, ongoing, and often repeated services, counselors who commit to serving this clientele could receive a reduction in their total caseload.

Inclusion of Consumers

Involving consumers as providers helps to ensure that policies and services reflect consumer needs and priorities. Consumers should be included as representatives at the highest levels of VR/mental health agencies, both in key policymaking decisions, and as key policymaking staff. In addition, consumers should be included as VR Staff. Most states utilize special civil service classifications that waive competitive test requirements for applicants with disabilities. Providing training opportunities and earmarking a block of these staff lines for VR offices statewide could encourage consumers to consider careers as VR counselors and aid in changing the system from the inside-out.

Linking VR with Mental Health and Homeless Services

Providing access to VR services at the same places where people who are homeless and have serious mental illnesses receive other services, as well as providing training to staff who provide those services, is also recommended. Examples include:

• Co-locating VR counselors. Co-locating VR counselors with mental health staff at provider agencies can increase service access. VR counselors could visit shelters and drop-in centers, where many homeless people with mental illnesses receive services, to provide information and begin the eligibility determination process;

• Linking outreach teams and VR. Outreach teams can employ a vocational specialist as a member of the multi-disciplinary team to provide direct employment-related services and linkage to other services. By establishing a strong bond between the outreach team vocational specialist and VR counselor who is also a mental health specialist, issues such as rapid access, return eligibility, and better service coordination may be improved; and

• Including shelters and drop-in centers in training. Orientation to VR services should be made available to shelters, outreach staff, and drop-in centers, not only to encourage awareness of VR services, but as a tool to reinforce work as a priority. If shelters can become VR vendors for work readiness assessments, both an early-stage orientation to work and a new funding source for case management staff might be achieved.

Chapter Summary

State Departments of Vocational Rehabilitation can be powerful allies in efforts to ensure that people with mental illnesses who are also homeless obtain and retain integrated employment. While many challenges to systems and services integration exist, effective relationships between mental health and homeless services providers and state VR agencies are occurring throughout the country. These partnerships often are based on efforts to develop understanding of each sector to commit resources to staff training, and to explore new funding mechanisms that acknowledge and support the often long-term needs of people with mental illnesses who are also homeless.

Chapter 6 Notes

^[1] This Chapter contains material adapted from: Oulvey, G. "Reconcilable differences: The Federal/state vocational rehabilitation system’s ability to collaborate in serving people who are homeless and mentally ill." Paper prepared for the CMHS Sponsored Employment and Vocational Rehabilitation for Homeless People with Serious Mental Illnesses Workshop, Washington, DC, September 1999.

^[2] Bond, G.R., Drake, R.E., Mueser, K.T., and Becker, D.R. An update on supported employment for people with severe mental illness. Psychiatric Services 48(3): 335-46, 1997.

^[3] Noble, J. H., Honberg, R.S., Hall, L.L., and Flynn, L.M. A Legacy of Failure: The Inability of the Federal State Vocational Rehabilitation System to Serve People with Severe Mental Illnesses. Washington, DC: National Alliance for the Mentally Ill, 1997.

^[5] Tarvydas, V., and Cottone R.R. A four level model of ethical practice. Journal of Applied Rehabilitation Counseling 22(4): 11-18, 1991.

^[6] Bevilaqua, J.J. The state vocational rehabilitation agency: A case for closure. Journal of Disability Policy Studies 10(1): 90-98, 1999.

^[7] Keller, E. Testimony to U.S. House of Representatives Committee on Ways and Means, Subcommittee on Social Security, on H.R. 3433, the Ticket to Work and Self Sufficiency Act of 1998. Washington, DC, March 17, 1998.

^[8] Noble, et al., op. cit. p. 67.

^[9] Ibid.

^[10] Conley, R.W. Severe mental illness and the continuing evolution of the Federal-state vocational rehabilitation program. Journal of Disability Policy Studies 10(1): 99-126, 1999.

^[12] Conley, op. cit., p. 68.

^[13] Oulvey, G. and Ingraham, K., op. cit., p. 68.

^[14] Rivard, J.C., Akabas, S. H. Evaluation of the "Linking Supportive Housing and Vocational Rehabilitation Systems" Project. New York, NY: Center for Social Policy and Practice in the Workplace, Columbia University School of Social Work, 1999.

^[15] Ibid.

^[16] Rivard and Akabas, op.cit., p. 68.

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