"Working here gives me the motivation to get up in the morning. It keeps me busy. It makes me feel good about myself. I would become sick if I was at home twelve hours a day. I would become depressed."

- Working the Margins, 1995

The Value of Work
Need for Specialized Services
Need for Policy Direction
Program Policy Framework for Employment Supports
The Key Program Elements
The Planning Process
Planning Partnerships
Performance Measures
Conclusion
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5

Employment is highly valued in our society and can provide people with significant economic, social and psychological benefits. When people are employed, they perceive themselves – and others perceive them – as productive individuals who are making a valuable contribution to society. Conversely, it is widely acknowledged that unemployment is generally associated with negative health outcomes – including diminished mental health and emotional well being.

Employment then is an important determinant for mental and physical health. Yet it remains the case that mental illness can be a tremendous obstacle to an individual’s attempts to find and hold employment. According to studies, the rate of unemployment for people with serious mental illness ranges from 75% - 89%¹.

Negative attitudes toward those with mental illness play a significant role in the high unemployment figures². Studies indicate that employers need assistance to understand how to create supportive environments for persons with mental illness and that others in the work environment hold negative attitudes toward persons with disabilities in general. In order to change this picture there is a need for a multi-faceted approach that includes the business community, the general public, mental health consumers, their families, and those who provide services to people with mental health problems³.

¹Wasylenki, D.A., Goering, P.N., Lancee, W.J., Ballantyne, R. & Farkas, M. (1985). Impact of a case manager program on psychiatric aftercare. The Journal of Nervous Mental Disease, 173, 303-308.
²National Institute on Disability and Rehabilitation Research (1993). Strategies for Employment of People with Mental Illness. Rehabilitation Brief, 15 (10).
³Conference Board of Canada (2000). Diversity Works! Roundtable on Integration of Persons with Disabilities into the Workplace: Summary Report.

Mental illness strikes people in all walks of life, in every economic sector, and at all levels of society. The effects of mental illness on an individual’s life and ability to fulfill job responsibilities depend on several factors, including the severity of the illness, and the quality of supports and services available. Within an employment context, different levels and types of employment support are appropriate depending on the severity and persistence of the mental illness. Some individuals with a mental illness who are employed are able to benefit from a workplace Employee Assistance Program or a return-to-work policy that includes accommodations such as flexible and/or reduced work hours.

There are also provincial and federal programs that provide a range of employment support programs and services for people with disabilities, including those with mental illness. The Ministry of Community and Social Services’ (MCSS) Employment Supports component of the Ontario Disability Support Program (ODSP) was created to remove disability-related barriers to employment for those with disabilities. The program provides people with specific goods and services, but does not provide broader community-based supports.

The federal government provides programs that offer a range of supports and services to people with various disabilities. Some people with mental illness receive Canada Pension Plan (CPP) disability benefits, and may qualify for assistance through the CPP’s Vocational Rehabilitation Program. The program is designed to help people develop and implement a return-to-work plan. Human Resources Development Canada also offers an Opportunities Fund that helps people with disabilities overcome barriers to participating in the labour market.

However, many people with a serious mental illness require employment-related supports and services that are more intensive and long-term than those provided by more generic government programs. (See Appendix 1 - Definition of Serious Mental Illness.) Research indicates that an approach in which employment supports are integrated into the mental health system, as opposed to one involving a parallel employment supports system that is not well linked, is more effective⁴.

⁴Drake, R., Becker, D., Xie, H., Anthony, W. (1995). Barriers in the brokered model of supported employment for persons with psychiatric disabilities. Journal of Vocational Rehabilitation, 5, 141-149.

With the release of Making It Happen, the government set the direction for a three-year plan to reform Ontario’s mental health system. A key component of a reformed mental health system is the provision of and implementation of an employment supports strategy that is comprehensive, provides the specialized supports needed by people with a serious mental illness, and reflects evidence-based best practices. Within this context, it is acknowledged that this framework must also be part of a shared service model approach that partners with the Ministry of Community and Social Services, federal government programs, the business community and the training and education sectors.

Currently, the Ministry of Health and Long-Term Care (MOHLTC) funds more than 40 dedicated employment supports programs and businesses that support people with serious mental illness. These programs are delivered by community mental health agencies, hospitals, provincial psychiatric hospitals and mental health consumers. (See Appendix 2 - Vocational Survey.) These programs have developed over a number of years in the absence of any formal policy direction to guide their creation and ongoing operation.

In order to ensure that the programs funded by the Ministry operate within the overall direction of Making It Happen, the Ministry undertook a policy development process. This process included a literature review of best practices and a survey of Ministry-funded employment supports programs. (See Appendix 3 - Literature Review Summary.) An external advisory committee, the Supports to Employment Policy Advisory Committee (SEPAC) also provided input in order to determine the most appropriate policy direction for employment supports. (See Appendix 4 - SEPAC Terms of Reference and Membership.)

This framework is intended to improve and enhance provincially funded employment services and supports for people with serious mental illness. With the release of this program framework and the integration of its objectives into the planning processes of the regional Mental Health Implementation Task Forces, the Ontario government will ensure that employment supports for people with serious mental illness are :

• More accessible to consumers across the province
• Focused on placing people directly in competitive employment with support and training on the job as required
• Comprehensive and provide a full range of program elements
• Using the best evidence-based practices
• Fully integrated with other mental health rehabilitation services and supports
• Developing strong linkages with local employers
• Utilizing shared service approaches as required with other sectors
• Based on a set of common principles and objectives. (See Appendix 5.)

To achieve a comprehensive system of employment supports, the following elements are essential. While individual agencies, programs and businesses need not provide each element, all elements should be available within each region of the province.

1. Job Development/Creation/Employer Outreach
   The goal of this core element is to increase the overall number of employment opportunities available, and improve consumers’ access to those opportunities. Employment opportunities include paid temporary employment and permanent jobs. Delivering this element may result in the creation of jobs, through the development of a consumer-operated alternative business, an agency-sponsored business or another enterprise. An essential component of this element includes providing outreach, education and support to employers who may be interested in hiring people with mental illness and this may result in an increased number of individuals in competitive employment.

2. Skills Development/Training for Job/Education
   This core element aims to develop the general and/or technical skills that consumers need to succeed in their chosen job search, or to pursue their chosen educational goals. Delivery could involve teaching generic skills, such as getting organized for work or getting along with colleagues. It could also mean teaching specific technical skills, such as operating a cash register or a computer software program.

   This core element can be delivered through volunteering, job coaching in unpaid or paid temporary placements with employers, or through educational programs or apprenticeships.

3. Skills Training on the Job
   This program element involves developing general and/or technical job skills during paid permanent employment. The support can be delivered by a job coach, a supervisor or colleagues at a local business, consumer-operated alternative business or agency-sponsored business.
4. Job Search Skills/Job Placement
   Local agencies and programs may provide one or both components of this core support element. Job Search Skills programs teach people how to prepare resumés, and how to conduct themselves during job interviews. Job Placement programs approach prospective employers, attempt to match consumers to jobs, and help consumers prepare for employment interviews.
5. Employment Planning/Career Counselling
   This element involves assisting people to develop a vocational or employment plan that leads either to further education, or to entry into the labour market. Vocational plans should be developed after a thorough assessment of aptitudes, abilities and interests, and after considering the local employment market.
6. Supported Education
   The goal of supported education is to help consumers develop a vocational goal. This may involve finding employment or pursuing further education. Delivering the support can be accomplished through a range of activities, such as providing instruction in English as a Second Language, academic upgrading and/or remediation, and sessions on career planning.

7. Supports to Sustaining Education/Employment
   The goal of this core element is to provide support, as required, to ensure that mental health consumers can keep their jobs or remain in their chosen educational programs.

   The support needed may involve education or problem solving for consumers, employers and co-workers alike. Supports can also involve coordination and advocacy to ensure consumers have access to necessary community supports, such as income, housing, medical benefits and counselling. The services themselves may be provided by an external resource person, or by someone at the job site.

8. Leadership Training
   The goal of leadership training is to teach mental health consumers the skills they need to take on a leadership role in creating and running a consumer-operated alternative business, or an agency-sponsored business. This may involve mentoring and job shadowing, or training consumers/survivors in community development techniques. The expertise of local employers represents a vital resource for leadership training.

The Ministry is asking the Mental Health Implementation Task Forces to take on the task of reviewing the current employment supports programs and businesses in their regions and making recommendations about how to refocus and enhance these supports in keeping with this framework.

The regional offices and the regional Mental Health Implementation Task Forces will work with mental health service providers, consumers and their families, and the business community on the implementation of this policy framework. The Ministry will provide standards and guidelines for employment supports that can be applied on a consistent basis throughout the province.

To make implementation successful, regional planning structures should reflect the major stakeholders in the region such as :

• Members of the business community
• Ontario Council of Alternative Businesses
• Consumer-operated alternative businesses
• Agency-sponsored businesses
• Mental health consumers and family members
• Hospital, community and provincial psychiatric hospital service providers
• ACT teams
• Chambers of Commerce
• Mental health staff at the Ministry’s regional offices
• District Health Councils
• Ontario Disability Support Program
• Canada Pension Plan Disability Program
• Universities and community colleges

Successful regional partnerships and planning will help create more employment opportunities and supports for people with mental illness, by taking advantage of potential local opportunities. But making progress requires effective leadership at all levels :

• Leadership is needed from the provincial and federal governments – to work together to provide a comprehensive range of services and supports without duplications or gaps;
• Leadership from the business community is needed – to create more job opportunities, and advise both consumers and providers on effective business practices;
• Leadership from mental health consumers is needed – to start up more consumer-operated businesses;
• Leadership is needed from service providers – to develop and coordinate the supports needed to find and retain jobs.

As a Ministry initiative, ensuring accountability for achieving goals and objectives is essential. Achievement of goals will be assessed by applying the following performance measures at the program level :

• The number of employer contacts made
• The number and types of jobs created (full-time, part-time, casual, contract, etc.)
• The number of people who actively participate in a program and/or business
• The number of people who successfully complete a program
• The number of people who are employed as a result of their participation in a program or business
• The number of hours/days/weeks worked
• The total duration of the job

In addition to reporting on such employment outcomes, performance measures should include a component that measures improved quality of life. Measures should also be developed to evaluate the costs and benefits of obtaining and keeping employment – both for the individual consumer, and for the health care and social welfare service systems.

Developing and implementing a more accessible, enhanced system of employment supports for people with mental illness is a challenging task. It calls for the commitment, cooperation and collaboration of consumers, families, the business community, service providers, and planners in both the provincial and federal government.

Making it work will be a challenge. But ultimately, such efforts will be rewarded with a better employment support system for people with mental illness. As more people find and sustain meaningful employment, they will be able to experience the many significant benefits that stem from a secure place in the world of work. One such benefit for people with serious mental illness and for the communities in which they live is that meaningful employment enables people to participate more fully in society. In this way, the community as a whole is able to benefit from the experiences, skills and abilities of people with a serious mental illness.

The primary target population for mental health reform remains those individuals with serious mental illness. Fundamental to the understanding of this population is the recognition that complex social, psychological, racial, cultural, political, spiritual and biological issues or forces impact on the mental health of any individual.

The three dimensions used to identify individuals with serious mental illness/serious mental health problems are : disability, anticipated duration and/or current duration, and diagnoses. The critical dimension is the extent of disability and serious risk of harm to themselves or others, related to a diagnosable disorder.

Disability refers to the fact that difficulties interfere with or severely limit an individual’s capacity to function in one or more major life activities. These activities include: basic living skills such as eating, bathing, or dressing; instrumental living skills such as maintaining a household, managing money, getting around the community, and appropriate use of medication; and functioning in social, family and vocational /educational contexts. Increasingly, disability has been seen as the most important defining characteristic of this population and instruments have been developed to quantify the extent of disability and measure change over time.

Anticipated Duration/Current Duration refers to the acute and ongoing nature of the problems identified which can be determined by empirical evidence and objective experience or through the subjective experience of the individual. It is important to note that this does not necessarily mean continuous, observable evidence of disorder but may include acute or intermittent episodes with periods of full recovery. More recently, duration has been defined and measured in relation to the amount of services being used, which also helps to assess the severity and chronic nature of the problem.

Diagnoses of predominant concern are schizophrenia, mood disorders, organic brain syndrome, and paranoid and other psychoses. Other diagnosable disorders such as severe personality disorder, concurrent disorder and dual diagnosis are also included. Source: Making It Happen: Implementation Plan for Mental Health Reform, p. 11.

A survey of vocational and employment programs funded by the Mental Health Branch, MOHLTC, was conducted as part of the policy development process. Currently the Branch funds 40 programs and businesses to provide supports to employment for mental health consumers. Community mental health agencies, hospitals, provincial psychiatric hospitals and consumers operate programs and businesses. The results revealed that currently two thirds of programs and businesses fall under the categories of vocational assessment/planning and employment placement programs. Approximately one third of programs and businesses fall under the category of supported employment/self-employment. There are only two supported education programs with funding from MOHLTC. The survey also revealed a dearth of programs in the East and Northern Regions. Lack of transportation poses a real challenge for consumers in Northern and rural areas even when some supports to employment are available.

For the purposes of the survey, existing programs and businesses funded by the Branch were categorized as follows :

1. Vocational Assessment/Planning programs assess mental health consumers’ aptitudes, interests and work/academic competencies in order to plan for future employment or education.
2. Employment Placement programs identify opportunities for and place consumers in temporary paid or unpaid work placements or permanent paid employment. External support is provided to help consumers sustain the employment, usually on a time-limited basis.
3. Supported Employment programs assist consumers in securing paid employment that fits with their interests and abilities. Consumers receive flexible and individualized support and training as required on the job.
4. Consumer-Operated Alternative Businesses are developed and operated by consumer/survivor employees. The businesses offer full and part-time employment at market rate or higher that is maintained by peer supports. They offer a unique combination of job development, work adjustment, job placement and supported education within a self-help context. They may also offer self-employment opportunities for consumers to earn income through independent contract work. Support and accommodation are provided on-site to consumer employees.
5. Agency-Sponsored Businesses are owned and operated by mental health agencies or hospitals to provide rehabilitation and part-time or full-time employment opportunities for minimum wage or higher for people with serious mental illness.
6. Supported Education programs prepare consumers for further education or employment and are integrated in educational settings and provide on-site support.

Literature reviews were conducted to inform the work of the advisory committee. The reviews indicated that the employment potential of people with serious mental illness has been underestimated. Studies pointed the way towards some evidence-based practices that can be adopted by vocational programs. The reviews also indicated that the brokered model has not worked well for clients with psychiatric disabilities and that vocational rehabilitation should be viewed as an essential and fully integrated component throughout the mental health treatment and rehabilitation process.

The findings of a sampling of the studies reviewed are outlined below.

• The 1997 Review of Best Practices In Mental Health Reform prepared for the Federal/ Provincial/ Territorial Advisory Network on Mental Health found that :

  "There are a number of fairly rigorous studies which demonstrate that :

• People with serious psychiatric illness have the capacity to work
• Employment programs should be encouraged for even the most disabled individuals
• Supported employment is more effective than other employment models
• Supported education enables clients to return to school on a full-time basis.
• There is a shift in programs from traditional methods of providing vocational services to supported employment, which includes :
• Continuous, time-unlimited individual support
• Attention to client preferences
• A place-train philosophy with on-site job specific skills training."

• An American study (Harding, C., Strauss, J., Hafez, H., and Lieberman, P. "Work and mental illness: Toward an integration of the rehabilitation process". The Journal of Nervous and Mental Disease, June 1987, 175(b), 317-327) identified the barriers in a brokered model where mental health services have collaborated with parallel vocational rehabilitation services. Some of the barriers to integration of vocational rehabilitation into the mental health system are :

  • Lack of flexibility in the mental health system;
  • Poorly linked and isolated vocational services;
  • An improvised non-system that emerged to cope with the rigidity of the mental health system;
  • Narrow frame of reference where the medical model was unable to recognize the knowledge, experience and value of rehabilitation.
• Another study (Drake, R., Becker, D., Xie, H. and Anthony, E. "Barriers in the brokered model of supported employment for persons with psychiatric disabilities". Journal of Vocational Rehabilitation, 1995, 5, 141-150) compared the vocational outcomes for clients assigned to a brokered program with the vocational outcomes for clients assigned to an integrated model in which vocational staff were employed by the mental health centre. Vocational outcomes for clients assigned to the integrated model were significantly better than vocational outcomes for clients assigned to the brokered program.
• Recent studies indicate that employment is responsible for both economic and personal good, since those who work enjoy not only an income, but also a range of social, physical and mental health benefits. Specifically with respect to persons with serious mental illness who are working, studies have reported a reduction in symptoms and reduced usage of hospital and crisis services. (Trainor, J. and Tremblay, J. "Consumer/survivor businesses in Ontario: Challenging the rehabilitation model". Canadian Journal of Community Mental Health, 1992, 11(2),65-71; Danley, K., (1996) Proceedings of the Conference on Psychological Disabilities in the Workplace.)
• Studies have indicated that employers need help to understand how to create supportive environments for persons with mental illness and that others in the work environment do hold negative attitudes toward persons with disabilities in general. Conference Board of Canada (2000). Diversity Works! Roundtable on Integration of Persons with Disabilities into the Workplace: Summary Report.
• Participants in five consumer/survivor run businesses were surveyed about their use of services before and after becoming involved in the businesses. Consumers/survivors reported significant reductions in hospital in-patient days, involvement with crisis services and number of hospitalizations after joining the businesses. (Trainor, J. and Tremblay, J.,1992)
• A recent comparative review demonstrated more positive employment outcomes for the Supported Employment model than for more traditional vocational services, such as sheltered worksites, prevocational services, day treatment programs with brokered vocational rehabilitation services or direct referral to Vocational Rehabilitation Services. (Bond, G.R., Drake, R.E., Mueser, K.T. and Becker, D.R. "Supported employment for people with severe mental illness: A review". Psychiatric Services, 1997, 48(3), 335-346)
• An American comparative study demonstrated that recipients of Supported Education as part of the rehabilitation process were more likely to return to college or school, had significantly higher educational aspirations and more independent community functioning than members of a control group who did not participate in Supported Education. (Hoffmann, F.L. and Mastrianni, X. "The role of supported education in the inpatient treatment of young adults: A two-site comparison". Psychosocial Rehabilitation Journal, 1993, 17(1), 109-111)

Purpose :

• This provincial internal/external stakeholder Advisory Committee will provide advice that will assist the Mental Health and Rehabilitation Reform Branch to develop a provincial policy framework for employment supports consistent with the direction outlined in Making It Happen.
• Policy development will be informed by available research evidence on best practices, information/data on the current Ontario employment supports and outcomes as well as experiential knowledge of committee members and key informants.

Rationale :

• In August 1999, the Ministry released Making It Happen, the government's three-year plan for reforming the mental health system. This policy document committed the government to further policy work in a number of areas including employment supports.
• Over the years, MOHLTC has funded training and employment initiatives, including consumer initiatives for people with mental illness (including concurrent disorders/dual diagnosis). Specific policy direction for employment supports has never been articulated.
• MOHLTC mental health employment supports must be reviewed and, if necessary, redesigned to be consistent with changes in federal/provincial policy and evidence-based best practices for successful rehabilitation and community integration.

Deliverables will include :

• Principles for the development of a comprehensive range of employment supports for people with mental illness (including concurrent disorders/dual diagnosis) consistent with the Ministry of Health and Long-Term Care's (MOHLTC) principles in Making It Happen.
• A statement of the best practices to be utilized to improve employment outcomes.
• Long-term goals and objectives for the range of employment supports to be provided across the province. (e.g. career planning, pre-employment training, job search skills, skills training, supported employment, job coaching, consumer/survivor-operated alternative businesses, supported education).
• Identification of gaps and barriers to access the current range of employment supports and recommendation of strategies and resources required to achieve the desired range of supports and the utilization of best practices in providing employment supports.
• Advice on an evaluation and accountability framework for employment supports that is consistent with MOHLTC requirements.
• Identification of issues and barriers with regard to the coordination of income and employment supports for people with mental illness (including concurrent disorders/dual diagnosis) and recommendations for improving coordination.

Parameters :

• The target population will include people with severe mental illness (including concurrent disorders/dual diagnosis) who may not achieve their optimum employment potential without the support and accommodation provided, arranged or partnered through programs with mental health expertise.
• Policy advice will allow for the development of employment supports solutions that can be implemented in a variety of community settings such as large urban, small urban, rural, and remote communities.
• Policy advice will allow for the development of employment supports that may be integrated with other community supports required by people with mental illness (including concurrent disorders/dual diagnosis).
• Policy advice will allow for the development of employment supports that are delivered in partnership with MCSS, HRDC and other employment and income support services.

Reporting Relationship :

• The Advisory Committee reports to the Director, Mental Health and Rehabilitation Reform Branch, Ministry of Health and Long-Term Care.

Composition :

• Membership aims to reflect a range of perspectives and expertise across the Ministry and among key external partners.

Role of Members :
Committee members are expected to :

• Actively participate in the work of the committee including participation in work groups that may be created from time to time.
• Bring to the table their expertise in providing employment supports to people with mental health (including concurrent disorders/dual diagnosis) and to assist in developing, communicating and promoting the committee's work with their respective constituencies.
• Other key informants with specialized expertise will be invited to meet with the advisory committee as required.

Susan Heximer, Coordinator,
Redirection Through Education, George Brown College

Don Palmer, Executive Director,
Causeway Work Centre Inc.

Wendy Nailer, Program Director,
Work Adjustment and Employment Support Program,
Centre for Addiction and Mental Health

Diana Capponi, Executive Director,
Ontario Council of Alternative Businesses

Marnie Shepherd,
Consumer/Survivor Development Initiatives

Claudia Maurice,
Penetanguishene Mental Health Centre

Laurie Hall, Executive Director,
A Way Express

Mary Taylor, Executive Director,
ABEL Enterprises

Diane Pelletier, Executive Director,
Community Mental Health Services, Kenora ON

Lisa McDonald,
Canadian Mental Health Association, Ontario Division

Chris Higgins, Executive Director,
Ontario Federation of Community Mental Health and Addictions Programs

Bonnie Kirsh, Professor of Occupational Therapy,
University of Toronto

Jim Hanna, Newport Centre,
Port Colborne General Hospital

Cathy French/Marti Cross, Programs Unit,
Ontario Regional Office, Human Resources Development Canada

Doug Dixon/Peter Amenta,
Ontario Disability Supports Program, Employment Supports

Brian Davidson/Barbara Dominic, Manager,
Mental Health, Operational Support Branch

Louise Paul, Manager, Program Policy Unit,
Mental Health and Rehabilitation Reform Branch,
Integrated Policy and Planning Division,
Ministry of Health and Long-Term Care

Nancy Douglas, Senior Policy Analyst

Janet Zanutto, Program Policy Analyst

i) Principles
The following principles provide the foundation for the development of a comprehensive system of employment supports.

Accessible
As far as possible, individuals with serious mental illness have access to a full range of employment supports and the information necessary to make informed choices.

Individualized
Employment supports are tailored to the needs of the individual recognizing that these may vary in intensity depending on individual circumstances.

Equitable
Employment supports demonstrate sensitivity to the gender, race, language, and cultural needs of individuals with serious mental health problems.

Accountable
There is a focus on consumer-identified employment outcomes and using evidence-based practices for employment supports.

Collaborative
Partnerships are developed with the business community, the training and education sectors and the social services sector to foster awareness of the needs of employees with serious mental illness and to develop job opportunities.

Provincial and federal programs recognize shared responsibility for enhancing employment support opportunities for individuals with serious mental illness.

ii) System Objectives
Based on the principles described, a comprehensive system of employment supports should accomplish the following objectives:

• Provide a comprehensive system of employment supports that incorporates the core program elements and evidence-based effective practices in each region. It is important to note that not every program or business need necessarily offer all employment support elements. Rather, the intention is that there should be a continuum of elements available within each Ministry region that reflects the identified needs of its consumers.
• Increase the total number of consumers who find jobs, or pursue educational goals.
• Recognize and promote the capacity of the system to offer employment to mental health consumers and survivors.
• Develop effective partnerships with the business community to create more job opportunities.
• Work with the business community and the public to address the issues of stigma in the workplace for people with serious mental illness.
• Promote coordination between federal and provincial employment support programs, to address barriers to employment for mental health consumers and survivors.