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Autumn 2009 | Vol 13 No 1

Focus

Supported employment

Helping clients return to work – and stay there

By Anne Ptasznik

Helene May, a case worker with the Employment Support and Development (ESD) team at the Centre for Addiction and Mental health (CAMH) in Toronto, looks a little unsettled when I arrive for our meeting in the coffee shop of a downtown office building. The plan was to meet with Jeremy Scott*, one of her clients, and George Petroff, his supervisor. Scott, who underwent substance use treatment at CAMH, has been successfully employed painting and doing other chores for more than a year in the building. May tells me that I just missed a frustrated Petroff, who had been discussing with May strategies to help Scott stay at work because in the past few months he has not been completing his hours or showing up on time and has developed a poor attitude on the job. Scott, who hasn’t yet shown up for our appointment, had been telling May that everything is fine.

But everything isn’t fine for many people with mental health and addiction issues when it comes to work. Unemployment rates can be as high as 90 per cent, according to the Canadian Mental Health Association, and the barriers to successful employment are many, including workplace discrimination, gaps in work history, limited employment experience, rigid income support and benefit programs, lack of confidence and fear and anxiety. Add to that the cyclical nature of these illnesses, and the need for supportive employment programs, which help clients deal with these barriers in real work settings and provide ongoing support, becomes clear. What’s also clear is that people with mental health and addiction issues want to work – about 70 per cent, according to the US Substance Abuse and Mental Health Services Administration.

In the past, CAMH’s employment programs, like many others across Canada and the United States, focused on providing pre-employment support and finding volunteer placements to ease clients back into the workforce, but not enough people were getting jobs. Today, the emphasis is on getting clients’ resumes updated, focusing on their strengths and helping them find work as quickly as possible and providing ongoing support, says intake co-ordinator Diana Musson. This individualized program and support (IPS) model, considered to be the best practices approach with this population, focuses on facilitating client choice of competitive employment and rapid job search.

Barriers to successful employment are many, including workplace discrimination, gaps in work history, limited employment experience, rigid income support and benefit programs, lack of confidence and fear and anxiety.

A 2001 Cochrane literature review found that people in supported employment were more likely to have competitive employment than those who underwent pre-vocational training. A 2008 study in the Psychiatric Rehabilitation Journal found that 61 per cent of IPS participants had competitive employment compared to 23 per cent of those involved with other vocational programs.

However, IPS does not meet the needs of all clients, so Wendy Nailer, who manages ESD, says the program is exploring modifications for particular populations, including people with addiction, who may need more time to re-establish themselves in new careers away from old triggers. The program, in partnership with the Law and Mental Health Program, is also considering on-site social enterprises for clients of this program, whose ability to work off-site may be restricted.

Today, while May and I sit in the coffee shop, waiting to see whether Scott will appear, she tells me about the varying levels of supervision that clients in the Law and Mental Health Program require. Petroff stops by again and I get the chance to ask him what the challenges are when hiring someone with a mental health or addiction problem. “The big thing is patience, and I’ve been a very patient person,” he says. Petroff shares with us that he overcame his own alcohol addiction 10 years ago but that he does not understand why Scott cannot do the same. May explains that unless Scott chooses to disclose more about his illness and treatment to Petroff, she is unable to discuss details that might help him to understand Scott’s situation better.

Whether or not to disclose their illnesses and how much to disclose is a decision that the ESD counsellors often help clients wrestle with. Musson says that they generally advise clients not to disclose unless they require accommodation, but that the decision is always left to the client.

A need for accommodation was the reason Margarita Spence chose to disclose to her current employer that she has mental health issues. Spence, an artist, who attributes the seven years it took her to finish art college to her illness, was originally teaching children part-time in an arts school, until she found it required too much energy. She was worried about disclosing because she thought there may be concerns about someone with a mental health problem working with children. When she recently found work as a graphic designer, she decided to disclose to her employer because she wanted him to understand why she sometimes took longer than other designers to finish projects. He arranged for Spence to work freelance part-time and told her to concentrate on her health. “So far, he is trying to be understanding and confidential, and he appreciates that I have abilities despite the fact that I have some difficulties,” she says. “I’m very grateful that there is support for going back to work and not just treatment of the illness.”

Marion Day has chosen to listen to Musson’s advice about not disclosing, for now. Day quit teaching about four years ago when she was using alcohol daily to cope with work stress. She had also been diagnosed with bipolar disorder many years earlier, but did not realize the significant impact the illness had on her until she sought help from CAMH for her alcohol problem. Day had actually ruled out returning to teaching, partly because she did not think she could handle the stress and partly due to shame that everyone knew about her difficulties. She credits Musson, her counsellor, for helping her to not only realize that teaching was her calling, but also for being the first person to encourage her to put her credentials to work.

Musson also helped Day to see that since she had been offered a raise and a renewed contract offer the last time she taught, it was unlikely that her employers knew about her substance use. Now, having successfully applied for a teaching job, she will begin in September. She is considering disclosing her illness after the three-month probation period, partially to help break the stigma for others.

The challenge of finding employment for people with fragmented work records and few full-time work references, which Day had emphasized as one of her constant worries, makes the effort that May at ESD has put into finding supportive employers that much more important. As we finish up our conversation with Petroff in the coffee shop, his demeanour changes, almost as if he were a social worker reframing a negative experience for a client. “We’ve got to figure out what to do, be positive about it, see if Scott really wants to work,” he says. He asks May not to tell Scott that he was frustrated. “Let’s take it more like ‘George was kind of hoping you could do more.’” When I ask Petroff why he doesn’t want Scott to know he is frustrated, he says, “I don’t want him to leave.” He agrees to have a meeting with the three of them and Scott’s social worker, adding, “It’s my own failure if he quits because there’s always a way around.”

While Petroff might be a rare find as an employer, May has successfully developed other supportive employment opportunities, including one with FoodShare, which provides access to healthy food, including delivering fresh produce boxes to people throughout Toronto. May and I meet at their industrial warehouse where she introduces me to Joe Winston, who has been working at FoodShare for three years as a box washer, one of a team of four CAMH clients who are now paid staff. At first, Winston was unsure whether he could handle the work after being out of the regular workforce for years, but he has since changed his mind about his one-day per week job: “I need the money and it’s work I can do. People are friendly; it’s a good atmosphere to work in.” The work has also helped him to be responsible, in keeping with his commitment to recovery from substance abuse.

Zahra Parvinian, FoodShare’s director of social enterprise, says that employers do not need to create a different working environment, as long as it’s a supportive one. She generally treats staff with disabilities the same as her other employees. However, there may be times when someone requires accommodation, for example, if they are adjusting to a new medication. She says it is helpful to have a liaison like May if difficulties arise. One regular challenge arises on pay day, when workers repeatedly ask for reassurance that they will get their cheques.

May explains that clients become anxious about their cheques, particularly because they have a time window within which they must submit their pay stubs, or they could receive notice from ODSP, the Ontario Disability Support Program, which could lead to a delay in them receiving their monthly cheque. Since their illnesses can cause some clients to forget to report, ESD staff help them with this task.

Over the years, there have been significant improvements in ODSP, including an extra monthly $100 work incentive. ODSP recipients are now also allowed to maintain their health care benefits for life or until an employer begins to pay for them. But social assistance can still present work disincentives for people with disabilities, say Nailer and Musson (also see p. 20). ODSP recipients used to only be able to keep $160 before additional earnings were clawed back; now they can keep 50 per cent of their earnings, but Nailor says she would like to see people be allowed to retain more of what they earn. The Canadian Pension Plan Disability program, which at one point did not even permit recipients to volunteer, now allows people to receive $4,700 without reporting that they are working. But a lot of fear remains about relapse. Although both the provincial and federal programs have instituted rapid reinstatement, clients do not trust that this will happen.

Considering mistrust and lack of work experience, deciding whether to go off ODSP is a big decision for people like Winston. While his current position with FoodShare is working out and his supervisor has even recommended a more responsible position, he is uncertain about his future work prospects. “I don’t have any knowledge to do with work. I’m so unsure of myself; I don’t know how to do anything,” he says. “If I got into a training course, I’m 47. By the time I’m 50 or 51, I’m trained to do a serious job. Then how many years can I work at that job, or if I get a job, will they keep me on? Will they fire me? Will the company still exist years after that?”

Since even applying for work can cause anxiety, Lada Banfield, an ESD counsellor, takes an approach to job development that addresses the anxiety that even the act of applying for work can cause. She walks with clients in a mall or along city streets discussing the different environments and people the client might like to work with, while looking for stores that are hiring. Sometimes she makes the introductions to hiring managers on behalf of clients, but if the clients feel comfortable, they will approach managers themselves. Banfield sometimes discretely observes the interaction and then discusses the experience with the client and helps them develop responses to questions they may have a hard time answering. It appears to be an approach that works: One day recently, she and a client visited 36 businesses, six or seven of which called up to arrange interviews. Banfield’s client is now awaiting the outcome.

As for Scott, he couldn’t make it to the coffee shop, but when I do meet him a few days later, he tells me what people with mental health and addiction issues need from employers: “Try to understand where we’re coming from – our lives are a little bit tougher, we have more rules, we might slip up – but don’t fire us right away.” Scott tells me that he is not experiencing problems with his work or substance use, which he also tells his social worker, Petroff and May when they meet to discuss Petroff’s concerns. They decide to give Scott another chance to work for the next two weekends, after which May will meet with him. She realizes that Scott likely should have received feedback about Petroff’s concerns sooner, and that he may need more supervision, or a different environment, and that she will need to consult more with his clinical team. “At the bottom of it, personally, I never give up on anyone; I still want to help,” she says.

*All names, except those of ESD and FoodShare staff, have been changed.