By Margarita Alegría, Ph.D.1,2, Amanda NeMoyer, J.D., Ph.D.1,3, Marie Fukuda, B.M.1, Jill Rosenthal, M.P.H.4, Najeia Mention, B.A.4, Gilberto Perez, Jr., M.S.W., A.C. S.W 5 , Deborah Delman, B.S.6, Valeria Chambers, C.P.S., Ed.M.6, Catherine Quinerly, C.P.S., C.P.R.P.6

This article is part of a GAINS Center series on promoting race equity in behavioral health and justice outcomes. Read Part 2 here.

Complex Linkages: Employment, Mental Illness, and Race Equity

In 2016, approximately 18.3 percent of adults in the United States were estimated to experience mental illness (National Institute of Mental Health, 2017). In addition to a mental health diagnosis, these individuals—especially ethnic and racial minorities—often face challenging social factors, such as poverty, low educational attainment, and unemployment that can negatively affect their wellbeing (Druss et al., 2011; Walker & Druss, 2016). For example, less than 20 percent of individuals receiving publicly funded mental health services report employment, despite data suggesting that most of them want to work (McQuilken et al., 2003) and that a large proportion of them could work successfully with appropriate supports (Lehman et al., 2002; Siegwarth & Blyler, 2014). Supported employment programs integrate employment specialists into the treatment teams of individuals with serious mental illness (SMI) so that these individuals can obtain and retain competitive employment matched to their skills and preferences (SAMHSA, 2009). Such programs help facilitate several important components of the recovery process, including developing personal agency, meeting functional needs, and increasing social activity and feelings of belongingness (Whitley & Drake, 2010).  Thus, in addition to improving employment outcomes, supported employment programs have been linked to improvements in behavioral health symptoms, quality of life, self-esteem, and social functioning (Marshall et al., 2014).

Employment Simulation Study

With Dr. Robert E. Drake and other colleagues, Dr. Alegría (2017) conducted statistical analyses that simulated improvements in employment among a national sample of individuals with mental health diagnoses in two groups: one group with common disorder diagnoses like depression and anxiety, and another with SMI diagnoses like schizophrenia and bipolar disorder. Simulated employment gains (i.e., giving employment to 60 percent of the unemployed), based on estimated potential improvements from supported employment programs, produced substantial reductions in the number of days out of role (i.e., missed work days, days unable to complete typical tasks) for African Americans, Asians, and non-Latino Whites with common mental health disorders.  Increasing employment rates also created substantial improvements in both mental and physical health for all respondents with severe mental health disorders.

Then, to heed the call for researchers to collaborate with relevant stakeholders to interpret and apply research findings related to mental health disparities (O’Day et al., 2014), we presented the results of these simulations to three focus groups composed of relevant stakeholders: 1) individuals with lived experience of mental health conditions, 2) community health advocates, and 3) state health policymakers to explore the implications of our findings and generate ideas for how they could be interpreted and used. These focus groups were held as part of a National Institute of Minority Health and Health Disparities Study examining barriers to mental health care and mechanisms underlying racial/ethnic differences in mental health outcomes.

When presented with simulation findings, members of all three focus groups identified a broad need for policies that better serve individuals with mental health challenges and facilitate their ability to obtain employment. Individuals with lived experience of mental health conditions frequently shared stories of firsthand experience as individuals in need of employment supports, community health advocates often framed the issue based on the needs of the diverse communities served by their organizations, and policymakers typically reported systems-level experiences and recommendations specific to their state agencies.

Recommendations from individuals with lived experience

In response to simulation findings, individuals with lived experience shared personal stories about supported employment. These individuals noted that wellbeing depends on many factors beyond employment, including food and housing security. More than any other group, members of this focus group spent time identifying barriers for supported employment program participation, including:

  • Uneven program availability
  • Geographic and economic challenges
  • Program inaccessibility for elderly individuals
  • Arduous bureaucratic processes as a prerequisite to program participation

This group recommended that supported employment programs for individuals with mental health conditions also include supports for substance abuse and a history of trauma, as these conditions and experiences can be co-occurring. This group endorsed the use of peer specialists for help with both obtaining employment and engaging in daily routines. They also suggested that programs provide resources related to wellness and skills training and provide education around basic and complex problem solving. Specific suggestions for reducing barriers included:

  • Helping individuals navigate complex paperwork and systems,
  • Expanding program safety nets for those individuals who might face relapse or unique challenges to employment (e.g., lack of transportation, lack of professional clothing), and
  • Incorporating a holistic, “whole-person” approach when working with individuals with mental health conditions.

Recommendations from community health advocates

Drawing from their work with service providers, individuals with lived experience, and service organization administrators, members of the community health advocate group (which included health and mental health advocates as well as health center administrators) discussed subjects that were also noted by the other two groups. Like individuals, they emphasized the need for reducing barriers posed to potential supported employment service users, for example, by improving the ability for individuals to move in and out of support systems and by raising existing resource limits. Like policymakers, this group recommended building on successful demonstration programs run by states to expand and sustain supported employment programs. This group also encouraged the development of innovative alliances to foster collaboration among individuals with lived experience, health professionals, and advocates.  Other suggestions from this group involved community capacity building, such as developing employment programs within existing mental health organizations and strengthening local partnerships with community health clinics.

Discussion and recommendations from this group focused more than either other group on racial/ethnic minority perspectives, perhaps because of their work with disadvantaged minority populations.  They identified potential explanations for the lack of simulated improvements among Latinos; for example, they noted that Latinos often experience different types and conditions for employment (e.g., higher rates of manual labor and cash employment, additional challenges related to economic and cultural differences), that Asian Americans are often not adequately included in national surveys, and that varying living conditions and geographic distribution of African American populations might impact gains made by increasing employment.

Recommendations focused more than other groups on needs related to race and ethnicity, as this group suggested that supported employment programs do the following:

  • Include language supports
  • Use promotoras (i.e., community health promoters in Latino communities) to facilitate awareness and understanding of these programs
  • Build solidarity across communities of color
  • Encourage the implementation of resident ID cards that could reduce barriers to services related to immigration concerns

Recommendations from policymakers

State policymakers described successes and challenges related to advancing supported employment programs, as well as various funding mechanisms available through state and federal resources that they have used to develop and leverage such programs. Policymakers discussed a range of strategies for funding supported employment programs, including mental health block grants, Medicaid demonstration waivers, SAMHSA-supported employment grants, and Workforce Investment Act funds.  These stakeholders noted that services would be limited for individuals who qualify for supports through specific programs (e.g., Medicaid) and suggested that services could be improved by allowing individuals to receive supported employment services from partnering agencies.  Finally, this group stressed the need for data collection and data sharing for program evaluation, so that agencies could adequately measure the impact of supported employment program implementation.

The importance of different representatives

Bridging the different perspectives and including the voice of different stakeholders in dissemination of results is paramount in implementing effective programs. Eliciting reactions and feedback from each of these three stakeholder groups enabled researchers to obtain a more robust picture of the opportunities and barriers to translate research into practice.  Given the additional challenges to employment faced by individuals with a history of justice involvement (e.g., Doleac, 2016), program administrators serving this population might wish to undertake similar procedures to investigate the potential benefit of supported employment programs.  Whenever possible, we encourage readers to identify those individuals that could spearhead changes to policy and practice based on their findings, as well as those individuals who could most benefit from such changes, and work collaboratively with them to take next steps on the way to progress.


1 Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, 2 Department of Psychiatry, Harvard Medical School, 3 Department of Health Care Policy, Harvard Medical School, 4 National Academy for State Health Policy, 5 Dean of Student Affairs, Goshen College, 6 The Transformation Center, Roxbury, Massachusetts

This study was supported by the National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health under Award Number R01MD009719. Additionally, Dr. Amanda NeMoyer was supported by the National Institute of Mental Health (NIMH) under Award Number T32MH019733. The content of the article is solely the responsibility of the authors and does not necessarily represent the official views of any of the funding institutions.


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