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Columbia Social Work Review, Volume IV       24 

Effective Employment of Individuals with Mental Health 
Conditions: Harnessing National, State, and Local Efforts to 
Improve Outcomes in New York City 
 
Camille Santistevan 
  
 According to the National Alliance on Mental Illness 
(NAMI), 60% to 90% of individuals with mental health conditions 
are unemployed. Employer stigma toward hiring people with 
mental illness, a lack of local-level professional coordination, 
and ineffective legal mandates have all contributed to under-
whelming employment for many qualified individuals. Employ-
ment outcomes of people with mental health conditions may be 
improved with a two-part, local-level employer awareness and 
stigma reduction campaign coordinated by social workers and 
other professionals. This article explores prior and ongoing ef-
forts at the national, state, and local levels, and argues that New 
York City is a prime location to pilot an employer awareness 
campaign. Recommendations include details for launching such a 
campaign by building organizational partnerships to harness ex-
isting resources.  
 
 Over the past three decades, people with disabilities and 
their advocates have lobbied for increased access to services and 
legal protections in the workplace. Despite the wide range of pro-
grammatic responses and the passage of the American with Dis-
abilities Act (ADA) in 1990, 60% to 90% of individuals with 
mental health conditions are unemployed, increasingly with the 
severity of their conditions (ADA, 1990; NAMI, 2010, p. 1). The 
ADA guarantees equal employment opportunity for individuals 
with physical or mental disabilities and requires that employers 
use nondiscriminatory hiring practices and make workplace ac-
commodations for qualified workers. The lack of coordination 
between social workers and other professionals—such as voca-
tional counselors, mental health practitioners, policy makers, and 
disability advocates—has contributed to high rates of unemploy-
ment and may explain why overriding stigma among employers 
remains a significant barrier to employment for individuals with 



Effective Employment of Individuals with Mental Health Conditions 

25        Columbia Social Work Review, Volume IV 

mental health conditions. This is no small matter; approximately 
25% of the working age population experiences a mental health 
condition over the course of a year, causing an indirect cost of 79 
billion dollars of lost productivity (U.S. Department of Health 
and Human Services, 1999).  
 This article is a comprehensive analysis that can serve as 
the foundation for a future mental health awareness and stigma 
reduction campaign targeted at local employers in New York 
City. I will begin by defining “mental health condition” and de-
scribing the importance of work for individuals with mental 
health conditions. Next, I will describe the strengths and short-
comings of the national response to the issue of unemployment of 
people with mental health conditions by reviewing the implemen-
tation and outcomes of the ADA and employee assistance pro-
grams (EAPs). I will then review programmatic responses in New 
York City by defining and describing the history of the Supported 
Employment (SE) movement and highlighting examples of two 
local direct-service SE program models: Personalized Recovery 
Oriented Services (PROS) and Young Adults Work Opportunities 
for Rewarding Careers (YA WORC). Lastly, I will argue that 
New York City can maximize the success of SE services by 
launching a targeted awareness and anti-stigma campaign directed 
at local employers by using resources from the Substance Abuse 
and Mental Health Services Administration’s (SAMHSA’s) state-
level anti-stigma initiative. To achieve better employment out-
comes, all stakeholders must engage in coordinated campaigns to 
educate local employers about the prevalence of mental illness 
and their obligation to accommodate current employees and 
qualified candidates. 
 

Defining Mental Health Condition in the Context of Work 
 

 For the purposes of this article, an individual with a men-
tal health condition is a person with a psychiatric impairment that 
disables his or her everyday functioning and may prevent him or 
her from completing essential work tasks (MacDonald-Wilson et 
al., 2011). This definition will encompass the broad spectrum of 
mental health conditions from minor disorders to severe and per-



Santistevan  

Columbia Social Work Review, Volume IV     26 

sistent mental illness. Recent legal actions have constricted ADA 
protections to only include severe mental illnesses that are not 
controlled by medication. However, most vocational rehabilita-
tive services are offered to individuals who may or may not be 
symptomatic or may not be on medication for mental illness.  
 

The Importance of Work 
 

 Decades of research have shown that with proper support 
services, employment can be an effective component of treatment 
for people with mental health conditions (Akabas, Gates, & Oran-
Sabia, 2006; Bond, Resnick, Drake, Xie, McHugo, & Bebout, 
2001). Work allows a person with a mental health condition to 
become financially independent and can improve the nonvoca-
tional realms of an individual’s life. The individual may learn to 
manage personal finances; live independently; and create mean-
ingful, lasting relationships (Akabas et al., 2006). The type of em-
ployment also matters—in one study, people with severe mental 
illness placed in integrated, competitive employment as part of a 
vocational rehabilitation program showed higher rates of self-
esteem, symptom improvement, and quality of life compared with 
groups receiving sheltered work, minimal work, or no work 
(Bond et al., 2001). Integrated, competitive employment refers to 
jobs in settings with other nondisabled employees that pay at least 
minimum wage and may be more beneficial than sheltered em-
ployment. The primary components of competitive employment 
include: socialization, routine and structure, and change in role 
status from unemployed to competitively employed. These com-
ponents may all work together to explain better employment out-
comes.  
 Additionally, surveys have consistently shown that people 
with mental health conditions strongly desire employment and 
believe that they can work in competitive settings (Cook, 2006; 
NAMI, 2010). A recent study of 20 high-functioning individuals 
with schizoaffective disorder and schizophrenia found that work 
was a crucial factor in supporting symptom management (Saks, 
2013). One subject in a focus group explained, “Work has been 
an important part of who I am…[w]hen you become useful to an 



Effective Employment of Individuals with Mental Health Conditions 

27        Columbia Social Work Review, Volume IV 

organization and feel respected in that organization, there’s a cer-
tain value in belonging there” (Saks, 2013, para. 10). The subject 
also reported working overtime because her job distracts her from 
her symptoms (Saks, 2013). 
 

The National Response 
 

The American with Disabilities Act (ADA) 
 
 At the national level, legislators have acknowledged the 
benefits of work for individuals with physical or mental health 
conditions by passing the ADA. The protections of the ADA were 
intended to safeguard the civil rights of people with physical or 
mental disabilities and to improve the poor employment rate of 
this group. Surprisingly, the ADA actually led to negative em-
ployment outcomes for many. For example, the employment rates 
of men with disabilities fell more than 7% within the first 5 years 
after the passage of the ADA. Employment rates declined because 
of the perceived costs that employers incur when they hire a per-
son with a disability (DeLeire, 2000). However, a report by the 
Job Accommodation Network showed that the median cost to ac-
commodate an employee with a disability was only $500, and 
51% of accommodations actually had no cost (DeLeire, 2000). As 
a result, the perceived costs of employing people with disabilities 
may prevent employers from hiring, even though the actual cost is 
minimal or zero. 
 Furthermore, protection under the ADA requires disclo-
sure, but people with mental health conditions may be apprehen-
sive to discuss their condition with an employer. Their conditions 
are invisible, making disclosure potentially more complicated 
than revealing a physical condition (MacDonald-Wilson et al., 
2011). These concerns are not unwarranted; numerous studies 
have shown that employers consistently rate individuals with psy-
chiatric disabilities lower than people with physical disabilities 
when all else is equal (Dalgin & Bellini, 2008; Cook, 2006). In a 
national survey, 32% of people with mental health conditions 
who disclosed their condition to employers reported negative em-
ployment outcomes, including hiring discrimination, firing, lower 



Santistevan  

Columbia Social Work Review, Volume IV     28 

pay, and fewer opportunities for advancement (Cook, 2006). Indi-
viduals with mental health conditions are often unaware or con-
fused about their rights in the workplace. They may not under-
stand the various ways in which they can strategically time their 
disclosure, limit disclosure to certain individuals, or limit the 
amount of information shared (MacDonald-Wilson et al., 2011).  
Recent legal actions may also undermine the ADA protections for 
people with mental health conditions. The United States Supreme 
Court recently ruled that ADA protections do not apply to work-
ers with conditions that “are not central to most people’s daily 
lives” (Cook, 2006, p. 1396) or that can be “controlled by medi-
cations” (Cook, 2006, p. 1396). Additionally, claims filed with 
the Equal Opportunity Commission—the entity that oversees 
ADA compliance—are usually considered low-priority if the 
claimant has a mental health condition (Paetzold, 2005). These 
low-priority cases made up one fifth of the cases that went to trial 
in 2004, and 76% were ruled in favor of the employer (Cook, 
2006). Employers’ misperceptions of the ADA and subsequent 
stigma demonstrate how ignorance continues to prevent positive 
employment outcomes for people with mental health conditions, 
despite legal supports and the economic benefits for businesses 
and society.  
 
Employee Assistance Programs (EAPs) 
 
 Another national response has taken place via large or-
ganizations that have developed EAPs to mitigate the costs of 
their employees’ untreated health and mental health conditions. 
These organizations recognize that they can save money and pro-
actively support their employees by providing flexible schedul-
ing, time-limited therapy, substance abuse counseling, and paid 
personal days off from work. The costs seem well worth it—a 
2010 Harvard Business Review article found that EAPs lead to 
lower healthcare insurance costs, greater productivity, and higher 
morale among workers (Berry, Mirabito, & Baun, 2010). Most 
EAPs, however, are only available in large organizations, because 
small business owners believe they cannot afford such programs. 
Small business owners are also exempt from the ADA—



Effective Employment of Individuals with Mental Health Conditions 

29        Columbia Social Work Review, Volume IV 

businesses with less than 15 employees do not have to comply 
with ADA provisions. (NAMI-NYC Metro, n.d).  
 

Local Programmatic Responses in New York City 
 

Supported Employment (SE) 
 
 New York City is a prime example of a targeted, local ef-
fort to improve employment outcomes of people with mental 
health conditions. The SE movement began in New York City at 
the Fountain House, a community-based mental health organiza-
tion that used a work-ordered day to help formerly institutional-
ized patients adjust to community living (Bond & Jones, 2005). 
Several decades later, seven main SE principles now serve as a 
foundation for many of today’s direct-service employment pro-
grams: (1) services should be integrated, (2) work is an individual 
choice, (3) ultimate goal is competitive employment, (4) job-
search and placement begins immediately, (5) job choices are de-
termined by clients’ preferences, (6) on-going support is avail-
able, and (7) clients are provided benefits counseling (Bond & 
Jones, 2005, p. 375). The success of the SE model of service has 
been demonstrated in several studies, and outcomes are markedly 
better than alternative programs (Bond & Jones, 2005; NAMI, 
2010). The city’s Department of Health and Mental Hygiene 
(DOHMH) and the New York State Office of Mental Health 
(OMH) have funded vocational programs for adults and adoles-
cents that are based on SE principles.  
 
Personalized Recovery Oriented Services (PROS) 
 
 The New York State OMH’s PROS program is one exam-
ple of a direct-service, integrated rehabilitation program founded 
on SE principles that combines clinical treatment with vocational 
rehabilitation. PROS centers use comprehensive, ongoing assess-
ment to adapt the program to any client’s needs through peer sup-
port, skill development, and intensive, goal-oriented rehabilitation 
(Office of Mental Health, 2009). The overarching goal of PROS 
is to “improve functioning, reduce inpatient utilization, reduce 



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Columbia Social Work Review, Volume IV     30 

emergency services, reduce contact with the criminal justice sys-
tem, increase employment, attain higher levels of education, and 
secure preferred housing” (Office of Mental Health, n.d., para. 
27).  
 
Young Adults Work Opportunities for Rewarding Careers 
 
 Young Adults Work Opportunities for Rewarding Careers 
(YA WORC) is another example of a local level SE program 
model in New York City that seeks to ameliorate the dishearten-
ing employment statistics for young people with mental health 
conditions. This model is currently being implemented at several 
nonprofit agencies that operate DOHMH’s Adolescent Skills 
Centers—community-based mental health centers that serve peo-
ple between 16 and 23 years of age. The YA WORC program 
consists of three components that are derived from SE principles: 
(1) comprehensive initial assessment to determine vocational and 
nonvocational barriers to employment, gaps in functional capac-
ity, and possible workplace accommodations; (2) Career Club, a 
peer support group with a structured curriculum that provides on-
going support throughout the job process; and (3) the develop-
ment of a labor market strategy, which requires the agencies to 
consider employers as equal and primary clients (Akabas, et al., 
2006). The YA WORC model acknowledges that partnerships 
between agencies and potential employers must be made before 
the job placement process begins so that the agency knows how 
to best prepare clients for these particular workplaces.  
 

Recommendations for New York City 
 

 While PROS and YA WORC are strong examples of SE 
programs and are effective at preparing their clients for employ-
ment, a major shortcoming of both models is their failure to ag-
gressively address existing employer stigma in the hiring process 
and within the workplace. The YA WORC model minimally ad-
dresses discrimination by requiring providers to establish rela-
tionships with employers, but it ultimately underestimates the 
power of stigma during the employment process. Both models 



Effective Employment of Individuals with Mental Health Conditions 

31        Columbia Social Work Review, Volume IV 

assume that people with mental health conditions are willing to 
disclose their conditions and that employers are willing to hire a 
person who discloses.   
 Earlier attempts to mitigate stigma have been launched 
primarily at the state level. In 2003, SAMHSA piloted a broad 
anti-stigma effort in eight states, called the Elimination of Barri-
ers Initiative. SAMHSA produced two publications during this 
initiative: (1) a toolkit entitled, Developing a Stigma Reduction 
Initiative (SAMHSA, 2006); and (2) a booklet for employers 
called, Workplaces That Thrive: A Resource for Creating Mental 
Health-Friendly Work Environments (SAMHSA, n.d). The suc-
cess of the initiative in reducing stigma is unknown, because the 
final evaluation of outcomes is not available. However, research 
on public service announcements about mental health conditions 
suggests that social marketing campaigns are more effective when 
focused on local groups (Corrigan, 2012). Thus, these publica-
tions can be better used in local-level campaigns designed to in-
crease awareness about mental health conditions, reduce em-
ployer stigma, and improve outcomes of workers with mental 
health conditions.  
 In New York City, DOHMH can use SAMHSA’s materi-
als to address employers’ knowledge, beliefs, and behaviors re-
garding mental health conditions and increase awareness of exist-
ing vocational programs, such as PROS and YA WORC, which 
are available to employers to support workers. DOHMH can also 
use the Community Health Survey database, EpiQuery, to priori-
tize the neighborhoods that are most in need of anti-stigma em-
ployer interventions. For example, an EpiQuery analysis showed 
that an estimated 34% of people in the Bronx who are not in the 
labor force reported a history of depression in 2010 (DOHMH, 
2012). DOHMH can conduct organizational needs assessments 
using surveys, focus groups, interviews, and observations at each 
PROS and YA WORC center to verify the data found using 
EpiQuery and gather additional qualitative details about employer 
stigma and other barriers to employment in each agency’s catch-
ment area. 
 After identifying the areas of highest need, DOHMH can 
establish coalitions consisting of representatives from the follow-



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Columbia Social Work Review, Volume IV     32 

ing organizations, as relevant to the particular locations: (1) 
PROS centers, (2) YA WORC centers, (3) community-based 
mental health centers, (4) hospitals with mental health inpatient 
and outpatient services, (5) professional associations of clinicians, 
and (6) local-level chapters of advocacy organizations such as 
NAMI-New York City Metro. Next, the coalition can develop a 
unique, culturally competent marketing plan, targeted at local em-
ployers near PROS or YA WORC centers, that include messaging 
strategies, communication approaches, outreach materials, an im-
plementation strategy, and an evaluation plan (Kotler & Lee, 
2008). During this stage, it is essential that the materials are con-
textually appropriate—a marketing plan created to reach a large 
corporate employer in lower Manhattan will likely not have the 
same impact on a small business owner in Queens. If the pilots 
are successful, different coalitions can be organized by borough 
or county to develop anti-stigma campaigns targeted at employers 
in their neighborhoods, using the boundaries of their catchment 
areas to create lists of employers to target.  
 

Conclusion 
 

 The consequences of failing to address unemployment of 
people with mental health conditions are critical. New York City 
is strikingly close to increasing the employment outcomes of its 
residents living with mental health conditions; however, federal 
legal protections, existing workplace supports such as EAPs, 
state-level public awareness campaigns, and the city’s strong his-
tory of SE programming can only go so far. Social workers and 
other professionals that serve this population must work together 
to create targeted, local anti-stigma campaigns to change the be-
liefs and behaviors of employers toward individuals with mental 
health conditions. This article contributes to the effort by compil-
ing existing resources and recommending new and more effective 
local campaigns in New York City. Professionals working in the 
mental health field in New York City must unite to eliminate the 
stigma faced by people with mental health conditions in the work-
place.  
 



Effective Employment of Individuals with Mental Health Conditions 

33        Columbia Social Work Review, Volume IV 

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