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Avoiding the Tyranny of Low Expectations: Employment Support for People with a Mental Illness

Dan O’Brien is the Deputy Associate Commissioner for Social Security’s Employment Support Programs. Prior to joining Social Security, Mr. O’Brien managed return to work programs for people with serious mental illness for 27 years.

Dan O'Brien Since 1949, May has been recognized as Mental Health Month, to help raise awareness for mental health in America and to bring attention to services that support people with mental health issues. The National Institute of Mental Health (NIMH) estimates that one in four adults in the U.S. will experience mental illness per year. That translates to more than 57 million Americans. Serious mental illness is the leading cause of disability in the U.S. for people between the ages of 15 and 44.

Nationwide, one of the most pressing issues for young adults is making the transition from education to full time employment.This is a challenging transition for many, especially in these tough economic times. However for those with mental illness, additional resources and support may be required. As a family member of someone with mental illness, I’ve been concerned for some time that society does not create the same high career expectations for people with a mental illness as it does for those without mental illness. Unemployment rates for people with mental illness hover around 80 percent- the highest unemployment rate of any disability group and more than twice than that of young adults without a disability. While this can be partially attributed to the debilitating effect of multiple barriers, I believe it’s also a result of what I call the “tyranny of low expectations.”

This “tyranny of low expectations” was demonstrated by a state mental health department (who shall remain nameless). The department ran a high school transition program that focused exclusively on transitioning students with mental health diagnoses to Social Security disability benefits, not to employment or college. Transition programs should encourage participants to explore higher education or employment rather than social security benefits. By offering transition only to disability benefits, the not –so– subtle message is that there is no hope for the future but a life of poverty on government benefits. The negative effects of this approach are two-fold. Not only are many talented students denied options to explore higher education or employment, but the low expectations that have been imposed on them, can be damaging to their self-confidence and limit their expectations for themselves. Many advocates consider this “tyranny of low expectations” to be more debilitating than the mental illness itself.

Research repeatedly reinforces that high expectations from family, friends and helpers lead to better employment outcomes. Decades ago, the National Institute of Mental Health conducted a study that perfectly illustrates this point. The study was comprised of three subject groups, with each group consisting of adults with mental illness. The control group received standard case management; the experimental group received case management in addition to extensive employment services; and the third group received only one hour of vocational planning - no other services. Not surprisingly, the control group experienced substantially lower employment rates than the group that received support with employment services.  More than half of the experimental group went to work. The surprise finding was that the third group (who received only an hour of vocational planning) experienced twice the employment rate of the control group. Curious, the researchers interviewed this group to determine the differentiating factor.  A response from one gentleman, who started working in response to the vocational planning, summed it up in simple terms. “I have been coming to this mental health center for 10 years and no one ever asked me if I wanted to work.” The ‘tyranny of low expectations” strikes again!

Join me in my encouragement and support for individuals with a mental illness to explore the risks and rewards of work! We should invite everyone to explore how work could work for them as part of their recovery from mental illness. Ticket to Work can help. It’s a free and voluntary program available  to anyone ages 18 through 64 on Social Security disability benefits. It’s supported by a network of more than 1,000 employment and career service providers who specialize in helping people with disabilities find employment.   

Ticket to Work and Work Incentives encourage many individuals with mental health illness to pursue work. Participants can work and pursue financial independence and a better life. One beneficiary put it succinctly, “you can’t make a living on Social Security benefits.”  Additionally, it offers the opportunity to meet new people, give back to the community and boost self-esteem. Collectively, the benefits of joining the work force through Ticket to Work have helped many participants find career success and transform their lives. Social Security offers a variety of supports in addition to the Ticket to Work program such as continuation of Medicaid and Medicare coverage and expedited reinstatement (for those who qualify). These make it easier for people to become employed and transition to financial independence without fear of being without vital healthcare coverage and cash benefits, should a job not work out, due to their disability.

Discover what the Ticket to Work program can do for you. For more information, visit www.socialsecurity.gov/work or email us at support@chooseworkttw.net or call (866) 968-7842 (V) or (866) 833-2967 (TTY/TDD).

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chris says:
May 24, 2012 at 9:32 AM

I think Mr. O'Brien is rather simplistic and generalizing in addressing the means to assist this population in increasing their employment levels. Regardless, I agree wholeheartedly with the goal. It is hard not to cookie cutter on such a large scale effort but SSA should consider that they have created Byzantine like rules and regulations and should consider simplifying them.  

Choose-Work-Blog-Staff says:
May 29, 2012 at 11:09 AM

Chris, Thank for your comments. We continue to make improvements to the program to simplify it and make it easier for people to understand. We suggest you participate in a WISE to get information on work incentives and how they can assist people with returning to work or work for the first time. You may register  for a WISE at www.choosework.net/wise.

Dave says:
May 29, 2012 at 4:10 PM

Dan O'Brian is right on this one in my experience. I think the unemployment rate for people with mental illness has been as high as 85% actually. It all depends on whose stats you consider.  The tyranny of low expectations not only holds people with mental illness hostage, but also the potential employer. The employer misses out on a good employee.   With the right meds, support from a counselor that encourages work as an important part of building self confidence, the cycle of low expectations can be chipped away one pay check at a time. Baby steps to longer strides.  Yes thats the real ticket. 

Choose-Work-Blog-Staff says:
May 30, 2012 at 2:04 PM

Thank you for your comment.

emp says:
June 2, 2012 at 1:16 PM

when in the middle of my career, I left work for SSDI (about 6 yrs after having been told inb rehab that I'd never be able to return to work). I was and remain frustrated by what I believe is Ticket to Work's bias towards individuals with mental illness.

The tyranny of low expectation impacts individuals with disabilities especially those who are going to require structual workplace accommodations. 

I have never seen a WISE session titled for anything except mental health consumers. I know of physically disabled individuals who have been assisted but they found it on their own or with assistance of an ILC not from an email from the state or federal program. 

Choose-Work-Blog-Staff says:
June 6, 2012 at 12:49 PM

Hello. We understand that some people may require certain accommodations to work and the Ticket program offers beneficiaries with both physical and mental disabilities improved access to meaningful employment with the help of specialized providers. Using the employment support of Ticket to Work and other resources from Job Accommodation Network (JAN) can help you and your provider successfully find job opportunities that meet your needs. Call our Ticket to Work Help Line at 1-866-968-7842 (V) or 866-833-2967 (TTY/TDD) to speak to a representative who can help match you with a provider. You may also find a service provider using our Find Help tool. For more resources, visit the JAN website  at http://askjan.org.

Jank says:
July 31, 2012 at 4:15 PM

Thanks for this.  I have battled the "you're mental health - so go to your corner and exist off the govt programs - expect no more out of life syndrome" for the last 5 yrs.  Dr misdiagnosed symptoms of a physical condition as "mental".  Put me on meds, and my physical condition worsened.  Suggested I go on SSDI and "fix my health" then go back to work - knowing all too well the meds were perpetuating/creating a "mental health" issue and would never allow real gainful employment.  With the help of some Dr's "off the record", I've empowered myself to learn and fight - but I can't afford the right specailists on my SSDI and medicaire.    I have a part time job lined up that I can increase my hours once I am medically able - but requires healthcare team/plan in place to weather the transition, keep up with the impact on my health and mental, and adjust meds until we get the right combination for a working person.  (not MH meds - the life sustaining meds.  Finally frustrated, I tried without the health support.  Worked hoping to put that toward at least 2 visits with the specialist - but fell flat on my face - health wise after a week - which took a month to cycle out of and mentally another few weeks in "failure depression" - NOT medical/clinical depression.)  

I have contacted several TTW agencies - but they all basically need me to be able to got to work full time, right now or call them when I can.  Soc Sec staff have repeatedly turned me away from submitting a PASS which would protect any earned income I am able to make and allocate it toward medical and work-related certificate type classes ONLY, while allowing me to work part time building up medically to fulltime AND not decrease food stamps/script help, etc. with the reasons being "SSDI is too high so I can't get SSI/PASS - even though I wan to put in the maximum SSDI $ that SS will allow.  Then told have to be able to live off the SSI income only - well rent will adjust with income and we'll adjust our food/electric usage in the home however we have to and l the money I'm already spending in health care, phone, internet, and will spend building up to get back to work - internet, computer, work clothes etc will are all needed to get to work and STAY working - so they'll be part of the plan and not an issue.


Many world known people have my same condition, and had their adjustment periods and went back to work within 1-2 yrs of diagnosis (they had enough money to pay for the healthcare and rent during the process).  I exhausted all funds on living expenses when going on SSDI asone dr suggested - and have not had $ to fix my health and get back to work.


So, I'm really interested in specific contact people in Soc Sec who know about PASS and TTW, and can help me put them to work reaching my goal of get back to living and being productive, non govt program citizen.

Choose-Work-Blog-Staff says:
August 1, 2012 at 11:18 AM

Hello Jank,

We’re sorry to hear about your struggles and we understand your frustration and would like to help you. We believe the Ticket to Work program can work for you! Your best way to get started is to call our Help Line at 1-866-968-7842/866-833-2967(TTY/TDD), 
M - F 8:00 AM - 8:00 PM EST to discuss your situation with our knowledgeable representatives. You may also get more information about PASS at www.socialsecurity.gov/disabilityresearch/wi/pass.htm.

Lyn says:
August 12, 2012 at 12:09 PM

Until claims representatives and SSA learn how to effectively and efficiently facilitate the process of using the Social Security Work Incentives, people will continue to shy away from them.  The process is burdensome, and if you don't know all the ins and outs, you're likely to get caught up at some point, resulting in a massive overpayment.  Then you're told that you "knew or should have known" what the regulations are, which is rediculous given that the staff themselves don't know the regulations.  I've worked with the SSWI since 1989, and am stunned by how many times I'm having the same conversation with a claims representative that just can't seem to get it.


Choose-Work-Blog-Staff says:
August 13, 2012 at 3:36 PM

Hi Lyn,
Thank for your comments. We understand Work Incentives can be confusing and at times frustrating. The Ticket program offers a Help Line of knowledgeable representatives who are available to discuss your personal situation. Please call 1-866-968-7842 (V) / 866-833-2967 (TTY/TDD) Mon-Fri, 8 a.m. - 8 p.m. EST. We also suggest you participate in a WISE webinar to get information on Work Incentives. You may register  for a WISE at www.choosework.net/wise.

Li says:
June 9, 2014 at 2:17 PM

Today I finally had to stop working my full time clinical care Management job b/c I cry all day at work.  I have been trying to find a therapist & MD to prescribe for over a month with no success.  How am I going to pay my bills??  I can't even find an MD to start meds for my Bi-Polar disease!!  Any suggestions??

Choose-Work-Blog-Staff says:
June 16, 2014 at 10:20 AM

Hi Li, we encourage you to contact our Help Line and speak with one of our representatives to determine your benefits status and to see what options are available. The number to call is 1-866-968-7842 (V) or 866-833-2967 (TTY) Monday through Friday from 8:00AM - 8:00PM ET. We hope this helps!