Financial Motivation to Work Among People with Psychiatric Disorders

Abstract

Background

Supported employment is an effective intervention for people with serious mental illnesses (SMI) but is underutilized. Clients’ desire to work might be heightened by programs that provide counseling about managing one's funds, since money management helps people become more aware of the advantages of having money.

Aims

To analyze the thoughts of recently homeless or hospitalized persons with SMI concerning their personal finances and employment.

Method

We interviewed 49 people with SMI about their finances, reviewed transcripts and analyzed their baseline characteristics.

Results

Twenty of the 49 participants spontaneously expressed a desire to work in order to earn more money. Those who expressed a desire to work managed their money significantly better than those who did not.

Conclusion

Discussion of finances, such as that fostered by money management programs, may promote engagement in vocational rehabilitation and working for pay.

Approximately 3.4 million people are currently receiving Social Security payments for a psychiatric disability, and than 1% of recipients will work enough to obviate their need for disability payments (Social Security Administration, 2008). Although the majority of people with SMI express a desire to work (Froundfelker, Wilkniss, Bond, Devitt, & Drake, 2011), only a quarter to one third are employed or involved in vocational rehabilitation activities (Connecticut Bureau of Rehabilitation Services, 2011; Rosenheck et al., 2006). This discrepancy is likely due to employment barriers in this population including severity of psychiatric symptoms, lack of education, limited access to vocational rehabilitation supports (Becker, Whitley, Bailey, & Drake, 2007; Cook, 2006; Secker, Grove, & Seebohm, 2001), and fear that working might endanger receipt of benefits (Drew et al., 2001; MacDonald-Wilson, Rogers, Ellison, & Lyass, 2003).

A benefits counseling intervention in which Social Security beneficiaries were advised they could return to work while retaining some disability benefits was associated with substantially higher incomes than a historical control (Tremblay, Smith, Xie, & Drake, 2006). Another study of a bundled intervention including support for participants’ work by a guarantee of at least three years maintenance of SSDI benefits found that beneficiaries’ participating in the bundled intervention were significantly more likely to work and earned more money than control participants (Frey et al., 2011). Thus, while vocational rehabilitation programs in general and supported employment in particular have been shown to be beneficial for people with severe mental illness, such services are underutilized (Drake, Skinner, Bond, & Goldman, 2009). For example, in a survey of individuals with SMI, only about a quarter were either participating in or had been referred to supported employment (Lehman et al, 1998).

One incentive to work is to earn more money than disability payments provide. The financial incentive to work might be strengthened by counseling clients on managing their funds, as such counseling emphasizes the advantages of having enough money to pay expenses. In our own qualitative interviews, participants in a voluntary money management arrangement called Advisor-Teller Money Management (ATM) described how having their money managed made their financial issues more salient and made them think about purchases they might make in the future if they save enough money (Serowik, Bellamy, Rowe, & Rosen, 2013). Clients who enroll in a money management program become more aware that living on disability benefits is difficult may conclude that a way to improve their financial situation is to work for pay.

Money management programs rarely encourage vocational rehabilitation as part of money management counseling (e.g. Burke-Miller et al., 2010). Most money management programs involving a representative payee/conservator who directly pays bills from clients’ income, pay minimal attention to vocational rehabilitation, focusing solely on assuring that clients’ basic needs are met.

This article describes thoughts people with SMI volunteer about employment as it relates to their money management, and compares people who expressed interest in working to those who did not. Data from this study emerged from brief qualitative interviews with people with psychiatric disorders who were receiving disability benefits.

Method

Participants

Recruitment was conducted at the day programs and inpatient unit of a mental health facility in an urban environment. Participants were recruited for a clinical trial in which they would receive four counseling sessions focusing on either money management or on coping with illness. Eligible participants were receiving Social Security Income (SSI) and/or Social Security Disability Income (SSDI), were receiving psychiatric treatment, and had in the past three months either been homeless for at least seven days or had had a psychiatric hospitalization. Participants were excluded if they were in the process of being assigned a payee/conservator or had already been assigned one.

Prior to random assignment, 49 participants completed brief qualitative interviews and standardized instruments, aimed at eliciting information about their money management. Forty-five percent were male, with a mean age of 46.06 (SD = 8.94), 32.7% were African American, 28.6% Hispanic, and 38.8% Caucasian. Participants had completed an average of 11.78 years of education (SD = 3.18). Participants reported lifetime histories of homelessness (an average of 22.43 months, SD = 39.09) and psychiatric hospitalization, (average 10.06 months, SD = 17.72). Chart review indicated diagnoses of Bipolar Disorder (42.9%), Schizophrenia (38.8%), Major Depression (34.7%), Personality Disorder (34.7%), Post-traumatic Stress Disorder (8.2%), and/or Anxiety Disorder (6.1%).

Procedure

Recruitment occurred by announcements at program meetings, after which clients could approach research staff, and by clinician referral. After providing written informed consent, participants completed the quantitative assessments, and then returned four weeks later to complete qualitative interviews. Interviews were conducted before any study-related therapy was provided.

Measures

Brief qualitative interviews focused on participants’ experience with money and thoughts about how money had affected their lives. Participants were asked about their current and past experiences with money and what, if anything, they would like to see changed with regard to their finances, with follow-up questions and probes as appropriate.

The following additional assessments were completed:

The Participant Intake Questionnaire is a demographic assessment adapted from the Access to Community Care and Effective Services and Supports study (Morrissey et al., 2002) that includes subsections on homelessness and psychiatric functioning.

The Money Mismanagement Measure is a 28-item self-report measure that assesses level of money management. The measure, with demonstrated construct and concurrent validity (Conrad et al., 2006), has items about housing, food/shopping, banking activities, budgeting, and victimization. Victimization items were excluded. For this assessment, lower scores represented better management of funds.

Self-reported income and expenses were collected using the Timeline Historical Review of Income and Financial Transactions (THRIFT), an assessment of financial transactions over the previous 28-days (Black, Serowik, Ablondi, & Rosen, 2013).

To objectively describe clients' functioning in regard to employment and household responsibilities, Instrumental Role Category subscale of The Heinrichs-Carpenter Quality of Life Scale was used. The full scale is a 21-item interviewer-rated measure originally developed for people with schizophrenia (Heinrichs, Hanlon, & Carpenter, 1984).

Data Analysis

Qualitative data

Qualitative analysis of the interviews was conducted using an empirical phenomenological framework that an investigator with the study had used in previous studies with people who were homeless and had mental illnesses (Rowe, 1999.) In this framework, narrative analysis is used to identify common themes found across individual in-depth interviews (Davidson et al, 1997). Following transcription of audio taped interviews, the first two authors reviewed and analyzed participant statements to identify key themes within and across individual interviews. They then discussed findings and reached partial consensus, reviewed the transcripts again, and brought key themes together through a cut and paste method, reconvening to reach final consensus. A general edited synthesis was produced regarding participants’ experiences with having and managing money.

Quantitative analysis

All quantitative analyses were computed using SPSS version 19. Total income and total expenses were derived by summing relevant items from the THRIFT. Differences between those who expressed the desire to work in the qualitative interviews and those who did not were assessed using T-tests and Mann-Whitney U tests.

Results

Qualitative Results

Twenty of the 49 participants spontaneously expressed a desire to work during the money management qualitative interview. Participants who initiated the topic of work did so most commonly in response to the interviewer question, “Was there ever a time when your money situation was different?” Many participants described having previously worked at least part-time and, during that time, being able to pay bills and avoid debt.

Many participants expressed hope for improvement in their financial situations if they were to gain some employment. Tim, a mid-40s resourceful African American with medical issues and substance use, illustrates this sentiment:

Oh God, if I had a job, I know I would have to start off small cause I haven't worked in over thirteen years . . . [It would mean so much more to me . . . I would better be able to handle life on my terms as opposed to being under the radar under the poverty level like I am now...I'm a very hard worker and once I get . . . into it. I'm dedicated and devoted and . . . reliable, all those good things when it comes to working.”

Some participants saw work as a long term goal requiring prior completion of specific tasks. For many, this included education. Christina, a Hispanic female who struggles with alcohol and cocaine dependence and has a diagnosis of Schizophrenia, stated that, “By me going to college, I could get a part-time job on my own. I could always be a help to someone.”

Luis, a Hispanic male with over 20 years of employment history who was coping with depression and opiate dependence, had more than 20 years of employment history, and was interested in training in a new different field:

“I would have to go back and study...because I've worked in construction for so many years. It's in the way of my health. It prevents me to work those kinds of shifts [I used to] work. So I would have to go to school and work in something that wouldn't strain myself that much . . . I'm getting older and I think that I should have more than what I am receiving. So you know, I'm planning to see if I can go to school and try to . . . find a job.”

Beth, in her mid 50s, had recently been homeless. With an 8^th grade education, she felt that finding a job would depend on finishing her high school degree: “Well first of all I would like to go back to school. I need to go back to school because I need at least a GED.” She added, however, “[If] I got a job first I think I would go for the job. . . ”

Many participants spoke of limitations caused by mental and physical illnesses, reporting that they would only be able to work part time or that, while they wished to, they weren't able to work at all at present. Irene, a 50 year-old white female with major depression, would become anxious when she thought about her financial situation and the amount of money she owed. She stated, “I don't think [I can work], not right at the moment, emotionally I don't think so but hopefully soon.” Al, a mid 40s African American male, stated, “It's not enough to take care of my responsibilities. I would rather work than to rely on this . . . but people tell me I'm not ready for work...” Jon, a Caucasian male in his mid 20s, felt he was not able to work right now:

“ . . . [I]t's really hard to pay for anything and I wish that I did get more money . . . [I] it would enable me to barely be able get a car and pay for insurance so I could get a part time job and work, but I [am] sort of stuck where I am now.”

While work felt out of reach to some, others, like Val, a mid 50s African American female with depression cocaine abuse, felt work was a necessary step for her to meet her current life goals:

If I could just have a little more than I have now, if I . . . could find a job whereas I could work without my health issue interfering . . . [If] I could work a few hours and be able to meet my bills as they come in, that would be much better, to have my own key to my own place. It would be much better mentally, physically and all.

A few clients had part-time employment but were interested in working more hours. Linda, a mid 40 year-old white female with major depression who, like Janet, became anxious when she discussed her financial situation, worked part time with the elderly:

Sometimes it's difficult to work and earn extra money so that I can make ends meet . . . I would like to be able to make enough money with part-time wages so that I can take some of the stress and pressure off of myself.

Quantitative Results

People who expressed a desire to work during the qualitative interviews managed their money better than those who did not (Table 1). The only other significant difference between the two groups is that “work-mentioners” self-reported significantly more months in psychiatric hospitals during the course of their lives.

Table 1.

Comparison of Clients Who Expressed a Desire to Work and Those Who Did Not

Variable	No Desire to Work (n = 29)	Desire to Work (n = 20)	Statistic	p-value
	M (SD)	M (SD)
Money Mismanagement Measure Items 1-15	9.0 (6.0)	5.8 (5.4)	192	.045*
SSDI income last 30 days	519 (500)	578 (538)	−.39	.695
Total Income last 30 days	1336 (735)	1291 (812)	.20	.842
Expenses last 30 days	1260 (784)	1287 (861)	−.12	.908
Instrumental Role Functioning from Quality of Life Scale	7.97 (6.39)	8.25 (5.49)	−.16	.872
Months spent in psychiatric hospitalization	9.5 (21.9)	11.0 (9.3)	184	.031*
Months homeless	32.0 (48.8)	10.6 (12.7)	212.5	.241

^*p< .05

Discussion

It is notable that two-fifths of participants spontaneously expressed a desire to work during brief qualitative interviews about money management that did not contain specific inquiries about work. The large number of clients interested in returning to work was unanticipated. A review of interview transcripts confirms that the interviewer did not directly or indirectly probe for employment information and thus did not appear to lead participants to express their views on employment. The interview was conducted prior to delivery of any study-related counseling, and the battery of study assessments had no particular vocational focus.

Work was brought up by participants most commonly in response to the prompt, “Was there ever a time when your money situation was different?” It is possible that expressions of wanting to work reflected nostalgia for a time when participants were less impaired by their psychiatric conditions and able to work. The mention of work is consistent with current literature demonstrating that most persons with severe mental illness want to work (Frounfelker et al., 2011) and are motivated to work, in part, to change their financial situation (Dunn, Wewiorski, & Rogers, 2010).

Participants who expressed a desire to work managed their finances better than those who did not mention wanting to work. One interpretation of this finding is that, having attempted to manage their money well, participants found their limited incomes insufficient in regard to their life goals. It is also possible that both managing money well and a stated desire to work reflect the influence of an unanalyzed third factor such as ambition, being stably housed, or having sufficient psychological health to consider working. Additional research is needed to assess additional factors that may contribute to the relationship between better money management and employment readiness.

Although some people receiving disability benefits shun work for fear of losing their benefits, focusing on disability benefits and how they are spent may prompt some individuals to consider, or reconsider, the benefits of work. Our findings suggest that money management programs might profitably address employment issues. Including a discussion of vocational rehabilitation in a money management program may help people manage both their finances better and earn more, especially in conjunction with benefits counseling. These findings appear to support those of Elbogen and others: money management can be used to encourage other behavioral change via financial skill-building (Elbogen, Wilder, Swartz, & Swanson, 2008; Rosen, Rounsaville, Ablondi, Black, & Rosenheck, 2010) and asset building (Swarbrick & Stahl, 2009), rather than simply accounting for and allocating funds (Rosen, Bailey, & Rosenheck, 2003). In one study by our group, a multi-component intervention that encouraged prudent spending was associated with less cocaine use (Rosen et al., 2010) and a greater preference for delayed but larger rewards versus smaller immediate rewards (Black & Rosen, 2011). Such willingness to defer gratification for larger long-term benefits is a useful skill in many work situations.

One limitation of this study is that talking about wanting to work is only one step towards enrolling in vocational rehabilitation, and talk may not translate into action. Another limitation is that it was conducted at a single facility in people who were recently homeless or hospitalized. Thus its findings may not generalize to other people and settings. However, it is important to note that similar populations may not be referred for vocational counseling because they may be viewed as too impaired for employment (Salzer, Baron, Brusilovskiy, Lawer, & Mandell, 2011). These data confirm that people recently hospitalized and homeless are thinking about employment, and suggest that referral to vocational rehabilitation services of individuals who are rarely considered eligible for, or likely to be helped by, such interventions, may be in order. Incorporating a focus on employment into money management programs can assist individuals in gaining employment who otherwise might not be referred for employment services.

A financial focus offers both a new modality and a new approach to the challenge of engaging people with serious mental illnesses in work. Work is associated with numerous benefits including symptom reduction, less social disability, better functioning and lowered rehospitalization rates (Bell, Lysaker, & Milstein, 1996; Burns et al., 2009; Kilian et al., 2011; Rosenheck et al., 2006). As such, vocational rehabilitation represents an effective psychological intervention, and finding ways to incorporate it into other services may have substantial benefits.