CHAPTER 8:
WORKPLACE AND EMPLOYMENT

 

It is in the workplace that the human and the economic dimensions of mental health and mental illness come together most evidently. On the one hand, the workplace can contribute positively to mental well-being — it is where we derive a good part of our sense of social integration. As Merv Gilbert, a psychologist at the Mental Health Evaluation and Community Consultation Unit, Department of Psychiatry, University of British Columbia, told the Committee:

Work provides a sense of structure, social meaning, social supports, a place to go outside the home…and it also provides an income, which we do know is good for your mental health.[298]

Work has also been found to play an important role in recovery from mental illness.  Employment decreases the rate and duration of hospitalization and enhances quality of life. Surveys show that most persons living with serious mental illness want to work and see employment as a primary goal.

But few are employed. In fact, unemployment for persons living with serious mental illness is estimated to be as high as 90%.[299] In addition to unemployment, exclusion from the workforce often results in dependency on income security programs for survival. Unemployment leads to impoverishment and reduced social engagement, which in turn may worsen mental and physical illnesses. It also contributes to feelings of worthlessness and depression, and can lead to substance abuse.

While participation in the workforce can contribute positively to mental health it can also contribute to the development of mental health problems, including stress, depression and anxiety. Mr. Gilbert added that:

Therein we have one of the fundamental paradoxes we face today: Work is good for your mental health and work can make you crazy.[300]

The issues surrounding mental health and the workplace are complex and multifaceted. As professor Romaine Malenfant from the Université du Québec en Outaouais told the Committee:

Research increasingly shows that we must not only counter the lack of work, or unemployment, in preserving mental health, but also preserve the quality of work so that work plays its full role in building identity and enabling people to achieve their full potential.[301]

8.1        UNDERSTANDING THE HUMAN COSTS OF MENTAL ILLNESS IN THE WORKPLACE

8.1.1     The Many Factors That Contribute to the Development of Mental Illness

Exploring the complex relationship between work and mental health, professor Marc Corbière, from the Institute of Health Promotion Research, University of British Columbia, told the Committee:

…it is not always possible to establish a causal relationship between mental health problems and the workplace. Sometimes, factors stemming from both work and outside of work can explain the occurrence of mental health problems.[302]

In a recent article, “Nature and Prevalence of Mental Illness in the Workplace,” Carolyn Dewa and colleagues point out that:

The picture of mental illness in the workplace is becoming increasingly compli­cated. It is clear that there is a link between mental illness among workers and work-related stress. In turn, both of these are likely to be related to occupation, the work environment and the sex of the worker.

There is also evidence of an association between mental illness and physical disorders. Yet, few studies have considered how all these various factors interact to affect the prevalence of mental disorders among workers. Even fewer have consid­ered their relative contributions to disability in the workplace.[303]

The authors note that many factors contribute to the development of mental illnesses such as depression, but that no one really knows as yet how they all interact:

Yet, the most advanced etiological models of adult depression include factors related to genetic vulnerability, as well as develop­mental factors, neurobiological factors, childhood experiences, life events, chronic situations (e.g., a stressful work environment) and the presence of other disorders. …It is not yet understood what the due weight of each of these factors is and how they fit together.[304]

There are many ways of classifying the risk factors that contribute to the development of mental illness. In her testimony to the Committee, Lucie France Dagenais, researcher for the Commission des droits de la personne et des droits de la jeunesse in Quebec, identified two broad categories of risk factor:

The first are those related to social relations in the workplace. This includes violence, harassment, lack of social support and poor work relations. The second category includes those found in the work organization, which are much less known on an analytical basis. We identified work intensification, lack of flexibility, non-standard work schedules, lack of recognition, lack of expression groups, advancement on the basis of merit and flexibility.[305]

However, as Michel Vézina and colleagues point out in a recent article, “there is a regrettable absence of scientific consensus on how to define and measure a high-risk psychosocial work environment.” These authors define “psychosocial factors” as those that “refer to all organiza­tional factors and interpersonal relationships in the workplace that may impact health.” Among the factors that “make it possible to document the stressful nature of a work situation” they list:

…control (latitude, participation, use and development of skills), workload (quantity, complexity and time pressures), roles (conflict and ambiguity), interpersonal relationships (social support, harassment and recognition), career prospects (promotion, precariousness and demotion), organiza­tional climate or culture (communication, hierarchical structure and fairness) and the interaction between work and private life.[306]

Negative attitudes towards mental illness remain widespread throughout society and can compound the difficulties generated by conditions in the workplace. Employers and co-workers may fear people living with a mental disorder; they may think of persons with mental illness as unskilled, unproductive, unreliable, even potentially violent.[307]  These unwarranted perceptions may contribute to a reluctance to hire someone with a history of mental illness, or to limit that individual’s career advancement if a previously undisclosed mental illness is revealed.  Job loss is also a possible danger for those with the courage to “come out” of the closet at work.

It is important to recognize that this lack of understanding of the relationship between work and mental illness is not only an issue inside the workplace; it extends also to health professionals.  Merv Gilbert told the Committee:

 

Most mental health providers do not have a clue — I say respectfully — about what goes on in the workplace. Typical GPs faced with a patient coming in tears with a diagnosable disorder and being asked to make decisions about whether or not to stay at work, to return to work, how to deal with workplace issues, often are poorly informed. They may have a poorly written job description in front of them, if they are lucky, on which to make a determination as to whether that person should be at work, how the individual should be accommodated and what kinds of issues should be addressed. Therefore, I strongly suggest we need to educate the health care system as well.[308]

 

8.1.2     The Episodic Nature of Mental Illness

The episodic and cyclical nature of most mental illnesses is another factor that makes it harder to assess the impact of mental illness in the workplace. It creates additional difficulties in making the necessary accommodations at work for people living with mental illness. Unlike other disability groups, people with mental illness are rarely ill continuously; rather, they tend to cycle between periods of illness and wellness. When they are symptom-free, they are usually able to work and carry out the normal tasks of life. During episodes of psychiatric illness, however, they may be incapable of functioning at a level that would permit them to work in regular, full-time employment.

The cyclical, episodic, and unpredictable nature of serious mental illness can impede the establishment of a long-term and stable employment history. Having unexplained work-gaps on one’s resumé poses a formidable challenge when seeking to return to employment.

 

8.1.3     The Varying Nature of the Relationship Between Mental Illness and Work

People fall into a number of different categories, each of which confronts its own particular challenges with respect to employment-related mental health issues.

In many cases, the onset of a mental disorder occurs in late adolescence or early adulthood, at a time when the affected person’s education and training are not yet complete.[309] The process of obtaining qualifications can be interrupted, often never to be resumed. Young individuals in this category are significantly disadvantaged; their lack of skills and qualifications constitute a major and lifelong barrier to future employment.

For others, their careers may be disrupted by serious mental illness or addiction. Many never regain their foothold in the marketplace. For those who do find work, the periods outside the labour force caused by their mental illness often hinder their re-entry.

Three key barriers apply. First, individuals may be subject to discrimination by their employer and/or co-workers. Second, to cope with their illness they may require flexible work arrangements that employers are unwilling, or do not know how to provide. And third, those who have been outside the labour force for extended periods are unlikely to have the type of credentials, skills and employment experience that make them attractive to employers.

Finally, there is the broad category of people who are currently employed but whose productivity is affected to varying degrees by mental health difficulties, a state often referred to as “presenteeism.”

This diversity means that the issue of mental illness, addiction and work has to be explored from a number of different perspectives: making employment accessible to individuals who have never had a job; enabling individuals who have lost their job due to mental illness or addiction to reintegrate into the labour market; and studying how mental illness and addiction affects currently employed individuals.

 

8.1.4     Many Unanswered Research Questions

A review of current research illuminates how little is known about work-based mental illness and stress-related disorders, in terms either of defining the scope of the problem or establishing best practices to manage it.[310] In a recent article, Elliot Goldner and colleagues note that:

 There has been significant research activity on workplace health that has considered disability management, return to work and treatment. For the most part, however, such research has not directly addressed mental health problems or mental illness but have been focused upon various physical health problems encountered in the workplace (e.g., back injury and other musculoskeletal problems, brain injury, cardiac illness and chronic rheumatic diseases).[311]

They also point out that the paucity of research into mental health at work is not a new phenomenon:

In an article in 1993, Rachel Jenkins asked why mental health at work was so under-researched. More than a decade later, the same question remains relevant. There are many gaps in knowledge to be filled. Little is known regarding best practices in managing the disability associated with the most prevalent mental disorders (i.e., depression, anxiety disorders and substance use disorders). Although some information is available to assist people with severe mental disorders in obtaining employment, knowledge to help people maintain employment is lacking. Additionally, knowledge regarding systemic factors that influence disability management and return to work (e.g., employee assistance programs and disability insurance regulations) relevant to people with mental disorders is yet unavailable.[312]

Importantly, a further barrier to integrated research into mental health at work originates in the fact that specialists in different fields do not always speak the same “language.” This point is well made by Aldred H. Neufeldt:

A major challenge is that much existing knowledge is subject to what might be called an “isolated pockets syndrome.” The different kinds of research…are published in different types of journal, with cross-referencing infrequent. Epidemiological journals examine the relationship between functioning and psychiatric impairment. Occupational psychology and health literature examines topics such as workplace stressors, health, performance and absenteeism. Literature on rehabilitation and psychiatric fields examines specific treatments for psychi­atric conditions, along with the effective­ness of interventions such as short- versus longer-hospital stays, supported employ­ment, case management and others.[313]

For employers and employees alike this “language” diversity makes it even harder to establish best practices derived from full reviews of the scientific literature.

8.2       THE ECONOMIC IMPACT OF MENTAL ILLNESS IN THE WORKPLACE

To repeat, there are many important gaps in the research into mental health in the workplace. In its interim report, the Committee noted the absence of definitive statistics on the prevalence of mental illness and addiction in the workplace.[314]

Nonetheless, the Committee was informed that disability claims attributable to mental illness have overtaken claims associated with cardiovascular disease as the fastest-growing category of disability costs in Canada. Currently, mental illness and addiction account for 60-65% of all disability insurance claims among selected Canadian and American employers.[315]

Dewa and colleagues report that:

Over the last few years, the number of disability claims for mental disorders has been soaring. Between 1989 and 1994, according to the Health Insurance Association of America (1995), such claims doubled. In Canada, short- and long-term disability related to mental illness accounts for up to a third of claims and about 70% of the total costs — $15 to $33 billion annually.[316]

When compared to all other diseases (such as cancer and heart disease), mental illness and addiction rank first and second in terms of causing disability in Canada, the United States and Western Europe. Of the ten leading causes of disability worldwide, five are mental disorders: unipolar depression, alcohol use disorder, bipolar affective disorder, schizophrenia and obsessive-compulsive disorder.[317]

Moreover, as the Global Business and Economic Roundtable on Addiction and Mental Health has pointed out, mental illnesses — depression, anxiety disorders and substance abuse — are concentrated among men and women in their prime working years and among people aged 15 to 24.[318] Those Canadians most likely to experience a mental illness are amongst those at the heart of our working and consuming population.

Mental disorders, unchecked and disabling, impair the capacity of a significant segment of our population to contribute actively to the economy. Innovation and productivity are increasingly key to economic growth and prosperity. Mental disorders should be recognized as a leading source of disability among those we rely on to wield these critical levers of growth and competitiveness.

Productivity is affected both by “presenteeism” — days during which an individual is present at work but functions at less than full capacity — and by absenteeism — days during which an employee did not report to work. Mental illness and addiction are among the most important causes of absenteeism and presenteeism worldwide: a 1998 report of the World Health Organization observed that “more working days are lost as a result of mental disorders than physical conditions.”

In Canada, 20% of the normal work time of employees suffering from an undetected mental illness or addiction is not productive because it is “taken off.” Absenteeism at this rate is four times the rate of unaffected co-workers.[319]

Dewa and colleagues point out that:

It has been observed that a significant proportion of the burden of mental disorders arises from presenteeism days…This disability pattern distinguishes mental disorders from chronic physical conditions. Chronic physical conditions are associated with total disability days, while the predominant effect of psychiatric disorders is on partial disability; in fact, psychiatric disorders were responsible for 23 times as many partial disability days as total disability days.[320]

The value of lost productivity in Canada that is attributable to mental illness alone has been estimated at some $8.1 billion in 1998. More recently, if substance abuse is taken into account as well, that estimate grows to a loss to the economy of some $33 billion annually. This corresponds to 19% of the combined corporate profits of all Canadian companies, or 4% of the national debt.[321]

The costs of mental disorders in the labour force in Canada fall mostly on employers and employees through their payment of operational, payroll, premiums and out-of-pocket expenses. In statements made to the Global Business and Economic Roundtable on Addiction and Mental Health,[322] a number of major Canadian companies have indicated the extent of the costs of mental disorders in their workforces:

§         At CIBC, mental disorders produced absences averaging 95 days, compared to 40 days for other illnesses.

§         Great-West Life Assurance Company estimates that 30% of disability insurance claims relate to mental illnesses, and in the remaining 70%, a quarter or more have mental illnesses as a secondary or underlying diagnosis.

 

8.2.1     The Impact of Global Economic Trends on Mental Health Issues in the Workplace

Two trends, both highlighted by the Global Business and Economic Roundtable on Addiction and Mental Health, are of great significance for how mental health issues in the workplace must be addressed in the 21^st century.[323]

The first — the growing importance of knowledge, and of brain-based skill sets generally, to economic performance — provides a major positive incentive to address mental health issues in the workplace.

The second — the demands imposed by an investment-driven, globally competitive economy — reinforces the first trend in many ways, but it can also be the source of significant risk factors for mental illness in the workplace, in particular by increasing the level of stress placed on employees.

Most new jobs today demand brain-based (cerebral) skills and not the manual ones that were so important to previous generations. If it is true (as it almost certainly is) that we are in the midst of the emergence of a brain-based economy, mental health issues must now become front and centre in the economic affairs of Canada. 

This new reality is increasingly recognized at the highest levels of corporate Canada. Gordon Nixon, President and CEO, RBC Financial Group, has been quoted as saying that “this is an economy of mental performance and this defines the capacity of employees to be innovative — to think — a key asset.” Robert MacLellan, Executive Vice-President and Chief Investment Officer of the TD Bank Financial Group, has pointed to the importance of mental health in this context: “High rates of mental illness (brain-based disorders) rob our economy of employee capacity to be productive, innovative.”[324]

The Honourable Michael Wilson, former special advisor to the Health Minister on mental health in the federal government workplace, has formulated what the Global Business and Economic Roundtable on Addiction and Mental Health calls “The Wilson Principle”:

We have seen tremendous progress in preventing physical injuries and illnesses at work. The safety records of companies I am associated with are a source of great pride to them. I strongly encourage employers to build on these achievements.

It would be a shame to un-do 30 years of great progress in physical health and safety as a result of massive losses of productive capacity due to untreated mental illness in the workplace, especially depression.[325]

Evolution of the economy has thus produced a new and costly convergence — the advent of a brain-based economy at the same time that brain-based disorders are becoming the principal cause of disability in the labour force.

 

 

However, the implications of this new reality are not always immediately apparent, especially given the second trend mentioned above. The tendency for business to face intense pressure, especially from investors, to maximize shareholder value has led some companies to lay people off, and to struggle to “do more with less.” Beyond the tremendous human costs for the people involved in massive corporate downsizing, it is also important to recognize the possible longer-term consequences of this strategy for the enterprises themselves.

In an economy that puts a premium on workplace productivity and innovation, the prudent deployment of human capital is critical to competitive success. Human capital is really productive capacity. In an economy based on the mental performance of employees, the capacity to think, concentrate and innovate is critical. Strategies that undermine this capacity are likely to have detrimental effects on the long-term interests of the corporations that engage in them.

There is thus a strong and compelling business case to be made for making the workplace an environment that is conducive to mental health, since the payback in greater productivity will outweigh the costs of the investment required to significantly reduce mental health risk factors in the workplace.

8.3       WORKPLACE-BASED INITIATIVES

There are two broad categories of mental health intervention in the workplace. First, primary prevention measures aim to eliminate, or at least reduce, factors in the workplace that have a negative impact on the mental health of the workforce. Second, there is a range of secondary intervention strategies designed principally to reduce the effects of stressful work situations by improving the ability of individuals to adapt to and to manage stress.

 

8.3.1     Primary Prevention

There is evidence to indicate that well-structured organizational approaches generate more important, longer-lasting effects than secondary intervention strategies directed at individuals.[326] Preventative intervention research identifies work-related causes that must be addressed in order to reduce or eliminate stress. Two risk models identify those psychosocial and interpersonal relationship factors that contribute to making people sick: 1) Karasek’s “job demand-control-support” and 2) Siegrist’s “effort/reward imbalance” models.

The “job demand-control-support” model is based on the finding that a work situation characterized by a combination of high psychological demands and low decision latitude increases the risk of developing physical and mental health conditions.[327] The “effort/reward imbalance” model is based on the finding that a work situation characterized by a combination of high effort and low reward can be accompanied by emotional and physio­logical reactions that can have a negative impact on mental health.[328]

While “control” is central to the Karasek model, “social reciprocity” (i.e., the possibility of having access to legitimate advan­tages, duly earned in the process of performing the work) is the key concept for Siegrist’s model. Siegrist’s model is particularly well adapted to measuring the impact on mental health of a major characteristic of workplace changes in the past decade, namely, reduced security of employment.[329]

Various studies have identified workplace attributes that contribute both to profitability and to better mental health, including: employment security, self-managed teams and decentralized decision-making, extensive training, reduced status distinctions, and reduced barriers to sharing financial and performance information across the organization. Vézina and his colleagues refer to studies that identify five factors that are necessary for the success of a primary intervention project. They are:

…support from senior management and involvement of all of the hierarchy; employee participa­tion in discussions of problems and possible solutions; preliminary identification of worker populations at risk on the basis of validated theoretical models or their associ­ated manifestations; rigorous implementa­tion of necessary changes in targeted worker populations; on-site management of the procedure and changes.[330]

Studies have shown that if those factors are in place, interventions focused on organization of work can have considerable benefits, notably decreased absenteeism and symptoms of depres­sion, and even increased well-being and productivity. Despite this empirical evidence to support the health impact of these models, however, few comprehensive workplace intervention strategies have been implemented.

The Global Business and Economic Roundtable on Addiction and Mental Health has identified 10 management practices or behaviours that can precipitate or aggravate mental health problems in the workforce:

1.      Imposing unreasonable demands on subordinates and withholding information materially important to them in carrying out their jobs.

2.      Refusing to give employees reasonable discretion over the day-to-day means and methods of their work.

3.      Failing to credit or acknowledge their contributions and achievements.

4.      Creating a treadmill at work — too much to do, all at once, all the time.

5.      Creating perpetual doubt, employees never sure of what’s happening around them.

6.      Allowing mistrust to take root. Vicious office politics disrupt positive behaviour.

7.      Tolerating, even fostering, unclear company direction and policies, job ambiguity and unclear expectations.

8.      Sub-par performance management practices — specifically employee performance reviews — even good ones — which fail to establish the employee’s role in the company’s near or mid-term future.

9.      Lack of two-way communication up and down the organization.

10.  Managers rejecting, out of hand, an employee’s concerns about workload.[331]

The Committee agrees with the Roundtable that a successful primary intervention strategy must attempt to modify these unhelpful practices, and therefore recommends:

31	That the Canadian Mental Health Commission (see Chapter 16) work with employers to develop and publicize best management practices to encourage mental health in the workplace.

 

8.3.2    Secondary Intervention

Three types of secondary intervention are of particular importance: (1) disability management; (2) workplace accommodations; and (3) Employee Assistance Programs (EAPs).

 

8.3.2.1  Disability Management

Workplace disability management is widely used to return people with physical disabilities to the workplace. Factors found to enhance return to work are: employer participation, a supportive work climate, and cooperation between labour and management.  Although widely practiced in association with physical conditions, disability management programs are relatively new to the mental health field and are too little studied to determine their effectiveness.^[332]

Managing disability within the workplace can be complex, given that it is a shared responsibility of the worker, supervisors and managers, employee assistance programs, human resource managers, and the public health system.^[333]  The lack of “mental illness literacy” amongst employees, managers and supervisors also reduces the likelihood of speedy identification and resolution of mental health and addictions problems in the workplace.

A further challenge stems from the fact that the health care system and the workplace are very different, with differing cultures, languages, practices and priorities. The differing conceptual frameworks used by mental health and occupational health professionals can create gaps in understanding, that can lead to a poor coordination of services and result in delays in returning people to work.^[334] Creating common goals, a shared understanding and a common language that will allow information to be shared and knowledge to be conveyed across different systems is essential. What is needed are boundary walkers — leaders who are versed in both mental health and employer issues and who can help to integrate disparate systems more effectively over time.

The Committee therefore recommends:

 

32	That the Knowledge Exchange Centre to be created as part of the Canadian Mental Health Commission (see Chapter 16) assist employers, occupational health professionals and mental health care providers in developing a common language for fostering the management of mental illness in the workplace and in sharing best practices in this area.

 

8.3.2.2 Workplace Accommodations

Accommodation refers to “any modification of the workplace, or in the workplace procedures, that makes it possible for a person with special needs to do a job.”[335] Just as individuals with physical disabilities may require physical aids or structural changes to the workplace, individuals with mental disorders most often require social and organizational accommodations to be made.

Generally these involve changes to the way things have traditionally been done in a particular workplace. Permitting someone with a mental illness to work flexible hours, for example, provides him or her access to employment in the same way a ramp does for an individual in a wheelchair. Accommodation means, in effect, providing equitable treatment for individuals with disabilities, regardless of their type and source.

 

According to the Canadian Psychiatric Association,[336] accommodation should be built on positive arrangements that promote equality in employment, including:

§         Creating an environment in which arrangements are made in relation to the individual needs of each employee;

§         Respecting the employee’s desire for confidentiality as well as identifying the specific form and the degree of confidentiality required;

§         Being willing to engage in joint problem solving;

§         Making all arrangements voluntary for the employee, and being prepared to review plans periodically to meet changing needs;

§         Being flexible in enforcing traditional policies;

§         Being concrete and specific when identifying accommodations that are made. Putting them in writing is a good idea.

One study followed 240 persons with serious mental illnesses over a 10-year period who were able to maintain gainful employment, largely because formal work reintegration programs were in effect. These individuals earned $5 million, paid $1.3 million in income taxes, and saved the government an estimated $700,000 in welfare costs. The result was a net $2‑million increase in collective wealth.[337]

According to Mental Health Works, CMHA Ontario,^[338] there is no comprehensive list of the accommodations needed by people who are dealing with mental health issues, nor is there research that defines “best practice” approaches. Accommodation requires consideration of the individual needs of employees and the resources available to the employer. In any case, as systemic barriers are removed, the need for individual accommodation will decrease. For example, flextime programs can benefit all employees, while also allowing an employee with a mental illness who needs to modify his or her hours of work to do so without having to ask for any special further accommodation to be made. 

The duty to accommodate is not the employer’s alone — trade unions share this responsibility. In the Committee’s view, the interests of the employee are best served when management and unions work cooperatively in accommodating the return to work through job modifications and other such arrangements. In this context, it is important for all parties to remind themselves that the return to work process is, in effect, part of the recovery process for employees living with a mental disorder.

 

8.3.2.2.1           Other Mental Health Accommodations

Other possible mental health accommodations include the following.

Flexible scheduling

§         Part-time shifts (which may be used to return a worker to a full-time position).

§         More frequent breaks.

 

Changes in supervision

§         Modifying the way instructions and feedback are given. For example, written instructions may help an employee focus on tasks.

§         Having weekly meetings between the supervisor and employee may help to deal with problems before they become serious.

Changes in training

§         Allowing extra time to learn tasks.

§         Allowing the person to attend training courses that are individualized.

Modifying job duties

§         Exchanging minor tasks with other employees.

Modifying work space or changing location

§         Allowing an employee to relocate to a quieter area where he or she will be free from distractions.

§         Allowing an employee to work at home.

8.3.2.3 Employee Assistance Programs (EAPs)[339]

EAPs are employer-sponsored programs designed to alleviate and assist in eliminating a variety of workplace problems.  The source of these problems can be either personal (legal, financial, marital or family-related, mental health problems and illnesses, including addiction) or work-related (conflict on the job, harassment, violence, stress, etc.).

Typically, EAPs provide counselling, diagnostic, referral and treatment services.  Those staffing EAP programs usually hold a degree in a mental health or social service discipline (social work, psychology, psychiatry, counselling and/or marital and family therapy).  Some services may also be contracted out to qualified persons.

EAP services are available both in private and public organizations and are usually administered completely independently of other programs within the organization.  Confidentiality is the cornerstone of an effective EAP.  The anonymity of clients, the confidentiality of interviews, the maintenance, transfer and destruction of files are subject to applicable federal and provincial laws that define the conduct of counsellors.  Generally, information may be released by an EAP counsellor only in situations in which the client has provided informed and signed consent specifying what information is to be released and to whom.

The Committee was told that between 60% and 80% of Canadians who are employed in a medium-sized or large company (over 500 employees) currently have access to some form of EAP.  According to Rod Phillips, President and CEO, Warren Shepell Consultants Corporation, EAPs are very effective; they have become the primary portal through which working Canadians often get their first access to mental health care and addiction treatment:

In many cases, in our experience, you would have about 85 per cent of the people who we see in a given year getting sufficient treatment through the EAP program that they would require no further treatment. About 15 per cent of the people would then be referred into community programs or into the public health care system.[340]

EAPs also have a strong prevention component.  Much of the work being done with employers focuses on wellness and other programs that support a healthy mental health work environment.

EAPs have been widely adopted across North America and are positively regarded by employers and employees.^[341] They have certain limitations, however. For example, Ash Bender and his colleagues[342] expressed concern about the number of therapeutic sessions being offered to EAP clients; based on anecdotal evidence, these have decreased dramatically from seven per individual to fewer than three over the last 10 years.  The authors concluded that the likelihood is low of effectively addressing any serious substance abuse or mental illness problem in this limited therapeutic time frame.  This concern requires particular attention.

Mary-Ann Baynton, Director, Canadian Mental Health Association in Ontario, suggested to the Committee that it would be helpful if EAPs were able to provide people with access to “advocates” who could assist them in a variety of ways: 

That leads to the last recommendation, which is that we should have advocates. Many times, employers will say that they sent out the forms and people never filled them out or called back, they are not doing their part. The employers do not understand that the mental illness itself often makes it impossible for the person to get out of bed, never mind fill out a complicated set of forms. We are looking into having an advocate who can do this on behalf of people with mental health issues. However, it could be something that the EAPs or the employers themselves could provide.[343]

With regard to EAPs, the Committee recommends:

33

That employers increase the number of counselling sessions offered through Employee Assistance Programs (EAPs), especially in communities where access to other mental health services is limited. That research be undertaken to evaluate EAPs, and that the results be shared through the Knowledge Exchange Centre that the Committee recommends be created as part of the Canadian Mental Health Commission (see Chapter 16), with a view to strengthening the effectiveness of these programs.

 

8.4       TRAINING OPPORTUNITIES

Canadians with serious mental illness have relied heavily on community vocational rehabilitation programs that have often struggled to obtain adequate funding. The limited research that has been done suggests that not all vocational rehabilitation approaches achieve the same degree of success in moving people into employment.^{[344],[345],[346]} 

 

8.4.1     Vocational Rehabilitation Programs

Vocational rehabilitation programs are intended to help people become or remain economically independent through work.  Specialized vocational rehabilitation programs include career counselling, work assessment, work adjustment and conditioning programs, temporary employment and transitional employment placement.

 

Research into vocational rehabilitation is limited in scope and tends to be descriptive and anecdotal.  The assumption behind most vocational rehabilitation is that careful planning combined with a supported and slow re-entry into the workforce will increase the likelihood of success. The evidence available, however, suggests strongly that moving people quickly towards employment is more effective than a gradual, slow re-entry.  The longer the delay, the greater the risk in reducing employability through insufficient work experience.^[347] 

An additional barrier to employment includes relegating people with mental illness to entry-level, low-wage fields where they often experience little economic progress even when their job retention rates are similar to those of people without disabilities.  Minimal expectations by staff, paternalistic protectionism that shields clients from failure, and lack of outcome accountability have all contributed to the low success rate of vocational rehabilitation programs.^[348]

 

8.4.2    Supported Employment

In the mid-1980s, a new approach to employment emerged, known as supported employment.  Its emergence was prompted by a concern to avoid models that tended to foster dependency and to reduce the need for mental health clients to compete in the job market for employment. Supported employment involves placing clients as quickly as possible into jobs without any extensive preparation, while simultaneously providing ongoing, intensive on-the-job support and training using assigned job coaches. 

 

A comparative research review indicates that supported employment models have produced more positive outcomes than traditional vocational rehabilitation services, brokered vocational rehabilitation services, day treatment programs, pre-vocational programs, or sheltered workshops.^[349]  Reviewing 18 randomized control trials, researchers found that people participating in supported employment programs were significantly more likely to be employed than those who received pre-vocational training (at 12 months, 34% of those in supported employment were employed, compared with only 12% who had pre-vocational training).^[350]  It is important to note however, that this success rate (34%), although positive, remains relatively modest. 

 

8.4.3    Consumer Economic Development Initiatives

Consumer development initiatives emerged in the 1990s as a response by people living with mental illness to the failure of traditional vocational rehabilitation programs to help them achieve their employment goals.  People living with mental illness began to develop businesses which they both owned and operated. The underlying belief was that, if given the tools, they could play an important role both in supporting themselves and in advocating for mental health services and supports that are more effective and accountable.^[351]

These initiatives have included self-help organizations in which peer counselors facilitated mutual aid and education initiatives, as well as diverse consumer-run businesses which offered employment opportunities and business development skills to mental health consumers.  The research done on consumer-run initiatives demonstrates that this is a promising avenue to move people living with serious mental illness into the workforce.^[352] 

 

8.4.4    The Club House Model 

In many jurisdictions, Club Houses continue to be a mainstay in funded community service delivery.  Initially developed in the 1940s by former psychiatric patients, the goal was to help others make the transition from hospital to community.^[353] Club Houses offer vocational opportunities, problem-solving groups, case management, recreational activities, and academic preparation.^[354]  They operate under egalitarian rules and are run by staff and clients who seek to provide an accepting, culturally sensitive environment where people can socialize, mutually support each other and gain experience in graded employment opportunities to prepare them for their return to competitive employment.^[355] 

Pre-vocational training programs are intended to assist people living with mental illness to make the transition to employment through a two-step process.  Phase one is the provision of a “work ordered day” where clients work in teams with staff to operate and manage the Club House.  The second phase is an opportunity to participate in transitional employment programs where clients are placed in a series of paid but temporary jobs controlled by the Club House.  Despite the longevity and continued popularity of this concept, however, there is, however, limited evidence of the efficacy of Club Houses in achieving their vocational goals.

 

8.4.5    Sheltered Workshops

Widely used up until a decade ago, sheltered workshops now primarily serve the needs of developmentally delayed adults, although some provinces continue to include sheltered workshops in their community-based rehabilitation programs for people with mental illness. The little research that has been done shows a low success rate (in the range of 5‑10%) in assisting people living with a mental illness to obtain non-sheltered employment. In fact, participation in sheltered workshops may further entrench in those involved and the general public alike low expectations of the capacity of people with mental illness to work. 

 

8.4.6    Federal Initiatives

The Opportunities Fund for Persons with Disabilities was originally created as a pilot program in 1997, as part of the Government of Canada’s response to the report of the Federal Task Force on Disability Issues (the Scott report) in 1996. Funding for the Opportunities Fund became permanent in December 2000 and is administered by Social Development Canada.

The Opportunities Fund is an employability program for people with disabilities who have had little or no attachment to the labour force. Its objective is to help these people prepare for, get and keep jobs, or to become self-employed. To meet this objective, the government works in partnership with non-governmental organizations that represent people with disabilities, with the private sector and with provincial governments.  

The Opportunities Fund supports initiatives that:

§         encourage employers to hire workers with disabilities;

§         help people with disabilities build their employment skills, integrate into the labour market and/or become self-employed;

§         provide opportunities for work experience that could lead to stable employment; and

§         improve access to employment or employment services by providing personal support.

The Opportunities Fund now serves about 4,500 people with disabilities a year, although it is not known what percentage of these are people living with mental illness.

According to an evaluation conducted in 2001, one of the Opportunities Fund’s strengths is its individual, flexible approach to delivering services to clients. Assessments from Opportunities Fund participants, as well as the outcome data, have also shown that the program has helped individuals find work and has improved their employability and quality of life.

The Committee recommends:

34

That the Department of Human Resources and Social Development, through the Opportunities Fund for Persons With Disabilities, facilitate the establishment of a nation-wide supported employment program to assist persons living with a mental illness to obtain and retain employment. That this program promote the development of, and provide support for, alternative businesses that are both owned and operated by persons living with mental illness. That the Department of Human Resources and Social Development report on how many people living with mental illness are assisted through the Opportunities Fund for Persons With Disabilities

 

8.5       INSURANCE AND INCOME SUPPORT

8.5.1     Workers’ Compensation Boards[356]

In all provinces and territories, Workers’ Compensation Boards (WCBs) receive an increasing number of mental health-related claims (referred to as “occupational stress”); and in a growing number of cases, the Boards have provided compensation for such claims.

A review of occupational stress claims reported to WCBs was undertaken by the Association of Workers’ Compensation Boards of Canada to find out how many types of claims were filed on an annual basis, whether they were of an episodic or chronic nature, and how much compensation was paid in each case. This review proved to be very difficult. In many cases, the Boards do not collect this type of data, or if they do, the data are not comparable because the definitions employed by each WCB may be different (see Table 8.1). The review could not, therefore, provide a national perspective on the number of claims resulting from occupational stress and the associated costs of compensation.

Terry Bogyo, Director of Corporate Planning, Workers’ Compensation Board of B.C., explained to the Committee that provincial and territorial variations in the treatment of stress disorders was a consequence of the different legislative frameworks that exist in each jurisdiction:

…It is not reluctance on the part of the boards to provide the benefit, because the boards do what the legislation tells us to do.  We are the body that gives life to the legislation.  …That variability goes back to the responsibility of legislators to design legislation that is responsive to the social, political, economic, cultural and historical values that are inherent to that jurisdiction.  Whether it is right is not for the boards to say.  It is our job to administer that legislation.  It is not a matter of reluctance.  If the legislation says that we cover it, then indeed it would be covered by us.[357]

A major issue raised with respect to compensation by WCBs concerns the fact that, regardless of jurisdiction, it is more difficult to prove the genesis of a mental disorder than that of a physical illness. As a result, there is some controversy about whether and how mental disorders should be covered under workers’ compensation schemes. Under the occupational disease model used by WCBs, compensation for a disability is based on whether the disability arises from continuous exposure to hazardous conditions related to an individual’s employment. Yet, as we have seen, most advanced etiological models of mental disorders include a variety of factors, such as genetic vulnerability, developmental circumstances and neurobiological factors, in addition to factors such as a stressful work environment. The relative weight of each of these dimensions is not yet understood, nor is it clear how they fit together.

The Committee believes that it is important for all concerned parties to address these issues and recommends:

35	That the Canadian Mental Health Commission (see Chapter 16) work closely with provincial and territorial governments as well as with Workers’ Compensation Boards, employers and trade unions across the country to develop best practices with respect to compensation for occupational stress-related claims.

 

8.5.2    Employer-Sponsored Disability Insurance Plans

Two types of disability income insurance plans are offered by employers: short-term disability (STD) and long-term disability (LTD). STD plans replace a percentage of pre-disability employment earnings (70%, for example) for periods of less than one year’s duration (e.g., six months). They are generally harmonized with sick leave, other employee benefits and Employment Insurance (EI) benefits, providing continuity of income for the plan member who has suffered a disabling illness or injury.

TABLE 8.1

WORKERS’ COMPENSATION BOARDS IN CANADA: INTERJURISDICTIONAL COMPARISON OF OCCUPATIONAL STRESS COMPENSABILITY

 

Alberta	Compensation for occupational stress provided if: §       there is a confirmed diagnosis under the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders; §       the work-related events or stressors are the predominant cause of the injury; §       the work-related events are excessive or unusual in comparison to the normal pressures experienced by the average worker in a similar occupation; and §       there is objective confirmation of the events.
British Columbia	Compensable forms of stress include: §       stress caused by a sudden and unexpected traumatic event; and §       stress that results from a compensable injury such as severe anxiety following the amputation of a leg. §       Stress that is caused by the pressures encountered in daily personal and work life is not compensable.
Manitoba	Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.
New Brunswick	Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.
Newfoundland and Labrador	Legislative definition of injury covers stress only where it results from an acute reaction to a sudden and unexpected traumatic event and to exclude stress due to labour relations issues.
NWT & Nunavut	Claims for occupational stress are considered on a case-by-case basis.
Nova Scotia	Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.
Ontario	Mental stress is compensable in respect of situations where there is an acute response to a sudden and unexpected traumatic event arising out of and in the course of employment. Mental stress due to the employer’s employment decisions does not entitle a worker to benefits.
Prince Edward Island	Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.
Quebec	Stress is compensable if the worker can show a relationship between the illness and the work or a risk in the work.
Saskatchewan	Compensation for occupational stress is specifically allowed for as a matter of policy where clear and convincing evidence is provided that the work stress was excessive and unusual; routine industrial relations actions taken by the employer are considered normal and not unusual.
Yukon	Post-traumatic stress considered compensable under legislation; current practice is to assess all other stress-related claims on a case-by-case basis.

Source: Kishchuk, P. (March 2003) Expansion of the Meaning of Disability. Paper commissioned by the Yukon Workers’ Compensation Board, p. 12.

 

LTD plans focus on longer periods of disability. They typically commence payments after the disabled individual has been off work for a significant period, such as six months, and replace a specified percentage of the person’s pre-disability employment income, for example 70%. LTD benefits typically run for up to two years for recipients who are unable to perform their own jobs, and can continue to a limit of age 65 or the onset of retirement benefits for recipients who cannot perform their own or any reasonably comparable job. LTD benefits provided by the employer’s plan may be reduced by the amount obtained by the recipient under the Canada Pension Plan (Disability) (CPP(D) — see below).

An important aspect of both STD and LTD plans is the commitment to assist recipients to return to the workplace, preferably to their own jobs, or to another job if that proves not to be feasible. Consistent with this commitment, disability income insurance plans are designed to ensure that there is a financial incentive for recipients to return to work; thus disability income replacement benefits do not exceed, and are usually less than, pre-disability employment income. Disability insurance should not be a disincentive to work. In this context, the Canadian Psychiatric Association explained:

Disability insurance for any illness requires a precise definition of that illness. Whereas it is important that disabled psychiatric patients receive an adequate income to protect themselves from serious financial reverses over the time that they are not able to work, it is just as important to recognize that disability payments may constitute a major secondary gain actually impeding a patient’s progress and delaying rehabilitation. There are two factors to be considered: a) the prevalent misconception that work is ipso facto stressful and likely to aggravate a diagnosed psychiatric disorder; and b) the recognition that some patients who have undergone a serious psychiatric disorder may want to avoid exposure to what they presume to be stressful factors at work because of lack of confidence even after they have improved clinically. It should be recognized that return to work as soon as possible is likely to improve the patient’s self-esteem, reestablish him/her in a familiar social network and otherwise aid rehabilitation. There is some evidence that work deprivation may be one of the causes of psychiatric disorder.[358]

Employers, managers and insurers must become more knowledgeable about mental illness and addiction in order to better manage disability claims. During a recent speech, Bill Wilkerson, co-founder and CEO, Global Business and Economic Roundtable on Addiction and Mental Health, commented:

[The insurance] industry must develop a perspective based on knowledge of mental health issues. Like business generally, the insurance sector needs a mental health education agenda.

An example of where this is especially true is in the comorbidity of mental illness and physical chronic diseases as this pertains to: origin and the duration of human disability; the complexity, lengths and risks of treatment and recovery; and, the pace and timing of the sufferer’s return to work.

The insurance industry needs — at the levels of claims management — to know more about the medical science of mental health. … The industry needs to develop a knowledge base about the expanding universe of neuroscience and its illumination of the origins of behaviour.

 

8.5.3    Provincial and Territorial Social Assistance Programs

Insurance and income support programs provide some level of protection for persons living with mental illness who find themselves unable to work.  However, programs operated by workers’ compensation boards, employers, and the Government of Canada (e.g., CPP(D) and EI) share a key attribute — to qualify, individuals must have a job, often for a prolonged period of time.  This, coupled with a myriad of other eligibility criteria and time-limited benefits, frequently results in people living with mental illness having to turn to the income assistance programs of last resort — social assistance (i.e., welfare) programs operated by the provinces and territories.

Most often, social assistance programs distinguish between individuals who are able to work but unable to find employment, and those who are unable to work due to illness, disability or other cause.  For example, the Government of Ontario operates the Ontario Works program to assist those persons who are able to work but unable to find employment.  Here, applicants are expected to first use up their personal assets before they become eligible for assistance.  Benefit levels are low, and recipients are required to participate in retraining or other “employment activities.”  In short, “eligibility rules are designed to ensure that people turn to welfare only when all other financial resources have been exhausted.”[359] 

In contrast, those who are unable to work may be streamed into the Ontario Disability Support Program (ODSP).  Benefit levels are roughly twice those of Ontario Works, and while recipients are encouraged to work to the greatest extent possible, participation in related programs, such as retraining, is voluntary.  Also, applicants may retain a small amount of personal assets, some $5,000 in cash and RRSPs.[360] 

Unfortunately, as is the case with other income support programs, eligibility for ODSP is restricted.  Applicants must “have a substantial physical or mental impairment that is continuous or recurrent and is expected to last one year or more.”  Given the cyclical and unpredictable nature of mental illness, persons living with mental illness, and unable to work, may find themselves ineligible for ODSP. They are thus forced instead to rely on Ontario Works, even though they are not the target group for this program.

Strict eligibility criteria, including a requirement to first exhaust one’s own financial assets, are not the only problem associated with social assistance programs for persons with disabilities.  Benefits, while generally higher than those available under general welfare assistance programs, remain at a level that may result in financial hardship.  The following table includes a sampling of assistance rates and earning exemption amounts (i.e., the amount that can be earned before benefits are reduced) from across Canada:

	British Columbia	Ontario	Quebec
Amount per month for a single person with a disability	$856.42[361]	$959.00[362]	$835.67[363]
Earning Exemption Amount	$400.00[364]	$160.00[365]	$100.00[366]

Those who seek to return to work may be dissuaded by policies that would result in varying amounts of earned income being deducted from their benefit cheques, a loss of specific benefits (i.e., medical or drug benefits) or a loss of benefits altogether. 

Joan Edwards-Karmazyn, Manager, Consumers Health Awareness Network Newfoundland and Labrador (CHANNAL), summed up the dilemma faced by persons living with mental illness who rely on social assistance programs, saying:

The members of CHANNAL expressed a need for more affordable housing; fewer barriers to receiving educational and vocational services; and increased wage earning allowances while receiving social income supports.

Members state that they are caught in the system due to the need…for medication allowances. Therefore, one is hesitant to stop income allowances as stopping income allowances has a direct impact on also having medication benefits stopped. People are afraid to come off their benefits because the income they would make out in the real work world would not allow them to afford the $1,500 a month for medication alone.[367]

Therefore, the Committee recommends:

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That benefit levels and earning exemption amounts for social assistance programs for persons living with a mental illness be increased to reduce financial hardship and increase the incentive to work. That recipients of supplementary aid, such as help with the costs of medication, continue to be eligible for assistance for an extended period of time even if their incomes increase to levels where they are no longer eligible for financial aid for shelter or other living expenses.

 

8.5.4    Federal Income Security Programs[368]

The federal government has two income support programs that may be of assistance to persons living with a mental illness: the Disability Benefit provided by the Canada Pension Plan, and sickness benefits provided by Employment Insurance.  Tax assistance is available through the Disability Tax Credit.

8.5.4.1  Canada Pension Plan (Disability) Program (CPP(D))

The Canada Pension Plan (Disability) program is the largest single disability income program in Canada.  It is generally the “first payer” of disability benefits, preceding other entities such as provincial workers’ compensation boards and private insurance companies.

CPP(D) benefits are paid to contributors under age 65 who have a physical or mental disability that is “severe and prolonged” (lasting at least one year and preventing work on a regular basis) and who meet specific requirements relating to the level of earnings and years of contribution (contributions must have been paid in four out of the previous six years). Between 1980 and 2000, the proportion of individuals receiving CPP(D) benefits attributable to mental disorders increased sharply — from 11% to 23%.  Mental illness ranked second, behind disease of the musculoskeletal system, and affected a higher proportion of females than males.  In 2000, mental disorders also represented the most prominent cause of CPP(D) disability among younger beneficiaries.

For many years, individuals with mental illness and addiction and their representatives have raised concerns that CPP(D) does not address the question of mental illness and disability appropriately.  For example:

§         Many individuals with mental illness have limited work histories.  Because mental illness often strikes in early adulthood at a time when education, job skills and careers are being developed, many of these individuals are not eligible for CPP(D) due to their having insufficient years of employment.  Out of necessity, many turn to provincial social assistance programs for support.

§         To qualify for CPP(D) disability benefits, the beneficiary must accept the designation of having a “severe and prolonged” disability that means they cannot pursue any gainful employment on a regular basis.  Because of the cyclical and unpredictable nature of mental disorders, many individuals with mental illness can work, but often only on a part-time basis; they are not necessarily capable of achieving full financial independence.  In this vein, Jason Turcotte, of the Canadian Mental Health Association Office in Portage La Prairie, a member of the Partnership for Consumer Empowerment, told the Committee that “the all-or-nothing approach must be eliminated.  To provide benefits only to someone while they are 100-per-cent disabled is discriminating, disempowering, and a disincentive to recovery.”[369] Individuals with mental illness and addiction have recommended that CPP(D) pay partial or reduced benefits rather than full benefits to enable them to work part-time and still retain a portion of their benefits.

§         Since disability is currently equated with permanent unemployability, individuals on CPP(D) are reluctant to look for or take employment for fear of losing their benefits.  Those affected are penalized for trying to improve their circumstances even if they are not capable of participating in regular full-time work again.

§         Just over half of all initial applications to CPP(D) are denied; almost two-thirds of those rejected do not apply for reconsideration.  It has been suggested that the proportion of applications rejected from those with mental illness is much higher.  Some claim that the system is designed in such a way as to discourage individuals from pursuing rightful claims.  This is particularly true for individuals with mental disorders who, because of their illness, may lack the ability to “push the system.”

Once qualified for CPP(D), individuals are often reluctant to make any attempt to return to work or engage in other activities that could bring their declared impaired health status into question. Many fear that to do so risks triggering a reassessment of their CPP(D) eligibility, and raises the potential of a loss of income support.  According to one individual living with mental illness:

CPP-Disability puts individuals in a position of having to paint themselves in the worst possible light, and define themselves in the most negative way, just to convince the worker they actually require assistance. The entire process is based on pathology rather than recovery.^[370]

An additional concern is that CPP(D) may also inadvertently contribute to the process by which persons living with mental illness come to be viewed as permanently unemployable. Private insurance companies, in an effort to reduce their financial liability, often require their clients to apply for  CPP(D) because of its “first payer” status.  However, moving from employer-sponsored private insurance coverage to CPP(D) may further distance the individual from his or her employer, making a return to work more difficult.

Some progress has been made in addressing a number of these issues in recent years. For example, an allowable earnings provision gives recipients the flexibility of earning up to $4,100 a year while remaining on CPP(D) benefits. Greater personalized contact with applicants means that clients receive telephone calls during the decision-making process to discuss individualized needs and provide appropriate information about programs and services.

As well, a legislative change to the CPP was made in 2005 allowing for the automatic reinstatement of CPP(D) benefits.  This provision allows beneficiaries who are able to return to employment to try working without fear of losing their CPP(D) benefits.  If their disability recurs within a two year period, these clients are quickly returned to benefits.  Cecilia Muir, Director General, Office of Disability Issues, Social Development Canada, explained to the Committee the significance of this modifications to CPP(D):

I acknowledge it is not a whole solution, but this is a huge step forward.  This feature allows a person for up to five years not to have to go back through a reapplication and all the process that one would normally need to go through.  … The projections were that at least 300 persons a year would be able to benefit.  Those are individual people.[371]

Finally, to make people more aware that CPP(D) supports clients in their efforts to return to work without risking a loss of benefits, the program has implemented a communication strategy.  Communication tools include an annual “Staying in Touch” newsletter, website and annual correspondence to clients outlining CPP(D)  return to work provisions.  In addition, clients who are most likely to benefit from automatic reinstatement, in particular those with episodic disabilities,  receive letters explaining how the new provision works.

In its 2003 report, the House of Commons Standing Committee on Human Resources Development and the Status of Persons with Disabilities recognized that CPP(D) does not address the question of mental illness and disability appropriately.  The Committee made a number of recommendations to ensure that CPP(D) takes into account the cyclical and unpredictable nature of mental illnesses.  In addition, it recommended that the federal government develop, in consultation with stakeholders and health care professionals, specific evaluation tools for these particular disabilities to be used in assessing eligibility for CPP(D).

In its response to the House of Commons committee’s report, the federal government indicated that CPP(D) guidelines already recognize recurrent and episodic disabilities, including mental disorders, and that many individuals with mental disorders currently receive CPP(D) benefits.  Furthermore, it stated:

The Government therefore does not believe regulations and guidelines need to be changed to accommodate the needs of individuals with episodic or recurring conditions. Because the determination of disability for CPP is based on the functional limitations that prevent a person from working, and not simply on a medical diagnosis or prognosis, the adjudication process is able to take into consideration the short- and long-term impacts of recurrent or episodic medical conditions on the client’s ability to function in the workplace.[372]

The Committee strongly rejects this view, and it recommends:

37

That the eligibility criteria for Canada Pension Plan — Disability (CPP-D) benefits be modified so that persons living with a mental illness are no longer required to demonstrate that their illnesses are severe and prolonged, but only that their illness has been diagnosed and that they are unemployable and need income support. That the Government of Canada review how to coordinate better Employment Insurance (EI) sickness benefits and CPP-D, and examine how to eliminate structural barriers (i.e., financial disincentives) that limit opportunities to return to work. That the Government of Canada grant authority to the CPP to permit it to sponsor research on, and the testing of, new approaches that could target people with episodic disabilities, particularly episodic mental illness. That the Government of Canada explore ways to provide incentives to employers who hire persons living with mental illness, including the possibility of offering them CPP premium “holidays”.

 

8.5.4.2 Employment Insurance (EI)

Individuals with mental illness may also be eligible to receive EI benefits as a source of temporary income replacement.  Some concerns have been raised, however, with respect to EI:

§         In terms of EI eligibility, employees who are dismissed because of “misconduct” or quit “without just cause” are not eligible for EI benefits.  Due to stigma, individuals with mental illness in the workplace often conceal their illness.  When they experience difficulty on the job, they may be fired or may quit as a result of their illness, but would not be in a position to claim EI benefits because they have not previously disclosed their illness.

§         When a person applies for EI sickness benefits, he/she is required to obtain a medical certificate indicating how long the illness is expected to last.  The unpredictable nature of mental illness makes it difficult to provide this kind of medical information.

§         Individuals with mental illness and addiction share the view that EI should exempt individuals with recurring illnesses or disabilities from fulfilling the additional number of insurable hours required of those who are considered new to the labour force.  In their view, without this exemption, individuals with mental illness are unjustly disadvantaged.  Few are able to meet the eligibility criteria in terms of the total number of insurable hours required of new workers.

In his brief to the Committee, Dr. Sunil V. Patel, then President of the Canadian Medical Association, recommended that the federal government review CPP(D) and other federal income support policies to ensure that mental illness is on a par with other chronic diseases and disabilities in terms of the benefits available to affected persons.

The Committee is of the view that the criteria for EI sickness benefits should be modified so that persons living with a mental illness can qualify more easily for EI.  Given the enormity of the surplus in the EI Account,^[373] this change would not represent an undue burden on the public purse.

Therefore, the Committee recommends:

38	That Employment Insurance (EI) sickness benefits be modified so that persons living with a mental illness can qualify more easily.  Specifically, for persons living with a mental illness, the number of hours to be worked since the last claim should be reduced.

 

8.5.4.3 Disability Tax Credit (DTC)

The Disability Tax Credit^[374] is a non-refundable tax credit that can be used by persons with disabilities to reduce the amount of income tax they have to pay.  A person can transfer the credit to his or her spouse, or to another supporting person.  It is intended to help persons with disabilities bear the additional costs of living and working generated by their disability.  The basic credit is worth $1,037.76 per year.

Qualifying for the DTC is not an easy task.  In order to be successful, a person must have a severe and prolonged (i.e., minimum of one year) impairment that markedly restricts his or her ability to perform a basic activity of daily living.  The definition of “basic activity of daily living” is highly restrictive, and does not include working, housekeeping, recreational or social activities.^[375]  Also, the amount of tax relief is small.  Therefore, the Committee recommends:

39	That the eligibility criteria for the Disability Tax Credit (DTC) be modified so that persons living with a mental illness can qualify more easily, and that the amount of the DTC be increased.

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