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Most consumers with severe mental illness (SMI) want to work
and feel that work is an important goal in their recovery.
When they identify work as a goal, consumers usually mean
competitive employment, defined as community
jobs that any person can apply for, in integrated settings
(and in regular contact with nondisabled workers), and that
pay at least minimum wage. Unfortunately, assistance with
employment is a major unmet need in most mental health programs:
less than 15% of consumers are competitively employed at any
time.
Supported
employment is a well-defined approach to helping
people with disabilities participate in the competitive labor
market, helping them find meaningful jobs and providing ongoing
support from a team of professionals. First introduced in
the psychiatric rehabilitation field in the 1980s, supported
employment programs are now found in a variety of service
contexts, including community mental health centers (CMHCs)
and psychosocial rehabilitation agencies.
The
evidence for the effectiveness of supported employment
comes mainly from two types of research: day treatment conversion
studies and experimental studies. Four studies have examined
what happens when day treatment programs are replaced with
a supported employment program. In every case there was a
substantial increase in employment rates. The percentage of
consumers obtaining competitive jobs quadrupled after conversion
of day treatment to supported employment, while competitive
employment rates in centers not converting their services
were unchanged. No negative outcomes were reported in any
of these studies, except a small minority of consumers who
missed the social contact in day treatment. Centers converting
to supported employment had overwhelmingly favorable reactions
from consumers, family members, and program staff.
A second source
of evidence has been 9 carefully controlled experimental studies
comparing supported employment to traditional vocational approaches
(e.g., skills training preparation, sheltered workshops, transitional
employment). All 9 studies showed better employment outcomes
for consumers receiving supported employment. Importantly,
these studies suggest that supported employment is superior
to other vocational approaches in both urban and rural areas,
for persons of different ethnicities, for both men and women,
and for a wide range of other consumer characteristics. In
fact, we have yet to find any characteristic that would be
the basis for excluding someone from a supported employment
program. For example, consumers seem to benefit more from
supported employment than alternative programs regardless
of employment history, clinical history, diagnosis, or, surprisingly,
the presence of co-occurring substance use disorders.
Together,
these two lines of research suggest that between
40% and 60% of consumers enrolled in supported employment
obtain competitive employment while less than 20% of similar
consumers do so when not enrolled in supported employment.
Other employment outcomes, such as duration of employment
and wages, also generally favor supported employment programs.
Moreover, the beneficial effects of supported employment are
long lasting, as seen in one study that interviewed consumers
10 years after they were first enrolled.
Many consumers
hold more than one competitive job before finding one that
is optimal for them. Research suggests that when consumers
have jobs that match their preferences and capabilities, they
are able, with ongoing assistance from the supported employment
team, case managers, family members, and others, to keep these
jobs over a period of time. Career advancement is a critical
issue for all workers. Unfortunately, job opportunities available
to consumers with SMI are often restricted because of consumers'
limited work experience, education, and training. Consequently,
most initial supported employment positions are unskilled.
In addition, most supported employment positions are part
time. A continuing challenge for supported employment programs
is helping consumers capitalize on educational and training
opportunities so that they may qualify for skilled jobs and
develop satisfying careers.
Research
has identified several critical ingredients of supported employment
that are predictive of improved employment outcomes. These
include the following:
-
Services focus on competitive employment:
The agency providing supported employment is committed to
competitive employment as an attainable goal for its consumers
with SMI, devoting its resources for rehabilitation services
to this endeavor, rather than to intermediate activities,
such as day treatment or sheltered work.
- Eligibility
is based on consumer choice: No one is excluded
who wants to participate.
- Rapid
job search:
Job search begins soon after a consumer expresses interest
in working. Lengthy pre-employment assessment, counseling,
training, and intermediate work experiences are not required.
- Integration
with mental health treatment: Employment specialists
coordinate plans with the treatment team (case manager,
psychiatrist, etc.).
- Attention
to consumer preferences:
Choices and decisions about work and support are individualized
based on the consumer’s preferences, strengths, and
experiences.
- Benefits
counseling: Employment specialists provide
individualized planning and guidance on an ongoing basis
with each consumer to ensure well-informed and optimal decisions
regarding Social Security and health insurance. (see information
on the Medicaid Buy-In)
- Time-unlimited
and individualized support: Individualized
supports are provided to maintain employment, as long as
consumers want the assistance.
Supported
employment programs with greater fidelity to these principles
have been found to have higher employment rates. We use a
"fidelity" rating scale to measure the degree to
which a program follows these practice standards. Already
in widespread use, the 15-item Supported Employment Fidelity
Scale provides consumers and family members with a tool to
identify local providers who offer the best practice and to
advocate for better services.
Supported employment
has not been found to lead to increased risk for rehospitalization
or any other negative outcomes. On the other hand, enrolling
in a supported employment program does not, by itself, increase
quality of life or self esteem. However, consumers who are
employed for a meaningful length of time demonstrate significant
improvements in self-esteem and symptom management compared
with clients who do not work.
Access
to supported employment continues to be a problem, despite
extensive evidence showing its effectiveness. Less than 25
percent of consumers with SMI receive any form of vocational
assistance, and only a fraction of them have access to supported
employment. Supported employment programs are now commonly
found in CMHCs, but their capacity falls far short of the
need. Barriers to implementation of high-quality programs
exist at many levels-within federal, state, and local governments
(e.g., insufficient and fragmented funding, complexity of
Medicaid reimbursement policy, lack of attention to outcomes),
within agency or program administrations (e.g., resistance
to change, preoccupation with financial issues, leadership
issues), among clinicians and supervisors (e.g., low expectations
for recovery, lack of understanding), and in the collaboration
with consumers or families (e.g., lack of information). Information
about a national strategy to address these issues can be found
at the New
Hampshire-Dartmouth Psychiatric Research Center web site.
Consumers and family
members can have influence over setting standards and ensuring
adherence to the standards of supported employment at all
levels. They need to know what good services look like and
how to advocate effectively in legislation and funding decisions.
They should seek membership on advisory boards at all levels.
They can collaborate with state officials to fund supported
employment programs and to establish standards according to
evidence-based practices and have them incorporated in licensing
standards, requests for proposals for grant funds, and so
on. At the program level, consumers and family members can
demand that entrance criteria for supported employment be
based on a consumer's desire to work rather than symptoms
or work history. They can also participate in designing supported
employment programs. On an individual level, consumers and
family members can advocate for consumer choice and for services
that are proven to be effective.
In conclusion,
the main message that we would like to convey is that supported
employment is well defined, it is effective, and it is relatively
easy to implement, compared with many other types of psychosocial
practices.
For more in-depth information about mental illness, treatments
and supports, and medications;
please choose from the following topics:
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Illness | What is Mental Illness?
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