SUPPORTED EMPLOYMENTSUPPORTED EMPLOYMENT

Improving Lives Through WorkImproving Lives Through Work

Deborah R. BeckerDeborah R. Becker

Dartmouth Psychiatric Research CenterDartmouth Psychiatric Research Center

Webcast - CIMHWebcast - CIMH

February 28, 2006February 28, 2006

Traditional Vocational Services:Traditional Vocational Services:Typical FeaturesTypical Features

StepwiseStepwise: Training or sheltered : Training or sheltered work firstwork first

Work readiness criterion: Work readiness criterion: Clients Clients screened for placementscreened for placement

Brokered: Brokered: Different agencies Different agencies provide vocational and mental provide vocational and mental health services health services

Short-term:Short-term: Services reduced when Services reduced when job is foundjob is found

Competitive Employment for Competitive Employment for People with Serious Mental People with Serious Mental

IllnessIllness

Say they want to work: 70%Say they want to work: 70% Are currently working: <15%Are currently working: <15% Current access to supported Current access to supported

employment: <5%employment: <5%

Definition ofDefinition of Supported Employment Supported Employment

Mainstream job in communityMainstream job in community Pays at least minimum wagePays at least minimum wage Work setting includes people who don’t Work setting includes people who don’t

have a disabilityhave a disability Service agency provides ongoing Service agency provides ongoing

supportsupport Intended for people with most severe Intended for people with most severe

disabilitiesdisabilities

Definition of Competitive Definition of Competitive EmploymentEmployment

Pays at least minimum wagePays at least minimum wage Integrated community Integrated community

settingsetting ““Owned” by the workerOwned” by the worker Not set aside for people with Not set aside for people with

disabilitiesdisabilities

Evidence-Based PracticeEvidence-Based Practice

Program model validated by Program model validated by rigorous research (different rigorous research (different investigators)investigators)

Has guidelines describing Has guidelines describing critical componentscritical components

Has a treatment manualHas a treatment manual

Primary Evidence for Primary Evidence for Supported EmploymentSupported Employment

5 day treatment conversion studies5 day treatment conversion studies

13 completed randomized 13 completed randomized controlled trialscontrolled trials

3 correlational3 correlational studies of work and studies of work and program implementationprogram implementation

Competitive Employment Rates in 12 RCTs of Supported Employment

0%10%20%30%40%50%60%70%80%90%

96 NH (IPS)

94 NY(SE)

04 CA

(IPS)

04 IL

(IPS)

04 CT (IPS)

05 SC

(IPS)

05HK

(IPS)

99 DC (IPS)

95 IN (SE)

00 NY(SE)

05QUE(IPS)

97 CA (SE)

02 MD(IPS)

Supported Employment Control Control 2

Conclusions: Randomized Controlled Conclusions: Randomized Controlled Trials of Supported EmploymentTrials of Supported Employment

In 13 of 13 studies, SE had significantly In 13 of 13 studies, SE had significantly better competitive employment better competitive employment outcomes than controls outcomes than controls

Mean across studies of consumers Mean across studies of consumers working competitively at some time:working competitively at some time:– 60% for supported employment60% for supported employment– 22% for controls22% for controls

Long-Term Follow UpLong-Term Follow Up

3 supported employment research 3 supported employment research studies - 8-12 yearsstudies - 8-12 years

Similar findingsSimilar findings– Most worked for payMost worked for pay– Current jobs were mostly Current jobs were mostly

competitivecompetitive– People held multiple jobs over People held multiple jobs over

timetime

Positive Outcomes from Positive Outcomes from Competitive WorkCompetitive Work

Higher self-esteemHigher self-esteem Better control of psychiatric Better control of psychiatric

symptomssymptoms More satisfaction with More satisfaction with

finances and with leisurefinances and with leisure

(Bond et al., 2001(Bond et al., 2001))

What Does Supported What Does Supported Employment Cost?Employment Cost?

Some programs, $2,000-$4,000 per Some programs, $2,000-$4,000 per client per year (Clark, 1998).client per year (Clark, 1998).

Latimer (2004) $2,449 per full-year Latimer (2004) $2,449 per full-year equivalent client.equivalent client.

Figures vary according to severity of Figures vary according to severity of disability, local wages of employment disability, local wages of employment specialists, caseload sizes, and how specialists, caseload sizes, and how much indirect costs and costs of much indirect costs and costs of clinical services are included.clinical services are included.

Evidence-Based Evidence-Based PrinciplesPrinciples

Eligibility is based on consumer choice Eligibility is based on consumer choice Personalized benefits planning is providedPersonalized benefits planning is provided Supported employment is integrated with Supported employment is integrated with

treatment treatment Competitive employment is the goalCompetitive employment is the goal Job search starts soon after a consumer Job search starts soon after a consumer

expresses interest in workingexpresses interest in working Follow-along supports are continuous Follow-along supports are continuous Consumer preferences are importantConsumer preferences are important

Eligibility Is Based on Eligibility Is Based on Consumer ChoiceConsumer Choice

Consumers are not excluded Consumers are not excluded because they are not “ready” or because they are not “ready” or because of prior work history, because of prior work history, hospitalization history, substance hospitalization history, substance use, symptoms, or other use, symptoms, or other characteristics. characteristics.

No one is excluded who wants to No one is excluded who wants to participate.participate.

ReferralReferral Make referral process simple!Make referral process simple! Have minimal eligibility criteriaHave minimal eligibility criteria

– Unemployed (or working non-Unemployed (or working non-competitively) and wants competitive competitively) and wants competitive employment, oremployment, or

– Employed, but not receiving Employed, but not receiving employment supports, and wants such employment supports, and wants such supportsupport

Involve multiple stakeholdersInvolve multiple stakeholders

EngagementEngagement Build trusting, collaborative Build trusting, collaborative

relationshiprelationship Assume contacts are mostly Assume contacts are mostly

outside mental health settingoutside mental health setting Maintain ongoing contact Maintain ongoing contact Involve family, treatment team, Involve family, treatment team,

and other supportersand other supporters

Personalized Benefits Personalized Benefits Planning Is ProvidedPlanning Is Provided

Benefits planning and Benefits planning and guidance help consumers guidance help consumers make informed decisions make informed decisions about job starts and changes.about job starts and changes.

Benefits CounselingBenefits Counseling Fear of losing benefits is major barrier to Fear of losing benefits is major barrier to

employmentemployment Concerns of consumers and families Concerns of consumers and families

often underestimated by cliniciansoften underestimated by clinicians Rules and regulations are complicatedRules and regulations are complicated Benefits counseling provides consumer-Benefits counseling provides consumer-

specific informationspecific information

Supported Employment Is Supported Employment Is Integrated with Mental Health Integrated with Mental Health

TreatmentTreatment Employment specialists Employment specialists

coordinate plans with the coordinate plans with the treatment team, e.g., case treatment team, e.g., case manager, therapist, manager, therapist, psychiatrist, etc.psychiatrist, etc.

Supported Employment UnitSupported Employment Unit

Individual caseloads, but help Individual caseloads, but help each other (with job leads, etc.)each other (with job leads, etc.)

Caseloads of about 20 consumers Caseloads of about 20 consumers or lessor less

Weekly team meetings + Weekly team meetings + individual supervisionindividual supervision

Effective Structure of Effective Structure of Integrated ServicesIntegrated Services

Co-located at the same agencyCo-located at the same agency Integrated recordsIntegrated records Frequent contact between employment Frequent contact between employment

staff and treatment team membersstaff and treatment team members Employment specialists in treatment Employment specialists in treatment

team meetingsteam meetings

Competitive Employment Competitive Employment Is the GoalIs the Goal

The agency needs to devote sufficient The agency needs to devote sufficient resources to supported employment to resources to supported employment to permit full access to all consumers permit full access to all consumers who seek competitive employment who seek competitive employment

Consumers interested in employment Consumers interested in employment are not steered into day treatment or are not steered into day treatment or sheltered work.sheltered work.

Vocational ProfileVocational Profile Gather comprehensive Gather comprehensive

information from variety of information from variety of sources over 1-2 weekssources over 1-2 weeks–ConsumerConsumer–Family, friendsFamily, friends–Former employersFormer employers–Treatment teamTreatment team

Employment PlanEmployment Plan

Explore jobs by visiting work Explore jobs by visiting work sitessites

Develop employment planDevelop employment plan Revise assessment and Revise assessment and

employment plan based on employment plan based on consumer’s experiencesconsumer’s experiences

Disclosure of Psychiatric Disclosure of Psychiatric StatusStatus

Disclosure is the consumer’s Disclosure is the consumer’s choicechoice

Nature of disclosureNature of disclosure–When to disclose?When to disclose?–How much to disclose?How much to disclose?–Who to disclose to?Who to disclose to?

Job Search Starts Soon Job Search Starts Soon After A Consumer After A Consumer

Expresses Interest In Expresses Interest In WorkingWorking

Pre-employment assessment, Pre-employment assessment, training, and counseling are training, and counseling are kept to a minimum.kept to a minimum.

Individualized Job SearchIndividualized Job Search

Base on person’s preferences, Base on person’s preferences, strengths, abilities, experiences, strengths, abilities, experiences, and deficits (e.g., substance use)and deficits (e.g., substance use)

Seek:Seek:–Permanent competitive jobs Permanent competitive jobs –Diverse jobs suiting individual Diverse jobs suiting individual

consumersconsumers–Different settingsDifferent settings

Ways to Find JobsWays to Find Jobs Identify leads primarily through Identify leads primarily through

networking networking Include family and treatment teamInclude family and treatment team Attend job fairsAttend job fairs Use Chamber of Commerce and Use Chamber of Commerce and

community organizations (e.g., community organizations (e.g., Rotary Club)Rotary Club)

More Ways to Find JobsMore Ways to Find Jobs Newspaper (Newspaper (HoweverHowever, lots of , lots of

others seeking same job)others seeking same job) InternetInternet Previous employersPrevious employers Tell everyone you meetTell everyone you meet Track contactsTrack contacts Stay persistentStay persistent

Employer QuestionsEmployer Questions Why is the applicant with an Why is the applicant with an

employment specialist (or not)?employment specialist (or not)? What is the role of the employment What is the role of the employment

specialist?specialist? Are there fees?Are there fees? Why are there work gaps ?Why are there work gaps ? Can the person do the job?Can the person do the job?

Benefits to EmployerBenefits to Employer Work Opportunities Tax CreditWork Opportunities Tax Credit Pre-screeningPre-screening Assessment of skills and strengthsAssessment of skills and strengths Guidance regarding accommodationsGuidance regarding accommodations Short-term job coachingShort-term job coaching Ongoing assistance available to Ongoing assistance available to

employer and employeeemployer and employee

Follow-Along Supports Follow-Along Supports Are ContinuousAre Continuous

Supported employment staff Supported employment staff continue to stay in regular continue to stay in regular contact with consumer and contact with consumer and (when appropriate) the (when appropriate) the employer without arbitrary employer without arbitrary time limits.time limits.

Reasonable Reasonable AccommodationsAccommodations

CommunicationCommunication–Temporary job coachTemporary job coach–Written instructionsWritten instructions–Co-worker buddy/mentorCo-worker buddy/mentor–Change in supervisorChange in supervisor–Praise and positive Praise and positive

reinforcementreinforcement

Reasonable Reasonable AccommodationsAccommodations

Flexible SchedulingFlexible Scheduling–Part-time hoursPart-time hours–Self-paced workloadSelf-paced workload–Frequent work breaksFrequent work breaks–Clinic appointmentsClinic appointments–Paid/unpaid hospital leavePaid/unpaid hospital leave

Reasonable Reasonable AccommodationsAccommodations

Work SettingWork Setting

–Access to waterAccess to water

–Access to rest areaAccess to rest area

–Changes in work stationChanges in work station

–Remove/reduce distractionsRemove/reduce distractions

–Use of headsets or white noiseUse of headsets or white noise

Reasonable Reasonable AccommodationsAccommodations

Work TasksWork Tasks–Additional training timeAdditional training time–Gradual increase in job dutiesGradual increase in job duties–Job sharingJob sharing–Restructuring job with Restructuring job with

essential featuresessential features

Job EndingsJob Endings

Each job viewed as learning experienceEach job viewed as learning experience Job transitions are considered normalJob transitions are considered normal With a job loss, consumer and entire With a job loss, consumer and entire

(SE and treatment) team strategize for (SE and treatment) team strategize for next stepnext step

Consumer Preferences Are Consumer Preferences Are ImportantImportant

Job finding is based on Job finding is based on consumers’ preferences, consumers’ preferences, strengths, and work strengths, and work experiences, not on a pool of experiences, not on a pool of jobs that are available.jobs that are available.

Job Preferences Are ImportantJob Preferences Are Important

Competitive JobsCompetitive Jobs LandscaperLandscaper Machine OperatorMachine Operator PhotographerPhotographer ReceptionistReceptionist ReporterReporter Sales ClerkSales Clerk Security officerSecurity officer WelderWelder

More Competitive JobsMore Competitive Jobs Baker’s assistantBaker’s assistant Childcare WorkerChildcare Worker Data EntryData Entry Deli Meat CutterDeli Meat Cutter Grocery Bagger/Carriage AttendantGrocery Bagger/Carriage Attendant HousekeeperHousekeeper DishwasherDishwasher

Role of PractitionersRole of Practitioners Provide encouragement and Provide encouragement and

support - foundation for support - foundation for realizing potentialrealizing potential

Point out strengths and gifts - Point out strengths and gifts - translate into job translate into job opportunitiesopportunities

Coordinate clinical and Coordinate clinical and vocational servicesvocational services

More RolesMore Roles Problem solve employment needsProblem solve employment needs Be positiveBe positive Develop transportation planDevelop transportation plan Help obtain supplies/equipment Help obtain supplies/equipment

for jobfor job Assist with 2 forms of ID, Assist with 2 forms of ID,

applications, researching jobs and applications, researching jobs and businessesbusinesses

More RolesMore Roles Help plan good job matchesHelp plan good job matches Help people manage their Help people manage their

illnessesillnesses Help people manage substance Help people manage substance

useuse Help people manage Help people manage

interpersonal issues on jobinterpersonal issues on job Provide follow-along supportProvide follow-along support

Role of Employment Role of Employment SpecialistsSpecialists

Engage peopleEngage people–ListenListen–Be respectfulBe respectful–Promote self efficacyPromote self efficacy

Develop vocational profileDevelop vocational profile Assist consumer with employment Assist consumer with employment

planplan

More RolesMore Roles

Ensure access to benefits counselingEnsure access to benefits counseling Discuss disclosure (ongoing)Discuss disclosure (ongoing) Job searchJob search Employer educationEmployer education Job supportJob support Team playerTeam player

Role of ConsumersRole of Consumers Develop your work planDevelop your work plan Access comprehensive benefits Access comprehensive benefits

counselingcounseling Identify job choicesIdentify job choices Participate in job searchParticipate in job search Connect with working peers Connect with working peers Update support planUpdate support plan

Collaboration with Collaboration with Vocational RehabilitationVocational Rehabilitation

Overcome system differencesOvercome system differences Learn each other’s systemLearn each other’s system Define rolesDefine roles Serve togetherServe together

VR ServicesVR Services

VR counselors VR counselors –purchase services purchase services –arrange services from arrange services from

other agenciesother agencies–provide guidance and provide guidance and

counselingcounseling

VR ServicesVR Services TrainingTraining Situational assessmentSituational assessment Job shadowingJob shadowing Job-related equipment, suppliesJob-related equipment, supplies TuitionTuition PlacementPlacement PlanningPlanning SupportSupport

Role of EmployersRole of Employers

Hire qualified employeesHire qualified employees Learn ways to support employeesLearn ways to support employees Communicate with employment Communicate with employment

specialistspecialist Tell other employers about Tell other employers about

untapped workforceuntapped workforce

Mental Health Agency’s Mental Health Agency’s RoleRole

Employment is an agency goalEmployment is an agency goal Employment is viewed as part of Employment is viewed as part of

quality of lifequality of life Agency demonstrates Agency demonstrates

importance of employmentimportance of employment Culture of recoveryCulture of recovery

Key Factors in Key Factors in ImplementationImplementation

Build ConsensusBuild Consensus Maximize FinancingMaximize Financing Examine Agency PhilosophyExamine Agency Philosophy Identify LeadershipIdentify Leadership Key on Organizational StructureKey on Organizational Structure Provide Ongoing TrainingProvide Ongoing Training Make Time CommitmentMake Time Commitment Track Process and OutcomesTrack Process and Outcomes

SE FidelitySE Fidelity StaffingStaffing

– Caseload SizeCaseload Size– Vocational Services StaffVocational Services Staff– Vocational GeneralistsVocational Generalists

OrganizationOrganization– Integration of Rehab. + MH Integration of Rehab. + MH

TreatmentTreatment– Vocational UnitVocational Unit– Zero Exclusion CriteriaZero Exclusion Criteria

SE Fidelity cont.SE Fidelity cont.

ServicesServices– On-going Work-based Assess.On-going Work-based Assess.

– Rapid Job SearchRapid Job Search

– Individualized Job SearchIndividualized Job Search

– Diversity of JobsDiversity of Jobs

– Permanence of JobsPermanence of Jobs

SE Fidelity cont.SE Fidelity cont.

Services Services –Jobs as TransitionsJobs as Transitions–Follow-along SupportsFollow-along Supports–Community-based ServicesCommunity-based Services–Assertive Engagement and Assertive Engagement and

OutreachOutreach

What About Supported What About Supported Education?Education?

Consumer choice always a primary Consumer choice always a primary considerationconsideration

Education and training expand optionsEducation and training expand options SE program should help consumers enroll SE program should help consumers enroll

in community programs (GED classes, in community programs (GED classes, colleges, technical schools)colleges, technical schools)

ResourcesResources

Dartmouth Vocational Dartmouth Vocational Publication ListPublication List

karendunn@dartmouth.edukarendunn@dartmouth.edu 603-448-0263603-448-0263

More ResourcesMore Resources

A A Working Life for People Working Life for People With Severe Mental IllnessWith Severe Mental Illness--Becker and Drake, Oxford Becker and Drake, Oxford University Press, 2003University Press, 2003

Supported employment Supported employment resource kit resource kit Mentalhealth.samhsa.govMentalhealth.samhsa.gov

SummarySummary People with severe mental illness People with severe mental illness

can work in competitive can work in competitive employmentemployment

Programs following evidence-based Programs following evidence-based principles of supported employment principles of supported employment have better outcomeshave better outcomes

Programs must address Programs must address implementation factors to be implementation factors to be successfulsuccessful