Abstract
Occupational dysfunction is one of the most devastating and disabling consequences of severe mental illness. Supported employment (SE) is an evidence-based practice for assisting clients with severe mental illness to find and keep competitive jobs in the community. The key elements of SE include rapid, individualized job searching, job-based assessment, benefits counseling, time-unlimited job support, and integration of vocational and mental health services. Further, any client who wants to participate is eligible for SE services, and all services are based on the client’s individual preferences.
Far and away the best prize that life offers is the chance to work hard at work worth doing.Theodore Roosevelt, 1903.
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Keywords
Definition and Background
Supported employment is a form of work rehabilitation that helps clients obtain competitive work (i.e., jobs that pay minimum wage or higher, that are available to any individual, regardless of disability status, and where disabled and nondisabled coworkers work together). The manualized form of supported employment, individual placement and support (IPS), was developed by Becker and Drake (2003).
Unlike conventional vocational approaches that emphasize prevocational training and extensive preparation, supported employment programs provide clients with rapid, individualized job searching and placement in competitive work. Placement is followed by on-the-job training as needed and ongoing, time-unlimited support from the employment specialist. Support can consist of any counseling , training, or coaching the client needs to keep the job; assessment of the client’s performance and preferences is continuous. Supported employment programs are integrated within mental health care, such that the employment specialist is part of a multidisciplinary treatment team. As this is a community-based intervention, the employment specialist often conducts meetings in the client’s setting of choice (e.g., library, career center, coffee shop, home) to focus on client strengths and rehabilitation rather than “patienthood.” Work rehabilitation and employment can result in greater income, community integration, and improvement in symptom severity, increased self-esteem , and quality of life (Bond et al. 2001).
Supported employment is an evidence-based practice in psychiatric rehabilitation, with multiple randomized controlled trials and meta-analyses demonstrating its effectiveness over conventional vocational rehabilitation (Bond et al. 2001, Bond 2004, 2007, 2008; Cook et al. 2005; Twamley et al. 2003).
Purpose
Supported employment helps clients obtain and maintain competitive employment.
Method
Candidates for the Intervention
Clients with psychiatric disabilities who want to return to work are good candidates for supported employment. Supported employment programs do not exclude clients for reasons of “work readiness,” diagnosis, substance use history, legal history, or level of disability (Bond 2004). Indeed, existing evidence strongly indicates that job searches should not be delayed in favor of skills training or other extended preparation (Bond et al. 2012a).
Epidemiology
Although most individuals with psychiatric illness want to work, employment rates are only 10–25 % (Latimer et al. 2004). With the assistance of supported employment, up to two thirds of clients who want to work can obtain jobs (Bond et al. 2008; Bond and Kukla 2011a; Cook et al. 2005; Twamley et al. 2003).
Settings
Supported employment is most commonly used in outpatient psychiatric settings. Any client with a stated goal of working should be offered supported employment.
The Role of the Occupational Therapist (OT)
The OT, referred to in supported employment as the employment specialist, is responsible for delivering all vocational services. The employment specialist typically has a bachelor’s or master’s degree and provides services to a caseload of 20–25 clients. In addition to the activities described above, the employment specialist may also provide transportation to interviews and attend interviews with the client, depending on the client’s preference for disclosure. Better employment outcomes have been linked to increased IPS service intensity and characteristics of the employment specialist (e.g., percentage of time in the community, frequency of contact with clients; Bond and Kukla 2011b; McGuire et al. 2011; Taylor and Bond 2012).
Results
Clinical Application
Supported employment programs consist of the following phases: (1) initial assessment: discussion of the client’s job skills, past employment experience, current employment goals and preferences, and benefits counseling; (2) job searching: collaborative effort to create a résumé, complete applications, and prepare for interviews; and (3) time-unlimited follow-up support: the employment specialist provides ongoing support as needed, and checks in regarding stressors, symptoms, or any problems at work.
How the Intervention Eases Impairments, Activity Restrictions, and Participation Restrictions
Severe mental illness is associated not only with psychiatric symptoms but also with cognitive impairment , including difficulty with attention , learning and memory, and problem solving. Employment specialists assist clients by helping them find jobs that are a good match for their energy level, their ability to cope with various job stressors, and their cognitive strengths. Once the client obtains a job, the employment specialist can help the client troubleshoot symptom exacerbations and cognitive problems on the job. For example, the employment specialist might help a client who hears voices learn to ignore the voices in order to maintain attention on job tasks. The integrated nature of supported employment allows the employment specialist to work closely with other providers to help the client navigate medication adjustments or participate in other psychosocial treatment .
Evidence-Based Practice
The effectiveness of supported employment has been well established in the literature. A 2003 meta-analysis of 11 randomized controlled trials of vocational rehabilitation in schizophrenia and other psychotic disorders showed that 51 % of supported employment participants obtained competitive work, compared to only 18 % of conventional vocational rehabilitation clients (Twamley et al. 2003); a 2008 updated review demonstrated similar findings (61 % vs. 23 %; Bond et al. 2008). Further, a recent meta-analysis including 14 randomized controlled trials and a total of 2265 people concluded that supported employment significantly increased rates of any employment over 1 year, and increased job tenure of competitive employment compared to other vocational approaches (Kinoshita et al. 2013). Follow-up studies ranging from 8 to 12 years have demonstrated that between 33 and 71 % of supported employment clients worked at least half of the follow-up years (Becker et al. 2007; Salyers et al. 2004).
In sum, IPS has consistently outperformed other vocational programs in job acquisition and a variety of other employment outcomes (Bond et al. 2012a); it has been adopted internationally (e.g., Bond et al. 2012b; Heffernan and Pilkington 2011; Heslin et al. 2011; Hoffman et al. 2012; Kin Wong et al. 2008; Rinaldi et al. 2010), and has demonstrated efficacy for middle-aged and older adults (Twamley et al. 2012) and young people with first-episode psychosis (Rinaldi et al. 2010). With this abundance of empirical support in North America and worldwide, IPS is now identified as the single preferred evidence-based practice for helping individuals with severe mental illness achieve employment.
Discussion
Possible Criticism/Limitations
Consistent with the supported employment value of “zero exclusion,” there is evidence that supported employment is superior to other vocational programs regardless of clients’ demographic, clinical, and employment characteristics; there appear to be no clearly contraindicated subgroups (Campbell et al. 2011). Despite these encouraging findings, up to half of clients with severe mental illness still do not work. Common obstacles may include comorbid medical illness, psychiatric symptom exacerbation, lack of motivation, cognitive problems that interfere with job hunting, or fear of losing disability benefits. Indeed, one US study showed that receiving disability benefits was associated with fewer weeks worked, adding to substantial evidence that fear of losing disability income and associated health-care entitlements is a significant disincentive to sustained employment (Campbell et al. 2010). Among those who do work, job tenure can be brief and unsatisfactory job endings are common (e.g., quitting or being fired without being hired elsewhere) (McGurk et al. 2005). Unskilled job placements are also common in supported employment programs, which may contribute to short tenure and job attrition.
Cost-Effectiveness
The annual cost of supported employment is US $ 2000–$ 4000 per client, which is similar to that of conventional vocational rehabilitation (Bond et al. 2001). A recent analysis of social cost impacts regarded the evidence as “strong” for expanding access to supported employment services by substituting them for traditional vocational services (Salkever 2013). In addition, a possible cost offset includes lower utilization of mental health services, such as day treatment among clients participating in supported employment (Bond et al. 2001).
Recommendations for Further Research
To improve the efficacy of supported employment programs, researchers are examining modifiable targets to enhance services. Current research efforts are aimed at augmenting supported employment with cognitive interventions to compensate for neuropsychological deficits commonly seen in severe mental illness (McGurk et al. 2007; Vauth et al. 2005; Wexler and Bell 2005), social skills training to decrease workplace interpersonal conflicts (Tsang et al. 2010), and supported education for young people with first-episode psychosis (Rinaldi et al. 2010). Razzano et al. (2005) examined clinical factors that may affect employment among individuals with severe mental illness, and found that poor self-rated functioning, negative psychiatric symptoms, and recent hospitalization were associated with failure to obtain competitive work. These findings suggest that amelioration of negative symptom severity may increase the likelihood of job placement. Investigations are also underway examining peers as providers of supported employment services (Kern et al. 2013). These novel treatment approaches will continue to be examined as interventions to improve vocational outcomes in individuals with severe mental illness.
References
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Appendices
Case Study
Introduction
The theme of this case study concerns supported employment for a person with a severe mental illness.
The students’ tasks include:
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1.
Finding information about supported employment principles (e.g., Becker and Drake 2003).
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2.
Finding information about how supported employment principles are implemented (e.g., Bond GR et al. (2001). Implementing supported employment as an evidence-based practice. (Psychiatr Serv 52(3):313–321)
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3.
Synthesizing the information into a report on how the key principles of supported employment are reflected in this case.
As a starting point, students should use the following references to gather background information. Important references are:
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1.
Becker DR, Drake RE (2003) A working life for people with severe mental illness. Oxford University Press, New York
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2.
Bond GR, Becker DR, Drake RE et al (2001). Implementing supported employment as an evidence-based practice. (Psychiatr Serv 52(3):313–321)
Overview of the Content
Major goals of the actual intervention
The major goals of supported employment are: (1) preparing the client for work and assisting with job searching, (2) competitive job attainment in the community, and (3) job maintenance over time.
Learning Objectives
By the end of studying this chapter the learner will:
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1.
Be able to identify the key activities in supported employment
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2.
Be able to apply knowledge of supported employment principles to a client
The Background History of the Clinical Case
Personal Information
JM is a 25-year-old, African American female with a certificate of high school equivalency, who lives with her parents in an apartment.
Medical Information
JM has a diagnosis of schizoaffective disorder and experiences hallucinations, paranoia, and mood liability and irritability. She was referred to supported employment for assistance with returning to work after having been laid off at the end of a seasonal retail job, and being unsuccessful in her independent job search. She had participated in several interviews, but had not been offered a job. JM’s psychiatrist initially advised her not to seek work due to concerns that the increased stress of work would exacerbate her psychiatric symptoms.
Occupational Therapy Interventions
JM was accepted as a supported employment client based on her stated goal of returning to work. She and the employment specialist discussed the effect of seeking work on a pending disability claim and following this benefits counseling, JM decided that she would prefer to pursue work rather than disability benefits. During their first one to two meetings, JM and her employment specialist discussed JM’s previous work experiences (likes and dislikes) and her preferences for future work. JM expressed interest in applying for both hospitality and security positions. The employment specialist communicated with her employer contacts in the security field to determine where to focus the job search. By the second meeting, JM and the employment specialist began searching for job leads and applying for positions. JM’s employment specialist had regular contact with JM’s psychiatrist and therapist through a shared electronic medical record, telephone calls, emails, and face-to-face contact at treatment team meetings. The employment specialist was able to collaborate with the other clinicians to ensure that the client attended her appointments and refilled her medications on time. All of JM’s clinicians supported her job search and goal of returning to work.
One month after her first appointment with the employment specialist, JM interviewed for and was offered full-time competitive employment with a security firm. She began working and continued to meet with her employment specialist for follow-along support, which included assistance obtaining a uniform, setting up a bank account and direct deposit, and setting up a meal and medication schedule.
One of JM’s security assignments involved guarding a bank. The bank manager complained to the security company that JM was listening to music on headphones and dancing on the job. She was sent home for the day and contacted the employment specialist to discuss the situation. They discussed her options, including going to the hospital, quitting her job, and meeting with her supervisor to try to keep the job. JM requested that the employment specialist accompany her to meet with her supervisor; following the meeting, the client was able to keep her job.
The employment specialist continues to provide vocational support to JM, including supporting life skills and decision making relevant to work, and budgeting her income. JM was considering looking for another full-time job to make more money. Support will continue for JM as long as she needs it.
The Student’s Report
The following guiding questions are intended to help clarify how supported employment principles are implemented:
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How did benefits counseling affect the intervention?
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What are the important issues to attend to when deciding what types of jobs would be a good fit for the client?
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How did the employment specialist involve other clinicians in supported employment, and what was the outcome of the team approach?
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4.
How should the employment specialist respond to the client’s request to look for an additional full-time job?
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Burton, C., Vella, L., Littlefield, E., Twamley, E. (2015). Supported Employment for Individuals with Severe Mental Illness. In: Söderback, I. (eds) International Handbook of Occupational Therapy Interventions. Springer, Cham. https://doi.org/10.1007/978-3-319-08141-0_51
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