Programs That Support Employment for People With Severe Mental Illness:
A Literature Review
Annette L. Becker MS, RN
Department of Nursing
1600 Burrstone Road
Utica, NY 13502
Lisa L. Flack MS, RN
Department of Nursing
The Sage Colleges
Carole A. Wickham MS, RN, CNS-BC
Clinical Nurse Specialist
St. Peter’s Hospital
Becker AL, Flack LL, & Wickham CA(2012).Programs That Support Employment for People With Severe
Mental Illness: A Literature Review International Journal of
Psychosocial Rehabilitation. Vol 16(1) 52-58
is a complex process engaging the values of hope, empowerment and
quality of life. Research from diverse fields has shown substantial
evidence demonstrating the importance of meaningful employment in the
recovery of individuals with severe mental illness (SMI). This
paper will focus on the practice of supported employment by reviewing
the literature and evaluating existing programs that support employment
of people with severe mental illness. Over time, the Individual
Placement and Support (IPS) model has emerged as the predominant
program representing the supported employment principles and tested by
IPS fidelity standards. The IPS model has consistently achieved better
work outcomes than the traditional vocational rehabilitation models
including the team approach (DPA) and transitional employment models.
Gaps in the literature include attention to psychosocial/spiritual
outcomes, quality of life outcomes and job satisfaction associated with
supported employment. It is recommended that future program development
and evaluation address these outcomes to encourage all aspects of
Key Words: recovery, supported employment, serious mental illness
from diverse fields has shown substantial evidence demonstrating the
importance of meaningful employment for individuals with severe mental
illness (SMI). Mental health experts view employment as important
to the process of recovery in this population (Cook & Pickett,
1995; Crowther, Marshall, & Hurley, 2001; Mueser, Salyers, &
Mueser, 2001). Recovery is a complex process engaging the values of
hope, empowerment and quality of life. Successful recovery has
associated outcomes of: (a) improved management and reduction of
psychiatric symptoms, (b) decreased hospitalizations, (c) improvement
in global functioning and (d) more meaningful participation in
activities (Barbic, Krupa & Armstrong, 2009). Although many
studies have shown those with SMI as able to successfully participate
in the labor market, in the United States, it is estimated that 75-90%
of people with psychiatric disabilities still remain outside the labor
force (Mueser, Salyers & Mueser, 2001; Mueser, Clark, Haines,
Drake, et al., 2004). Quality of life for this population is positively
impacted by the improvement of psychosocial health and well-being
thereby impacting the larger community by decreasing the financial
burden on mental health systems and reducing poverty (Baron, 2000;
Lucca, Henry, Banks, Simon, & Page, 2004). The public policy
considerations related to this population are vast and need to include
an understanding of how funding should include not only vocational but
clinical services (Cook & O’Day, 2006).
Efforts to support
and encourage recovery in this population have been as complex as the
process itself and have included the evidence based practices of
assertive community treatment, family psychoeducation, illness
management and recovery, integrated dual disorders treatment,
medication management and supported employment (Bond & Campbell,
2008). This paper will focus on the practice of supported employment by
reviewing the literature and evaluating existing programs that support
employment of people with severe mental illness. By definition,
supported employment is a model designed to enable people with
psychiatric disabilities to attain competitive employment (Drake &
Bond, 2008; Mueser et al., 2004). Competitive employment for persons
with SMI is an outcome of the programs that will be evaluated.
Unlike volunteer opportunities or sheltered workshops, competitive
employment refers to employment in integrated settings receiving at
least minimum wage (Mueser et al., 2004; Bond, Drake & Becker,
2008; Schonebaum, Boyd & Dudek, 2006).
Programs to support
employment in the SMI population have been developed, implemented and
evaluated primarily in the field of vocational rehabilitation within
the context of psychiatric rehabilitation. Although limitations to
these programs exist, studies evaluating these programs continue to add
to a body of knowledge affirming the benefits of supported employment
as an evidence-based practice contributing to the recovery of people
with SMI (Drake & Bond, 2008; Cook and O’Day, 2006).
Comparison of Existing Programs
models have been implemented over the past twenty years to support
persons within the SMI population to achieve and maintain competitive
employment. The supported employment programs that will be addressed in
this paper are the application and implementation of varying Individual
Placement and Support Models (IPS), compared with the traditional Team
Model also referred to as the Diversified Placement Approach (DPA) and
the Transitional Employment Model.
The Individual Placement
and Support (IPS) model is the most recognized and supported employment
program with the most compelling evidence (Bond & Campbell, 2008;
Kulka and Bond, 2009; Lucca, et al., 2004; Mueser, Aalto, Becker,
Ogden, et al.,2005). This model is not different from supported
employment (SE), but rather is an intervention using the principles of
SE. (Twamley, Veste & Lehman, 2003). The IPS model supports the
client in securing and maintaining a job as long as the client and
employer agree. There is an integration of mental health services with
employment services and individual support is provided in an ongoing
manner in the context of small case loads (Lucca et al., 2004; Mueser
et al., 2005). The studies reviewed were conducted to evaluate
the effectiveness of the IPS model as it has been applied in different
settings and in comparison to older non-IPS models.
al. (2004) compared the effectiveness of an IPS model with the non-IPS
transitional model in the Hartford Study. Unlike the IPS model, the
Transitional Model secures a number of available jobs and offers them
to clients for a limited period of time (6-9 months). A contract
exists between the employer and the agency, rather than the
client. A client assumes one of these positions for the appointed
period of time and is able to move to other designated jobs thereafter.
The transitional model has been implemented most exclusively within day
treatment programs. The Hartford Study measured employment rates, days
to the first job, annualized weeks worked and job tenure in the longest
job held during a follow-up period of time. The Structured Clinical
Interview for DSM-IV (SCID) and the Positive and Negative Syndrome
Scale (PANSS) were used to determine diagnostic background information.
Overall functioning was measured using the Global Assessment Scale
(GAS) and social and leisure functioning was assessed with a
Social-Leisure subscale from the Social Adjustment Scale Social network
information was obtained using a Social Network Interview and the
Quality of Life Interview assessed areas of general life, social,
leisure and finance. Self-esteem was also assessed using the Rosenberg
Self-Esteem Scale. In this study, clients in the IPS program had
statistically modest improvements in both vocational and nonvocational
outcomes than clients who were not in the IPS program.
two independent studies were published in 2006 comparing supportive
employment (SE) programs in two different treatment models. Schonebaum,
Boyd and Dudek (2006) and Macias, Rodican, Hargreaves,
Jones, Barreira and Wang (2006) conducted studies comparing outcomes of
SE programs in Clubhouse participants (an established psychosocial
rehabilitation model) and Assertive Community Treatment (ACT)
program participants. ACT is an evidence-based team treatment
approach designed to provide comprehensive, community-based psychiatric
treatment, rehabilitation, and support to persons with serious and
persistent mental illness (Assertive Community Treatment Association,
2007). Schonebaum et al. (2006) conducted a five year
longitudinal study while Macias et al. (2006) used a randomized
controlled trial (RCT) to make the comparison of employment outcomes in
Clubhouse and ACT participants who were participating in SE
programs. In both studies, demographic and diagnostic baseline
data was obtained and both studies utilized quantitative measures to
determine effectiveness of the supported employment. These
measures included job placement rates, weeks worked, total jobs worked,
job duration, hours and wages. In addition, Schonebaum et al.
(2006) enlisted independent interviewers to collect information on
service satisfaction, symptoms, social networks, medication, job
history and hospitalizations, while Macias et al. (2006) focused on
performance benchmarks to address the need to standardize supported
employment models. In the Schonebaum et al. (2006) study,
outcomes demonstrated higher job placement rates in the ACT model
participants than those in the Clubhouse model, but higher wages and
longer employment duration were demonstrated for Clubhouse
participants. Macias et al. (2006) concluded that both models
integrated with supported employment programs can achieve employment
outcomes comparable to the exemplary SE programs, but suggested that
this might also be related to whether participants were assigned a
preferred program and/or the amount of job search services
Services for Employment and Education (SEE)
was developed as an IPS program and implemented in Massachusetts. While
RCT’s have assisted in establishing evidence-base IPS programs, this
study set out to test whether the SEE would achieve comparable
outcomes. Extensive data was collected from three locations in the
state to determine employment outcomes and predictors of employment
success (Lucca et al., 2004). Participants in this study were also
recipients of Massachusetts Department of Mental Health case management
services, which allowed for diagnostic information to be included in
the baseline data and tracked along with level of functioning and work
related information. To evaluate the effectiveness of the program, the
IPS Fidelity scale was used. The IPS Fidelity Scale was developed in
1997 to evaluate the quality of IPS models (Bond, Becker, Drake, &
Vogler (1997). This scale defines the key aspects of supported
employment and has been described as a compass giving direction to
obtaining good vocational outcomes (Bacon, Lockett & Rinaldi,
2008). In this study, the average score of 74 on the fidelity scale
showed good implementation of the SEE ISP model. Although the
study intended to correlate employment outcomes with the implementation
of SEE, limited employment data pre-SEE was available to effectively
compare outcomes post- implementation of the SEE program.
However, correlations between individual experiences in SEE and
employment outcomes indicate that participants who were more involved
in the SEE program and given more employer accommodations tended to
improve their job tenure (Lucca et al., 2004). These results continued
to add to the body of knowledge that implementing an ISP program such
as the SEE program improve vocational outcomes including job tenure.
two-year longitudinal study (Kulka and Bond, 2009) compared the
strength of the working alliance in a traditional model utilizing a
team approach (DPA Diversified Placement approach) to an evidence-based
supported model (IPS) utilizing individual caseloads. The working
alliance is defined as “the trusting, collaborative relationship, in a
counseling relationship has long been demonstrated as a key element in
positive therapeutic outcome and more recently linked to important
outcomes in psychiatric rehabilitation programs” (Kulka and Bond, 2009,
p. 157). One of the major questions this study addressed was whether
numerous players as in DPA approach dilute a bond between caseworker
and client. Studies show that people with SMI take longer to
develop relationships (up to 6 months) versus general population (2
weeks) (Kulka and Bond, 2009). Like the other studies evaluating
IPS, demographic data, employment information and an assessment of
psychiatric symptoms using the PANSS was obtained. The working
alliance scale was developed for this study and has six measurement
areas to assess the client’s social network and relationship with
vocational worker and was used to determine the impact of the working
alliance as it influenced employment outcomes. Authors found that
those studied who were more independent and stable had better job
performance and less need for a relationship with vocational worker
than those who have a less stable job history needed more of a
relationship with the vocational worker. The relationship between
participants in the ISP (individualized approach) had a stronger
“working alliance” with their vocational workers than those in the DPA
(team approach) (Kulka & Bond, 2009).
One of the major
challenges of mental health organizations is the dissemination of
complex innovative practices. While there has been substantial progress
in evidenced-based practices of people with SMI, mental health experts
believe the development of approaches for dissemination on a
large-scale has lagged, creating a gap between research and practice.
Implementation of programs like SE is needed in order to promote a
recovery-oriented culture (Resnick & Rosenheck, 2007).
descriptive SE study by Bond, McHugo, Becker, Rapp & Whitley (2008)
examined the dissemination plan of nine new SE programs from three
states and evaluated fidelity changes over two years: at baseline and
every six months thereafter. Experienced expert trainers were
utilized. The study utilized a mixed-methods research design.
Mixed-method design is the blending of qualitative and quantitative
data that has the potential to avoid the limitations of a single
approach (Polit & Beck, 2004). Quantitative methods
consisted of ongoing SE fidelity evaluation; qualitative techniques
consisted of semi-structured interviews that were transcribed verbatim
that were coded along twenty-six dimensions of implementation activity,
and then examined to identify factors that could improve
fidelity. The SE fidelity scale is the gold standard of fidelity
assessment, extensively validated and used in all recent randomized
controlled trials of SE. The 15 items are rated on a 5-point scale and
organized into 3 subscales: staffing, organization, and services. The
SE fidelity scale successfully differentiates between types of vocation
programs with empirically validated cut-off scores (Bond, et al.,
2001). Site-level fidelity outcomes were reported as follows: at
baseline all sites rated in the low fidelity range; at six months high
fidelity was attained in four of the eight sites, at 12 months in all
sites, and six of the nine sites at 18 months. At a two-year follow-up,
eight of the nine sites were operating at high fidelity (Bond, et al.,
2008). Competitive job rates were not provided.
In 2004, Resnick
and Rosenheck of the Veterans Health Administration initiated a
national SE dissemination effort. It is the largest dissemination
initiative of any psychosocial rehabilitation model of any single
healthcare system to date in the United States. The goal of the program
was to train employment specialists at the 21 mentor-trainer sites to
both practice and teach with a “train the trainer” model. This study
also utilized a mixed-methods research design, a similar dissemination
plan, and utilized expert trainers. Due to limited resources,
Resnick and Rosenheck (2007) developed and evaluated a mentor-trainer
system at two intensity levels (basic and intense) over a three-year
period. All 21 sites received the basic training, which consisted
of an initial visit, follow-up site visits and fidelity visits every
six months and thereafter, provision of manuals an other resources,
data-based performance feedback, and access to national telephone
conference calls. The intensive sites received more frequent
individualized feedback. Fidelity scores were reported as a composite
over time (baseline not completed): at six months – no fidelity, at 12
and 18 months, low fidelity, and at 24 months high fidelity). SE
implementation was evident at mentor-trainer sites with 29% of veterans
working at competitive jobs as a part of SE compared with 16% at the
non-mentor training sites (Resnick & Rosenheck 2007) .
goal of the Johnson & Johnson – Dartmouth Community Mental Health
Program was to develop high fidelity SE programs over nine states.
Unlike the other two studies, this study was a private- public-
academic collaboration to disseminate SE. While the researchers
employed a similar mixed-methods research design compared to the other
two studies, this study in contrast occurred over four years,
dedicating one year to building support and implementation and
evaluation in years two to four. The competitive employment is
reported as 50%. In addition, this study utilized a three-site pilot
for one year and provided strategies for program sustainability
(Becker, Lynde, & Swanson, 2008).
studies reviewed in this paper generally agree that employment is an
important factor contributing to recovery in the population of those
who have severe mental illness. Supported employment described in
the 1980’s has been accepted by many as a preferred outcome of
vocational services. Over time, the Individual Placement and
Support (IPS) model has emerged as the predominant program representing
the supported employment principles and tested by IPS fidelity
standards. The IPS model has consistently achieved better work outcomes
than the traditional vocational rehabilitation models including the
team approach (DPA) and transitional employment models. When applied in
various treatment settings, the IPS model has contributed to better
work outcomes regardless of the treatment setting. Most of these
studies were conducted by researchers within the vocational
rehabilitation discipline, thus the consistent focus was on employment
Although the research over
the past 20 years on supported employment has provided a strong body of
knowledge for the benefits of ISP programs for vocational outcomes,
several critical gaps were identified as they relate to clinical
outcomes of the consumer. The following outcomes were not fully
addressed and studied in the programs reviewed and have an impact on
the consumer with SMI in their recovery process: psychosocial/spiritual
outcomes, quality of life outcomes and job satisfaction.
with SMI have the same desires and aspirations as those in the general
population to achieve personal goals and improved quality of
life. Recovery not only includes positive job outcomes and
tenure, but also a person’s psychosocial and spiritual wellbeing.
Recovery as defined by Deegan is “…the need to re-establish an new and
valued sense of integrity and purpose within and beyond the limits of
the disability; the aspiration to live, work, and love in a community
in which one makes a significant contribution.” (Deegan, 1988, p.12)
The reality for many suffering from a SMI is a lack of meaning in life
and this has a tremendous impact on ability to obtain and maintain
employment (Bond & Campbell, 2008). Historically, research in
this area has neglected the role of spirituality in the recovery
process, yet some studies suggest that in review of self-reports of
spiritual wellness has been associated with improvement of symptoms and
outcomes (Comptom & Furman, 2005).
critical gap that was identified in all but one study was related to
the acknowledgement of the varying level of symptoms that often exist
between participants in these programs and how this relates to the
overall vocational outcomes. However, in Lucca’s study where individual
diagnostic and functioning levels were gathered, the study did not find
a relationship to the employment outcome (Lucca et al., 2004).
the vocational workers perspective of SE would give the body of
knowledge new information in regard to how relationships are formed and
maintained with those with SMI (Kulka & Bond, 2009). As SE is
a relationship oriented program, obtaining the perspective of the
vocational worker could provide a more well-rounded approach to
assisting those with SMI on their road to recovery and stabilization.
Further research to identify to factors that promote SE implementation would be important for future dissemination efforts.
notion that recovery is multifaceted is one that needs to be further
developed and studied in the future. The quality of life beyond
work has been shown to impact vocational outcomes, yet has not in
itself been included in many research studies of IPS/SE programs to
this point. The quality of life/job satisfaction scales is a
large part of the recovery picture and should be included in the
program and researched to see the statistical impact it has or doesn’t
have on the recovery of a person with SMI. SE programs need to be
developed holistically to ensure all aspects of
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