The International Journal of Psychosocial Rehabilitation

Programs That Support Employment for People With Severe Mental Illness:
A Literature Review

Annette L. Becker MS, RN
Assistant Professor
Department of Nursing
Utica College
1600 Burrstone Road
Utica, NY 13502

Lisa L. Flack MS, RN
Assistant Professor
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

Recovery 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 recovery.    
Key Words: recovery, supported employment, serious mental illness

Research 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
Several 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.

Mueser et 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.

Interestingly, 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 received. 

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.

A 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).

A 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) .

The 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).

Key Themes
The 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 outcomes.

Critical Gaps
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.

People 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).  

Another 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). 

Measuring 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.

The 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 recovery.    



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