Supported Employment: An Evidence-Based Practice
by Gary R. Bond, Ph.D., and Kikuko Campbell, M.P.H., M.A.
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 non-disabled workers), and that pay at least minimum wage. Unfortunately, assistance with employment is a major unmet need in most mental health programs, and fewer than 15 percent 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 was nine carefully controlled experimental studies comparing supported employment to traditional vocational approaches such as skills training preparation, sheltered workshops, and transitional employment. All nine studies showed better employment outcomes for consumers receiving supported employment. 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. Consumers seem to benefit more from supported employment than from alternative programs, regardless of their 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 percent of consumers enrolled in supported employment obtain competitive employment, compared with fewer than 20 percent of similar consumers 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 when consumers have limited work experience, education, and training.
Consequently, most initial supported employment positions are unskilled. In addition, most supported employment positions are part time. Consumers often limit work hours to avoid jeopardizing Social Security and Medicaid benefits. 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:
- Competitive employment: The agency providing supported employment is committed to competitive employment as an attainable goal for its consumers with SMI and devotes its resources for rehabilitation services to this endeavor rather than to intermediate activities such as day treatment or sheltered work.
- Consumer choice: No one who wants to participate is excluded.
- 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.
- Time-unlimited and individualized support: Individualized supports are provided to maintain employment, as long as consumers want the assistance. For a more detailed description, we suggest an outstanding newly published manual: A Working Life for People with Severe Mental Illness, by Deborah R. Becker and Robert E. Drake (Oxford Press, 2003).
Supported employment programs with greater fidelity to the above principles have been found to result in 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 offers consumers and family members a tool to identify local providers who offer best practices and to advocate for better services.
Supported employment has not been found to lead to increased risk for re-hospitalization 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 those who do not work.
Access to supported employment continues to be a problem, despite extensive evidence showing its effectiveness. Fewer 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 in some states, 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: http://www.mentalhealthpractices.org/se.html.
Consumers and family members can influence standards of supported employment and adherence to these standards 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; to establish standards according to evidence-based practices; and to have these standards incorporated into 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, we believe supported employment is well defined, effective, and relatively easy to implement, compared with many other types of psychosocial practices.
Gary R. Bond, Ph.D., is Chancellor’s Professor of Psychology at Indiana University Purdue University Indianapolis (IUPUI), where he has been on the faculty since 1983. Since 1979, his research has been devoted to identifying evidence-based practices in the treatment of individuals with severe and persistent mental illness, with a primary focus on supported employment and assertive community treatment. His current research includes an NIMH-funded study comparing supported employment to a group placement approach and a series of psychometric studies on the fidelity scales to measure implementation of evidence-based practices. Bond was co-developer of the Evidence-Based Practice Supported Employment Implementation Resource Kit and is the state project director for Indiana for the National Implementing EBP Project.
Kikuko Campbell, M.P.H., M.A., is currently a doctoral student in the Department of Psychology at IUPUI. Her research interests include evidence-based psychiatric rehabilitation and geriatric mental health.
**This article was taken from the Summer/Fall 2003 issue of the NAMI Advocate. The NAMI Advocate is provided to our members. If you are interested in membership with NAMI please contact your State or Affiliate office.