Supported Employment

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 nondisabled workers), and that pay at least minimum wage. Unfortunately, assistance with employment is a major unmet need in most mental health programs: less than 15% 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 has been 9 carefully controlled experimental studies comparing supported employment to traditional vocational approaches (e.g., skills training preparation, sheltered workshops, transitional employment). All 9 studies showed better employment outcomes for consumers receiving supported employment. Importantly, 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. For example, consumers seem to benefit more from supported employment than alternative programs regardless of 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% of consumers enrolled in supported employment obtain competitive employment while less than 20% of similar consumers do so when 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 because of consumers' 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. These include the following:

• Services focus on competitive employment: The agency providing supported employment is committed to competitive employment as an attainable goal for its consumers with SMI, devoting its resources for rehabilitation services to this endeavor, rather than to intermediate activities, such as day treatment or sheltered work.
• Eligibility is based on consumer choice: No one is excluded who wants to participate.
• 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 new manual that has just been published: Becker, D. R., & Drake, R. E. (2003). A working life for people with severe mental illness. New York: Oxford Press.

Supported employment programs with greater fidelity to these principles have been found to have 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 provides consumers and family members with a tool to identify local providers who offer the best practice and to advocate for better services.

Supported employment has not been found to lead to increased risk for rehospitalization 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 clients who do not work.

Access to supported employment continues to be a problem, despite extensive evidence showing its effectiveness. Less 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.

Consumers and family members can have influence over setting standards and ensuring adherence to the standards of supported employment 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 and to establish standards according to evidence-based practices and have them incorporated in 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, the main message that we would like to convey is that supported employment is well defined, it is effective, and it is relatively easy to implement, compared with many other types of psychosocial practices.

Reviewed by Gary R. Bond, Ph.D. & Kikuko Campbell, M.P.H., M.A., June 2003

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