Employment Services for People with Psychiatric Disabilities

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Employment Services for People with Psychiatric
Disabilities

• CWD Behavioral Task Force Conference Call
• Deborah R. Becker, M.Ed., CRC
• Dartmouth Psychiatric Research Center
• March 29, 2007

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Employment

• Only 10-15 of people with psychiatric
  disabilities are working
• 70-80 want to work
• Work improves self-esteem, income, and recovery
• Supported employment is most effective
• Current access to supported employment lt5

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Historical Perspective of Employment Options

• Low expectations
• Sheltered workshops
• Department of Vocational Rehabilitation
• Stepwise, work readiness criterion, brokered,
  short-term
• Supported employment

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Evidence-Based Practice

• Program model validated by rigorous research
  (different investigators)
• Has guidelines describing critical components
• Has a treatment manual

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Definition of Supported Employment

• Mainstream job in community
• Pays at least minimum wage
• Work setting includes people who dont have a
  disability
• Service agency provides ongoing support
• Intended for people with most severe disabilities

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Definition of Competitive Employment

• Pays at least minimum wage
• Integrated community setting
• Owned by the worker
• Not set aside for people with disabilities

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Primary Evidence for Supported Employment

• 6 day treatment conversion studies
• 15 completed randomized controlled trials
• 3 correlational studies of fidelity of
  implementation

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6 Day Treatment Conversions to Supported
Employment

• Discontinued day treatment
• Reassigned day treatment staff to new positions
  in center
• Replaced with supported employment

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Similar Results in All 6 Day Treatment
Conversions

• Large increase in employment rates
• No negative outcomes (e.g., relapses)
• Consumers, families, staff liked change
• Overall, all former day treatment clients got out
  into community more
• Resulted in cost savings

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Mean Competitive Employment Rates in 6 Day
Treatment Conversions
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Competitive Employment Rates in 15 Randomized
Controlled Trials
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Summary Randomized Controlled Trials of
Supported Employment

• In 14 of 15 studies, SE had significantly better
  competitive employment outcomes than controls
• Mean across studies of consumers working
  competitively at some time
• 58 for supported employment
• 24 for controls

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CT Supported Employment Study(Mueser, 2004)
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Successful vs. Unsuccessful Programs (Gowdy, 2000)

• Surveyed 27 mental health centers in Kansas
• Identified 5 high-performing and 4 low-performing
  centers based on employment rates
• Interviewed staff and consumers

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Predictive Validity of SE Fidelity Scale

• Total Scale .76
• Items
• Community-Based Services .82
• Staff Focused on Voc Only .69
• Zero Exclusion Policy .43
• Correlations with competitive employment in 10 VT
  mental health centers (Becker, 2001)

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Johnson Johnson-Dartmouth Project

• Mental health-vocational rehabilitation
  collaboration
• Implement evidence-based SE
• Local programs selected by states
• Dartmouth provides training, consultation, and
  evaluation
• Training videos, informational newsletters
• First states CT, DC, KS, MD, OR, SC, VT
• New states DE, IL, MN, OH
• 
  (Drake, 2006)

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Explaining Outcomes Variance in Employment

• 26 sites in JJ program (Becker, 2004)
• 25 local economy
• 25 SE fidelity
• ?50 individual practitioner

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JJ Project Conclusions

• Start with early adopters states and programs
• VR-MH collaboration
• Longitudinal training
• Outcome-based supervision
• Problem solving by local experts

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National EBP Project

• 5 evidence-based practices SE, IMR, FPE, ACT,
  IDDT
• 53 sites in 8 states
• Programs studied for 2 years

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Supported Employment Resource Kit - SAMHSA

• Informational brochures
• Implementation guidelines
• SE Workbook
• Videotapes
• SE Fidelity Scale, General Organizational Index
• Tracking outcomes
• Resources

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8-12 Year Follow-up of SE

• 71 working at follow-up
• Nearly all in competitive jobs
• 7 sheltered, 10 volunteer
• 71 worked more than 50 of FU
• But 90 still receiving benefits
• (Becker, 2007)

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Positive Outcomes from Competitive Work

• Higher self-esteem
• Better control of psychiatric symptoms
• More satisfaction with finances and with leisure
• (Bond et al., 2001)

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What Does Supported Employment Cost?

• Some programs, 2,000-4,000 per client per year
  (Clark, 1998).
• Latimer (2004) 2,449 per full-year equivalent
  client.
• Figures vary according to severity of
  disability, salaries of employment specialists,
  caseload sizes
• Exclude costs of clinical services

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UCLA Study (Neuchterlein, 2005)
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Cognitive Training

• Practicing cognitive tasks to create new neuronal
  connections
• Tasks can be directly relevant to work tasks
• New capacity may translate to work
• 
  (McGurk, 2005)

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Social Security Administration Mental Health
Treatment Study

• Randomized Controlled Trial
• 22 cities
• 3,000 SSDI beneficiaries
• Intervention
• IPS supported employment
• EB medication management
• EB mental health practices

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Evidence-Based Principles

• Eligibility is based on consumer choice
• Personalized benefits planning is provided
• Supported employment is integrated with treatment
  
• Competitive employment is the goal
• Job search starts soon after a consumer expresses
  interest in working
• Follow-along supports are continuous
• Consumer preferences are important

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Eligibility Is Based on Consumer Choice

• No one is excluded who wants to participate.
• Consumers are not excluded because they are not
  ready or because of prior work history,
  hospitalization history, substance use, symptoms,
  or other characteristics.

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Personalized Benefits Planning Is Provided

• Benefits planning and guidance help consumers
  make informed decisions about job starts and
  changes.

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Supported Employment Is Integrated with Mental
Health Treatment

• Employment specialists coordinate plans with the
  treatment team, which includes case managers,
  therapists, and psychiatrists.

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Effective Structure of Integrated Services

• Co-located at the same agency
• Integrated records
• Frequent contact between employment staff and
  treatment team members
• Employment specialists in treatment team meetings

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Competitive Employment Is the Goal

• The agency needs to devote sufficient resources
  to supported employment to permit full access to
  all consumers who seek competitive employment.
• Consumers interested in employment are not
  steered into day treatment or sheltered work.

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Job Search Starts Soon After A Consumer Expresses
an Interest in Working

• Pre-employment assessment, training, and
  counseling are kept to a minimum.

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Follow-Along Supports Are Continuous

• Supported employment staff continue to stay in
  regular contact with consumer and (when
  appropriate) the employer without arbitrary time
  limits.

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Consumer Preferences Are Important

• Job finding is based on consumers preferences,
  strengths, and work experiences, not on a pool of
  jobs that are available.

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Competitive Jobs

• Landscaper
• Machine Operator
• Photographer
• Receptionist
• Reporter
• Sales Clerk
• Security officer
• Welder

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More Competitive Jobs

• Bakers assistant
• Childcare Worker
• Data Entry
• Deli Meat Cutter
• Grocery Bagger/Carriage Attendant
• Housekeeper
• Dishwasher

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Supported Employment Unit

• Individual caseloads, but help each other (with
  job leads, etc.)
• Caseloads of about 20 consumers or less
• Weekly team meetings individual supervision

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Referral

• Make referral process simple!
• Have minimal eligibility criteria
• Unemployed (or working non-competitively) and
  wants competitive employment, or
• Employed, but not receiving employment supports,
  and wants such support
• Involve multiple stakeholders

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Collaboration With Vocational Rehabilitation

• Overcome system differences
• Learn each others system
• Define roles
• Serve together

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VR Services

• VR counselors
• purchase services
• arrange services from other agencies
• provide guidance and counseling

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VR Services

• Training
• Situational assessment
• Job shadowing
• Job-related equipment, supplies
• Tuition
• Placement
• Planning
• Support

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Benefits Counseling

• Fear of losing benefits is major barrier to
  employment
• Concerns of consumers and families often
  underestimated by clinicians
• Rules and regulations are complicated
• Benefits counseling provides consumer-specific
  information

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Engagement

• Build trusting, collaborative relationship
• Assume contacts are mostly outside mental health
  setting
• Maintain ongoing contact
• Involve family, treatment team, and other
  supporters

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Vocational Profile

• Gather comprehensive information from variety of
  sources over 1-2 weeks
• Consumer
• Family, friends
• Former employers
• Treatment team

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Disclosure of Psychiatric Status

• Disclosure is the consumers choice
• Nature of disclosure
• When to disclose?
• How much to disclose?
• Who to disclose to?

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Employment Plan

• Explore jobs by visiting work sites
• Develop employment plan
• Revise assessment and employment plan based on
  consumers experiences

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Job Search

• Begin soon after referral
• Employer contacts within 1 month
• Preparatory work
• Resumé
• Job application
• Two forms of identification
• Practice interviewing
• Release of information

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Individualized Job Search

• Base on consumers preferences, strengths,
  abilities, experiences, and deficits (e.g.,
  substance use)
• Seek
• Permanent competitive jobs
• Diverse jobs suiting individual consumers
• Different settings

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Job Support

• Individualized and time-unlimited support
• Mostly away from work site
• Include consumers support network (treatment
  team, family, friends, employer, coworkers)
• Negotiate accommodations with employer

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Job Endings

• Each job viewed as learning experience
• Job transitions are considered normal
• With a job loss, consumer and entire (SE and
  treatment) team strategize for next step

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What About Supported Education?

• Consumer choice always a primary consideration
• Education and training expand options
• SE program should help consumers enroll in
  community programs (GED classes, colleges,
  technical schools)

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Resources

• Dartmouth Vocational Publication List
• karendunn_at_dartmouth.edu
• 603-448-0263
• http//dms.dartmouth.edu/prc

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More Resources

• A Working Life for People With Severe Mental
  Illness-Becker and Drake, Oxford University
  Press, 2003
• Supported employment resource kit
  Mentalhealth.samhsa.gov

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Summary

• Supported employment has created hope for
  providers and people with psychiatric
  disabilities
• Programs following evidence-based principles of
  supported employment have better outcomes
• Public policy changes are needed