SUPPORTED EMPLOYMENT AS AN EVIDENCE-BASED PRACTICE Presented by: Rick DeGette, M.A., MFT ricder_ricder@yahoo.com 510-383-1678 cell & Dan Chandler, Ph.D. dwchandl@yahoo.com

PART I: COMPETITIVE EMPLOYMENT

Why Focus on Employment? Work is the typical role for adults in our society and the source of much identity and self-esteem It is viewed by many consumers as an essential part of recovery Most consumers want to work (71%) but few do (15%) 1 Working is not the only adult role for adults in our society, but it is clearly very important. It is each consumer’s choice whether or not he/she would like to pursue work, but mental health centers should make it possible if it is their choice. 2. Working is often mentioned by consumers in describing their recovery process. For example: J. Bailey, “I’m an Ordinary Person,” Psychiatric Rehabilitation Journal, 22, (1998), 8-10. Rogers, J. A. (1995). Work is key to recovery. Psychosocial Rehabilitation Journal, 18(4), 5-10. Drake: Recovery from mental illness involves developing hope, moving beyond preoccupation with one’s illness, forging a new identity, and pursuing meaningful life activities [3,25,31]. For most people who describe their recovery stories, work is a central part of the recovery process [29,31,32]. 3. Say they want to work: 70% Are currently working: <15% Want to Work Surveys backing the 70% figure include a statewide survey by Rogers (1991); a survey of a case management program in Washington, DC (Drake, 1999). A British study has reported a slightly lower figure of 60% (Crowther, 2001). Mueser (2001) also reports 60%. Currently Working This figure is backed by many surveys conducted over the past 30 years, using a variety of sampling methods. See Bond, Becker (2001) for some of the studies.

Positive Results of Competitive Work Sense of meaning Structures to the day and life Normal adult role Higher self-esteem Better control of psychiatric symptoms More satisfaction with finances and with leisure Enhanced social contact, relationships, and community integration Significantly reduced treatment costs (Bond 2001; Becker, 2007; Drake 2009; Bond 2009) 1. 149 unemployed clients with severe mental illness receiving vocational rehabilitation were classified into four groups: Competitive Work, Sheltered Work, Minimal Work, and No Work. Competitive Work group showed higher rates of improvement in symptoms, in satisfaction with vocational services, leisure, and finances, and in self-esteem, than those in a combined Minimal Work / No Work group. The sheltered work group showed no such advantage. (Bond, Resnick 2001). On relationships: (Becker, 2007) Drake on tx costs> Used the IDDT study participants over ten years. Found 51 who worked pretty steadily 141 who did not. “The average cost per participant for outpatient services and institutional stays for the minimum-work group exceeded that of the steady-work group by $166,350 over ten years. “ Bond: 2009. work provides structure, activity, meaning, a normal adult role, social contact, community integration, self-esteem, increased income, and better quality of life

Is Work Too Stressful? Research shows stresses of work in Individual Placement and Support do not translate into higher rates of hospitalization or other problems of functioning Joe Marrone, an employment trainer: “If you think work is stressful, try unemployment.” 1. Reviews suggest that hospitalization rates for people enrolled in supported employment are no higher and sometimes lower than those who are not. Hospitalization rates for supported employment clients are no higher and are sometimes lower than before they enrolled. (Bond, Drake, 1997; Crowther, 2001) Hayes (1996) found than men with schizophrenia who were not working spent more time sleeping and much less time socializing than unemployed men without a psychiatric diagnosis . Not working makes the negative symptoms of schizophrenia worse by reinforcing passivity. It is harder to be energetic and hopeful if you are not working. Bond 2009: two studies of the conversion from day treatment to IPS reviewed above also assessed changes in rates of suicide attempts, hospitalizations, incarcerations, homelessness, and program dropouts (Drake et al., 1994; Drake et al., 1996). A third study in this group examined psychiatric symptoms and hospitalization (Becker, Bond et al., 2001). The general hypothesis tested was that the replacement of supportive day treatment with the more demanding IPS program would be stressful and lead to negative outcomes. In fact, there were no changes supporting the hypothesis of negative outcomes from IPS; the only significant change was a reduction in the hospital rate in one study. Bond 2009: none of the IPS studies documented increased rates of psychiatric hospitalization for the IPS group, compared to controls. In one study, the IPS group had significantly fewer days hospitalized than controls (Burns et al., 2009).

PART II: The Individual Placement and Support Model

Definition of Supported Employment Mainstream job in community (not “protected”) Pays at least minimum wage Work setting includes people who are not disabled Service agency provides ongoing support Intended for people with most severe disabilities Competitive employment - work in the community that anyone can apply for and pays at least minimum wage. The wage should not be less than the normal wage (and level of benefits) paid for the same work performed by individuals who do not have a mental illness. Previous approaches were geared toward prevocational training such as work crews, work units, sheltered work (jobs in settings with others with mental illness, often doing piecework), and volunteer positions. Is a successful approach that has been used in various settings by culturally diverse consumers, employment specialists, and practitioners. Defined in Rehabilitation Act Amendments of 1986 (Federal Register, Aug 14, 1987).

Evidence-Based Principles of Individual Placement and Support Model (IPS) Eligibility is based on consumer choice Supported employment is integrated with treatment Competitive employment is the goal Personalized benefits planning is provided Job search starts soon after a consumer expresses interest in working Follow-along supports are continuous Consumer preferences are important 1

REVIEW: How Individual Placement and Support Differs from California Models Quick entry into employment (average of about 4 months of job search until employed) (Bond 2008) Minimum emphasis on “readiness” (many sources especially Bond 2007) No preconditions, including substance use (though tailoring necessary, Cook 2007, Becker 2005) Competitive rather than jobs “owned” by the agency or other protected settings (Bond 2007) Integrated with treatment team rather than referral to a separate agency (Drake) IPS is not Choose, Get, and Keep because of latter’s focus on prevocational career planning, which is less effective 2006 Choose Get Keep study: 22% competitive employment after two years (Rogers) Put in the narrative about how both SED and SE started in 80s with psych rehab, but then in California we just stayed there. IN supported employment they hae tone on to Find out what the critical elements are Show that there has been enormous change in supported education. Metadata.

Individual Placement and Support Is Affordable Costs average about $2,500 per person per year assuming a caseload of 18 per employment specialist (Lattimer 2004) A 2008 study found per capita expenditures for “supported employment” in the state-federal vocational rehabilitation system to be less for clients with psychiatric disabilities A 2004 cost analysis of 7 high-fidelity IPS programs representing different regions of the U.S., including both rural and urban sites, estimated that annual direct costs per client served varied from $1,400 to nearly $7,000 (Latimer, Bush, Becker, Drake, & Bond, 2004). The most influential variable in determining cost was caseload size; assuming a typical caseload of 18 clients, the annual per-client direct costs of IPS was estimated to be $2,500. Focusing on the state-federal vocational rehabilitation system, Cimera (2008) estimated annual per capita expenditures for supported employment clients to range from $2,579 to $3,846 for clients with psychiatric disabilities, compared to $4,683 for all supported employment clients served by vocational rehabilitation. This analysis suggests that it is less expensive to fund supported employment services for clients with psychiatric disabilities than other disabilities.

SECTION III: OUTCOMES

Randomized Controlled Studies Only ACT has more randomized controlled studies showing effectiveness Typical results in 9 studies: Average of 62% worked, range 25% to over 80% (Bond 2008) Much better than control groups of other approaches (average of 37% more having employment in Individual Placement and Support condition) (Bond 2008)

Results from 13 Randomized Controlled Trials of SE Note Callifornia is the Village in 1990-1992

Other Positive Findings Participating in supported employment does not worsen clinical or social functioning--including hospitalization (Burns, 2008) Long term results Salyers 2004: 47% of Individual Placement and Support clients currently working 10 years later Becker 2007: 71% of Individual Placement and Support clients currently working 10 years later Caveats: there are methodological weaknesses and not all work in competitive settings

Head to Head with a Psychiatric Rehabilitation Model like the Village Study looked at Thresholds, a Chicago psychiatric rehabilitation program very like The Village. A “menu approach” was compared to an Individual Placement and Support approach. (Bond 2007) Competitive employment for Individual Placement and Support was 75% vs 37% for the diverse approach In study, total with paid work was equal – indicating menu approach substitutes non-competitive for competitive employment. Village 5 year: [Village competitive employment was 20% in best year, 48% in 5 years; 74% worked for pay in 5 years] Costs and Effectiveness of Employment Services. Second year Vil- lage expenditures per person on the 95 who did receive employment services averaged $5,014 versus the comparison client average of $2,495 for the three clients getting vocational services. The Village al- located 25 percent of total mental health expenditures ($476,294 of $1,900,343) to vocational services in 1991-92, while comparison cli- ents received 1.3 percent ($7,485 of $582,153). The 75 working Village members were employed during an average of 19.8 of the 60 month study period (SD = 14.1; median = 18.5 months), or about one third of the time. Tenure was not uniform among clients, however. Thirteen (17%) of the 75 consumers worked six months or less; eight (11%) worked between 6 and 12 months; 28 (37%) worked between 12 and 24 months; and 26 (35%) worked more than 24 months out of the 60 study months. The total number of months worked in each year did not show a steady trend. In the first year, member worked a total of 229 months, increasing to 421 in the second year. In succeeding years, however, the total amount of work declined from 343 months in Year Four to 171 months in Year Five. Hours Worked The mean number of hours worked per week per job was 13.6; the median was 12. Seventy-nine percent (79%) of the 273 jobs held by consumers over the 5 years were for less than 20 hours per week; 16.5% were for between 20 and 39 hours per week; and 4% of the jobs were for 40 hours per week. A total of 36 person worked competitively at some time during the 5 years. This represents almost half of those working at all (48%), and over a third of all Village members (35 %). Of the 273 jobs held during the 5 years by Village members, 74, or 27.11% were competitive. Competitive jobs differed from in-house jobs on several dimensions. First, competitive jobs averaged twice as many hours per week (21.98 versus 10.49; t = 11.906, df = 271,p </= 0.0001). And although the differences are not statistically significant, competitive jobs lasted a mean of 6.12 (SD = 7.8) months compared to 5.18 (SD = 5.9) months for in-house jobs. Finally, the average wage per hour for competitive jobs was $5.81 (SD = 2.77) versus $4.35 (SD = 0.37) for in house jobs. These factors combined so that the average amount earned per competitive job was $4,525 versus $1,136 per in-house job (t = 4.893, df = 271,p </= 0.0001).

SE Is Not a Panacea Job tenure averages 22 weeks for the first job (Bond 2008) Only 43% of persons work 20 or more hours a week (Bond 2008) Average weeks working in a year 10 – 17 (2.5 times controls) (Bond 2008) SE has not been shown to reduce use of SSI (Drake 1998) Research rates of 60% reflect work over a 18 month or 24 month period. Quarterly rates for high fidelity Individual Placement and Support programs range from 23% to 35%. (Drake 1998) Many barriers to work are external: e.g., stigma and discrimination (Corrigan 2007), low wages, disincentives (Bond 2007) since income, housing, health insurance tied to disability (Cook 2006 ), “dire poverty” (Alverson 1998)

National EBP Project Findings Compared to other evidence-based practices, IPS is easier to implement (next two slides) Achieve higher fidelity Achieve high fidelity faster

National EBP Project Implementation SE Achieved Highest Fidelity (Bond 2008[2])

National EBP Project Implementation High Fidelity in Six Months (Bond 2008[2])

SECTION IV IMPLEMENTATION

ELEMENTS OF Individual Placement and Support SUCCESS THAT REFER TO PROGRAM, COUNTY, AND STATE LEVELS TRAINING: Intensive, on-going, hands-on LEADERSHIP: Program, Agency, County, and State levels STAFF ATTITUDES: Staff who believe in competitive employment and have a high opinion of the abilities, talents, and spirit of their consumers FUNDING: Continuing to fund non-evidence based vocational programs while implementing IPS INDEPENDENT MEASUREMENT OF FIDELITY: Low fidelity programs are not effective. County and state can assess fidelity. Point to need for DR to have IPS trainers This is a point found throughout the implementation literature Documented in recent (Rapp and Bond, 2008) study of SE and in earlier Rapp study of high and low performing programs The VA implemented a number of supported employment programs but compromised on fidelity in many ways. Effectiveness was much lower than found in other studies.

Getting to work!

Compatibility of SE & IPS Approaches Supported Education IPS Employment A focus on main stream education Readiness based on consumer choice, Rapid enrollment into courses Integration of mental health and supported education services, Attention to consumer preference in course and degree choice Individualized Ed supports Personalized academic counseling Implementation to a fidelity scale A focus on competitive employment, Eligibility based on consumer choice, Rapid job search, Integration of mental health and employment services, Attention to consumer preference in the job search, Individualized job supports Personalized benefits counseling Implementation to a fidelity scale PUT THIS UP AFTER SUPPORTED EMPLOYMENT DISCUSSION, AS PREFACE TO THE CAMINAR PRESENTATION.