© Springer International Publishing Switzerland 2015Ingrid Söderback (ed.)International Handbook of Occupational Therapy Interventions10.1007/978-3-319-08141-0_51
51. Supported Employment for Individuals with Severe Mental Illness
UC San Diego Outpatient Psychiatric Services, 140 Arbor Drive, 92103 San Diego, CA, USA
Department of Psychiatry, UC San Diego School Of Medicine, 140 Arbor Drive, 92103 San Diego, CA, USA
Cynthia Z. Burton
Occupational dysfunction is one of the most devastating and disabling consequences of severe mental illness. Supported employment (SE) is an evidence-based practice for assisting clients with severe mental illness to find and keep competitive jobs in the community. The key elements of SE include rapid, individualized job searching, job-based assessment, benefits counseling, time-unlimited job support, and integration of vocational and mental health services. Further, any client who wants to participate is eligible for SE services, and all services are based on the client’s individual preferences.
KeywordsPsychosisPsychosocial interventionSchizophreniaVocational rehabilitation
Far and away the best prize that life offers is the chance to work hard at work worth doing.Theodore Roosevelt, 1903.
Definition and Background
Supported employment is a form of work rehabilitation that helps clients obtain competitive work (i.e., jobs that pay minimum wage or higher, that are available to any individual, regardless of disability status, and where disabled and nondisabled coworkers work together). The manualized form of supported employment, individual placement and support (IPS), was developed by Becker and Drake (2003).
Unlike conventional vocational approaches that emphasize prevocational training and extensive preparation, supported employment programs provide clients with rapid, individualized job searching and placement in competitive work. Placement is followed by on-the-job training as needed and ongoing, time-unlimited support from the employment specialist. Support can consist of any counseling , training, or coaching the client needs to keep the job; assessment of the client’s performance and preferences is continuous. Supported employment programs are integrated within mental health care, such that the employment specialist is part of a multidisciplinary treatment team. As this is a community-based intervention, the employment specialist often conducts meetings in the client’s setting of choice (e.g., library, career center, coffee shop, home) to focus on client strengths and rehabilitation rather than “patienthood.” Work rehabilitation and employment can result in greater income, community integration, and improvement in symptom severity, increased self-esteem , and quality of life (Bond et al. 2001).
Supported employment is an evidence-based practice in psychiatric rehabilitation, with multiple randomized controlled trials and meta-analyses demonstrating its effectiveness over conventional vocational rehabilitation (Bond et al. 2001, Bond 2004, 2007, 2008; Cook et al. 2005; Twamley et al. 2003).
Supported employment helps clients obtain and maintain competitive employment.
Candidates for the Intervention
Clients with psychiatric disabilities who want to return to work are good candidates for supported employment. Supported employment programs do not exclude clients for reasons of “work readiness,” diagnosis, substance use history, legal history, or level of disability (Bond 2004). Indeed, existing evidence strongly indicates that job searches should not be delayed in favor of skills training or other extended preparation (Bond et al. 2012a).
Although most individuals with psychiatric illness want to work, employment rates are only 10–25 % (Latimer et al. 2004). With the assistance of supported employment, up to two thirds of clients who want to work can obtain jobs (Bond et al. 2008; Bond and Kukla 2011a; Cook et al. 2005; Twamley et al. 2003).
Supported employment is most commonly used in outpatient psychiatric settings. Any client with a stated goal of working should be offered supported employment.
The Role of the Occupational Therapist (OT)
The OT, referred to in supported employment as the employment specialist, is responsible for delivering all vocational services. The employment specialist typically has a bachelor’s or master’s degree and provides services to a caseload of 20–25 clients. In addition to the activities described above, the employment specialist may also provide transportation to interviews and attend interviews with the client, depending on the client’s preference for disclosure. Better employment outcomes have been linked to increased IPS service intensity and characteristics of the employment specialist (e.g., percentage of time in the community, frequency of contact with clients; Bond and Kukla 2011b; McGuire et al. 2011; Taylor and Bond 2012).
Supported employment programs consist of the following phases: (1) initial assessment: discussion of the client’s job skills, past employment experience, current employment goals and preferences, and benefits counseling; (2) job searching: collaborative effort to create a résumé, complete applications, and prepare for interviews; and (3) time-unlimited follow-up support: the employment specialist provides ongoing support as needed, and checks in regarding stressors, symptoms, or any problems at work.
How the Intervention Eases Impairments, Activity Restrictions, and Participation Restrictions
Severe mental illness is associated not only with psychiatric symptoms but also with cognitive impairment , including difficulty with attention , learning and memory, and problem solving. Employment specialists assist clients by helping them find jobs that are a good match for their energy level, their ability to cope with various job stressors, and their cognitive strengths. Once the client obtains a job, the employment specialist can help the client troubleshoot symptom exacerbations and cognitive problems on the job. For example, the employment specialist might help a client who hears voices learn to ignore the voices in order to maintain attention on job tasks. The integrated nature of supported employment allows the employment specialist to work closely with other providers to help the client navigate medication adjustments or participate in other psychosocial treatment .
The effectiveness of supported employment has been well established in the literature. A 2003 meta-analysis of 11 randomized controlled trials of vocational rehabilitation in schizophrenia and other psychotic disorders showed that 51 % of supported employment participants obtained competitive work, compared to only 18 % of conventional vocational rehabilitation clients (Twamley et al. 2003); a 2008 updated review demonstrated similar findings (61 % vs. 23 %; Bond et al. 2008). Further, a recent meta-analysis including 14 randomized controlled trials and a total of 2265 people concluded that supported employment significantly increased rates of any employment over 1 year, and increased job tenure of competitive employment compared to other vocational approaches (Kinoshita et al. 2013). Follow-up studies ranging from 8 to 12 years have demonstrated that between 33 and 71 % of supported employment clients worked at least half of the follow-up years (Becker et al. 2007; Salyers et al. 2004).
In sum, IPS has consistently outperformed other vocational programs in job acquisition and a variety of other employment outcomes (Bond et al. 2012a); it has been adopted internationally (e.g., Bond et al. 2012b; Heffernan and Pilkington 2011; Heslin et al. 2011; Hoffman et al. 2012; Kin Wong et al. 2008; Rinaldi et al. 2010), and has demonstrated efficacy for middle-aged and older adults (Twamley et al. 2012) and young people with first-episode psychosis (Rinaldi et al. 2010). With this abundance of empirical support in North America and worldwide, IPS is now identified as the single preferred evidence-based practice for helping individuals with severe mental illness achieve employment.
Consistent with the supported employment value of “zero exclusion,” there is evidence that supported employment is superior to other vocational programs regardless of clients’ demographic, clinical, and employment characteristics; there appear to be no clearly contraindicated subgroups (Campbell et al. 2011). Despite these encouraging findings, up to half of clients with severe mental illness still do not work. Common obstacles may include comorbid medical illness, psychiatric symptom exacerbation, lack of motivation, cognitive problems that interfere with job hunting, or fear of losing disability benefits. Indeed, one US study showed that receiving disability benefits was associated with fewer weeks worked, adding to substantial evidence that fear of losing disability income and associated health-care entitlements is a significant disincentive to sustained employment (Campbell et al. 2010). Among those who do work, job tenure can be brief and unsatisfactory job endings are common (e.g., quitting or being fired without being hired elsewhere) (McGurk et al. 2005). Unskilled job placements are also common in supported employment programs, which may contribute to short tenure and job attrition.
The annual cost of supported employment is US $ 2000–$ 4000 per client, which is similar to that of conventional vocational rehabilitation (Bond et al. 2001). A recent analysis of social cost impacts regarded the evidence as “strong” for expanding access to supported employment services by substituting them for traditional vocational services (Salkever 2013). In addition, a possible cost offset includes lower utilization of mental health services, such as day treatment among clients participating in supported employment (Bond et al. 2001).