Author: Robert E Drake, Deborah R Becker, Gary R Bond \

Curr Opin Psychiatry 16(4):451-455, 2003. © 2003 Lippincott Williams & Wilkins

Purpose of review
This review examines the 2002 literature on vocational services for people with psychiatric disabilities.

 

Recent findings

Vocational rehabilitation has emerged as a mainstream intervention in community mental health, and supported employment has become an evidence-based practice. In addition to clarifying and confirming the effectiveness and principles of supported employment, the literature describes clients' needs, innovative modifications of supported employment for special groups, the subjective experiences and non-vocational outcomes of clients related to employment, impacts of the Americans with Disabilities Act, costs of vocational services, cultural disparities, and the development of vocational services in other countries.

 

Summary

Increasing demands for employment services and for empirical outcomes influence clinical practice. Supported employment has by far the strongest evidence base of any vocational intervention for people with psychiatric disabilities and continues to be disseminated rapidly. Further research is needed to clarify the principles, impacts, and modifications of supported employment.

 

Introduction

In the fields of vocational rehabilitation and community mental health for persons with psychiatric disabilities, supported employment has rapidly emerged as a recommended practice because of its strong evidence base.[1-5] The recent literature clarifies many aspects of supported employment and points toward several new developments.

This review examines the 2002 literature on vocational services for persons with severe mental illness in order to identify trends, to clarify current research and emerging ideas, and to anticipate clinical implications and research directions. We searched for articles that addressed vocational services for people with severe mental illness in the 2002 issues of several major journals of mental health (American Journal of Psychiatry, Archives of General Psychiatry, Journal of Nervous and Mental Disease, Schizophrenia Bulletin), psychiatric rehabilitation (Community Mental Health Journal, Psychiatric Rehabilitation Journal, Psychiatric Services), and general rehabilitation (Journal of Vocational Rehabilitation, Rehabilitation Counseling Bulletin, Rehabilitation Psychology). Because experimental studies produce robust and reproducible findings, we emphasize randomized controlled trials. We also note quasi-experimental and ethnographic studies, again because the findings tend to be more reproducible than those from studies using descriptive and open clinical trial methods.

 

Needs for Vocational Services

Recent studies confirmed that clients with severe mental illness are interested in competitive employment. Studying middle-aged and geriatric clients with schizophrenia, Auslander and Jeste[6] found that a large proportion of those who were unemployed ranked having a job as a high priority. Fischer et al.[7] found that clients with schizophrenia in Arkansas on average rated working as a mid-range priority. Meanwhile, providers rated working as a low priority and showed little agreement with clients regarding outcome preferences.

 

The Emergence of Supported Employment

The field continues to shift toward supported employment and related models that include less emphasis on pre-employment experiences and more focus on real-world conditions and competitive jobs. To a large extent, this change reflects the movement toward evidence-based practices, which refer to models and principles of mental health care that have consistent scientific support for effectiveness. As described by Carpinello et al.,[8] New York (and nearly every other US state) has developed explicit plans for adopting evidence-based practices, including supported employment.

 

Studies of Supported Employment

Two separate studies using experimental designs provided further evidence in favor of supported employment over traditional vocational services. Lehman et al.[9] showed that the individual placement and support model of supported employment was more effective than a traditional vocational rehabilitation program in helping inner-city clients in Baltimore with severe mental illness to achieve competitive employment (odds ratio=5.58). In a separate experimental study of the same individual placement and support model of supported employment in Washington, DC, Dixon et al.[10] also found that inner-city clients in supported employment attained significantly better outcomes in competitive employment. While supported employment was more cost-effective, service costs relative to wages earned were higher for supported employment because clients in traditional stepwise programs earned similar amounts of income by working extensively in sheltered, noncompetitive settings.

The evidence-based components of supported employment were also a common topic. In a survey of 144 vocational programs, Bond et al.[11] documented large differences in the organization and provision of services between supported employment and other vocational approaches. Focusing on the issue of integrating clinical and rehabilitative services, Jacobs et al.[12] provided suggestions for successful integration, such as educating the medical staff about rehabilitation and building multidisciplinary treatment teams. Lal and Mercier[13] addressed the issue of integration and collaboration among stakeholders from a more theoretical standpoint related to building consensus and coalitions for change. Paulson et al.[14] emphasized the importance of attention to client preferences and choices throughout the vocational process.

Several articles addressed innovative attempts to modify or expand the basic model of evidence-based supported employment. Furlong et al.[15] modified the individual placement and support model slightly by including rapid placement in agency-run businesses as an alternative to competitive employment for clients on assertive community treatment teams and found good outcomes in a quasi-experimental study. Similarly, Gaal et al.[16] involved parents in finding and supervising jobs as part of the individual placement and support model for young clients with schizophrenia and found success in a pilot project.

Research also continues to focus on skills training, often as a supplement to supported employment. Kern et al.[17] showed experimentally that clients who have cognitive deficits can be taught entry-level job tasks with a technique called errorless learning, which relies on implicit rather than explicit memory and therefore compensates for cognitive deficits.

Many programs add supported education to supported employment: the same workers provide both services. In a study of three supported education programs, Unger and Pardee[18] found that almost half of the participating clients worked competitively during their tenure in the programs. Furthermore, there was some evidence that education improved the quality and appropriateness of the jobs they secured.

 

Clients as Mental Health Workers

Two articles reported that clients with severe mental illness have unique experiences and talents that help them to become successful workers within the mental health system. In Connecticut, Fisk and Frey[19] demonstrated that formerly homeless persons with psychiatric disabilities were successful as employees performing outreach, supported socialization, and engagement with homeless clients who had difficulty connecting with services. The two part-time employees established relationships with six individuals over 18 months and helped four of them to become connected with mental health services. In a similar report, Henry et al.[20] described their experience employing 22 clients in 12 part-time positions as research assistants in a mental health research center over 4 years. Job satisfaction was generally excellent.

 

Other Countries

As vocational interventions increase in effectiveness and centrality, more studies of employment also appear in other countries and cultures. Thio[21] reported on the development of a continuum of rehabilitation services, including employment, in Singapore. Diversification of traditional services was inspired by visits to psychosocial rehabilitation and skills training programs in the US. Van Busschbach and Wiersma[22] described the use of a skills training intervention in The Netherlands. Approximately half of the clients were successful in meeting their rehabilitation goals, and they were most likely to have success with housing and vocational goals. Yip and Ng[23] identified multiple barriers for males with psychiatric disability in Chinese culture. The authors argue that work in China is understood in terms of Confucian ideals, such as diligence and honoring ancestors, which have thus far precluded competitive employment for men with psychiatric disabilities.

 

Factors that Influence Employment Outcomes

A major area of research interest in schizophrenia has been cognitive deficits. A study by Gold et al.[24] added some clarity to the inconsistent literature on cognition and employment by showing that cognitive measures (intelligence quotient, attention, working memory, and problem solving) did not predict competitive employment but did predict the total number of hours worked among clients who were employed. Another study by Lysaker et al.[25] showed that poor insight regarding illness was related to poorer ratings of work quality, work habits, cooperation, and personal presentation among clients with schizophrenia in a rehabilitation program.

Clients with co-occurring disorders, or dual diagnosis, also continue to be a focus of attention. These clients, who represent approximately 50% of the population of persons with severe mental illness, have traditionally been excluded from vocational services because of their substance abuse, despite some previous evidence that they do as well as single diagnosis clients in supported employment programs. Three new studies by Bell et al.,[26] Drebing et al.,[27] and Pickett-Schenk et al.[28] supported the finding that clients with dual diagnosis do as well or better than those with severe mental illness alone in vocational programs or in achieving competitive employment. In contrast, Lehman et al.[9] found that clients with severe mental illness and current substance abuse had worse vocational outcomes than those who did not have co-occurring substance abuse.

Client attitudes have also been identified as an important factor in employment. Dorio et al.[29] interviewed long-term (greater than 1 year) and short-term (less than 1 year) workers retrospectively and found that long-term workers were less disabled by illness, more positive in general, and more realistic about vocational goals.

Several studies addressed the impact of the Americans with Disabilities Act. MacDonald-Wilson et al.[30] described accommodations provided for a large number of clients with psychiatric disabilities in supported employment programs. The majority of accommodations related to changes in personnel to provide assistance or to change interactions, or to alter company procedures such as activities or operations. Accommodations rarely involved direct expenditures; rather they affected indirect costs related to, for example, reallocations of time and extra supervision. Using ethnographic methods, Francis et al.[31] found that legislation requiring accommodations and giving employees the right to sue also encouraged employers to emphasize performance obligations. Studying employment within the mental health system, they noted that the field is shifting away from a beneficent model to one with an equally strong emphasis on accountability. In a study of employment discrimination complaints filed with the Equal Employment Opportunity Commission under the Americans with Disabilities Act, Moss et al.[32] found that individuals with such complaints based on psychiatric disabilities were slightly less likely to be referred for mediation and that employers were significantly less willing to mediate with claimants than with those who had non-psychiatric disabilities. When employers agreed to mediation, however, cases were usually settled.

 

Disparities In Vocational Services

Cultural, racial, and gender-related disparities remain an important issue. Capella[33] showed that women and racial minorities were less likely than men and European Americans to be accepted by federal-state vocational rehabilitation programs and to achieve good employment outcomes. Similarly, Olney and Kennedy[34] found racial and ethnic disparities in access to vocational services and in vocational outcomes. On the other hand, Wilson et al.[35] found that African Americans were more likely than European Americans to be accepted for vocational rehabilitation services. Because these studies of disparities included people with all disabilities, not just psychiatric disabilities, the findings need to be confirmed for the subgroup of persons with severe mental illness.

 

The Impact of Working

Several studies examined the experiences and effects of working, particularly the meaning, process, and non-vocational outcomes related to work, for individuals with mental illness. Using qualitative interviews, Provencher et al.[36] found that work had different meanings for different groups of clients but was inevitably part of their personal sense of recovery. Based on personal accounts of recovery, Ralph[37] described how disclosure of mental illness in the workplace can lead to acceptance and support as part of the recovery process. With quantitative methods, Rollins et al.[38] also found that employed clients often found supports from employers and coworkers. Angell and Test[39] found associations in a longitudinal data set suggesting a possible beneficial impact of working on social networks. According to a study by Donnell et al.,[40] clients reported that a strong working alliance with counselors was critical to maintaining employment. In addition to using supports, Killeen et al.[41] delineated a variety of coping strategies, such as negotiating accommodations, which clients reported using to maintain employment.

Casper and Fishbein[42] found that self-esteem was positively related to satisfaction and success with work, not merely to work status (work versus no work). Their study helped to clarify the complex and inconsistent relationship between working and self-esteem. Bryson et al.[43] found that pay and fuller participation in paid work activity led to increased quality of life and improvements in subjective areas (motivation, purpose, anhedonia, empathy). Tillyer and Accordino[44] described the personal accounts of several clients who are professional artists. For these individuals, work provided meaning and often restoration, even when it did not result in much income.

Conclusion

Research shows that over half of most clinical samples of adults with severe mental illness express strong interests in working. It would be helpful to know not only how many clients have the goal of competitive employment but also how program offerings and staff attitudes influence clients' goals, and what the rehabilitative goals are of clients who are not interested in competitive employment.
Rigorous randomized controlled trials have been important in extending the research on supported employment from rural settings to urban populations with the additional complications of cultural issues, homelessness, and co-occurring addictions. The research evidence regarding the effectiveness of supported employment is now quite robust. Additional, as yet unpublished, studies from the Federal Employment Demonstration Program provide further evidence for the individual placement and support model of supported employment.[1, 45] As evidence for supported employment and its principles of practice expands, research will be needed to clarify the limits as well as the effective components of supported employment. Not all clients achieve success in supported employment, and attempts to modify and expand the model, as well as continued research on other approaches, is critical. Individualized approaches for clients with special needs, such as those with cognitive problems, lack of motivation, dual diagnosis, and language and cultural barriers, will need to be developed and tested. Because research shows that pre-employment skills training does not have much impact on employment outcomes, clinicians and researchers are shifting attention to skills training that is provided in conjunction with rapid job search or following job starts. Different models of skills training, including errorless learning, are being used and need rigorous testing. Similarly, controlled research on supported education and its relationship to supported employment and long-term career success is extremely important. Many clients, particularly adolescents and young adults, have education as a primary goal, with the long-term aim of enhancing career opportunities.

Supported employment and the related improvement in employment outcomes have suddenly gained momentum in other countries as well as the US. Initial studies of supported employment are underway in Canada and several countries in Europe and Asia.
Better understanding of the relationship between work, recovery, and longitudinal outcomes is critical because vocational services must reflect clients' goals to achieve long-term success. Because most of the current research has a short-term perspective (typically 1-2 years), it will be important for future studies to assume a long-term perspective. Studies of job retention, changing jobs, developing careers, and the impacts of employment are critical.
Although studies of the Americans with Disabilities Act are appearing, we identified no studies of other administrative and regulatory barriers to employment for persons with mental illness. The complex benefits system remains a major barrier for many, and studies of benefits counseling, regulatory changes, and other system changes are needed.

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Reprint Address
Correspondence to Robert E. Drake, New Hampshire-Dartmouth Psychiatric Research Center, 2 Whipple Place, Lebanon, NH 03766, USA Tel: +1 603 448 0126; fax: +1 603 448 0129; e-mail: robert.e.drake@dartmouth.edu

Robert E Drake;a Deborah R Becker;b Gary R Bondc

 

aPsychiatry and bCommunity and Family Medicine, Dartmouth Medical School, Lebanon, New Hampshire and cDepartment of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA