ABILITY House Magazine Article IllustrationSupported Employment

Let’s call him Jake. He is a composite of a possible consumer in a supported employment program. He wakes up every morning at 5:00 a.m. He takes a shower, brushes his teeth, and slips into the clothes that he carefully laid out the night before. He doesn’t want to wake the others in his group home by preparing breakfast, so he grabs an Egg McMuffin and a coffee on the way to the bus stop. Two bus transfers and two hours and 15 minutes later, Jake arrives at work. Jake has worked as a custodian at a small company for approximately seven months, and until recently he has had an impeccable work record there. On this particular day, Jake’s job coach from the state vocational office will be stopping in to see him at the job site.

Jake is a 36-year-old who was diagnosed with schizophrenia at the age of 16. He came from a lower middle-class background where private hospitalization was unaffordable. His disorder was so severe that his family was forced to have him hospitalized at a state facility. Jake’s education was interrupted by his illness. Although the opportunity to work on a General Education Diploma (GED) was available to him, schizophrenia impaired his attention, reasoning, and motivation; additionally, the medications needed to control hallucinations and paranoia during his first five years of hospitalization had sedating side effects that may have affected his ability to focus. He later lost interest in pursuing his education. He was fortunate, as compared with others in the system, to have a good support structure from his family and friends; however, as the years have gone by and people have moved on with their lives, the support has somewhat minimized.

After 10 years in the system, Jake finally achieved a more stable level of functioning and his treatment team recommended some vocational training. Jake was receptive to this idea. Over the years he had participated in occupational therapy, art therapy, music therapy, etc., but now it was time for something that would prepare him for a more self-reliant existence. The team’s eventual goal was to help him move to a structured environment within the community. Work would be one important element contributing to his self-sufficiency. Since he had not pursued a GED and was still rejecting the idea of going back to school, there were few vocations available for him within a competitive work environment. The team asked Jake if there was a particular vocation he wanted to train for. Initially, he was noncommittal. After giving it some thought, he stated that he often helped clean around the hospital ward and really enjoyed it. He told the team he might consider custodial work. Jake was then assigned to an employment specialist/job coach from the state vocational rehabilitation office’s supported employment program. He trained with this individual for two months, practicing tasks needed to prepare for a job such as developing a resume, filling out employment applications, dressing appropriately, and role-playing what he would say in job interviews.

Then the actual job search began. After submitting numerous resumes and weathering several interviews, Jake finally attained a custodial position at the small company where he presently works. Jake decided that his employer should be aware of his diagnosis, as he was used to being surrounded by people who were receptive to his needs, and he was somewhat unnerved about entering competitive employment in the “real world.” The employer had previously hired staff through this employment specialist, and he was willing to train Jake for the position.

Recently, Jake has been feeling inadequate, and this demoralization has had a damaging effect on his work performance. His employment specialist, Steven, is spending some time with Jake this particular day in order to identify some of the issues affecting his performance on the job. Jake is entitled to this service, has a successful rapport with Steven, and feels comfortable communicating his concerns. Steven will take this information and will then meet with Jake's mental health treatment team to collaborate in adjusting treatment. This team approach allows all of Jake's treatment providers to share information and make coordinated changes in medication and other therapies to give Jake the best chance of remaining gainfully employed.

What is supported employment?
Supported employment is based on the following six principles: 1) eligibility of the consumer is based on the consumer’s choice, and therefore no one is prevented from participating; 2) supported employment is incorporated with other treatments, and the employment specialists arrange plans and goals with the treatment team; 3) competitive employment is the goal, focusing on local full-time or part-time employment that pays at least minimum wage and is open to anyone; 4) a job search begins almost immediately after the consumer conveys an interest in employment, and there are no prerequisites required prior to this process; 5) follow-up support systems work on a steady basis, and individualized provisions continue until the consumer no longer wants assistance; and 6) the preferences of the consumer are essential, and the options and choices regarding work are founded on the consumer’s requirements and skills.

Supported employment programs afford those with severe mental illness the opportunity for employment in viable and valid work scenarios with supportive assistance on-site and as needed. These services are tailored to the individual strengths and deficits of each person to facilitate learning and carrying out a chosen job. While the concept of supported employment has been in use for some years, recently it has received increased attention as an integral component of programming to afford better access for those with disabilities to significant and comprehensive work venues.

Any individual with a disability who has an aspiration and a need to work is entitled to supported employment services if he or she needs support in order to find and sustain a job. Consumers should always understand that they have the right to work, and contacting supported employment agencies within their communities is the first step. The next step is for the agency to assign the consumer an employment specialist/job coach, whose responsibility is to connect with the consumer and, if possible, the family to look for suitable employment for the individual. The specialist should always take into account the consumer's work preference, as well as his or her interests, skills, and preferred work environment. Once a worksite is found, the job coach is responsible for providing individualized job counseling and assistance. Types of help might entail thorough job training on the job, direction, transportation, or other support enabling that individual to retain his or her employment. There is no time limit attached to the supported employment process. If the consumer requires continuous support, then the specialist is responsible for assisting the consumer for the extent of the consumer’s employment. The specialist might need to provide full time assistance on a one-to-one basis or might need to assist only on an occasional basis if the consumer needs minimal support or training. Since the requirements are based entirely on the needs of the consumer, the specialist must invest the time to truly understand the needs of the consumer and establish an effective rapport.

Supported employment programs are different from more conventional approaches to job placement. Traditional programs utilized pre-employment vocational training aimed at learning and practicing general job skills before looking for employment. Supported employment employs a rapid job search and trains consumers on-site in real-life jobs in their communities. As such, it allows for new employment opportunities for people with disabilities who might not be ready to move directly into independent competitive employment. Often people with disabilities begin the process of workforce re-entry in a graduated fashion. Volunteer work, training, and supported employment can serve as a springboard to independent competitive employment.

Roberta Hurley, a specialist on supported employment and CEO of Southeastern Employment Services in Connecticut, has been providing employment services to people with mental illness for approximately 20 years. She believes that mental health recovery requires a holistic approach that considers the multiple aspects of a person's life (social, spiritual, occupational, psychological) and not simply psychiatric diagnosis. When people are supported as active community members, often they experience success, and recovery transpires. Hurley explains that historically people who were diagnosed with a mental illness were treated under the “medical model of care,” which viewed people in terms of their illnesses or deficits. The focus of the model was to define the illness and then treat the “patient” with medication and other therapeutic interventions. Under this model, institutionalization and isolation were often implemented to the point where those with mental illness were unable to fulfill their dreams and goals. Hurley states that it is important to treat the symptoms of mental illness; however, people also need to return to a life worth living. Medication and treatment are often necessary for recovery, yet she views employment as a more vital component of a holistic and effective approach toward integrated life in treating people who have mental illness. Hurley’s experience with supported employment reflects its value for our society. Those diagnosed with mental illness often realize important social roles from having a job.

Alternatively, Evelyn Lyles, a PhD candidate in clinical psychology at Indiana University and CEO for The Council for the Educational Development of Disabled Children & Adults (CEDDCA) in Rockville, Maryland, has a different take on the supported employment approach. Lyles feels positively about the many supported employment models that exist and the successes that have evolved from these programs; however, these programs are not beneficial for the entire population. She reasons that not all individuals are ready for such programs, and supported employment is not a viable route for all consumers. According to Lyles, supportive employment programs are primarily designed to facilitate the needs of individuals with disabilities who have already been a part of the workforce but at some point in their lives experienced illness that overwhelmed their ability to function as they had previously. Factors associated with a better outcome in supported employment include greater work history, lack of a debilitating diagnosis, ability to show needed skill improvement, and adequate educational level. Research illustrates that supported employment is less likely to work for the segment of the mentally ill population that is homeless, incarcerated, or receiving long-term hospital treatment. Nevertheless, some current programs face requirements that all participants partake in the supported employment process, whether or not they are good candidates.

Lyles continues to ask what is out there for those who are poor candidates for supported employment, and what chance they have for a “real jobs”? In the past, some attended what were called sheltered workshops, where people with mental disabilities came to work in assembly-line fashion, often making small goods that could be constructed by hand, collating and folding pages for mass-mailings, etc. The workshops either sold the products directly or contracted for the work with outside businesses. While some sheltered workshops still exist, they have fallen out of favor because of concerns that individuals capable of doing higher-level work are too often left in sheltered workshops rather than assisted with individualized job programming. Additionally, critics charge that the very low wages sheltered workshops pay are exploitive for people capable of more independent work. Lyles, however, remains concerned about those left out of supported employment; she believes that because there should be a place in the community for everyone, the best answer may be a return to sheltered workshops for some. “These programs worked before. And with the proper supports and adequate designs, they can work again. Supported employment should not be the only option.”

Evidence-Based Practice
Most supported employment programs are founded on evidence-based practices that have displayed positive results. Researchers have collected far-reaching statistics for the past 15 years to delineate which psychosocial and pharmacological management approaches to mental illness have the most influence on recovery, and supported employment has a demonstrated effect in improving outcomes for
people with mental illness.

In 1998, the Robert Wood Johnson Foundation formed a panel of researchers, clinicians, administrators, consumers, and family advocates to confer about the existing research and establish which modes of assistance presently display a compelling evidence base. Supported employment was one practice identified as objectively beneficial, along with standardized pharmacological treatment, teaching illness management and recovery skills, psycho-education, assertive community treatment, and integrated treatment for substance abuse and mental disorders.

In July of 2002, six states and the Netherlands initiated a project to study how these evidence-based practices fare when they are implemented in public agency settings. The University of Kansas School of Social Welfare was chosen to impart the training, consultation, and research components for this project, and the Kansas Department of Social and Rehabilitation Services was selected to execute evidence-based practice in supported employment and dual-diagnosis (combined mental illness and substance abuse) services.

The eventual goal of this research is the translation of the evidence-based principles into practice. The research looks at the effective approaches, ineffective approaches, and existing barriers. It also investigates economic value, evaluates the dependability of the project sites, and tracks how closely outcomes match performance expectations. Conquering barriers that threaten the availability of supported employment services has been a major endeavor. The best evidence, compiled from an exhaustive review of available research, reflects that supported employment far surpasses all other vocational rehabilitation approaches for people with severe mental illness. It is imperative that there is continuous research conducted to improve the process.
Studies have shown that 7 out of 10 consumers are interested in finding paid and useful employment, and that 6 out of 10 consumers are able to work in the community if the right type of supports and services are easily accessible. Because research demonstrates that supported employment is responsible for greater numbers of consumers getting and maintaining jobs than any other approach, it has been praised as a worthy approach toward a successful and therapeutic employment outcome.

Although researchers recognize the importance of expanding outcomes and improving the revitalization practices for persons with severe mental illness, the carrying out of evidence-based practices lags significantly behind the level of knowledge. For instance, “case-management” activities like linkage to agencies providing supported employment are not considered by insurance providers to be reimbursable care. Consequently, rarely do consumers with mental health problems such as schizophrenia have access to more holistic evidence-based treatments within a general mental health setting. The practice of using evidence-based approaches must often overcome ideological, economic, and practical obstacles. All the same, the field of mental health services is gradually striving to afford a broader spectrum of research-based services as the basis of care. Supported employment affords consumers the prospect of self-sufficiency through productive employment, and it is vital that it be available in this spectrum of care.

by Gale Alexander Kamen, PhD
Dr. Kamen is an educational
consultant and employment specialist
working for the D.C. government.

Southeastern Employment Services

The Council for the Educational Development of
Disabled Children & Adults (CEDDCA)

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