An Update on Supported Employment for People With ... - CiteSeerX

Update on Supported Employment

An

for People With Severe Mental Illness Gary R. Bond, Ph.D. Robert E. Drake, M.D., Ph.D. Kim T. Mueser, Ph.D. Deborah R. Becker, M.Ed.

Objective: This review for people with severe made for quantitative Seven

descriptive

studies,

six experimental obtaining

examines

of supported

surveys, one found. All studies

were for

In experimental

effectiveness

illness. Methods: primarily in the

three

studies

employment

grams.

the

mental studies,

persons

studies,

enrolled

a mean

nonhandicapped

employment

A comprehensive search was published literature. Results: quasi-experimental suggested significant

in

supported

of 58 percent

study, and gains in

employment

of clients

pro-

in supported

also

No evidence

favored

was

cipitating

higher

ployment

programs

health

and

found have

with

tention

to

most

services

Services

48:335-346,

program

employment employment

over control subjects. led to stress levels pre-

Two

of many

rates.

the

within

widely

of supported

illness.

and the avoidance

long-term

approach with close

follow-up.

people

with

employment

for at-

These federal tended to provide oping

ing,

ap-

supporting

serving

severe review

mental the

people

with

(4-8).

four

definition bilitation

in 1992) features:

preferably

adoption,

systematic information on the impact of supported employment is lacking.

as

the

regular

settings

and included clients work prevailing

employees and

in

regular

the folfor pay,

wage in

rate,

integrated

contact

with

Within

velopment

versity

Drake,

in the department

at lndianapoiis, Di: Mueser, and

402

North

ofpsychology Blackford

Ms. Becker

Psychiatric

Research

Center

PSYCHIATRIC

SERVICES

. March

Street,

are affilwted

in Concord, 1997

at Indiana

Vol.

New 48

with

Hatnsphire. No.

3

indianapolLs,

the New

University-Purdue

Indiana 46202. Hampshire-Dartmouth

UniDr.

voca-

on the de-

of supported job

employment

coach

the

assertive

model,

model,

the

transitional

em-

community

and

the

“choose-

model.

Initially

pilot

tested

for people

disabilities,

employment

was

to

as a more

and

cost-effective

sheltered (16)

“place-then-train”

workshops advocated

for a

approach,

to the conventional

philosophy,

ignored

in con-

“train-place”

targeting

severe

with

supported

justified

humane, Wehman

mostly

for field,

treatment

the most

im-

psychiatric

ployment,

trast

job

illness

and

(9-16).

and

sustained

influences

the

such train-

mental

model

persons

disabilities,

with

who

by traditional

were

employ-

ment programs, and minimizing prevocational assessment. Wehman showed the feasibility of an “individual

is professor

were infor devel-

employment

the

significant

placement”

coaches

Di: Bond

(3).

little

severe

alternative was first A formal

was outlined in the RehaAct Amendments of 1986

(revised lowing

have

on competitive

effective,

its effectiveness.

Supported employment defined during the 1980s.

psy-

illness

literature

for

services”

employment,

which

developmental

with

handicaps,

be eligible

to traditional

sheltered

clubs,

employment

critically

is inbecause

guidelines flexibility

alternatives

of supported for persons

their

re-

Further-

tional rehabilitation approaches, as vocational counseling, skill

get-keep”

programs

of

rehabilitation

we provide a brief hisof the development

and

atric rehabilitation literature less than a decade ago (1), they have been disseminated to many mental health and chiatric populations. Despite this widespread

severity

include

(Psychiatric

and (2).

not traditionally

In this update torical overview

ac-

in the psychi-

programs

the

would

pact

support evaluated.

support

supported employment for “individuals who,

clubhouse

Although

first appeared

rehabilitation

team

held principles-ongoing not been systematically

and

of supported

for

counts

proaches

service

em-

of mental

1997)

rehabilitation mental

supported

integration

appears to be a promising but more studies are needed,

implementation

development

severe

support:

a single

employment marked an important shift in the history of voca-

tional

features

empirical

Supported employment severe mental illness,

people

he

supported

training. Two other to client preferences-have

Conclusions:

T

that

rehospitalization

vocational

ofpreplacement and attention

in supported

clients

more, tended of

workers,

ongoing

vocational

employment programs achieved competitive employment, compared with 21 percent for control subjects, who typically received traditional vocational services. Employment outcomes relating to time employed and employment earnings

ceive

at the

training and

clients

providing

port, even though intensive on-site

model, work

in

with

site

their

work

time-unlimited fading coaching

job

intensively

roles sup-

out the more over time. 335

Advocacy ment

by

supported

proponents

tion

and

employ-

tun(ling

‘ides

legislafor support-

ed employment through partment of Education. expansion

ployment

cal

services

with

the

of case

(17,18),

are

literature projects,

and

illness

primarily

pioneered

at

community

stimed petitive

living

was

House outside

in New York Cit Operating ofthe mental health system,

Fountain

cause central

meeting

to socialize.

dered

place

for

Meml)ers

day”

leagues

toward

avoidance

individualized

com-

placement

it

hypothesized

l)enefite(l

from

the clubhouse

that

because

they

transitional with

stress

tolerance

mate

them

and

to

negotiate

with

of the clubhouse its focus on the nor-

some

experts

tions

dissolve

argue

history.

usually

jOI)5 and

that the

skill

entry even not

Both

assume

that

professional

need

to help

clients

provide

and

are

continuing

lo-

sup-

the fact that positions are

controlled

clubhouse (23). The client’s l)ase remains the clubhouse. The assertive community model is a comprehensive to community-based

and

the

rehabilitation

job

into supported though these part

they

employelements

of the with

Weh-

conceptualization.

clubhouses

sometimes

supported

transitional

employment

employment,

transitional

who

federal

guidelines,

consistent

both

clubs,

be required

employment

clients ble.

practice, approach-

may

place-train

ing

In

hybrid

training,

formally

are

and

reserv-

employment

for

are vocationally

less capa-

Methods

services

by the home

treatment approach devel-

literature

ies

of

supported The “choose-get-keep” person-cen tered approach ported

employment,

by Danley

was

and Anthony

University

model, a to supdeveloped

(27) at Boston

A fundamental

on

feature

client

choice

is

in se-

lecting, obtaining, and maintaining jobs. Unlike transitional employment, which gives priority to building work career curs siOflS.

histort;

this

planning, in preplacement All

of

ment models incorporated and achieve ways.

the

encourages typically

counseling supported

ocses-

employ-

goal

employment,

although

they

varying

program quantitative data for

regardless

illness

were

methods of the Psych

included rehabilitation

manual litera-

and Index searches of

abstracts; and searches of (31,32), conference and listings of federally

studies.

Many different outcome were used in these studies, most

included

nient rate the federal

PSYCIIIATRIC

We inby 1995; studies.

Abstracts,

dissertation bibliographies proceedings,

outsevere

reported.

computerized

Medicus;

of

provided

employment people with

any study completed were unpublished

Search searches

studoffering

features,

eluded a few

funded

in widely

included

programs

mental

ture, a

reviewed below have a focus on client choice

preferences,

this

model which

that come

search

vocational

specific

an emphasis

distinc-

(7,22).

port. Differences include traiisitional employment temporary

Tran-

bears a resememployment, and

in practice

approaches

use

planning

offer

em-

giving all nieml)ers regardless of em-

employment to supported

(28,29).

career

man’s

vocational

employ-

of community

or psychiatric

sitional 1)lance

of work

support,

in which

Our

an(l on to work,

ploynient

the

system.

Contributions model include function

or mobile

community

transitional

iiolovnient a chance

system

supported

federal-state

build staff

training,

instead

of client preferences. coach model has been

Furthermore,

employers for nient positions.

malizing

through

their

self-confidence, and help them up their r#{233}sum#{233}s. Clubhouse workers

programs

to accli-

increase

in enclaves

programs

before ment,

coninien-

designed

work,

prevocational

time-unlimited

nor

and

appear to be comsupported employ-

placement

many

are

employment

stamina

of

tation

and

on supported

funded

sobs

nieml)ers

dominant

felt need-

functioning. al SO pioneered

community

surate

the

influence

in

en1ployment-teniporarA

part-time

been

niem-

Particil)ation

ed for its successful Foun taut House

model

es

has

col-

severe follow-

dominant influence on supported employment programs funded through the federal-state vocational rehabili-

The job

and

components many

crews,

coach

Howevei;

es-

em-

with the

persons

111011 CO55

even

encour-

Beard

for

field on the

of supported

illness.

consideration The job

“niembers”

were

(19-21).

(20)

hers

336

step

vo-

employment.

aged to participate in work units at the clubhouse as part of the “work-or-

cate

goal,

components

is as-

known as the clubhouse, beits identity revolved around a

I)eCailie

staff

a vocational first

one

client

consensus

ment programs (28-30): a goal of permanent competitive employment, minimal screening for employability,

teams

A hilly

at least

Every

as-

rehabilitation

reached

ployment

ing

by

(26).

not

mental

in-

models

program

psychiatric

sential A

used

includes

is a modest

has

rehabilitation.

time

counselor. to have

sup-

team

treatment

over

team

cational ifit

community

and

Current The

environments.

strategies

evolved

stafled

Aspro-

assistance,

treatmeiit

treatment

have

surveys.

to

individualized in natural

sertive

dciii-

(24,25).

time-unlimited

Emplovnient

an innovative appeople with severe adjust

and

tegrates

thin,

Test

treatment

multidisciplinary

empiri-

nonexperiniental

In the 1950s, proach to helping mental

the

and

intensive,

primarily

ciii-

surrisingly

consisting

studies,

onstration

supported

Stein community

port

the U.S. DcDespite eon-

of

foundations

by

sertive

targeted

tinning

oped

led to federal

SERVICES

some

form

indicators although of employ-

as one measure. guidelines define . March

1997

Vol.

Although support48

No.

3

ed

employment

as an outcome

(and

in a program),

most

not as enrollment studies

report

the

the percentage a program

who

community

at any as

that

a

year

after

of clients

work,

report

tailed sures

findings may

1)roadly

but

rates

A more

discussion

ofemploynient

is available

elsewhere

from

liv

conducted.

experi

nient

iiental

in

wh ichi

health

re-

(44).

\Ve

IPS,

study has a natural ty day

operating

mea-

with

mental

illness

studies

are

severe of the 2. The

scribe

the

niodel,

saniple,

and

general

We located studies

reports

of individual

ployment

lacks

(50)

surveys

(33-40),

(28,30,41),

perimental

and

study

in Table

and results 1. Despite

sampling,

program

features

surement

nlodels,

employment.

and

rates

The

Of

pre-post

after

tional

approach

which

in the

One

concluded

ployment

that

support

creased

job

Several

re59

interpreting

rates suggest

findings

from

faced

site

closed

with

in

program

was

found

for

ceived vices

any meaningful

ders

36 per-

vocational

program clients,

(37).

PSYCHIATRICSERVICES #{149} March

1997

Vol.

48

hospi

No.

3

day iii

One

Two

the

l)e-

supported

(49).

services

the

site

m that

treatment

employment

did

treatnient.

not

itself

regular Moreover,

the

to I PS had no outcomes ,

brokered

ployment

services

such

incarceration, attempts,

dropouts. Interviews their families, and

or with mental

clients enrolled

in

rnent. ated

condition

‘ocational

with in day

During ofthe

the

em-

remaining

of unem-

severe mental illtreatment or case expressed

an

competitive

the study

participants and

condition

oth-

agenc

centers.

who

cent

gradual

The

coiisisted

seeking

t

and

supported to

stibjects

management est

coordi-

eiiiploynien services.

health

niental

ness

of

closely management

health

proided

I)lO’ed

atten-

case

centers. the fIve

a rehabilitation

Study

were

one

five

the

health

centers,

with

supported

for

s U)pOIte(I

niental

four

the

men tal

em. agenc

program. rates

for

suicide

change

readiiiess preparation.

progranis

program

(42).

loijob

operated

commun it One agenc)c

up-

for both condicoach niod-

prevocational

agencies

t

jOl)

no screening no

employnient

Individual

rate;

marked

of day

hoi’nelessness,

ser-

cuts.

treatment program to I PS had an in-

talization

its

especially

identified as eligiemployment re-

and

(IPS)

itation

day

employment

Increases

dropout.

only

same

other

rehahul

in negative

that

the

vocational

as

found

was

the

increases

project

for

eml)lovnieli

It followed

tiateci

that converted

cent of the clients ble for supported

con-

of irevo-

training

eligible

sup)orted

The other site continued its day treatiiient along with traditional brokered

program

One

adniis-

gradual

iltOflthis

readiness

were

ser-

study

the

iii

foni

work

the

to

)ndi tions. conditioii

employnient

tlli)se

health

Support

document

of study

sites

progranti, employ-

as

known and

convert

rate

niral

treatment a supported

of studies. Sonic did not make clear whether any clients are screened out at admission to the supported employment program, and some (lid not the

at-

C(

“

after

attended

nental

creased

group

tliV()

budgetary

it with

Clients at the that converted

(45,46).

in

its day

Placement

in-

this

was

nient

em-

caution

programs

replacing

addi-

sul)stantially

retention factors

while

el, vith

treatment

of

a hybrid

workplace

supported

proach tions.

studies

examined

for

illness

employment.

combining supported emand transitional employ-

ployment ment,

months.

six

study,

services

assigned

‘gradual aCcelerate(l

im mediately

fore

indefinitely.

and survey results suggest a job tention rate of between 35 and percent

remain

niea-

pre-post

col-

referral

niental

randomly

were

The

the

and

rapid

employment

(Ii tion

in

increased

,

all suggest

they

key

are summarized wide variation

strategies

studies

Their

sup-

Bond

severe

cational

quasi-ex-

each

of accelerated

evaluated

with

vices

three

one

(42-44).

limit,

may

of

to sul)ported

SiOli,

em-

limitations,

clients

Clients

a

pre-post

supported

programs

time

findings,

study

“accelerated”

strict

of seven

program

conclusions

employment.

Clients

a prevocational

experimen-

studies

de-

design,

study.

received

Nonexperimental

zed

sections

following

research

(5()-56).

su mntiari

day treatment in lIve coiniiiunit)’ iiiental health cetiters in hidiana.

clients

that

studies for ieoi1e

tending

search

program

favorable

eniploynient

leagues

tal studies.

c(fl_

similar

of supported

ported

enter

Stul)seqtletltl\’

with

six experiiiiental

Indiana

(Ic-

non-

sat(43).

studies

located

in Table

(5).

and

results

Results

dissemi-

a conununi

center

Once

studies

differ-

mixed

iiien

widespread conversion

site

to

based

of our literature in two categories:

experimental

the

tal It involved

quasi-expei

is

This

suggested

second

verted

Experimental

experi-

eniploynient

several statewide projects (5,47,48).

l)eeii

investiga-

employment.

is

stilts

One

exclude

some

ence

The

staff revealed with the

prO-

of typical

s111)1X)rted

implemented.

nation

at

employed

studies of model

than

isfaction

the

nonexpenniental

rather

health

to as-

Moreover,

representative

when

sethe

sample suggest

designs

effects.

in

grams,

admission.

usually

rates

be

ence

inter’al,

tiDne

about

dropout

for experimental

a paid percent-

aml)iguities and

prograni

report

employment

Findings The results are presented

sess

rates-percent-

rates

on any paid

need

to

after program admissometinies reported.

Eniplovment sheltered

the

currently

interval also

as

employment

“status”

a fixed sion-are

tors

is,

during

OflC

However, ages

studies

ol)talning

time

such

obtain

Most

rates,

of clients

rate

admitted

actually

job.

“interval” age

employment

of clients

Thus lection

44

term

inter-

employ-

year, 42 Perin the accelerpercent

i nated

in the from

services. 337

Table

I

Summary

of key features

for persons

with

severe

Study

results

mental

of pre-post

Sample

Referral

source

or study

group

phrenia

19

Self-referred

249

Vocational

rehab-

ilitation community

et al.

(36) Mowbray

et al.

88

(37) Nichols

25

(38)

tal health Shafer

and

Huang

86

employment

37 442

% employed’

% retaining

job

Program

Base

Follow-

Three

Six

Nine

Other

model

line

up

months

months

months

findings

Choose-get-keep

31

73

nr

nr

nr

Job coach

nr

36

75

59

50

Less hospitalization No change

53

Assertive

commu-

50

70

55

nr

nr

67

84

nr

nr

nr3

-

nity treatment 68

Assertive nity

commutreatment

32

Joh coach

nr

80

nr

nr

nr4

31

J 01)

coach

nr

60

63

35

29

40

Choose-get-keep

nr

35

nr

nr

nr

Joh coach

nr

nr

66

53

43

Joh coach

nr

nr

66

59

nr

-

Joh coach

nr

542

2

nr

nr

-

25

39

nr

nr

nr

No nega-

center

Vocational

114

et al.

of supported

men-

tal health (40)

studies

in quality of life

rehabagency,

community

Trotter

quasi-experimental

center

Vocational ilitation

(39)

and

agency, men-

tal health center Agency serving homeless persons Community mental health center Community men-

82

surveys,

illness

size

(34,35)

Kirszner

studies,

% with schizo-

Pre-post studies Danley et al. (33)

Fabian

and

rehab-

ihitation

-

agency,

community

men-

tal health

center

Surveys

MacDonald

212

Vocational

rehabagency Vocational rehabihiation agency Directors of supported employ-

ihitation

etal.(30)

Wehman

et al.

233

(41) et al. (28)

Gervey

12

ment programs Quasi-experi-

mental

studies 71

Drake etal. (42,43)

Day treatment program

42

Individual ment and

clients

Place-

Sup-

live out-

port 27

Regular

33

56

nr

nr

nr

13

13

nr

nr

nr

Nonegative outcomes

Day treatment

14

9

Individual

13

23

nr

nr

nr

Less

ment port

attendees 1 12

Day

comes

Individual

program

treatment clients

44

Day

Place-

-

and Sup-

treatment

program

35

Day treatment

1 12

et al. (44)

Drake

Regular program attendees program

44

Place-

ment and Sup-

clients

hospi-

tahization

port 35

Regular

Individual Placement and Sup-

program

attendees

40

9

nr

nr

nr

-

port nr, not reported 1 MI studies used competitive tered

employment,

and

2

Estimated

3

Clients

4

Clients retained jobs 12 program directors

5

After erated

taming 338

for calculating

et al. (40),

who

defined

employment employment

rates,

except

as acceptance

et al. (37), who included

Mowbray as a permanent

employee

after

a four-

all

paid

to-six

employment, month

even

trial work

shelperiod.

percentage retained

one

jobs

year,

differences

for a median for a mean surveyed

clients

condition

employment the gradual cant

employment

Trotter

of eight of3.5

in the accel-

had modestly

outcomes condition,

better

than clients in with signifi-

in the percentage

employment,

months.

months.

the

percentage

ob-

holding

a full-time

which Finally, that gram mental

job,

clients worked, a serendipitous

the

supported

developed health

weeks

during

and earnings. finding was

employment

pro-

at the community center was more sue-

cessfully

implemented

and had better

employment outcomes than kered supported employment

the

bropro-

gram. Limitations of the study problems in implementing

PSYCHIATRIC SERVIcES

#{149} March

1997

Vol.

included the bro48

No.

3

Table

2

Summary Feature

ofkey

features

or

and results

ofsix

experimental

Bond et

Chandler

result

al. (50)

(51,52)

Referral

Five

source

community

mental centers

Admission

mental

health

ofsupported

employment

for persons

Drake et al. (53)

Drake et al. (54)

Gervey Bedell

Two CMHCs

Case

Secondary

system

manage-

ment

program

in work,

“Cross

eligible

for or a

recipient

of SSI

section,”

interest not

Interest

in work

required

in work,

six months area,

or SSDI

no

cognitive physical ment,

Screening method

Case manager referral

Interviewed by team of three

Sample N % with schizophrenia

74

210

severe

and (55)

mental

illness

McFarlane et al. (56) schools

Two CMHCs

and CMHCs

Follow-up

One

no

Interest

in

in work,

enrolled

severe

case

or impair-

agement gram

15 to 24, family available

Age

in

man-

to participate

66

Three

available

sub-

stance abuse Four informational sessions

Four informational sessions

One month of prevocational

140

152

34

47

55

35

18 months

18 months

One

nr

training

55 year

Stable for six months, family

pro-

clinicians

period

with

(CMHCs)

Interest

criteria

et al.

County

health

studies

years

69 65 year

18 months

Intervention

Experimental

Rapid entry into supported employment with job coach

Assertive community treatment, clubhouse

Individual Placement and Support

Individual Placement and Support

Supported employment with a job coach, clinical services

Assertive community treatment, family therapy

Control

Prevocational

Usual

Skills training,

Referral

Sheltered

Usual

training

before supported employment

% ofclients employed at baseline

None; clients employed a mean of one month

% ofclients ohtaming employ-

Within 12 months, 56% ofexperi-

services,

to

referral to vocational rehabihitation 12% ofclients employed within year before

choose-get-keep supported employment None

vocational habilitation

re-

workshop

None

None; 12% employed within year before

During year 12% ofboth

Within

nr

Within 12 months, 76%

in year before

ment time

at any during

group

mental group, 29% ofcontrol

follow-up

services,

referral to vocational rehabilitation 14% of experimental group, 9% of control

groups;

1,

year 2,

16% ofexperimental, 7% of control group; year 3, 20% of

group

18 months,

78% ofexperimental group, 40% ofcontrol group

Within

18

months,

46%

of experimental

experimental

group, control

group, control

6% of group

of

19% of group’

experimental,

6% of control group % of clients employed At 12 months Experimental

26

nr

36

nr

nr

17

nr

24

nr

nr

8

Control At 18 months Experimental

37

332

nr

Control Duration of employment

172

nr

38 22

nr nr

nr nr

27 8

Experimental Control Annual earnings Experimental

9.4weeks 3.1 weeks

nr nr

6O7hours 205 hours

nr nr

l46days 9 days

4.8 months 1.3 months

$1,525

Year 1, $602; year 2, $1,086; year3, $1,135

$2,263

nr

$3,682

$755

$718

nr

$1,Q97

$214

nr

No differences between groups in hospitalization, symptoms

No differences between groups in hospitalization, symptoms

Control

$574

Year

1, $226;

year

Other

findings

2, $329 year 3, $233 Experimental group had less hospitalization; no difference

No differences between groups in hospitalizalion

between

groups

in self-esteem

No differences between groups in hospitalizaion, self-esteem, quality of life,

symptoms

nr, not reported 2

Paid employment, At only one study

3

Paid employment,

1

PSYH1ATRIC

excluding site

sheltered

employment

including

sheltered

employment

SERVICES .

March

1997

Vol.

48

No.

3

339

kered gram, ple

supported employment brevity offollow-up, small size,

more,

and

the

both

high

study

attrition. design,

experimental

prosam-

and

routinely

Program

Further-

which

made

control

and available

management,

sub-

crisis services not to control subjects.

participants

cross-section of mental illness,

constituted

clients with including

with severe community a

severe stable

mental mental

illness health

attending centers in

two small cities. Admission criteria included an interest in competitive employment, local residence for at

jects eligible for the same supported employment services, may have compromised the integrity of the experi-

clients who lived in group homes, frequently hospitalized clients, and homeless clients. Interest in employ-

least

mental

ment

Clients also were required to attend four sessions of an informational

manipulation.

side,

this study

tenet

of supported

advantages

al

On the

directly

study

One

have

expected

that sub-

the accelerated condition but achieve the outcomes somewhat even

dent

three

years

at the center

later,

ex-

were

with

implemented

ployment

would later.

still evithe more sue-

differences

cessfully

supported

program.

One

em-

interpreta-

tion is that entry into competitive employment is influenced by the expectations

of staff

though

study

ual

condition

ported

and clients (58,59). Alparticipants in the gradwere eligible for sup-

employment

preparatory

not

services

period,

many

a prerequisite

for the

interviews for three

competitive

for Village

in the gradual condition would outcomes equivalent to those in

However,

The

a pre-

(57).

penmental

was

study. Follow-up conducted annually

the did not beafter

employment

clients

ly different jects during 13 percent),

was

versus

year 2 (16 perand year 3 (20

6 percent).

Moreover,

of quarters

of the

creased over year period, clients

year

worked)

time. Over 32 percent

obtained

competitive

ment, compared with the control subjects

employ-

1 1 percent (Chandler

communication,

Strengths

to the study was its focus geneous group of clients.

California study of integrated services. Chandler and colleagues (51, 52) evaluated a capitated mental

vocational

health based

mated the way vocational frequently implemented.

sites,

the Village,

developed program opportunity ness of Clients

in Long

Beach,

a supported as a centerpiece,

employment offering

to examine supported

the effectiveemployment.

randomly

selected

an

to partici-

blending

of D,

1996).

ofthis study include

model,

in-

the threeof Village

pie size, length of follow-up, sessment under “real-world” tions. Also lending ecological

tion

month

outcomes

period

strongly

with

clients

over

an 18-

favored

IPS.

in the parallel

condition, IPS clients were more likely to obtain a competitive job during follow-up

and

averaged

more

hours

spent working in competitive jobs and more earnings from employment. IPS clients were also more likely to

found in nonvocational outcomes, eluding global functioning, quality life, self-esteem, and symptoms.

who worked, the conti(defined as the number

enter

program in California that was on a philosophy of wraparound services. One of the two demonstra-

group (60). Employment

Village clients nuity of work

once

limit,

in-

obtain worked

personal

program that lacks a strict time they may remain indefinitely.

ofsevere

Village clients earned more wages from paid employment than did control subjects during each year. Among

those services expedifinding suggests that a prevocational

absence

or physical impairment, and of substance dependence.

Compared

from that for control subyear 1 (12 percent versus although the two groups’

rates differed during cent versus 7 percent) percent

rate

not significant-

gin receiving tiously. This clients

were years af-

ter admission.

prevocation-

replicated

might

jects have

a basic

employment-the

of bypassing

preparation-and

vious

positive

tested

six months,

tellectual absence

on a heteroAs a hybrid

the Village

supported

sam-

and ascondivalidity

No

employment

and

in which or more per

experimental

This

differences

study

had

trition

rate.

Given

IPS had outcomes

the

ments

job

search

ofmental

health

and

tional

services-it

follows

two elements may in effective program District of the leagues

of

Columbia

management

of IndividDrake

and those factors

replication

IPS study. Drake and (54) recently completed

nents. New

Support.

of

voca-

that

be critical design.

much of the of the methods

study

that

to those

of IPS-rapid

integration

cated many

and

finding

a comparison supported employment program that lacked two major ele-

clubhouse approaches precluded evaluation of the unique contributions of different vocational compoHampshire

inof

sample

superior

in Washington,

Placement

were

adequate

study

ual

they week.

size, follow-up period, and data collection procedures and a very low at-

approxi-

services are However,

a position 20 hours

described.

The

D.C.,

cola

that repli-

design and of the study

study

site

agency

and just

a case

was

serving

people

with severe mental illness. The experimental group was assigned to IPS,

pate in this program were compared with control subjects who received usual services, including referrals to

and colleagues (53) compared ferent supported employment proaches in New Hampshire.

two difapOne

while the control group was assigned to an enhanced vocational rehabilita-

the state vocational system. The Village offered

group received and rehabilitation

integrated

clinical

services

through

evaluated rapidly tional counselor

rehabilitation an array of voca-

tion

model,

comprehensive

tional options, including paid agency positions and transitional employ-

the IPS model described above. The “parallel” group was referred to a separate rehabilitation agency and re-

ment,

in addition

to individual

sup-

ceived

ment.

ported

employment

placements.

Ex-

perimental ly generous 340

clients array

received a relativeof residential, case

two

followed services. Subjects

by

months

of skills

supported were

training

employment

unemployed

clients

offering

work

preparation

in

which

clients

were

by a special and referred

vocato a

rehabilitation adjustment

agency training

for competitive

as

employ-

Subjects were unemployed case management clients. They were required to attend four sessions ofan in-

PSYHIAThIC

SERVKES .

March

1997

Vol.

48

No.

3

formational

tween three

26 and percent

Sixty-six

percent

substance

use

had

suggest

that,

in

IPS

better

comparison

are the

group,

than

of hospitalization at follow-up.

with

that

in New

trast.

Hampshire for both conditions. This study suggests that the IPS model is generalizable to urban settings and diverse ethnic and socioeconomic

The

may

an

study

be initially job

apgroup

important

showed

con-

with even

to conventional

program

based

that

at a community

mental

Experimental

center in New York. Using an adapted job coach model (61), the supported employment one-month ing

program prevocational

module

therapy.

and

Control

located

concurrent

family

to be

mental

Sheltered

workshop

couraged ployment

to develop job leads

workshop

health staff

ofhours

center. were

en-

the

clients. Subjects emotional

were clients disturbance

ages

of 15 and

cent

had been

ucation

25.

with serious between the

Seventy-one

enrolled

classes.

earn.

Thirty-five

ed-

19

disorders,

ality

percent

and

13 percent

disorders.

quired

All

to have

friend

who

family

would

subjects

to

satisfy a minimum on in a prevocational Employment the

strongly

ratings

similar

in

dropout

rate

cantly

higher

the

two for the

to

year,

programs, was

control

PSYCHIATRIC SERVICES #{149} March

and

York

1997

the

study

ducted mental

em-

State

mi-

assigned program

were the

Aided

and

in which

they

either called

family-aided

compared

to the

Assertive

18 months,

a

of the 90

per-

still

receiving

treat-

outcomes three

months. mental

Significantly clients than competitively

were for

more control

expericlients

employed

and 18 months

18

at

only;

12

however,

the experimental tently higher rates

group had ofcompetitive

ployment,

from

ranging

as-

months

consisem-

19 to 37 per-

than did control subjects, whose ranged from 7 to 14 percent. Ex-

usual

mental

health

trol

subjects.

during

Hospitalization

follow-up

were

two groups. Although

the

comes

modest,

were

supportive

ofthe

rates

equal

for the

employment they

outare

effectiveness

mildly of sup-

ported employment. involvement of the

The systematic family is an in-

tnguing

the

feature,

but

study

design

services.

did not permit the contribution of the family component to be disentangled

(56)

from

con-

clients

an experimental Work in Family-

Community

group.

3

of

a study at two community health centers in New York

or to a control

No.

small

inclusion

colleagues

ment

48

on

extending beillness classi-

of

signifi-

Vol.

the

employment

McFarlane

the supportAlthough

year

size

fication. New

earn-

days

satisfaction

at one

including

supported

of

group. of job

sample

criteri-

rates,

favored

ed employment

sampling,

clients with diagnoses yond the severe mental

condi-

required

at one

number

the

in the

study

such the

chances of competitive employment. The limitations of the study center

Before

outcomes

ings,

tial

or

attendance module.

employment

ployed,

member

were

including and

re-

participate

also

a subminimum wage. However, work opportunities may decrease

person-

were

component.

assignment

tions,

had

After

at one

perimental clients averaged significantly more in earnings over the 18month follow-up period than did con-

affective

clients

a family

therapy

random

had

in obtaining

clients in the experimental 77 percent of the control

every

cent, rates

percent

had a diagnosis of schizophrenia, 33 percent had childhood and impulse disorders,

they

per-

in special

interest

sessed

months

or

member who the program,

be in treatment

were

were

and

wages

expressed sites.

45,

be symptomatically

have a family participate in and

clients

18 and

of schizophrenia

Employment

spend

in theirjobs

competitive emfor work-ready

of sheltered

ages

disorder,

subjects ment.

number

clients

experimen-

use

to the study,

a diagnosis

study

for

in the

the

between

cent ofthe group and

employment

programs

of the

was

employment.

have

advantages

feature

To be admitted

job,

generally

supported

participated

sheltered

the

in

provided a skills train-

subjects

in an agency-run

show

family to assist Another

tive

have

studies

Also,

a guarif it pays

had

health

multi-

and volunteer employment placements as steppingstones to competi-

to

was

combined

approach.

tal approach

stable, would

adults

re-

experimen-

were encouraged vocational process.

distinctive

Supported employment for youth in New York. Gervey and Bedell (55) evaluated a supported employment young

model

treatment

members in the

affective

for

The

pIe family therapy (62) with a vocationally-oriented assertive communi-

populations.

program

vocational

services.

clients

that

satisfied

placement,

tal

ty

features of this study inuse of a well-defined sup-

represented

ferrals habilitation

or levels

employment program and the use of a control

anteed

ten

for control did not dif-

of symptoms

ported proach

was

employment

fer in rates

than

albeit

rates

tenure

supported

and five months The two groups

Positive dude the

have

outcomes

employment

not find-

program

for

clients subjects.

New

clients

average

months

a co-occurring

as

study,

substantially lower

were

from this study but preliminary

Hampshire the

Subjects

disorder.

Final data yet available, ings

The

be64 years of age. Eightywere African American.

group.

Treat-

group

receiving

services,

with

re-

that of the

treatment

in itself

may

employment

This

assertive

program.

study

of whether approach competitive fective than

community

Family

contribute

treatment

to increased

rates (63).

also

raises

a supported with

pure

the

question

employment emphasis

on

employment is more efa hybrid model encour341

aging

sheltered

and

volunteer

work.

do

Another issue is the restrictive admission criteria, which may have led to selection of an unusually high-functioning

sample.

the diversity ofsupported emmodels, settings, sampling and research designs, of the studies we reviewed

strategies,

results

encouraging.

The

employment noteworthy

in studies

mental

Among

for

illness

with

percent.

The

the

control

with

studies

a range

a range

from

rate

6 to 40

percent.

studies were similar-an mean of55 percent, with

stud-

ies generally

comparable

advan-

tages

for supported

employment

in the number

significant

discuss

Our ples

limitations,

to making

Information clients

available

and

ofsupported

clients

need

more

control

over

direct

assistance

in find-

provide

management

(64),

skills

approach within

only

case

training

(65),

or

prevoca-

We hypothesize that general proaches to clinical stabilization do not

outcomes

lead

that

and keep

competitive

be-

do not prothey need

jobs.

Second, direct ing and attaining place-train

voca-

want

models,

employment

(51,53,54,56). in which

are referred tion services

Like

(51,56).

69),

this

review

rates

planation

more

than

tegration

Broclients

to vendors of rehabilitathrough the state voca-

tional rehabilitation system, impact on employment

to findthat is, of

of services teams sup-

approaches,

with severe not benefit rehabilitation

approaches employment, increase

of integration multidisciplinary

followed treatment

this principle

kered

apand

to the

clients

cause those approaches vide the specific assistance

342

port

training (5), without an explicit on competitive employment.

rehabilitation

been experimentally tested, results of two studies that latter approach (51,56) raise

but the used the the ques-

of whether

the work

previous suggests

had little outcomes

research that

development options

the overall

of

may

have

focus.

vocational

outcomes.

al studies

found

tam

jobs

in their

tan

their

jobs

correlation-

clients

preferred

who

ob-

areas

re-

approximately

as clients areas

Two

that

who

twice

work

as

in nonpre-

(71,72).

ongoing

support

long-term reviewed

is a cen-

(68, people

mental illness often do from brokered vocational services. One likely exfor this principle is that inforces providers to commu-

supports (73). above provide

details about the ofsupports needed

ofthe rehabilitation er, two studies

that

that

direct placeemployment

and shelhas not

few tent

that

sup-

programs

tral tenet of the supported employment model, we have limited re-

-

princiFirst,

that

of competitive This hypothesis

search on The studies

outcomes for programs the assertive community

to find

own

rehabilitation

employment

empiri-

hypothesize

may obtain higher competitive employment rates than those using a

ferred

we

Employment by programs

tional

them

their

further

solely on competitive

Although

developing

to

of support-

need

employment

long

ing and keeping jobs. rates are not increased

tional focus

to

to giving

of integration

practice leads miscommunica(70).

principles

We

to pre-

plan, while parallel sys-

Many supported employment programs assume that attending to clients’ preferences will lead to better

plans.

review supports several of supported employment.

study.

concentrate ment into

clients

which

other

diluted

approaches

and

the burden

intermediate

and

innovative

below.

Principles

Positive

cal

tion

to develop

spend in their jobs and the wages they earn. Tempering these optimistic findings on supported employment are

approaches.

We need

pro-

of hours

places

on clients and in conflicting plans, tions, and dropouts

combination tered options.

em-

Experimental

grams

brokered

study

23 to 84 percent.

tems

ported

than

unweighted a range from

brokering

clients (67). Third, integration clinical approaches

ofvocational and is more effective

another

coherent between two

Several

for

percent,

one

a unified,

ed employment

32 to 78

21

with

sent

competitive

58

clients’ obtaining the nonexperimental

show

from

of

was

was

from

for in

attention

nicate

employment consume the limited time and resources of providers and

the unobtain-

corresponding groups

The rates ployment

deflect

of that

with

employment

percent,

parsimonious explanation findings is that activities

vo-

persons

employment, mean rate ofclients’

competitive

approaches clients pre-

(5,6).

experimental

supported weighted ing

of traditional

approaches

severe

of enhanced

outcomes is particularly in light offindings of limit-

ed success cational

pattern

the are

stepwise Moreover,

fer approaches that offer paid employment to those that require unpaid prevocational training (50,53,66). The most these

Discussion Despite ployment

gradual,

(50,53,54,57).

employment

rates

termination

of

nature and exat each phase

process. Howevshowed decreased around grant

the time

support,

gesting that uncertainty availability may affect tenure

staff job

of employment

Traditionally, mental illness merous

people with have encountered

barriers

entering

longed

about clients’

(33,56).

Components supported

ing

of

sug-

that

vocational

readiness

prevented

their

programs,

includ-

requirements,

assessments,

severe nu-

pro-

requirements

for

prevocational training programs, lack ofaccess and availability of programs, and health result,

rigid

interfaces

and vocational only a small

PSYCHIATRIC SERVRIS

#{149} March

between

mental

programs. As a minority of mdi1997

Vol.

48

No.

3

viduals

with

have

severe

had access

ment programs One common these

mental

(74). feature

barriers

is the

professionals

illness

to supported

of that

determine

when

mental health clients are linked with vocational services. This approach is at odds

with

consumerism,

phasizes

which

principles

support

of

system

sizes

the

model,

the

current

ward

trend

shared

and

with

who

are

in

sonal

initial

care

to-

making

findings

given

with (75);

that

access

clients

about

choices about their own program (54,60). To at-

the

ideal

of access

can make

to supported

approaches

to

available

making

to clients

more

control

own

over

Retention in ment programs Dropout

rates

cent

common

ents

of more

terminate

grams

many

own

a strong petitively

(5,50,77).

finding

in the studies

is that

retention

when

supported

vices

are

and services

easily

nated

improved

multidis-

and

for any

reason,

to fluctuations

are

al-

not

termi-

and

are

sensi-

ofthe

client’s

din-

ical condition. Another area in need

of clarification

is

development.

the

process

of

Self-directed job sume

club,

that

most

searching tacts with

Similarly,

perhaps are

The

reasons

jobs

of place-

education

career

for

(30,89).

jobs

are

readily

employment

markets.

that

for

evidence

rates

of

over

job

ed-

time

supports

still

cial

be

a role

for

not

skills

only

that

job

are

skills

feet

of improving

ing

symptoms,

have

self-esteem,

on

the little

other

but

the

the

interventions

may

be an effective role

means

models

and

studies to

to as-

on entry-level

for

employment

short-term

jobs

in most

programs

may

be reahis-

tic, it raises questions about the longterm picture of career development.

opportunities, No. 3

and

to

satisfying

been

other pen

se.

to bettraining ca-

increased negative

relapse outcomes

Two domains na-

in

that

additional

due

to program

than

the

rates

these gains

vocational On

refor

improve-

comprehensive

the competing hypothesis grams with high expectations

supported

Do clients make the transition ter jobs, to educational and

suggests

ventions

emphasis

do show

nonvocational

have

ments

them find jobs commensurate their abilities (84). the

may

quahi-

studies support

outcomes.

in

of

ef-

supported emhave a general-

(52,85),

tune

emreduc-

improving

the hypothesis that ployment programs studies

so-

a secondary

and

effect

also

to a par-

attaining

ments

suitable

but

of support-

is that

can

the

might

pertinent

nical skills, matching pathetic professionals field

also

after

Training

controlled

same

are

training

is employed.

for more skilled jobs (83). For clients who have advanced degrees or techthem with symworking in the

if inten-

(46,51,85,90).

clearly needed. Although skills training before searching for a job does not seem to be effective, there may

ized

potential

that

be maintained

continue

Studies

than

suggests

may

increased

supports

men-

Americans

ty of life. However, viewed above lend

available

the

Some

ployment

to supported

offers

severe

to l)e no higher

nondisabled

clients and

Supported

for supported

with

appear

ed employment

Furthermore,

(30, turnover

jobs

clients

in un-

needed

tracks.

experi-

endings

Nevertheless,

in entry-level

six 86).

termina-

clients

ticularjob (91). A common assumption

positions.

for placement

and

with

clients

Vol. 48

and

within

of job

job

employment

as

clerical

skilled jobs are obvious: many lack job experience, credentials,

responsibility

1997

for

a supported

studies

employment

sive

such

19 percent, percent

in skilled

require

. March

jobs

range

10 to 20

ments

Although

PSYCHIATRIC SERVKES

rates

can re-

41 and 77 per-

that many

82,86-88).

men-

evidence

substantial

terminate

negative

or even

place-

any

employment placement months (28,30,34,38,39,55,71,

ence

that it

the

Between

indicate

Test

to clan-

clients

for

of clients

address

with

ap-

oftime.

cent

The

is 6 to

as the

conventional

length

client

such

the

jobs

who work in such jobs 35 to 62 percent (30,36,

help

for the large majority of severe mental illness

on whether

those

is-

by

severe

jobs,

tam

ment clients ranging from

to provide

forjobs and for making conemployers, do not appear to

jOl) most

with

is less clear

the percentage

strategies, of the

be satisfactory persons with (78).

job

service

is an alternative

are

to obtain

tal illness

persons

entry-level

labor

ad-

in-

job

unskilled,

on these study

demonstrate

tal illness

or janitorial work are the type of placement, with of supported employ-

entry-level

sup-

with

in

in most

the

to

employment

ucation

services

accessible,

are

data

studies for people

those

outreach

is that

em-

possibly of

Although is possible

lions

attention

tenure

vocational

Perhaps

programs

(80),

the rhetoric about and job preferences,

training

ser-

that provide

employment

ways

above

within

clinical

of these

ported

consistent

are

Despite matching

com-

employment

(53,54,56).

vantage

is

Amen-

(81).

37,39,61,82).

fear

reviewed

rates

teams

integrate

tive

One

integrated

ciphinary

The

to working

disabilities

placements

entitlements

disincentive

job

popular

pro-

Act

few a recent

Furthermore,

accommoda-

efforts

the

most

including

(76).

creasing

Entry-level

employment

staff

accommodations,

service

Cli-

This

of the

more

systematic

food

40 per-

government

more

job

passage

giving

jobs.

than

ambivalence

of losing

are

R, per-

of disclosure,

Disabilities

their

employan issue.

reasons,

the

With

who

employment and

With

supported

(39,40,50,55).

from

for

their

supported is also

between

ments

plans.

those 1995).

the issues

them

developing

rehabilitation

are

information

and to giving

specialist

than

We have although

and colleagues (85) may serve ify the longer-term view. One

(Gervey

employers,

tions.

with

employment for all clients (3), we need to develop and study innovative

offers

raises

reasonable

information

tam

programs

job

reers? sues,

that clients on a job in-

communication,

phoyers

appropriate rehabilitative

from

study.

unaccompanied

cans

to appropriate

empirical

by an employment

contacts and

leads

impersonal (61,79).

study found accompanied

more

finding

empha-

health

decision

terview went

services;

needs

correlational who were had

job

and other not be useful

role of staff in the interviewing

process

services; which

client-centered

em-

The

community

client-directed

with

of developing

newspapers sources may

of many

assumption

should

proach

employ-

ele-

inter-

other

hand,

that prolead to and

as a result

other of in-

creased stress (92,93) is not supported in the literature on supported employment. The relationship between employment and other life domains 343

appears linear

to be complex, not a simple impact oii nonvocational out-

Studies Several

conies

(94-97).

should standing

Methodological

considerations

Several

niethodological

dations

emerge

from

use

of randomized

First,

the

mental

designs

point,

studies

ed

employment

our

understanding.

study

for

groups,

is needed.

and

will allow

comparisons

Third,

programs

in terms

fidelity Fourth, control

measures (98,99). the services groups,

“standard

which

should as

the

services

tal

groups

I)eniiiieli comes

of hybrid

and

ployment

for people

services

are

approach

treatnien

more

t

represent com-

as caneby

cx-

lish

the

and

then

izal)ility

of supported

the

spectrum

full

vere

niental

who

are most

explored identifIed

ous

Sixth,

era

to know

the

general-

not

client

to

with

1.

se-

just

those

needs

to l)e

have

not

Federal

from

:3.

van-

approaches. in studies is cost-effec-

( 100).

of managed more

the

supported to clinical

vices,

and

offsets,

4.

costs

studies

client’s

perspective

perspectives

tems, 344

should

em5cr-

and

of

society.

as families,

well health

the as

the sys-

Boyer

Bond

CR,

and outcomes, of Persons

Baltimore,

Issue: With Reha-

of 1986.

14, 1987

Edited

SL: Rehabilitation proin Vocational RehabilWith Prolonged NIental

by Ciardiello

Johns

Hopkins

JA, Bell MD. University

Press,

1988

benefits.

consider

Aug

grams itation

Illness.

5.

These

the

1988

we need

about

by

%Vhiiaii P: Supported employment: toward zero exclusion of perSIS with severe disabilities, in \‘ocatli)nal Rehabilitation and Supported Employment. Edited by Webman I %1(x)n MS. Baltimore, Brookes,

Particularly care,

of rehal)ihitation and ploynient in relation cost

of

Act Amendnients

Register,

Supported

AF:

Vocational

rehabilitation

Employment:

an(l

WC,

Issues.

Arnold

ject Transition: service for the

Mod-

Sycamore,

Ill,

RehabiliBalti-

tallY retarded. 31-35, 1982 Revell

WC,

S. Taylor

B. et al: Pro-

competitive employment severely handicapped mnenJournal of Rehabilitation 48:

for persons

Wehnsan l Arnold, 5: Supportof competitive employment with mental retardation: impli-

cations

rehabilitative

for

of Rehabilitation

in

services.

50:30-38,

Competitive for Severely Baltinmre, Brookes,

Vi(lUalS.

P: Supported

ployment for ties. Journal

Counseling

Journal

1984

15. \Vehman P: New Horizons

Employment: Disabled mdi1981 conipetitive

persons with of Applied 17:24-29, 1986

severe

emdisabili-

Rehabilitation

17. Wehman P Kregel J, Shafer MS: Emerging Trends in the National Supported Employnient Initiative: A Preliminary Analysis of 27 States. Richmond, Virginia Commonwealth Universit#{231} Rehabilitation Research and Training Center on Supported Employment, 1989 18. Revell WC, Wehman ported employnmnt disabilities: positive

els, and funding.

P Kregel J, et al: Supfor persons with severe trends in wages, mod-

Education

Mental Retardation Disabilities 29:256-264,

and

and Training

in

Developmental 1994

19. Dincin J (ed): A Pragmatic Approach to Psychiatric Rehabilitation: Lessons From Chicago’s Thresholds Prograni. New Directions for Mental Health Services, no 68, 1996

20. Beard JH, Propst Fountain House 47-53, 21. Macias tional

RN,

Malamud

TJ: The

model of rehabilitation. Rehabilitation Journal 5(1):

Psychosocial

Bond CR: Vocational rehabilitation, in Handbook of Psychiatric Rehabilitation. Edited by Liberinan RE New York, Macmillan, 1992 6. Lehnmn

eflec-

ed work model

9(2), 1987

J000litl

of the

1990

16. Wehman

Rehabilitation

2.

FR:

Methods,

13. Revell

14.

supported

Melku \ Danlev K (eds): Special Supported Employment for Persons Severe Mental Illness. Psychosocial

1)ilitation

characteristics most

on

An overview

MC:

McCurrin

12. Revell WG, Arnold SM: The role of the rehabilitation counselor in providing job-onented services to severely handicapped mentally retarded persons. Journal of Applied Rehabilitation Counseling 15:22-27, 1984

of

and of the integraamid clinical services. research

for

11. Wehman I MoOn MS: Vocational tation and Supported Employment. more, Brookes, 198.8

on

References

employment

l)eflefits

tuuch

focus outcomes,

Work on this paper was supported grants MH00842 and MH00839 from National Institute of Mental Health.

models

Studies

analysis

in this

estab-

components

One critical element supported employment tiveness

explicit

employment

direct placement, tion ofvocational

key

employment indicate the

Acknowledg,nents

Another,

.

is to

motivated,

vocational

of supported Initial findings an

may

identified

the

illness,

who

employment

has

is to establish

of people

which

predict

statis-

of future

employment is in its infancy, and flumerous methodological and substantive issues warrant further study. #{149}

their

further.

benchmark

It also

of

recent

The

try to test studies.

on

the results

of supported

importance

emmen-

carefully.

of hybrid

in further

which

competitive

of the

Nevertheless,

approach

outcomes

mostly

It provides

principles programs.

synthesis

and

niodahities

complex

based

l)e gauged.

efficacy of pure models and components l)efore melding theni with other

studies.

Rehabilitation

10. Rusch

to interpret

to I)e examined

simplest

illness,

by

the outof vocational

Fifth,

difFicult

tal

studies

niodels

outcomes.

on supported with severe

outcomes

mental illness. PsyJournal 17(2):43-

9. Marrone J, Cold M: Supported employment for people with mental illness: myth and facts. Journal of Rehabilitation 60(4): 38-47, 1995

employment

is the first findings

l)o5iti’e

severe

Sycamore,

empirical

received

received

This

should clanthe differences

nonvocational

21:

tiveness of traditional vocational rehabilitation services in the treatment of long term mental illness. Psychosocial Rehabilitation JOUrflai 17(3):37-54, 1994

to generalizabihit

dc-

tics against

measured

.

and

8.

Creating

with

chosocial 62, 1993

Services (101).

supported in relation

and

in the same

be

1995

demonstration details about

nianuals

often

services”

munity,

need

need

criteria,

ofprogram

Heath

in

J:

l)e0Ple

studies

Bulletin

1996

7. Marrone

Center for Mental of the Substance

Mental

Conclusions This review

Ideally, efforts to define more clearly will result in

development

fully

costs,

eight

Schizophrenia

645-656.

els,

of specific

implementation

personnel. programs

multisite f, many models

outcomes

terminology

and

between

models,

coiiinion

studies.

to be defined ments,

Administration

standard-

program

designs,

Only

and categories across

Abuse

to

of

iy the Services

At this little

Second,

of terms

funded Health

of support-

contribute

a group

expeni-

is Paramount.

descriptive

ization

including

recorunienour review.

schizophrenia.

in the field studies currently in the field enhance our overall underof supported employment,

1982 C, Kinney employment:

tion of Fountain Vocational

PSYCHIATRIC SERVICES

R, Rodican an evaluative

House

practice.

Rehabilitation

.

March

C:

Journal

5:151-158,

1997

Transidescrip-

Vol. 48

of

1995

No. 3

22. Kirszner

ML Baron RC, ployer P’articipation in grams for Persons \Vith Illness. Final Report to tute on Disalility and search (#E-C008720122). Matrix Research Institute,

agement: implementation analysis of Project WINS. Journal of Vocational Rehabilitation

Donegan K: EmEmployment ProI.ong-Teni Mental the National InstiRehabilitation RePhiladelphia, 1994

5:89-102, 38.

Nichols

M: Detiionstration study of a supfiOrted employment program for persons vrith severe mental illness: benefits, costs, and outcomes. Unpublished master’s thesis, Department of Psychologc Indiana University-Purdue University at Indianapolis, 1989

23. Bond CR: Supported

work as a modification transitional eiiployment model for with psychiatric disabilities. Psychosocial Rehabilitation Journal 11(2):5573, 1987 of the clients

24.

Stein LI, Test MA: Alternative health treatment: I. conceptual ment program, and clinical Archives of General Psychiatry

39. Shafer

MA: Training

HV The utilization analysis to evaluate supported ployment services. Journal ofVocational habilitation 5:103-113, 1995

to mental model, treatevaluation. 37:392-397,

in Community

Living,

40. Trotter ported

27.

in

chology

Danley KS, Anthony WA: The choose-getkeep model: serving severely disabled psychiatrically disabled people. American Rehabilitation 13(4):6-9,27-29, 1987

l Banks

31.

1994

43.

PD: The effects

32.

R

(eds): Psychiatric

of Vocational

B2ZZW1() L: Natural vocational supports for persons with severe mental illness: Thresholds supported competitive employment program. New Directions for Mental Health Services, () 36:23-41, 1992

Im-

46. Cook tional atric

JA, Pickett rehabilitation disability. 20(4):2-12,1994

Donegan K, Raudenbush D (eds): Special Issue on Mx,ational Rehabilitation and Long Term Mental Illness. Psychosocial Rehabilitation Journal 18(4), 1996

33. Danley

demonstration

Psychology 34.

35.

39:269-276,

37.

Rehabilitation

E: Longitudinal outcomes in employment: a survival analysis. habilitation Psychology 37:23-35, 1992 Fabian

ES:

Supported

employment

does a job Counseling

CE

McCrohan

vocational

PSYCIIIATRIC SERYIQIS

Botterbusch

supRe-

1995

49.

and the

make a difference? Bulletin 36:84-.

NM,

services #{149} March

Bybee

into case 1997

50.

Vol.

48

Placemental rehabil-

itation.

Journal

Community

Mental

Health

1994

Bond CR, Dietzen LL, McCrew JH, et al: Accelerating entry into supported employment for persons with severe psychiatric disabilities. Rehabilitation Psychology 40: 91-111, 1995

51. Chandler D, Meisel J, Him T, et al: A capitated m(xlel for a cross-section of severely mentally ill clients: employment outcomes. Community Mental Health Journal, in press

D: InmanNo.

3

J, McCowen

M, et al:

in two model capitated agencies. Psychiatric

inSer-

1996

53. Drake RE, McHugo The New Hampshire

Becker supported mnent study. Journal ofConsulting cal Psychology 64:391-399, 1996

DR. et al: eniployand Clini-

CJ,

54. Bond CR, Drake RE, Becker DR. et al: The District ofColumbia stud ofsupp()rted employment for people with severe mental illness. Presented at the Institute on Psychiatnc Services, Boston, Oct 6-10, 1995 55. Cervev R, Bedell JR: Supported employment in vocational rehabilitation, in Psychological Assessment and Treatment of Persons With Severe Mental Disorders. Edited by Bedell JR. Washington, DC, Taylor & Francis, 1994 56. McFarlane Employment

WR, Stastnv l Deakins 5, et al: outcomes in family-aided ascommunity treatment (FACT). Preat the Institute on Psychiatric 5crBoston, O(t 6-10, 1995

sertive

sented vices,

57. Bond CR, transitional rehabilitation

chology

Dincin J: Accelerating entry into employment in a psychosocial agency Rehabilitation Psy-

31:143-155,

1986

58. Bond

CR, Friedmeyer MH: of situational assessment atric rehabilitation center. Psychology 32:99-i 12, 1987

Predictive vaat a psychiRehabilitation

59. Schultheis AM, Bond CR: Situational assessment ratings of work behaviors: changes across time and between settings. Psvchosocial Rehabilitation Journal 17(2): 107-119, 1993

60. Drake RB, Becker DR. Anthony %VA: The use of a research induction group in mental health services research. Hospital and Cornrnunity Psychiatry 45:487-489, 1994

61. Gervev

R, Kowal R: Job development strategies for placing persons with psychiatric (usabilities into supported employment jOI)s in a large city. Psychosocial Rehabilitation Journal 18(4):95-113, 1995

62. McFarlane WR, Sta.stny P Deakins S: Faniily-aided assertive community treatment: a comprehensive rehabilitation and intensive case management approach for pens with schizophrenic disorders. New Directions for Mental Health Services, no 53: 43-.54, 1992 63. Falboon IRH, McGill CW, Boyd JL, et al: Family management in the lrevention of morbidity of schizophrenia: social outcome of a two-year longitudinal study Psychological Medicine 17:59-66, 1992 64. Mueser

Becker DR. Drake RE: Individual ment and Support: a community health center approach to vocational 30:193-206,

Kirszner ML, McKay CD, ‘flppett ML: Homelessness and mental health: replication and adaptation of the PACT model in Delaware, in Proceedings from the Second Annual Conference on State Mental Health Agency Services Research. Mexandria, Va, National Association of State Mental Health Program Directors Research Institute, 1991 Mowbray tegrating

KE Menz

FE: Diffusion Network Project, Volume 1: Technical Report. Menornonie, Wmsc, University of %Visconsin-Stout, Research and Training Center,

48.

1994

Fabian ported

quality oflife: Rehabilitation 97, 1992 36.

project.

SA: Recent trends in vocaftr people with psychiAmerican Rehabilitation

47. Noble JH, Conley RW, Banerjee 5, et al: Supported employment in New York State: a comparison of benefits and costs. Journal of Disability Policy Studies 1:39-73, 1991

KS, Rogers

ES, MacDonald-Wilson K, et al: Supported employment for adults with psychiatric disability: results ofan innovative

WC, Becker DR, Drake RE: Rehabilitative (lay treatment versus supported employment: II. client, family, and staff reactions to a program change. Psychosocial Rehabilitation Journal 18(3):67-75, 1995 Torrey

45. Cook JA,

Rehabilita-

D, Meisel

Client outcomes tegrated service vices 47:175-180,

lidity

44. Drake RE, Becker DR. Biesanz JC, et al: Day treatment versus supported employment for persons with severe mental illness: a replication study. Psychiatric Services 47:1125-1127, 1996

MacDonald-Wilson KL, Revell WC, Nguyen N, et al: Supported employment outcomes for people with psychiatric disability: a c)mparative analysis. Journal of Vocational Rehabilitation 1:30-44, 1991 Shafer MS, Cervev pairments. Journal tion 5(2), 1995

198.8

employment: I. vocational outcomes. Cornmunitv Mental Health Journal 30:519-532,

of client characteristics and type of employment model on individual outcomes in supported employment. Journal of Applied Behavior Analysis 22:407-415, 1989 30.

33:27-36,

42. Drake RE, Becker DR. Biesanz JC, et al: Rehabilitation (la% treatment vs supported

28. Cervev R, Parrish A, Bond CR: Survey of cxemplary supported employment programs for persons with psychiatric disabilities. Journal of Vocational Rehabilitation 5:115-125, 1995

J, Wchmian

K, Harrison

41. Wehman PH, Revell VC, Kregel J, et al: Supported employment: an alternative model for vocational rehabilitation of persons with severe neurologic, psychiatric, or physical disability. Archives ofPhysical Medicine and Rehalilitation 72:101-105, 1991

Russert MC, Frey JL: The PACT vocational model: a step into the future. Psychosocial Rehabilitation Journal 14(4):7-18, 1991

29. Kregel

5, Minkoff

of emRe-

K, et al: Supwork: an innovative approach to the vocational rehabilitation of persons who are psychiatrically disabled. Rehabilitation Psy-

Handbook of Psychiatric Rehabilitation. Edited by Liberman RP New York, Macmillan, 1992 26.

MS. Iluang

survival

1980

25. Test

1995

52. Chandler

KT,

et al: mental illness: a review of research on case management. Schizophrenia Bulletin, in press Models

65. Dilk

Bond

CR,

ofcornrnunitv

care

Drake 6r

RE,

severe

Bend CR: Meta-analytic evaluatraining research for individuals with severe mental illness. Journal of Con. suIting and Clinical Psychology 64: 1337-1346, 1996 tion

66. Bell

MN,

of skills

RM, Ixsaker PH: Pa’ as work participation by patients with severe mental illness. Hospital and Community Psychiatry 44:684-686, 1993 an

MD,

incentive

67. Vandergoot

Milstein in

D:

Review

of

placement

re 345

search

literature:

inplications Rliahilitatioii :30:243-272. 197

11KI

Bulletin 68.

\tarslmak

Ii,

Bostick

1).

smite umitcunies for clients (liSal)iliti(’S scrvc(l h tla bilitatiOlt system.

ing 69.

for research (ommnsling

1)mL(tiL(.

Biillttiii

lurtomi. with

U:

:3:3:247-250.

199()

Bclmal)ilitation : Eidence for lc(leral I’rogranis Fi1(’cti\(IIeSS Is \Iixe(l. PEIl)-9:3-19. \%tshingtomi. l)C, US Ceo(‘la1 .ccommmmting 0111cc. 199:3 HE.

ens in thc 1)h)\I1I(I)t

l’ckcr hnokcrcd for Irs1is

Ll)iliti(S. journal

1)11. Xic I I, tt al: Barnno(kl olsupport(d cmiivitlm l)SY(l1iLt1iC disof \ocational

tiomi 5:141-150.

lF:

Widefleld

Dl

NIowbnav

CE

84.

.

72.

IL Kowal

(‘t’

1110(1(1 tOt

svith

plating

Rchal)ilita-

l)ittt

NbA, Albness of sesen

treatuimeot.

psychiatric

I I: A description

of a

\()tltli dIi(lvoting

1(lILlts

(lisal)ilities

DJ,

\ears

Knoedler at

for

74. iimslmjiao al: Best

Services

Persons.

\\a.sliiogtoo.

sociates,

1989

l’iser

Sj:

Ii

(Xl)(tieI1((

of

of health

SiOtis

88.

Bj. Stoddard S. et of \()catiolial Rehato Seyenel Nleotall Ill DC. Policy Stud As-

era of the I)ati(’t: using the illness in shaping the miscare. JA\IA 269:1012-1017.

P I)avenport R. et Ll: ( ;O1iiI)tI15Ofl of latrniers to (9liplOVOleflt fm tiiteitiplotd aIi(l tI1)I)l()Vt(l clients in d mnaoagemo(ot pnogranm: an exploratory StLl(l\. Psychiatric Rehabilitation jommnial 19( 1 :3-8, 1995

77. \tlls

H’[ l)owler

tivts

l)L,

111(l (lisiI)c(’Oti\(’5

l)lOYI0eu1t.

\h)dels, lltusch

in

Support’d

\lethods. FR.

Sycamore,

and

Fullmer SL: to supported

been-

I : Achieving lot vorkcrs understanding

\ldIutLIS()

abilities: l)(rsl)(cti\’(. 2-8,

AOi(flcdfl

Ill, .Scaoiore.

1990

accoun-

1)syclmiatnic (listhe (‘mnpbov(ns

Rehabilitation

21(1):

1994

346

ES.

Fsychiatrv

NbA: ( A)uiiulltuulitV

sup)ort

prognanis,

Schizophrenia:

1984

5, \\olkou CU. et al: )y_ an(l sul)jecti\e expein schizophrenia. Schizophrenia 19:599-608. 1993 JS, Lein

chosocial

functioning

nience

95. Alersoo Nb, Becker ethnographic study tI5((l In 1)(’0l)l( sitli

6- 10.

in

CR, iii

se\ere

su)ponte(l

11itc’d Scaunone.

seParatiOn

enipbovnient,

pboiueuut:

b

\bodels, Rusch 1990

issues

Strauss

in

iii Supported

\Iethods. and FR. Sycamore,

H : Predicting

Rosenberg

nity euupbonment chiatnic disability:

J5.

91.

92.

aniong

1)erS5

a

logistic

of Rehal)ilitation

tration

199:3

Issues.

98. \k(;rc \leasuning

Anderson

(;E,

18(4):

1)niuicil)les.

(\I,

Journal

1985

JIb,

the

67().-678,

99.Teague Eabuating

1994

(;B, use

l)rake of

for ierss abuse. 689-695, 1995 substance

RE, Ackerson Til: continuous treatnu’nt ith mental illness and Psychiatric Services 46:

1(X). 13011(1 (;R. Clark RE. 1)rake RE: Cost effecti’eness of 1)5cliiatric rehabilitation. Psvchotherap and Rehabilitation Research Bulletin 4:26-31. 1995

.\dniinis-

1eiss

Auiericaum

142:289-296,

l3oncl CR. I)ietzen LL, et al: fIdelity of iuipleuientation of a niental health )rograui na)(lel. Journal of (ouisiultiuig and (linical Pschobogv 62:

Ill,

\bueser KT. b’c I)\V Carter \1J: Social skills training fr job maintenanc’ in a pschiatnic 1)#{149}tti(’uit Journal ofCounseling Psvchobogy :3:3:360-362. 1986 1-bogart

Journal

I Iafez 1-I, lJel)enulmLn b ct al: of 1)5Y1lmittniL disorder: I II.

longitudinal of Psychiatry

Euim-

couiiuiiuwith I5Y regression

analysis. Journal

18:6-22,

illness

euiipbovuiient.

1995

teanus

JA.

mental

supportc’d

Au

1995

167:3:31-342,

89. Adams-Slullenbergen CE, Mitchell ‘I’E: A comparison ofjanitonial vorkers vith macntal retardation dn(l their nouidisabled 1)(ers on teteuttiout aIRl dl)s(’Ot(eisull. Jotmnial of Rehabilitation 62(3):5(i-60, 1996

cx). Cook

sey’re

RE: strategies

\Ic’ntal Health 97.

‘l’R: jol)

1agoolarcio() su1p)orted

I)rake

coping

96. 1)e5isto XII. ilar(ling CM, \lcConuuick 11\ t tl: ihe \laine and \ernmont three(l(’Cd(le stLI(lics of serious omental illness: I. uliatche(l ()flipaIi5OO of cross-sectional otitcouuie. British Journal of Isvchiatrv

ct al: Job

vitli

1)11, of

Rehabilitation

11.5-128,

in press

Reviewers

101

.

Carey

\IA:

search

on

The

continuing

vocational

grants. Psychosocial 18(4):163-164, 1995

DJ, et al:

nc’e(l

fr

rehal)ilitation

mepro-

Rehabilitation Journal

A, 11i1)k(’

Needed

Psychiatric

Sermices

seeks

expert

reviewers

in the

fullowing

areas:

.

Cost-effectiveness

analysis

of drugs

. Utilization

.

of services involvement with

Police Reviewers of

should

expertise,

jounials,

should

have

be familiar

with

ill persons the literature

published

with

in

in their

an-

peer-reviewed

the content

and focus

of

Sertices.

Prospective

chiatric

mentally

be familiar

and should

Psychiatric

ifying \‘iat(rvortlu

( ;(‘u1(utl

1986

94. Brekke

on

Oct

Bond

Couimniuunitv

eas reasonable

vith

B: ik’asOuIal)le acc(flhmnIOdatiOO fr svorkers vith serious omeumtal illness: type. frc’quenc and associated OuItCi)flies. Psychosocial Relial)ilitatfl)ui jotinuual 17(2): 163-I 72. 1993

8 1 . Fabian

of

I.

cut-

79. Cook JA. Itzzano L. Straiton 1)\l, et al: ( ;uulti\atO)ui and ulldiulteulauic( of relationslips vitli coipbovers of b)e01)le vith i)sycltiatnic (lisalalities. Psychouxial RehabilitatO)ui Journal 17(3):103-l 16, 1994

uuiO(IatH)ui

RE,

schizophrenia: aO(l eXpresse(l

Ireatnient. \t anagemacnt, (10(1 Rehabilitation. Edited by Bellack AS. Orlando. Fla. (uiune & Stratton, in

JA: Job en(liflg aniong ouuth and vitlm severe acotal illness. Journal of bIealth Adnunistration 19:158-169,

1)11. b)nake

of

relapse

trainin the

liii-

Institute

Boston.

skills

1’.fl1pli)fl1eflt: 15511(5. Edited by

78. JLC0l)s I IF. Vissusik I). (llier H. et dl: ( a)rrelations hetsveeo 1)sYcliiatric (lisal)ilities tuic1 ticatiouial OfltcOulie. Ibospital and (;uumuimiuuiit Psychiatry 4:3:365-369, 1992

80.

Cook a(lfllts \Itntal 1992

journal.

A, (nmots

Braitmoan

9:3. 1st

social chemotherapy

on

)artici)atiog

euiuplovuient.

199:3 76.

Archiyes

‘l’he

\1 1). 1 Ia\var(l lIactic( Stnd

l)ilitatu)II

75.

l)(OPl(

Services

enmotion. 43:633-642,

cooinitmnitv

the

terounations aniong 1)cr55 uttental illness participating

(;old si : l.niplooieot itli I1I(’Otal illness. 46:707-712, 1995

\,

\\11:

of assertiy(

Preseote(l

87. Becker

in (OtOI)etitie

\Iav 9-1:3, 1994 j. Balzll

effects

Psychosocial 86.

Presented at the annual cooft’reiict’ Of the I oternational Association of PS#{188}chosocial HelIal)ilitatioll Senices. Albo-

7:3. \Ianli)o( supports lschiatnic

KS: Sup-

Brown

one-year

1995

(I01)h)\fllCOt.

(I1(n(lI(,

Faniilv psychoedttcatioui, ing. and niaintenance aftercare treatment

Bulletin 85. list

1995

Bcckcr DR. l)rakt lIE. Farabatigli A. ct al: j oh prtf(r(mc(s of clients vith scerc psvelijtt,ic (lisordvns partici)LtiImg in support(‘(I (‘muplovoIcot )nogramns. F’svclmiatnic SeticeS -17:1223-1226. 1996

em-

hood (;R: .)plving psychiatric rehabilitatiout principles to efluph)Vflient: recent fluidlogs. in Schizophrenia: Exploring the Spec(ruin of lsvclmosis. Edited by Ancill RJ, I h)llida#{188} S. 1-ligenbottani J. Cliicliesten, England. \Viley. 1994

Services. 71

Supported

psychiatric disabled study. Pschosocial 13(2):53-(iO, 1990

IR)rte(l t’1ucation. in Psychiatric Rehal)ilitation in Practice. ldited h Flexen R\\ Solomon P1. Boston, AiuIoer \ledical, 1993

(oimnsel-

\()(atiOIlal

70. l)rakc

E,

83. \boxk

reha-

Rehal)ilitdtioll

Fabian

l)lOYfl1(0t for severely pc’rss: a (lescniptie Rehabilitation Journal

(lo-

psychiatric

ocational

82.

areas

reviewers

of interest,

Serrkes,

APA,

should to John 1400

send a curriculum A. Talbott, M.D.,

K Street,

N.W,

vitae, Editor,

Washington,

specPsy-

D.C.

20005.

PSYCHIATRIC SERVICES .

March

1997

Vol.

48

No.

3