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Supported EmploymentSupported Employmentfor People with Mental Illnessfor People with Mental Illness
Bob DrakeBob Drake
NAMINAMI
July, 2009July, 2009
Dilemma in 1990Dilemma in 1990
3-5% population disabled by mental illness People with severe mental illness identify work as
their top goal– More than 70% want to work
Less than 10% working No effective interventions
• Bond, 1992
Gary Bond’s 1992 ReviewGary Bond’s 1992 Review
“Traditional psychiatric rehabilitation programs do not prepare clients for competitive employment, but instead help clients adjust to various agency-sponsored employment options.”
Supported EmploymentSupported Employment
From developmental disabilities fieldPlace and train approachFocus directly on competitive jobsLong-term supportsModifications for mental health
clients based on ACT
Supported EmploymentSupported Employment
Mainstream jobs in communityPays at least minimum wageIntegrated work settingsOngoing supportFor people with most severe disabilitiesPlace and train model
The President’s New Freedom The President’s New Freedom Commission Report (2003)Commission Report (2003)
““The main goal of the mental health system is to help people to The main goal of the mental health system is to help people to live, learn, work, and participate fully in their communities”live, learn, work, and participate fully in their communities”
Mike Hogan (2006): “Work is the most direct step to recovery”Mike Hogan (2006): “Work is the most direct step to recovery”
““Supported employment is the most effective strategy to help Supported employment is the most effective strategy to help people achieve their employment goals.”people achieve their employment goals.”
Current Status of SECurrent Status of SE
SE model is simple and effectiveSE model is simple and effective Other benefits accrue with consistent workOther benefits accrue with consistent work Work outcomes improve over timeWork outcomes improve over time SE is relatively easy to implementSE is relatively easy to implement
IPS Supported EmploymentIPS Supported Employment Competitive employmentCompetitive employment Team approachTeam approach Client choice regarding timingClient choice regarding timing Benefits counselingBenefits counseling Rapid job searchRapid job search Job matching based on client preferencesJob matching based on client preferences On-going supportsOn-going supports
• Becker (IPS Fidelity Scale, 2008)Becker (IPS Fidelity Scale, 2008)
Figure 1. Competitive Employment Rates in 16 Randomized Controlled Trials of Supported Employment
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
07 Aust (IPS)
96 NH (IPS)
94 NY (SE)
07 IL
(IPS)
04 CT
(IPS)
05 HK (IPS)
06 SC
(IPS)
06MA
(ACT)
99 DC (IPS)
07 CA (IPS)
95 IN
(SE)
07EUR(IPS)
06QUE(IPS)
00 NY (SE)
97 CA (SE)
02MD(IPS)
Supported Employment Control Control 2
Percent Competitively Employed in 24 month period
0
5
10
15
20
25
30
35
40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Study Time
Percent competitively employed
Standard
IPS
Chrysalis Center
CT Supported Employment StudyCT Supported Employment Study(Mueser, 2004)(Mueser, 2004)
Integration of Vocational and Integration of Vocational and Mental Health ServicesMental Health Services
In 7 controlled studies, the more successful program was integrated, while comparison program was not.
– Bond, 2004
Job Preference StudiesJob Preference StudiesMost clients have stable and
realistic job preferences.Clients matched to initial job
preference stay in job twice as long as those not.
(Becker, 1996; Gervey, 1995)
Impact on Impact on Other OutcomesOther Outcomes
Improved self-esteem, symptom control, quality Improved self-esteem, symptom control, quality of lifeof life
Related to sustained competitive employmentRelated to sustained competitive employment No changes with sustained sheltered employmentNo changes with sustained sheltered employment
(Bond, 2001)(Bond, 2001)
Long-Term OutcomesLong-Term Outcomes
4 studies with 10-year follow-ups4 studies with 10-year follow-ups(Test, 1989; Salyers, 2004; Becker, 2006; Bush, in prep)(Test, 1989; Salyers, 2004; Becker, 2006; Bush, in prep)
Work outcomes improve over timeWork outcomes improve over time Costs decrease dramatically for consistent Costs decrease dramatically for consistent
workers workers (Bush, in prep)(Bush, in prep)
8-12 Year Follow-up: 8-12 Year Follow-up: Day Treatment to SEDay Treatment to SE
71% working at follow-up71% working at follow-up85% in competitive jobs85% in competitive jobs71% worked more than 50% of FU71% worked more than 50% of FU90% still receiving benefits90% still receiving benefits
(Becker, 2006)(Becker, 2006)
Cost SavingsCost Savings
Each person with a SMI who becomes employed achieves an average savings in health costs of $5,000 per year (Bush et al. in press)
Figure 1. Cost Outpatient Services and Institution Days
8000
13000
18000
23000
28000
33000
38000
43000
48000
0 1 2 3 4 5 6 7 8 9 10
Years
Mean Cost
Minimum Work
Steady Work
People with Severe Mental Illness in Treatment
Already Employed
10%
Not Interested in Employment
25%
Evidence-Based
Supported Employement
2%
No Employment
services40%
Ineffective Employment
Services23%
Vitamin C for Scurvy: An Vitamin C for Scurvy: An Early Randomized TrialEarly Randomized Trial Methods: Four-ship
voyage to India in 1601. In one ship, sailors received 3 teaspoons of lemon juice per day
Results: At halfway point, no sailors had died in the treatment group. In the control group 110 of 278 (40%) had died of scurvy
Source: Berwick, JAMA, 2003
The British Navy Adopted The British Navy Adopted Dietary Standards for Scurvy:Dietary Standards for Scurvy:
(a) 1602
(b) 1625
(c) 1697
(d) 1795
S. Biestly, Man-of-War (1993).
National EBP ProjectNational EBP Project
5 evidence-based practices: SE, IMR, FPE, ACT, IDDT
53 sites in 8 statesPrograms studied for 2 years
Fidelity of SE Programs
2.8
4.24.6 4.5 4.4
1
2
3
4
5
BL 6 mo. 12 mo. 18 mo. 24 mo.
(n = 9) (n = 8) (n = 9) (n = 9) (n = 9)
SE Fidelity Scale Mean
Johnson & Johnson-Johnson & Johnson-Dartmouth ProjectDartmouth Project Mental health-vocational rehabilitation collaboration Mental health-vocational rehabilitation collaboration implement evidence-based SEimplement evidence-based SE Local programs selected by statesLocal programs selected by states Dartmouth provides training, consultation, and Dartmouth provides training, consultation, and
evaluationevaluation First states: CT, DC, KS, MD, OR, SC, VTFirst states: CT, DC, KS, MD, OR, SC, VT New states: IL, MN, MO, OHNew states: IL, MN, MO, OH
• (Drake, 2006)(Drake, 2006)
Total Number of Clients Served in Ten States by Quarter
0
1000
2000
3000
4000
5000
6000
7000
8000
No of Clients
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Supported Employment & National
Unemployment Rate
# Served # New Clients % of SE
# Served 792 121 141 192 203 236 281 287 292 285 302 318 329 341 373 410 486 474 468 478 489 516 599 657 735
# New Clients 915 974 117 118 131
% of SE 38 42 46 44 43 40 43 49 48 50 52 53 54 55 55 55 49 50 51 49 50 48 46 45 45
4Q02
1Q03
2Q03
3Q03
4Q03
1Q04
2Q04
3Q04
4Q04
1Q05
2Q05
3Q05
4Q05
1Q06
2Q06
3Q06
4Q06
1Q07
2Q07
3Q07
4Q07
1Q08
2Q08
3Q08
4Q08
Employment rates consistently exceed 40% (yellow line)Employment rates consistently exceed 40% (yellow line)
J&J-Dartmouth Community J&J-Dartmouth Community Mental Health ProgramMental Health Program
Early InterventionEarly Intervention
First episode psychosis First episode psychosis (Nuechterlein, 2005; Rinaldi, in (Nuechterlein, 2005; Rinaldi, in
press; Killackey, in press)press; Killackey, in press)
SSA: change adjudication processSSA: change adjudication processSSA: accelerated benefitsSSA: accelerated benefitsHealth insuranceHealth insurance
IPS Supported Employment for Clients with First-episode Schizophrenia
0
20
40
60
80
100
Baseline 6 Months 12 Months 18 Months% of Employment or
school
IPS
SAU
Early Intervention Early Intervention (Nuechterlein, 2005)(Nuechterlein, 2005)
Benefits Counseling(Tremblay, 2005)
Outcomes for Psychiatric Benefit Counseling Intervention Group Versus Two Nonparticipant Psychiatric Voc Rehab Comparison Groups
$0
$100
$200
$300
$400
$500
$600
$700
$800
$900
$1,000
$1,100
Quarters Relative to Date of Enrollment
Quarterly Earnings
Intervention 608 612 585 549 557 464 504 552 615 852 887 928 830 804 765 812 796
Contemporaneous 382 521 525 575 540 553 566 519 546 511 459 538 602 478 441 353 542
Historical 441 464 511 359 305 333 284 320 279 365 290 335 357 309 315 369 384
-8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8
Post-EnrollmentPre-Enrollment
(N = 364 per group)
Addressing CognitionAddressing Cognition
Concentration, memory, reaction speed, Concentration, memory, reaction speed, and problem-solvingand problem-solving
Job match Job match Improve cognitive function Improve cognitive function Compensatory strategiesCompensatory strategies
(McGurk, 2008)(McGurk, 2008)
Cognitive TrainingCognitive Training
Practicing cognitive tasks may create Practicing cognitive tasks may create new neuronal connectionsnew neuronal connections
Tasks directly relevant to work tasksTasks directly relevant to work tasksNew capacity may translate to workNew capacity may translate to work
(McGurk, 2005)(McGurk, 2005)
Computer Training and Memory
30
35
40
45
50
Baseline 3 Months
Total Number Correct
Computer Training and Work
0
5
10
15
20
25
30
Baseline 3 MonthsHours worked per Month
Benefits ReformBenefits Reform
People are socialized into disabilityPeople are socialized into disabilityChanging benefits structure essentialChanging benefits structure essential
Policy ChangesPolicy Changes
People with disabilities need cash, health insurance, and a job
They do not need to be assigned to a lifetime of unemployment and poverty in order to get health insurance
Legislative change is critical
Carl Suter, CSAVR (2006)
ConclusionsConclusions SE has created hope for for people with SE has created hope for for people with
psychiatric disabilities, their families, and psychiatric disabilities, their families, and MH/VR practitionersMH/VR practitioners
Outcomes can be enhanced furtherOutcomes can be enhanced further New researchNew research Policy changesPolicy changes
Financial Support to PRCFinancial Support to PRC
Grants from NIDA, NIDRR, NIMH, RWJF, SAMHSA
Contracts from Guilford Press, Hazelden Press, MacArthur Foundation, Oxford Press, New York Office of Mental Health, Research Foundation for Mental Health
Gifts from Johnson & Johnson Corporate Contributions, Segal Foundation, Thomson Foundation, Vail Foundation, West Foundation
Many ThanksMany Thanks Deborah Becker Gary Bond Greg McHugo Haiyi Xie Jon Skinner Phil Bush Will Torrey Kim Mueser Rob Whitley Susan McGurk
Matt Merrens Paul Gorman Sarah Swanson David Lynde Howard Goldman Eric Latimer Kikuko Campbell Will Haslett Saira Nawaz Crystal Glover
Updates on SEUpdates on SE
Psychiatric Rehabilitation JournalPsychiatric Rehabilitation Journal– Spring, 2008, special issue on SESpring, 2008, special issue on SE
Supported Employment: A Practical Guide for Supported Employment: A Practical Guide for Practitioners and Supervisors Practitioners and Supervisors
(Swanson, 2008)(Swanson, 2008)
Information: books, Information: books, videos, research articlesvideos, research articles
Karen [email protected]://dms.dartmouth.edu/prc