EvidenceBased Employment Services

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Evidence-Based Employment Services

• Integrated Employment Institute
• UMDNJ
• Scotch Plains, NJ
• Gary R. Bond
• Indiana U. - Purdue U. Indianapolis
• 11/28/01

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Outline for Day

• Barriers to employment ? Role of work in
  recovery
  
• Supported employment An evidence-based
  practice
  
• Nuts and bolts of supported employment
• Implementation strategies

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Competitive Employment for People with Severe
Mental Illness

• Say they want to work 60-70
• Are currently working

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Barriers to Employment

• Consumer Factors
• Societal Attitudes
• Systems Factors
• Staffing Issues
• Program Factors

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CONSUMER FACTORS

• Fears and concerns
• Symptoms
• Problems with medications

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1 Barrier to Employment for Many Consumers

• Fear of losing benefits SSI, SSDI, and
  especially Medicaid
  
• Consumers probably perceive more risk than do
  professionals
  
• Complications lack of knowledge, distrust of
  bureaucracies, confusing rules

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What People with Schizophrenia Say Interferes
with Working

• Fear of failing
• Anxiety
• Lack of energy
• Lack of job skills

• Lack of job opportunities
• Depression
• Difficulty concentrating

(Source Westermeyer Harrow, 1987)
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Symptoms of Schizophrenia

• Positive Symptoms
• hallucinations, delusions
• Negative Symptoms
• poverty of speech, flat affect
• Cognitive Impairments
• attention, abstract thinking, executive
  functioning, and memory

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Symptoms and EmploymentResearch Evidence

• Positive symptoms not found to be closely linked
  to poorer work outcomes
  
• However, negative symptoms are linked
• Cognitive impairment also related to work
  impairment

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MEDICATION PROBLEMS Traditional Antipsychotics

• Not effective for about 30
• Unpleasant side effects
• Dont help negative symptoms
• Must take other medications to counteract side
  effects
  
• Consumers often do not take medications as
  prescribed
  

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Overcoming Consumer BarriersPromising
Developments

• Recovery movement
• New medications
• Strategies to address fears and misconceptions
• Flexibility of supported employment

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Goals from Consumer Perspective

• Personal goals are similar to the rest of
  society
  
• To be happy and successful in whatever I
  choose to do.

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Quotes from Consumers

• I feel so much better about myself now that I
  have a job.
  
• Holding down my job is not always easy but it
  has helped my self esteem.
  
• When I go to work I dont hear the voices.
• Now that I am working again I can buy my
  daughter presents.

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Consumer PerspectiveWhy is Work Important?

• Most consumers want to work!
• Work is a key to recovery (Rogers, 1995)
• Income
• Structure
• Social contacts

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Hypothesized Influence of Medications on Work
Outcomes
Symptom Control Cognitive Functioning
Medication Type
Work Outcomes
Compliance
Adverse Effects
Program Factors
Client Factors
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SOCIETAL BARRIERS STIGMA
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NAMI Survey

• One-third of mental health clients turned down
  for a job
  
• for which they were qualified because of a
  psychiatric
  
• label (Wahl, 1997)

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Overcoming Societal Barriers Promising
Developments

• Attitudes change with individual successes
• Acceptance of recovery perspective on broader
  scale is possible
  

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Recovery Perspective

• Does not mean curebut a point in someones
  illness in which the illness is not the first and
  foremost part of his or her life.
  
• --Flynn Weiden, 2001

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Recovery Goals, As Viewed From Society

• Traditional goals Reducing symptoms, attaining
  stability, preventing hospitalization
  
• Recovery goals Normative adult roles related to
  working, learning, living independently, primary
  relationships, friendships, and recreation

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Societal PerspectiveWhy Is Work Important?

• Being productive is an important need (Maslow)
• A normative adult role
• Cost-effective alternative to day treatment

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Quotes from Employers

• Andre is as good as any worker that I have.
  (Auto parts store manager)
  
• I count on Juanita. If she is feeling stressed,
  she sits in the back room for awhile. Thats OK
  she gets the job done. (Bakery supervisor)
  
• The employment counselor helped me understand
  why Tony paces. Its okay in the security
  business. (Security business owner)

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Quotes from Family Members

• I was worried that if my son got a job he would
  get stressed. But just the opposite happened.
  He is doing so much better.
  
• I was really glad that my sons employment
  counselor asked me about work ideas. He landed a
  job that I suggested.
  

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SYSTEMS FACTORS

• Limited access to employment services
• Fragmented service systems
• Rules for government entitlements

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Limited Access

• 23 of mental health clients have any mention of
  employment goals in treatment plan
  
• (Lehman, 1998)
• In 1998, only 2 of clients had access to any
  supported employment services
  
• (NASMHPD, 1998)

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Fragmentation

• Many different service agencies mental health ,
  voc rehab, Social Security, office of employment
  
• Consumer may be expected to do footwork

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Rules for Government Entitlements

• Fear of losing disability benefits
• Confusion about complicated and
  constantly-changing rules

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Overcoming Systems BarriersPromising
Developments

• Access to high quality supported employment is
  increasing (Bond survey, 2001)
  
• Changes in SSA Legislation
• Supported employment model helps overcome systems
  fragmentation

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STAFFING FACTORS

• Do direct service staff have the necessary
  attitudes, knowledge, and competencies to help
  consumers gain employment?

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Common Barriers in Staffing

• Staff attitudes
• Inadequate pay
• Staff turnover
• Unclear job descriptions
• Inexperienced staff
• Staff burnout

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Clinician Attitudes as a Barrier

• Common Clinician PerspectiveWork is Desirable,
  But is My Client Ready?

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Barriers to Employment Rated by Mental Health
Professionals
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Is Work Too Stressful?

• As compared to what?
• Joe Marrone If you think work is stressful, try
  unemployment

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Negative Effects of Unemployment in General
Population

• Increased substance abuse
• Increased physical problems
• Increased psychiatric disorders
• Reduced self-esteem
• Loss of social contacts
• Alienation and apathy
• (Warr, 1987)

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Key Research Finding

• Although many clinicians fear that consumers who
  work increase their risk for relapse
  
• Supported employment does not lead to higher
  rates of psychiatric hospitalization

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Where Are Vocational Staff Trained?

• Most training is informal and on the job
• University preparation seldom emphasizes
  psychiatric rehabilitation
  
• Promising New Developments
• Technical assistance centers
• Dartmouth implementation kits

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PROGRAM FACTORS

• Are vocational programs based on evidence-based
  principles?
  
• Are there clear guidelines for implementation?
• Are staff prepared to implement them?

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Traditional Vocational ServicesTypical Features

• Stepwise Training or sheltered work first
• Work readiness criterion Clients screened for
  placement
  
• Brokered Different agencies provide vocational
  and mental health services
  
• Short-term Services curtailed once job is
  found
  

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Conclusions Regarding Traditional Vocational
Approaches

• Often poorly defined
• Not adequately studied
• Effectiveness not established
• (Bond, 1999 Cook, 2000 Crowther, 2001
• Honey, 2001 Lehman, 1998)

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Lack of Agreement Among Practitioners About What
is Evidence-Based Practice

• We do whats best for our community
• We follow a different model.

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Conclusions

• Barriers to employment are found at consumer,
  clinician, system, and societal levels
  
• We have strategies to overcome these barriers
• These strategies only make sense if we are
  confident that our employment services actually
  work