Employment and Its Impact on Recovery

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• Employment and Its Impact on Recovery
• Michael Boyle
• mboyle_at_fayettecompanies.org

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Is Employment an Outcome of Recovery orDoes
Employment Facilitate Recovery?
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Is Employment for Persons with SMI

• A stressor that should usually be avoided?
• A choice of persons with SMI to pursue regardless
  of the opinions of mental health professions who
  treat them?
• A responsibility of citizenship that should be
  promoted?

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• What is Individual Placement and Support Model of
  Supported Employment?

• Goal of permanent competitive employment
• Minimal screening for employability
• Avoidance of pre-vocational training
• Individualized placement instead of enclaves or
  mobile work crews
• Time-unlimited support
• Consideration of client preferences

A Working Life for People with Mental
Illness.(2003) Deborah Becker and Robert Drake,
Second Edition. Oxford University Press. Oxford,
New York. Bond, G. (1998). Principles of the
individual placement and support model Empirical
support. Psychiatric Rehabilitation Journal,
22(1), 11-23.
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• What does IPS look like?
• Requires full-time job coaches
• Hard work
• Complex but not complicated
• Community context 80
• Team and office context 20
• 1-1 with client f2f or phone 60
• Interdependent problem-solving

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Fidelity Measures

• Caseload does not exceed 25
• Employment specialists provide only vocational
  services.
• Each vocational specialist carries out all phases
  of vocational services including engagement,
  assessment, job placement and follow-along
  supports.

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Fidelity Measures

• Integration of vocational services with mental
  health treatment
• Employment specialists function as a unit/team
• Zero exclusion criteria
• Ongoing, work-based vocational assessment
• Rapid search for competitive job

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Fidelity Measures

• Individualized job search based on job choices
• Diversity of jobs developed that are in different
  settings
• Jobs have permanent status rather than temporary
  or time-limited
• Vocational specialists help persons find new jobs
  when one ends.

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Fidelity Measures

• Time-unlimited follow along supports
• Community based services 70 of time spent in
  community
• Ongoing assertive engagement and outreach
  ongoing encouragement

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Motivational Interviewing

• Based on Stage of Change theory
• Weighs pros and cons of a change i.e. getting a
  job
• Helps person identify discrepancies between life
  goals and behaviors

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Practices Differentiating High Performing from
Low Performing Supportive Employment Programs

• Gowdey, E.L., Carlson, L.S. and Rapp, C.A.
  Practices Differentiating High-Performing from
  Low Performing Supportive Employment Programs,
  Psychiatric Rehabilitation Journal, Vol. 26,
  No.3, 2003.Gowdey,E.L., Carlson, L.S. and Rapp,
  C.A. Organizational Factors Differentiating High
  Performing from Low Performing Supported
  Employment Programs, Unpublished Manuscript.

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Effective Practices

• Exposure to supportive employment occurs during
  intake.
• Case Managers initiate conversation about work.
• Consumers are less fearful about working due to
  staff support of employment.

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Effective Practices

• De-emphasis on pre-vocational services.
• Ensuring vocational assessment happens rapidly.
• Rapid approval of vocational services and strong
  relationship with State vocational rehab
  services.
• More comfort of staff in allowing disclosure of
  mental health problems.

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Effective Practices

• More direct contact with perspective employer on
  behalf of a specific client.
• More frequent contact with employers on an
  ongoing basis.
• Consumers perceive a high degree of ongoing
  support after starting a job.
• Consumers view their work environment as helpful
  and flexible.

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Organizational Factors

• Program leaders emphasize the value of work in
  peoples lives and the belief that people can
  work.
• Program leaders emphasize strength-based
  practices.
• Program leaders use vocational data to guide
  programming and practice.
• Staff do not view stigma as a barrier to
  employment

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Organizational Factors

• Staff believe persons have a desire and
  motivation to work.
• Stories are shared that reflect belief in the
  ability of individuals to succeed in the world of
  work.
• SEP staff and case managers work as a team with a
  high degree of collaboration.

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Organizational Factors

• Case managers support individuals employment
  interests and vocational progress.

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• How to implement the IPS principles

posters, graphs, cork boards, resource room with
computers/fax/phone, networking, simple
vocational plans, communicate with family and
mental health team, team meetings, speed-dial
mentality, job shadows, job clubs, simple
questionnaires, generic job application, on the
job evaluations, job satisfaction questionnaires,
performance evaluations, natural supports, follow
up plans
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What impact would this model have on recovery?
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What problems may be encountered in implementing
the supportive employment model?
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Two years of implementation experience at Human
Service Center
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Outcomes

• 110 persons have obtained employment
• 33 are currently working
• 194 different jobs have been obtained
• 5 have obtained health benefits through their
  employer

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The beginning

• Five year grant from US Dept. of Labors Office
  of Disability Employment Policy
• One of three Olmstead Action grants awarded in
  2003
• Training and Evaluation from the Center for
  Psychiatric Rehabilitation

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Intensive Training

• Supervisor, job developer and 7 job coaches (two
  primary consumers)
• All new staff except for supervisor
• Ten days of IPS/MI training from CPR staff
• Two days benefits training from Health and
  Disability Advocates and DRS Benefits Planning
  and Outreach

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Advisory Committee

• Primary consumers
• Advocates NAMI GROW
• One Stop Vocational Center
• DMH staff
• DRS state and local staff
• Local Workshop
• Center for Independent Living

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Partnering with One Stop Job Center

• SEP staff trained on resources available and
  their use
• Job coaches assist consumers in utilizing the
  resources at One Stop employment center for
  resume development, interest inventories and job
  searches
• Purchase of software for development of math and
  reading skills and software licenses for
  international computer licenses
• Job clubs conducted at One Stop by SEP staff

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Early Surprise

• Employers were very receptive to hiring persons
  with serious mental illness when visited by job
  developer.
• Only two of over 100 slammed door.

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Problems Encountered

• Problem Clients not having phone number for job
  applications
• Solution Phone line at staff office with
  answering machine having generic leave a
  message. Staff check for messages and contact
  client.

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Problems Encountered

• Problem Clients lack funds for needed expenses
  for beginning work when hired
• Solutions Establish revolving fund for minor
  expenses such as hair cut, bus passes. Rapid
  opening with DRS for expenses that are more
  costly i.e. fork truck license.

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Problems Encountered

• Problem Client and family fear of losing
  benefits.
• Solution Partnership with DRS Benefits Outreach
  and Planning project. HSC staff work with
  consumer to complete background information and
  obtain SSA information. BPAO specialist
  completes individual analysis detailing impact of
  perspective earnings on benefits and available
  options to retain benefits.

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Problems Encountered

• Problem early resignation from jobs due to fear
  of poor performance/firing.
• Not contacting job coach before quitting
• Solution Over-teaching availability of ongoing
  support. Contingency management for contacting
  job coach during first week of employment
• Cell phone numbers given to clients

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Problems Encountered

• Problem culture change from protection to
  empowerment. Case management staff sabotaging
  employment
• -It will be too stressful for you
• -Only work part-time
• -Start at a workshop first
• - You tried this before and it did not work

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Problems Encountered

• Solutions
• Continued education of all staff on IPS model and
  research findings
• Set organizational goal of 50 of clients
  employed in five years
• - Management intervention for those not willing
  to change

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Problems Encountered

• Problem Clinical teams not integrating job
  coaches with their work.
• Solutions
• -Mandate joint meetings between job coach, case
  manager and client during first two weeks of IPS
  involvement.
• -Brochure to all staff outlining IPS services
  and expectations
• -Job coaches attend full case management team
  meetings.

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Problems Encountered

• Problem More referrals needed
• Solutions Developed brochures for both staff and
  clients describing SEP services monthly
  marketing meeting for consumers encouraging
  referrals from peer mentors.

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Problems Encountered

• Problem DPA rule that persons in LTC facilities
  may only retained 55 of monthly earnings
  resulting in disincentive to work and inability
  to save for moving.
• Solution Legislative change, pilot study, and
  NOW A LAW SUIT!

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Next Steps

• Cognitive training for those who have lost jobs -
  Mueser and McGurk study
• Compensatory training and adaptation on the job
• Engage in supportive employment combined with
  Illness Management and Recovery at intake for new
  admissions.
• Supportive Education

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• What are some resources?
• www.samhsa.gov Evidence Based Practices
  Resource Kits
• www.bhrm.org Clinical Guidelines/Mental Health
• Bissonnette, D. (1994). Beyond Traditional Job
  Development
• Work as a Priority. (2003). U.S. Department of
  Health and Human Services.
• Psychiatric Rehabilitation Journal. (Spring
  2004). Volume 27 Number 4.