CRP Brief - Your Source for Issues and Trends in Community Rehabilitation
April 2004

Issues in Supported Employment for People with Psychiatric Disabilities

Background
Employment is an important priority among people with psychiatric disabilities. Research regarding vocational rehabilitation services and employment outcomes has yielded powerful evidence that mental health consumers not only want to work, but can successfully participate in the labor market in a variety of competitive jobs. In fact, many of these studies have identified personal, as well as social, benefits of work among consumers in a number of areas, including: therapeutic gains; improvements in quality of life; alleviating poverty; reductions in the use of disability entitlements; and overall decreases in the costs of mental health care.  
Results from a recent multi-site, longitudinal study of diverse employment models, the Employment Intervention Demonstration Program (EIDP), underscore the knowledge that even people who live with what could be considered the most disabling mental health conditions (i.e., diagnoses of schizophrenia spectrum, bi-polar, or major depression disorders), who have limited work experience (e.g., no paid work in over five years), or who depend on disability entitlements such as SSI or SSDI to live, can engage in economically productive employment.  For example, over the course of 24 months in the EIDP, 1,648 such individuals worked over 820,000 hours in 2,230 jobs, and earned almost $5,000,000.
Greater opportunities for people with psychiatric disabilities to enter and remain in the labor force also have been facilitated through social and scientific developments. Important among these developments are advancements in mental health and recovery-focused rehabilitation services. At the same time, strong advocacy movements including consumers and their family members have asserted the right to equal employment opportunities for people with mental illnesses. Federal legislation has mandated fair hiring and reasonable accommodation practices for people with disabilities (Americans with Disabilities Act, 1990), although protections have been somewhat curtailed by recent Supreme Court decisions. Finally, advancements in mental health services, including formulation and use of new psychopharmacologic agents, have provided consumers with more treatment options. 
Yet the overwhelming majority of mental health consumers remain either outside of the American labor force or in the labor force but unemployed. It is estimated that almost two-thirds (61%) of working age adults with mental health disabilities are out of the labor force (defined as not having a job and not having looked for work in the past 2 weeks), compared to only 20% of their counterparts in the general population without psychiatric disabilities. Among those with mental health disabilities who are in the workforce, unemployment rates are three to five times higher than among the adult working age population at large. Even a college education does not appear to ameliorate the disadvantageous position of consumers in the labor market. In the mid-1990's, 43% of college graduates with mental health disabilities were not working compared to only 13% of college graduates without mental health disabilities.
Implications for Consumers
Over the last few decades, major developments have occurred in our understanding of research-based, best practices in the field of vocational rehabilitation for people with psychiatric disabilities. Based on consensus among experts as to "what works well" for mental health consumers, a series of principles of vocational rehabilitation, rather than endorsement of any single program type or model, has emerged. These principles can be incorporated into a variety of program types or models, including psychosocial rehabilitation programs and community mental health centers, and by a number of different models of service delivery, including Individual Placement & Support (IPS), Assertive Community Treatment (ACT), and psychosocial rehabilitation clubhouses among others. 
One of the key principles identified involves integrating vocational services with mental health services, typically on teams in which service planning and delivery is done by clinical and employment staff who interact at least three times per week. Another major principle of vocational rehabilitation includes the importance of offering consumers competitive employment placements in socially integrated settings, rather than sub-minimum wage, subsidized, set-aside, sheltered, or unpaid work. Studies also have shown the value of respecting consumer choice and career preferences in the kinds of job placements developed for consumers, the need for rapid job placement as soon as possible after program entry, the importance of on-going vocational support services with no time limits, and the inclusion of peer-facilitated or peer-run support services among those offered within vocational rehabilitation programs.  
Each of these principles characterizes elements of  "supported employment" (SE) that have been specifically adapted for people with psychiatric disabilities. SE services can be organized under a wide variety of vocational and rehabilitation service delivery models and can incorporate elements of a number of different program and agency types. However, unless these principles are adhered to, research shows that service recipients are unlikely to have lasting, positive employment outcomes.  
Findings from the EIDP contribute additional evidence that services grounded by these principles produce beneficial employment outcomes among people with psychiatric disabilities. Analyses of the EIDP longitudinal data found that over 24 months, most EIDP participants were able to work. However, study participants who received services from vocational program models that engaged in these SE principles were significantly more likely to achieve competitive employment placements, and to a lesser but still significant extent, to earn more money, and work more hours per month.
All mental health consumers are capable of engaging in competitive employment, and best-practice supported employment services should be available to all consumers. Once these basics are in place, there are three other principles of successful vocational rehabilitation that can be applied to any program, and are not unique to SE. First, consumers and service providers can work collaboratively to address issues of stigma and discrimination, and to negotiate any needed reasonable accommodations with employers. Second, all vocational programs should explicitly address financial planning and provider education around disability benefits and entitlements. And finally, whenever possible, providers and services should involve family and friends in supporting consumers' effort to work.
Relevance for CRPs
In considering your own organization, the following questions can assist you in determining to what extent SE services are available at your program. These items are taken from a consumer toolkit on choosing the right supported employment program entitled, Seeking Supported Employment:  What You Need to Know, developed by Cook and Petersen (2003). The toolkit is available from the University of Illinois at Chicago National Research and Training Center on Psychiatric Disability (see Resources below for a web address).

1.	Do at least 80% of your clients work in competitive jobs that are open to anyone who applies?
2.	Do at least 80% of your clients work in settings where most of the co-workers are not people with disabilities?
3.	Can people who are working continue to receive support from program staff for as long as they want?
4.	Does your program work with anyone interested in employment, regardless of his or her abilities?
5.	Do at least 80% of your clients earn minimum wage or above?
6.	Do at least 50% of your clients get a job in the field they want?
7.	Does your program continue to serve clients as long as they want to receive services, without termination?
8.	Will your agency accept clients who want to work AND keep their SSI and/or SSDI benefits at the same time?
9.	Does your program help clients keep their jobs if they go into the hospital or need to take some time off for mental health reasons?
10.	Will your staff talk frequently with case managers or psychiatrists if clients ask them to?
11.	Do at least 25% of your clients have psychiatric disabilities?
12.	Does your program have peer support services available from other people with mental health problems?

•	Overall, the more questions you answered with YES, the more the services at your agency reflect these core, research-based principles of supported employment.  
•	For issues on which your response was NO, to what extent can services be refined to move more toward the supported employment framework?

Summary
People with psychiatric disabilities tend to be marginalized from the labor market, at a great detriment to those individuals who want to work, and to society at large. However, much is known about what works in vocational services for mental health consumers. Both consumers and providers can educate themselves on best practices in supported employment using available tools, and a series of research-based principles, including the importance of: integration of vocational services with mental health services; competitive job placements in socially-integrated settings; consumer choice and career preferences; rapid job placement; on-going vocational support services; and peer-run or peer-facilitated services. 
Websites & Resources
For additional information regarding research on supported employment, research based principles of successful vocational rehabilitation, the Employment Intervention Demonstration Program, or to obtain a copy of the Seeking Supported Employment toolkit, visit www.psych.uic.edu/mhsrp, or write to or call the University of Illinois at Chicago Center on Mental Health Service Research & Policy, 104 S. Michigan Ave., Suite 900, Chicago, IL 60603, 312-422-8180 (phone), 312-422-0740 (fax) or 312-422-0706 (TDD). 
The following references also are available at www.psych.uic.edu/mhsrp.  
Cook, J.A., & Burke, J.K. (2002). Public policy and employment of people with disabilities: Exploring new paradigms. Behavioral Sciences and the Law, 20, 541-557.
Cook, J.A., Carey, M.A., Razzano, L.A., Burke, J.K., & Blyler, C. (2002). The Pioneer: The Employment Intervention Demonstration Program - A multisite study of vocational rehabilitation interventions. In J.M. Herrell & R. B. Straw (eds.), "Conducting Multiple Site Evaluations in Real-World Settings," New Directions in Evaluation, (pp. 31 - 44), 94, San Francisco, CA:  Jossey-Bass/American Evaluation Association.
Cook, J.A. & Razzano, L.A. (2000). Vocational rehabilitation for persons with schizophrenia: Recent research and implications for practice. Schizophrenia Bulletin, 26, 87-103.
Jane Burke, M.S. is a Research Specialist at the University of Illinois at Chicago Center on Mental Health Services Research & Policy (UIC CMHSRP). Judith A. Cook, Ph.D. is Professor of Psychiatry at the University of Illinois at Chicago Department of Psychiatry and Director of the UIC CMHSRP, and Lisa Razzano, Ph.D. is Associate Professor of Psychiatry in the UIC Department of Psychiatry and Director of Research for the UIC National Research and Training Center on Psychiatric Disability. The UIC CMHSRP houses several federally funded centers, including the Employment Intervention Demonstration Program, as well as other projects that focus specifically on employment and vocational rehabilitation services research. Dr. Cook has consulted on employment and income support issues with a variety of federal agencies and the White House, including both the Clinton and Bush Administrations.