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 DunnKaren.Dunn@Dartmouth.edu603-448-0263http://dms.dartmouth.edu/prc