Deborah R. Becker

An Update on Randomized Controlled Trials of Evidence-Based Supported Employment

BACKGROUND The Individual Placement and Support (IPS) model of supported employment for clients with severe mental illness has been described as a standardization of evidence-based supported employment. Although several reviews on the literature on its effectiveness have been conducted, the completion of several new studies suggests an updated review is warranted. METHODS We conducted a comprehensive literature search for randomized controlled trials of IPS, limiting our review to programs with high-fidelity IPS programs, locating 11 studies. We examined the following competitive employment outcomes: employment rates, days to first job, annualized weeks worked, and job tenure in longest job held during the follow-up period. FINDINGS Across the 11 studies, the competitive employment rate was 61% for IPS compared to 23% for controls. About two-thirds of those who obtained competitive employment worked 20 hours or more per week. Among those who obtained a competitive job, IPS participants obtained their first job nearly 10 weeks earlier than did controls. Among IPS participants who obtained competitive work, duration of employment after the start of the first job averaged 24.2 weeks per year, or 47% of the 52-week year. CONCLUSIONS The current review is consistent with earlier reviews, although the evidence for high-fidelity IPS appears to be somewhat stronger here than in reviews evaluating studies with more heterogeneity in the supported employment models examined. The number, consistency, and effect sizes of studies of evidence-based supported employment establish it as one of the most robust interventions available for persons with severe mental illness.

A working life for people with severe mental illness

PART I: CONCEPTUAL AND EMPIRICAL SUPPORT FOR INDIVIDUAL PLACEMENT AND SUPPORT 1. Introduction 2. Conceptual, Historical and Ideological Underpinnings of Supported Employment 3. Theoretical Underpinnings of Individual Placement and Support (IPS) 4. Introduction to the IPS Approach to Supported Employment 5. Research on IPS PART II: PRACTICE GUIDELINES FOR IMPLEMENTING SUPPORTED EMPLOYMENT 6. Introduction to IPS 7. The Structure of IPS in the Mental Health Agency 8. Getting Started 9. Comprehensive, Work-based Assessment 10. Finding Jobs 11. Maintaining Jobs PART III: SPECIAL ISSUES 12. Dual Diagnosis and Work 13. Highly Trained Individuals and Work 14. Supported Education 15. Work and Cultural Competence 16. Conclusions APPENDICES: 1. Individual Employment Plan 2. Vocational Profile 3. Job Descriptions: Employment Specialist, Employment Coordinator 4. Sample Letter to Employers 5. Supported Employment Fidelity Scale and Implementation Questions

Work and nonvocational domains of functioning in persons with severe mental illness: a longitudinal analysis.

In this study we sought to understand the relationship between obtaining competitive employment and changes in nonvocational domains of functioning (symptoms, substance abuse, hospitalizations, self-esteem, quality of life) in persons with severe mental illness. A group of 143 unemployed patients participating in a study of vocational rehabilitation programs were assessed in nonvocational areas of functioning at baseline and 6, 12, and 18 months later. Statistical analyses examined the relationship between work status at the follow-up assessments and nonvocational functioning, controlling for baseline levels of nonvocational variables. Patients who were working at follow-up tended to have lower symptoms (particularly thought disorder and affect on the Brief Psychiatric Rating Scale), higher Global Assessment Scores, better self-esteem, and more satisfaction with their finances and vocational services than unemployed patients. Employment is associated with better functioning in a range of different nonvocational domains, even after controlling for baseline levels of functioning.

Generalizability of the Individual Placement and Support (IPS) model of supported employment outside the US

While reviews of controlled studies of the Individual Placement and Support (IPS) model of supported employment for clients with severe mental illness have documented its effectiveness in the US, its generalizability to other countries has not been systematically evaluated. This is the first review to compare US to non-US studies. We identified 15 randomized controlled trials of IPS programs, 9 in the US and 6 outside the US. We examined competitive employment outcomes, including employment rate, days to first job, weeks worked during follow-up, and hours worked. We also considered noncompetitive employment, program retention, and nonvocational outcomes. IPS programs had significantly better outcomes across a range of competitive employment indicators and higher retention in services than control groups. The overall competitive employment rate for IPS clients in US studies was significantly higher than in non-US studies (62% vs. 47%). The consistently positive competitive employment outcomes strongly favoring IPS over a range of comparison programs in a group of international studies suggest that IPS is an evidence-based practice that may transport well into new settings as long as programs achieve high fidelity to the IPS model, but further research is needed on international adaptations.

The Hartford study of supported employment for persons with severe mental illness.

The authors compared 3 approaches to vocational rehabilitation for severe mental illness (SMI): the individual placement and support (IPS) model of supported employment, a psychosocial rehabilitation (PSR) program, and standard services. Two hundred four unemployed clients (46% African American, 30% Latino) with SMI were randomly assigned to IPS, PSR, or standard services and followed for 2 years. Clients in IPS had significantly better employment outcomes than clients in PSR and standard services, including more competitive work (73.9% vs. 18.2% vs. 27.5%, respectively) and any paid work (73.9% vs. 34.8% vs. 53.6%, respectively). There were few differences in nonvocational outcomes between programs. IPS is a more effective model than PSR or standard brokered vocational services for improving employment outcomes in clients with SMI.

Individual Placement and Support: a community mental health center approach to vocational rehabilitation.

Individual Placement and Support (IPS) is a vocational rehabilitation intervention for people with severe mental disabilities. IPS draws from components and philosophies of several other models. Employment specialists, who are part of the community mental health center team, provide services in the community. IPS emphasizes client preferences, rapid job finding, continuous assessment, competitive employment, integrated work settings, and follow-along supports. Initial research on IPS shows favorable results.Individual Placement and Support (IPS) is a vocational rehabilitation intervention for people with severe mental disabilities. IPS draws from components and philosophies of several other models. Employment specialists, who are part of the community mental health center team, provide services in the community. IPS emphasizes client preferences, rapid job finding, continuous assessment, competitive employment, integrated work settings, and follow-along supports. Initial research on IPS shows favorable results.

Job Terminations Among Persons with Severe Mental Illness Participating in Supported Employment

For persons with psychiatric disabilities, maintaining a job is often more difficult than acquiring a job. A large proportion of jobs end unsatisfactorily. This study explored job terminations among 63 persons with severe mental illness who participated in competitive jobs through supported employment programs. More than half of the job terminations were unsatisfactory, defined as the client quitting without having other job plans or being fired. Baseline ratings of demographic and clinical characteristics, preemployment skills training, and early ratings of job satisfaction and work environment did not predict unsatisfactory terminations. Clients with better work histories were less likely to experience unsatisfactory terminations. In addition, unsatisfactory terminations were associated retrospectively with multiple problems on the job that were related to interpersonal functioning, mental illness, dissatisfaction with jobs, quality of work, medical illnesses, dependability, and substance abuse. These results suggest that supported employment programs need to address job maintenance with interventions that identify and address different types of difficulties as they arise on the job.

Individual Placement and Support: An Evidence-Based Approach to Supported Employment

Employment is the highest priority for many people with severe mental illness and it is a central aspect of recovery. Over the past two decades, the Individual Placement and Support (IPS) model of supported employment has emerged as the prominent evidence-based approach to vocational rehabilitation. This comprehensive monograph synthesizes the research and experience on IPS supported employment: historical context, core principles, effectiveness, long-term outcomes, non-vocational outcomes, cost-effectiveness, generalizability, fidelity, implementation, policy, and future research. In tracing the evolution of IPS, readers are equipped with an elegant example of the transition from needs assessment, to model development, to testing, and to dissemination.

Individual placement and support for individuals with recent-onset schizophrenia: integrating supported education and supported employment.

OBJECTIVE To describe the adaptation of the Individual Placement and Support model of supported employment to individuals with a recent first episode of schizophrenia or a related psychotic disorder. METHODS AND RESULTS Given that the vocational goals of persons with a recent onset of schizophrenia often involve completion of schooling rather than only competitive employment, the principles of Individual Placement and Support were extended to include supported education. This extension involved initial evaluation of the most appropriate goal for individual participants, having the IPS specialist working on placement either with the participant or directly with educational and employment settings (depending on permitted disclosure and individual need), and follow-along support that included work with teachers and aid in study skills and course planning as well as typical supported employment activities. Work with family members also characterized this application of IPS. A randomized controlled trial is comparing the combination of IPS and skills training with the Workplace Fundamentals Module with the combination of brokered vocational rehabilitation and broad-based social skills training. Participants in the IPS condition have returned to school, competitive work, and combined school and work with approximately equal frequency. CONCLUSIONS IPS principles can be successfully extended to integrate supported education and supported employment within one treatment program. The distribution of return to school, work or their combination in this group of individuals with recent-onset schizophrenia supports the view that an integrated program of supported education and supported employment fits this initial period of illness.

Rehabilitative day treatment vs. supported employment: I. Vocational outcomes

Day treatment remains a core component in many community mental health programs for persons with severe mental disorders throughout the United States. Many other mental health centers are moving away from day treatment toward psychosocial and vocational rehabilitation programs. Empirical research directly comparing these two systems of organizing outpatient services is needed. In this study the authors compared a rehabilitative day treatment program in one small city with a similar program in a nearby city that changed from day treatment to a supported employment model. Clients who were enrolled in community support services during a baseline year prior to the change and during a follow-up year after the change (71 in the program that changed and 112 in the other) were evaluated during both intervals. In the program that changed, competitive employment improved from 25.4% to 39.4% for all clients, and from 33.3% to 55.6% for those clients who had been regular attenders of day treatment during the baseline. Hours worked and wages earned similarly improved after the program change. For all work variables, clients who had not worked during the baseline year accounted for the improvements in outcome. Meanwhile, employment remained stable in the day treatment program. No negative outcomes were detected. These results indicate that eliminating day treatment and replacing it with a supported employment program can improve integration into competitive jobs in the community.