The work ethic has been found to be alive and well in Americans with
serious mental illness, and American ingenuity has led to a concept that may
revolutionize their ability to enter the work force.
The concept, called supported employment, was pioneered in the early 1980s
by Paul Wehman, Ph.D., a mental retardation researcher at Virginia
Commonwealth University in Richmond.
Supported employment consists of offering vocational help to persons not
only with serious mental retardation, but with other serious mental
disabilities such as brain injury, autism, or mental illness.
The goal is to find a job for such people in the competitive job market, as
soon as possible and then provide them with ongoing support.
Several randomized, controlled trials have found that supported employment
can help people with serious mental illness find work. A new one published in
the May Archives of General Psychiatry adds to these findings.
In the opinion of the lead investigator, Judith Cook, Ph.D., a professor of
psychiatry at the University of Illinois at Chicago, these study results are
the strongest yet endorsing the value of supported employment for those with
serious mental health problems.
Anthony Lehman, M.D., chair of psychiatry at the University of Maryland and
one of the study investigators, agreed.
The study conducted by Cook and her colleagues included some 1,300
outpatients with serious mental illness who wanted to work. They hailed from
Arizona, Connecticut, Maine, Maryland, Massachusetts, South Carolina, and
Texas and had various racial and ethnic backgrounds.
Subjects were assigned either to a services-as-usual condition or to a
supported-employment program. Both offered clinical services such as
psychiatric evaluation and diagnosis, medical management, counseling,
psychosocial rehabilitation, partial hospitalization, and emergency services.
Yet while the services-as-usual conditions provided subjects with, on average,
five hours of vocational help, the supported-employment programs offered, on
average, 43 hours of such assistance.
Moreover, all of the supported-employment programs shared certain
characteristics. For example, clinical treatment and employment services were
provided by the same team; efforts were made to find a job rapidly for
patients, and even after patients obtained a job, they were provided with
continuing support by the treatment team.
Nonetheless, the programs varied somewhat in their design. For example, in
addition to offering supported employment, the Texas program helped patients
strengthen their current friendships and develop new acquaintances. The Maine
program combined supported employment with a Mental Health Employer
Consortium. This consortium formed partnerships among businesses and mental
health and vocational service providers to develop a diverse work-force
including people with mental illnesses.
"That each of the study sites implemented supported employment in its
own way" is an "interesting aspect of this study," Stephen
Marder, M.D., commented to Psychiatric News. Marder is a professor of
psychiatry at UCLA. He also has a special interest in functional recovery, and
especially supported employment, for individuals with schizophrenia
(Psychiatric News, November 19, 2004).
Cook and her colleagues followed the employment outcomes of the subjects in
both the supported-employment programs and in the control conditions for two
years, then compared the outcomes. A significantly greater number of subjects
in the supported-employment programs than in control conditions found
work—55 percent versus 34 percent. Subjects in supported employment were
also more likely than those in the control conditions to work 40 or more hours
a month and to earn more money. These differences too were significant.
If the control conditions had provided no job assistance at all, the job
outcome differences between the supported-employment subjects and the control
condition subjects would probably have been even more dramatic, Cook and her
Yet even with this powerful evidence arguing for supported employment for
those with serious mental illness, getting it to those people is no easy
"At this point, supported employment has moved beyond the status of
an experimental treatment to being an evidence-based practice," Cook
said in an interview. "However, as noted in the 2003 report of the
President's New Freedom Commission on Mental Health, the large majority of
individuals with severe mental illness are not receiving supported employment,
and it is not being made available to them.
"We know the model works, we know how to deliver the services (there
is currently a toolkit for providers of supported employment), and we have
large-scale surveys showing that people with severe mental illness want to
work. What we need now is the national will to allocate time and money to
policies and program changes that make supported employment more widely
"Organization and funding are the big issues," Robert Drake,
M.D., director of the New Hampshire-Dartmouth Psychiatric Research Center, an
authority on supported employment for mentally ill individuals and one of the
study investigators, told Psychiatric News. "Mental health care
and rehabilitation are often in separate agencies at federal, state, and local
levels, yet the evidence shows that integration is more effective. Federal
mental health and rehabilitation agencies, Medicaid, and Social Security need
to be involved in solutions that will make effective services available to all
who need them."
The study was funded by the Center for Mental Health Services/Substance
Abuse and Mental Health Services Administration.
An abstract of "Results of a Multisite Randomized Trial of
Supported-Employment Interventions for Individuals With Severe Mental
Illness" is posted online at<http://archpsyc.ama-assn.org/cgi/content/short/62/5/505>.▪
Arch Gen Psychiatry