Targeted Assistance Overcomes Barriers to Work World

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.

Program Designs Differed But Worked

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 team suggested.

Opportunities Still Too Few

Yet even with this powerful evidence arguing for supported employment for those with serious mental illness, getting it to those people is no easy feat.

“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 available.”

“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 2005 62 505