Individual Placement & Support Employment and Education Services

1. Individual Placement & Support Employment and Education Services MISA Cross-Divisional Conference 2010

2. Overview of the day • EBSE & MISA research, principles, practice, org. structure • EBSE & Recovery in consumers voices • IPS/Mot. Intv. & practice skills • VR Ill. & other states • Opportunities for leadership

3. Why Focus on Employment? • Viewed by many as an essential part of recovery • Most consumers want to work • A typical role for adults in our society • Cost-effective alternative to day treatment

4. Positive Outcomes from Competitive Work • Higher self-esteem • Better control of psychiatric symptoms • More satisfaction with finances and with leisure (Bond et al., 2001)

5. Is Work Too Stressful? • As compared to what? • Joe Marrone, an employment trainer: “If you think work is stressful, try unemployment.” • Stresses of work do not translate into higher rates of hospitalization

6. Negative Effects of Unemployment in General Population • Increased substance abuse • Increased physical problems • Increased psychiatric disorders • Reduced self-esteem • Loss of social contacts • Alienation and apathy • (Warr, 1987)

7. Competitive Employment for People with Severe Mental Illness • Say they want to work: 70% • Are currently working: <15% • Current access to supported employment: <5%

8. J & J-Dartmouth Project • mMental health-vocational rehabilitation collaboration • iImplement evidence-based SE • LLocal programs selected by states • DDartmouth provides training, consultation, and evaluation • FFirst states: CT, DC, KS, MD, OR, SC, VT • NNew states: DE, IL, MN, OH, Ky, WI. Mo. • (Drake, 2006)

9. J&J Project Strategies • SStart with “early adopters”: states & programs • VVR-MH collaboration • LLongitudinal training • OOutcome-based supervision • PProblem solving by local experts • (Drake, 2006)

10. Thresholds/Dartmouth NRTC on Evidence-Based SE • PPart of Dartmouth Medical School • PPhase I: $30 million, ½ Thresholds ½ Dartmouth • EEndowed Chair, 4 Resource Centers in Ill. • TTraining of practitioners including VR staff • SServices to customers including employers • RResearch priorities: ex-offenders, improve mental/physical health, less need public benefits, outcome measurement tools, public policy re SE & employment

11. Overview for Narcoleptics • SSupported employment is an effective evidence-based practice • LLong-term perspective is even better • IImplementation is critical • AAmplifying effectiveness: more people and more hours

12. OOnly 10-15% of people with psychiatric disabilities are working • 770-80% want to work • WWork improves self-esteem, income, and recovery • TTraditional programs are ineffective • SSupported employment is effective Employment

13. What Is Evidence-Based Practice? • A practice validated through rigorous research • Has guidelines describing critical ingredients • Ideally, has been successfully implemented in a wide range of settings

14. Randomized Controlled Trials (RCTs) of Supported Employment • Strongest scientific design for evaluating whether a treatment works • Studies include: • 4 conducted before evidence-based principles articulated by IPS model • 9 used full implementation of IPS

15. Competitive Employment Rates in 12 RCTs of Supported Employment

17. Current Status RCTs • 1 • 660% vs. 22% employment • FFindings very consistent • RRecent IPS studies over 70% employment

18. Indirect Impact on Other Outcomes • RRelated to sustained competitive employment • IImproved self-esteem, symptom control, life satisfaction • NNo changes with sustained sheltered employment • (Bond, 2001)

19. Studies of Long-Term Outcomes from Supported Employment • TTest: 10 years • MMcHugo: 3.5 years • BBond: 3.5 years • SSalyers: 10 years • BBecker: 8-12 years • DDrake: 10 years

20. 10-Year Follow-up of Day Treatment to SE Conversion • 992% worked during follow-up • 447% currently working • 333% worked at least 5 years • MMany reported increases in hope, self-esteem, relationships • (Salyers, 2004)

21. 8-12 Year Follow-up of SE • 771% working at follow-up • NNearly all in competitive jobs • 77% sheltered, 10% volunteer • 771% worked more than 50% of FU • BBut 90% still receiving benefits • (Becker, 2006)

22. Current Status of SE • EEveryone who wants to work should receive SE • MMost will succeed and difficult to predict • LLimitations of current SE • CCurrent efforts to improve outcomes

23. Limitations of SE • OOne-fourth do not work • MMost people do not work full-time • MMost people stay on benefits

24. Amplifying the Effects • SSkills training (Marder) • EErrorless learning (Kern) • BBenefits counseling (Tremblay) • MMotivational interviewing (Drebing) • CContingency management (Drebing) • CCognitive training (McGurk) • CCompensatory mechanisms (Velligan) • MMedications (MATRICS)

25. Explaining Variance • 225% local economy • 225% SE fidelity • 550% individual practitioner • (Becker, 2006)

26. “There are a range of effective treatments for people with mental illness. . . if these effective treatments were more efficiently delivered through our mental health services system ….Millions of Americans would be more successful in school, at work, and in their communities.” • Michael Hogan, Chairman

27. Quotes from Consumers • “I feel so much better about myself now that I have a job.” • “Holding down my job is not always easy but it has helped my self esteem.” • “When I go to work I don’t hear the voices.” • “Now that I am working again I can buy my daughter presents.”

28. Quotes from Family Members • “I worried that if my son got a job he would get stressed. But just the opposite happened. He is doing so much better than before.” • “I feel better that she tries working when she has the support of mental health.” • “I was really glad that my son’s employment counselor asked me about work ideas. He landed a job that I suggested.”

29. Quotes from Employers • “Andre is as good as any worker that I have.” Automotive parts store manager. • “I count on Juanita. If she is feeling stressed, she sits in the back room for awhile. That’s OK; she gets the job done.” Bakery supervisor. • “The employment counselor helped me understand why Tony paces. It’s okay in the security business.” Security business owner.

30. Definition of Supported Employment • Mainstream job in community • Pays at least minimum wage • Work setting includes people who are not disabled • Service agency provides ongoing support • Intended for people with most severe disabilities

31. Evidence-Based Principles • Eligibility is based on consumer choice • Supported employment is integrated with treatment • Competitive employment is the goal • Personalized benefits planning is provided • Job search starts soon after a consumer expresses interest in working • Follow-along supports are continuous • Consumer preferences are important

32. Eligibility Is Based on Consumer Choice • No one is excluded who wants to participate. • Consumers are not excluded because they are not “ready” or because of prior work history, hospitalization history, substance use, symptoms, or other characteristics.

33. Supported Employment Is Integrated with Mental Health Treatment • Employment specialists coordinate plans with the treatment team, which includes case managers, therapists, and psychiatrists.

34. Valued Gateway Client : Inserted slide Do Client Characteristics Predict Success in Supported Employment? • Co-occurring substance use does not lead to lower employment rates. • Consumers generally do better in supported employment than in alternative programs regardless of background characteristics such as: • gender, education, ethnicity, diagnosis, hospitalization history, cognitive functioning

35. Competitive Employment Is the Goal • The agency needs to devote sufficient resources to supported employment to permit full access to all consumers who seek competitive employment. • Consumers interested in employment are not steered into day treatment or sheltered work.

36. Personalized Benefits Planning Is Provided • Benefits planning and guidance help consumers make informed decisions about job starts and changes.

37. Job Search Starts Soon After A Consumer Expresses an Interest in Working • Pre-employment assessment, training, and counseling are kept to a minimum.

38. Follow-Along Supports Are Continuous • Supported employment staff continue to stay in regular contact with consumer and (when appropriate) the employer without arbitrary time limits.

39. Consumer Preferences Are Important • Job finding is based on consumers’ preferences, strengths, and work experiences, not on a pool of jobs that are available.

40. Job Preferences Are Important

41. S E Unit:Recommended Structure • Minimum of 2 full-time staff • Staff devoted exclusively to SE • Full-time leader/supervisor who also provides employment services • Offices physically located in mental health center

42. Supported Employment Unit • Individual caseloads, but help each other (with job leads, etc.) • Caseloads of about 20 consumers or less • Weekly team meetings + individual supervision

43. Roles of an Employment Specialist • Problem-solver • Team player • Networker • Employment specialist • Customer-oriented • Community-oriented • Outcome-oriented

44. Characteristics of Effective Employment Specialists • High energy • Optimistic • Likes to meet new people • Good listener • Knows the community • Creative • Projects confidence and professionalism

45. Employment Coordinator Duties • Manages referrals • Hires and supervises employment staff • Ensures employment specialists are learning and using effective skills in: Engagement Assessment Job development Job support

46. More Employment Coordinator Duties • Role model good employment practices • Provide supported employment information and training to all staff • Ensure employment services are integrated with treatment teams

47. Referral • Make referral process simple! • Have minimal eligibility criteria • Unemployed (or working non-competitively) and wants competitive employment, or • Employed, but not receiving employment supports, and wants such support • Involve multiple stakeholders

48. Valued Gateway Client : What about the collaboration? This slide is not very informative Collaboration With Vocational Rehabilitation • VR counselor meets consumers at mental health agency • VR counselor is part of the treatment team • VR counselor conveys same message as rest of team

49. Vocational Rehabilitation A federally funded program available in all states that assists persons with severe mental, physical, cognitive, or sensory disabilities to return to or enter into employment. A federal program since 1920. Authorized under the federal Rehabilitation Act. Persons with mental illness added in 1943.

50. Vocational Rehabilitation (cont.) • Referral can be from any source. • State VR Counselor determines eligibility based upon a review of the records or new information. • Typical services can be: • VVocational Evaluation • CCareer Counseling • JJob seeking skills trng., job development, job placement • - Consultation on job site accommodations