To the Editor: In the article "Can SSDI and SSI Beneficiaries With Mental Illness Benefit From Evidence-Based Supported Employment?" in the November issue, Bond and colleagues concluded that "supported employment … extends optimism that SSA beneficiaries with severe mental illness have excellent potential to return to competitive employment." Although there is little doubt that compared with customary rehabilitation supported employment enables significantly more persons with psychiatric disabilities—both SSA beneficiaries and nonbeneficiaries—to return to competitive employment, the clinical significance of this outcome should not lull practitioners and administrators into viewing the intervention as strong enough to overcome disincentives to entering the workforce for SSA beneficiaries.
In the study by Bond and colleagues, the mean number of weeks worked for SSDI beneficiaries ranged between 18.5% and 22.8% of the 18-month study period. Thus very few persons in the sample exhausted the SSA's nine-month trial work period after which they would "fall off the cliff" and lose their pensions. The nine-month trial work period permits individuals to be employed full-time for 39 weeks, a duration which far exceeds the means of 14.5 to 21.3 weeks worked half-time among SSDI recipients in the study. Similarly, the SSI recipients worked half-time, for a mean of 17.8 weeks over the 18-month study period, an amount that would not threaten their SSI benefits.
Although Bond and colleagues clearly acknowledged that the benefits of supported employment will be limited unless disincentives inherent in SSA policies are reduced, it is important for stakeholders to grasp the realistic constraints of supported employment in promoting sustained employment. Individual placement and support, the evidence-based practice for vocational rehabilitation, generally is successful in recruiting not much more than 50% of persons with serious mental illness in the total population of disabled persons (1). Thus it is not clear that this evidence-based practice can overcome reluctance to join the workforce, deficits in social skills, and neurocognitive impairments that militate against enduring employment (2,3,4). Even with systematic efforts to disseminate individual placement and support, mobilizing sufficient administrative, service system, and clinical supports for this evidence-based practice is often difficult (5).
Notwithstanding these qualifications, supported employment that follows individual placement and support procedures remains the best model of vocational rehabilitation for persons with psychiatric disabilities. There is every reason to anticipate that this model will stimulate the design of the next generation of interventions for giving this stigmatized population even greater opportunities to achieve durable working lives.
Dr. Liberman is distinguished professor of psychiatry, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), and director of the UCLA Psychiatric Rehabilitation Program.
Drake RE, McHugo GJ, Becker DR, et al: The New Hampshire study of supported employment for people with severe mental illness: vocational outcomes. Journal of Consulting and Clinical Psychology 64:391—399, 1996
Lehman AF, Goldberg R, Dixon LB, et al: Improving employment outcomes for persons with severe mental illnesses. Archives of General Psychiatry 59:165—172, 2002
Tsang HWH: Augmenting vocational outcomes of supported employment with social skills training. Journal of Rehabilitation 69:25—30, 2003
McGurk SR, Mueser KT: Cognitive functioning, symptoms and work in supported employment: a review and heuristic model. Schizophrenia Research 70:147—173, 2004
Van Erp NHJ, Giesen FBM, van Weeghel J, et al: A multi-site study of implementing supported employment in the Netherlands. Psychiatric Services 58:1421—1426, 2007