Supported Employment: Helping Members Achieve Recovery and Economic Independence

For most Americans, a job or career defines much of who we are. Even in times of great economic uncertainty and unemployment, Americans describe themselves as teachers, architects, computer geeks, and more. A career is a badge of honor, establishing a sense of industry and a place in the social strata. For the eight million Americans with serious mental illness, dreams of a career or even a job regularly fade or fail to materialize. The staggering unemployment rate for this population (85%–90%) often results in lives of poverty and disability. A critical piece of the recovery puzzle is missing.

Employment is one of the most powerful clinical interventions available. When one considers the benefit of employment to consumers, including reports of higher self-esteem, better quality of life, better symptom control, greater financial independence, and longer-term careers, finding jobs for this underserved population is a priority. In contrast, unemployment engenders huge personal loss for consumers and great societal burden because of loss of productivity and more frequent use of mental health care services. Thresholds, Illinois' largest and oldest provider of services for people with serious mental illness, supports the independence of its member-consumers by helping them find meaningful, competitive employment through the evidence-based practice of supported employment.

The Supported Employment Program is a cornerstone of Thresholds' diverse array of services, helping its members live their lives with dignity, independence, and respect by obtaining paid employment. By partnering with 130 Chicago-area employers, Thresholds places members in jobs of their choice to achieve economic independence and further their recovery. Thresholds partners include Banana Republic, FedEx, Jewel-Osco, Kohl's, and numerous other area employers.

In recognition of its commitment to supporting its members in finding competitive work, for integrating employment services with psychiatric treatment, and for enriching the lives of its members through greater economic independence and quality of life, the Thresholds Supported Employment Program was selected to receive an APA Gold Achievement Award in the category of community-based programs. In the category of academic or institutionally based programs, the program selected for a Gold Award is described on page 1395. Each Gold Award recipient receives a plaque and a $10,000 prize made possible by a grant from Pfizer, Inc.

Earlier models

Thresholds was founded as a clubhouse program in the Chicago area in 1959. The earliest employment opportunities for its mental health consumers began with the introduction of prevocational work crews in 1962. Later, these opportunities expanded to include group placements, agency-run businesses, and sheltered workshops. Sheltered workshops and agency-run business gradually gave way to competitive employment opportunities within the community, consistent with members' recovery goals. In the late 1990s Thresholds participated in a large, randomized controlled trial comparing employment outcomes of members enrolled in Thresholds traditional diversified job placement services and those in supported employment. Findings showed superior effectiveness of supported employment in helping members obtain competitive employment. After that study, Thresholds shifted fully to an individual placement and support model.

Innovation at work

When a Thresholds member expresses interest in working, the member is referred to a supported employment specialist who, consistent with supported employment principles, fully engages in helping the member find a job and thrive in it. Specialists conduct individualized assessments, taking into account the member's history, interests, and preferences for everything from job location to work environment. Specialists then provide individualized support throughout the job process, including the search, application, hiring, continuity of performance, and transition (such as promotion or transfer) or exit processes from a job. The model also includes the principles of zero exclusion, a rapid and individualized job search, integration with mental health treatment, time-unlimited follow-along supports, individualized benefits planning, and a goal of competitive employment at a job with a fair wage. All of these principles are in line with Thresholds' mission to offer recovery-oriented services, making supported employment services a natural extension of Thresholds' work.

The employment specialist is part of an interdisciplinary team of mental health workers who combine their interventions to help a consumer find and keep employment. Teams consist of staff from various backgrounds, such as social work, psychology, and rehabilitation counseling. Their purpose is to provide for the wraparound services that enable consumers to learn strategies that help them manage in all domains of their lives, including employment. When someone is referred to employment services, the employment specialist reviews with the team what strategies have been helpful for that consumer in learning the skills that help in managing his or her illness and recovery. In addition, all members of the team help the consumer use strategies in the workplace that also assist in managing interpersonal issues, incorporating supervisory feedback, and improving job performance to maximize the chances for success on the job.

In this model, the psychiatrist is an essential member of the team. The mental health staff and the employment specialist consult with the doctor to discuss issues involving medication. Because the doctor is part of the team, access is simplified, and the doctor can advise about a consumer who may be experiencing increased symptoms at work. At such times, the psychiatrist may adjust medications or dosages to help a consumer stabilize symptoms and maintain job performance. This attentiveness often stops a downward cycle and reduces the risk of job termination.

Supported employment's reach, access, and impact at Thresholds

Thresholds' provision of supported employment to hundreds of consumers makes a positive impact on both individual consumers and the city of Chicago. Thresholds currently employs 26 supported employment specialists who work at more than a dozen Thresholds sites throughout the Chicago area. By caseload, Thresholds has the static capacity to serve more than 500 members who seek employment services. Based on agency intake statistics, an estimated 96% of individuals are unemployed at entry to Thresholds, and roughly half have no work history. Of the more than 3,600 individuals served by the agency in fiscal year 2009, a total of 914 received supported employment services. Across supported employment teams, competitive employment rates ranged 18%–63%, with 283 consumers working at 366 competitive jobs at roughly 130 businesses in the Chicago area. Consumers worked an average of 23 hours a week and earned an average wage of $9.04 per hour. Average job tenure was 311 days. This is an astounding 500% increase over the employment levels at intake for Thresholds members.

In 2008 Thresholds secured funding to add an employment team (leader and two employment specialists) to its young adults program. Since the second quarter of 2008, 24 young consumers have found work at 29 jobs. Employment rates for this program overall were above 50% for the past two quarters. These early outcomes indicate the positive impact of employment services on assisting consumers in achieving economic independence early in their lives. In addition to these quantitative results, consumers and employers regularly tout the effectiveness of the program in creating a sense of self-sufficiency and independence.

Evaluating success and making improvements

Thresholds offers three evidence-based practices that complement supported employment—assertive community treatment, integrated treatment for co-occurring disorders, and illness management and recovery. In addition, Thresholds has introduced several recovery initiatives, including ongoing self-advocacy training, a recovery steering committee, and ongoing staff training on integrating a recovery orientation into routine service activities.

For example, a group of staff and consumers conduct fidelity-like visits at the various Thresholds programs where they interview staff and members involved with supported employment to determine what is going well with recovery initiatives and where more support, training, and supervision are needed. Such a focus ensures that consumer choice and preference—an important tenet of a recovery orientation, and of supported employment especially—are kept at the forefront.

The supported employment steering committee meets monthly. Its mission is to ensure that Thresholds provides high-quality supported employment services to all consumers who want to work. Through the collaborative efforts of various stakeholders, including research, quality assurance, training, clinical, and supported employment staff, as well as consumers and a vocational rehabilitation supervisor from the State Division of Rehabilitation Services, the committee implements, sustains, and improves supported employment practices within the agency. In addition, two researchers from the Dartmouth Psychiatric Research Center meet with the steering committee quarterly, sharing information about their experience with implementation and sustainability of supported employment in mental health centers across the nation. Overall, the committee's charge is to ensure program fidelity, brainstorm around barriers to implementation, and identify agencywide interventions to improve the quality of employment services.

Improving outcomes: turning research into action

Thresholds has long recognized the need for a strong system for gathering and analyzing data and disseminating those results, especially with regard to the supported employment program. For 30 years, the agency has had a formal research department and institutional review board, one of only a handful in the country outside of major university research centers. Thresholds is committed to ongoing program evaluation for quality improvement and participation in rigorous scientific studies of supported employment.

The Thresholds Supported Employment Program is unique in that its research and clinical arms are fully integrated. This integration allows the program to base its interventions in tested, evidence-based knowledge and nimbly revise its strategies for the program as the research informs its work. This approach bypasses the typical 15- to 20-year gap between empirical evidence that an intervention works and its implementation. Closing this gap is a central goal of the Thresholds Institute, created in 2007 as a research and training arm of the organization to disseminate valued psychiatric and mental health research through multiple media formats, including papers, seminars, and conferences.

Thresholds has also recently entered into a partnership with Dartmouth's Psychiatric Research Center to create the Thresholds-Dartmouth Employment Research and Training Center. With this collaboration, the center builds on a solid foundation of effective services, empirical research, and education. The partners envision a center—both physical and virtual—that welcomes investigators, clinicians, consumers, family, employers, and others to receive state-of-the-art training, technical assistance, and consultation in the supported employment model. The center will also serve as a resource for stakeholders nationally and internationally.

A history of community support

The Thresholds Supported Employment Program has a long history of community support, in addition to access to funding streams from the Division of Mental Health and federal sources. Community supporters include the Rebecca Susan Buffett Foundation, Johnson & Johnson, the NoVo Foundation, the Chicago Community Trust, Chicago White Sox Charities, and private donations and fundraising. These sources, which total to just under $2 million, pay for direct services to Thresholds members and fund initiatives that further the supported employment model. Various pharmaceutical companies, including AstraZeneca and Eli Lilly, have sponsored research conferences for Thresholds.

With the new partnership for research with Dartmouth, Thresholds has embarked on a capital campaign for supported employment and for the research and training center. The $15 million, multiyear campaign will focus on building a research and training facility as well as an endowment for funding further research and clinical practice opportunities at Thresholds. The organization plans to aggressively disseminate the resulting research and clinical findings around the world.

The campaign focuses on funding in five key areas: employment opportunities and capacity building; capital projects, including the construction of a physical research and training center and four local employment and recovery engagement centers; research; technology enhancements; and education, training, and dissemination of research findings through Thresholds and Dartmouth. The campaign is considered transformational for the agency and will enhance supported employment opportunities for consumers not only in Chicago but nationally and internationally as well.

The future of supported employment services

Thresholds is dedicated to furthering supported employment as an effective and powerful clinical tool in the realm of psychiatric rehabilitation. Thresholds is committed to gathering, analyzing, and disseminating research on the model and to building necessary capacity to reach more consumers within Thresholds and beyond.

Thresholds supported employment staff train others around the country in this recovery model, and it has been studied for effectiveness internationally. With continued support for the program, the capital campaign for supported employment, and its partnership with Dartmouth, Thresholds will become the preeminent leader in evidence-based supported employment nationally and internationally. Thresholds has welcomed visitors from Singapore, Taiwan, Australia, Mexico, Israel, and New Zealand and welcomes other providers from across the country and around the world who wish to see the model in action. Thresholds believes in the use of evidence-based practices, and supported employment will continue to be a cornerstone of Thresholds care.

For more information, contact Virginia Fraser, M.S., associate director, Thresholds Psychiatric Rehabilitation Centers, 4101 N. Ravenswood Ave., Chicago, IL 60613 (e-mail: [email protected]).