Supported Employment Specialist Strategies to Assist Clients With Severe Mental Illness and Criminal Justice Issues

Employment rates among people with severe mental illness remain extremely low compared with the general population ( 1 ). People with severe mental illness are also considerably overrepresented as recipients of Social Security and welfare benefits. Supported employment has become one of the most effective interventions in the field of psychiatric rehabilitation, enabling people with severe mental illness to benefit from the economic and psychosocial rewards of work ( 2 , 3 ). The individual placement and support model of supported employment is widely regarded as the most successful approach ( 4 , 5 , 6 ). A recent review suggests that the competitive employment rate for this model was 61%, compared with 23% for other models ( 7 ).

Sixty-one percent is a laudable employment rate for what is proving to be a very robust intervention. Still, it is incumbent on researchers to find ways to improve service quality and delivery so that the competitive employment rate continues to rise. Current or previous involvement with the criminal justice system may hinder the ability of clients to find work via the supported employment system. Numerous commentators have suggested that criminal justice involvement is a potentially influential impediment to psychiatric rehabilitation but that this is an underresearched area in need of elucidation ( 8 , 9 , 10 ). A recent study found that 45% of new clients at outpatient mental health agencies had at least one recent contact with the criminal justice system; 36% had at least one criminal conviction, and 19% had a felony conviction ( 8 ). Clients involved with the criminal justice system had on average eight contacts and four convictions before arrival at the agency. Most had spent time in jail. To our knowledge, no study has attempted to document the views and experiences of supported employment specialists when working with clients with criminal justice issues. In this study, we aimed to document and critically analyze common approaches that supported employment specialists use when working with clients with criminal justice issues.

Methods

We conducted 22 semistructured qualitative interviews with supported employment specialists and their supervisors during summer 2007. These specialists and supervisors were recruited from three agencies delivering supported employment to people with severe mental illness. The agencies were located in three counties in a small, ethnically diverse northeastern state. We selected these agencies because they had relatively large supported employment programs that followed the individualized placement and support model. We worked with the State Mental Health Authority in designing the research and seeking agency permission for collaboration. Once we obtained this permission, we e-mailed or telephoned (or both) all specialists and supervisors at these three agencies, asking them if they would consider participating in an in-depth interview on the topic of challenges and facilitators to their practice. Out of 27 people contacted, 22 eventually participated, giving a recruitment rate of 81%. After completely describing the study to the participants, we obtained their written informed consent. The Dartmouth College Institutional Review Board reviewed and approved the study protocol.

These interviews lasted approximately one hour each and followed standard guidelines ( 11 ). The first five interviews were conducted by the first author, who was shadowed by the second author as part of her training. The second author conducted the rest of the interviews alone. All interviews occurred at agency offices. Interviews followed a topic guide, the aim of which was to elicit the overall attitudes and experiences of supported employment specialists and supervisors in regard to various domains, including criminal justice issues. The second author also conducted one-day participant observation with three supported employment specialists, shadowing them in their everyday work activities ( 12 ). Notes based on these observations were transcribed.

Data analysis was conducted inductively, according to guidelines for qualitative content analysis, which involves the progressive abstraction of themes from raw data ( 13 ). Specifically, all transcriptions were entered into the ATLAS-ti qualitative data analysis software program. We then began to independently code the data for prominent themes. We met regularly or conducted conference calls to discuss emerging themes. Key themes were discussed at final meetings until agreement was reached.

Results

Demographic characteristics of the sample are provided in Table 1 .

Enlarge table

Criminal justice issues arose repeatedly in the interviews. Assisting people with criminal justice issues was one of the most difficult challenges for participants. They noted that these issues were a growing problem, affecting up to half of their clientele. We divided these issues into two broad domains for analysis. First, we examined strategies commonly used by specialists when working with people with criminal justice issues. We documented and analyzed three specific strategies commonly used by participants. These were taking an incremental approach with clients, using a strengths-based approach, and focusing the job search on "mom and pop" businesses. Second, we focused on sex offenders, who were singled out as a subgroup that faces unique challenges.

Strategies

First, many participants reported that the key to assisting clients involved in the criminal justice system was to take an incremental approach. Participants stated that clients' options were circumscribed by the unwillingness of employers to hire people with past or present criminal justice involvement. Participants would work with the client to find an entry-level position, which, though agreeable to the client, may not be his or her first choice. However, they would also focus the client on the future, describing the initial job as a springboard to a better position. This is encapsulated in the extract below, where the participant conveys optimism and confidence in this approach:

"We say 'Look. We may have to start with a part-time shoveling-snow thing because you've got three violent assaults in the past two years. Now we've got you working, we can change your resume, now you're a part-time employee.' This is going to look good to somebody else, who may say 'Well, you know, he's been working, he's got part-time hours. He's saying he wants more or [something] different.' But there is a population out there that's very, very, very tough."

The participants in this study were dedicated to core principles of supported employment such as rapid job search and finding competitive employment. However, the incremental, start-low approach described by many participants is somewhat inimical to other core principles of supported employment. Specialists noted that criminal justice issues made it difficult to work with consumer preferences, because employers for whom clients wished to work had regulations preventing the hiring of people with criminal histories. So the job search was indeed tailored to the individual, but in the shadow of these external constraints. This form of incrementalism was a strategy used by specialists with many clients, regardless of criminal histories. However, this strategy was used more frequently when working with clients with criminal justice issues.

Second, many participants consciously used the strengths-based model when working with clients with criminal justice histories ( 14 ). Again, this is not a strategy unique to people with criminal justice issues; in fact it is comprehensively encouraged among all recovery-oriented practitioners working with people with severe mental illness. However, this approach appeared to be prominently and consciously used when dealing with clients with criminal justice involvement. When talking about clients with criminal justice issues, one participant noted that "I always try selling the person's strengths and abilities first." Another participant attempted to frame time that clients spent working in prison (for example, in the kitchen) positively as "work experience." Other participants focused on the hiatus between the offense and the present. Doing so not only suggested that some rehabilitation had occurred—with rehabilitation being a strength of the client—but also that the offense was less likely to be flagged in criminal record checks. Below is an extract from field notes from a participant observation with an employment specialist interacting with a client with a criminal record—indicating the enactment of a strengths-based approach. They were looking over the criminal record before a job interview:

"The client said 'It's bad, isn't it?' but the specialist said 'No, no, I'm just looking over it.' She had been arrested five or six times for burglary, assault, disturbing the peace, and failing to appear in court numerous times. If she were asked about this in an interview, the specialist encouraged her to focus not on the arrests themselves but on the past four years of no arrests—that she has been out of trouble and working with counselors since, and probation was nearly finished."

The third and final strategy refers to a tendency among specialists to channel clients with criminal justice histories into jobs in mom-and-pop stores. This is the only strategy commonly used by employment specialists that appeared distinctly unique to clients with criminal justice issues. As stated, clients with criminal justice involvement were effectively precluded from many jobs or employment locations as a result of official company policy or because of federal and state laws prohibiting the employment of people with criminal records. For example, an international airport was a rich source of employment for supported employment clients at one agency. However, new regulations meant that people with criminal records could not be employed at the airport in any capacity. One participant noted:

"He wanted to work in the airport itself, but he had an assault history. Not really a real bad one, but enough so that, you know … and after 9/11 nobody gets employed at the airport with that … even [to work for] coffee vendors, you have to be cleared, cleared, cleared. He didn't want to hear that, but eventually he backed off a little."

Again this example indicates the tension experienced by specialists wanting to abide by core supported employment principles. Specialists stated a strong commitment to individualized job search and consumer preferences, but structural policies imposed by client-favored businesses and organizations prevent those same clients from working therein. This is a difficult problem to solve.

Participants stated that the best way to overcome structural barriers was to focus on mom-and-pop businesses for clients with criminal justice involvement, although this often meant some level of compromise and negotiation vis-á-vis consumer preferences. Participants perceived this deviation from the core principles of supported employment as the only practical response to externally imposed constraints. Mom-and-pop stores were less likely to run criminal record checks. Some participants said they deliberately cultivated relationships with such stores. This gave them a reasonable chance of assisting clients with criminal records to find work, even if it was not their clients' first preference. Some participants saw the mom-and-pop approach as consistent with the incremental approach previously described. Finding someone a job in such a location was seen as a first step to building up experience and a work routine that could be used as a springboard for jobs in the future that may align better with consumer preferences.

Sex offenders

When probed in more detail about their experience with clients with criminal justice histories, participants noted that structural barriers were most severe for sex offenders. It was noted that employers were most reluctant to employ clients with sex offenses, even with the three strategies described above. One participant said,

"One huge obstacle is registered sex offenders, just their charges. You know, it's been one of the … the hardest thing[s].… it's been so difficult to find employment for someone who's a registered sex offender. And, you know, not a lot of employers are willing to work with registered sex offenders. You know, you can't blame 'em, but then, … I also have to say, you know, 'this is my client—they're a person, they need to work also.' "

Participants noted that sex offenders face legally imposed temporal and spatial prohibitions on their activity. For example, it was commonly stated that sex offenders could not work at or near schools, daycare centers, or other places where children gather. One participant noted that he could find sex offenders jobs that had only nighttime hours or shifts. Others said that employees have lost interest in clients they were ready to hire once they discovered they were sex offenders. One said that this occurred even if the offense was not predatory but a case of "mistaken age." Structural, temporal, and spatial factors thus intertwined to constrict opportunities for clients with sex offenses, as expressed by this participant:

"This particular person is a, uh, sex offender. Those are the hardest individuals to get jobs for. They're relegated to nights, overnights, in a warehouse. And if you could find a warehouse that is stocking stuff overnight, please let me know. They're basically nonexistent. The stats that they have to meet, to go to work or live, [are] ridiculous. They basically gotta live in Maine, in the woods, near a lake, with nobody around for 50 miles."

The mildly defeatist attitude expressed above indicates that some participants find it challenging to use the strengths-based model in the case of sex offenders. This attitude echoes the previous participant who empathically said "you can't blame 'em" with regard to employers' hesitancy in working with registered sex offenders. Such attitudes may hinder advocating for the client, which is a core component of the strengths-based approach.

Background checks were identified as a pervasive barrier to all clients with criminal justice involvement but especially to sex offenders. Some participants mentioned the State Government Sex Offender Registry that is publicly searchable online. It was reported that many employers used this registry to vet potential employees. Also, participants noted that probation officers had to approve employment for sex offenders. Often, they would do this only under circumscribed conditions—for example, working a nighttime shift or when the location was far from a school or daycare center. According to participants, sex offenders faced an even greater number of barriers to employment than others with criminal justice histories of a nonsexual nature.

Discussion

With a focus on delivery of supported employment services, this study confirms previous work suggesting that criminal justice issues can be a crucial impediment to psychiatric rehabilitation ( 8 , 9 , 10 ). In this study, specialists identified clients with criminal justice issues as facing challenging structural impediments in their effort to obtain work. Within this group, sex offenders were identified as facing the most pronounced structural barriers. Participants noted that they used a variety of strategies to work with people with criminal justice involvement, drawing on strategies from their professional training as well as on-the-job experience. Participants commonly used two of these strategies with all clients but used them more frequently with clients with criminal justice involvement. The strategy of placing clients with mom-and-pop businesses appears unique to the criminal justice population. A limitation of this study is that the design precludes precise verification of the success (or lack thereof) of these strategies in the field. We thus briefly discuss these strategies in the light of current literature before discussing implications for future research and practice.

The strengths-based approach has been highlighted as a successful strategy in generic social work with people with severe mental illness ( 14 ) and should be an integral part of supported employment training. This approach has also been found to be a characteristic of high-performing supported employment programs elsewhere in the United States ( 15 , 16 ). A supportive, nonstigmatizing attitude from specialists appeared to be a corollary of a strengths-based approach in our sample. Further imparting and emphasizing this approach to employment specialists may be vital to their success in the field, especially given that some of the felonies committed by clients (such as sex crimes) are likely to be stigmatized by the general public and potential employers.

Participants often took what we call an incremental employment approach to clients with criminal justice involvement. Participants simultaneously considered the short- and medium-term work trajectories of their clients. Entry-level jobs were seen as springboards to better positions in the future. This involved deviation from the individualized placement and support model, which states that a rapid job search should be aligned to individual preferences in finding a position ( 6 ). Specialists felt they had no choice but to mildly deviate from core supported employment principles. They justified such compromise as an inevitable consequence of the structural (and sometimes legal) constraints and circumscription placed on clients with criminal justice issues. It is these constraints, especially those that limit client choice, to which we now turn.

Participants noted that many businesses simply refused to employ people with criminal records. The international airport was an oft-mentioned example. This reality limited the range of options from which clients could select potential work sites. Consumer preferences were thus externally circumscribed. Participants deliberately targeted mom-and-pop businesses as a source of employment for clients with criminal records, which involved negotiation with the client regarding preferences. These stores were more lenient toward clients with criminal justice issues and less likely to run background or urine tests.

Participants stated that sex offenders were the most difficult subpopulation to assist. This perception supports a finding from a similar qualitative study of employment specialists in Indiana ( 17 ). Legal sanctions prohibit sex offenders from working at or near schools and other places where children congregate. Their criminal history is also available through a simple online search of the state sex registry. Probation officers would often veto jobs preferred by the client. The only common strategy for placement of sex offenders was for participants to search for nightshift jobs in isolated locations.

Conclusions

Our findings suggest that clients of supported employment services with criminal records (especially sex offenders) make up a unique group facing unique challenges. Our findings are a first step to answer recent calls demanding more research in this area ( 8 , 9 , 10 ). The results suggest a need for more guidance for specialists working with people with criminal justice involvement. Current practices may need to be adapted to reflect the unique circumstances of supported employment clients who have been involved with the criminal justice system. Strategies that assist clients with criminal records (emphasizing the strengths-based approach or listing employers that run stringent background checks for clients' information) could be added to manuals frequently used in training. Agencies and research institutes may consider developing specific training and practice adaptations to deal with clients with past and present criminal justice involvement. These adaptations, strategies, and training courses could then be formally evaluated through more rigorous research.

Acknowledgments and disclosures

The authors thank Johnson and Johnson Charitable Contributions for funding the study. The authors also thank Robert E. Drake M.D., Ph.D., and Deborah R. Becker, M.Ed., for support during this project.

The authors report no competing interests.