Rehab Rounds: Implementing Supported Employment Services in a Real-World Setting

In 1994 the South Middlesex Opportunity Council (SMOC), a private, nonprofit community action agency in Framingham, Massachusetts, was asked by the state's mental health department to convert a custodial care day program serving 35 clients to a community-based program with a stronger vocational focus. SMOC contracted with the New Hampshire- Dartmouth Psychiatric Research Center, which had developed and empirically validated the individual placement and support model of supported employment, for technical assistance with and consultation on implementing the model. After training by consultants from Dartmouth, newly hired staff launched the program in 1995 with 15 clients who chose to seek employment. The 20 clients who chose not to seek employment were referred to other day programs in the area.

During the past seven years the program, called SEE (Services for Education and Employment), has provided employment services to more than 450 clients with serious mental disorders. SEE currently has a program director with a background in vocational rehabilitation as well as four employment specialists. The SEE program is open to any interested client in the area, not just those who receive clinical and residential services from SMOC. Case managers, residential staff, and other clinicians typically refer clients to the program. Consistent with individual placement and support program values, no one is denied services because of a lack of work experience. The program accepts anyone who is interested in seeking a job, even clients who are not sure that they want to work. Rather than relying on formal work assessments, employment specialists start the engagement of new clients by inquiring about their work goals, experiences, interests, and preferences.

On the basis of this assessment plus a realistic evaluation of the clients' assets and deficits, work plans are developed. Consistent with the philosophy of the individual placement and support model, the goal is to place clients directly in competitive jobs as soon as possible. However, when necessary the work plans may include offering clients training in job readiness skills—for example, interviewing and résumé preparation—or participation in a computer-training course offered by SMOC's MetroWest Career Center, an employment service available to the general public.

Depending on clients' needs, employment specialists may be more or less actively and directly involved in job development and placement. For some clients, employment specialists may negotiate directly with employers for specific positions, work hours, or wages. They may accompany the client to job interviews and provide on-site support, such as job coaching or acting as an intermediary between the client and the interviewer if problems arise and the client requests assistance. For clients who do not want or need this level of support, employment specialists may help identify possible jobs, participate in practice interviews, assist with transport, and provide encouragement.

Employment specialists regularly attend team meetings with practitioners and residential staff of the behavioral health division of SMOC, who have clinical responsibility for a majority of SEE's clients. This high level of personal contact and communication ensures that all team members know about each client's work activities. In addition, employment specialists maintain an awareness of relevant clinical information, thus enabling them to intervene on behalf of the client or the employer, if necessary, to help the client keep the job.

Real-world challenges to implementation

Bringing the individual placement and support model to SMOC was challenging in several respects. It took time to meet the model's standard of placing clients directly in competitive jobs. Because SEE's original clients were making the transition from a long-term, custodial day program, many individuals lacked not only work experience but also confidence. Consequently, for the first six months of the program, employment specialists continued to use more traditional strategies, such as group job placements, day labor, and agency-owned jobs. As clients achieved work success, employment specialists were able to eventually discontinue reliance on these options.

Another challenge to the implementation of the SEE program was the initial resistance on the part of clinicians, case managers, and residential staff who questioned whether their clients could work. Clinicians and case managers feared that the stress of work might lead to relapse and at times suggested to clients that they should not work. In addition, residential managers sometimes undermined the needs of working clients by scheduling clinical appointments during work hours.

Several efforts were undertaken to address these challenges. First, because the state-level administrators were invested in the program, they exerted a top-down influence on SMOC. In addition, the senior managers of SMOC, who fully supported the SEE program, encouraged cooperation among clinical, residential, and SEE services. Moreover, to encourage "buy in" at the individual provider level to create bottom-up support for the program, employment specialists provided education about the program to staff from other SMOC services. Although these efforts were important, actual client success was the most important factor in influencing providers. Once clinicians saw that clients could work successfully, referrals to the SEE program increased dramatically.

Another challenge was that some employment specialists initially felt intimidated when they sat in on weekly interdisciplinary team meetings of clinicians in the local mental health center. Some team members communicated disdain toward the employment specialists' lack of clinical background. This challenge was addressed by educating the clinicians about the unique skills of the employment specialists and by training clinicians on the efficacy of the individual placement and support approach. Moreover, as more SEE clients succeeded at employment, employment specialists became more confident and were viewed as important members of the team. In fact, clinicians whose clients were among the first successful SEE participants became the program's most vocal advocates. Although the program is now well established, education and outreach to new clinicians and residential staff is an ongoing effort.

Program outcomes

From July 1995 to December 1999, of the 90 SMOC clients who received SEE services, 74 (82 percent) obtained at least one paid job. The clients' mean age was 42.1 years, with a range of 21 to 65 years; 51 clients (57 percent) were men, and 81 (90 percent) were Caucasian. A total of 60 clients (67 percent) had a diagnosis of schizophrenia or another psychotic disorder, 70 (78 percent) had never married, and 38 (42 percent) had completed at least some post-high school education. A total of 82 clients (91 percent) received disability benefits (Social Security Disability Insurance or Supplemental Security Income), which frequently act as a disincentive to work, thus making the employment outcomes of these clients' even more impressive.

Data on previous work experience were available for 69 clients. The mean number of jobs held before SEE enrollment was 3.35 per client (range, zero to eight). Among the 74 clients who obtained at least one paid job, the average number of jobs obtained after enrollment in SEE was 2.7. The average job tenure was 255 days, or 8.5 months, and the average hourly wage was $6.64. The average number of days until the first paid job was 107.2. A more detailed description of the employment outcomes has been published elsewhere (6). These results are comparable to data published for other individual placement and support programs (2,3,7).

Case vignette

Ms. B, a 28-year-old, single, white woman with a diagnosis of paranoid schizophrenia, had numerous hospitalizations and periods of homelessness. She received case management services and lived in a supervised residential program. At the time of her referral to SEE, Ms. B was responding favorably to changes in her medication regimen and had expressed interest in work. Her clinical team, although they supported a referral to SEE, voiced concerns that working might precipitate a stress-related relapse. In response to these concerns, an employment specialist agreed to communicate weekly with the team and to report any indications of symptom exacerbation.

Building trust and offering support

Ms. B attended her initial SEE meeting accompanied by a staff member from her residence and appeared extremely shy and withdrawn. It took several meetings before she would meet independently with the employment specialist. She identified sports and children as potential career interests but decided to pursue food service because her last job, eight years earlier, had been in her family's restaurant. After visiting a busy coffee shop, Ms. B and her employment specialist agreed to target slower-paced coffee shops. Her first job applications were completed and submitted jointly by Ms. B and the employment specialist, who was present during the job interviews. Ms. B was eventually offered a job but turned it down because it involved too many hours, including early mornings.

Ten weeks into the program, Ms. B was meeting weekly with her employment specialist but was starting to feel discouraged. The employment specialist then identified a job that combined Ms. B's interests in sports and children in the local recreation department—seasonal work in a skating rink collecting tickets for youth hockey and open skating. Ms. B received help putting together a résumé and applying for the job and was accompanied on her job interview by her employment specialist. She got the job. Her employment specialist provided intensive follow-along support during Ms. B's first couple of days and then shifted to weekly in-person contact. The managers at the skating rink were very supportive and wrote Ms. B a letter of recommendation at the end of the season.

Promoting a shift from dependence to independence

A few months after her job at the skating rink ended, Ms. B and her employment specialist identified another job with the recreation department—an attendant at a public beach. This time, assistance from the employment specialist was "behind the scenes" and included help with the job application and preparation for the interview. Ms. B submitted her application along with the letter of recommendation from the skating rink and interviewed independently with the director of parks and recreation. She was hired and worked successfully all summer.

At the end of the summer, despite her positive experience with both recreation department positions, Ms. B decided to seek a permanent rather than a seasonal position. Entirely on her own, she identified a food service position at a nursing home. Her employment specialist provided help with the application and with figuring out the bus schedule, but Ms. B turned in the application and interviewed independently. After she was hired, she had weekly contact with her employment specialist to talk through issues, such as conflicts with her coworkers and changes in her schedule.

Coordinating across providers to confront job-related stress

After a few months on this new job, Ms. B talked to her therapist about quitting because she feared losing her Social Security benefits. Her employment specialist joined a therapy session to discuss Social Security benefits and offered to contact Ms. B's employer on her behalf. However, Ms. B refused this offer, because she did not want her employer to know that she was "in a mental health program." Instead, together with her therapist and her employment specialist, Ms. B developed a strategy for talking to her employer about reducing her hours without disclosing her disability. In addition, her employment specialist informed Ms. B's residential program and case manager about her plan. After hearing a consistent message across providers, Ms. B was able to successfully talk to her employer about her hours.

Graduation

After several months on the job, Ms. B reduced her contact with her employment specialist to monthly meetings. After several additional months, she decided to quit her job because her work hours no longer matched the public transportation schedule. She made this decision independently and identified a food service job at a hospital within walking distance of her house. She applied for and got the job without any assistance from her employment specialist. Instead, Ms. B notified the employment specialist of her job change at their next monthly meeting. She had learned to problem solve and search for jobs independently. After she had been at her new job for more than six months, Ms. B chose to graduate from the SEE program. However, she knew that her employment specialist was available by telephone if support was needed. Eventually, Ms. B moved into her own apartment and saved enough money to buy a car.

Conclusions

Although many elements of Ms. B's story are representative of the average client in the SEE program, what makes Ms. B's experience special is her steady progress toward increasing success and independence with only minor setbacks along the way. Many SEE clients have symptom exacerbations that temporarily stymie their rehabilitation efforts. However, once their clinical status improves, they reactivate their involvement with the SEE program and begin the process over again. With the indefinite support of employment specialists, many clients are able to enjoy some degree of vocational success that improves the quality of their lives.

Afterword by the column editors: To successfully implement evidence-based practices in a community setting, innovators must identify potential obstacles and develop a plan to overcome these barriers. Handler and colleagues refer to the efforts used to influence a variety of stakeholders who were critical to the implementation process. For instance, they note that administrators should provide sustained, visible, and tangible support to blunt the damaging effects of staff skepticism and sabotage. However, it is equally essential for program developers to recognize that supported employment is not for everyone. For clients whose level of functioning, cognitive deficits, or lack of interest may preclude participation in supported employment, there is still a legitimate need for more recreationally oriented day treatment services. Failure to provide such alternatives does a disservice to clients who are unable to benefit from the supported employment approach and may jeopardize the vocational success of clients who can benefit.

Dr. Handler and Ms. Doel are affiliated with the MetroWest Career Center at South Middlesex Opportunity Council, 300 Howard Street, Framingham, Massachusetts 01702 (e-mail, [email protected]). Dr. Henry is with Sargent College of Health and Rehabilitation Sciences at Boston University and with the center for mental health services research at the University of Massachusetts Medical School in Worcester. Dr. Lucca is with the Lewin Group in Falls Church, Virginia. Robert Paul Liberman, M.D., and Alex Kopelowicz, M.D., are editors of this column.