Evidence-Based Practice for Justice Involved Individuals

 Expert Panel Meeting

Discussion Paper:
Supported Employment for People in Contact with the Criminal Justice System

William A. Anthony

Presented at the Evidence-Based Practice for Justice-Involved Individuals:  Supported Employment
Expert Panel Meeting
September 7, 2005
Bethesda, MD

The Expert Panel Meetings were Sponsored by:  The National GAINS Center for Systemic Change for Justice-Involved Persons through the Center for Mental Health Services, SAMHSA.

Acknowledgement & Disclaimer:  The views and opinions expressed in this publication are those of the authors, and do not necessarily represent the official position or policies of the National GAINS Center (operated by Policy Research Associates, Inc.) or the Center for Mental Health Services (CMHS).

Research has shown that people with psychiatric disabilities want to work (Mueser, Salyers, & Mueser, 2001; Rogers, Walsh, Danley, & Smith, 1991), can work at a variety of positions (Russinova, Wewiorski, Lyass, Rogers, & Massaro, 2002), but as a group are most apt to be unemployed (Anthony, Buell, Sharratt, & Althoff, 1972; Bond & McDonel, 1991).  It is only within the last 25 years of the previous century that the mental health system has viewed competitive work as a legitimate and critical outcome for people with psychiatric disabilities (Anthony, Cohen, & Farkas, 1990).  Concurrent with this renewed interest in the importance of work to people with psychiatric disabilities, has been the growth of the practice of supported employment (SE).
           
People with psychiatric disabilities who are in contact with the criminal justice system would also seem to be in need of vocational interventions. Data indicate that most individuals who are incarcerated have limited job skills.  Furthermore, during the month prior to arrest only two thirds of the inmates were employed, typically part time and in low paying jobs (U.S. Department of Justice, 1977).  For example, incarcerated offenders in Florida averaged about $1200-$2000 a year in earnings prior to incarceration (Bushway, 2003). For purposes of this paper it is noted that the poor employment figures of people who are incarcerated are then complicated by their severe mental illnesses; only 10-20% of people with severe mental illnesses are working (Anthony, Cohen, Farkas & Gagne, 2002).  Thus it can be assumed that most individuals with psychiatric and criminal justice histories are missing out on the benefits of work (Solomon, Johnson, Travis & McBride, 2004).

In this paper we will define SE and its evolution, summarize the research supporting SE as an evidence based practice (EBP), and present an overview of the research specific to criminal justice clients.  Non-EBPS that target the same outcomes for criminal justice clients are mentioned.  Conclusions based on the current state of the field are advanced, and questions for discussion are proposed.

Defining SE

One factor that has facilitated SE’s popularity and its subsequent designation as an EBP is that the definition of SE is relatively straightforward.  The essential characteristics of SE have even been defined in federal regulations.  As Bond (2004) points out, SE is both an outcome indicator and a practice. As noted by Becker, Drake, and Naughton (2005), the Rehabilitation Act Amendments (1986) defined supported employment as competitive work in integrated work settings with follow-along supports for people with the most severe disabilities. 

As a practice, SE is designed to help the person select, find, and keep competitive work.  Historically, the development of the practice of SE was most innovative in several important ways: 1) placement into jobs was achieved more quickly without the extensive job preparation common in sheltered workshops; 2) the provision of supports after the person obtained a competitive job was offered for as long as was needed; and, 3) the assumption was made that all people, regardless of disability severity, could do meaningful, productive work in normal work settings (Anthony & Blanch, 1987).

The evolution of SE

SE can be traced in terms of its evolution from the field of developmental disability and from the field of psychiatric rehabilitation.

SE and the Field of Developmental Disability

SE was initially developed for people with developmental disabilities (Wehman & Krevel, 1985) and adapted into the psychiatric rehabilitation field (Anthony & Blanch, 1987).  Like many innovations in the disability arena, it was an innovation not based on data but on values (Anthony, 2004a, 2005).  The lead proponent in making this service reimbursable was Madeline Will, the Assistant Secretary in the Department of Education’s Office of Special Education and Rehabilitation Services.  Ms. Will had a teenage son with Down Syndrome and was personally aware of the deficiencies in adult vocational services for people with disabilities who were transitioning into the adult service system.  The predominant vocational practices at the time were sheltered workshops, which were notably unsuccessful in helping people obtain competitive work (Wehman, 1986).  As a result Ms. Will collaborated with professionals in the disability field to develop and incorporate into federal regulations and funding streams the notion of supported employment (Will, 1987). 

SE and the Field of Psychiatric Rehabilitation

In describing the evolution of supported employment, SE is also seen as a special application of psychiatric rehabilitation (PR), and in particular psychiatric vocational rehabilitation (Bond, 1992; Danley, Rogers, & Nevas, 1989).  Data collection in early psychiatric vocational rehabilitation settings (e.g., clubhouses, psychosocial rehabilitation centers, workshops) confirmed the need for psychiatric vocational rehabilitation services and resulted in a list of empirically supported principles to guide the developing field.  There is great similarity, as one would hope, between the basic principles of psychiatric rehabilitation and the principles of supported employment.  Particularly relevant to the evolution of the basic principles of SE (Becker, 2005; Bond, 2004) and the five essential components of SE (Cook, Leff, Bleyler, et al., 2005a), are the following PR principles; the PR principles are in italics with the corresponding SE principle or component in bold:

• Rehabilitation outcomes cannot be accurately predicted by professionals nor their psychological tests (Anthony, 1979; Anthony & Jansen, 1984); in SE no one is excluded who wishes to participate (Becker, 2005; Bond 2004).
• A critical problem affecting rehabilitation outcome is whether or not people can qualify for disability benefits and maintain those benefits throughout the rehabilitation process (Anthony & Jansen, 1984); benefits counseling is a part of SE (Becker, 2005).
• The practice of psychiatric rehabilitation and psychiatric treatment complement one another and ideally occur in close sequence or simultaneously (Anthony, Cohen, & Farkas, 1990); SE is integrated with treatment (Becker, 2005; Bond, 2004; Cook et al., 2005b).
• A major outcome of psychiatric rehabilitation is competitive employment (Anthony, Buell, Sharratt & Althoff, 1972); in SE competitive employment is the goal (Becker, 2005; Bond, 2004; Cook et al., 2005a).
• Support interventions improve psychiatric rehabilitation outcome (Anthony & Liberman, 1986; Farkas & Anthony, 1989); in SE follow along supports are continuous (Becker, 2005; Bond, 2004; Cook et al., 2005a).
• Psychiatric rehabilitation begins with the person figuring out the goals they wish to achieve (Anthony, Pierce  & Cohen, 1980); in SE consumer preferences are important (Becker, 2005; Bond, 2004; Cook et al., 2005a)
• Provide assessment and training in natural settings (Bond, 1994); job search starts soon after a person expresses interest in working (Becker, 2005; Bond, 2004; Cook  et al., 2005a)

Also relevant to the psychiatric rehabilitation field was that in the legislative regulations for SE, transitional employment was cast as a variation of SE.  In reality this merging of different vocational programming was a way for funding transitional employment interventions within the SE legislative initiative, despite the resulting conceptual confusion.  In an attempt to clear up this confusion, Anthony & Blanch (1987) identified the programmatic differences between SE and transitional employment.  In particular they stressed differences in goals, placement length, wages, job level, the agency’s access to the work environment, and client disclosure.

SE as an EBP

Compared to rigorous research on most psychiatric rehabilitation interventions, the research on SE is voluminous.  Bond and his colleagues have reviewed this research most regularly (Bond, 2004; Bond et al., 2001; Bond, Drake, Mueser & Becker, 1997; Crowther¸ Marshall, Bond, & Huxley, 2001), and concluded from their literature reviews that SE is in fact an EBP. In Bond’s most recent review of the SE research (Bond, 2004), he based his conclusions on a review of four studies of the conversion of day treatment to supported employment and nine randomized controlled trials (RCT). Bond (2004) estimated that in the RCTs 40-60% of people with psychiatric disabilities obtained jobs, compared to less than 20% in the controlled conditions. Anthony, Cohen, Farkas & Gagne (2002) estimated that supported employment interventions could triple the employment base rate from 15% to 45%.

No doubt the most extensive research of SE reported after Bond’s reviews is the seven state, multi-site study of supported employment (Cook et al., 2005a, 2005b) called the Employment Intervention Demonstration Program (EIDP). This RCT study showed that SE participants were significantly more likely (55%) than comparison participants (34%) to achieve competitive employment. Based on the research cited above, the Center for Mental Health Services (CMHS, 2005) has sponsored the Supported Employment implementation resource kit, designed to support the implementation of SE as an evidenced based practice.

Fidelity scales have been developed for SE in order to be a source of technical assistance for designing programs, for research purposes, and as a way to track, monitor and evaluate SE implementation.  However, the focus of discussions on the empirical support for SE seems to be on the SE principles, rather than on unbundling the specific components of the fidelity scales to determine exactly which component contributes to SE outcome. The program implementation kits (CMHS, 2005) also emphasize to consumers of SE the principles upon which SE is based.

By far the most significant influence on the conceptual and empirical development of SE has been the work of Becker and Drake in creating the Individual Placement and Support (IPS) model of SE (Becker & Drake, 1993).  “The IPS research is an example of how programmatic research can be accomplished effectively and efficiently. Within the space of a decade, the IPS model has become the major program model for supported employment for people with psychiatric disabilities” (Anthony et al., 2002, p. 209).  It is the IPS model of SE from which the key principles of SE have arisen.

Current research on SE is moving toward addressing some of the deficiencies of the existing research. Examples are: examining various predictors of SE outcome (Mueser, Essock, Haines, Wolfe, & Xie, 2004); designing various add-ons to SE (McGurk, Mueser, & Pascaris, in press; Mueser et al., in press; Wallace & Tauber, 2004); identifying system level facilitators and barriers to SE (Bond, Becker, Drake, Rapp, et al., 2001); studying the 5-10 year employment outcomes of people who participated in SE (Salyers, Becker, Drake, Torrey, & Wyzik, 2004); and focusing on strategies to increase dollars earned by SE participants (Cook et al., 2005a).

SE applications to criminal justice system clients

In order to examine this topic a comprehensive literature search was undertaken.  In the course of this examination of SE for criminal justice clients, select researchers and program directors from around the country were contacted to gain information on the research of programs that might serve a preponderance of clients with a history of criminal justice involvement, or that specifically target this population.

In contrast to the plethora of research on supported employment interventions, there is a dearth of research on its application to criminal justice clients.  This is not to imply that criminal justice clients have not been served by SE interventions; rather rarely have they been identified as a subgroup of SE clients and studied accordingly.  Furthermore, the deliberate programmatic and research focus on this particular group is practically nonexistent.  In contrast to the supported housing field, which does have some program growth in relation to this population, but little formal research (Roman, McBride, & Osborne, 2005), SE seems to have only minimal program growth for criminal justice system clients.  Such a finding is difficult to accept, because of the obvious needs for this population to enter the job market and become more self-sufficient (Solomon, Johnson, Travis, & McBride, 2004).

Several SE intervention descriptions of current programs that focus on the targeted population may be found in Appendix A.  These descriptions were provided by the staff of these programs; it should be noted that to date no significant research has been published on these programs.

Also worthy of mention are other vocational rehabilitation programs that focus on competitive employment outcomes for people with psychiatric disabilities (job clubs, clubhouses, choose-get-keep, or social firms or co-operatives located in Europe). In general the research on these interventions relative to SE research is scarce.  However it is worth mentioning some of these as possible examples of interventions that could be used in the future with this population, and perhaps be guided by SE principles.

Suggestion for Practice and Research

Based on this analysis of existing SE research and its application to people with psychiatric disabilities in contact with the criminal justice system, there are a number of suggestions of what to do given the absence of data specific to employment interventions for these individuals.

• The implied logic model for people with psychiatric disabilities in contact with the criminal justice system assumes that after an arrest people should have the opportunity to receive mental health treatment.  Such mental health treatment is assumed to lead to fewer arrests, less violence, and less public nuisances. However, with respect to employment outcomes, we can not expect that mental health treatment will also lead to future employment (Anthony et al., 2002); in this instance, “you get what you pay for”. If a supported employment intervention is not part of the mental health treatment, then employment outcomes should not be expected to be effected. Nevertheless, employment remains a legitimate goal for this population, as being employed consumes time in worthwhile activities and provides a legitimate source of income. Without a mental health treatment intervention that incorporates an SE practice, the possibility of achieving employment outcomes for this population is insignificant.
  
• Assume, unless proven otherwise, that the empirically supported principles of SE apply to people with a criminal justice background. This assumption is in line with the notion that people are more alike than clinically/functionally different, and that research based, SE knowledge gained on people with psychiatric disabilities may apply across different subgroups of individuals with psychiatric disabilities, including those in contact with the criminal justice system.  This is not to imply that there are not inherent differences between subgroups, but that the place to start an examination is with the assumption of similarities in the principles of how to help people achieve competitive work.  In accordance with this line of reasoning, future SE studies of criminal justice clients can use the data generated by studies on non-criminal justice clients as a starting off point.
  
• Assume, unless proven otherwise, that the empirically based evidence about the principles of how people without severe mental illnesses change should also guide the work in the area of helping people with severe mental illnesses to change and grow.  In a series of editorials, Anthony (2001, 2003a, 2003b, 2004a, 2004b) has argued for expanding the evidence base in mental health beyond mental health services research to include evidence based findings on the principles and processes of change for “temporarily able bodied” people.  For example, the broader field of behavioral science has found that people change positively in the context of a positive relationship  (Martin, Garske, & Davis, 2000), when they set their own goals (Goldman, Locke, Masterson, Groh, & Jensen, 2002; Locke & Latham, 2002; Locke, Shaw, Saari & Latham, 1981), are taught skills (Carkhuff & Berenson, 1976), receive support (Cohen & Wills, 1985; Cohen, Underwood, & Gottlieb, 2000), have positive expectations or hope for the future (Snyder, Irving, & Anderson, 1991), and when they believe in their self efficacy (Bandura & Locke, 2003).  The use of this behavioral science literature seems relevant to the SE empirical base for several reasons: 1) the movement of the field of SE research toward identifying the empirically based, underlying principles of change rather than the entire intervention model package (Drake, 2005; Hughes, 1999; Leff et al., 2005; O’Brien & Anthony, 2002); and, 2) the underlying assumption of psychiatric rehabilitation that people are people first, before they are cases, labels, etc. (Anthony, 2004b).  Furthermore, the current National Institute of Mental Health (NIMH, 2001) initiative on translational research presupposes that behavioral science research conducted on non-mental health participants is significant to mental health services research.
  
  
• It is clear that increasing numbers of individuals are becoming involved with both the mental health system and the criminal justice system (Massaro, 2004), with the resulting need for providers trained across both systems. The literature would suggest that mental health providers and criminal justice providers each need to know about the others’ system and the nature of its clientele (Massaro, 2004; 2005).  In particular, mental health providers need to know about the barriers to employment experienced by people in the criminal justice system (Legal Action Center, 2004).  Furthermore, it must be noted that while there are unique knowledge components integrated into each of these fields, it should be presently assumed that both groups would need to become expert in the fundamental principles of supported employment.
  
  
• The lack of evidence based SE programs for this population group attests to the lack of vocational interventions for people with psychiatric disabilities and criminal justice involvement. Access to such programming can occur either by increasing the programs directly focused on this population, or by explicitly targeting this population for involvement in generic SE programs.  Given the dearth of current programming available, it would seem both type of access initiatives are critically needed.
  
  
• Conduct studies that evaluate the efficacy and effectiveness of supported employment for this population.   Preliminary evidence supporting the potential value of such research comes from  the multi-site EIDP study (Cook et al., 2005a) in which several criminal justice questions were included as part of their baseline and follow-up  data collection.  Cook (personal communication, September 22, 2005) conducted  an exploratory analysis of the EIDP data and found some evidence, albeit highly preliminary, that supported employment may be efficacious for people with psychiatric disabilities who have been in contact with the criminal justice system. In the EIDP, 1,273 newly enrolled participants who met criteria for “severe and persistent mental illness” based on diagnosis, duration, and disability were randomly assigned at seven sites to EBP supported employment programs or services as usual/comparison control programs and followed for two years (Cook et al., 2005a). At baseline, participants were asked whether they had been arrested or picked up for any crimes in the past 3 months and, if so, how many times this had occurred. Only 3% of the sample (n=37) responded in the affirmative, and the large majority of these individuals said that they had been arrested/picked up once (78%) with the remainder reporting multiple incidents. Regarding background characteristics, there were no significant differences between those with recent forensic involvement and those without on gender, minority status, education, marital status, self-rated functioning, prior hospitalizations, self-reported substance use, diagnosis with mood disorder, diagnosis with depressive disorder, or level of negative symptoms (such as blunted affect or emotional withdrawal). However, compared to their counterparts, the people who had been in contact with the criminal justice system were significantly younger, more likely to have worked in the five years prior to study entry, and less likely to have a diagnosis of schizophrenia. They also had significantly higher levels of positive symptoms (such as hallucinations and delusions) and general symptoms (such as anxiety and disorientation).  There was no significant difference in study condition assignment:  57% were assigned to experimental condition programs and 43% to the control condition programs.

Turning next to vocational outcomes, there was no difference between those who reported criminal justice involvement and the remainder of the cohort on the likelihood of employment over the two year follow-up period, the likelihood of working full-time during the follow-up, the total number of hours worked during this time, or the total number of dollars earned. Next, these four outcomes were tested in multivariate models that included study condition (experimental condition vs. control) and recent criminal justice involvement, while controlling for time and all background variables on which the criminal justice sample and the non-criminal justice sample differed (i.e., age, prior work, schizophrenia, positive symptoms, and general symptoms). In all of the models, the indicator for criminal justice involvement was non-significant while study condition remained significant, indicating that experimental condition participants had better work outcomes. These preliminary results suggest that evidence-based practice supported employment services produced better outcomes regardless of whether participants had been arrested or picked up for a crime in the three months prior to study entry. Future research could replicate the EIDP design using a forensic population served at multiple sites and in a variety of settings.

• Continue to use several variations of employment outcomes (Anthony & Farkas, 1982; Cook et al., 2005a, 2005b).  The recent multi-site study reported on by Cook et al. (2005a) used several measures of vocational outcome that might be considered future benchmark indicators for new SE studies. This range and benchmarking of vocational indicators is particularly important in order to compare intervention outcomes across studies.  The survey work of Ellison, Russinova, Massaro, and Lyass (2005) has shown that some individuals with severe mental illnesses, such as those who are managers or professionals, are able to sustain relatively well paying jobs over time.
  
  
• Conduct long-term follow-up studies of people with psychiatric disabilities in contact with the criminal justice system who have experienced SE.  While we know that initial SE jobs are typically entry level, low paying jobs, we do not know how SE participants have matured vocationally over time (Ellison, Danley, Bromberg, & Palmer-Erbs, 1999).  It may be that these early positions were just the first step in building a career, similar to how other folks build their careers after entry level employment.
  
  
• Develop and evaluate studies of programs that combine the opportunity for both SE interventions and supported education interventions (Rogers, Anthony, & Lyass, in press).  With respect to the issue of career development, supported education (Anthony & Unger, 1991; (Mowbray, Brown, Sullivan-Soydan, & Furlong-Norman; 2002) has emerged as a potential contributor to people’s aspirations for more than entry level work. 

 

Appendix A

Descriptions of Some Existing Programs

OVERVIEW OF THE HOWIE THE HARP PEER ADVOCACY SUPPORTED EMPLOYMENT PROGRAM
(STEPS TO A RENEWED REALITY)

Background:  The Howie the Harp Peer Advocacy Center is a consumer run program.  It is a part of Community Access, Inc.  The Center was founded in 1995, following the death of Howie The Harp, the founder of the Peer Specialist Training Program (the Center’s first employment program). The Center is a peer run and driven program.  The center does not directly provide clinical services but believes that peer support and services provided by consumer can complement services provided by mental health “professionals”.

Model:  Both programs are a hybrid of the traditional supported employment model and career training programs developed by local community colleges to rapidly train and place non-traditional workers.  Our training model includes the following features:

• In class training
• 3-6 month supervised internship with a human services provider
• Placement
• Lifetime individualized post placement supports

Program Description:  The Center has two “supported employment programs; The Peer Specialist Training Program and the STARR Program.  The Center’s primary mission is to train individuals with a severe and persistent mental illness to work in human services.  In 2000, the Center in collaboration with the New York State Office of Mental Health, created the STARR Program.  This program was specifically designed to provide human services training, placement and support services to individuals with a severe and persistent mental illness who have also experienced incarceration in jail or prison.

Applicants to both programs must be diagnosed with a severe and persistent mental illness as defined by the DSM IV.   The STARR program targets consumers who have a significant criminal justice history.  This includes incarceration in state prison or lengthy periods of incarceration in city jails.  All applicants must complete a rigorous application and admissions process.  All applicants are personally interviewed by staff evaluating the following criteria:

• Motivation and desire to work
• Stability
• Insight into “illness”
• Natural supports (family, friends and peers)
• Professional supports (treatment)

Relationship to Criminal Justice System:  The Center receives direct referrals from parole, probation and other court supervised programs.  The Center has successfully collaborated with many jail diversion programs both as sources of referrals and internship and employment opportunities for trainees and graduates.   The Center has also collaborated with agencies such as the Center for Court Innovation in providing technical assistance to new mental health courts.

Funding:  The STARR Program is fully funded by the New York State Office of mental Health, however funding provided by the New York City Department of Heath and Mental Hygiene and VESID also fund staff positions. 

Targeted Outcomes:

Peer Specialist Training Program	STARR Program
Services provided to 35 unduplicated Consumers each year	Services provided to 30 undup.
85% retention rate through training	85% retention rate through training
75% placement rate for grads	75% rate for grads
70% employed for 1 yr or more	70% employed for one yr or more

Contact:  LaVerne D. Miller, Esq., Director
212-865-0775 ext. 108 Cell 917-842-7554
e-mail: lavernwill2k@aol.com

Theresa Towers
2090 Adam Clayton Powell, Jr. Blvd, Suite 1101
New York, NY  10027-4990
Telephone: (212) 663-1501
Fax: (212) 663-7305

The Center for Behavioral Health Services (CBHS) specializes in serving consumers involved with the criminal justice system. CBHS is committed to the values of recovery and rehabilitation, and provides vocational, educational, case management, and housing services. CBHS currently operates three New York State Office of Mental Health-funded programs for men and women including: 1) an Assisted Competitive Employment (ACE) Program, which serves 75 consumers on work release and parole; 2) a Career Development Program (CDP), which serves 15 consumers between the ages of 18-25; and 3) a 30-bed supported housing program for consumers with severe and persistent mental illness, including many individuals who are dually diagnosed and have histories of homelessness.

The ACE program is a comprehensive vocational, rehabilitative and case management program integrating many different services under the guidance of a dedicated team of specialists. The program is tailored specifically to serve consumers who are referred from general confinement, work release, and parole. The main goal of the program is to coordinate the vocational, rehabilitative and clinical services so individuals can obtain and maintain employment, and reintegrate into the community. Close coordination with adjunct agencies, parole officers, New York State Department of Corrections (DOCS) work release counselors, and Office of Mental Health (OMH) service providers ensure participants receive streamlined and cohesive services.

Individual sessions with ACE Counselors focus on addressing issues related to mental health management.  Sessions are used to support community integration by addressing issues concerning employment, family, relationships, and avoidance of dysfunctional behavior.  Anger management, trauma recovery, substance abuse recovery, medication management and social skills training are addressed in both individual and groups sessions. Staff also assists in the completion of applications for entitlements, housing and other services.

Vocational services emphasize consumer choice and active participation in the development of career goals. Counselors work in collaboration with consumers to find jobs that not only satisfy immediate needs, but could also provide rewarding, long-term employment.  The program’s focuses on locating positions with career advancement so increased responsibility and income are possible. 

Vocational services continue after employment is obtained. Staff remains in contact weekly, to offer assistance in negotiating workplace issues as they arise. Additionally, staff may meet at a consumer’s workplace to ensure ongoing in-person communication. It is during this second phase of career development that participants work in collaboration with staff to reach their long-term vocational goals, including job training and education.

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