Supported Employment

One factor that has facilitated Supported Employment’s (SE’s) popularity and its subsequent designation as an evidence-based practice (EBP) is that the definition of SE is relatively straightforward. The essential characteristics of SE have even been defined in the Rehabilitation Act Amendments of 1986 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. 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 that all people, regardless of disability severity, could do meaningful, productive work in normal work settings (Anthony & Blanch, 1987).

Supported Employment as an Evidence Based Program
Compared to rigorous research on most psychiatric rehabilitation interventions, the research on SE is voluminous. Bond’s 2004 review of the SE research based its conclusions on a review of four studies of the conversion of day treatment to supported employment and nine randomized controlled trials (RCT). Bond estimated that in the RCTs 40–60 percent of people with psychiatric disabilities obtained jobs, compared to less than 20 percent in the controlled conditions. Anthony, Cohen, Farkas, and Gagne (2002) estimated that supported employment interventions could triple the employment base rate from 15–45 percent.

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 has sponsored the Supported Employment implementation resource kit. (www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/employment/).

Supported Employment Applications to Criminal Justice System Clients
No known published studies have addressed the effectiveness of supported employment services in populations of justice-involved individuals with severe mental illness. There is some evidence, albeit highly preliminary, that supported employment may be efficacious for forensic populations, based on an exploratory analysis of data from a large multi-site study of evidence-based practice (EBP) supported employment programs called the Employment Intervention Demonstration Program (EIDP) (J.A. Cook, personal communication, September 22, 2005). 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 2 years. 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 percent 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 justice 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 justice-involved group was significantly younger, more likely to have worked in the 5 years prior to study entry, and less likely to have a diagnosis of schizophrenia. The justice-involved group 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.

Turning next to vocational outcomes, there was no difference between those who reported forensic involvement and the remainder of the cohort on the likelihood of employment over the 2 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 4 outcomes were tested in multivariate models that included study condition (experimental condition vs. control) and recent forensic involvement, while controlling for time and all background variables on which the forensic and non-forensic groups differed (i.e., age, prior work, schizophrenia, positive symptoms, and general symptoms). In all of the models, the indicator for forensic 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 3 months prior to study entry. Further study is required to refute or confirm these initial findings, and to address whether and how supported employment assists consumers with forensic involvement to return to work.

Suggestion for Practice

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 cannot 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. 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.
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. 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 presently should be assumed that both groups would need to become expert in the fundamental principles of supported employment.
The lack of evidence-based SE programs for justice-involved persons with mental illness attests to the lack of vocational interventions for this group. 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. With this group being younger and more often employed in the past five years than comparable, non-justice-involved persons with mental illness, there is every reason to place a high priority on supported employment programs to enhance recovery and to offer the prospects of reduced long range service costs to the community.

Employment is a stabilizing factor for justice-involved individuals and important to maintaining a healthy, productive lifestyle. Research has stated that there is an increasing number of individuals becoming involved with both the mental health and criminal justice systems, so it is important for providers to be trained across both mental health and criminal justice systems to be better able to understand the challenges in improving employment outcomes. Two programs, Howie the Harp and the Center for Behavioral Health Services, both located in New York City, offer comprehensive supported employment programs that integrate many services under the guidance of teams of specialists.

References

Anthony, W. A., & Blanch, A. (1987). Supported employment for persons who are psychiatrically disabled: An historical and conceptual perspective. Psychosocial Rehabilitation Journal, 11(2), 5-23.

Anthony, W. A., Cohen, M. R., Farkas, M. D., & Gagne, C. (2002). Psychiatric rehabilitation (2nd ed.). Boston, MA: Boston University, Center for Psychiatric Rehabilitation.

Bond, G. R. (2004). Supported employment: Evidence for an evidence-based practice. In R. Ancill (Ed.) Exploring the Spectrum of Psychosis. New York: Wiley & Sons.

Cook, J. A., Leff, H. S., Blyler, C. R., Gold P. B., Goldberg, R. W., Mueser, K. T., et al. (2005a). Results of a multisite randomized trial of supported employment interventions for individuals with severe mental illness. Archives of General Psychiatry (62), 505-512.

Cook, J. A., Lehman, A., Drake, R., et al. (2005b). Integration of psychiatric and vocational services: A multi-site randomized implementation effectiveness trial of supported employment,” American Journal of Psychiatry, 162, 1948-1956.

Legal Action Center. (2004). After prison: Roadblocks to reentry: A report on state legal barriers facing people with criminal records. www.lac.org/roadblocks.html.

Massaro, J. (2004). Working with people with mental illness involved in the criminal justice system: What mental health service providers need to know. Delmar, NY: National Gains Technical Assistance and Policy Analysis Center for Jail Diversion.

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