Future of Supported Future of Supported EmploymentEmployment

Bob DrakeBob Drake

Sainsbury Centre Sainsbury Centre

March, 2008March, 2008

The President’s New Freedom The President’s New Freedom Commission Report (2003)Commission Report (2003)

““The main goal of the mental health system is to help people to The main goal of the mental health system is to help people to live, learn, work, and participate fully in their communities”live, learn, work, and participate fully in their communities”

Mike Hogan (2006): “Work is the most direct step to recovery”Mike Hogan (2006): “Work is the most direct step to recovery”

““Supported employment is the most effective strategy to help Supported employment is the most effective strategy to help people achieve their employment goals.”people achieve their employment goals.”

OverviewOverview

Current Status of SECurrent Status of SELimitations of SELimitations of SECurrent Research on SECurrent Research on SEThresholds-Dartmouth CenterThresholds-Dartmouth Center

Current Status of SECurrent Status of SE

SE model is simple and effectiveSE model is simple and effective Other benefits accrue with consistent workOther benefits accrue with consistent work Work outcomes improve over timeWork outcomes improve over time SE is relatively easy to implementSE is relatively easy to implement

IPS Supported EmploymentIPS Supported Employment Competitive employmentCompetitive employment Team approachTeam approach Client choice regarding timingClient choice regarding timing Benefits counselingBenefits counseling Rapid job searchRapid job search Job matching based on client preferencesJob matching based on client preferences On-going supportsOn-going supports

• Becker (IPS Fidelity Scale, 2008)Becker (IPS Fidelity Scale, 2008)

Figure 1. Competitive Employment Rates in 16 Randomized Controlled Trials of Supported Employment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

07 Aust (IPS)

96 NH (IPS)

94 NY (SE)

07 IL

(IPS)

04 CT

(IPS)

05 HK (IPS)

06 SC

(IPS)

06MA

(ACT)

99 DC (IPS)

07 CA (IPS)

95 IN

(SE)

07EUR(IPS)

06QUE(IPS)

00 NY (SE)

97 CA (SE)

02MD(IPS)

Supported Employment Control Control 2

Percent Competitively Employed in 24 month period

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Study Time

Percent competitively employed

Standard

IPS

Chrysalis Center

CT Supported Employment StudyCT Supported Employment Study(Mueser, 2004)(Mueser, 2004)

Impact on Impact on Other OutcomesOther Outcomes

Improved self-esteem, symptom control, quality Improved self-esteem, symptom control, quality of lifeof life

Related to sustained competitive employmentRelated to sustained competitive employment No changes with sustained sheltered employmentNo changes with sustained sheltered employment

(Bond, 2001)(Bond, 2001)

Long-Term OutcomesLong-Term Outcomes

4 studies with 10-year follow-ups4 studies with 10-year follow-ups(Test, 1989; Salyers, 2004; Becker, 2006; Bush, in prep)(Test, 1989; Salyers, 2004; Becker, 2006; Bush, in prep)

Work outcomes improve over timeWork outcomes improve over time Costs decrease dramatically for consistent Costs decrease dramatically for consistent

workers workers (Bush, in prep)(Bush, in prep)

Average Hours of Employment, 3 group analysis

0

100

200

300

400

500

600

700

800

900

Baseline Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10

Year

Hours

No Work

Slow Increase

High Work

National EBP ProjectNational EBP Project

5 evidence-based practices: SE, IMR, FPE, ACT, IDDT

53 sites in 8 statesPrograms studied for 2 years

Fidelity of SE Programs

2.8

4.24.6 4.5 4.4

1

2

3

4

5

BL 6 mo. 12 mo. 18 mo. 24 mo.

(n = 9) (n = 8) (n = 9) (n = 9) (n = 9)

SE Fidelity Scale Mean

Johnson & Johnson-Johnson & Johnson-Dartmouth ProjectDartmouth Project Mental health-vocational rehabilitation collaboration Mental health-vocational rehabilitation collaboration implement evidence-based SEimplement evidence-based SE Local programs selected by statesLocal programs selected by states Dartmouth provides training, consultation, and Dartmouth provides training, consultation, and

evaluationevaluation First states: CT, DC, KS, MD, OR, SC, VTFirst states: CT, DC, KS, MD, OR, SC, VT New states: IL, MN, MO, OHNew states: IL, MN, MO, OH

• (Drake, 2006)(Drake, 2006)

J&J-Dartmouth ProjectJ&J-Dartmouth ProjectTotal Number of Clients Served & Working in All Ten States by Quarter

792

12161419

1928 20332369

2810 2872 2929 28503027

3181 3298 34153737

4108

4865

299516

654839 884 958

11981406 1396 1415

1579 1675 1766 18642060

2251 2384

0

1000

2000

3000

4000

5000

6000

9-12/02 1-3/03 4-6/03 7-9/03 10-12/03

1-3/04 4-6/04 7-9/04 10-12/04

1-3/05 4-6/05 7-9/05 10-12/05

1-3/06 4-6/06 7-9/06 10-12/06

Total Number of Clients

# Served# Working

Limitations of SELimitations of SE

1.1. Many do not express interest in SEMany do not express interest in SE2.2. Many in SE do not achieve consistent Many in SE do not achieve consistent

employmentemployment3.3. Consistent workers in SE do not work Consistent workers in SE do not work

full-timefull-time

1. Lack of Interest in SE1. Lack of Interest in SE

ExpectationsExpectationsBenefits trapBenefits trap

8-12 Year Follow-up: 8-12 Year Follow-up: Day Treatment to SEDay Treatment to SE

71% working at follow-up71% working at follow-up85% in competitive jobs85% in competitive jobs71% worked more than 50% of FU71% worked more than 50% of FU90% still receiving benefits90% still receiving benefits

(Becker, 2006)(Becker, 2006)

Early InterventionEarly Intervention

First episode psychosis First episode psychosis (Neuchterlein, 2005)(Neuchterlein, 2005)

SSA: change adjudication processSSA: change adjudication processSSA: accelerated benefitsSSA: accelerated benefitsHealth insuranceHealth insurance

IPS Supported Employment for Clients with First-episode Schizophrenia

0

20

40

60

80

100

Baseline 6 Months 12 Months 18 Months% of Employment or

school

IPS

SAU

Early Intervention Early Intervention (Neuchterlein, 2005)(Neuchterlein, 2005)

MotivationMotivation

People fear losing benefits People fear losing benefits (NAMI, 2003)(NAMI, 2003) Benefits counselingBenefits counseling Motivational counselingMotivational counseling Contingency managementContingency management

Benefits Counseling(Tremblay, 2005)

Outcomes for Psychiatric Benefit Counseling Intervention Group Versus Two Nonparticipant Psychiatric Voc Rehab Comparison Groups

$0

$100

$200

$300

$400

$500

$600

$700

$800

$900

$1,000

$1,100

Quarters Relative to Date of Enrollment

Quarterly Earnings

Intervention 608 612 585 549 557 464 504 552 615 852 887 928 830 804 765 812 796

Contemporaneous 382 521 525 575 540 553 566 519 546 511 459 538 602 478 441 353 542

Historical 441 464 511 359 305 333 284 320 279 365 290 335 357 309 315 369 384

-8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8

Post-EnrollmentPre-Enrollment

(N = 364 per group)

Motivational InterviewingMotivational Interviewing

Counseling to clarify goals,Counseling to clarify goals,Resolve ambivalence,Resolve ambivalence,And enhance motivationAnd enhance motivation

(Drebing, 2006)(Drebing, 2006)

Contingency ManagementContingency Management

Behavioral principlesBehavioral principles Reinforce desired behaviorsReinforce desired behaviors Attendance, reduced substance abuse, job Attendance, reduced substance abuse, job

finding tasksfinding tasks Initial results positiveInitial results positive

(Drebing, 2006)(Drebing, 2006)

Benefits ReformBenefits Reform

People are socialized into disabilityPeople are socialized into disabilityChanging benefits structure essentialChanging benefits structure essential

Policy ChangesPolicy Changes

People with disabilities need cash, health insurance, and a job

They do not need to be assigned to a lifetime of unemployment and poverty in order to get health insurance

Legislative change is critical

Carl Suter, CSAVR (2006)

Current InitiativesCurrent Initiatives

National health insuranceNational health insuranceExperiments with Social Security Experiments with Social Security Administration regulations Administration regulations Temporary assistance and extended Temporary assistance and extended benefits with returns to work benefits with returns to work

2. Inconsistent Employment2. Inconsistent Employment

Only one-third become consistent Only one-third become consistent workersworkers

One-third do not become competitively One-third do not become competitively employedemployed

One-third do not become consistent One-third do not become consistent workersworkers

Efforts to Improve SEEfforts to Improve SE

Address symptom barriersAddress symptom barriers Improve job developmentImprove job development Improve job supportsImprove job supports Improve career development supportsImprove career development supports

Social Security Administration Social Security Administration Mental Health Treatment StudyMental Health Treatment Study

RCT in 22 citiesRCT in 22 cities 3,000 SSDI beneficiaries3,000 SSDI beneficiaries InterventionsInterventions

– Insurance packageInsurance package– IPS supported employmentIPS supported employment– Systematic medication managementSystematic medication management– EB mental health practicesEB mental health practices– Medical careMedical care

(Frey, 2008)(Frey, 2008)

Addressing CognitionAddressing Cognition

Concentration, memory, reaction speed, Concentration, memory, reaction speed, and problem-solvingand problem-solving

Job match Job match Improve cognitive function Improve cognitive function Compensatory strategiesCompensatory strategies

(McGurk, 2008)(McGurk, 2008)

Cognitive TrainingCognitive Training

Practicing cognitive tasks may create Practicing cognitive tasks may create new neuronal connectionsnew neuronal connections

Tasks directly relevant to work tasksTasks directly relevant to work tasksNew capacity may translate to workNew capacity may translate to work

(McGurk, 2005)(McGurk, 2005)

Computer Training and Memory

30

35

40

45

50

Baseline 3 Months

Total Number Correct

Computer Training and Work

0

5

10

15

20

25

30

Baseline 3 MonthsHours worked per Month

MedicationsMedications

MATRICS studyMATRICS studyCognitive medications for schizophreniaCognitive medications for schizophreniaWill they impact functioning?Will they impact functioning?

(NIMH, (NIMH, 2007)2007)

Improve the SE ModelImprove the SE ModelJob findingJob finding

– Variability in styles and successesVariability in styles and successesJob supportsJob supports

– Skills training while working Skills training while working (Mueser, 2006; Marder, in prep)(Mueser, 2006; Marder, in prep)

– Individualized job supports Individualized job supports – Errorless learning Errorless learning

(Kern, in press)(Kern, in press)

Career DevelopmentCareer Development

Long-term studiesLong-term studiesSupported educationSupported educationDisability policiesDisability policiesCareer counselingCareer counseling

3. Part-time Work3. Part-time Work

Disability ReformsDisability Reforms

Insurance reformsInsurance reforms

Thresholds-Dartmouth CenterThresholds-Dartmouth Center

6,000 clients per year6,000 clients per yearRecovery center Recovery center Multiple protocol choicesMultiple protocol choices90% participation goal90% participation goalElectronic decision support systemsElectronic decision support systems

ConclusionsConclusions SE has created hope for for people with SE has created hope for for people with

psychiatric disabilities, their families, and psychiatric disabilities, their families, and MH/VR practitionersMH/VR practitioners

Outcomes can be enhanced furtherOutcomes can be enhanced further New researchNew research Policy changesPolicy changes

Dartmouth SE TeamDartmouth SE Team

Hoyt AlversonHoyt Alverson Marianne AlversonMarianne Alverson Deborah BeckerDeborah Becker Gary BondGary Bond Phil BushPhil Bush Robin ClarkRobin Clark Bob DrakeBob Drake Laura FlintLaura Flint Paul GormanPaul Gorman David LyndeDavid Lynde

Greg McHugoGreg McHugo Susan McGurkSusan McGurk Kim MueserKim Mueser Doug NoordsyDoug Noordsy Michelle SalyersMichelle Salyers Sarah SwansonSarah Swanson Will TorreyWill Torrey Rob WhitleyRob Whitley Rosemarie WolfeRosemarie Wolfe Haiyi XieHaiyi Xie

Updates on SEUpdates on SE

Psychiatric Rehabilitation JournalPsychiatric Rehabilitation Journal– Spring, 2008, special issue on SESpring, 2008, special issue on SE

Supported Employment: A Practical Guide for Supported Employment: A Practical Guide for Practitioners and Supervisors Practitioners and Supervisors

(Swanson, 2008)(Swanson, 2008)

Information: books, Information: books, videos, research articlesvideos, research articles

Karen DunnKaren.Dunn@Dartmouth.edu603-448-0263http://dms.dartmouth.edu/prc