T-TAP - Training and Technical Assistance for Providers The Office of Disability Employment Policy, U.S. Department of Labor Virginia Commonwealth University & The Institute for Community Inclusion University of Massachusetts Boston Employment Supports for Individuals with Severe Mental Illness Updated, May, 2012 Programs providing employment supports are a valuable resource for people with severe mental illness seeking competitive employment. Employment is a key component of recovery. Individuals with severe mental illness who hold competitive jobs for an extended period of time frequently experience a number of benefits, including improvements in their self-esteem and symptom control. Effective employment programs targeting individuals with severe mental illness emphasize encouraging interest and building confidence in working, getting a job consistent with individual work goals, and retaining employment. Employment services that follow eight evidenced-based practices have proven successful in assisting people with severe mental illness in achieving and sustaining employment outcomes. The following information summarizes these eight key practices and provides additional resources on effective employment supports for individuals experiencing severe mental illness. 1. Participation in the employment program is based on consumer choice. True consumer choice requires access to the information necessary to make an informed choice. Practices that encourage informed consumer choice about employment include: - Creating an atmosphere where anyone who chooses to work can work. - Asking consumers if they want to work as soon as they enter the employment program. - Promoting employment consistently and regularly as a positive, achievable outcome. - Encouraging consumers to talk about their fears and concerns about work and providing the assistance needed to address these concerns. - Building confidence by giving attention to each individual’s strengths and motivations. -Customizing employment strategies to match individual goals. Programs that successfully promote informed consumer choice take a systematic approach incorporating these practices. These programs recognize that for individuals with severe mental illness, consumer characteristics do not predict success in competitive employment. Gender, ethnicity, diagnosis, hospitalization history, cognitive functioning, education, or substance abuse history are not predictors of employment success. Instead, employment programs are most successful when they operate on the principle of “zero exclusion.” Anyone who expresses a desire to work and makes an informed choice to participate in an employment program is eligible. For a variety of reasons, programs that use the zero exclusion approach do not assess consumers for work readiness using traditional methods, such as standardized aptitude tests. These assessment methods have in the past screened out consumers with mental illness at a high rate, including many who could successfully work, and take resources away from services that could be better directed to helping people find jobs. Also, most standardized assessment approaches do not actually predict which individuals will work. And finally, these assessments typically do not give information about what interventions to offer as a way to help consumers work successfully. 2. Employment supports are integrated with mental health treatment. It is critically important for consumers with severe mental illness that employment supports be integrated with any mental health treatment. Employment efforts are unlikely to be effective if the person is not receiving adequate clinical case management. Practices that encourage the integration of employment services and supports with mental health treatment include: - Employment support team members are in frequent contact with case managers. - Treatment plans and employment plans are coordinated and mutually supportive. - Treatment team meetings include employment staff and consideration of employment plans and issues. For integration of employment and mental health services to be effective, there must be genuine collaboration and mutual problem solving. For example, medication or housing changes should be coordinated with employment changes. If they aren’t, responsibility for follow-up becomes unclear, and employment staff may be doing crisis intervention, a role more appropriate for case managers. Integration of employment and mental health services contributes to lower employment program dropout rates, because case managers are involved in keeping consumers engaged. Better communication has been reported. Clinicians become involved and excited about employment, and the close working relationship with the employment team results in clinical information being a part of the vocational plan. 3. Services are focused on competitive employment as the goal. Individuals with severe mental illness have historically received services in day treatment or sheltered pro-grams that focus on an array of rehabilitation activities, protected job options, or short-term work experiences. However, prevocational preparation, extended career counseling, or other work readiness activities do not effectively promote competitive employment outcomes. Practices that focus on competitive employment as the goal include: - Targeting attention and resources on work as a goal from the moment the individual enters the program. - Stating benefits of work and encouraging success. - Avoiding spending time and resources on work readiness experiences or extended periods of assessment. - Assuring assessments occur quickly and build on consumers desire and motivation to work. In providing employment services and supports, it’s essential to devote resources and energy assisting consumers in finding competitive jobs. From the moment a consumer begins the program, communicate clearly that an integrated competitive employment outcome is the goal and focus all employment services and supports on meeting that goal. Avoid volunteer approaches or employment options not from the competitive employment job market. 4. A rapid job search approach is used. A rapid job search approach means that contact will be made with employers within the first month after a consumer enters the employment program. Consumers with mental health support needs prefer working towards an employment outcome instead of transitional preparatory activities. In fact, work readiness or other preparatory activities that delay competitive work can actually reduce prospects for employment. Practices focusing on a rapid job search include: - Providing direct assistance in job finding through leads and active job development. - Emphasizing on-the-job training with supports at the job site. - Obtaining rapid approval from funding agencies for employment plans. Many employment programs receive funding through fee-for-service programs such as Vocational Rehabilitation (VR). A rapid job search will not take place when there is limited coordination between the funding entity and the employment agency. Let funding sources such as VR and other fee-for-service programs know as early as possible when new consumers who potentially have employment goals enter the program. Make any testing, treatment, or related background information available (as long as there is approval by the consumer to share this information). Schedule regular staffings or case conferences to be sure information is shared as necessary. The job search process will vary in strategy and timing from person to person. However, established collaborative practices among key stakeholders in the job search process will help support a rapid movement to employment. 5. Job finding is individualized with attention to consumer preferences. Job finding is a collaborative process between the consumer and employment support team. This process emphasizes use of the consumer’s preferences, strengths, and work experiences. Practices that focus on the consumer preferences include: - Working closely with consumers’ personal interests. - Seeking jobs and workplace environments that match individual preferences. - Helping individuals make informed choices about disclosing a disability to employers. - Working closely with the consumer and employer on identifying and negotiating needed workplace accommodations. The collaborative process between the consumer and the employment support team emphasizes job selection taking into account job duties, location, hours of employment, work environment, and other factors related to satisfaction and success in working. Job matching can include arranging customized employment opportunities with employers through job carving, negotiating job descriptions, or creating job descriptions. Consumers are much less likely to quit their jobs if these initial positions are consistent with their preferences. In addition, consumers working in fields consistent with their preferences have higher job satisfaction. The emphasis on job matching contrasts with conventional ideas of developing a pool of jobs and then offering consumers jobs from this pool. 6. Employment specialists systematically develop relationships with employers based upon their client’s job preferences. Employment specialists emphasize building relationships with employers. Employment specialists ask to meet with employers who may have the types of jobs that their consumers prefer, whether or not those businesses currently have job openings. They spend time meeting with employers to learn about their businesses and understand their hiring practices. Employment specialists view each employer as a customer whom she or he can help by introducing job applicants who have the right skills and strengths for that particular business. Practices that focus on systematic job development include: - Employment specialists build an employer network based on clients’ interests, developing relationships with local employers by making systematic contacts. - First contact is for the employment specialist to introduce herself/himself to the employer and request another meeting. Second contact is to learn about the business and human resources. - Future contacts are to discuss potential employees when there might be a good job match. New employment specialists often have not developed skills in making face-to-face employer contacts. Instead they try to find job leads on the internet or make cold calls to employers and ask directly about job openings. Cultivating relationships with employers is crucial to the success of an employment program Successful employment specialists devote considerable time to building a network of employers with whom they maintain contact for the sake of matching clients to specific jobs. 7. Supports are ongoing. Placing arbitrary time limits on supports after a person is employed is very detrimental to employment success. The availability of continuous supports, including replacement assistance, is often closely tied to funding policies and performance standards of various employment support programs. Funding agencies will be more flexible in approving job related supports when there is clear evidence these supports improve job success. Practices that emphasize the continued availability of ongoing supports include: - Assisting individuals in discovering their job interests by working in competitive employment. - Maintaining direct supports to consumers and employers (where appropriate to an employment plan) after obtaining employment. - Assisting people moving into new jobs as long-term job interests are clarified. Funding for employment services provided through Vocational Rehabilitation Agencies is time-limited, by law. To assure that supports are ongoing after the completion of VR funded services, funding for these services must shift to other non-VR sources. It is critical that employment programs find ways to customize the supports to the individual ongoing support needs of consumers and continue to stay in touch over the long term. Maintaining ongoing supports reduces “revolving door” demands on funding agencies such as when a consumer receives a time-limited service and then loses employment as soon as supports are removed, necessitating a whole new employment plan. The Medicaid 1915i State Plan Option is an excellent potential resource for ongoing support employment services when services are not being provided by Vocational Rehabilitation. 8. Benefits counseling is used to educate consumers on the effect of earnings on benefits Some individuals with severe mental illness receive disability benefits such as Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). Many also receive benefits related to health care, housing and/or food assistance. Benefits planning services are an important employment support. Practices that focus on benefits planning include: - Assuring consumers have access to benefits counselors and understand the interaction between work earnings and disability-related benefits. - Addressing concerns individuals have about the potential loss of benefits after employment, fears frequently based on rumors and misconceptions. - Assuring job plans (hours of employment, pay, and benefits) are coordinated with benefit plans developed during benefits counseling. Conclusion These eight principles establish a core framework for building an effective program of employment supports for individuals with severe mental illness. Many are drawn from the Individualized Placement and Support (IPS) approach to providing employment supports to these individuals. The principles have direct implications for employment service providers, agencies purchasing employment services, and consumers. - Providers -- the principles provide clear guidelines for program development. - Funding agencies -- the principles establish a basis for purchase of service guidelines and quality indicators. - Consumers -- the principles provide a measure for making informed choices about service providers and identifying which providers will be most effective in supporting the achievement of the employment goals. Employment programs that follow these evidence-based practices will be more likely to effectively and successfully assist consumers with severe mental illness in meeting their employment goals. Resources for further study from which this fact sheet was developed: Bond, G., Drake, R., & Becker, D. (2008). An update on randomized controlled trials of evidenced-based supported employment. Psychiatric Rehabilitation Journal. 31(4), 280-290. Federal Financing of Supported and Customized Employment for People with Mental Illness: Final Report. (February 2011). U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care. Available at: http://aspe.hhs.gov/daltcp/reports/2011/supempFR.pdf Gowdy, El, Carlson, L, & Rapp, C. (2003). Practices differentiating high-performing from low-performing supported employment programs. Psychiatric Rehabilitation Journal. 26(3), 232-239. Leff, H. S., Cook, J. A., Gold, P. B., Toprac, M., Blyler, C., Goldberg, R. W., et al. (2005). Effects of job development and job support on competitive employment of persons with severe mental illness. Psychiatric Services, 56, 1237-1244. http://ps.psychiatryonline.org/data/Journals/PSS/3654/1237.pdf McGuire, A. B., Bond, G. R., Clendenning, D., & Kukla, M. (2011). Service intensity as a predictor of competitive employment in an Individual Placement and Support program. Psychiatric Services, 62. Dartmouth IPS Supported Employment Ctr. http://www.dartmouth.edu/~ips/index.html T-TAP is funded by the Department of Labor (DOL), Office of Disability Employment Policy (ODEP) cooperative agreement # E 9-4-2-01217. The contents of this product do not necessarily represent the interpretations or opinions of DOL. Virginia Commonwealth University, is an equal opportunity/affirmative action institution providing access to education and employment without regard to age, race, color, national origin, gender, religion, sexual orientation, veteran’s status, political affiliation, or disability. Privacy Policy. If special accommodations or language translation are needed contact Katherine Inge at: kinge@atlas.vcu.edu or Voice (804) 828 - 1851 | TTY (804) 828 - 2494. Information for this FAQ sheet came from: T-TAP (Training and Technical Assistance for Providers) Contributor for this issue include: Grant Revell (wgrevell@vcu.edu)