Vocational outcomes of an integrated supported employment program for individuals with persistent and severe mental illness

https://doi.org/10.1016/j.jbtep.2008.12.007Get rights and content

Abstract

We examined the effectiveness of an integrated supported employment (ISE) program, which augments Individual Placement & Support (IPS) with social skills training (SST) in helping individuals with SMI achieve and maintain employment. A total of 163 participants were randomly assigned to three vocational rehabilitation programs: ISE, IPS, and traditional vocational rehabilitation (TVR). After fifteen months of services, ISE participants had significantly higher employment rates (78.8%) and longer job tenures (23.84 weeks) when compared with IPS and TVR participants. IPS participants demonstrated better vocational outcomes than TVR participants. The findings suggested that ISE enhances the outcomes of supported employment, endorsing the value of SST in vocational rehabilitation.

Introduction

The traditional vocational rehabilitation (TVR) services adopt a step-wise approach which offers pre-vocational training at the beginning of the service. In Hong Kong and mainland China, participants usually undergo a prolonged period of preparation before seeking competitive employment (Crowther, Marshall, Bond, & Huxley, 2001). Sheltered jobs are tailor-made for people with psychiatric problems in a segregated setting where jobs are supervised by mental health staff. Participants are paid with less than minimum wage (Crowther et al., 2001, Drake et al., 1999). Club houses, day activity centers, and transitional employment offer vocational trainings, job placements, and transitional employment for the participants grounded on the rationale of the “train and place” approach. Each of these TVR approaches is usually beneficial for individual needs. However, they are time-consuming with a lengthy pre-employment training that participants are not expected to obtain jobs directly (Crowther et al., 2001). Rates for competitive employment are usually less than 20% (Bellamy, Rhodes, & Albin, 1986). As TVR is the most common form of vocational rehabilitation in Hong Kong, it was important to local service development to benchmark innovative interventions against standard interventions.

The current local practice echoed data available from extant literature that only 15%–30% of people with severe mental illness (SMI) are competitively employed (Anthony et al., 2002, Equal Opportunities Commission, 1997, Rosenheck et al., 2006). In view of the unsatisfactory outcomes of TVR approaches, a supported employment program, Individual Placement and Support (IPS), was developed to help those with severe SMI obtain competitive employment. SMI has been defined in this study as individuals with mood, personality and schizophrenia spectrum disorders who are disabled as adjudicated by the Social Security Administration in the USA, reflecting their inability to productively function in a work or work-like setting, deficits in social and self-care skills and vulnerability to stress-induced relapse (American Psychiatric Association, 1994, National Institute of Mental Health, 1987).

IPS is an evidence-based rehabilitation service that includes job development and placement, on-going employment supports, coordination of vocational services with multi-disciplinary treatment teams, indefinite services and the opportunity for choice of jobs by participants. Success rates average over 50% employment during the course of a six-month period of IPS. This employability is achieved with approximately 50% of samples of SMI who are deemed eligible for IPS after screening those who express interest in employment (Drake and Becker, 1996, Drake et al., 1999). IPS is less than optimal in clients' maintaining their jobs, with 50% of those employed experiencing job terminations by the six-month follow-up. Over a longer follow-up period, considerably fewer than half of the participants in IPS are working during any single month (Bond, Drake, Mueser, & Becker, 1997).

To improve vocational outcomes from IPS, various enhanced versions (Gold et al., 2006, McGurk et al., 2005, Mueser et al., 2005, Wallace, 2004) were developed by augmenting IPS with additional psychosocial interventions. We developed an Integrated Supported Employment program (ISE), which combines IPS with social skills training (SST), an evidence-based treatment that has been shown to improve social communication, social problem-solving and social functioning in persons with schizophrenia and other disabling mental disorders (Kopelowicz et al., 2006, Kurtz and Mueser, 2008). The choice of SST was inspired by the fact that interpersonal difficulties have been found to be the most frequently reported job problem leading to unwanted job terminations (Becker et al., 1998). In addition, social competence has been found to be a significant predictor of gainful employment. Service protocol of ISE follows the steps of a typical IPS program (Becker & Drake, 1993) which include: (1) referral; (2) building a relationship; (3) vocational assessment; (4) individual employment plan; (5) obtaining employment; and (6) follow-along support. SST begins to be part of the ISE approach during vocational assessment. Assessment on social skills necessary for seeking and maintaining a job is incorporated into the ISE. In employment plan formulation, an emphasis is on the role social skills play in the individual employment plan. Before obtaining employment, WSST module (Tsang & Pearson, 2001) will be used. On-going support includes an emphasis on providing assistance to the clients how to develop and maintain good and cooperative working relationship with their fellow workers, supervisors, and customers.

In the current study, IPS was amplified by the addition of work-related, social skills training (WSST) together with on-going supports in the community for aiding generalization of social skills in the workplace following the ISE protocol (Tsang, 2003). A standardized and manualized WSST comprises teaching individuals skills that are essential to keeping a job, including maintaining a good working relationship with supervisor and colleagues (Tsang and Pearson, 1996, Tsang and Pearson, 2001). WSST also equips patients with social skills to cope with specific situations in the workplace that may cause interpersonal conflicts. In contrast, IPS alone engages employment specialists to provide indefinite supports, stress management and encouragement, but not skills training (Bond, 1998); thus, it lacks the specific focus on reinforcing the work-related, behavioral skills learned in the WSST.

We report a randomized, controlled trial to test the relative effectiveness of ISE as compared to IPS and traditional vocational rehabilitation (TVR). Although overseas studies have consistently demonstrated that the vocational outcomes of the traditional approach are not satisfactory, we included the TVR as the control condition as similar studies of this kind in Hong Kong are still limited. This is to ensure the internal validity of our results. We hypothesized that ISE outcomes would outperform IPS and traditional services in terms of employment and coping with stressors in the workplace. A secondary objective was to determine whether vocational interventions originally developed in the United States could be culturally adapted for effectiveness within a Chinese context in Hong Kong.

Section snippets

Participants

Between 2003 and 2005, we recruited 163 participants from community mental health programs which offered a range of rehabilitation services. Each program provided a full array of services by a multi-disciplinary team consisting of psychiatrist, rehabilitation managers, case workers and social workers. Vocational rehabilitation services that clients received included sheltered workshop and supported employment. The recruitment was based on the following selection criteria: (1) suffering from SMI

Comparing the dose of the two interventions

The mean number of telephone contacts was once per 1.63 (S.D. = 0.81) and 1.63 (S.D. = 0.85) weeks for ISE and IPS participants, respectively. The mean number of face-to-face contacts was once per 3.77 (S.D. = 0.37) and 3.90 (S.D. = 1.27) weeks for ISE and IPS participants, respectively. No significant differences were found in telephone (t = 0.00, p = 1.00) and face-to-face contact (t = 0.39, p = 0.70).

Program attrition

Of the original 163 participants, 153 (93.9%) completed the three-month intervention, 144 (88.3%) completed

Discussion

Bond (2004) reviewed nine RCTs on IPS program among individuals with severe mental illness and reported that the employment rates of IPS participants ranged from 31.3% to 78.1%. On average, 56% participants obtained competitive employment. The employment rate of our IPS participants is similar to this review which further suggests that the fidelity of implementation of our study is comparable to standards set out by the originators. Wong, Chiu, Tang, Chiu, and Tang (2006), using a similar

Acknowledgment

This study was funded by the Health Services Research Fund, Health, Welfare and Food Bureau, HKSAR (HSRF Project No.: S121014).

References (44)

  • M. Bell et al.

    Cognitive predictors of symptom change for participants in vocational rehabilitation program

    Schizophrenia Research

    (2007)
  • C.R. Bowie et al.

    Predicting schizophrenia patients' real-world behavior with specific neuropsychological and functional capacity measures

    Biological Psychiatry

    (2008)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders: DSM-IV

    (1994)
  • W.A. Anthony et al.

    Psychiatric rehabilitation

    (2002)
  • D.R. Becker et al.

    A working life: The individual placement and support (IPS) program

    (1993)
  • D.R. Becker et al.

    Job terminations among persons with severe mental illness participating in supported employment

    Community Mental Health Journal

    (1998)
  • G.T. Bellamy et al.

    Supported employment

  • G.R. Bond

    Principles of individual placement and support model: empirical support

    Psychiatric Rehabilitation Journal

    (1998)
  • G.R. Bond

    Supported employment: evidence for an evidence-based practice

    Psychiatric Rehabilitation Journal

    (2004)
  • G.R. Bond et al.

    A scale to measure quality of supported employment for persons with severe mental illness

    Journal of Vocational Rehabilitation

    (2002)
  • G.R. Bond et al.

    Accelerating entry into supported employment for persons with severe psychiatric disabilities

    Rehabilitation Psychology

    (1995)
  • G.R. Bond et al.

    An update on supported employment for people with severe mental illness

    Psychiatric Service

    (1997)
  • Y.E. Chen

    Mental health in China

    (September 1995)
  • R.E. Crowther et al.

    Helping people with severe mental illness to obtain work: a systematic review

    British Medical Journal

    (2001)
  • L.W. Davis et al.

    The Indianapolis vocational intervention program: a cognitive behavioral approach to addressing rehabilitation issues in schizophrenia

    Journal of Rehabilitation Research and Development

    (2005)
  • R.E. Drake et al.

    The individual placement and support model of supported employment

    Psychiatric Services

    (1996)
  • R.E. Drake et al.

    A randomized clinical trial of supported employment for inner-city patients with severe mental illness

    Archives of General Psychiatry

    (1999)
  • Equal Opportunities Commission

    Full report: A baseline survey on employment situation of persons with a disability in Hong Kong

    (1997)
  • P.B. Gold et al.

    Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness

    Schizophrenia Bulletin

    (2006)
  • R. King

    Intensive case management: a critical re-appraisal of the scientific evidence for effectiveness

    Administration and Policy in Mental Health Services Research

    (2006)
  • A. Kopelowicz et al.

    Recent advance in social skills training for schizophrenia

    Schizophrenia Bulletin

    (2006)
  • M.M. Kurtz et al.

    A meta-analysis of controlled research on social skills training for schizophrenia

    Journal of Consulting and Clinical Psychology

    (2008)
  • Cited by (0)

    View full text