Evidence-Based Supported Employment in the Rural United States: Challenges and Adaptations

State mental health and vocational rehabilitation leaders nominated IPS specialists from successful IPS programs in 15 states. National IPS trainers confirmed these specialists’ expertise and the success of the programs they supervised. We conducted interviews with 27 key informants who had knowledge of and experience with IPS (trainers, supervisors, and specialists). Regions included Appalachia, Midwestern farming states, mountain areas, northern New England, the Southeast, the Northwest, and the Southwest. The rural areas differed in terms of degree of rurality, type of industries, and number of individuals from racial-ethnic minority groups, immigrants, and Native Americans.

The interviewer (R.E.D.) started with one question: “What are the barriers to delivering IPS in rural areas and how do you overcome them?” Follow-up questions probed for expansions on answers, for example, “Tell me more about how you overcome stigma in your area.” The interviewer documented participants’ responses with detailed notes, including verbatim quotations.

Two authors (M.A., R.E.D.) independently reviewed the interview notes manually to generate initial lists of issues relevant to adapting IPS services in rural areas. Through discussions with a third author (E.C.-S.), the team identified points of overlap and unique issues noted in the initial review to construct a more complete catalog of key concepts and categories in the data set. Qualitative codes reflected both a priori categories driven by the research question (e.g., barriers to IPS delivery) and categories that were developed through inductive review. The team worked collaboratively to synthesize prominent themes, by using standard methods of thematic analysis, and stopped interviewing when it reached saturation of themes (10). To enhance the rigor of interpretations, we used multiple researchers, all familiar with mental health and IPS, to allow for multiple perspectives (11). We also selected emblematic quotations to illuminate the main themes. The study was reviewed and approved by the Westat Institutional Review Board. All interviewees gave verbal consent for participation.

All interviewees stressed that IPS is effective in rural areas but that providing IPS services in rural communities presents a variety of challenges. They converged on similar challenges and recommended diverse local adaptations (Table 1). None of the recommended adaptations altered basic IPS principles, such as service integration, following client preferences, in-person job development, rapid job search, and follow-along supports (12).

The successful implementations of IPS in rural settings that are highlighted in this report demonstrate the viability of implementing IPS to address the need of rural mental health service areas for evidence-based practices. Although the IPS interviewees shared some similarities in the challenges they faced, the strategies they used to overcome these challenges differed from one area to the next. For instance, a majority of those interviewed mentioned the lack of available public transportation, but the alternative methods of transportation used differed on the basis of local resources. Many interviewees also mentioned the lack of local employment opportunities, but their responses reflected the local job market, including local trades and their seasonality as well as relationships with potential employers. Small team size sometimes reduced fidelity scores. We found the lack of anonymity in rural areas to be dual in nature, posing challenges of bias against clients but also helping to strengthen relationships with employers. Rural communities have different cultures; some sites are involved with Native American reservations, and others serve a sizable population of immigrants and refugees. These differences, in turn, have affected local employment patterns generally and the types of jobs clients seek individually.

Such findings highlight the importance of local knowledge, which IPS workers must understand and consider when implementing mental health and vocational interventions (13). Adoption of IPS requires adaptation; in rural areas, we consistently found that adaptations of the model were specific to the local area but did not change any of the core principles of IPS. The model remained personalized, client centered, direct, and integrated with behavioral health care (14).

Implementing IPS in rural areas may be easier than implementing other evidence-based practices in rural settings, because IPS was developed in a rural state and has been demonstrably effective in rural areas (12). Other community-based interventions, such as assertive community treatment, have undergone varied modifications for use in rural settings that rendered the services provided less intensive than the standard model and without empirical validation (15).

Our findings reflect interviews with IPS experts in rural states within the IPS learning community. We did not include rural states outside of the learning community, where different challenges and strategies may exist but where evidence of effectiveness could not be confirmed. Moreover, our interviews focused on identifying challenges and solutions to providing IPS in rural areas. Future research could also address facilitators, such as the ease of integrating mental health and employment services. Findings from this exploratory study suggest that specific strategies should be shared and examined across additional rural areas.

Rural communities across the United States are fraught with limitations in public transportation, Internet connectivity, employment opportunities, and other challenges. Nevertheless, IPS supported employment can be effective in rural areas. Although these communities contain different cultures and have varying adaptations to IPS, successful implementations of IPS preserve the principles of the model. IPS should be a core behavioral health service in the rural United States.