Rehab Rounds: Implementing Supported Employment Services in a Real-World Setting

Bringing the individual placement and support model to SMOC was challenging in several respects. It took time to meet the model's standard of placing clients directly in competitive jobs. Because SEE's original clients were making the transition from a long-term, custodial day program, many individuals lacked not only work experience but also confidence. Consequently, for the first six months of the program, employment specialists continued to use more traditional strategies, such as group job placements, day labor, and agency-owned jobs. As clients achieved work success, employment specialists were able to eventually discontinue reliance on these options.

Another challenge to the implementation of the SEE program was the initial resistance on the part of clinicians, case managers, and residential staff who questioned whether their clients could work. Clinicians and case managers feared that the stress of work might lead to relapse and at times suggested to clients that they should not work. In addition, residential managers sometimes undermined the needs of working clients by scheduling clinical appointments during work hours.

Several efforts were undertaken to address these challenges. First, because the state-level administrators were invested in the program, they exerted a top-down influence on SMOC. In addition, the senior managers of SMOC, who fully supported the SEE program, encouraged cooperation among clinical, residential, and SEE services. Moreover, to encourage "buy in" at the individual provider level to create bottom-up support for the program, employment specialists provided education about the program to staff from other SMOC services. Although these efforts were important, actual client success was the most important factor in influencing providers. Once clinicians saw that clients could work successfully, referrals to the SEE program increased dramatically.

Another challenge was that some employment specialists initially felt intimidated when they sat in on weekly interdisciplinary team meetings of clinicians in the local mental health center. Some team members communicated disdain toward the employment specialists' lack of clinical background. This challenge was addressed by educating the clinicians about the unique skills of the employment specialists and by training clinicians on the efficacy of the individual placement and support approach. Moreover, as more SEE clients succeeded at employment, employment specialists became more confident and were viewed as important members of the team. In fact, clinicians whose clients were among the first successful SEE participants became the program's most vocal advocates. Although the program is now well established, education and outreach to new clinicians and residential staff is an ongoing effort.

From July 1995 to December 1999, of the 90 SMOC clients who received SEE services, 74 (82 percent) obtained at least one paid job. The clients' mean age was 42.1 years, with a range of 21 to 65 years; 51 clients (57 percent) were men, and 81 (90 percent) were Caucasian. A total of 60 clients (67 percent) had a diagnosis of schizophrenia or another psychotic disorder, 70 (78 percent) had never married, and 38 (42 percent) had completed at least some post-high school education. A total of 82 clients (91 percent) received disability benefits (Social Security Disability Insurance or Supplemental Security Income), which frequently act as a disincentive to work, thus making the employment outcomes of these clients' even more impressive.

Data on previous work experience were available for 69 clients. The mean number of jobs held before SEE enrollment was 3.35 per client (range, zero to eight). Among the 74 clients who obtained at least one paid job, the average number of jobs obtained after enrollment in SEE was 2.7. The average job tenure was 255 days, or 8.5 months, and the average hourly wage was $6.64. The average number of days until the first paid job was 107.2. A more detailed description of the employment outcomes has been published elsewhere (6). These results are comparable to data published for other individual placement and support programs (2,3,7).

Ms. B, a 28-year-old, single, white woman with a diagnosis of paranoid schizophrenia, had numerous hospitalizations and periods of homelessness. She received case management services and lived in a supervised residential program. At the time of her referral to SEE, Ms. B was responding favorably to changes in her medication regimen and had expressed interest in work. Her clinical team, although they supported a referral to SEE, voiced concerns that working might precipitate a stress-related relapse. In response to these concerns, an employment specialist agreed to communicate weekly with the team and to report any indications of symptom exacerbation.

Although many elements of Ms. B's story are representative of the average client in the SEE program, what makes Ms. B's experience special is her steady progress toward increasing success and independence with only minor setbacks along the way. Many SEE clients have symptom exacerbations that temporarily stymie their rehabilitation efforts. However, once their clinical status improves, they reactivate their involvement with the SEE program and begin the process over again. With the indefinite support of employment specialists, many clients are able to enjoy some degree of vocational success that improves the quality of their lives.

Afterword by the column editors: To successfully implement evidence-based practices in a community setting, innovators must identify potential obstacles and develop a plan to overcome these barriers. Handler and colleagues refer to the efforts used to influence a variety of stakeholders who were critical to the implementation process. For instance, they note that administrators should provide sustained, visible, and tangible support to blunt the damaging effects of staff skepticism and sabotage. However, it is equally essential for program developers to recognize that supported employment is not for everyone. For clients whose level of functioning, cognitive deficits, or lack of interest may preclude participation in supported employment, there is still a legitimate need for more recreationally oriented day treatment services. Failure to provide such alternatives does a disservice to clients who are unable to benefit from the supported employment approach and may jeopardize the vocational success of clients who can benefit.

Dr. Handler and Ms. Doel are affiliated with the MetroWest Career Center at South Middlesex Opportunity Council, 300 Howard Street, Framingham, Massachusetts 01702 (e-mail, [email protected]). Dr. Henry is with Sargent College of Health and Rehabilitation Sciences at Boston University and with the center for mental health services research at the University of Massachusetts Medical School in Worcester. Dr. Lucca is with the Lewin Group in Falls Church, Virginia. Robert Paul Liberman, M.D., and Alex Kopelowicz, M.D., are editors of this column.