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Supported Employment:
Art or Science?
by Francine M. Bates, Ellen B. Nalven, and
Carlos W. Pratt
Supported employment (SE) can be viewed as
an intuitive process, with good job matches influenced by
the experience and personal characteristics of the professionals
who provide the supports. The skillful, experienced professional
is rightfully seen as both ingenious and creative. The depth
of knowledge and skills from which such a person draws often
seems unfathomable to the beginning vocational counselor,
and the results they achieve often seem to be more the product
of art than of science. But what looks like art is more likely
the result of the gradual acquisition of lessons learned through
experience resulting in an organized body of knowledge. Since
its inception, SE has continuously evolved, resulting in an
ever-increasing understanding of what works. The compilation
of knowledge gained through experience in the form of articles,
academic curricula, books, etc. has been a gradual but continuous
process. This evidence has been useful in advancing the effectiveness
of SE with funding sources and large system administrators.
The impact of this effort has been extremely important for
the field of psychiatric rehabilitation. Today, SE is one
of only six services which, based on evidence, are seen as
effective for persons with severe mental illness.
Psychiatric rehabilitation practices found
to be effective based on research evidence are labeled, not
surprisingly, Evidence Based Practices (EBP). An EBP is a
rehabilitation strategy or technique that has been determined,
based on the results of controlled clinical trials, to achieve
specific desirable outcomes. The exact definition of the practice
is important. Major aspects (e.g., staffing pat-terns, techniques,
client demographics, etc.) of the EBP model must be clearly
defined. Once the EBP model is defined, a fidelity scale is
created to evaluate each program's adherence to the model.
While no actual service can exactly fit the theoretical model,
the fidelity scale measures just how closely a given program
or service resembles the model.
In vocational rehabilitation, the desired
outcome, of course, is competitive employment. Controlled
clinical trials have shown that SE programs that show evidence
of high model fidelity have the best results securing integrated
employment for their clients. A rehabilitation approach is
considered an EBP when it contains certain key characteristics.
The practice must be well defined, providing a clear picture
of key features of the service, and how it is implemented.
To accomplish this, manuals exist that provide step-by-step
procedures to guide the development of the service. The effectiveness
of various practices is supported by reliable, objective evidence
that has been confirmed by several researchers. The research
also must demonstrate that the results are generalizable across
a variety of populations and geographic areas, so that it
is not specific to one particular demographic area or socioeconomic
group.
A vocational rehabilitation model that meets
the characteristics of an EBP is the Individual Placement
and Support (IPS) model of supported employment. A manual
describing the model, its interventions and implementation
was published by the New Hampshire-Dartmouth Psychiatric Research
Center (Becker and Drake, 1993, 1994, 1996). The IPS model
has been well researched in both urban and rural areas, and
across a variety of demographic populations, including age,
ethnicity, education, diagnosis, and work history. These studies
compared the IPS model with other types of vocational services.
In all cases the IPS model was superior in outcomes or number
of job placements. Job tenure and income are also higher than
other traditional services.
Critical Characteristics of the IPS Model
(1) Eligibility is based on consumer choice.
This has also been called zero exclusion criteria. Consumers
are not excluded or deemed not ready by professional staff.
Consumers are not required to have lengthy assessments to
decide their eligibility or pre-vocational training to improve
readiness.
(2) Assessment is continuous and comprehensive.
Assessment begins with the initial contact and continues after
employment. Information is gathered from the consumer, family,
clinical staff, and in vivo. Job search, interviews, and real
employment are seen as the best possible assessment tool.
Assessment does not stop at any specific time. Initial information
gathered is used to improve job match and satisfaction. Once
someone is employed assessment continues and will improve
supports and accommodations if needed. If an individual looses
or leaves a job for any reason, that experience is utilized
to improve the next job match and tenure. Again assessment
is not used to decide work readiness.
(3) Attention is paid to consumer preferences.
Consumer job preference is the deciding factor in job placement.
Contrary to the beliefs of some, preferences of mental health
consumers are usually realistic. Type of job, hours, location,
and wage are all choices the individual needs to make. Consumer
preference includes types of services offered. Studies show
consumers prefer services that offer rapid job search without
extended prevocational services. Placement in paid positions
is preferred to work units or sheltered work. Job satisfaction
and tenure increases when consumer preferences are realized.
(4) Focus on competitive employment as
the goal.
Competitive employment is defined as jobs in the community
that pay at least minimum wage in integrated settings. When
agencies focus their efforts in the area of competitive employment
for participants, job placements increase.
(5) Promote rapid job search.
With rapid job search the first job application will typically
be within one month of intake. Long assessment or pre-vocational
training are not used and have not been shown to increase
job placements or satisfaction.
(6) Follow-along supports are continuous
and time-unlimited.
No arbitrary time limit is placed on services after a job
is secured. Vocational staff continue to stay in regular contact
with consumers offering support and services for an indefinite
period of time. These services may include
problem solving, communication or negotiations with the employer,
or assistance with advancement. If a job does not work out
or advancement means finding a new employer, the consumer
continues to be eligible for job search services.
(7) Supported employment is integrated
with mental health treatment.
More successful vocational programs are those that are integrated
with mental health services. Total integration includes colocation
of vocational and clinical programs. Vocational staff participate
in clinical staff meetings and are seen as a vital part of
the treatment team. In addition to formal staff meetings,
frequent meetings between clinical and vocational staff improve
communication and coordination of services. Services to clients
improve both clinically and vocationally with the integration
of services.
So, what does this mean for the field of supported employment?
The good news is that it means that successful SE, while it
looks like an art when carried out by some professionals,
is in reality a definable strategy that can be carried out
effectively by any dedicated professional. Although the IFS
model described above was developed based on programs for
persons with psychiatric illness, we believe these principles
apply to all people with disabilities. They provide clear
guidelines to providing effective services that result in
outcomes that individuals participating in supported employment
services want competitive, integrated employment.
References
Becker, D. R., Drake,R. E. (1993). A working life: The individual
placement and support (1PS) program. New Hampshire-Dartmouth
Psychiatric Research Center.
Bond, G. R. (1998). Principles of the individual placement
and support model: empirical support. Psychiatric Rehabilitation
Journal, 22(1), 11-23.
Bond, G. R., Becker, D. R., Drake,R. E., Rapp, C. A., Meister,
N., Lehman, A. F., et al. (2001). Implementing supported employment
as an evidence-based practice. Psychiatric Services, 52(3),
313-322.
Re-printed from APSE - the Advance, Volume
13,#2, January '03.
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