Customized Employment: Employment Supports for Individuals with Severe Mental Illness

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 seven evidenced-based practices have proven successful in assisting people with severe mental illness in achieving and sustaining employment outcomes. The following information summarizes these seven 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.

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 integration of employment services and supports with mental health treatment include:

• Employment support team members are in close and frequent contact with the mental health case managers.
• Treatment plans and employment plans are coordinated and mutually supportive.
• Treatment team meetings include the 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 always be coordinated with employment changes If they aren’t, responsibility for follow-up becomes unclear, and employment staff may be caught up doing crisis intervention, a role more appropriately fulfilled by 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. Clinicians and employment specialists report better communication. Clinicians become involved and excited about employment, and the close working relationship between the clinicians and 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 programs 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. In comparison, 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 the benefits of work and encouraging success.
• Avoiding spending time and resources on work readiness experiences or extended periods of assessment.
• Assuring that assessments occur rapidly and build on the desire and motivation of the consumer to seek work.

In providing employment services and supports, it’s essential to devote resources and energy to assisting consumers with finding competitive jobs. From the moment a consumer begins the program, communicate a clear message that an integrated competitive employment outcome is the goal and focus all employment services and supports on directly meeting that goal. Avoid volunteer approaches or paid employment options that are not drawn 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. Most consumers with mental health support needs prefer to work towards an employment outcome instead of going through transitional preparatory activities. In fact, work readiness or other preparatory activities that delay competitive work can actually reduce prospects for community employment. Practices focusing on a rapid job search include:

• Providing direct assistance in job finding through job 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 the employment support team. This process emphasizes use of a consumer’s preferences, strengths, and prior work experiences. Practices that focus on 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 the presence of 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 that takes 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 create 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. 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 the various employment support programs. Funding agencies will usually be much more flexible in approving job related supports when there is clear evidence that these supports improve the likelihood of job success. Practices that emphasize the continued availability of ongoing supports include:

• Assisting individuals in discovering their true job interests by working in competitive employment.
• Maintaining direct supports to consumers and employers (where appropriate to an employment plan) after obtaining work.
• Assisting people with moving into new jobs as long-term job interests are clarified.

In many states, funding for employment services is time-limited, triggering rules about how long someone is eligible. Or, the funding may shift from one source (such as Vocational Rehabilitation) to a second source (such as Medicaid) after a specific period of time that a consumer is employed. It is critical that employment programs find ways to customize the supports for consumers and continue to stay in touch over the long term.

For example, try to negotiate flexible funding arrangements that are not tied to strict rules about time limits. The key to success in these negotiations is demonstrating that maintenance of supports minimizes “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.

7. 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 that consumers have access to professional benefits counselors and understand the interaction between work earnings and disability-related benefits.
• Addressing fully the many concerns individuals have about the potential loss of benefits after employment, fears that are frequently based on rumors and misconceptions.
• Assuring that job plans (in terms of hours of employment, pay and benefits) are coordinated with benefit plans developed during benefits counseling.

The Social Security Administration has implemented a national Benefits Planning, Assistance and Outreach (BPAO) to assist individuals with disabilities who receive SSDI and/or SSI. The BPAO program is comprised of 117 projects throughout the United States. These projects provide information and direct assistance on how benefit programs and work incentives interface with earnings from employment and self-employment.

The location of the BPAO projects in each state can be obtained from the VCU Benefits Assistance Resource Center at -- http://www.vcu-barc.org/ In some states, there are also individuals and organizations that can provide fee-for-service benefits counseling and assistance for individuals with severe mental illness who do not receive SSI or SSDI benefits.

Conclusion

These seven 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 individuals with severe mental illness. The principles have direct implications for employment service providers, agencies that purchase employment services, and consumers of these services.

• For providers, the principles provide clear guidelines for program development.
• For funding agencies, the principles establish a basis for purchase of service guidelines and quality indicators.
• For 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 individualized 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:

Employment Information for Consumers -- http://www.mentalhealthpractices.org/se.html
Employment Information for Practioners -- http://www.mentalhealthpractices.org/se_pcs.html
National Alliance for the Mentally Ill (NAMI) -- http://www.nami.org
National Mental Health Consumers’ Self-Help Clearinghouse -- http://www.nostigma.org/
Implementing Supported Employment as an Evidenced Based Practice -- http://www.mentalhealthpractices.org/pdf_files/bond.pdf
Fact Sheet on Customized Employment –
http://www.t-tap.org/strategies/factsheet/odepfactsheet.htm

Resources for further study from which this Fact Sheet was drawn:

Bond, G. (2004). Supported employment: Evidence for an evidence-based practice. Psychiatric Rehabilitation Journal. 27(4), 345-359.

Gowdy, El, Carlson, L, & Rapp, C. (2003). Practices differentiating high-performing from low-performing supported employment programs. Psychiatric Rehabilitation Journal. 26(3), 232-239.

Ridgway, P., & Rapp, C. (1998). The active ingredients in achieving competitive employment for people with psychiatric disabilities: A research synthesis. Lawrence, KS: University of Kansas School of Social Work.

Information for this Fact Sheet came from T-TAP:

Training and Technical Assistance for Providers. The contributor for this issue is Grant Revell, T-TAP Training Director. For additional information on customized employment, you may contact ODEP at (202) 693-7880 or T-TAP, kinge@atlas.vcu.edu or (804) 828-5956. For more information on T-TAP, please visit http://www.t-tap.org.