Positive Approaches Journal, Volume 11, Issue 3

Volume 11 ► Issue 3 ► November 2022

Employment Services Designed for Individuals with Serious Mental Illness (SMI)

Randall Loss, M.A., C.R.C.

Abstract

The Individual Placement and Support (IPS) supported employment model has considerable research conducted to show it’s an evidenced based practice (EBP) for individuals with serious mental illness (SMI).  Additionally, this supported employment service is designed for use with individuals ages 16 and older. This article describes IPS as an EBP including focus on data and programs such as Assertive Community Treatment (ACT), First Episode Psychosis (FEP) and Clubhouse that use this tool as part of a larger continuum of services. This description draws from published and nonpublished material about definitions, impact, and the best use of IPS service. While IPS is an EBP, implementation requires collaboration between state vocational rehabilitation and mental health offices in collaboration with county mental health offices to fund and support.

Are there opportunities within the mental health system for people to truly improve their lives?  Are there a range of affordable, normal housing situations from which people can choose a place to live?  Is there work available?  A person who just recently went back to work after many years of hospitalization said to me, "What's all this talk about empowerment?  I can tell you the definition of empowerment: "It's a decent paycheck at the end of the week". ¹

The previous paragraph is a quote from Dr. Pat Deegan delivered at a conference in 1996. Despite its age, it’s a powerful statement regarding empowerment as seen through the eyes of an individual with serious mental illness (SMI).  Also, it is an essential starting point to discuss the role employment has for those with SMI.  Employment is a significant wellness component and a clear indicator of an individual being on a successful mental health recovery path.

Serious mental illness is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. ² Further, there are a few more definitions that are needed before continuing the discussion on the impact of employment in the lives of those living with an SMI.  “Wellness is a broad concept. Think of wellness as being healthy in many dimensions of our lives.” ³ Recovery is defined “as a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.” ⁴

According to the United Nations Universal Declaration of Human Rights of 1948, Article 23, “Everyone has the right to work, to free choice of employment, to just and favorable conditions of work, and protection against unemployment.” ⁵  Even with the right to work in place, a job seeker with a disability is not guaranteed they will be able obtain employment unless supports are provided that address disability-related challenges in finding and keeping work.  Data suggests that people with severe and persistent mental illness have low employment rates ranging from 13–55%. ^6,7

Holding a job is the central hub from which many other areas of functioning emanate.  For this reason, employment is considered one of the most important factors in promoting recovery and social inclusion.  It not only provides financial independence but also structure and purpose, opportunities for socializing and developing new relationships, a sense of identity, self-worth, and meaning in life.⁷ The onset of mental health conditions is associated with more than double the risk of leaving employment compared to other health conditions or impairments.  Evidence suggests that unemployment is a risk factor for the development or exacerbation of mental health conditions and misuse of substances.  Unemployment also results in decreased social networks and loss of structure, purpose, and identity. ⁷

Having a job is important to the mental well-being of any individual but, as identified above, even more so for persons with SMI.  Many individuals with SMI do successfully gain employment through applying directly to employers or using public resources like the PA CareerLink or JobNET.  On the other hand, there are times when supports specifically designed to address the nature of SMI are needed to help an individual seek, obtain, and maintain employment.  When multiple SMI-related issues need to be simultaneously addressed for a job seeker, there are a few programs that incorporate supported employment alongside other mental health interventions.  The reader may now ask, what is an available tool to assist those with SMI in gaining community-based employment?  Additionally, what mental health service programs use these tools to assist an individual towards an effective recovery path?  The remainder of this article identifies the most successful evidence-based practice (EBP) employment service for individuals with SMI and which mental health programs could include this service as a resource.

It is the experience of this author that the primary tool to assist individuals with SMI to gain employment is supported employment (SE). Supported employment is a universal service designed to assist those with disabilities to successfully enter the workforce.  Research has shown the SE version to work most effectively for those with SMI is the Individual Placement and Support (IPS) model.  Individual placement and support is an EBP and is the heart of the Substance Abuse and Mental Health Services Administration (SAMHSA) supported employment toolkit for assisting those with SMI in pursing employment. Individual placement and support embodies the following principles: (1) competitive employment, (2) eligibility based on client choice, (3) integration of rehabilitation and mental health services, (4) attention to client preferences, (5) personalized benefits counseling, (6) rapid job search, (7) systematic job development and (8) time unlimited and individualized support. ⁶ Although relatively more effective than traditional supported employment services, IPS employment rates still show that it’s not effective for everyone.  What research does indicate is that IPS is moderately more effective for those with SMIs, schizophrenia spectrum disorders, and a low symptom severity.⁸

The competitive employment rate outcomes of gainful community employment for IPS are on average 58–60% successful versus 23–24% of the traditional train-and-place supported employment . In addition, Loveland et al. point out that almost three-quarters of people using IPS require additional services such as cognitive, psychosocial skills, and illness management training. ⁶

The best application of the IPS SE service as a stand-alone service or in conjunction with a larger program is when it follows the IPS Fidelity Scale.  This tool is a measurement of how closely the service provider is following the EBP of IPS.  The closer the provider follows the IPS program fidelity, the better the employment outcomes for the job seekers with SMI who are receiving SE services. This tool can easily be found online and at no cost for any employment service provider interested in using this resource to enhance its employment programming.

One mental health services program that assists individuals with SMI by using IPS SE, along with other mental health treatment services, is the Assertive Community Treatment (ACT) team.   ACT teams in Pennsylvania must include the following: a psychiatrist, nurse, peer specialist, substance abuse specialist, vocational specialist along with MH clinical staff and many staff require Masters’ level degrees.  Assertive Community Treatment services are designed for individuals with SMI who have had at least two psychiatric hospitalizations in the past 12 months and who are at least 18 years of age. There are currently 43 ACT programs in 26 counties across Pennsylvania.  Assertive Community Treatment is a person-centered approach to care for adults that aims to lessen or eliminate symptoms of mental illness; minimize or prevent recurrent episodes of illness; enhance an individual’s ability to live independently within his or her own community; and lessen the family’s burden of providing care.  What follows are widely accepted, essential-features of the model to reduce symptoms of mental illness: a multi-disciplinary ACT team with small case-loads (typically staff: patient ratios between 1:10 and 1:12) providing high intensity integrated services and a team approach to sharing responsibility for the whole caseload.  The ACT team is assertive in its attempts to engage patients for whom the team has continuous responsibility 24 hours a day, 7 days a week.⁹ The ACT teams which should have more successful employment outcomes are the ones  that have the employment specialist function distinctly from the mental health treatment team.  Basically, the employment specialist does employment supports only for the ACT client.

Another program that assists individuals with SMI in a comparable fashion to the ACT program is the First Episode Psychosis (FEP) program.  There are currently nine FEP sites in Pennsylvania with five only serving one to four counties each and four programs serving all of Pennsylvania.  The premise of the FEP program is based on coordinated specialty care (CSC), which is a recovery-oriented treatment program for people with first episode psychosis (FEP).  CSC promotes shared decision making and uses a team of specialists who work with the client to create a personal treatment plan.  The specialists offer psychotherapy, medication management geared to individuals with FEP, family education and support, case management, and work or education support, depending on the individual’s needs and preferences.¹⁰ Approximately 100,000 adolescents and young adults in the United States experience FEP each year. With a peak onset occurring between 15-25 years of age, psychotic disorders such as schizophrenia can derail a young person’s social, academic, and vocational development and initiate a trajectory of accumulating disability.¹⁰ Ideally, the FEP employment specialist that uses and adheres to the IPS Fidelity Scale can increase successful employment outcomes for program participants.

Clubhouse is another program that can potentially use IPS supported employment.  The big difference when compared to ACT and FEP is the approach staff take in helping individuals with SMI, known as Clubhouse members, realize their employment potential.  The daily activity of a Clubhouse is organized around a structured system known as the work-ordered day (WOD).  Members and staff work side by side as colleagues to perform the work that is important to their community.  Instead of traditional talk therapy, members and staff share responsibility for running every aspect of the Clubhouse.  By sharing responsibility for critical work, members and staff build relationships focused on each other’s strengths and gifts, rather than weaknesses and liabilities.¹¹ One theme that emerged  throughout a research study’s interview sessions of Clubhouse members was the value of having ‘‘things to do.’’  Although participants were either regularly working for WOD or at their own community-based jobs at the time of the study, their stories revealed that they had virtually no involvement in activities that they felt were ‘‘meaningful,’’ ‘‘constructive,’’ or ‘‘productive’’ before they had come to the Clubhouse. Work ordered day can also mean preparation for a job to live independently.  L., a member from Ohio, compared the Clubhouse to school.  Work-ordered day, then, may be classroom.  While WOD chores are needed to run the clubhouse, they also serve to help members learn a wealth of job skills that can serve as initial steps toward more complex tasks.  This study illustrated peer-to-peer collaboration, side by side during the WOD and personal peer relationships—how they emerge and develop as secondary to WOD participation—revealing various self-help effects including feelings of ‘‘we are not alone’’ and what has been described as the ‘‘helper therapy’’ whereby people feel they are being helped themselves by their efforts to help others.¹¹ It is important to note that once a member is ready to seek competitive community-based employment, a staff whose focus is on employment support can potentially use the IPS supported employment model to assist that member obtain a job using the WOD foundation from which that member learned while at the Clubhouse.

So, what does the information shared above mean for employment supports to those with SMI?  The fact that IPS supported employment is seen as the center of the EBP SAMHSA toolkit and the employment tool for most mental health programs such as ACT, FEP and Clubhouse, speaks volumes to its use as the best method of helping those with SMI get and keep employment.  The biggest challenge IPS has is that of funding which will likely be an ongoing barrier into the foreseeable future.  Many states that have implemented IPS statewide typically use braided funding between the state vocational rehabilitation agency and the state office of mental health.  These state offices of mental health have used various funding ranging from grants, rehabilitation options of Medicaid waivers, Mental Health Block Grant funds, among others.¹² Solid IPS supported employment funding requires many partners collaborating for the benefit of those with SMI. The benefit is individuals with SMI having a job that offers a decent paycheck is not only employment but empowerment and independence.

Contact Information

Randall E. Loss’ vocational rehabilitation (VR) career spans 30 years, starting in 1991 as a wilderness camp counselor for adjudicated youth.  He next worked with students in an alternative schooling program. His role in both settings was to help these students learn socially appropriate and pre-vocational skills in preparation for community and public-school reintegration.  He then transitioned to assisting individuals with intellectual disabilities, first in a sheltered workshop, then as a supports coordinator and finally as a job coach until 1999.  He subsequently became a field operations manager for the Experience Works older-adult employment training program with a staff of seven program participants.  In 2002 he started at OVR in the contracts and grants division as a specialist overseeing letters of understanding and grant management.  He then moved into policy and program development until he left OVR in 2017.  While in policy he supported a variety of disability populations and program areas including: Supported Employment, Vehicle/Home Mods, Assistive Technology, Farm and Ranch, ID, MH, TBI and Veterans. In 2008 he became focused on working with criminal justice system involved individuals and was the lead policy staff on several projects to improve employment outcomes for this population. In 2017, he led Memorandum of Understanding (MOU) efforts with the Pennsylvania Bureau of Juvenile Justice Services (BJJS) to connect students in the juvenile justice system with positive employment outcomes. In 2018 he left OVR to provide technical assistance to VR agencies nationwide as a Senior Technical Advisor with the Youth Technical Assistance Center (Y-TAC).  He was a subject matter expert on Mental Health peer mentoring and guiding VR agencies’ work with youth and students in the juvenile justice system, and/or were in foster care, were homeless or were out of school. Since late 2018 he returned to Commonwealth service as the policy employment lead for the PA Office of Mental Health and Substance Abuse Services (OMHSAS). In addition to employment services, he led certified peer, suicide prevention, COVID-19 emergency funding, Fairweather Lodge, supported education and Veterans program development.  He lives in Camp Hill with his wife and has two sons.  His favorite sport teams are the Steelers and Penguins.  He also is very active in local ministries serving those with criminal records and mental illness. 

Contact Information

Randall E. Loss

Pennsylvania Office of Mental Health and Substance Abuse Services

Human Service Analyst