Transcript Psychiatric Rehabilitation: 2006 Update

Future of Supported
Employment
Bob Drake
Sainsbury Centre
March, 2008
The President’s New Freedom
Commission Report (2003)

“The main goal of the mental health system is to help people to
live, learn, work, and participate fully in their communities”

Mike Hogan (2006): “Work is the most direct step to recovery”

“Supported employment is the most effective strategy to help
people achieve their employment goals.”
Overview
Current
Status of SE
Limitations of SE
Current Research on SE
Thresholds-Dartmouth Center
Current Status of SE

SE model is simple and effective
 Other benefits accrue with consistent work
 Work outcomes improve over time
 SE is relatively easy to implement
IPS Supported Employment







Competitive employment
Team approach
Client choice regarding timing
Benefits counseling
Rapid job search
Job matching based on client preferences
On-going supports
• Becker (IPS Fidelity Scale, 2008)
Figure 1. Competitive Employment Rates in 16 Randomized
Controlled Trials of Supported Employment
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
07
Aust
(IPS)
96
NH
(IPS)
94
NY
(SE)
07
IL
(IPS)
04
CT
(IPS)
05
HK
(IPS)
06
SC
(IPS)
Supported Employment
06
99
MA
DC
(ACT) (IPS)
Control
07
CA
(IPS)
95
IN
(SE)
Control 2
07
EUR
(IPS)
06
QUE
(IPS)
00
NY
(SE)
97
CA
(SE)
02
MD
(IPS)
CT Supported Employment Study
(Mueser, 2004)
Impact on
Other Outcomes

Improved self-esteem, symptom control, quality
of life
 Related to sustained competitive employment
 No changes with sustained sheltered employment
(Bond, 2001)
Long-Term Outcomes

4 studies with 10-year follow-ups
(Test, 1989; Salyers, 2004; Becker, 2006; Bush, in prep)

Work outcomes improve over time
 Costs decrease dramatically for consistent
workers (Bush, in prep)
Average Hours of Employment, 3 group analysis
900
800
700
500
No Work
Slow Increase
High Work
400
300
200
100
Year
0
r1
Ye
a
r9
Ye
a
r8
Ye
a
r7
Ye
a
r6
Ye
a
r5
Ye
a
r4
Ye
a
r3
Ye
a
r2
Ye
a
r1
Ye
a
el
in
e
0
Ba
s
Hours
600
National EBP Project
5
evidence-based practices: SE,
IMR, FPE, ACT, IDDT
 53 sites in 8 states
 Programs studied for 2 years
SE Fidelity Scale Mean
Fidelity of SE Programs
5
4
3
4.2
4.6
4.5
4.4
2.8
2
1
BL
6 mo.
12 mo.
18 mo.
24 mo.
(n = 9)
(n = 8)
(n = 9)
(n = 9)
(n = 9)
Johnson & JohnsonDartmouth Project






Mental health-vocational rehabilitation collaboration
implement evidence-based SE
Local programs selected by states
Dartmouth provides training, consultation, and
evaluation
First states: CT, DC, KS, MD, OR, SC, VT
New states: IL, MN, MO, OH
•
(Drake, 2006)
J&J-Dartmouth Project
Total Number of Clients Served & Working in All Ten States by Quarter
Total Number of Clients
6000
# Served
# Working
5000
4865
4108
4000
3737
2810
3000
2872
2929
2850
3027
3181
3298
3415
2369
1928
2000
1216
1000
2033
1419
1198
839
884
9-12/02 1-3/03 4-6/03 7-9/03
1012/03
792
299
516
654
1406
1396
1415
1579
1675
1766
1864
2060
2251
2384
958
0
1-3/04 4-6/04 7-9/04
1012/04
1-3/05 4-6/05 7-9/05
1012/05
1-3/06 4-6/06 7-9/06
1012/06
Limitations of SE
1.
2.
3.
Many do not express interest in SE
Many in SE do not achieve consistent
employment
Consistent workers in SE do not work
full-time
1. Lack of Interest in SE
 Expectations
 Benefits
trap
8-12 Year Follow-up:
Day Treatment to SE
71% working at follow-up
 85% in competitive jobs
 71% worked more than 50% of FU
 90% still receiving benefits

(Becker, 2006)
Early Intervention
First episode psychosis (Neuchterlein, 2005)
 SSA: change adjudication process
 SSA: accelerated benefits
 Health insurance

Early Intervention (Neuchterlein, 2005)
% of Employment or
school
IPS Supported Employment for Clients with Firstepisode Schizophrenia
100
80
IPS
SAU
60
40
20
0
Baseline
6 Months
12 Months 18 Months
Motivation

People fear losing benefits (NAMI, 2003)
 Benefits counseling
 Motivational counseling
 Contingency management
Benefits Counseling
(Tremblay, 2005)
Quarterly Earnings
$1,100
$1,000
$900
Outcomes for Psychiatric Benefit Counseling Intervention Group
Versus Two Nonparticipant Psychiatric Voc Rehab Comparison Groups
(N = 364 per group)
Pre-Enrollment
Post-Enrollment
$800
$700
$600
$500
$400
$300
$200
$100
$0
Intervention
-8
-7
-6
-5
Quarters Relative to Date of Enrollment
-4 -3 -2 -1
0
1
2
3
4
5
6
7
8
608 612 585 549 557 464 504 552 615 852 887 928 830 804 765 812 796
Contemporaneous 382 521 525 575 540 553 566 519 546 511 459 538 602 478 441 353 542
Historical
441 464 511 359 305 333 284 320 279 365 290 335 357 309 315 369 384
Motivational Interviewing
Counseling to clarify goals,
 Resolve ambivalence,
 And enhance motivation

(Drebing, 2006)
Contingency Management

Behavioral principles
 Reinforce desired behaviors
 Attendance, reduced substance abuse, job
finding tasks
 Initial results positive
(Drebing, 2006)
Benefits Reform
People are socialized into disability
 Changing benefits structure essential

Policy Changes

People with disabilities need cash, health
insurance, and a job
 They do not need to be assigned to a
lifetime of unemployment and poverty in
order to get health insurance
 Legislative change is critical
Carl Suter, CSAVR (2006)
Current Initiatives
National
health insurance
Experiments with Social Security
Administration regulations
Temporary assistance and extended
benefits with returns to work
2. Inconsistent Employment
Only one-third become consistent
workers
 One-third do not become competitively
employed
 One-third do not become consistent
workers

Efforts to Improve SE
Address symptom barriers
 Improve job development
 Improve job supports
 Improve career development supports

Social Security Administration
Mental Health Treatment Study



RCT in 22 cities
3,000 SSDI beneficiaries
Interventions
–
–
–
–
–
Insurance package
IPS supported employment
Systematic medication management
EB mental health practices
Medical care
(Frey, 2008)
Addressing Cognition
Concentration, memory, reaction speed,
and problem-solving
 Job match
 Improve cognitive function
 Compensatory strategies

(McGurk, 2008)
Cognitive Training
Practicing cognitive tasks may create
new neuronal connections
 Tasks directly relevant to work tasks
 New capacity may translate to work

(McGurk, 2005)
Total Number Correct
Computer Training and Memory
50
45
40
35
30
Baseline
3 Months
Hours worked per Month
Computer Training and Work
30
25
20
15
10
5
0
Baseline
3 Months
Medications
MATRICS study
 Cognitive medications for schizophrenia
 Will they impact functioning?

(NIMH, 2007)
Improve the SE Model

Job finding
– Variability in styles and successes

Job supports
– Skills training while working
(Mueser, 2006; Marder, in prep)
– Individualized job supports
– Errorless learning
(Kern, in press)
Career Development
Long-term studies
 Supported education
 Disability policies
 Career counseling

3. Part-time Work
Disability Reforms
Insurance reforms
Thresholds-Dartmouth Center
6,000 clients per year
 Recovery center
 Multiple protocol choices
 90% participation goal
 Electronic decision support systems

Conclusions

SE has created hope for for people with
psychiatric disabilities, their families, and
MH/VR practitioners
 Outcomes can be enhanced further
 New research
 Policy changes
Dartmouth SE Team

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Hoyt Alverson
Marianne Alverson
Deborah Becker
Gary Bond
Phil Bush
Robin Clark
Bob Drake
Laura Flint
Paul Gorman
David Lynde
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Greg McHugo
Susan McGurk
Kim Mueser
Doug Noordsy
Michelle Salyers
Sarah Swanson
Will Torrey
Rob Whitley
Rosemarie Wolfe
Haiyi Xie
Updates on SE

Psychiatric Rehabilitation Journal
– Spring, 2008, special issue on SE

Supported Employment: A Practical Guide for
Practitioners and Supervisors
(Swanson, 2008)
Information: books,
videos, research articles
Karen Dunn
 [email protected]
 603-448-0263
 http://dms.dartmouth.edu/prc
