Transcript Supported Employment for People with Mental Illness Bob Drake NAMI

Supported Employment
for People with Mental Illness
Bob Drake
NAMI
July, 2009
Dilemma in 1990
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3-5% population disabled by mental illness
People with severe mental illness identify work as
their top goal
– More than 70% want to work
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Less than 10% working
No effective interventions
• Bond, 1992
Gary Bond’s 1992 Review
“Traditional psychiatric rehabilitation
programs do not prepare clients for
competitive employment, but
instead help clients adjust to
various agency-sponsored
employment options.”
Supported Employment
From developmental disabilities field
 Place and train approach
 Focus directly on competitive jobs
 Long-term supports
 Modifications for mental health
clients based on ACT

Supported Employment
Mainstream jobs in community
 Pays at least minimum wage
 Integrated work settings
 Ongoing support
 For people with most severe disabilities
 Place and train model

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.”
Current Status of SE
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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
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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
MA
(ACT)
99
DC
(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)
Integration of Vocational and
Mental Health Services
 In
7 controlled studies, the
more successful program was
integrated, while comparison
program was not.
– Bond, 2004
Job Preference Studies
 Most
clients have stable and
realistic job preferences.
 Clients matched to initial job
preference stay in job twice as
long as those not.
(Becker, 1996; Gervey, 1995)
Impact on
Other Outcomes
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Improved self-esteem, symptom control, quality
of life
 Related to sustained competitive employment
 No changes with sustained sheltered employment
(Bond, 2001)
Long-Term Outcomes
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4 studies with 10-year follow-ups
(Test, 1989; Salyers, 2004; Becker, 2006; Bush, in prep)
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Work outcomes improve over time
 Costs decrease dramatically for consistent
workers (Bush, in prep)
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
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(Becker, 2006)
Cost Savings
Figure 1. Cost Outpatient Services and Institution Days
Minimum Work
48000
Steady Work
Mean Cost
43000
38000
33000
28000
23000
18000
13000
8000
0
1
2
3
4
5
6
7
8
9
10
Years
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Each person with a SMI who becomes employed achieves an average savings in
health costs of $5,000 per year (Bush et al. in press)
People with Severe Mental Illness in
Treatment
No
Employment
services
40%
Already
Employed
10%
Ineffective
Employment
Services
23%
EvidenceBased
Supported
Employement
2%
Not Interested
in Employment
25%
Vitamin C for Scurvy: An
Early Randomized Trial
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Methods: Four-ship
voyage to India in 1601. In
one ship, sailors received
3 teaspoons of lemon juice
per day
Results: At halfway point,
no sailors had died in the
treatment group. In the
control group 110 of 278
(40%) had died of scurvy
Source: Berwick, JAMA, 2003
The British Navy Adopted
Dietary Standards for Scurvy:
1602
(b) 1625
(c) 1697
(d) 1795
(a)
S. Biestly, Man-of-War (1993).
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
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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
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(Drake, 2006)
J&J-Dartmouth Community
Mental Health Program
8000
100%
7000
90%
Employment rates consistently exceed 40% (yellow line)
80%
No of Clients
6000
70%
5000
60%
4000
50%
3000
40%
30%
2000
20%
1000
0
# Served
10%
4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q
02 03 03 03 03 04 04 04 04 05 05 05 05 06 06 06 06 07 07 07 07 08 08 08 08
792 121 141 192 203 236 281 287 292 285 302 318 329 341 373 410 486 474 468 478 489 516 599 657 735
915 974 117 118 131
# New Clients
% of SE
38 42 46 44 43 40 43 49 48 50 52 53 54 55 55 55 49 50 51 49 50 48 46 45 45
# Served
# New Clients
% of SE
0%
Supported Employment & National
Unemployment Rate
Total Number of Clients Served in Ten States by Quarter
Early Intervention

First episode psychosis (Nuechterlein, 2005; Rinaldi, in
press; Killackey, in press)
SSA: change adjudication process
 SSA: accelerated benefits
 Health insurance
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Early Intervention (Nuechterlein, 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
Benefits Counseling
(Tremblay, 2005)
$1,100
Quarterly Earnings
$1,000
Outcomes for Psychiatric Benefit Counseling Intervention Group
Versus Two Nonparticipant Psychiatric Voc Rehab Comparison Groups
(N = 364 per group)
Pre-Enrollment
Post-Enrollment
$900
$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
Addressing Cognition
Concentration, memory, reaction speed,
and problem-solving
 Job match
 Improve cognitive function
 Compensatory strategies
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(McGurk, 2008)
Cognitive Training
Practicing cognitive tasks may create
new neuronal connections
 Tasks directly relevant to work tasks
 New capacity may translate to work
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(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
Benefits Reform
People are socialized into disability
 Changing benefits structure essential
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Policy Changes
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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)
Conclusions
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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
Financial Support to PRC
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Grants from NIDA, NIDRR, NIMH, RWJF, SAMHSA
Contracts from Guilford Press, Hazelden Press,
MacArthur Foundation, Oxford Press, New York
Office of Mental Health, Research Foundation for
Mental Health
Gifts from Johnson & Johnson Corporate
Contributions, Segal Foundation, Thomson
Foundation, Vail Foundation, West Foundation
Many Thanks
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Deborah Becker
Gary Bond
Greg McHugo
Haiyi Xie
Jon Skinner
Phil Bush
Will Torrey
Kim Mueser
Rob Whitley
Susan McGurk
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Matt Merrens
Paul Gorman
Sarah Swanson
David Lynde
Howard Goldman
Eric Latimer
Kikuko Campbell
Will Haslett
Saira Nawaz
Crystal Glover
Updates on SE
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Psychiatric Rehabilitation Journal
– Spring, 2008, special issue on SE
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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
