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					  Research in Supported
Employment for People with
  Psychiatric Disabilities

     Sandra G. Resnick, Ph.D.
         June 23rd, 2008

Department of Psychiatry, Yale University
        School of Medicine and
VA Northeast Program Evaluation Center
               (NEPEC)
      Disclaimer:
    The conclusions
    presented in this
presentation are my own
opinion, and nothing but
      my opinion.
Disability and employment:
Are psychiatric disabilities different?
    Veterans: who are they?
    Researchers: lumpers or splitters?
        Universal design
        Accommodations
    Stigma
    Where are services provided?
        State vocational rehabilitation
        Community Mental Health
        Part of treatment
Research Agenda: Two Levels

   Individuals: How to improve work success?

   Programs: Implementation & dissemination
Models of Vocational Services
   Sheltered Workshops
       Piece rate
       Not integrated
   Transitional Employment
       Goal may not be competitive employment
       General job development
       Some sheltered, some integrated
   Diversified Placement approaches
       Gradualism
       Goal is PAID employment
       Array of options
   Supported Employment
       Goal is competitive employment in community
       Individualized approach
Supported Employment Principles
   Goal is competitive employment
   Zero-exclusion
   Rapid job search
   Individualized job search
   Long-term follow along support
   Benefits Counseling
   Integration with Mental Health Team

   Job Carving (small businesses)
            Competitive Employment Rates
            Figure 1. Competitive Employment Rates in 15 in
        Randomized Controlled Trials of Supported Employment
90%
                     15 RCTs of Supported Employment
80%                                                                                   Bond (2007)
70%

60%

50%

40%

30%

20%

10%

0%
        96      94     07      04      05      06      06      99      07     95        07      06      00    97      02
       NH      NY      IL     CT      HK      SC      MA      DC      CA      IN      EUR     QUE      NY    CA      MD
      (IPS)   (SE)   (IPS)   (IPS)   (IPS)   (IPS)   (ACT)   (IPS)   (IPS)   (SE)     (IPS)   (IPS)   (SE)   (SE)   (IPS)

                                     Supported Employment            Control        Control 2
Mean days to first competitive job:
7 IPS RCTs

 250

 200
                       Control
 150
                      206 days
 100       IPS (SE)
           138 days
  50

  0


                                 Bond, 2008
     Weeks worked (annualized):
     7 IPS RCTs
20


15
                             IPS/SE      control
                             19.2 wks   18.9 wks
10
         IPS/SE
5       12.1 wks
                   control
                   4.8 wks
0
        total sample           workers only

                                         Bond, 2008
Improving Employment Rates in SE:
Research Areas
   Adjunctive interventions
       Illness Management and Recovery
       Cognitive remediation
       Work-specific skills training
       Peer-provided services
   Disclosure and accommodations
   Critical ingredients
   Employer interventions
What is Fidelity?
   Degree to which program follows a model
   Fidelity Scales operationalize a model
   IPS (SE) Scale gold standard
       Empirical norms
       Discriminates between vocational models
   Implementation tool
       Initial training
       Program drift
       Sustainability
   VHA example
     Fidelity in VHA as of June 2008:
     Total Score
75                                                                   Consistent
70                                                                    with SE
65                                                                       Fair SE
60                                                                   Implementation
55                                                                      Not SE
50
45
40     52.2        60.8      63.5      64.4      64.7      64.3
35
30
25
20
15
      6 months   12 months 18 months 24 months 30 months 36 months
       n = 21     n = 21    n = 21    n = 20    n = 19    n=3
Who trains and rates?
   In VHA – one person
   Limited number of experts
   Mentor-trainers: different skill sets
       Doing is not teaching
       Teaching is not evaluating
   How much can be taught?
     What influences dissemination?

 BASELINE                                             YEAR 1                           YEAR 2
Administrative                                        Training
                   Training
  Support                                             Intensity
                   Intensity
                                                   Administrative
    Work
                                                     Support
 Environment
                          SE          Employment                           SE          Employment
                     Implementation    Outcomes        Work           Implementation    Outcomes
Congruence:                                         Environment
Values & Beliefs

                                                   Congruence:
Congruence:                                        Values & Beliefs
 Behaviors
Gowdy (2004)
   High Performing          Low Performing
 Weekly meetings with       No regular forum
   clinicians (80%)

Both SE & clinical staff     Rigid boundaries
 talk about teamwork        between programs

All staff have philosophy    Work is “wishful
that work is achievable        thinking”
Gowdy (2004)

  High Performing            Low Performing
Staff don’t view stigma,    Stigma, symptoms,
symptoms, motivation,       motivation, etc. are
   etc. as barriers to       “reasons” for low
      employment            employment rates

  Clinicians monitor       Clinicians view work as
 vocational progress          the SE team’s job
Summary
   Unique aspects of psychiatric disabilities
   SE is effective, but still has shortcomings
       Adjunctive interventions
       Disclosure and accommodations
       Critical ingredients
       Employer interventions
       Access and interest
       Benefits
   Programmatic research
       How to train
       How to rate
       What influences successful dissemination

				
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