1. IPS SUPPORTED EMPLOYMENT
The Evidence-Based Practice for Employment
Kick-off training presentation
Individual Placement and Support (IPS) is the evidence-based practice of supported employment for adults with severe mental illness.
See accompanying notes for IPS Supported Employment PPT (9/10/14).

2. Why Focus on Employment?
Viewed by many as an essential part of recovery
Most consumers want to work
A typical role for adults in our society
Cost-effective alternative to day treatment
When many people request services from a mental health agency, it is not with the hopes that they will spend more time in treatment groups or take more medication. What most people want is to get their lives back. “What people want is a car, a job, and a date on Friday night.”—Pat Deegan
Working is often mentioned by consumers in describing their recovery process.   
Cost-effective alternative to day treatment: See:
- Clark, R. E. (1998). Supported employment and managed care: Can they coexist? Psychiatric Rehabilitation Journal, 22(1),
Show Introductory Video to Supported Employment or 3 Faces, 3 Lives Video.

3. Benefits of Steady Competitive Employment
Increased income
Improved self esteem
Improved social networks
Increased quality of life
Better control of symptoms
Reduced substance use
Reduced use of mental health services -

4. Is Work Too Stressful? As compared to what?
Joe Marrone, an employment trainer:
“If you think work is stressful, try unemployment.”
Stresses of work do not translate into higher rates of hospitalization

5. Negative Effects of Unemployment in General Population
Increased substance abuse
Increased physical problems
Increased psychiatric disorders
Reduced self-esteem
Loss of social contacts
Alienation and apathy
(Warr, 1987)

6. Competitive Employment for People with Severe Mental Illness: The Gap
Say they want to work: 66%
Are currently working: <20%
Have access to evidence-based employment services: 2%

7. Evidence-Based Practice
Program model validated by rigorous research (different investigators)
Has guidelines describing critical components
Has a treatment manual

8. Quotes from Consumers
“I feel so much better about myself now that I have a job.”
“Holding down my job is not always easy but it has helped my self esteem.”
“When I go to work I don’t hear the voices.”
“Now that I am working again I can buy my daughter presents.”
There are now many qualitative studies amplifying the subjective experiences of working: M. Alverson(1995), H. Alverson (1998); Quimby (2001).

9. Quotes from Family Members
“I worried that if my son got a job he would get stressed. But just the opposite happened. He is doing so much better than before.”
“I feel better that she tries working when she has the support of mental health.”
“I was really glad that my son’s employment counselor asked me about work ideas. He landed a job that I suggested.”

10. Quotes from Employers
“Andre is as good as any worker that I have.” Automotive parts store manager.
“I count on Juanita. If she is feeling stressed, she sits in the back room for awhile. That’s OK; she gets the job done.” Bakery supervisor.
“The employment counselor helped me understand why Tony paces. It’s okay in the security business.” Security business owner.
Employers are looking for people who can do the job.
Many employers have direct experience with severe mental illness: in their own lives, family members, friends, other workers. They provide support and job accommodations as needed.
Sometimes suggestions from the employment specialist assist employers in how best to support a person working.

11. Competitive Employment Rates in 22 Randomized Controlled Trials of IPS
Study references are listed on website: (About IPS>References for IPS Supported Employment Evidence>Randomized Controlled Trials of IPS).
Studies were conducted by different research investigators, in different locations and different labor markets, with different populations. Generally, in these studies IPS was compared to stepwise approaches in which people were expected to participate in prevocational, stepwise services prior to being given assistance seeking competitive jobs.

12. Overall Findings for 22 RCTs
All 22 studies showed a significant advantage for IPS
Mean competitive employment rates for the 22 studies:
56% for IPS
23% for controls

13. Definition of Supported Employment
Mainstream job in community
Pays at least minimum wage
Work setting includes people who are not disabled
Service agency provides ongoing support
Intended for people with most severe disabilities
Previous approaches were geared toward prevocational training such as work crews, work units, sheltered work (jobs in settings with others with mental illness, often doing piecework), and volunteer positions.
Is a successful approach that has been used in various settings by culturally diverse consumers, employment specialists, and practitioners.
Defined in Rehabilitation Act Amendments of 1986 (Federal Register, Aug 14, 1987).

14. Evidence-Based Practice Principles
Eligibility is based on consumer choice
Competitive employment is the goal
Supported employment is integrated with treatment
Personalized benefits planning is provided
Rapid job search is encouraged
Employment specialists build employer relationships
Follow-along supports are continuous
Consumer preferences are important
Swanson, S. J., & Becker, D. R. (2013). IPS supported employment: a practical guide. Lebanon, NH: Dartmouth Psychiatric Research Center.
Bond, G. R. (1998). Principles of the Individual Placement and Support model: Empirical support. Psychiatric Rehabilitation Journal, 22(1),
Drake, R. E., Bond, G. R., & Becker, D. R. (2012). Individual Placement and Support: An evidence-based approach to supported employment. New York: Oxford University Press.

15. Eligibility Is Based on Consumer Choice
Consumers are not excluded because they are not “ready” or because of prior work history, hospitalization history, substance use, symptoms, or other characteristics.
No one is excluded who wants to participate.
Most factors used to screen consumers don’t do very well in predicting who can work (Anthony & Jansen, 1984). This is especially true for standardized tests. Clinicians are not very accurate in picking out who is not ready, either.
Kansas study: In interviews at successful employment programs, staff focus on consumer success stories in working; staff from unsuccessful programs preoccupied with consumer deficits, how they are too symptomatic, have poor skills, and are lower functioning (Gowdy et al., 2003). Staff expectations may have a lot to do with success.
Although many programs exclude people for alcohol use, a review of 5 studies found that dually disordered clients did no better or worse than clients without alcohol problems (Sengupta, 1998). Other studies also support the view that people with dual disorders benefit from IPS. Needless to say, alcohol use should be taken into account in job matching, as should all client characteristics.
The IPS model subscribes to the value, as John Beard from Fountain House espoused, that everyone deserves a chance to work, regardless of history or background (Beard, Propst, & Malamud, 1982).

16. Competitive Employment Is the Goal
The agency needs to devote sufficient resources to supported employment to permit full access to all consumers who seek competitive employment
Consumers interested in employment are not steered into day treatment or sheltered work.
Competitive employment is a job in the community that anyone can apply for and pays at least minimum wage. The wage should not be less than the normal wage (and level of benefits) paid for the same work performed by individuals who do not have a mental illness. The duration of the job is determined by the needs of the business, rather than the employment program. Part-time jobs and seasonal jobs that are part of the regular labor market are considered competitive. Positions for “peers” are also competitive because a lived experience of mental illness is required for these positions.
Vocational programs employing stepwise approaches with preparation such as skills training, prevocational training, and transitional employment are not effective in helping people achieve competitive employment:
Rapp and Goscha (2011) have documented the dispiriting, demeaning and infantilizing culture fostered by day treatment centers that organize services around training clients for some future life outside the day center. Research findings on the conversion of 6 different day treatment programs to supported employment in New Hampshire, Rhode Island, and Massachusetts have been consistent (summarized in Bond, 2004). These studies have found better employment outcomes, especially for regular attenders of day treatment; no increase in negative outcomes (no increase in hospitalizations, dropouts, symptoms, homelessness, etc.).
Studies comparing IPS to sheltered work show a sharp advantage for IPS.

17. IPS Is Integrated with Mental Health Treatment
Employment specialists coordinate plans with the treatment team, e.g., case manager, therapist, psychiatrist, and other community providers, e.g., Vocational Rehabilitation
Integration is important because you are treating “the whole person.” Studies have found if you broker services, communication breaks down and important tasks are not done in a coordinated fashion. Because vocational rehabilitation and mental health are often funded by different sources, mental clinicians and employment specialists often are employed by different agencies with little coordination. Stein and Test (1980) articulated the concept of a multidisciplinary team providing services for a range of client needs. The IPS model adopted this principle and the evidence strongly supports this approach as a critical component of the model.
Employment specialists learn about mental illnesses and treatment by participating in mental health treatment team meetings. And mental health practitioners learn about employment, and begin to value employment, by having the employment specialist on their team.
In many places, Vocational Rehabilitation (VR) counselors also participate in the mental health treatment team meeting so that all of the practitioners working with a person coordinate their efforts to support the person’s work goals. VR counselors also benefit from these meetings as it provides them with a greater understanding of how the mental health system operates, including information about strategies to help people who have active substance use disorders. And VR counselors share information about the services that they can provide, as well as information about other disabilities, types of jobs, etc.
Family members (as defined by each person) are also invited to be part of a meeting along with the job seeker to discuss ideas for good job matches, and helpful job supports.

18. Personalized Benefits Planning Is Provided
Benefits planning and guidance help consumers make informed decisions about job starts and changes.
Fear of losing benefits is the single most common barrier to seeking employment (MacDonald-Wilson, Rogers, Ellison, & Lyass, 2003). For this reason IPS programs provide accurate individualized information regarding the consequences of starting a job or increasing employment earnings through increasing hours or a raise. Individualized benefits planning is associated with increased earnings from employment (Tremblay, Smith, Xie, & Drake, 2006). Studies show that IPS is an effective model for clients receiving Social Security disability benefits (Bond, Xie, & Drake, 2007; Drake et al., 2013).
Employment specialists also provide assistance with reporting earnings to entitlement systems for some people. They may provide side-by-side assistance until people understand how to report earned income on their own.

19. Rapid Job Search Is Encouraged
Job search starts soon after a consumer expresses interest in working.
Pre-employment assessment, training, and counseling are kept to a minimum.
Studies dating from the 1980s have consistently shown that helping consumers to find paid community jobs is more effective than requiring them first to attend prevocational training (Bond & Dincin, 1986; Dincin & Witheridge, 1982). IPS studies show that rapid job search for competitive jobs is more effective than stepwise approaches (Drake et al., 1999; Drake, McHugo, Becker, Anthony, & Clark, 1996; Mueser et al., 2004).
Most clients prefer the rapid job search approach to stepwise approaches that use prevocational work units and transitional employment as preparation for competitive jobs (Bedell, Draving, Parrish, Gervey, & Guastadisegni, 1998; Lucca, 1998). If we really believe in designing services consistent with consumer preferences, then we should be hesitant to promote lengthy pre-employment services.
Requiring clients to complete prevocational training before seeking work is often demoralizing. Paradoxically, staff rate clients on prevocational work crews paradoxically as less work ready than those who begin paid employment immediately (Schultheis & Bond, 1993).
Generally, the employment specialist and job seeker spend a few weeks getting to know each other and developing a career profile. Afterwards, either the employment specialist and/or job seeker makes in-person contact with an employer about a job. Occasionally, someone may state that he is not quite ready to begin applying for jobs. In those cases, the employment specialist still helps the person make contact with employers, though it may be to learn about different types of jobs and businesses.

20. Employment Specialists Build Employer Relationships
Employment specialists meet face-to-face with employers over time to learn about business needs and positions.
Each specialist makes at least 6 contacts with hiring managers each week.
Some vocational models, such as the job club, provide classroom training to help clients to find jobs on their own. The evidence is quite clear, however, that many people with serious mental illness get discouraged and give up with self-directed job searches (Bond, 1992; Corrigan, Reedy, Thadani, & Ganet, 1995). Many studies have shown that employment specialists and vocational counselors who devote more time to employer contacts have higher job placement rates (Leff et al., 2005; Rosenthal, Dalton, & Gervey, 2007; Vandergoot, 1987; Zadny & James, 1977). In recent years, IPS specialists have defined specific job development strategies (Carlson, Smith, & Rapp, 2008; Royer, 2014; Swanson, Becker, & Bond, 2013; Swanson, Becker, Drake, & Merrens, 2008) for a range of clients, including those with criminal justice histories (Swanson, Langfitt-Reese, & Bond, 2012).
In IPS supported employment, the initial focus is on learning about the workplace and business needs of each employer. By doing that, employment specialists become a resource to employers for introducing qualified candidates. Employment specialists help their clients by making better recommendations about potential places to work. Employers begin to trust employment specialists through this process because the specialists demonstrate their desire to help the employer, and also because they show that they are reliable by coming to the business on more than one occasion.

21. Follow-Along Supports Are Continuous
Employment specialists continue to stay in regular contact with consumer and (when appropriate) the employer without arbitrary time limits.
McHugo et al. (1998) assessed employment outcomes 42 months after enrolling in an IPS study for IPS clients who gained employment. The sample was divided into two groups: those who continued to receive vocational services and those who did not. Among those who were receiving vocational support, 71% were employed, while among those who were not, 28% were working.
Bond and Kukla (2011) found a significant positive correlation (r =.27) between frequency of employment specialist contacts and months employed for 142 clients who had obtained employment in an IPS program.
Job supports are also individualized based upon the person’s preferences, strengths, work history, current living situation and other issues. An employment specialist might offer weekly meetings to talk about the job, help with transportation to work, family meetings to discuss progress at work, employer meetings with the worker present for feedback on performance, assistance with work clothing or uniforms, wake-up calls, etc. Mental health practitioners help with other skills that are specific to each person, for example, conversational skills with co-workers, getting feedback from a supervisor, etc. And medication prescribers offer assistance with medication adjustments to help the person feel at his best when he is working.

22. Consumer Preferences Are Important
Job finding is based on consumers’ preferences, strengths, and work experiences, not on a pool of jobs that are available.
Matching clients to jobs matching their preferences is associated with greater job satisfaction and job tenure (Huff, 2005; Kukla & Bond, 2012). An important part of this is the occupational matching hypothesis, which states that clients who obtain jobs matching their initial preferences will be more satisfied with their job and will continue working longer than those who are not matched. Most studies fully or partially supported this hypothesis (Becker, Drake, Farabaugh, & Bond, 1996; Gervey & Kowal, 1994; Mueser, Becker, & Wolfe, 2001), although some studies have not (Becker, Bebout, & Drake, 1998; Bond, Campbell, & Becker, 2013)
The employment specialist talks with the client about how aspects of his/her culture may impact working. Culture can be related to race or ethnicity, but it can also be related to socio-economic status, age, sexual orientation, veteran status, disability status, etc. Not everyone who shares a culture has the same perspective.  It is critical to remember that each person has a unique viewpoint.

23. Job Preferences Are Important
Preferences can relate to type of job, but also to amount of work, work shifts, work environment, job location, whether or not to share information about a disability at work, and IPS services.

24. Key Factors in Implementation
Build Consensus
Maximize Financing
Examine Agency Philosophy
Identify Leadership
Key on Organizational Structure
Provide Ongoing Training
Make Time Commitment
Track Process and Outcomes
The three phases of implementing a program include: motivating, enacting, and sustaining. Six stakeholder groups participate in each of these phases: consumers, families, practitioners, program leaders, state and county mental health authorities.

25. Build Consensus
Commitment of state mental health authority is not enough
Better to involve all stakeholders - consumers, family members, providers, and local and state MH and VR administrators
Surveys show that both consumers and family members rank employment programs high on the list of services that are not easy to access (Crane-Ross, Roth, & Lauber, 2000; Noble, Honberg, Hall, & Flynn, 1997; Steinwachs, Kasper, & Skinner, 1992). Therefore, these groups may be advocates for such services. However, consumer groups also are sometimes suspicious of supported employment if it is being introduced as a change in the status quo, and their viewpoint should be heard. McFarlane et al. (2001) provide a case example where a lack of consensus interfered with dissemination. Cohen and Becker (2014) provide examples of the role of family advocacy in promoting positive change for promoting IPS dissemination. See the discussion of consensus-building in CSAT (2000).

26. Maximize Financing
Determine how supported employment services can be funded
Explore funding through Mental Health, Vocational Rehabilitation, and Medicaid
Reallocate resources to supported employment when feasible
Without stable and adequate funding, IPS programs cannot survive (Bond et al., 2013). Currently most states implementing IPS in the U.S. use braided funding, drawing primarily on three sources: state mental health funds, federal-state Vocational Rehabilitation (VR) funding, and Medicaid.
State leadership is a key to maximizing funding. Many examples of maximizing funding are found in the experiences of states in the IPS learning collaborative. Maryland’s approach to blending funding for IPS is often given as a model (Becker et al., 2007). Modifying the state Medicaid plans to provide easy funding access for IPS is one strategy many leaders are advocating for funding IPS (Hogan, Drake, & Goldman, 2014). A guide to financing IPS was developed by Karakus et al. (2011).
At an agency level, some agencies have been able to shift resources from day treatment (Clark, 1998) or sheltered work (Murphy & Rogan, 1995) to implement supported employment. But this reallocation is not easy, because of stiff resistance within the organization.
Examine the vocational process to ensure that each phase is funded: engagement, employment planning (career profile), job search, job supports, and career development. Strive to answer key questions such as how will all of these services be paid for if the person is not eligible for VR or does not want VR services? Will VR counselors help people who have active substance use disorders with competitive employment? Will VR counselors be able to help with more than one job, if needed? How quickly can VR open cases—if it takes more than a month or two, how will services be paid for prior to a VR authorization for services? How will long-term job supports (post VR closure) be funded?

27. What Does IPS Cost? Estimates of per-client annual costs
$2500 (Latimer et al., 2004)
$4300 (HMC, 2006)
$6400 (Cimera, 2007)
Adjusting for inflation, 2014 estimates range from $3200 to $7300
Factors affect cost: severity of disability, local wages, indirect costs and which clinical services included
- Cimera, R. E. (2008). The costs of providing supported employment services to individuals with psychiatric disabilities. Psychiatric Rehabilitation Journal, 32,
- Health Management Consultants. (2006). Evaluation of the adequacy of the rates for evidence based best practice supported employment services in the public mental health system. Columbia, MD: State of Maryland Department of Health and Mental Hygiene, Mental Hygiene Administration and Medicaid Administrations.
- Latimer, E., Bush, P., Becker, D. R., Drake, R. E., & Bond, G. R. (2004). How much does supported employment for the severely mentally ill cost? An exploratory survey of high-fidelity programs. Psychiatric Services, 55,
- Salkever, D. S. (2013). Social costs of expanding access to evidence-based supported employment: concepts and interpretive review of evidence. Psychiatric Services, 64,

28. Examine Agency Philosophy
Determine if service agency’s philosophy, mission statement, and service paradigm are consistent with recovery-oriented, evidence-based approach to IPS supported employment.
Gowdy’s qualitative study in Kansas shows this most vividly (Gowdy et al., 2003; 2004).
Does the agency support competitive employment as a consumer goal? Is everyone encouraged to think about employment?
Does the service orientation promote rehabilitation and recovery or does it promote stabilization and dependence on the mental health system?
Is consumer choice honored?

29. Identify Leadership You need a champion!
Identify committed leader with sufficient authority to oversee and ensure implementation
Leaders at all levels visibly show support for supported employment
Center director buy-in is critical
Leadership from Vocational Rehabilitation aids collaboration
Agency leadership (i.e., executive director, clinical director, fiscal director, and quality assurance director) may not be involved in every phase of implementation, but must understand how IPS is different from other employment approaches and should receive regular updates about progress on implementation. Agency leaders may be needed to help with the relationship with VR, funding for employment specialist positions, integrated team meetings, etc.
Charlie Rapp’s work describes the role of leadership.
Rapp, C. A., & Poertner, J. (1992). Social administration: A client-centered approach. White Plains, NY: Longman Publishing.
Rapp, C. A., Bond, G. R., Becker, D. R., Carpinello, S. E., Nikkel, R. E., & Gintoli, G. (2005). The role of state mental health authorities in promoting improved client outcome through evidence-based practice. Community Mental Health Journal, 41,
Rapp, C. A., Etzel-Wise, D., Marty, D., Coffman, M., Carlson, L., Asher, D., et al. (2008). Evidence-based practice implementation strategies: Results of a qualitative study. Community Mental Health Journal, 44,

30. Leadership Roles Provide necessary resources
Seek buy-in from consumers, families, and practitioners
Give recognition to staff and consumer for successes
Rapp’s finding – Critical role of supervisor in program success
IPS steering committees are an effective method to include leaders in implementation. These committees meet quarterly until good fidelity is obtained, and twice yearly thereafter. Membership can include agency leaders, VR supervisors and counselors, the IPS supervisor, family members, agency clients, employers and others. The focus of the committee is to examine barriers to implementation and to develop written plans for better fidelity to IPS supported employment.

31. Organizational Structure
Employment specialists
Join one or two treatment teams.
Share office space with treatment team.
Communicate frequently with treatment team members.
Team integrates supported employment, benefits counseling, case management, psychiatric services, and dual diagnosis treatment.
Employment specialists need to communicate frequently with treatment team members to coordinate planning. Employment outcomes are higher in programs that have an integrated service system rather than a brokered service system (Drake, 1995).

32. Provide Ongoing Training
Initial training for all team members, including medical staff
Continuing access to expert consultation
Ongoing supervision that is outcomes-oriented
Effective training for IPS includes not only classroom training, but also working alongside staff as they make employer contacts, collaborating with mental health practitioners, meeting with VR counselors, helping job seekers consider what work they would enjoy and so forth. IPS trainers and supervisors focus on demonstrating skills, observing employment specialists at work, and providing feedback to help specialists improve their effectiveness.
Swanson, S. J., & Becker, D. R. (2013). IPS supported employment: A practical guide. Lebanon, NH: Dartmouth Psychiatric Research Center.
Dartmouth PRC Online Courses on IPS Supported Employment and Supervision.
Dartmouth IPS website for training videos, outcome measures and program resources.

33. Make Time Commitment
Typically, months needed to develop skills, interest, and confidence for implementing evidence-based supported employment
Becker et al. (1998) followed over 12 programs that took between 6-12 months to implement evidence-based supported employment.
Bond et al. (2008) found that 9 newly-implemented IPS programs needed about 6 months to achieve good fidelity to IPS.

34. Track Implementation Process and Outcomes
Track employment outcomes monthly
Set goals: 40% rate of competitive employment is achievable
Use the IPS-25, a 25-item supported employment fidelity scale to measure implementation
The IPS learning collaborative has tracked employment outcomes for the past decade (Becker, Drake, & Bond, 2014). Empirical benchmarks for good employment outcomes have been established (Drake, Bond, & Becker, 2012). The IPS-25 is now widely used and is significantly associated with competitive employment outcomes (Bond, Peterson, Becker, & Drake, 2012).
Measure outcomes, not just for the IPS team, but also for individual specialists. Help staff improve by setting goals and offering to work on those goals along with employment specialists.

35. Summary
People with severe mental illness can work in competitive employment
Programs following evidence-based principles of supported employment have better outcomes
Programs must address financial and organizational barriers to be successful
IPS changes the culture of agencies and provides a service that most people want.