1. Supported Employment for People with Mental Illness Bob Drake NAMI July, 2009

2. Dilemma in 1990 3-5% population disabled by mental illness People with severe mental illness identify work as their top goal –More than 70% want to work Less than 10% working No effective interventions Bond, 1992

3. 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.”

4. 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

5. 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

6. 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” “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” 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.” “Supported employment is the most effective strategy to help people achieve their employment goals.”

7. Current Status of SE SE model is simple and effective SE model is simple and effective Other benefits accrue with consistent work Other benefits accrue with consistent work Work outcomes improve over time Work outcomes improve over time SE is relatively easy to implement SE is relatively easy to implement

8. IPS Supported Employment Competitive employment Competitive employment Team approach Team approach Client choice regarding timing Client choice regarding timing Benefits counseling Benefits counseling Rapid job search Rapid job search Job matching based on client preferences Job matching based on client preferences On-going supports On-going supports Becker (IPS Fidelity Scale, 2008)Becker (IPS Fidelity Scale, 2008)

10. CT Supported Employment Study (Mueser, 2004)

11. Integration of Vocational and Mental Health Services In 7 controlled studies, the more successful program was integrated, while comparison program was not. –Bond, 2004

12. 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)

13. Impact on Other Outcomes Improved self-esteem, symptom control, quality of life Improved self-esteem, symptom control, quality of life Related to sustained competitive employment Related to sustained competitive employment No changes with sustained sheltered employment No changes with sustained sheltered employment (Bond, 2001)

14. Long-Term Outcomes 4 studies with 10-year follow-ups 4 studies with 10-year follow-ups (Test, 1989; Salyers, 2004; Becker, 2006; Bush, in prep) Work outcomes improve over time Work outcomes improve over time Costs decrease dramatically for consistent workers (Bush, in prep) Costs decrease dramatically for consistent workers (Bush, in prep)

15. 8-12 Year Follow-up: Day Treatment to SE 71% working at follow-up 71% working at follow-up 85% in competitive jobs 85% in competitive jobs 71% worked more than 50% of FU 71% worked more than 50% of FU 90% still receiving benefits 90% still receiving benefits (Becker, 2006) (Becker, 2006)

16. Cost Savings  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)

18. Vitamin C for Scurvy: An Early Randomized Trial 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

19. The British Navy Adopted Dietary Standards for Scurvy: (a) 1602 (b) 1625 (c) 1697 (d) 1795 S. Biestly, Man-of-War (1993).

20. National EBP Project 5 evidence-based practices: SE, IMR, FPE, ACT, IDDT 53 sites in 8 states Programs studied for 2 years

22. Johnson & Johnson- Dartmouth Project Mental health-vocational rehabilitation collaboration Mental health-vocational rehabilitation collaboration implement evidence-based SE implement evidence-based SE Local programs selected by states Local programs selected by states Dartmouth provides training, consultation, and evaluation Dartmouth provides training, consultation, and evaluation First states: CT, DC, KS, MD, OR, SC, VT First states: CT, DC, KS, MD, OR, SC, VT New states: IL, MN, MO, OH New states: IL, MN, MO, OH (Drake, 2006) (Drake, 2006)

23. Employment rates consistently exceed 40% (yellow line) J&J-Dartmouth Community Mental Health Program

24. Early Intervention First episode psychosis (Nuechterlein, 2005; Rinaldi, in press; Killackey, in press) First episode psychosis (Nuechterlein, 2005; Rinaldi, in press; Killackey, in press) SSA: change adjudication process SSA: change adjudication process SSA: accelerated benefits SSA: accelerated benefits Health insurance Health insurance

25. Early Intervention (Nuechterlein, 2005)

26. Benefits Counseling (Tremblay, 2005)

27. Addressing Cognition Concentration, memory, reaction speed, and problem-solving Concentration, memory, reaction speed, and problem-solving Job match Job match Improve cognitive function Improve cognitive function Compensatory strategies Compensatory strategies (McGurk, 2008)

28. Cognitive Training Practicing cognitive tasks may create new neuronal connections Practicing cognitive tasks may create new neuronal connections Tasks directly relevant to work tasks Tasks directly relevant to work tasks New capacity may translate to work New capacity may translate to work (McGurk, 2005)

31. Benefits Reform People are socialized into disability People are socialized into disability Changing benefits structure essential Changing benefits structure essential

32. 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)

33. Conclusions SE has created hope for for people with psychiatric disabilities, their families, and MH/VR practitioners SE has created hope for for people with psychiatric disabilities, their families, and MH/VR practitioners Outcomes can be enhanced further Outcomes can be enhanced further New research New research Policy changes Policy changes

34. Financial Support to PRC 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

35. Many Thanks Deborah Becker Gary Bond Greg McHugo Haiyi Xie Jon Skinner Phil Bush Will Torrey Kim Mueser Rob Whitley Susan McGurk Matt Merrens Paul Gorman Sarah Swanson David Lynde Howard Goldman Eric Latimer Kikuko Campbell Will Haslett Saira Nawaz Crystal Glover

36. Updates on SE Psychiatric Rehabilitation Journal Psychiatric Rehabilitation Journal –Spring, 2008, special issue on SE Supported Employment: A Practical Guide for Practitioners and Supervisors Supported Employment: A Practical Guide for Practitioners and Supervisors (Swanson, 2008)

37. Information: books, videos, research articles Karen Dunn Karen.Dunn@Dartmouth.edu 603-448-0263 http://dms.dartmouth.edu/prc