1. Research & Evaluation of Supported Employment: Where Are We? Lisa A. Razzano, Ph.D. Associate Professor of Psychiatry National Research & Training Center University of Illinois at Chicago Annual Meeting of the National Alliance on Mental Illness June 22, 2007 San Diego, CA

2. Do we still need to talk about employment? Definitely. Research indicates that the unemployment rate among people with mental illness ranges 3-5 time higher than among those with no mental illnesses… … And an even higher proportion of people with severe mental illnesses are out of the labor force, i.e., not working and not looking for work.

3. Research on Employment There continues to be strong evidence regarding the importance of employment to people living with severe mental illnesses in terms of: alleviation of poverty; therapeutic gains; skill acquisition; and quality of life.

4. Research on Employment There are social and community benefits from reductions in overall cost of care and use of disability entitlements. Advancements in policy (ADA, TWWIIA, Olmstead) and treatment options (community-based care and pharmacological agents) support return-to-work Over the last decade, mounting evidence from small scale trials that Supported Employment is an effective, evidence-based practice in mental health treatment.

5. An Evidence-Based Practice? Guide to Research Methods-The Evidence Pyramid; http://servers.medlib.hscbklyn..edu/2100.htm

6. Characterizing the Levels LevelType of Evidence 1a Evidence obtained from meta-analysis of randomized controlled trials (RCTs)  (underway – Dr. Gary Bond) 1b Evidence obtained from at least 1 RCT  2a Evidence obtained from at least 1 well-designed controlled study without randomization 2b Evidence obtained from at least 1 other type of well-designed quasi-experimental study 3 Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case control studies 4 Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

7. The Employment Intervention Demonstration Program (EIDP) A multi-site, longitudinal (1996-2001) evaluation of clinical & rehabilitative employment interventions, into which newly-enrolled participants were randomly assigned and followed for two years, with bi-annual in-person interviews, & ongoing employment and services data collection. Sites Arizona Massachusetts Connecticut Pennsylvania Maine South Carolina Maryland Texas

8. All EIDP Experimental Interventions Provided… fully integrated clinical, case management, & vocational services multidisciplinary provider teams representing mental health, vocational rehabilitation, concurrent mental health & substance use treatment, peer support, & benefits counseling rapid job search & placement activities a desired outcome of competitive employment jobs that were customized to meet the needs & preferences of consumers ongoing supports available with no time limits

9. Core EIDP Study Outcomes Employment Status (ever worked) Earnings Amount of Work (hours) Competitive Employment* *Competitive Employment: pays minimum wage or higher; located in mainstream, integrated settings; not set-aside for mental health consumers; and job is consumer-owned.

10. EIDP Findings: SE vs. Comparison those in the experimental (SE) groups had better outcomes than those in the comparison groups the advantage of the experimental group participants increased over time relative to the comparison groups

11. Effects of Participant Characteristics Outcomes were better for… people with fewer symptoms (positive or negative) people with lower levels of functional impairment people with no health problems or co-occurring disabilities people not receiving disability income people with diagnoses other than schizophrenia people with better work histories people with a high school education or equivalent younger people

12. Even though participants with some characteristics did better, the experimental models were effective….. ….. REGARDLESS OF CONSUMERS’ PERSONAL CHARACTERISTICS

13. Bottom Line : Some people may need extra assistance or tailoring of programs to meet special needs (e.g. help with medical problems, support for dealing with troublesome symptoms, extra training for those with little prior work experience) Integrated, supported employment services result in positive employment outcomes regardless of consumers’ personal characteristics, health problems, diagnoses, symptom levels, work histories, and functioning levels.

14. Research-Based Principles of Successful Vocational Rehabilitation Strategies: Are These Available in Your Area? 1. People with serious mental illness can be successfully engaged in competitive employment. 2. Vocational rehabilitation services should involve employment in integrated settings for minimum wage or above. 3. Consumers should be placed in paid jobs as quickly as possible and according to their preferred pace. 4. Ongoing vocational support should be available as needed and desired. 5. Consumers should be helped to find jobs that match their career preferences.

15. Research-Based Principles 6. Vocational rehabilitation services should explicitly address financial planning and provider education/support around disability benefits and entitlements. 7. Vocational and mental health services should be integrated and coordinated. 8. Vocational service providers should work collaboratively with consumers to address issues of stigma and discrimination, and to help negotiate reasonable accommodations with employers. 9. Vocational rehabilitation services should be made available to all mental health consumers. 10. Vocational services should involve family and friends in supporting consumers’ efforts to work. Employment Intervention Demonstration Program www.psych.uic.edu/eidp Center for Mental Health Services Substance Abuse and Mental Health Services Administration