Overview of Supported Employment

Supported employment is a model of vocational rehabilitation that helps consumers with developmental disabilities, serious mental illness, or other significant disabilities get placed in jobs that they want to pursue (Florida Department of Education, Division of Vocational Rehabilitation, 2018; Moll, Huff, & Detwiler, 2003 as cited in Brown & Stoffel, 2011; SAMHSA, 2009). This model also gives consumers the supports, accommodations, and training needed to enable their success in the workplace (Moll, Huff, & Detwiler, 2003 as cited in Brown & Stoffel, 2011). Rather than using a “train and then place” approach from the traditional vocational rehabilitation model, a “place and then train” approach is used instead, also known as the Individual Placement and Support (IPS) model within supported employment (Becker & Drake, 1993 as cited in Brown & Stoffel, 2011; Drake & Becker, 1996 as cited in Brown & Stoffel, 2011; Bond et al., 2001 as cited in Brown & Stoffel, 2011; Bond, 2004 as cited in Brown & Stoffel, 2011). The IPS model was created to increase treatment outcomes for consumers as well as helping them acquire competitive employment like people who do not have disabilities (Becker & Drake, 1993 as cited in Brown & Stoffel, 2011; Drake & Becker, 1996 as cited in Brown & Stoffel, 2011; SAMHSA, 2009). Supported employment in its entirety shows consumers that regardless of their condition, it is possible for them to find a job that best fits their strengths and experiences instead of trying to become “perfect workers” (SAMHSA, 2009).

Populations that benefit from supported employment

Although supported employment helps consumers with developmental disabilities and other significant disabilities, consumers with serious mental illness are an important population in supported employment (Florida Department of Education, Division of Vocational Rehabilitation, 2018; U.S. Department of Labor, 1993 as cited in Brown & Stoffel, 2011). One example of a serious mental illness is schizophrenia, as well as other psychotic disorders (Brown & Stoffel, 2011). Consumers with schizophrenia or other psychotic disorders may show one or more of these abnormalities, which include “delusions, hallucinations, disorganized thinking and speech, grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms” (American Psychiatric Association, 2013). These abnormalities can affect how a consumer is in the workplace. Negative symptoms can decrease a consumer’s performance, which are more prevalent in consumers with schizophrenia (American Psychiatric Association, 2013). Consumers that exhibit these negative symptoms may not speak as much, express emotions, have motivation to initiate purpose activities, experience pleasure, show interest in social interactions, or have opportunities for social interactions (American Psychiatric Association, 2013). As for developmental disabilities, these would include neurodevelopmental disorders that “produce impairments of personal, social, academic, or occupational functioning” (American Psychiatric Association, 2013). These impairments can widely vary “from very specific limitations of learning or control of executive functions to global impairments of social skills or intelligence” (American Psychiatric Association, 2013). No matter what disability a consumer may have, supported employment will help that consumer find a job.

Expected outcomes of supported employment

The goal of supported employment is to help consumers find jobs in typical settings in the community outside of segregated workshops and also having the supports needed to be successful at work (U.S. Department of Labor, 1993 as cited in Brown & Stoffel, 2011; SAMHSA, 2009). Examples of such supports include “job coaches, arranged transportation, and assistive technology” (U.S. Department of Labor, 1993 as cited in Brown & Stoffel, 2011). It allows for consumers to take part in work settings with people who do not have disabilities and earn competitive wages (SAMHSA, 2009). There are a several components that make up supported employment programs. One component consists of integrating the consumer’s mental health services with the employment assistance services and having them work in synchrony with each other (Bond & Jones, 2005 as cited in Brown & Stoffel, 2011; SAMHSA, 2009). A second component involves allowing a consumer to use supported employment services based off of their desire to work and not on their illness or employment history (Bond & Jones, 2005 as cited in Brown & Stoffel, 2011; SAMHSA, 2009). A third component focuses finding a competitive job that fits the consumer’s preferences, which is the goal (Bond & Jones, 2005 as cited in Brown & Stoffel, 2011; SAMHSA, 2009). A fourth component is comprised of starting the job search as soon as a consumer decides to enter the supported employment program (Bond & Jones, 2005 as cited in Brown & Stoffel, 2011; SAMHSA, 2009). A fifth component includes unlimited customized support for the consumer whenever they need it (Bond & Jones, 2005 as cited in Brown & Stoffel, 2011; SAMHSA, 2009). Lastly, a sixth component incorporates Social Security benefits counseling, which helps the consumer take care of their Social Security, health insurance, and other government benefits efficiently (Bond & Jones, 2005 as cited in Brown & Stoffel, 2011; SAMHSA, 2009). This counseling will further help the consumer’s entry into the workforce, as well as helping them keeping their job (Bond & Jones, 2005 as cited in Brown & Stoffel, 2011). Therefore, supported employment helps consumers get competitive jobs and makes the transition into those jobs go more smoothly.

Team members of supported employment

In order to make supported employment work effectively, a team is needed to help with different responsibilities. The supported employment staff is made up of supported employment leaders, employment specialists, benefits specialists, and mental health practitioners (SAMHSA, 2009). Supported employment leaders supervise employment specialists and serve as the link to other coordinators within a mental health agency (SAMHSA, 2009). Employment specialists are the servicers of supported employment by assisting consumers with acquiring and upholding jobs that go along with their vocational goals and recovery (SAMHSA, 2009). Benefits specialists are the go-to people when a consumer needs complete information about benefits and work incentives (SAMHSA, 2009). They help consumers who want to go to work by looking over their benefits and informing them about how work will affect them (SAMHSA, 2009). As the consumers work more and make more money, benefits specialists can provide individualized benefits planning to help them handle their benefits and health care coverage (SAMHSA, 2009). Mental health practitioners uphold vocational goals of consumers as well as talk about clinical and rehabilitation concerns that pertain to work (SAMHSA, 2009). These concerns can include side effects from medication, ongoing symptoms such as hallucinations, cognitive problems, and other rehabilitation needs that will facilitate better work performance, such as social skills training to improve a consumer’s ability to socialize (SAMHSA, 2009). Once a consumer is in the competitive workforce, supervisors and coworkers can also provide natural support to them as they transition into the job, which can help them retain a job for a longer period of time (McGurk, Mueser, & Pascaris, 2005 as cited in Brown & Stoffel, 2011).

Literature review

Kirsh, B. (2016). Client, contextual and program elements influencing supported employment: A literature review. Community Mental Health Journal, 52, 809-820.

Here is a literature review that focused on issues within supported employment (SE) that have not been the main points of research for this model. There were six research questions that were asked. They were as follows: 1) What impact do labor market trends have on the effectiveness of SE? 2) How lasting are the effects of SE and what factors influence longevity of SE? 3) What levels and types of employment are targeted by SE? 4) What are the characteristics of people who benefit most from SE? 5) What is the role of peer support in SE? 6) What are the barriers to effective SE implementation? A literature search that looked at peer-reviewed articles that ranged from 1988 to 2010 was performed using major databases. Two keywords that were used were “supported employment” and “individual placement and support.” Articles that were included in the study were about supported employment with people with mental illnesses or comorbid addiction and mental disorders. Articles that were not included were about fidelity measurements or were simply program descriptions without any outcomes. For each article reviewed, a template cover sheet was created as data was extracted. A cover sheet had the type of study, purpose, design, context, and participants of each study. There were also headings for each research question. Once all of the information was collected from the articles, a separate document was made for each research question, and the data pertaining to that question was put into that document. The information on these documents were then summarized to look at the complete answer for each question being asked.

Results revealed that labor market trends are inversely related to SE efficacy rates. When there are high unemployment rates, there are lower employment rates for SE. On the other hand, a healthy economy leads to higher rates of job acquisition and longer lengths of employment. Participants in SE programs worked longer than other groups across all studies. The presence of skills training, cognitive training, funding models, and job matching positively contribute to the long-lasting effects of supported employment. Participants of SE programs had jobs in competitive settings that were the same as coworkers without mental illnesses. The jobs were at least minimum wage, either part-time or full-time, and mostly entry-level positions that were involved in retail, service, general laborer, and clerical work. They did not require technical skills, advanced education, or prior work experience.

In regards to characteristics within each participant, positive personal attitudes and beliefs, higher education (at least a high school degree), prior employment history, higher cognitive and mental health characteristics, supportive families, and association with income support increased their ability to find and keep jobs. Males tended to find and get jobs more than females due to the physical nature of some jobs. Age had mixed results with participants under the age of thirty-five having better employment outcomes or older participants between the ages of forty and forty-nine having longer job tenure. Demographics did not significantly determine job tenure. The presence of peer support helped participants in SE programs feel like they were not alone in their pursuit for competitive jobs. It was helpful for participants to talk to people in similar situations, and it pushed them to continue with the job search. There were several barriers found that negatively affected supported employment.

Negative attitudes toward participants and the lack of skills, training, and knowledge of SE staff led to decreased effectiveness of SE. There were leadership challenges that affected the productivity of SE programs. Screening and referral challenges were presented through some teams only wanting to help participants who were more likely to perform well in the workforce and some mental health professionals seeing work as a stressor for participants rather than a benefit. Then there was the fear of losing health insurance and other benefits based on disability policies and social security programs. Stigma towards people with mental illness continues to be prevalent, which can affect a participant’s ability to get a competitive job.

From this article, it was found that supported employment can be very effective for people with serious mental illness. On the other hand, the effectiveness of this model also depends on many factors. For instance, supported employment is more successful when a person has the interest and motivation to find a job. Although supported employment programs do not discriminate against people based on their mental illness or prior work experience, it looks like people who are in supported employment programs have a higher probability of getting a job if they have previous employment history, are higher functioning and have a handle on their symptoms, and participate in peer support groups. There are also outside influences that can change the effectiveness of supported employment, such as labor market trends, an inefficient supported education staff, and discrimination against people who are participating in supported employment. With all of this information in mind, it looks like the research shows that the effectiveness of supported employment depends on factors within the participants of a supported employment program and factors outside of the participants’ control.

Occupational therapy’s role in supported employment

With supported employment being dependent on the preferences of the consumer, it is not difficult to incorporate its principles in the client-centered profession of occupational therapy. Occupational therapy can complement supported employment by finding ways for a consumer to successfully participate in their desired activities and tasks in the workplace. Occupational therapists can advocate for the right of consumers to pursue competitive jobs. Along with this, they can advocate for consumers to get special transportation so they can get to work safely and on time. If consumers are placed in a job that they are interested in but are having difficulties with some job tasks, occupational therapists can do activity analysis and find ways to adapt the environment or job task or introduce the use of assistive technology to complete job tasks.

Besides job tasks, occupational therapists can help with skills training that will help further support consumers’ success in the workplace. For example, if a consumer is having difficulties engaging in social interactions with supervisors, coworkers, or customers if applicable, occupational therapists can organize a social skills training for them. If a consumer is having difficulties expressing their wants and needs in the workplace, occupational therapists can organize an assertion skills training. Other examples of skills training can pertain to organization or time management to help consumers perform efficiently and in a timely manner at work. As a consumer starts making more money, money management techniques can also be taught by an occupational therapist, perhaps in collaboration with the benefits specialists. Together with the supported employment staff, occupational therapists can help uphold the principles of supported employment.

Areas of impairment that supported employment addresses

The main impairment that supported employment addresses is work. It helps consumers identify their interests that can help them pinpoint potential jobs and then look into those jobs. Employment specialists can then help consumers find and get jobs. Once consumers get jobs, then the supported employment staff can help improve their job performance as necessary through skills training, occupation modifications, environmental modifications, and introducing assistive technology when needed. A second impairment that is addressed is driving and community mobility. Special transportation may need to be arranged in order for a consumer to get to work safely and on time, as well as get picked up when the work day is finished. A third impairment that is addressed is financial management. Thanks to the presence of a benefits specialist on the supported employment staff, consumers will have knowledge of their benefits and healthcare coverage. They will also learn money management techniques as they earn more money. Addressing these impairments will help a consumer be successful in their everyday life.

PEO Model and supported employment

To relate supported employment back to occupational therapy, an occupational therapy model that will best complement supported employment is the PEO model. The PEO model focuses on the dynamic relationships that occur when people participate in their occupations in different environments over time (Brown & Stoffel, 2011). These relationships between people, occupations, and environments can either positively or negatively affect each other, and changes within any part affects the other parts on various levels (Brown & Stoffel, 2011). Analyses are performed on the relationships between the person and the occupation, the occupation and the environment, and the person and the environment during a specific point of time and space (Brown & Stoffel, 2011). Depending on the circumstances, the amount of each part can vary, and occupational performance can look different every time (Brown & Stoffel, 2011). The overlapping of all three components and the resulting performance from it is the person’s occupational performance (CAOT, 1997).

This occupational therapy model works well with supported employment when a consumer gets a job. In order to see if a consumer needs skills training, job task modifications, or assistive technology, the relationship between the consumer and the occupation can be analyzed to see if the interaction between them promotes success at work. The relationship between a consumer and the environment can be looked at to see if there are any outside influences that are affecting the consumer while at work. Furthermore, the relationship between an occupation and the environment can be examined to see if there are outside influences affecting how an occupation at work is performed or if an occupation is affecting the environment. Looking at the interactions between a consumer, their occupation, and their environment through this model can help adjust themselves, the job task, or the workplace accordingly so the consumer can increase their occupational performance.

Evaluation tools that can complement supported employment

Assessment tools that can be used to evaluate consumers and complement supported employment are client interview, interest checklist, and activity analysis. Through a client interview, the consumer can express their interests in their own words, and from there, potential jobs can be determined. If it is difficult for a consumer to think of what they are interested in, an interest checklist with a list of different activities can be used to specifically pinpoint interests. Once a consumer is in the workplace, activity analysis can be performed. The consumer can be observed doing a job task and analyze their performance. If there are problems, then modifications can be incorporated, such as changing the job task or the environment or introducing assistive technology in order to increase the consumer’s job performance. Occupational therapy can help assess consumers before or after they obtain a competitive job.

Occupational therapy intervention goals

There are five general intervention goals that can be worked on based on the supported employment model. The first goal is for the consumer to identify interests to help with their job search. For a consumer who participated in social skills training, the second goal is for the consumer to interact with supervisors, coworkers and customers using skills obtained from the social skills training. If a consumer needs to use assistive technology, the third goal is for the consumer to successfully complete job tasks while using assistive technology. For a consumer who needs to work on time management, the fourth goal is for the consumer to manage their time effectively by getting to work on time, completing job tasks during the time allotted, and leaving work at their designated time. As for a consumer who received organization skills training, the fifth goal is for the consumer to incorporate techniques to help them stay organized in the workplace.

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