Vocational Services: Where We Have Been and Where We Are Going
Recovery & Rehabilitation Newsletter
Individuals with psychiatric disabilities remain unattached to the workforce in large numbers and are disproportionately represented on the Social Security Disability Beneficiary rolls. Employment rates among individuals with psychiatric conditions are meager and do not appear to be improving in comparison to the general population1, 2, 3, 4. Without the benefit of vocational services the rates of employment among individuals with psychiatric disabilities work remain low5, 6, 7. This unemployment and underemployment has enormous societal costs and burdens8.
What We Have Learned from the Past
It does help to take a longer view when thinking about how vocational services have evolved over the years. A few decades ago the idea of work for individuals with significant psychiatric disabilities was, by and large, not even a consideration. When I was employed as a rehabilitation counselor for the state of New Jersey, I had a client who was a very bright individual with a law degree. He was interested in returning to the world of work after struggling with a significant psychiatric condition and being unemployed for many years. But functioning well in his previous profession seemed out of the question. He needed to build stress hardiness around work and increase his sense of work self-efficacy prior to considering a return to the law. Unfortunately, given the state of vocational services at that time, we had very little to offer short of a “sheltered workshop,” which was not only a complete mismatch for this individual’s needs and goals, but was demeaning as well. At that time, the concepts and models that we have available today, such as supported employment, supported education, job coaching, progressive employment, and customized employment, had not been developed yet.
Historically, when work goals did begin to enter the conversation for individuals with psychiatric disabilities, vocational rehabilitation interventions emphasized a linear “train-then-place” model, as was exemplified by sheltered workshops. The idea underpinning this model was that individuals needed time to get ready for employment and to gradually acclimate to increased work demands before moving into competitive employment. This often was accomplished with well-meaning programs, but mind-numbing tasks, such as assembly work. Unfortunately, sheltered workshops often led to years in segregated training prior to entry into the competitive employment market, if entry into the competitive employment arena happened at all9, 10.
What We Learned More Recently
Supported employment transformed the paradigm for vocational rehabilitation services and flipped the “train-then-place” paradigm to “place-then-train”9, 10. This resulted in a significant shift in underlying principles regarding the provision of services, emphasizing rapid job search and choice (i.e., see https://ipsworks.org/ for the supported employment principles). Currently, Individual Placement and Support (IPS) is the only evidence-based model of supported employment with numerous trials showing that it is more effective than a host of comparison services in helping people obtain and maintain employment10, 11.
However, despite the growth of supported employment and its implementation in many states12, the very high unemployment rates experienced by the majority individuals with psychiatric disabilities have not been ameliorated4, 13. Evidence suggests that despite these advances, many individuals with significant psychiatric disabilities do not have ready access to supported employment14, 15, obtain low wage jobs without benefits14, and cannot or do not retain employment for long periods16. Thus, critical disparities remain in vocational recovery for individuals with psychiatric disabilities. Clearly, new and innovative initiatives in employment are needed.
Examples of Innovations in Vocational Interventions
Recently, additional interventions have been developed that are designed to better address the vocational needs of individuals with psychiatric disabilities and address gaps in existing services. Examples include the addition of cognitive remediation to supported employment to improve outcomes17, Vocational Illness Management and Recovery18, Vocational Empowerment Photovoice19, 20, Vocational Peer Support21, progressive employment initiatives, and others. Together, these initiatives are designed to address needs for services that can improve competitive work outcomes, job performance, job retention, or job advancement.
Vocational Illness Management and Recovery (VIMR) is an approach designed to address issues of coping and symptoms in the workplace. The intervention was built from an evidence-based practice, called Illness Management and Recovery (IMR)22, which includes strategies to educate individuals about mental illness, to explain and explore the stress-vulnerability model and treatment strategies, to build social support, to educate individuals about the effective use of medications, relapse prevention, and coping with persistent symptoms. VIMR was designed to extend these basic psycho-educational concepts to address concerns in the workplace. The intervention has been developed and tested and manuals and materials developed for its use. The VIMR curriculum, consists of a series of weekly sessions in which mental health practitioners help individuals who have mental health conditions develop personalized strategies for managing symptoms as they move forward in their vocational recovery. Sessions are designed to be flexible and non-linear, allowing practitioners and the person they assist to select content and strategies that are most useful and meaningful for the person at that time. In the sessions, practitioners work collaboratively offering information, opportunities for self-assessment, and strategies and skills that individuals can use both on and off a job to help them further their recovery. There is a strong emphasis on helping people put newly-learned strategies and skills into action in their lives and in the workplace.
Thinking Skills for Work (TSW) is an intervention that is designed to address significant problems related to employment—that is, the cognitive capacity to perform in a work setting. Meta-analyses of over 40 randomized controlled trials (RCTs) of cognitive remediation for persons with psychiatric disabilities have shown that it improves cognitive functioning and psychosocial adjustment, including work functioning23, 24. However, gains in psychosocial functioning occur primarily in studies in which cognitive remediation is added to psychiatric rehabilitation, but not when added to usual services. Ten RCTs have shown that cognitive remediation increases the effectiveness of vocational services in improving work outcomes25, 26, including six RCTs of the Thinking Skills for Work program27, 28, 29, 30. TSW is a manualized program that integrates cognitive remediation and vocational rehabilitation. TSW is implemented by a cognitive specialist, who works as a member of the vocational team and facilitates agency-based computer cognitive practice and strategy coaching using a 24-session curriculum drawn from COGPACK, a commercially available software program31. The specialist also teaches coping strategies to reduce the impact of cognitive challenges on job seeking or work. Training sessions are conducted once or twice a week and require 3-6 months to complete, with the cognitive specialist serving as a consultant to the vocational team after training is completed. Studies of TSW have demonstrated that it improves work outcomes, even among the most difficult to serve individuals29.
Progressive employment is another employment concept that has been gaining traction (https://www.explorevr.org/content/vermont-progressive-employment-model). The progressive employment model does not assume that everyone will be able to or desires to be placed in competitive employment, but rather that “everyone is ready for something” in the world of work. This could include unpaid internships, volunteer work, and so forth. The additional principles that underlie progressive employment include: the notion that small successes leads to further success; that flexibility and creativity based on each person or employer’s situation is needed, that hiring a person with a disability should be low risk for both the employer and the participant, and that a person need not be “job ready” to benefit from progressive employment.
Vocational Empowerment Photovoice (VEP) has been designed to address the gap in our interventions, specifically for individuals who lack a vocational identity or the self-confidence needed to be a worker. The VEP program is a 10-week manualized, structured, peer-led intervention delivered in a group setting that has shown promise in a small clinical trial20 and is now being tested in a larger randomized controlled trial. The VEP program integrates Photovoice methodology, Rehabilitation Readiness technology32, and elements of the Anti-Stigma Photovoice (ASP) curriculum previously developed and tested by our Center33. The VEP program is designed to empower participants to pursue employment services and opportunities, all refined with input from individuals with a lived experience. VEP manuals and materials have been developed including a participant workbook and a leader’s guide. Examples of the sessions include: My Working Life, Writing Your Photovoice Narrative, My Vocational Values, My Vocational Identity, Costs and Benefits of a Working Life, Vocational Supports and Services, Setting Vocational Goals, and My Vocational Journey.
Peer support in the context of work is another important area of development. Peer support has grown dramatically in the past two decades with the majority of efforts focused on promoting overall recovery. More recently however, peer support has expanded to assist individuals to reach goals, such as independent employment and housing, improved access to primary care, and so forth. Among these extensions is the use of peer support to assist individuals in the pursuit of vocational goals. As evidence-based supported employment services have proliferated (Individual Placement and Support, IPS), peer support specialists have begun to work on supported employment teams. The Center for Psychiatric Rehabilitation developed a Vocational Peer Support (VPS) curriculum to address the need for peer specialists acquire the skills and knowledge they require to assist individuals in their vocational recovery. VPS is designed to be delivered by experienced peer specialists, who have been further trained in the following critical components: Knowledge of vocational recovery, using one’s own vocational recovery story, partnering for vocational recovery, inspiring the person to consider work, developing motivational foundations for vocational change, facilitating vocational decision making, and so forth. VPS is designed to be delivered in individual sessions with a trained vocational peer specialist.
Employment Services for Young Adults Experiencing Their First Episode of Psychosis
New models of supported employment and education services were developed as a result of two research projects funded by the National Institute of Mental Health RAISE (Recovery After Initial Schizophrenia Episode) initiative. Both of these research projects were aimed at developing and evaluating Coordinated Specialty Care (CSC) programs for people recovering from a first episode of non-affective psychosis. In addition, both programs adapted supported employment and education programs based on the principles of the Individual Placement and Support (IPS) model and integrated those programs into the other comprehensive treatments using a shared decision-making approach.
The first research project was the RAISE Connection program, now adapted and disseminated as “OnTrackNY” (http://ontrackny.org). This program provides supported employment and education, delivered by a specialist as one component of an array of services delivered by a multidisciplinary team of clinicians, with other components including recovery coaching, family psychoeducation, and pharmacological treatment. OnTrackNY and has been evaluated with results suggesting positive effects including a reduction in symptoms and increased involvement in work and school34, 35.
The second research project was the RAISE Early Treatment Program (RAISE-ETP), within which “NAVIGATE” was developed (http://navigateconsultants.org). The NAVIGATE program is led by a director and usually includes five mental health professionals. One specialist on the team provides supported employment and education services, which involves assisting the person in identifying and pursuing employment and educational goals. Other specialists on the team provide Individual Resiliency Training, aimed at enhancing illness management skills and building strengths, the Family Education program, aimed at working with the family to support the individual’s recovery, Personalized Medication Management, and case management. The NAVIGATE program was evaluated in a rigorous cluster randomized controlled trial36 and suggested higher rates of involvement in school or work among other positive findings.
Initiatives to Improved Job Development and Placement
One example of innovations in job development (a notoriously difficult aspect of providing employment services) is currently being run by the Riverside Employment Collaboratives in Massachusetts (http://www.riversidecc.org/services-for-communities/employment-collaboratives/). There are currently six regional collaboratives which are networks of state agencies and human service providers, employers, workforce development organizations, and employment providers who expand employment opportunities for individuals with disabilities. Employment Collaboratives have been in operation for eight years and began as a way to streamline the process of finding and hiring individuals with disabilities. They work to engage a wide variety of employers in a given region and regularly partner with businesses seeking to enrich their organization and communities through a diverse and inclusive workforce. Employment Liaisons meet with employers and with other vocational service providers to coordinate job development and placement efforts. This approach to job development, partnering with employers, and job placement has improved employment rates significantly for individuals receiving vocational services.
The Center for Psychiatric Rehabilitation is in the process of developing and testing a new intervention focused on career development and guidance, called Opening Doors37.
This group and individually-delivered intervention focuses on bringing mainstream and web-based, career-related information to individuals with psychiatric disabilities, who may not have knowledge of or access to them. The intervention focuses on developing those knowledge-based resources and helping individuals integrate challenges that may arise from their psychiatric disability with their career planning. A manual is not yet ready for dissemination, but more information is available on the Opening Doors webpage.
What We Hope to Learn in the Future
The field needs to continue to work towards the development and testing of new and innovative services, models, and interventions aimed at improving employment outcomes for individuals with psychiatric disabilities. This requires that we continue to listen to and learn from the individuals affected by these interventions, as well as the employment and peer specialists who deliver services.
As providers, researchers, and policy makers, we should examine not only the employment rates and earnings of individuals with psychiatric disabilities enrolled in employment interventions, but also the typical job types, health benefits received, overall attachment to the workforce, and exit from (or avoidance of) the disability rolls. To date, employment initiatives tend to yield minimum wage jobs, low overall earnings, jobs without benefits, and employment without long-term prospects.
In this regard, concepts detailed by the International Labour Organization of the United Nations around the definition of “decent work” may be instructive to our field. While it may be difficult to achieve decent work in all instances, striving for it is a worthwhile goal. Decent work is critical to reducing poverty. The ILO defines decent work as involving “opportunities for work that is productive and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development, and social integration…” among others38.
We need to continue to develop and test enhancements to vocational services that can be used in conjunction with evidence-based or best-practice supported employment interventions, that are effective, that enlarge access for individuals with psychiatric disabilities, and that lead to provide “decent” work.
- Bureau of Labor Statistics. (2017). Employment status of the civilian noninstitutional population by disability status and age, 2015 and 2016 annual averages.
- National Alliance on Mental Illness. (2014a). Mental Illness: NAMI Report Deplores 80 Percent Unemployment Rate; State Rates And Ranks Listed—Model Legislation Proposed. Retrieved from: https://www.nami.org/Press-Media/Press-Releases/2014/Mental-Illness-NAMI-Report-Deplores-80-Percent-Une
- National Alliance on Mental Illness. (2014b). Road to recovery: Employment and mental illness. Retrieved from: https://www.nami.org/about-nami/publications-reports/public-policy-reports/roadtorecovery.pdf
- Substance Abuse and Mental Health Administration. (2015). Mental health statistics. Retrieved from: https://www.samhsa.gov/data/sites/default/files/2015_Mental_Health_Client_Level_Data_Report.pdf
- Mechanic, D., Blider, S., & McAlpine, D. D. (2002). Employing persons with serious mental illness. Health Affairs (Millwood), Sep-Oct; 21(5), 242-53.
- Rosenheck, R., Leslie, D., Keefe, R., McEvoy, J., Swartz, M., Perkins, D., Stroup, S., Hsiao, J. K., & Lieberman, J. (2006). Barriers to employment for people with schizophrenia. American Journal of Psychiatry, 163, 411-417.
- Salkever, D. S., Karakus, M. C., Slade, E. P., Harding, C. M., Hough, R. L., Rosenheck, R. A., Swartz, M. S., Barrio, C., Yamada, A. M. (2007). Measures and predictors of community-based employment and earnings of persons with schizophrenia in a multisite study. Psychiatric Services, 58(3), 315-24.
- Banerjee, S., Chatterji, P., & Lahiri, K. (2017). Effects of psychiatric disorders on labor market outcomes: A latent variable approach using multiple clinical indicators. Health Economics, 26(2), 184-205. doi:10.1002/hec.3286
- Anthony, W. A., & Blanch, A. (1987). Supported employment for persons who are psychiatrically disabled: An historical and conceptual perspective. Psychosocial Rehabilitation Journal, 11(2), 5-23. doi:10.1037/h0099582
- Drake, R. E., Bond, G. R., & Becker, D. R. (2012). Individual placement and support: An evidence-based approach to supported employment. New York, NY: Oxford University Press.
- Metcalfe, J. D., Drake, R. E., & Bond, G. R. (2017). Predicting employment in the mental health treatment study: Do client factors matter? Administration and Policy in Mental Health, 44(3), 345-353. doi: 10.1007/s10488-016-0774-x.
- Bond, G. R., Drake, R. E., Becker, D. R., & Noel, V. A. (2016). The IPS learning community: A longitudinal study of sustainment, quality, and outcome. Psychiatric Services, 67(8):864-9. doi: 10.1176/appi.ps.201500301. Epub 2016 Apr 1.
- Bureau of Labor Statistics. (2014). Labor force statistics from the current population survey. Retrieved from: https://data.bls.gov/timeseries/LNS14000000
- Frey, W., Drake, R., Bond, G., Miller, A., Goldman, H., Salkever, D., & Holsenbeck, S. (2011). Mental health treatment study: Final report to Social Security Administration. Rockville, MD: Westat.
- Marshall, T., Goldberg, R. W., Braude, L., Dougherty, R. H., Daniels, A. S., Ghose, S. S., George, P., & Delphin-Rittmon, M. E. (2014). Supported employment: Assessing the evidence. Psychiatric Services, 65, 16-23.
- Cook, J. A., Burke-Miller, J. K., & Roessel, E. (2016). Long-term effects of evidence-based supported employment on earnings and on SSI and SSDI participation among individuals with psychiatric disabilities. American Journal of Psychiatry, 173, 1007-1014.
- McGurk, S. R., Mueser, K. T., Xie, H., Feldman, K., Shay, Y., Klein, L., & Wolfe, R. (2016). Cognitive remediation for vocational rehabilitation nonresponders. Schizophrenia Research, 175, 48-56.
- Hutchinson, D., Farkas, M. D., & Gagne, C. (2015). Vocational illness management and recovery.Boston, MA: Boston University, Center for Psychiatric Rehabilitation.
- Restrepo-Toro, M. E., Gagne, C., Russinova, Z., Bloch, P., Pritchett, S., Woods, T., & Nicolellis, D. (2015). Vocational employment photovoice. Boston, MA: Boston University, Center for Psychiatric Rehabilitation.
- Russinova, Z., Gidugu, V. Bloch, P., Restrepo-Toro, M., & Rogers, E. S. (Accepted for publication). Empowering individuals with psychiatric disabilities to work: Results of a randomized trial. Psychiatric Rehabilitation Journal.
- Nicolellis, D., & Legere, L. (2015). Vocational peer support. Boston, MA: Boston University, Center for Psychiatric Rehabilitation.
- Mueser, K. T., & Gingerich, S. (2008). Illness self-management training. In K. T. Mueser & D. V. Jeste (Eds.), Clinical Handbook of Schizophrenia (pp. 268-78). New York, NY: Guilford Press.
- McGurk, S. R., Twamley, E. W., Sitzer, D. I., McHugo, G. J., & Mueser, K. T. (2007). A meta-analysis of cognitive remediation in schizophrenia. The American Journal of Psychiatry, 164, 1791–1802. http://dx.doi.org/10.1176/appi.ajp.2007.07060906
- Wykes,T., Huddy, V., Cellard, C., McGurk, S. R., & Czobor, P. (2011). A meta-analysis of cognitive remediation for schizophrenia: Methodology and effect sizes. The American Journal of Psychiatry, 168, 472–485.http://dx.doi.org/10.1176/appi.ajp.2010.10060855
- Bell, M. D., Zito, W., Greig, T., & Wexler, B. E. (2008). Neurocognitive enhancement therapy with vocational services: Work outcomes at two-year follow-up. Schizophrenia Research, 105(1-3), 18-29.
doi: 10.1016/j.schres.2008.06.026. Epub 2008 Aug 19.
- Tan, B. L., & King, R. (2013). The effects of cognitive remediation on functional outcomes among people with schizophrenia: A randomized controlled study. Australian & New Zealand Journal of Psychiatry. 2013 Nov; 47(11):1068-80.
doi: 10.1177/0004867413493521. Epub 2013 Jun 19.
- Lindenmayer, J. P., McGurk, S. R., Mueser, K. T., Khan, A., Wance, D., Hoffman, L., Wolfe, R., & Xie, H. (2008). A randomized controlled trial of cognitive remediation among inpatients with persistent mental illness. Psychiatric Services, 59(3):241-7.
- McGurk, S. R., Mueser, K. T., Xie, H., Welsh, J., Kaiser, S., Drake, R. E., Becker, D., Bailey, E., Fraser, G., Wolfe, R., & McHugo, G. J. (2015). Cognitive enhancement treatment for people with mental illness who do not respond to supported employment: A randomized controlled trial. American Journal of Psychiatry, 172(9), 852-61.
- McGurk, S. R., & Mueser, K. T. (2016). Sustaining the long-term effects of supported employment for persons with psychiatric disabilities. American Journal of Psychiatry, 173, 953-955.
- McGurk, S. R., & Mueser, K. T. (2017). Introduction to special issue on cognitive remediation. Psychiatric Rehabilitation Journal, 40 (1), 1-3.
- Marker Software. Cogpack. http://www.markersoftware.com/
- Farkas, M., Cohen, M., McNamara, S., Nemec, P., & Cohen, B. (2000). Psychiatric rehabilitation training technology: Assessing readiness for rehabilitation. Boston, MA: Boston University, Center for Psychiatric Rehabilitation.
- Russinova, Z., Rogers, E. S., Gagne, C., Bloch, P., Drake, K., & Mueser, K. (2014). A randomized controlled trial of a peer-run anti-stigma photovoice intervention. Psychiatric Services, 65(2), 242-246. doi:10.1176/appi.ps.201200572
- Dixon, L. B., Goldman, H. H., Bennett, M. E., Wang, Y., McNamara, K. A., Mendon, S. J., Goldstein, A. B., Choi, C. W. J., Lee, R. J., Lieberman, J. A., & Essock, S. M. (2015). Implementing coordinated specialty care for early psychosis: The RAISE connection program. Psychiatric Services, 66, 691–98.
- Humensky, J. L., Essock, S. M., & Dixon, L. B. (2017). Characteristics associated with the pursuit of work and school among participants in a treatment program for first episode of psychosis. Psychiatric Rehabilitation Journal, 40, 108-12.
- Kane, J. M., Robinson, D. E., Schooler, N. R., Mueser, K. T., Penn, D. L., Rosenheck, R. A., Addington, J., Brunette, M. F., Correll, C. U., Estroff, S. E., Marcy, P., Robinson, J., Lynde, D. W., Meyer-Kalos, P. S., Gottlieb, J. D., Glynn, S. M., Pipes, R., Kurian, B. T., Miller, A. L., Azrin, S. T., Goldstein, A. B., Severe, J. B., Lin, H., Majnu, J., & Heinssen, R. K. (2016). Comprehensive versus usual care for first episode psychosis: Two-year outcomes from the NIMH RAISE Early Treatment Program. American Journal of Psychiatry, 173, 362-72.
- Millner, U., & Satgunam, S. (2017). Opening Doors: a career development and guidance intervention. Boston, MA: Center for Psychiatric Rehabilitation.
- International Labour Organization of the United Nations. (2018). Decent work.
Numerous products and services of the Center for Psychiatric Rehabilitation are supported by a Rehabilitation Research and Training Center Grant from the National Institute on Disability and Rehabilitation Research, Department of Education and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (NIDRR/CMHS), and specifically Grant: H133B090014. Content of these products do not represent the policies of these federal agencies and viewers should not assume endorsement by the federal government.