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Mueser K.T., Campbell K., Drake R.E.
Journal of Dual Diagnosis: 2011, 7(1–2), p. 90–102.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Mueser at kim.t.Mueser@dartmouth.edu.
Compared to more gradualist approaches, with appropriate support targeted at rapidly achieving this objective, far more mentally ill problem substance users in the USA were enabled to find competitive employment in the open labour market rather than sheltered placements.
Summary Controlled research has consistently demonstrated that supported employment programmes, especially the Individual Placement and Support model, are more effective at promoting employment than a range of other vocational rehabilitation approaches such as group skills training, brokered vocational services, or transitional employment programmes. However, it has not yet been established whether clients suffering from both psychiatric and substance use problems also have better outcomes in supported employment programmes. The featured analysis addressed this issue, drawing on data from four randomised controlled trials of Individual Placement and Support.
All four studies recruited unemployed patients suffering from severe mental illness who were attending mental health centres, and randomly allocated them to a newly established Individual Placement and Support programme or to one or more well established comparison vocational services. All the comparison services were highly regarded, active programmes, considered at the time to be state-of-the-art. Generally they shared an emphasis on stepwise entry into competitive employment and brokered services in which the vocational programme was provided by a separate agency from the mental health programme.
Importantly, none of the studies excluded clients on the basis of substance use disorders, illness severity, lack of readiness, poor job history, or other clinical factors. Across the four studies, about two thirds of the 1063 clients agreed to participate. A few were later excluded or not followed up, leaving 681 patients in the studies. Of these, 106 'dual diagnosis' patients also suffered currently or in the past six months from substance abuse or dependence, and formed the subgroup for the featured analysis. Typically they were psychotic single black men around 40 years of age.
Over the 18 months after the studies started, the featured analysis assessed entry in to competitive employment at prevailing wages in businesses independent of the rehabilitation service and not provided as part of a rehabilitation package. It found that on all the measures, the dual diagnosis participants in the studies had significantly better employment outcomes after being allocated to an Individual Placement and Support programme than to comparison services. More obtained competitive employment (60% v. 24%) and had worked 20 or more hours per week over the 18 months (47% v. 10%). On average per person they had also worked on more weeks (20 v. 13) and hours (607 v. 219) in total and earned more ($3050 v. $807) than comparison clients. When the focus was narrowed to the clients in both groups who worked at some time during the 18 months, it remained the case that more clients allocated to Individual Placement and Support had worked 20 or more hours per week (78% v. 43%) and they had also found their first job sooner (in 133 days v, 252). The other measures all favoured the Individual Placement and Support clients but not to a statistically significant degree.
Dually diagnosed clients randomly allocated to Individual Placement and Support had significantly better competitive work outcomes than those offered comparison vocational services. Despite engaging a greater range of clients in work, including some presumably at the 'less ready' end of the readiness for work range, Individual Placement and Support clients were also more likely to work at least half time and on average found a job much sooner. Afforded the advantages conferred by Individual Placement and Support, the overall work outcomes of these dually diagnosed clients were comparable to those of mentally ill patients in general after being offered supported employment programmes.
These results underscore the importance of one of the principles of the approach – that anyone who wants competitive work should be allowed to participate in supported employment, regardless of any other challenges they experience, such as symptoms, recent relapses, cognitive impairment, or substance abuse. There is no need to wait until these problems have been resolved; in particular, sobriety is not a prerequisite for benefiting from supported employment. The findings also suggest that supported employment may be an important rehabilitation adjunct for many people with dual diagnoses, aiding their recovery. Competitive employment and the income it brings with it are also often valued outcomes in themselves for the patients and contribute to their quality of life.
commentary These impressive results suggest that given individualised and intensive support geared to this objective, some of the most difficult to place patients can successfully enter the labour market. They are a counter to over-pessimistic or over-cautious concerns that such people can never be found normal employment, or not until step by step they have resolved their problems and got used to working through volunteering and sheltered employment.
The Individual Placement Support model was the one highlighted in a report on what might work best in employment support for people with drug and alcohol problems in London based on experience in the city and international research with mentally ill populations. The report said the approach has been found more successful in placing participants into competitive employment than the traditional 'train and place' approach, where an individual has a long period of vocational training and voluntary work experience before attempting to access paid work. In contrast, the Individual Placement Support model involves rapid job search and minimal pre-vocational training. The Sainsbury Centre for Mental Health also chose the approach as the most effective method of helping people with severe mental health problems achieve sustainable competitive employment and in 2009 declared itself committed to "supporting the implementation of Individual Placement and Support (IPS) in the UK".
The approach is described as embodying the following key principles:
• It aims to get people into competitive employment.
• It is open to all who want a job.
• It tries to find jobs consistent with people's preferences.
• Job search is rapid.
• Employment specialists are located in clinical teams.
• It provides time-unlimited, individualised support for both employer and employee.
• Welfare benefits counselling is included.
Now the featured analysis has confirmed that in the US context the approach truly is superior to well established alternatives for problem substance users with severe mental illness. It should however be remembered that the analysis was not concerned with employment or productive occupation as such, but with employment closely defined to be the kind Individual Placement and Support services target. In the four studies which fed data in to the analysis, sometimes alternative schemes sometimes achieved as high a rate of employment, but of a different kind. Neither is it necessarily the case that increased competitive employment rates associated with Individual Placement and Support also mean this approach leads to greater improvements in functioning and symptoms and greater job satisfaction, and while clearly applicable to a substantial proportion of patients, the studies do not provide support for using the approach for people unwilling to try the open labour market or who are unable to sustain engagement with psychiatric rehabilitation services. Details below.
In one study Individual Placement and Support was compared against a more traditional approach which placed severely mentally ill patients in a range of vocational options based on their readiness for work, including businesses run by or contracted by rehabilitation agencies offering protected employment, and sometimes the patient-employees were supervised by rehabilitation agency staff. In this study there was the expected advantage for Individual Placement and Support in helping patients find competitive employment (75% v. 34%) but the proportions attaining any kind of paid employment were roughly the same at 80% and 75% respectively. The reason was that the alternative approach placed many more patients in forms of protected employment run by the rehabilitation agency. In another similar study, 45% of Individual Placement and Support patients obtained competitive employment but just 8% sheltered employment; for patients offered alternative vocational services the situation was almost exactly reversed, with just 7% finding competitive employment but 54% sheltered employment.
Neither is it necessarily the case that increased competitive employment rates associated with Individual Placement and Support also mean this approach leads to greater improvements in functioning and symptoms and greater job satisfaction. In one study, generally patients in the two groups were equally satisfied with their jobs. As well as job satisfaction, other studies (1 2 3) have found that improvements in global functioning, quality of life, self-esteem, and psychiatric symptoms did not significantly differ. This finding of equivalence does however mean that there were no widespread negative psychological consequences of these vulnerable patients being encouraged to rapidly try competitive employment.
It is also the case that participants in the studies were self-selected as willing and able to join a programme which might (depending on their random allocation) seek to rapidly insert them in to the competitive labour market. In two studies (1 2) this was half the patients admitted to the rehabilitation services. Also it is unclear from the featured report just how severe were the patients' substance use problems; at a minimum they met the equivalent of standard US criteria for 'abuse' but – especially in a mentally ill population – this need not be indicative of a problem severely limiting ability to benefit from an employment programme. The four studies also demonstrate that it can take a year for an Individual Placement and Support service to find its feet and that it is not always successfully implemented.
The most recently published of the four studies amalgamated in the featured analysis recruited patients between 1999 and 2002. It must be open to question whether in labour market conditions in Britain today, any approach will be able to make a big difference to the chances of severely mentally and drug or alcohol dependent patients finding normal paid employment.
Thanks for their comments on this entry in draft to Kim Mueser of the Dartmouth Psychiatric Research Center in Concord, USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 26 September 2011
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HOT TOPIC 2015 Promoting recovery through employment