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The Illinois Employment & Recovery Revolution. Emerging Options for Persons with Co-Occurring Disabilities Regions I & II . Overview of the day. EBSE & MISA research, principles, practice, org. structure EBSE & Recovery in consumers voices VR unique contributions

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The illinois employment recovery revolution

The Illinois Employment & Recovery Revolution

Emerging Options for Persons with Co-Occurring Disabilities

Regions I & II

Overview of the day
Overview of the day

  • EBSE & MISA research, principles, practice, org. structure

  • EBSE & Recovery in consumers voices

  • VR unique contributions

  • Opportunities for collaboration & leadership

Why focus on employment
Why Focus on Employment?

  • Viewed by many as an essential part of recovery

  • Most consumers want to work

  • A typical role for adults in our society

  • Cost-effective alternative to day treatment

Positive outcomes from competitive work
Positive Outcomes from Competitive Work

  • Higher self-esteem

  • Better control of psychiatric symptoms

  • More satisfaction with finances and with leisure

    (Bond et al., 2001)

Is work too stressful
Is Work Too Stressful?

  • As compared to what?

  • Title of an article:

    “If you think work is stressful, try unemployment.”

  • Stresses of work do not translate into higher rates of hospitalization

Negative effects of unemployment in general population
Negative Effects of Unemployment in General Population

  • Increased substance abuse

  • Increased physical problems

  • Increased psychiatric disorders

  • Reduced self-esteem

  • Loss of social contacts

  • Alienation and apathy

  • (Warr, 1987)

Competitive employment for people with severe mental illness
Competitive Employment for People with Severe Mental Illness

  • Say they want to work: 70%

  • Are currently working: <15%

  • Current access to supported employment: <5%

J & J-Dartmouth Project

  • mMental health-vocational rehabilitation collaboration

  • iImplement evidence-based SE

  • LLocal programs selected by states

  • DDartmouth provides training, consultation, and evaluation

  • FFirst states: CT, DC, KS, MD, OR, SC, VT

  • NNew states: IL, MN, OH

  • (Drake, 2006)

J&J Project Strategies

  • SStart with “early adopters”: states & programs

  • VVR-MH collaboration: Consistent finding

  • LLongitudinal training

  • OOutcome-based supervision

  • PProblem solving by local experts

  • (Drake, 2006)

Overview for Narcoleptics

  • SSupported employment is an effective evidence-based practice

  • LLong-term perspective is even better

  • IImplementation is critical

  • AAmplifying effectiveness: more people and more hours

Narcoleptics cont
Narcoleptics (cont.)

  • Illinois leads through partnerships

  • VR & SA role is unfolding

  • Cross-fertilization of SA, MH, VR models and methods in our state

What is evidence based practice
What Is Evidence-Based Practice?

  • A practice validated through rigorous research

  • Has guidelines describing critical ingredients

  • Ideally, has been successfully implemented in a wide range of settings

Randomized controlled trials rcts of supported employment
Randomized Controlled Trials (RCTs) of Supported Employment

  • Strongest scientific design for evaluating whether a treatment works

  • Studies include:

    • 4 conducted before evidence-based principles articulated by IPS model

    • 13 used full implementation of IPS

Current Status RCTs Employment

  • 117 studies: add UCLA , EU, Thresholds, Australia

  • 660% vs. 22% employment

  • FFindings very consistent

  • RRecent IPS studies over 70% employment – early intervention

Indirect Impact on EmploymentOther Outcomes

  • RRelated to sustained competitive employment

  • IImproved self-esteem, symptom control, life satisfaction

  • NNo changes with sustained sheltered employment

  • (Bond, 2001)

Studies of Long-Term Outcomes from Supported Employment Employment

  • TTest: 10 years

  • MMcHugo: 3.5 years

  • BBond: 3.5 years

  • SSalyers: 10 years

  • BBecker: 8-12 years

  • DDrake: 10 years

10-Year Follow-up of Day Treatment to SE Conversion Employment

  • 992% worked during follow-up

  • 447% currently working

  • 333% worked at least 5 years

  • MMany reported increases in hope, self-esteem, relationships

  • (Salyers, 2004)

8-12 Year Follow-up of SE Employment

  • 771% working at follow-up

  • NNearly all in competitive jobs

  • 77% sheltered, 10% volunteer

  • 771% worked more than 50% of FU

  • BBut 90% still receiving benefits

  • (Becker, 2006)

Current Status of SE Employment

  • EEveryone who wants to work should receive SE

  • MMost will succeed and difficult to predict

  • LLimitations of current SE

  • CCurrent efforts to improve outcomes

Limitations of SE Employment

  • OOne-fourth do not work

  • MMost people do not work full-time

  • MMost people stay on benefits

Amplifying the Effects Employment

  • SSkills training (Marder)

  • EVR role (Illinois/Dartmouth)

  • BBenefits counseling (Tremblay)

  • MMotivational interviewing (Corrigan, Drebing)

  • CContingency management (Drebing)

  • CCognitive training (McGurk)

  • CCompensatory mechanisms (Velligan)

  • MMedications (MATRICS)

Explaining Variance Employment

  • 225% local economy

  • 225% SE fidelity

  • 550% individual practitioner

  • (Becker, 2006)

Definition of supported employment
Definition of Employment Supported Employment

  • Mainstream job in community

  • Pays at least minimum wage

  • Work setting includes people who are not disabled

  • Service agency provides ongoing support

  • Intended for people with most severe disabilities

Evidence based principles
Evidence-Based EmploymentPrinciples

  • Eligibility is based on consumer choice

  • Supported employment is integrated with treatment

  • Competitive employment is the goal

  • Personalized benefits planning is provided

  • Job search starts soon after a consumer expresses interest in working

  • Follow-along supports are continuous

  • Consumer preferences are important

Eligibility is based on consumer choice
Eligibility Is Based on Consumer Choice Employment

  • No one is excluded who wants to participate.

  • Consumers are not excluded because they are not “ready” or because of prior work history, hospitalization history, substance use, symptoms, or other characteristics.

Supported employment is integrated with mental health treatment
Supported Employment Is Integrated with Mental Health Treatment

  • Employment specialists coordinate plans with the treatment team, which includes case managers, therapists, and psychiatrists.

Do client characteristics predict success in supported employment

Valued Gateway Client : Treatment

Inserted slide

Do Client Characteristics Predict Success in Supported Employment?

  • Co-occurring substance use does not lead to lower employment rates.

  • Consumers generally do better in supported employment than in alternative programs regardless of background characteristics such as:

    • gender, education, ethnicity, diagnosis, hospitalization history, cognitive functioning

Competitive employment is the goal
Competitive Employment Is the Goal Treatment

  • The agency needs to devote sufficient resources to supported employment to permit full access to all consumers who seek competitive employment.

  • Consumers interested in employment are not steered into day treatment or sheltered work.

Personalized benefits planning is provided
Personalized Benefits Planning Is Provided Treatment

  • Benefits planning and guidance help consumers make informed decisions about job starts and changes.

Job search starts soon after a consumer expresses an interest in working
Job Search Starts Soon After A Consumer Expresses an Interest in Working

  • Pre-employment assessment, training, and counseling are kept to a minimum.

Follow along supports are continuous
Follow-Along Supports Are Continuous Interest in Working

  • Supported employment staff continue to stay in regular contact with consumer and (when appropriate) the employer without arbitrary time limits.

Consumer preferences are important
Consumer Preferences Are Important Interest in Working

  • Job finding is based on consumers’ preferences, strengths, and work experiences, not on a pool of jobs that are available.

Job Preferences Are Important Interest in Working

Key Factors in Implementation Interest in Working

  • Build Consensus

  • Maximize Financing

  • Examine Agency Philosophy

  • Identify Leadership

  • Key on Organizational Structure

  • Provide Ongoing Training

  • Make Time Commitment

  • Track Process and Outcomes

Examine Agency Philosophy Interest in Working

  • Determine if service agency’s philosophy, mission statement, and service paradigm are consistent with recovery-oriented, evidence-based approach to supported employment.

Build Consensus Interest in Working

  • Commitment of state mental health authority is not enough

  • Better to involve all stakeholders - consumers, family members, providers, and local and state MH, VR, SA, etc. administrators

Maximize Financing Interest in Working

  • Determine how supported employment services can be funded

  • Explore funding through Mental Health, Vocational Rehabilitation, and Medicaid (Ill. DRS/DMH co-funding model)

  • Reallocate resources to supported employment when feasible (DMH Rule 132 changes)

What Does Supported Employment Cost? Interest in Working

  • Some programs, $2,000-$4,000 per client per year (Clark, 1998).

  • Latimer (2004) $2,449 per full-year equivalent

  • Figures vary according to severity of disability, local wages of employment specialists, and how much indirect costs and costs of clinical services are included (Illinois Model – VR $5117)

Ticket to work
Ticket to Work Interest in Working

  • Revisions in the Social Security employment support program designed to support EBSE programs.

  • Milestone payments in 3 phases, up to 60 months

  • Milestone I in Phase I triggered when an individual earns $335 in a month

  • Employment Networks (EN)

Ticket cont
Ticket (cont.) Interest in Working

  • EN be any entity except an individual and a federal agency

  • Partnership Plus: VR and community programs

  • Considering becoming an EN: Contact CESSI (877 743-8237 v/tty)

  • Getting started: Contact Maximus (866 968-7842 v, 866 833-2967 tty)

Identify Leadership Interest in Working

  • You need a champion!

    • Identify committed leader with sufficient authority to oversee and ensure implementation

  • Leaders at all levels visibly show support for supported employment

  • Center director buy-in is critical

  • Leadership from Vocational Rehabilitation integral to the collaboration

Leadership Roles Interest in Working

  • Provide necessary resources

  • Seek buy-in from consumers, families, and practitioners

  • Give recognition to staff and consumer for successes

  • Rapp’s finding – Critical role of supervisor in program success

Problem Solving Interest in Working

  • What does consumer want?

  • Are SE principles being followed?

  • Is leader ensuring staff has skills to implement supported employment?

  • Have training and resource materials been utilized?

Provide Ongoing Training Interest in Working

  • Initial training for all team members, including medical staff

  • Continuing access to expert consultation (e.g. Ill. T.A. Team)

  • Ongoing supervision that is outcomes-oriented

Make Time Commitment Interest in Working

  • Typically, 6 - 12 months needed to develop skills, interest, and confidence for implementing evidence-based supported employment

Track Implementation Process and Outcomes Interest in Working

  • Track employment outcomes monthly

  • Set goals: 40% rate of competitive employment is achievable

  • Service agencies should use Supported Employment Fidelity Scale to measure implementation of evidence-based practice (Becker et al., 2008)

Supported employment unit recommended basic structure
Supported Employment Unit: Interest in WorkingRecommended Basic Structure

  • Minimum of 2 full-time staff

  • Staff devoted exclusively to SE

  • Full-time leader/supervisor who also provides employment services

  • Offices physically located in mental health center

Supported employment unit
Supported Employment Unit Interest in Working

  • Individual caseloads, but help each other (with job leads, etc.)

  • Caseloads of about 20 consumers or less

  • Weekly team meetings + individual supervision

Roles of an employment specialist
Roles of an Employment Specialist Interest in Working

  • Problem-solver

  • Team player

  • Networker

  • Employment specialist

    • Customer-oriented

    • Community-oriented

    • Outcome-oriented

Characteristics of effective employment specialists
Characteristics of Effective Employment Specialists Interest in Working

  • High energy

  • Optimistic

  • Likes to meet new people

  • Good listener

  • Knows the community

  • Creative

  • Projects confidence and professionalism

Employment coordinator duties
Employment Coordinator Duties Interest in Working

  • Manages referrals

  • Hires and supervises employment staff

  • Ensures employment specialists are learning and using effective skills in:

    Engagement Assessment

    Job development Job support

More employment coordinator duties
More Employment Coordinator Duties Interest in Working

  • Role model good employment practices

  • Provide supported employment information and training to all staff, including upper management

  • Ensure employment services are integrated with treatment teams

Referral Interest in Working

  • Make referral process simple!

  • Have minimal eligibility criteria

    • Unemployed (or working non-competitively) and wants competitive employment, or

    • Employed, but not receiving employment supports, and wants such support

  • Involve multiple stakeholders

Collaboration with vocational rehabilitation

Valued Gateway Client : Interest in Working

What about the collaboration? This slide is not very informative

Collaboration With Vocational Rehabilitation

  • VR counselor meets consumers at mental health agency

  • VR counselor is part of the treatment team

  • VR counselor conveys same message as rest of team

Vocational Rehabilitation Interest in Working

  • - VR has a corporate culture that values work-first and assumes anyone is capable of employment.

  • - VR staff have job placement/development skills & networks.

  • - VR staff have expertise in multi-disability work accommodations.

  • - VR staff have access to an array of resources.

Vocational Rehabilitation (cont.) Interest in Working

  • -- VR system designed to monitor quality of services at local – regional – state levels

  • e.g. fidelity to best practices.

  • -- VR staff collaborate across systems.

  • Enhanced Shared Practice:

  • -- Career counseling (Motivational Interviewing)

  • -- Strength - Based Case Management

Engagement Interest in Working

  • Build trusting, collaborative relationship

  • Assume contacts are mostly outside mental health setting

  • Maintain ongoing contact

  • Involve family, treatment team, and other supporters

Vocational profile
Vocational Profile Interest in Working

  • Gather comprehensive information from variety of sources over 2-3 sessions

    • Consumer

    • Family, friends

    • Former employers

    • Treatment team

Disclosure of psychiatric status
Disclosure of Psychiatric Status Interest in Working

  • Disclosure is the consumer’s choice

  • Nature of disclosure

    • When to disclose?

    • How much to disclose?

    • Who to disclose to?

A vignette gloria
A Vignette: Gloria Interest in Working

  • Gloria, “I don’t want my boss to know that I have a mental illness. I will be treated differently.”

  • What would you, the employment specialist, say?

Benefits counseling
Benefits Counseling Interest in Working

  • Fear of losing benefits is major barrier to employment

  • Concerns of consumers and families often underestimated by clinicians

  • Rules and regulations are complicated

  • Benefits counseling provides consumer-specific information

A vignette paul
A Vignette: Paul Interest in Working

  • Paul, “I don’t know what I want to do. Maintenance work would be okay. I will do anything. I want to make money.”

  • What would you, the employment specialist, say?

Employment plan
Employment Plan Interest in Working

  • Explore jobs by visiting work sites

  • Develop employment plan

  • Revise assessment and employment plan based on consumer’s experiences

Job search
Job Search Interest in Working

  • Begin soon after referral

    • Employer contacts within 1 month

  • Preparatory work

    • Resumé

    • Job application

    • Two forms of identification

    • Practice interviewing

    • Release of information

Individualized job search
Individualized Job Search Interest in Working

  • Base on consumer’s preferences, strengths, abilities, experiences, and deficits (e.g., substance use)

  • Seek:

    • Permanent competitive jobs

    • Diverse jobs suiting individual consumers

    • Different settings

Ways to find jobs
Ways to Find Jobs Interest in Working

  • Identify leads primarily through networking

  • Include family and treatment team

  • Attend job fairs

  • Use Chamber of Commerce and community organizations (e.g., Rotary Club)

More ways to find jobs
More Ways to Find Jobs Interest in Working

  • Newspaper (However, lots of others seeking same job)

  • Internet

  • Previous employers

  • Tell everyone you meet

  • Track contacts [employer log]

  • Stay persistent

Engaging employers
Engaging Employers Interest in Working

  • Present confidently and professionally

  • Help solve employer problem

    • Recommend qualified applicant

  • Respect employer’s time

  • Identify next step: Meet job candidate?

  • Be dependable: Do what you say you will do

Job support
Job Support Interest in Working

  • Individualized and time-unlimited support

  • Mostly away from work site

  • Include consumer’s support network (treatment team, family, friends, employer, coworkers)

  • Negotiate accommodations with employer

Common job accommodations macdonald wilson 2002

37% Interest in Working




Cognitive (e.g., learning job, concentrating)

Social (e.g., interacting, reading social cues)

Emotional (e.g., managing symptoms, tolerating stress)

Physical (e.g., stamina)

Common Job Accommodations (MacDonald-Wilson, 2002)

Job endings
Job Endings Interest in Working

  • Each job viewed as learning experience

  • Job transitions are considered normal

  • With a job loss, consumer and entire (SE and treatment) team strategize for next step

A vignette marguerite
A Vignette: Marguerite Interest in Working

  • Marguerite worked for three weeks at a dry cleaners. She was let go because of slow work speed.

  • What would you, the employment specialist, say?

Community based services
Community-Based Services Interest in Working

  • Employment specialists in community > 65% time

  • Best way to contact consumers, families, employers

  • Services do not generalize well to different settings

  • People reveal more about who they are outside of the agency

Time management
Time Management Interest in Working

  • Focus on spending time with a few consumers nearing employment vs. meeting everyone each week

  • Take phone book, cell phone, maps, newspapers, address book if possible when job developing

  • Review daily/weekly schedule with supervisor

The dreaded paperwork
The Dreaded Paperwork Interest in Working

  • Comes with territory

  • As much as feasible, supervisor protects staff from busy work

  • Important paperwork:

    • Vocational profiles

    • Employment plans

    • Fidelity checks on

      program implementation

    • Monitoring outcome

Track outcomes
Track Outcomes Interest in Working

  • Track employment outcomes monthly

  • Set goals: 40% rate of competitive employment is achievable

  • Things that you pay attention to are more likely to be improved

Track implementation
Track Implementation Interest in Working

  • Use SE Fidelity Scale to measure implementation of evidence-based practice

  • Staff in supported employment program can see if they are on track

  • Basis for giving objective feedback

What about supported education
What About Supported Education? short start-up

  • Consumer choice always a primary consideration

  • Education and training expand options

  • SE program should help consumers enroll in community programs (GED classes, colleges, technical schools)

What about dual diagnosis and work
What About Dual Diagnosis and Work? short start-up

  • Work to support sobriety

  • Money as a cue

  • Same SE process

Motivation and work
Motivation and Work short start-up

  • State vs. trait

  • Hopelessness as part of illness

  • What has been offered?

  • Program norms –support Recovery?

  • What ES and practitioners say

  • What does consumer want?

  • Change over time

Stages of change pre contemplation contemplation determination action maintenance relapse
Stages of Change short start-upPre-contemplationContemplationDeterminationActionMaintenanceRelapse

Motivational Interviewing short start-upFive Early Strategies

  • Aask open-ended questions

  • Llisten reflectively

  • Aaffirm

  • Ssummarize

  • Esolicit self-motivational statements

  • What are these?: problem recognition, expression of concern, intention to change, optimism about change

Five Basic Principles of short start-upMotivational Interviewing

  • Eexpress empathy

  • Ddevelop discrepancy

  • Aavoid argumentation

  • Rroll with resistance

  • Ssupport self-efficacy

Motivational Interviewing short start-up

Enhancement technique for behavioral change through identifying and resolving ambivalence and discrepancies between verbal and behavioral actions.

  • costs/benefits analysis

  • discuss the readiness ruler

  • engage with active listening

  • promote change talk

  • avoid arguments

IPSMI Intervention Framework short start-up

Review Handout (Appendix N)

IPSMI Tips short start-up

  • Continually assess stages of change

  • Contextually based application

  • Modify

  • Problem-solve

  • Practice

  • Role-play

Summary short start-up

  • Programs following evidence-based principles of supported employment have better outcomes

  • Effective employment coordinators are key to good implementation

  • Resource materials complement training and supervision

Information: books, videos, research articles short start-up