What Works in Vocational Rehabilitation for People with Psychiatric Disabilities

1
What Works in Vocational Rehabilitation for
People with Psychiatric Disabilities?

• Judith A. Cook, Ph.D.
• Professor Director
• National Research Training Center on
  Psychiatric Disability
• University of Illinois at Chicago, Department of
  Psychiatry
• Funded by the National Institute on Disability
  Rehabilitation Research, U.S. Department of
  Education, the Center for Mental Health
  Services, Substance Abuse and Mental Health
  Services Administration

2
What Do People Want from Employment that Promotes
Recovery?

• Employment careers, not just a series of
  sequential jobs
• Work with dignity that they can feel proud of
• Help returning to work in ways that do not
  endanger their benefits entitlements
• Pathways to economic security

3
Employment Intervention Demonstration Program
(EIDP)

• Funded by the Center for Mental Health Services,
  Substance Abuse and Mental Health Services
  Administration

4
How did the study work?

• People in recovery who wanted to work were
  offered an opportunity to participate in a
  research study.
• If they agreed, they were randomly assigned to a
  supported employment program in the experimental
  or control group condition.
• They completed in-person interviews with
  researchers every 6 months for 2 years, their
  employment was tracked weekly, and their services
  were monitored on a monthly basis
• Participating States
• Connecticut Arizona
• Maryland Massachusetts Pennsylvania
  Maine
• South Carolina Texas

5
Research Questions Well Focus on This Afternoon

• What is the effectiveness of vocational
  rehabilitation in establishing successful work
  outcomes?
• Does employment significantly improve peoples
  personal financial situations?
• What service recipient characteristics are
  related to intervention effectiveness?
• How do different types and amounts of services
  affect employment outcomes?
• How does an areas local economy influence the
  success of supported employment programs?

6
Names of Vocational Models Tested

• Arizona Supported Employment (SE)
• Connecticut Individual Placement Support (IPS)
  
• Maryland Individual Placement Support (IPS)
• South Carolina Assertive Community Treatment
  Individual Placement Support (ACTIPS)
• Maine Employer Consortium Family-Aided
  Assertive Community Treatment (FACTConsortium)
• Massachusetts ICCD Clubhouse
• Texas Supported Employment and Employment
  Assistance through Reciprocity in Natural
  Supports
• Pennsylvania Long-term Employment Training and
  Supports (LETS) vs. Services as Usual

7
All of the Experimental Interventions Provided

• fully integrated clinical, case management,
  vocational services
• multidisciplinary provider teams representing
  mental health, vocational rehabilitation,
  concurrent mental health substance abuse tx,
  peer support, benefits counseling
• rapid job search and placement activities
• a desired outcome of competitive employment
• jobs that were customized to meet the needs and
  preferences of participants
• ongoing supports available with no time limits

8
EIDP Study Participants N1816

• Roughly half were male half female
• Ages ranged from 18-76 years average38 years
• 48 Caucasian, 31 African-American, 14
  Hispanic/Latino, 7 mixed/other
• 90 diagnosed w/schizophrenia, bipolar disorder,
  or major depression
• 64 with concurrent substance abuse diagnoses
• Average of 6 lifetime psychiatric
  hospitalizations, 24 hospitalized within 6
  months prior to study entry
• 96 prescribed psychiatric medications, 43
  taking 3 meds
• 40 had co-occurring physical disabilities or
  serious health conditions
• Close to half (47) had no employment in the 2
  years prior to study entry

9
EIDP Key Findings Achieving Employment Outcomes
10
Economic Productivity of All EIDP Participants (E
and C combined) Over a 24-month period...

• 2230 jobs were held by clients, an average of 2.2
  jobs per worker
• 4.7 million was earned by clients, an average of
  5,786 per worker
• 820,293 hours were worked by EIDP clients

11
Features of All Jobs Held by EIDP Participants

• Almost all jobs (86) were minimum wage or above
• Jobs paid an average of only 5.91 per hour
• Most jobs were worked an average of 19.4 hours
  per week
• Only 17 of all jobs were full time (35 hours
  per week)

12
We might want to ask ourselves

• Since participants worked at low-paying jobs
  most worked part-time, did these jobs make a
  difference in their personal economies?
• In other words, were they significantly better
  off financially if they worked?

13
One Way to Measure ThisRatio of Income to
Expenses

• What is this Ratio?
• The individuals income for a month divided by
  his/her expenses for that month
• Break-Even Point 100
• if 100 - income equaled expenses
• if lt 100 - expenses exceeded income
• if gt 100 - income exceeded expenses

14
Ratios of Income to Expenses for Employed vs.
Unemployed(break-even 100)

• EMPLOYED 120
• NOT EMPLOYED 80
• significant difference at p lt .05
• So, people were significantly better off if they
  worked.

15
How did participants work status interact with
their disability beneficiary status?

• Did people who worked do better if they were
  receiving SSI/SSDI or worse?

16
How Does Being on SSI/SSDI Interact with
Employment Status to Affect the Ratio of Income
to Expenses?(break-even ratio 100)
17
Is Work Worth It? Yes!

• Participants monthly cash income was very low
  and their monthly expenses were high relative to
  monthly income
• In a typical month, the average ratio of income
  to expenses was barely more than 100 (i.e.,
  participants barely break even)
• Employed participants had significantly better
  ratios than nonemployed participants
• Employed participants receiving SSI/SSDI had the
  best ratios and those with no SSI/SSDI who were
  not working had the worst ratios

18
What does this tell us?

• Benefits and entitlements counseling is an
  essential service for consumers who are returning
  to work, since many depend on SSI or SSDI.
• Financial education and planning are needed to
  address consumers financial situations over the
  short-term and the long-term

19
Proportion of EIDP ParticipantsEngaged in Any
Paid Work

• 30 of those receiving services for 3 months
• 42 of those receiving services for 6 months
• 50 of those receiving services for 9 months
• 54 of those receiving services for 12 months
• 61 of those receiving services for 18 months
• 64 of those receiving services for 24 months
• 
  
• The longer people received services, the more
  likely they
• were to become employed. Vocational
  rehabilitation is a
• long-term process for many people in
  recovery.

20
Average Length of Jobs by Number Held
Average Length in Days
21
Average Number of Days Unemployed Between Jobs
Among Those with More than One Job
Average Number of Days
22
Among All EIDP Participants

• Over time, more and more people worked
• Their jobs lasted longer and longer
• The time between jobs grew shorter and shorter

23
To Test the Experimental vs. Control Programs, We
Had to Consider Participants Personal Situations

• Living with Children lt 18 years old
• Diagnosis of Schizophrenia
• Co-occurring Health Problem or Disability
• Receiving Disability Income

• Male vs. Female
• Race/Ethnicity
• Age
• Education
• Prior Work History
• Symptoms
• Functioning
• Marital Status
• Drug/Alcohol Abuse

24
We Examined Multiple Employment Outcomes

• Competitive Employment
• Work for 40 hours per month
• Monthly Earnings
• Any Work for Pay
• Competitive Employment
• pays minimum wage or higher
• located in mainstream, integrated settings
• not set-aside for mental health consumers and
• job is consumer-owned.

25
Findings Effects of Study Condition

• Controlling For Participant Characteristics...
• in both the experimental and control groups,
  peoples employment outcomes improved over time
• those in the experimental groups had better
  outcomes than those in the control groups
• the advantage of the experimental group
  participants increased over time relative to the
  control group

26
Participants Features Did Influence Their Work
Outcomes

• Most consistently, those with better outcomes
  were
• people with better work histories
• people with fewer symptoms
• younger people
• 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 without co-occurring substance abuse
  problems
• (Razzano, Cook et al., Journal of Nervous
  Mental Disease, 2005 Burke-Miller, Cook et al.,
  Community Mental Health Journal, 2006)

27
Types of Services Measured in EIDP Study

• Vocational
• Vocational Assessment/Evaluation
• Client Specific Job Development
• Collaboration with Employer
• Vocational Support Groups
• Collaboration with Family/Friends
• Vocational Treatment Planning/Career Development
• Off-Site Skills Training/Education
• Off-Site Vocational Counseling
• On-Site Job Support
• Transportation

• Clinical
• Case Management
• Family/Couples Counseling
• Emergency Services
• Evaluation/Diagnosis
• Individual Counseling
• Group Counseling
• Medication Evaluation/Maintenance
• Partial Hospital Program

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What We Found About Services...

• People received many more hours of clinical
  services than vocational services

29
What We Found About Services...

• Controlling for all other factors, those who
  received more total hours of vocational services
  had better employment outcomes
• Those who received more total hours of clinical
  services had poorer vocational outcomes

30
What We Found About Services...

• While overall, those who received more vocational
  services and less clinical services had better
  employment outcomes
• In the experimental programs, those who received
  MORE vocational and MORE clinical services had
  better outcomes.
• This may be because the experimental programs
  provided WELL-INTEGRATED clinical and vocational
  services.
• (Cook, Lehman, Drake et al., American Journal of
  Psychiatry, 2005)

31
What Do We Mean by Clinical Vocational Services
Integration?

• Level of services integration was defined as
  high when vocational mental health services
  were delivered
• by the same agency
• at the same location
• using a single case record
• with regularly scheduled meetings of vocational
  clinical providers (i.e., daily or no less than 3
  times/week)

32
Effects of Specific Program ComponentsThe
following types of services were associated with
better outcomes...

• Vocational Services
• job development
• on-site job support
• collaboration with employers
• vocational assessment
• vocational treatment planning
• vocational counseling
• transportation
• Clinical Services
• individual counseling
• psychosocial rehabilitation programs

33
How are the careers of people with psychiatric
disabilities affected by the local economy?

• Does the local labor market make a difference?
• Does the local unemployment rate influence
  vocational success?
• Can best-practice supported employment help to
  overcome a poor local economy?

34
People with Psychiatric Disabilities ARE Subject
to General Labor Market Trends

• In the EIDP, all four vocational outcomes were
  worse for those residing in counties with higher
  employment, regardless of
• Participants study condition (E or C)
• Participants individual characteristics
  (demographics, clinical features, work
  experience, etc.)

35
If Local Unemployment is So Important, Do
Best-Practice Services Even Matter?To answer
this question, we needed to look at study
condition PLUS local unemployment rate (UR)

• We divided participants into 4 groups
• Those getting best practice in areas with low UR
• Those getting best practice in areas with high UR
• Those in C conditions with low UR
• Those in C with high UR

36
Can Best-Practice Overcome Effects of High UR?

• Not completely unemployment rate still matters
• But best-practice services do make a difference
  by reducing the effects of a poor local economy
• Most important without best-practice services,
  those in areas with high UR are highly unlikely
  to work or build careers
• (Cook, Grey et al., Journal of Vocational
  Rehabilitation, 2006)

37
Many People with Severe and Persistent Mental
Disorders Live in Poverty

• Among those participating in the EIDP, almost
  three-quarters (73.9) were at or below the
  poverty level, including those receiving
  disability income support
• living in poverty on SSI 78
• living in poverty on SSDI 59
• living in poverty on SSI SSDI 75
• living in poverty on neither 87

38
When People Live in Poverty Its Difficult to
Risk Employment

• For people with disabilities on SSI/SSDI,
  employment is a RISK
• Those unable to take that risk lose out on
  federal programs designed to stimulate their
  employment
• Examples
• Under the ADA, reasonable accommodations require
  disclosure
• Under the Ticket to Work, people need to work
  above SGA for their providers to get paid

39
THE VAST MAJORITY OF MENTAL HEALTH CONSUMERS DO
NOT WORK ABOVE SGA, MAKINGTHEM ARE POOR
CANDIDATESFOR TICKET TO WORKMANY WHO HOLD
FULL TIME JOBS DO NOT HAVE HEALTH CARE COVERAGE,
MAKING THE TICKET A BAD DEAL FOR THEM
(Cook, Grey et al., Psychiatric Services, 2006)
40
Consumers Whose Return to Work Makes them
Ineligible for Health Care Coverage are Unlikely
to be Holding Jobs that Provide Health Care or
Other Benefits

• IN THE EIDP, FEW FULL-TIME JOBS PROVIDED HEALTH
  INSURANCE OR OTHER BENEFITS
• Of all full-time jobs held by EIDP
  participants...
• only 24 provided medical coverage
• only 16 provided dental coverage
• only 8 provided mental health coverage
• only 23 provided vacation benefits
• only 20 provided sick leave

41
EIDP Results Tell Us Why Commonly Used
Vocational Rehabilitation Approaches DO NOT Work
EIDP Findings Also Show Why Current Policies
Laws DO NOT Address the Needs of Individuals with
Psychiatric DisabilitiesWhat Do The Results
Tell Us About What DOES Work?
42
Best Practices of Supported Employment

• Mental health consumers achieve superior
  vocational outcomes when they receive
• carefully coordinated clinical vocational
  services
• from multidisciplinary provider teams
• with rapid job placement
• into competitive employment
• in clients' preferred fields
• with availability of ongoing supports
• with adequate amounts of appropriate vocational
  services
• (Cook, Leff, Blyler et al., Archives of General
  Psychiatry, 2005)

43
What More Have We Learned?

• The more vocational services people receive, the
  better their employment outcomes.
• People who receive a relatively balanced amount
  of well-integrated and coordinated vocational and
  clinical services have much better employment
  outcomes than those who receive non-integrated
  services.

44
Additional Lessons Learned

• Integrated employment services result in positive
  employment outcomes regardless of consumers
  personal characteristics, health problems,
  diagnoses, symptom levels, work histories
  functioning levels
• Peoples employment success increases over time,
  making it important that programs be prepared to
  offer ongoing support and services that build on
  career achievements.

45
When Its Not a Perfect World

• What can we do when vocational mental health
  services are NOT delivered
• at the same location
• using a single case record
• with regularly scheduled face-to-face meetings
  of vocational clinical providers (i.e., daily
  or no less than 3 times/week)
• by the same agency
• How do we coordinate better?

46
Tips for Enhancing Clinical Vocational Service
Integration in Non-Integrated Settings

• Teleconferencing of vocational clinical staff
  on a frequent, regularly scheduled basis
• Staff co-location on a weekly or greater basis
• Use of job sharing or rotation of employment
  support responsibilities among direct service
  providers
• Peer service delivery, linkage, and follow-along
• Co-supervision on an ongoing basis
• Problem-specific cross-training

47
Current Disability Income Support Policies Limit
Self-Determination

• Current SSI/SSDI policies need to be changed to
  to promote maximal choice for people in recovery
  regarding whether to work, how much, how long,
  and with what consequences for their
• Economic safety net
• Health insurance coverage

48
Resources Are Available

• For people in recovery
• For providers
• For employers

49
UIC NRTC Vocational Materials(available at
replacement cost or no cost upon request)

• Seeking Supported Employment (consumer guide)
• Managing Workplace Conflict (consumer guide)
• On-the-Job Series (Social Skills, Stress
  Management, Drinking Drug Use)
• Assessing Vocational Performance Among Persons
  with Severe Mental Illness
• Providing Vocational Services Employment
  Support
• Positive Partnerships (consumer/provider guide)
• The Community Scholar Series
• Peer Support for Post-Secondary Students
  (consumer guide)

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Learn more about the EIDP by visiting its
website

• www.psych.uic.edu/eidp/
• full descriptions of study conditions including
  research provider contact information
• downloadable protocols documentation
• latest study findings publications
• downloadable presentations re the study
• links to relevant sites

51
Web Site Address for Vocational Materials from
the UIC National Research Training Center

• http//www.psych.uic.edu/uicnrtc/

52
Thank you!