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Ready, Willing, and Able To Work: Employment for People in Recovery

Gary R. Bond, Ph.D.

Ask the Expert:  Gary R. Bond, Ph.D. is Professor of Psychiatry at Dartmouth Medical School and senior researcher at the Dartmouth Psychiatric Research Center.  Bond’s research aims at identifying evidence-based psychiatric rehabilitation practices, with a primary focus on the evidenced-based supported employment for people with severe mental illness.  He has devoted over 30 years to the study of vocational services for people with psychiatric disabilities.  Recently he has examined factors influencing successful implementation and sustainability of evidence-based practices.  His publications include over 200 peer-reviewed journal articles.  He has received several national research awards, including from the American Psychological Association and the National Institute of Mental Health.  Bond has consulted with local and state mental health planners throughout the U.S. and outside the U.S.  Bond is co-author of two major resources on evidence-based supported employment; he and his colleagues at Dartmouth developed the SAMHSA toolkit as well as a research reference book on this model.

1. Question: When would one know when recovery was complete and the individual was ready to go back to work if they had TBI and post-traumatic stress disorder (PTSD) from the battlefield and substance dependency?

Answer: Recovery is an ongoing process with phases.  However, it is never complete.  It is a lifelong adventure.  For most people, working is not something that comes after recovery, but is part of recovery itself.  In Individual Placement and Support (IPS) supported employment programs, employment specialists work with clients to help clients decide when they want to seek employment. 

We know that veterans with PTSD struggle with isolation, unemployment, and many other related problems.  They are a very vulnerable group.  Fortunately, we have good news to report.  Recently, Dr. Lori Davis from the Tuscaloosa Veterans Affairs Medical Center in Alabama conducted a randomized controlled trial showing outstanding competitive employment rates for veterans with PTSD receiving IPS supported employment.  Veterans enrolled in this study were not required to be recovered from PTSD before going back to work.  Dr. Davis is now in the process of expanding this project to other sites in the VA.

Dr. John Corrigan from Ohio State University is a noted expert on employment services for people with traumatic brain injury.  He has been studying the application of the IPS supported employment for this population.  Dr. Corrigan responded to this question by stating:  “…While we would prefer to move into work immediately, practical issues are always a challenge.  We start with ‘in vivo assessment.’  But just as frequently, other goals of the client's will delay the immediacy of work. Work may be one of their goals but may not be at the top.  So they may ask the case manager to prioritize something else (e.g., getting an MD appointment, finding housing, or dealing with their probation officer).”

2. Question: I work in Supported Education at a peer run organization.  For folks with psychiatric/substance abuse issues, does the research show any effects of furthering one's education on the psychiatric/substance abuse issues?

Answer: Let me begin by noting that the research on supported education is less extensive than that on supported employment.  For clients who work steadily in competitive employment over a period of years, the evidence suggests a reduction in their psychiatric symptoms.  For clients with mental illness and co-occurring substance use, steady work also often leads to abstinence.  Research suggests that the most effective treatment plan sequence is first working on personal goals (working, making new friends) followed by seeking abstinence, not the other way around.  So, the idea that people need to be abstinent before they consider working on their recovery goals is not an effective approach.  We have less evidence about the impact of education on symptoms and substance use, but it is plausible that pursuit of the personal goal of further education has a similar impact. 

3. Question: We need to be up to date on the issues involving training and employment for persons disabled by severe mental illness. Also, it would be useful to have current recommendations being made for additional needed legislation by such groups as NAMI. Can you provide more information on the issues involving training and employment for people disabled by severe mental illness?

Answer: Even though employment services are relatively inexpensive and ultimately lead to reduced health care costs, employment services are terribly underfunded.  Therefore, the No. 1 issue that advocates should focus on is securing stable, predictable, and adequate funding for IPS supported employment services in every community in the U.S.

ASPE is a branch of the U.S. Department of Health and Human Services.  It recently released a report indicating that less than 1% of Medicaid beneficiaries with mental illness received any supported employment services whatsoever funded through Medicaid.  See: 

http://aspe.hhs.gov/daltcp/reports/2012/ebpsbd.shtml). 

Our military veterans also experience lack of access to supported employment.  A 2011 report on mental health services in the VA found that only 2% of veterans with severe mental illness received supported employment services.

Two other ASPE reports document the costs of IPS supported employment and how it might be financed:

 http://aspe.hhs.gov/daltcp/reports/2010/supempLR.pdf

http://aspe.hhs.gov/daltcp/reports/2011/supempFR.pdf

Another area needing urgent advocacy regards disincentives to employment.  A very common reason for not seeking employment is fear of losing benefits, including Medicaid and Social Security disability income support.  If we changed the regulations to encourage people to work, it would make a huge difference. 

At the national level, NAMI has not taken any formal steps to formulate legislative policy around IPS specifically, other than to recognize it as an important evidence-based practice that promotes recovery.  One exciting development has been the formation of Family Advocacy Teams in 14 states, in collaboration with the Dartmouth Psychiatric Research Center.  These family advocacy teams have been informing constituents of the benefits of IPS.  NAMI state affiliates have also advocated for integrating IPS into Medicaid Managed Care initiatives as well as in the essential health benefits associated with health exchanges as part of the Affordable Care Act.  See: 

http://www.dartmouth.edu/~ips/page31/page31.html

4. Question: For years, the subject of employment for the mentally disabled has not been in vogue in the field of recovery and rehabilitation.  Do any statistics exist that support mainstream job hiring and permanent employment for those who've recovered from a co-occurring disorder?

Answer: Yes, very encouraging statistics!  Many people will be surprised to learn that employment outcomes for people with co-occurring mental illness and substance use disorders are very similar to those for people with mental illness and no substance use problems.  Several different research groups have replicated these findings.  Citations for these studies can be found at:

http://www.dartmouth.edu/~ips/page66/page66.html

5. Question: Regarding the efficacy of psychosocial interventions for persons challenged with schizophrenia, I have worked in a large clinic for SMI (Severely Mentally Ill) individuals that utilized these interventions very successfully with dual diagnosed SMI/ addiction clients.  What do we know about the efficacy of the psychosocial model as it employs meaningful activity/community integration (volunteer time or limited/ supported employment, etc.)?

Answer: I am not sure what psychosocial model your clinic uses or which interventions you provide, so I cannot comment specifically on your services.  But we do know that the IPS supported employment model is very effective in helping people gain competitive employment.  It is the most effective of all psychosocial practices for people with severe mental illness.  These findings also apply to people with co-occurring mental illness and substance use disorders. 

I should add that the employment outcomes are strongest when the IPS supported employment model is followed closely.  Other employment models do not have the same evidence for effectiveness.  For example, some vocational approaches emphasize volunteer jobs.  I don’t know of any studies reporting positive outcomes from programs emphasizing volunteer jobs.

6. Question: How does peer counseling differ from that of a licensed psychologist or psychiatrist? Is this a trend that will take over the counseling industry? 

Answer: My main expertise is in employment, so I should explain that other experts would be more prepared to speak to your question in more detail.

Peer counseling takes many forms.  It can be an opportunity for one person who has had the experience of mental illness and/or substance use and now is successfully employed to model that experience for a peer considering a return to the work force.  This intervention can be very powerful.

Peer counseling is a nonclinical form of assistance.  In that respect it differs from counseling provided by psychology and psychiatry.  Research suggests that some people prefer to use peer counseling as a complement to professional treatment.  With reference to what peer counseling offers, I recommend reading reports on the SAMHSA-funded study that found that people attending consumer operated service programs increased their feelings of empowerment.  See: 

http://store.samhsa.gov/pages/searchResult/COSP_PowerPoint8.25.ppt

Consumer-operated services are found throughout the U.S.  One example among many is the Collaborative Support Programs of New Jersey, Inc.  Their web site is:

http://cspnj.org/

This group produces an informative newsletter:

http://welltacc.org/

You also asked about predicting the future for peer services.  Predicting future trends is a tricky business; so I will not venture a prediction!  However, researchers and program leaders should identify the most helpful approaches and then do our best to make them available to people who can benefit from them.

7. Question: How should an employment specialist (ES) provider who is rehabilitation-oriented and separate from behavioral health treatment service meet the Dartmouth IPS integration criterion? These integration criterion include things like:
- ES are attached to one or two MH treatment teams, from which 90% of the ES’s caseload is comprised.
- ES actively participate in weekly mental health treatment team meetings that discuss individual clients & their employment goals with shared decision-making. ES’s office is in close proximity to their mental health treatment team members.  Documentation of mental health treatment & employment services are integrated in a single client chart.

Answer: Research shows that integration of employment services with clinical services leads to better outcomes.  Therefore it’s important for employment specialists to work closely with behavioral health treatment teams.  Despite this evidence-based principle, many states fund rehabilitation and behavioral health service systems in separate silos, requiring each agency to provide either rehabilitation or behavioral health, but not both.  This is the situation you are facing.

If your agency is completely independent from the mental health center, it’s still possible to have integrated services, but it’s a lot harder.  It requires that the behavioral health treatment teams and the employment teams both agree to a close partnership (or often to form multiple partnerships).  Like any other relationship, both sides of the partnership need to work at collaboration.  For example, agency leaders should meet and discuss how to manage HIPAA regulations so that the employment specialists can attend weekly team meetings and have access to client records.  Employment specialists should be able to attend the entire behavioral health team meeting in order to suggest work for people served by the team and also to be viewed as a full member of the team.  Ideally, employment specialists would also have office space at the mental health agency so that they can communicate easily outside of team meetings and establish good working relationships with mental health practitioners.  In addition, strong advocacy for collaboration by state leadership in vocational rehabilitation and mental health agencies makes a huge difference. 

8. Question: I work in the medical field, where there is a lot of stigma. I have had difficulty in obtaining employment even with close to 5 years of documented recovery and a friend of mine was rejected for a job with 12 years of recovery. When, how, and who will make sure our rights to work are upheld?

Answer: I am sorry that you and your friend have been discriminated against.  I suspect that one of the challenges you face is proving that discrimination has occurred.  You may want to contact one of the following groups to help you and your friend understand what steps you can take to make sure your rights are upheld.

At the national level, the Bazelon Center for Mental Health Law is a wonderful advocacy organization for the rights of people with mental illness.  The legal rights of people with psychiatric disabilities in the work place are spelled out in the Americans with Disabilities Act.  The Commissioners on the U.S. Equal Employment Opportunity Commission held a hearing specifically on this issue in 2011:

http://www.eeoc.gov/eeoc/meetings/3-15-11/

At the local level, most state mental health administrations have an office of consumer advocacy.  In addition, mental health professionals, consumer groups, and family members can be strong advocates.  All states have a federally-funded disability rights center whose function it is to address the very issues raised by this question.
Another avenue for fighting stigma is positive publicity, such as in the news stories found at:

http://www.dartmouth.edu/~ips/page128/page128.html

IPS supported employment has a strong record helping people find and keep jobs. If there is such a program in your community, enrolling in IPS is a further option.

9. Question: In the present job market with college graduates taking an average of 4 years to find a job, do you think it is setting consumers up for disappointment and failure to push supported employment?  Our clubhouses have dropped that goal and service.

Answer: I am sorry to learn that your clubhouse has dropped employment as a goal.  No, I don’t think it’s setting consumers up for disappointment to help them find a job, I think it’s helping them fulfill their dreams.  Recovery sets up people to achieve what they want and our job is to help with ambitious goals like employment, even in tough economic times; after all we don't discourage people who have goals for a good place to live when housing is difficult to find.  We help them find good housing instead.

It is true that the recession has especially affected the employment prospects for people with disabilities.  And when we looked at national statistics for IPS supported employment programs, we did see a drop in the quarterly employment rates from about 43% to 40% in the last few years.  But this drop is relatively small and high quality employment programs can overcome the challenges of poor economic conditions.  If I had any one message to send to psychiatric rehabilitation agencies, it would be this:  Don’t give up employment as a goal!

10. Question: What can you do when the employer says they believe in recovery, but they will "stonewall" you every chance they can?

Answer: It sounds like the employer is saying one thing, but doing another.  IPS employment specialists are experts in identifying the barriers to employment and overcoming resistance.  In many cases, understanding the employer’s point of view and making appropriate changes lead to a win-win situation for both the employer and the worker.  For example, some employers may appear to be unwilling to hire because of stigma toward people with psychiatric disabilities, when their actual concern is working with employment programs.  That is because employers often fear that employment programs do not understand how businesses operate and will not be able to meet their needs.  Begin employer relationships by asking to learn about how their businesses operate, the type of people who tend to be successful in their businesses, and so forth.  Do not discuss a job candidate until you understand the business manager’s hiring needs and preferences.  Finally, sometimes it may be best to move on and find a job where the supervisor is supportive and you can maximize your talents.



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