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SAMHSA News - May/June, Volume 14, Number 3

Employment: Help for People with Mental Illness (Part 1)

Very few people with the most serious mental illnesses have jobs, according to Crystal R. Blyler, Ph.D., a social science analyst in the Division of Service and Systems Improvement at SAMHSA's Center for Mental Health Services (CMHS). Yet despite the fact that these individuals want to work, they rarely receive vocational services that could help them find and keep jobs.

A CMHS-funded study called the Employment Intervention Demonstration Program (EIDP) explored ways of helping people with serious mental illnesses fulfill their employment dreams. Launched in 1995, the 5-year, multi-site study sought to answer questions about the kind of services that would be most useful in helping people with serious psychiatric diagnoses obtain and retain jobs (see SAMHSA News, Vol. 10, No. 1).

Now the answers are in, and they're already informing the field. Several major journal articles have recently emerged from the study, with more on the way.

"SAMHSA's vision is a life in the community for everyone, and that includes jobs for people with serious mental illnesses," said CMHS Director A. Kathryn Power, M.Ed. "This study gives us the information we need to help make that vision a reality."

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An Overview of Findings

With eight sites in Arizona, Connecticut, Maine, Maryland, Massachusetts, Pennsylvania, South Carolina, and Texas, the EIDP examined the impact of innovative employment services for more than 1,600 unemployed people who had schizophrenia, bipolar disorder, major depression, or other serious mental illnesses.

The researchers randomly assigned the participants either to services-as-usual programs or to innovative "supported employment" programs combining vocational rehabilitation with clinical services and other supports. Using uniform data collection methods, the researchers then tracked participants for 2 years to see whether they were able to get and keep jobs.

The jobs weren't the kind people typically associate with disabled job-seekers, emphasized Dr. Blyler. Instead of the sheltered workshops and similar programs that were once common, the participants sought what the researchers call "competitive employment"—regular jobs open to anyone. "People with mental illnesses want to work in the mainstream with everybody else and have the same pay and the same career advancement opportunities," she said.

To help participants achieve that goal, the EIDP offered various kinds of supported employment interventions. All of the services were based on the following common principles:

Integrated services. The programs integrate employment services and mental health treatment, with co-location of services at the same agency, a single case record, and face-to-face interaction between psychiatric and vocational staff at least three times a week.

Consumer preference. The programs focus on getting participants the competitive jobs they want, with job development tailored to their own career interests and capabilities. Job hunts begin immediately after participants announce their intention to start working.

Ongoing support. Unlike some vocational services, the support doesn't stop once participants get jobs. Instead, the program provides support for as long as needed.

The EIDP's major finding? According to Judith A. Cook, Ph.D., Principal Investigator of the EIDP Coordinating Center and a professor of psychiatry at the University of Illinois at Chicago (UIC), supported employment works.

In an American Journal of Psychiatry article co-authored by Dr. Cook, the researchers reported that participants in supported employment programs did a lot better than those in the services-as-usual comparison group.

After taking into account differences in such factors as work history and clinical status, the researchers found that participants in programs integrating psychiatric and vocational services were more than twice as likely to have competitive employment than those in the comparison group. They were also nearly 1.5 times as likely to work at least 40 hours a month. And the more vocational services they received, the better their employment outcomes.

Participants in supported employment programs also earned significantly more than their counterparts in services-as-usual programs, Dr. Cook and her co-authors reported in an article in the Archives of General Psychiatry. Those in supported employment programs made an average of $122 a month, compared to $99 a month for those in the comparison group.

And all of these advantages increased during the 2-year study period.

According to Dr. Cook, the EIDP study's value lay in its size. Thanks to its multi-site nature, she explained, the study was big enough to allow the researchers to examine the impact of supported employment on different subpopulations, something that can be difficult to do in smaller, single-site studies. In doing so, she added, the researchers were able to challenge some long-held beliefs in the field.

The idea that individuals with schizophrenia can't work is one example. "There's still a very entrenched belief that people with schizophrenia can't work—that somehow that diagnosis and the impairments that accompany it make it the one diagnosis where supported employment isn't effective," said Dr. Cook. "We found that wasn't the case."

Another myth the study dispelled was the common belief that parents with mental illnesses who have young children shouldn't work. "There's been some talk that work is too stressful for parents who have a mental illness," said Dr. Cook, noting that 22 percent of the study participants had children under 18 living with them. The study found that supported employment does help parents get competitive employment, just like it does every other subpopulation—men and women, members of different racial and ethnic minorities, people with various diagnoses, individuals with a lot of work experience and those without, residents of high-unemployment areas, and those in low-unemployment areas.

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