Employment,
Evidence-Based Supported
Employment
and
Recovery
David Lynde, MSW
Supported Employment Consultant
Which came first
employment
or
mental health?
• Dorothea Lynde Dix
• Born, Hampden,
Maine, 1802
• Relentless advocate
and crusader for
people with mental
illness
From the Biography of Dorothea
Lynde Dix…
• “The indigent insane and feebleminded
usually lived under the most shocking
conditions of all. Some communities
actually placed their "paupers" on the
auction block. Leasing, in effect, "their
weak minds and strong bodies" to work for
the bidder who made the most attractive
offer to the town or county.”
From the Biography of Dorothea
Lynde Dix…
“Dorothea Dix traveled thousands of
miles from state to state - by train,
coach, carriage and river boat - always
systematically gathering facts which
she could use to try to convince those
in authority of the need of improvement
in the care of the mentally ill.”
Is This You?
“Superior functioning in a wide
range of activities, life's problems
never seem to get out of hand, is
sought out by others because of
his or her many qualities. No
symptoms.”
Is This You?
Competitively employed
or
Capable of being Competitively
Employed?
Where do Work
and Recovery Travel
Common Pathways?
Where do Work
and Recovery Intersect?
What is Recovery?
What is not Recovery?
Recovery?
“I need to be
given advice and
guidance about
work so I won’t
make any
mistakes or fail”
Dartmouth PRC
12
Recovery?
“I have a dream
that someday I
will be
treatment
adherent”
Recovery?
“Recovery
means mental
illness is not the
center of my
world.”
Recovery?
“My life has
enough meaning
now that I have
a psychiatrist,
medications and
a case
manager.”
Dartmouth PRC
15
Recovery?
“Someday, I
hope to be
compliant and a
well managed
case.”
Recovery?
“I want a
warm and
safe place
for my
family”
17
Recovery?
“Before I was
really depressed
but after I
started working,
it was a relief. I
feel better
working…”
Recovery?
“I want to be the
very best
mental health
client that I can
be”
Recovery?
“I want a good
place to live, a
sweet car to
drive, a good
job and a date
on Friday
night”
20
Young Adults & Recovery
• The aspirations of young people following a
first episode of psychosis appear to be
similar to those of any other young person:
wanting to be rich and powerful (Brady
2008); to drive a sports car, live in a nice
house, to have a job and a career, and be
totally self-sufficient (BGW, 2002); wanting
to lead a life free of symptoms of illness
with a partner, a family and a career
(Parker 2001)
– Rinaldi, Miles, Killackey, Eoin; et al. First episode psychosis and
employment: A review. International Review of Psychiatry (Submitted
2010)
“Now that I
have served
my country I
want to collect
disability
income to
support my
family”
National Consensus
Statement on Mental Health
Recovery
www.SAMHSA.gov
Self-Direction
Consumers lead, control, exercise choice
over, and determine their own path of
recovery by optimizing autonomy,
independence, and control of resources to
achieve a self-determined life. By
definition, the recovery process must be
self-directed by the individual, who defines
his or her own life goals and designs a
unique path towards those goals.
Individualized and Person-Centered
There are multiple pathways to recovery
based on an individual’s unique strengths
and resiliencies as well as his or her
needs, preferences, experiences
(including past trauma), and cultural
background in all of its diverse
representations….
Empowerment
Consumers have the authority to choose
from a range of options and to participate
in all decisions—including the allocation of
resources—that will affect their lives, and
are educated and supported in so doing….
Holistic
Recovery encompasses an individual’s whole
life, including mind, body, spirit, and community.
Recovery embraces all aspects of life, including
housing, employment, education, mental health
and healthcare treatment and services,
complementary and naturalistic services,
addictions treatment, spirituality, creativity, social
networks, community participation, and family
supports as determined by the person….
Non-Linear
Recovery is not a step-by-step process but
one based on continual growth, occasional
setbacks, and learning from experience.
Recovery begins with an initial stage of
awareness in which a person recognizes
that positive change is possible….
Strengths-Based
Recovery focuses on valuing and building
on the multiple capacities, resiliencies,
talents, coping abilities, and inherent worth
of individuals. By building on these
strengths, consumers leave stymied life
roles behind and engage in new life roles
(e.g., partner, caregiver, friend, student,
employee)….
Peer Support
Mutual support—including the sharing of
experiential knowledge and skills and
social learning—plays an invaluable role in
recovery. Consumers encourage and
engage other consumers in recovery and
provide each other with a sense of
belonging, supportive relationships, valued
roles, and community.
Respect
Community, systems, and societal acceptance
and appreciation of consumers —including
protecting their rights and eliminating
discrimination and stigma—are crucial in
achieving recovery. Self-acceptance and
regaining belief in one’s self are particularly vital.
Respect ensures the inclusion and full
participation of consumers in all aspects of their
lives.
Responsibility
Consumers have a personal responsibility
for their own self-care and journeys of
recovery. Taking steps towards their goals
may require great courage. Consumers
must strive to understand and give
meaning to their experiences and identify
coping strategies and healing processes to
promote their own wellness.
Hope
Recovery provides the essential and
motivating message of a better future—
that people can and do overcome the
barriers and obstacles that confront them.
Hope is internalized; but can be fostered
by peers, families, friends, providers, and
others. Hope is the catalyst of the recovery
process….
Recovery Concepts in
Supported Employment
Self-directed
Individualized
Empowering
Holistic
Non-Linear
Strengths-Based
Peer Supports
Respect
Responsibility
Hope
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34
Personal Factors That Predict
Better Employment Outcomes
• Diagnosis
• Symptoms
• Medication
•
•
•
“Compliance”
Hospitalization
History
Treatment
“Compliance”
Gender
Better
Employment
Outcomes
Supporting People “Thinking”
About Work
Have conversations about:
• What are your goals?
• Have you thought about how work may help with
your goals?
• Do you have goals related to employment or a
career?
• What types of work have you done in the past?
Supporting People “Thinking”
About Work
Have conversations about:
• What types of jobs do your family members or
friends have?
• What types of hobbies do you enjoy?
• Which people do you respect or admire? What
do they do for work?
Employment Myth Busting
“People should only apply for jobs
when they know that they will
definitely like the job and when they
are absolutely sure that they will be
successful at the job”
Employment Myth Busting
“There is evidence that, when it
comes to mental health, we can
predict who will and who will not
be a successful employee”
Low Expectations
Research about the low expectations of mental
health professionals in relation to people with
mental health conditions gaining employment is
now very well documented. These expectations
are often underpinned by concern about issues of
risk, stress and relapse. Such low expectations …
can result in them and their families receiving very
cautious messages from mental health
professionals about gaining employment.
– Rinaldi, Miles, Killackey, Eoin; et al. First episode psychosis and
employment: A review. International Review of Psychiatry (Submitted 2010)
40
Does It Matter How We See
People When It Comes to
Employment?
Can we see an employee with
these on?
Recovery Lenses?
Can we see an employee with
these on?
Recovery Lenses?
“I want to live my life not my
disability”
–Pat Deegan
Which is most stressful?
•Employment
Or
•Unemployment
How many of us have managed the
stress of…
•
•
•
•
•
Poverty?
Discrimination?
Homelessness?
Hallucinations?
Involuntary treatment commitment?
How many people with mental
illness have managed the stress
of…
• Poverty?
• Discrimination?
• Homelessness?
• Hallucinations?
• Involuntary treatment commitment?
Simple Stress Test
•The following is a picture of two
identical dolphins
•If you are struggling with managing
stress you will see differences in
these two dolphins
Employment Myth Busting
“Employment is far too stressful
for a person with a mental illness”
Extra, Extra
There is Scientific Evidence
Supported Employment
An Evidence-Based Practice
Evidence Based Practice
Definition
1. The practice is clearly defined in a manual
or other method to train practitioners
2. The practice has a well-defined and
operationalized fidelity scale
3. The practice has demonstrated positive
outcomes in a “RCT”
4. The practice has demonstrated positive
outcomes with different investigators in
repeated research trials
16 Randomized Controlled Trials
of Supported Employment
• 4 conducted before Individual
Placement and Support (IPS) model
was developed
• 11 used full implementation of IPS
• 1 studied supported employment on an
ACT team
RCTs: “Pre IPS”
Study (Year) Site
Control Group
Gervey (94)
Bond (95)
Chandler (97)
McFarlane (00)
Sheltered Work
Prevoc prep
VR Referral
VR Referral
NY
IN
CA
NY
RCTs: IPS Studies
Study (Y ear) Site
Control Group
Drake (96)
Drake (99)
Lehman (02)
NH
DC
MD
Skills Training
Sheltered Work
Psychosocial Rehab
Mueser (04)
CT
1. Brokered Supp Emp
2. Psychosocial Rehab
Latimer (05)
Quebec
Wong (05)
Hong Kong
Gold (06)
SC
Burns (06)
Europe
Bond (06)
IL
Twamley (06)
CA
Killackey (07) Australia
Traditional Voc Services
Sheltered Work
Sheltered Work
Traditional Voc Services
Diversified Placement
VR Referral
Treatment as Usual
Summary: Randomized Controlled
Trials of Supported Employment (SE)
• In 15 of 16 studies, SE had significantly
•
better competitive employment outcomes
than controls
Mean across studies of consumers working
competitively at some time:
–60% for supported employment
–24% for controls
• Effect size (d) = .77
When food is scarce, we don’t think
malnutrition is okay
When housing is hard to find, we don’t think
homelessness is okay
When healthcare is difficult to obtain, we
don’t think sickness is okay
Then why, when jobs are scarce, do we
begin to think that unemployment is okay?
61
Dartmouth Supported
Employment Web Site
http://www.dartmouth.edu/~ips/
Helping People “Thinking”
About Work
Have conversations about:
• What are the potential benefits or
drawbacks to employment for you?
• Did you know that people who have
symptoms are able to work?
• Did you know that work actually helps
reduce substance use?
Helping People “Thinking”
About Work
Have conversations about:
• What concerns do you have about
employment?
• Is there anyone in your family or group of
friends that may be supportive of your
work goals?
Being Employed
More income
Pros
Being Unemployed
Keep my disability
income
Feel better
about myself
Cons
Worried about
benefits
Don’t know
what to say to
co-workers
Bored
Don’t like
relying so much
on others
Employment Myth Busting
“Employers don’t hire people who have
mental health symptoms, they only hire
mentally healthy, well adjusted and nondisabled employees”
Employment Myth Busting
“Employment is something that people
should begin to think about only when they
are stable and free of mental health
symptoms”
Employment Myth Busting
“The Americans with Disabilities Act will
provide you with complete protection
against stigma and discrimination in the
work place if you decide to discuss your
mental health with any of your supervisors
or colleagues”
Supporting People Who Are
Searching for Work
Have conversations about:
• Areas at work where coping strategies and
skills may be useful for the person
• Plans for the first day of work, help the
person identify and use structured
problem-solving to work out seemingly
“little” things
”I thought ‘Oh No’, what will my
son do now.”
• Mother, Detroit Michigan
Recovery & Hope
“If people are treated as capable,
they often surprise everyone
and live up to expectations.”
• Ken Steele “The Day the Voices Stopped.”