Community-Based Treatment of Schizophrenia and Other Severe Mental Disorders: Treatment Outcomes


Medscape General Medicine. 2001;3(1) 

In This Article

Supported Employment

Surveys of persons with schizophrenia and other SMI indicate that a significant majority want competitive employment in integrated community settings.[85] Despite these ambitions, the rate of competitive employment among this population is low, with most estimates varying between 5% and 15%.[86] Traditionally, mental health centers have used a brokered approach to vocational rehabilitation for clients with SMI, referring them to state vocational rehabilitation services, which in turn have relied on rehabilitation agencies providing mostly sheltered workshops to gradually transition clients into competitive employment or extensive skills training interventions designed to develop the requisite working skills before competitive job placement. Numerous reviews of the research literature on these traditional approaches to vocational rehabilitation have shown them to be ineffective, resulting in very low rates of competitive employment that are similar to rates achieved by clients who do not have access to vocational rehabilitation.[87,88,89]

The supported employment approach to vocational rehabilitation for persons with SMI is an alternative to traditional methods. Bond and coworkers[87,88] have traced the roots of supported employment models for persons with SMI to several historical developments in the vocational rehabilitation and mental health services fields.

Individuals with developmental disabilities. One important influence was the development of supported employment programs for individuals with developmental disabilities. In the early 1980s, Wehman[90,91] began exploring the feasibility of placement and then training of clients with developmental disabilities on competitive jobs, rather than the more traditional approach of extensive training of clients before placement. Wehman also advocated for ongoing support after job placement. Although models of supported employment for persons with developmental disabilities have not been carefully examined with controlled research, the success of early supported employment programs led to its adoption in federal legislation and subsequent funding nationwide.

Clubhouse approach. A second important influence on the development of supported employment programs for the SMI population was the emergence of the clubhouse approach to psychiatric rehabilitation. The original clubhouse, Fountain House in New York City, began in the 1940s as a group of mental health consumers banded together to organize a setting in which they could provide mutual support.[92] Over the years, Fountain House evolved into a pragmatic approach emphasizing consumerism, self-help, and the normalizing function of work. The emphasis in clubhouses on work in the community helped pave the road toward the development of supported employment approaches for persons with SMI.

ACT model of case management. A third innovation that contributed to the development of supported employment programs was the ACT model of case management, as previously described. The emphasis of the ACT model on providing community-based, rather than clinic-based services, is reflected in the use of similar community-based services to help clients find and keep jobs in supported employment programs. The ACT model assumes that all psychiatric clients have a vocational goal, and 1 role of ACT teams is to help clients achieve those goals.

"Choose-get-keep" model. A fourth influence on supported employment programs was the articulation of the "choose-get-keep" model of vocational rehabilitation developed at the Boston University Center for Psychiatric Rehabilitation.[93] This model emphasizes the importance of client choice in identifying work and career areas of interest to the client and career planning on an individualized basis. The emphasis of the choose-get-keep model on client choice is clearly reflected in supported employment programs developed for persons with SMI.

Individual placement and support model. A number of different models of supported employment have been developed in recent years. One such model, which has been examined in several studies and is currently the subject of a number of ongoing controlled trials, is the individual placement and support (IPS) model.[94] Common features of the IPS model include:

  • Rapid job search in place of extensive prevocational assessment

  • Focus on jobs paying competitive wages in integrated settings in the community priority given to client preferences in selecting jobs

  • Provision of ongoing supports after the client has obtained a job

  • Viewing job endings not as failures but as helpful learning experiences

  • Close integration between the vocational team and mental health case management

As reviewed by Bond and colleagues,[95] 6 controlled studies of supported employment have been completed over the past several years.[96,97,98,99,100,101] The overall vocational findings of these studies have been uniformly positive, with superior outcomes achieved by the clients who have received supported employment compared with usual services, typically involving referral to a rehabilitation agency. Specifically, competitive employment rates at some time during the follow-up period (ranging from 12 months to 3 years) for clients receiving supported employment averaged 58% across the studies (range, 32%-78%), compared with competitive employment rates of an average of only 19% for clients receiving usual services (range, 6%-40%), as shown in Figure 3.

In a series of quasi-experimental studies comparing employment rates before and after converting day treatment to supported employment, the employment rates among active day treatment attendees increased from an average of 18% before the conversion to 54% after conversion, while the rate among clients not involved in the conversion remained essentially unchanged, 13% before and 13% after at 1 site and 16% before and 19% after at a second site.[102,103,104] Similarly, the mean rate for obtaining competitive employment in 8 other uncontrolled studies of supported employment was 62%.[95] Other employment outcome measures, such as number of hours worked and wages earned also have consistently favored the beneficial effects of the supported employment programs.

Figure 3.

Competitive employment rates in randomized control trials of supported employment.

The results of studies on supported employment suggest that competitive employment may indeed be an attainable goal for many persons with SMI. Of course, most clients who obtain employment only work part time, and most continue to receive benefits, such as supplemental security income. However, successful employment is associated with a range of positive outcomes in persons with SMI, including greater satisfaction with finances and modest improvements in self-esteem.[105]

Despite the positive results of research on supported employment, there are limitations, and further research in this area is sorely needed. Although studies indicate that supported employment improves the work outcomes for persons with SMI, in most studies a significant proportion (on average, about 40%) of clients failed to obtain competitive employment. Previous work experience is the most consistent predictor of work. Otherwise, it is unclear which clients are able to find and keep work with the assistance of supported employment programs, and which clients may require additional or different efforts to help them achieve the goal of employment.

For many clients, another limitation of obtaining competitive employment is the nature of the entry-level positions for which they are eligible but which offer little potential for growth. Many clients have a low educational level, which serves as a barrier to achieving more satisfactory and better-paying employment.

The long-term employment prospects of some persons with SMI may need to be enhanced by supported educational interventions, but research has not yet examined how these types of interventions need to be dovetailed with one another. Nevertheless, there is strong evidence indicating that many people with SMI can be assisted in finding and maintaining competitive employment.