Supplementing supported employment with workplace skills training

Introduction by the column editors: Supported employment, as designed for persons with serious and persistent mental illness, has been termed individual placement and support. In two randomized controlled trials (1,2), clients who received individual placement and support services were more likely to obtain at least one job in the competitive sector, to work more hours, and to have a higher total income than their counterparts who received more traditional types of vocational rehabilitation. However, individual placement and support did not improve the length of time the employed participants kept their jobs.An adjunctive or additional element of individual placement and support, aimed at improving the job tenure of individuals with mental illness, would be a constructive contribution to the vocational rehabilitation for this population. In a previous Rehab Rounds column, Wallace and colleagues (3) described the development of the workplace fundamental skills module, a highly structured and user-friendly curriculum designed to teach workers with mental illness the social and workplace skills needed to keep their jobs. The workplace fundamental skills module supplements individual placement and support by conveying specific skills that enable workers to learn the requirements of their jobs, anticipate the stressors associated with their jobs, and cope with stressors by using a problem-solving process. The earlier report described the production and validation of the module's content. The purpose of this month's column is to present the preliminary results of a randomized comparison of the module's effects on job retention, symptoms, and community functioning when coupled with individual placement and support. To enable wide generalization of the findings of the study, the program was conducted in a typical community mental health center.     

Brief reports: the fidelity of supported employment implementation in Canada and the United States

Supported employment has been documented in the United States as an evidence-based practice that helps people with severe mental illness obtain and maintain employment. The evidence is strongest for the programs that follow the individual placement and support model. This brief report examines the degree to which supported employment programs in British Columbia, Canada, are similar to those in the United States. Data from the Quality of Supported Employment Implementation Scale were compiled in 2003 for ten supported employment programs from vocational agencies in British Columbia and were compared with data from 106 supported employment programs and 38 non-supported employment programs in the United States. Overall, the Canadian supported employment programs that followed the individual placement and support model had the highest fidelity.     

Social relationships at work: does the employment model make a difference?

Social networks at work are a poorly understood component of the vocational experience of persons with severe mental illnesses. In an exploratory study, we interviewed 104 employed clients from two types of employment programs: one emphasizing a gradual sequence of group and individual placements in protected jobs and the other consisting of a supported employment model emphasizing individual, competitive placements. Using a newly developed instrument, interviewers asked clients to identify coworkers and supervisors with whom they had contact and to rate each on several aspects of their relationships, including disclosure, emotional support, criticism, and overall satisfaction. The gradual, group-oriented approach was associated with more disclosure, emotional support, and overall satisfaction with supervisor relationships, and more emotional support but also more stress from coworker relationships, than the individual placement approach. We conclude that clients enrolled in gradual group-oriented vocational programs perceive more supervisory and coworker support than do clients working in individual placement programs, although implications for long-term success in community employment are unknown.     

Individual placement and support for individuals with recent-onset schizophrenia: integrating supported education and supported employment

OBJECTIVE: To describe the adaptation of the Individual Placement and Support model of supported employment to individuals with a recent first episode of schizophrenia or a related psychotic disorder. METHODS AND RESULTS: Given that the vocational goals of persons with a recent onset of schizophrenia often involve completion of schooling rather than only competitive employment, the principles of Individual Placement and Support were extended to include supported education. This extension involved initial evaluation of the most appropriate goal for individual participants, having the IPS specialist working on placement either with the participant or directly with educational and employment settings (depending on permitted disclosure and individual need), and follow-along support that included work with teachers and aid in study skills and course planning as well as typical supported employment activities. Work with family members also characterized this application of IPS. A randomized controlled trial is comparing the combination of IPS and skills training with the Workplace Fundamentals Module with the combination of brokered vocational rehabilitation and broad-based social skills training. Participants in the IPS condition have returned to school, competitive work, and combined school and work with approximately equal frequency. CONCLUSIONS: IPS principles can be successfully extended to integrate supported education and supported employment within one treatment program. The distribution of return to school, work or their combination in this group of individuals with recent-onset schizophrenia supports the view that an integrated program of supported education and supported employment fits this initial period of illness.     

TEACCH-Supported Employment Program

Division TEACCH has served over 100 persons with autism through its supported employment program. Three models of supported employment are utilized: individual placement model, dispersed enclave model, and mobile crew model. Within each of these models there is an emphasis on utilizing individual strengths and interests, identifying appropriate jobs, and providing extensive long-term support. A retention rate of 89% demonstrates the success of the program which is due in large part to the broad array of long-term support services that are provided.     

Organizational and individual factors associated with breakdown of residential placements for people with intellectual disabilities

Background People with intellectual disabilities (IDs) whose behaviour challenges services are at increased risk of placement breakdown. Most previous research has tended to focus on the role of individual characteristics in predicting breakdown. A small number of studies have suggested that service variables may impact on intervention effectiveness and hence placement breakdown. Method This study used a non‐experimental group comparison design to investigate potential differences between two groups of residential homes, one of which had experienced placement breakdown, and one of which had successfully maintained placements in the community. Results More residents in the breakdown group had inappropriate sexual behaviours but there were no other differences. Services in the breakdown group had more limited procedural guidance for staff, weaker training, supervision and team meetings and less external professional support. Conclusion Placement characteristics may be an important determinant of community placement success for people with IDs and challenging behaviour. Those selecting and funding residential placements for such people should attend to the technical competence of the placement (in terms of its use of procedural guidance, training and professional advice) and to the extent of support for staff (in terms of training, supervision and team meetings).     

Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual

BACKGROUND: Unemployment is a major problem for people with first-episode psychosis and schizophrenia. This has repercussions for the economy, social functioning and illness prognosis. AIMS: To examine whether a vocational intervention - individual placement and support (IPS) - which has been found to be beneficial in populations with chronic schizophrenia, was a useful intervention for those with first-episode psychosis. METHOD: A total of 41 people with first-episode psychosis were randomised to receive either 6 months of IPS + treatment as usual (TAU) (n=20) or TAU alone (n=21). RESULTS: The IPS group had significantly better outcomes on level of employment (13 v. 2, P<0.001), hours worked per week (median 38 v. 22.5, P=0.006), jobs acquired (23 v. 3) and longevity of employment (median 5 weeks v. 0, P=0.021). The IPS group also significantly reduced their reliance on welfare benefits. CONCLUSIONS: Individual placement and support has good potential to address the problem of vocational outcome in people with first-episode psychosis. This has economic, social and health implications.     

Enlisting indigenous community supporters in skills training programs for persons with severe mental illness

OBJECTIVE: This study evaluated the generalization of skills training for severely and persistently mentally ill individuals who were paired with indigenous supporters. The supporters monitored the individuals' environments and prompted them to use their skills. METHODS: A total of 85 individuals with severe and persistent mental illness received six months of skills training. Forty-five of the participants received support from an individual of their choosing. The other 40 participants did not have supporters. At the end of the six-month skills training period, the supporters' participation was officially terminated, although they were encouraged to remain in their role for as long as both parties felt comfortable. The effects of the support were measured in terms of interpersonal functioning, acquisition and retention of the skills, psychopathology, global functioning, and satisfaction. Several process measures were also collected. RESULTS: The support procedures were evaluated favorably by both patients and supporters. The interpersonal functioning of the group with supporters was found to be significantly better than that of the nonsupported group at six- and 12-month follow-ups. No differences were found between the groups in symptoms-which were minimal during the entire training period-or skills learning and retention. CONCLUSIONS: The effects of support are likely applicable for a variety of individuals, supporters, and facilities. Indirect evidence suggested the importance of providing support for the supporters.     

Predictors of life satisfaction in individuals with intellectual disabilities

Background The purpose of this study was to examine factors that predict life satisfaction in individuals with intellectual disabilities (ID). Two groups of variables were studied: life skills (interpersonal, instrumental and leisure) and higher‐order predictors (social support, self‐determination and productivity). Method Fifty‐six participants with ID were recruited from two community agencies in Wisconsin. Data were collected using both a self‐report inventory, which was administered to each individual in an interview format, and a behaviour rating scale, which was completed by a knowledgeable staff member. Hierarchical regression was used to analyse the data. Results Both sets of variables were found to explain a significant amount of the variance in life satisfaction. Within the sets, social support and interpersonal skills were individually significantly associated with life satisfaction. Conclusion It is hoped that the results of this study will help support providers organise services in such a way that maximises the life satisfaction of the consumers that they serve.     

A multisite study of implementing supported employment in the Netherlands

OBJECTIVE: This article reports on the implementation of the individual placement and support model of supported employment in four Dutch regions. METHODS: The authors used structured site visits, employment data, and semistructured interviews to assess fidelity, employment outcomes, and facilitators of and barriers to successful implementation. RESULTS: At 24 months, the four sites reached a mean+/-SD fidelity score of 4.1+/-.3 (possible scores range from 1 to 5, with higher scores indicating closer adherence to the model). Of the 316 persons with mental illnesses, 57 (18%) obtained competitive jobs. Barriers to implementation included lack of organizational standards, loss of vocational staff, funding problems, insufficient time for program leaders, and inadequate cooperation between the involved organizations. Important facilitators were the skills and commitment of the vocational team members and the integration of vocational and mental health staff. CONCLUSIONS: To implement evidence-based supported employment in the Netherlands will require changes in financing, organizational structures, attitudes, cultural beliefs, and labor and disability regulations.     

Brief report: A randomized controlled trial examining peer support and behavioral weight loss treatment

Peer support among adolescents has been positively associated with heath behaviors; however, enhancing peer support for weight loss has rarely been studied among adolescents. This study examined whether a peer support training component delivered to enhance a standard weight loss program led to improved outcomes. Forty-one overweight adolescent females were randomly assigned to a Standard or Enhanced Peer Support intervention. The Enhanced group received in person peer support skills training and practiced skills using social networking. At 16 weeks, participants in the Enhanced condition reported significantly increased perceptions of friend support. Both groups demonstrated significant weight loss (6.4 lbs, ± 8.3). Attendance and self-monitoring were associated with weight loss. Perceptions of peer support can be increased with a peer training component, but did not increase weight loss during the short term.     

Cost-utility and cost-effectiveness of individual placement support and cognitive remediation in people with severe mental illness: Results from a randomized clinical trial

BackgroundAdministrators and policymakers are increasingly interested in individual placement and support (IPS) as a way of helping people with severe mental illness (SMI) obtain employment or education. It is thus important to investigate the cost-effectiveness to secure that resources are being used properly.MethodsIn a randomized clinical trial, 720 people diagnosed with SMI were allocated into three groups; (a) IPS, (b) IPS supplemented with cognitive remediation a social skills training (IPSE), and (c) Service as usual (SAU). Health care costs, municipal social care costs, and labor market service costs were extracted from nationwide registers and combined with data on use of IPS services. Cost-utility and cost-effectiveness analyses were conducted with two primary outcomes: quality-adjusted life years (QALY) and hours in employment. Incremental cost-effectiveness ratios (ICER) were computed for both QALY, using participant’s responses to the EQ-5D questionnaire, and for hours in employment.ResultsBoth IPS and IPSE were less costly, and more effective than SAU. Overall, there was a statistically significant cost difference of €9,543 when comparing IPS with SAU and €7,288 when comparing IPSE with SAU. ICER’s did generally not render statistically significant results. However, there was a tendency toward the IPS and IPSE interventions being dominant, that is, cheaper with greater effect in health-related quality of life and hours in employment or education compared to usual care.ConclusionIndividual placement support with and without a supplement of cognitive remediation tends to be cost saving and more effective compared to SAU.     

Anatomical properties of the arcuate fasciculus predict phonological and reading skills in children

For more than a century, neurologists have hypothesized that the arcuate fasciculus carries signals that are essential for language function; however, the relevance of the pathway for particular behaviors is highly controversial. The primary objective of this study was to use diffusion tensor imaging to examine the relationship between individual variation in the microstructural properties of arcuate fibers and behavioral measures of language and reading skills. A second objective was to use novel fiber-tracking methods to reassess estimates of arcuate lateralization. In a sample of 55 children, we found that measurements of diffusivity in the left arcuate correlate with phonological awareness skills and arcuate volume lateralization correlates with phonological memory and reading skills. Contrary to previous investigations that report the absence of the right arcuate in some subjects, we demonstrate that new techniques can identify the pathway in every individual. Our results provide empirical support for the role of the arcuate fasciculus in the development of reading skills.     

The psychosocial treatment of schizophrenia: an update

OBJECTIVE: The authors sought to update the randomized controlled trial literature of psychosocial treatments for schizophrenia. METHOD: Computerized literature searches were conducted to identify randomized controlled trials of various psychosocial interventions, with emphasis on studies published since a previous review of psychosocial treatments for schizophrenia in 1996. RESULTS: Family therapy and assertive community treatment have clear effects on the prevention of psychotic relapse and rehospitalization. However, these treatments have no consistent effects on other outcome measures (e.g., pervasive positive and negative symptoms, overall social functioning, and ability to obtain competitive employment). Social skills training improves social skills but has no clear effects on relapse prevention, psychopathology, or employment status. Supportive employment programs that use the place-and-train vocational model have important effects on obtaining competitive employment. Some studies have shown improvements in delusions and hallucinations following cognitive behavior therapy. Preliminary research indicates that personal therapy may improve social functioning. CONCLUSIONS: Relatively simple, long-term psychoeducational family therapy should be available to the majority of persons suffering from schizophrenia. Assertive community training programs ought to be offered to patients with frequent relapses and hospitalizations, especially if they have limited family support. Patients with schizophrenia can clearly improve their social competence with social skills training, which may translate into a more adaptive functioning in the community. For patients interested in working, rapid placement with ongoing support offers the best opportunity for maintaining a regular job in the community. Cognitive behavior therapy may benefit the large number of patients who continue to experience disabling psychotic symptoms despite optimal pharmacological treatment.     

Predictors of employment for people with severe mental illness: results of an international six-centre randomised controlled trial

BACKGROUND: An international six-centre randomised controlled trial comparing individual placement and support (IPS) with usual vocational rehabilitation for people with serious mental illness found IPS to be more effective for all vocational outcomes. AIMS: To determine which patients with severe mental illness do well in vocational services and which process and service factors are associated with better outcomes. METHOD: Patient characteristics and early process variables were tested as predictors of employment outcomes. Service characteristics were explored as predictors of the effectiveness of IPS. RESULTS: Patients with previous work history, fewer met social needs and better relationships with their vocational workers were more likely to obtain employment and work for longer. Remission and swifter service uptake were associated with working more. Having an IPS service closer to the original IPS model was the only service characteristic associated with greater effectiveness. CONCLUSIONS: The IPS service was found to be more effective for all vocational outcomes. In addition, maintaining high IPS fidelity and targeting relational skills would be a valuable focus for all vocational interventions, leading to improved employment outcomes. Motivation to find work may be decreased by satisfaction with current life circumstances.     

Supportive group action for women: a self-help strategy

A major goal of the demonstration project described was to test a model of self-help and voluntary support in developing groups for female single parents. Community meetings, study programs, and related experiential strategies were used to promote coping skills and strategies; access to resources; decision-making learning and responsibility; social contacts and networking; work skills and employment opportunities. The effectiveness of the model, which emphasized self-help, consumer power, and accessibility, was reflected in increased membership, self-awareness and confidence, leadership, employment and development of community resources. Initial individual contact, informal contracting, and community support were seen as important factors in the project's success.     

The Mental Health Nursing Clinical Confidence Scale: a tool for measuring undergraduate learning on mental health clinical placements

A significant proportion of the undergraduate preparation of student nurses in the tertiary sector involves the opportunity for experience in a variety of clinical placements. The majority of nursing students in Australian universities spend time in mental health settings. This compulsory clinical experience provides the opportunity for the application of nursing theory and the development of clinical confidence. Whereas there have been attempts to quantify the attainment of confidence to perform skills in general nursing settings, there has been little attention to this issue in mental health settings. The Mental Health Nursing Clinical Confidence Scale was developed as part of a larger study aimed at investigating the impact of mental health clinical placements on undergraduate nurses' attitudes and clinical confidence. Students were surveyed using the scale before and after a mental health nursing placement. The scale revealed robust psychometric properties. Significant changes in the self-reported confidence levels of students were found at the completion of the clinical placement. A number of key factors impacted on student confidence levels both before the clinical and after the placement. The 20 item scale will be a useful instrument in future evaluations of the effectiveness of student learning in mental health settings.     

A randomized controlled trial of a supported employment program for persons with long-term mental illness in Hong Kong

OBJECTIVES: Supported employment is an evidence-based practice that has proved to be consistently more effective than conventional vocational rehabilitation in helping people with severe mental illness find and sustain competitive employment. Most research on the effectiveness of supported employment comes from the United States. This study examined the effectiveness and applicability of a supported employment program based on the individual placement and support model in a Hong Kong setting. METHODS: Ninety-two unemployed individuals with long-term mental illness who desired competitive employment were randomly assigned to either a supported employment program or a conventional vocational rehabilitation program and followed up for 18 months. Both vocational and nonvocational outcomes were measured. RESULTS: Over the 18-month study period, compared with participants in the conventional vocational rehabilitation program, those in the supported employment group were more likely to work competitively (70% versus 29%; odds ratio=5.63, 95% confidence interval=2.28-13.84), held a greater number of competitive jobs, earned more income, worked more days, and sustained longer job tenures. Repeated-measures analysis of variance found no substantive differences between participants in the two groups and no significant change from baseline over time for psychiatric symptoms and self-perceived quality of life. CONCLUSIONS: Consistent with previous research findings in the United States, the supported employment program was more effective than the conventional vocational rehabilitation program in helping individuals with long-term mental illness find and sustain competitive employment in a Hong Kong setting. The supported employment program based on the individual placement and support model can thus be recommended for wider use in local mental health practice.     

Assessing a crisis of faith and making a pastoral crisis intervention

Evaluating the spiritual impact of a critical incident upon an individual is a vital aspect of restoring an individual to functioning in their relationships and work responsibilities. Being able to recognize and respond to spiritual symptoms of critical incident stress will allow crisis interventionists to address crisis recovery issues that are often central to an individual's identity and purpose for living. Spiritual symptoms of traumatic stress issue from the defining identity of an individual. With an understanding of the nature of a crisis of faith crisis interventionists can employ critical incident stress management skills to support a person in spiritual as well as psychological trauma.     

Switching skills on by turning off part of the brain

Snyder and Mitchell (1999) have argued that the extraordinary skills of savants, including mathematics and drawing, are within us all but cannot normally be accessed without some form of brain damage. It has also been argued that such skills can be made accessible to normal people by switching off part of their brain artificially using magnetic pulses (Carter, 1999). Using repetitive transcranial magnetic stimulation (rTMS) to interrupt the function of the frontotemporal lobe, a region of the brain implicated in the development of savant skills (Miller et al., 1996,1998), we tested this hypothesis. Here we show that savant-type skills improved in 5 out of 17 participants during the period of stimulation. The enhanced skills included declarative memory, drawing, mathematics, and calendar calculating. In addition to overall improvement being observed, striking improvements in individual performance on various tasks were also seen.