Answers to Questions about Supported Employment

Question: Do you have any information on providing supported self employment services for individuals with a psychiatric disability?

Answer: Helping individuals with self-employment can be part of IPS supported employment. When helping clients with self-employment, practitioners should carefully discuss the person's preferences for hours, work environment, wages, etc. to ensure that self-employment will satisfy the person's needs. Further, in order to self-employment to be considered a competitive job, wages should be recorded and reported to all sources of entitlements (e.g., Social Security Administration) and the IRS.

For resources about how to help people with self-employment, we recommend connecting with your local VR office. In addition, you may be interested in:

Question: Please clarify the difference between IPS and Supported Employment. Are the names considered interchangeable?

Answer: Supported employment is a widely used term that does not necessarily refer to the evidence-based practice. Consequently, some states and countries are choosing to use the term Individual Placement and Support (IPS),which refers to the evidence-based approach to supported employment for people with serious mental illness. At this time, the Dartmouth Psychiatric Research Center is using "IPS supported employment" to differentiate the evidence-based approach from other vocational models.

Question: I have a question regarding the fidelity review. Item T4 (Rapid job search for competitive job) - it shows our average is 29.71 days from first meeting to employer contact. To clarify, does this mean from the first time we meet our client to the first time we meet an employer specifically for that client?

Answer: Yes, "Rapid Job Search for Competitive Job" refers to the time between meeting with a client to first face-to-face contact with an employer. The following scenarios would constitute an employer contact:

The scenarios below would NOT constitute an employer contact:

Question: I have a question about the item called, "On-going work-based assessment". I was interested in knowing why it is necessary to update the vocational profile with each new job experience since the employment specialists are writing progress notes along the way.

Answer: Employment specialists are encouraged to update the vocational profile with each new job experience for the same reason that mental health practitioners update the mental health assessment on a regular basis. It is important to store lessons learned about the person's strengths, needs and preferences in a location that is easy to find.

A person might have to wade through numerous progress notes in order to gain an understanding of what was learned from each job experience. Further, at many agencies progress notes focus on the interaction between the client and employment specialist and may leave out important information such as job duties. If an employment specialist leaves his or her job, the next specialist will benefit from all of this information.

Finally, a good job update form does more than document history. It also leads practitioners and clients to think about key issues.

An example of job update forms are on this website under "program tools".

Question: Regarding Individual Placement and Support (Evidence-Based Supported Employment), would the only entrance criteria to be listed on our service definition be "An Individual that has a Serious and Persistent Mental Illness or a Severe Mental Illness diagnosis or a Dual Diagnosis with Substance Abuse" and "The Individual is experiencing barriers to employment" AND "The individual has a desire to work"?

Answer: Most programs have an entry statement similar to this one: "Evidence-Based Supported employment (Individual Placement and Support) is available to any person served by the agency who has a serious mental illness and a desire to work at a competitive job."

Ideally, clients can self-refer to supported employment, so any person who believes that he or she would benefit from supported employment would be eligible if s/he has a serious mental illness and a desire to work at a competitive job. We encourage agencies to share information about self-referrals to all clients and any family members who are involved in the person's treatment.

You raise an interesting point that some people with serious mental illness are able to find and keep jobs on their own. Therefore, we also encourage agencies to spend time talking to case managers about ways that they can promote employment and help individuals problem-solve job related issues. For example, at some agencies case managers will help clients think of ways to answer interview questions and might also help clients fill out applications that they bring to appointments. When case managers and counselors focus on employment, they often find that some people will return to work independently.

Question: We are working on improving our fidelity, but are questioning the criteria for #4- Rapid Job Search for Competitive Employment. It reads that "first face to face employer contact occurs with employment specialist or by individual within first 30 days after program entry." With the economy and technology we have a lot of individuals applying on line for jobs. Would that meet standards?

Answer: We realize that many employers are now using online applications, however, the standard for rapid job search is still face-to-face contact with employers. As you know, when clients are applying for jobs online, they are competing with a large number of applicants. We encourage employment specialists and clients to go into the community and ask to speak directly to hiring managers and human resource departments. If an online application is required, the job applicant might consider submitting the application before going to meet with the employer.

Recently we heard a couple of tips for working with managers in regards to the online applications. First, employment specialists should spend time getting to know employers. For example, asking about the employer's needs: "Can you tell me about someone who has been successful here--why are they successful?", "What are some of your headaches as a manager?", "What type of person does well in these positions?", "What is a typical day like for a clerk in your office?". As you are doing that, you may begin asking about the hiring process as well. If an employer says that applicants must submit an online application along with everyone else, try something like this: "You mentioned that you need people who are energetic and friendly. If you had a friend who had just that type of personality, how would you go about helping that person get hired?"

As it turns out, many managers are able to ask their human resources department to pull certain applications. Some will do that because of their relationship with the employment specialist or because they have had contact with a client whom they believe to be a good candidate. We encourage employment specialists not to undervalue the importance of face-to-face relationship building with employers.

Question: What's the difference between IPS and Supported Employment?

Answer: IPS (Individual Placement and Support) is synonymous with evidence-based supported employment. However the term "supported employment" is sometimes used to describe programs and funding streams that are for people with any type of disability who need long-term job supports. In contrast, evidence-based supported employment, or IPS, is a carefully defined employment service based on a 25-item fidelity scale. The evidence base includes studies with participants who have serious mental illness.

Question: The Supported Employment Fidelity Scale also indicates there should be Zero Exclusion Criteria - how would this work for clients that are currently exhibiting evidence of or high risk factors for violence?

Answer: Mental health teams work with people who have the potential for violence from time to time. When helping people with housing in the community, teams work together with supervisors and psychiatrists to determine an acceptable level of risk for the person and community. We see employment in a similar light.

It is important for the mental health team, employment specialist, psychiatrist and SE supervisor to meet and discuss the person's employment goal. They should also consider the person's history of violence. For example, many people have a history of one aggressive incident that took place in a particular situation and may never recur. Others tend to be aggressive only in specific situations, for instance, when drinking and not taking medication. The group should consider any history of violence, current treatment, substance use, stressors, etc. Further, the team should discuss the type of job and work environment that might be best for that person and can offer extra follow-along supports from the mental health team and employment specialist.

Finally until the team is very clear about the type and level of risk, it is critical that they take precautions in their own work. Safety should come first for everyone as none of us can do well in our jobs unless we are feeling safe.

Question: We have two MH SE providers in our county. One is a clubhouse with transitional employment and the other facilitates individual employment. The individual employment team is located within a mental health agency. This IP program has been providing services for 15 plus years. It is currently a team of 2.5 individuals. One full time and one part-time function primarily as job developers. ( the part-time primarily DVR and the other RSN funded services). The developers also do some job coaching (i.e.: the first week or so on the job). The other FTE team member provides intake, ongoing benefits analysis and reporting, customized on-going coaching support, vocational group facilitation, and WRAP plans ( as part of long term support strategies). All three participate in treatment team meetings with case managers and therapists and are flexible at covering for each other as needed.

This vocational program is looking at becoming an EBP. They believe that because of their small size and their approach that every staff member is part of each individual clients employment journey at all stages of the employment process that it is ok to delegate roles in the team. Client drop out is low and outcomes are high. Two members of this team have worked together for 13 years and feel like their system is structured on the strength based rather than generalist approach ( one excels at working with employers and the other has great coaching and WRAP facilitation skills.)

Is it necessary for this program to restructure itself from Employment Specialists to Employment Generalists to be an EBP?

Answer: Programs that have good fidelity to the supported employment (IPS) model have better outcomes. Even when the economy is troubled, good fidelity is something programs can focus on in order to help more people with employment. During research trials for supported employment (IPS), clients were most likely to drop out of services when asked to transfer from one employment specialist to another. Many clients value the relationships that they form with employment specialists and do not wish to give these up in order to work with someone new. It has also been observed by some supported employment teams that most employers prefer to work with only one employment specialist throughout the employment process.

To follow good fidelity, each employment specialist carries out all phases of employment service, including intake, engagement, assessment, job placement, job coaching, and follow-along supports before step down to less intensive employment support from another mental health practitioner. (It is not expected that each employment specialist will provide benefits counseling to their clients. Referrals to a highly trained benefits counselor are in keeping with good fidelity.)

Some programs attempt to divide job duties between employment specialists because they believe that only a certain type of person will be able to be effective at job development. However, we have worked with numerous supported employment programs and it is our observation that most people can master job development if they have access to good training and ongoing mentoring. A key seems to be field mentoring by the supported employment supervisor. For example, when a new employment specialist is hired, the supervisor might go out with that person weekly to help him make employer contacts. The supervisor would continue this practice for couple months until s/he determined that the specialist was skilled at job development, and then might drop back and provide field mentoring for job development on a less frequent basis. Experienced co-workers and VR counselors can also help the employment specialist develop this skill.

We have one final suggestion regarding the WRAP plans that you mentioned. As part of "Employment Services Staff" (another fidelity item), we would suggest that case managers or counselors help clients with WRAP plans, rather than the employment specialist. Although many people might include employment in their WRAP plans, we would suggest that employment specialists focus on helping people with jobs, rather than facilitating WRAP activities. Ideally, mental health practitioners provide services that support the employment plan. For example, mental health practitioners might help a person manage his paycheck, work on social skills that could be used on the job, help with clean clothing for work, etc. The WRAP plan is another way to involve mental health staff in the employment process without distracting employment specialists from their essential duties.

Thanks for your question. Grappling with issues such as these will help your program achieve good fidelity and better outcomes for clients.

The Dartmouth PRC Supported Employment Team

Question: What are the employment outcomes (rate of placement-percentage) for all the referrals you receive of consumers with mental illness. What is the rate of a successful closure of all consumers placed in competitive employment?

Answer: In research studies that looked at good fidelity IPS-supported employment programs, 61% of people who were in supported employment obtained competitive jobs. In the control groups in which traditional, stepwise vocational services were provided, 23% of individuals found jobs.

Currently, ten states and the District of Columbia are working with the Dartmouth Psychiatric Research Center on supported employment for people with serious mental illness. Each state has multiple supported employment programs and reports program outcomes on a regular basis. At any given time, about 50% of the people in those supported employment programs have competitive jobs.

In IPS-supported employment, people are offered support for as long as people want or need services, typically one year following steady employment. Long-term follow up studies (e.g., 8-12 years) indicate that people transition through several jobs. In general, people who have recieved supported employment services work in several jobs over time, as many people do. We recommend that you read the following article that provides an update on the resarch. Bond et al., 2008. An update on randomized controlled trials of evidnece-based supported employment. Psychiatric Rehabilitation Journal, 31, 280-290.

Question: Why doesn't supported employment use vocational evaluations? Wouldn't it be helpful for people to know more about the type of job that would be a good fit?

Answer: Traditional approaches to assessment and evaluation, such as standardized pencil and paper tests, work samples and situational assessments are not a good source of information. Research has shown us that in regards to adults with serious mental illness, these tests do not predict who will succeed in the workforce. One reason may be that work environments and supervisors are so often the key to success. For example, a data entry job with an approachable supervisor who gives feedback in a friendly manner is entirely different than a data entry job with a critical boss who does not provide training. No matter how good the test, it can't anticipate these types of factors.

Further, the testing process can be discouraging to some people who want to move towards employment right away. Finally, vocational evaluation can feel demeaning to some people who want to go about finding a job just like everyone else--by going out to meet employers and put in applications.

Instead, supported employment (IPS) attempts to help people make good job matches by learning as much as possible about each individual. The employment specialist talks to the person's mental health workers, and with permission, family members. The specialist also has a series of conversations with the job seeker about his work history (jobs he liked, strategies that worked, etc.), his job preferences, work skills, interests, current symptoms and coping strategies, etc.

Employment specialists also spend time in the community talking to employers about the types of jobs that they have available, job requirements and hiring preferences. This information about local jobs is invaluable as the specialist can combine this information with client preferences to suggest jobs to the job seeker.

Of course, not every job works out, but this is also true for workers without disabilities. If a job doesn't go well, the employment specialist, client, VR counselor, mental health practitioners, and with permission, family members, talk about the things that went well, as well as those things that didn't go well. Practitioners try to look for lessons learned and help the person develop a new job plan. They offer to help with a new job search without delay.

Question: Why do you have to have two employment specialists for supported employment?

Answer: Forming a unit of at least 2 employment specialists provides the organizational structure for sharing information and resources with each other for better client outcomes. A single employment specialist at an agency typically has no one to help him learn skills such as job development and to share job leads. Further, it is often difficult for a single employment specialist to promote the importance of work and supported employment services with practitioners who may not have similar values.

Some agencies report that it is not possible to hire more than one employment specialist because the mental health program is very small. However, even mental health programs serving as few as 60 people will eventually find that more than one employment specialist is necessary. As mental health practitioners begin to value employment, and clients spread the word about their jobs, it is not uncommon to find that 50-70% of adults served by the mental health program are interested in getting a job.

Rural programs or new supported employment (IPS) programs may find that it is necessary to begin with just one employment specialist. We recommend that these programs try to hire another employment specialist as soon as possible. In the meantime, try to help the employment specialist to connect with other job development programs in the area. For example, VR may be able to make introductions to other programs doing similar work.

Question: Who conducts a fidelity review and who sponsors the review?

Answer: In some states, state supported employment trainers are available to conduct supported employment fidelity reviews. These trainers usually work for either Vocational Rehabilitation, a department of mental health or a state-supported center of excellence for supported employment. Some states have hired people (other than trainers) specifically to conduct supported employment fidelity reviews. If your state is not one of the states participating in the Johnson & Johnson-Dartmouth Community Mental Health Program (CT, KS, IL, MD, MN, MO, OH, OR, SC, VT, District of Columbia) then it is possible that a state fidelity reviewer is not available.

External fidelity reviewers who have been trained in supported employment are the ideal candidates for conducting fidelity reviews. However, if such a person is not available, agencies can still benefit by using the fidelity scale. Dartmouth Psychiatric Research Center (PRC) has Supported Employment Fidelity Kits (available through this website) that include the fidelity scale, fidelity manual, demonstration DVD and sample fidelity reports. Two to three people from the agency who are not closely connected to the SE program (for example, people who work in the QA department) might spend time becomming familiar with the fidelity materials and then conduct a review for the agency. The fidelity manual provides detailed information about conducting reviews, scoring items and writing reports.

New fidelity reviewers who have questions about the scale or scoring items should also feel free to submit their questions to this website.