The primary purpose of this study was to improve our understanding of who gets referred to evidence-based Supported Employment (SE) services and what characteristics predict entry into competitive employment for adult consumers diagnosed with co-occurring mental and substance use disorders.
The study assessed the impact of consumer- and agency-level facilitators and barriers to competitive employment for people diagnosed with co-occurring disorders. Research questions focused on the impact of these variables upon referral to and use of evidence-based SE services, on being competitively employed, on time to employment entry, and on hours worked and wages earned. Additionally, the impact of SE on various aspects of consumer well-being was examined.
Consumer-level variables included the following: demographic and socioeconomic characteristics; mental health and substance use status; consumer functioning and life status; work history/work interest. Agency-level variables included the following: organizational characteristics.
Statement Of The Problem
Individuals with co-occurring mental and substance use disorders have many obstacles to overcome on the road to recovery. They can gain confidence in their ability to recover or develop independent living skills to meet their daily living needs when they experience incremental successes. One such success is the attainment of gainful employment. Unfortunately, the current rate of employment among persons with severe and persistent mental illness is very low. Less than 20 percent of the people with severe mental illness in the United States are employed.
The evidence-based Supported Employment (SE) model has been shown to be effective in increasing rates of employment for individuals with severe mental illness. The application of SE for individuals with co-occurring mental and substance use disorders has received less empirical attention than for individuals with severe mental illness alone. Most studies indicate that work outcomes are no worse for those with co-occurring disorders as compared to individuals with mental illness alone. However, relatively little is known about the factors related to consumers' decisions to pursue employment and factors affecting employment entry, especially for consumers with co-occurring substance use and mental disorders.
Research Design And Methodology
In this study, substance use status was not a predictor of competitive employment. Therefore, service teams should not dissuade people with co-occurring severe mental illness and substance use disorders from pursuing their employment dreams.
The study utilized a quasi-experimental longitudinal design with a randomly selected non-equivalent comparison group. Consumers with co-occurring mental and substance use disorders who were receiving evidence-based Integrated Dual Disorders Treatment (IDDT) (see sidebar) from four mental health agencies in Ohio were assigned to one of two conditions:
- An intervention group of 113 consumers who were not currently employed, expressed a desire to work, and were referred to the Supported Employment treatment group
- A randomly selected comparison group of 81 consumers who met the criteria for the study but did not express a desire to work and were not referred to the Supported Employment program during the course of the study.
Consumers in both conditions were tracked for a twelve month period.
Prior to the beginning of data collection, approval of data collection procedures and consent forms were received from the Case Western Reserve University IRB. Data for the study were generated through five sources:
- Consumer and provider questionnaires already in use by the study agencies (ODMH's "Consumer Adult Form A" and "Provider Form A")
- Data collection forms designed specifically for this research project that were completed by case managers and Supported Employment staff at the study agencies
- Data from agency administrative records
- IDDT and Supported Employment (SE) fidelity scores from the Ohio SAMI and SE Coordinating Centers of Excellence
- County unemployment data
- Almost half (46.9 percent) of consumers referred for Supported Employment services were competitively employed at some time during the 12 month post-referral study period.
- Consumers worked an average of 352 hours over the course of the study with a mean hourly wage of $8.16 per hour.
Referral to Supported Employment (SE)
- The single best predictor of an IDDT consumer being referred to SE is a history of previous employment. Consumers with previous work experience were almost five times more likely to be referred to SE services.
- Consumers who self-identified as disabled were half as likely to be referred to SE.
- Consumers who had a diagnosis of substance dependence were three-fifths less likely to be referred to SE.
- Competitive Employment Six Months Post Study Entry (Intervention & Comparison Groups Combined)
- Consumers with schizoaffective disorder, greater psychological distress, and those not referred for Supported Employment services were less likely to enter competitive employment.
- Lack of previous work experience and consumers self-identification as disabled had an indirect effect on consumers' employment through their referral status. That is, consumers without previous work experience and consumers who self-identified as disabled were less likely to be referred for SE services, which, because they were less likely to receive services, subsequently reduced the likelihood that they would become employed.
- Consumers' substance use status was not a predictor of competitive employment.
Time to Employment Entry Twelve Months Post Referral for Supported Employment Services (Intervention Group)
The odds of consumers entering employment increased as the consumer empowerment score at baseline increased and the odds of entering employment were double for consumers utilizing at least 30 minutes of SE services per month.
The odds of consumers entering competitive employment decreased as their perception of having adequate income increased. Consumers living in areas with higher regional unemployment rates were at reduced odds of employment entry as were consumers who were non-White.
Consumers' substance use status was not a predictor of time to employment entry.
Recommendations For Policy & Practice
The competitive employment rates in this study, although below the employment levels found in clinical trials of Supported Employment, were significantly higher than those of the control groups in those trials and within the range found in other studies. This finding, coupled with the finding that substance use was not a deterrent to employment of consumers in this study, demonstrates the appropriateness of the Supported Employment model for adults with co-occurring mental and substance use disorders.
Consumer- and agency-level barriers may negatively impact the referral of consumers for Supported Employment services and subsequent competitive employment of consumers who are referred for Supported Employment services.
To address potential consumer-level barriers, agencies should hold educational sessions for consumers about employment to discuss potential ambivalence, fear, or concerns about working: this may enhance the likelihood of their request for and referral to SE services.
In particular, to address the fact that some consumers may see themselves as less capable of work than others, agencies should offer psychosocial programs designed to increase consumer self-efficacy and empowerment in the context of employment.
Agencies should discuss the non-monetary benefits of employment with consumers but should also offer benefits counseling to consumers and their families to address misconceptions and potential concerns about the impact of employment on cash benefits from programs like Social Security's SSI and SSDI.
To address potential agency-level barriers, agencies should assess the optimism of service team members about the role of work in the recovery process and build consensus for the evidence-based SE model as a source of competitive employment opportunities for all consumers.
Agencies should evaluate and advance knowledge and skills of case managers, psychiatrists, nurses, counselors, and program managers in applying appropriate motivational techniques on a regular and consistent basis with consumers to help enhance motivation for work as a realistic goal.
Mental health agency supervisors should reinforce principles of consumer behavioral change in supervision, through staff observation, and through competency-based training.
- David E. Biegel, PhD, Principal Investigator, Henry Zucker Professor of Social Work Practice and Professor of Psychiatry and Sociology, Associate Dean for Research and Training, Mandel School of Applied Social Sciences.
- Robert J. Ronis, MD, MPH, Co-Principal Investigator, Douglas Danford Bond Professor and Chairman, Department of Psychiatry, Case School of Medicine.
- Patrick E. Boyle, MSSA ('89), LISW-S, LICDC, Co-Investigator, Director of Implementation Services at the Center for EBPs at Case.
- David Beimers, MSW, Project Director
- Lauren Stevenson, MSSA, Data Analyst
This research was supported by grant # 05.1209 from the Office of Program Evaluation and Research, Ohio Department of Mental Health. Our research study would not have been possible without the cooperation and assistance that we received from a number of individuals and organizations. We thank Wilma J. Lutz, Ph.D., RN, Project Supervisor, Office of Program Evaluation and Research, Ohio Department of Mental Health, for her consultation and guidance in the implementation of this research project. Dr. Lutz' assistance in securing necessary data and resources to help implement this project was very much appreciated.
We owe a debt of gratitude to the direct-service, supervisory, and administrative staffs of our study agencies- the Center for Individual and Family Services, Nord Center, Neighboring, and Southeast, Inc., and to the consumers of these agencies who consented to participate in this research project. This study benefitted greatly from their active involvement and assistance. Shiri Katz-Saltzman, Ph.D., served as the Project Director for the first year of the study and made invaluable contributions to our work. Our faculty and staff colleagues at the Substance Abuse and Mental Illness and Supported Employment Coordinating Centers of Excellence were very generous with their time and offered helpful advice to us throughout the course of this project.
Page created and edited by Paul M. Kubek, MA, director of communications at the Center for Evidence-Based Practices at Case Western Reserve University.