The Effects of a Supported Employment Program on Psychosocial Indicators
This paper describes the psychosocial effects of a program of supported employment (SE) for persons with severe mental illness. The SE program involves extended individualized supported employment for clients through a Mobile Job Support Worker (MJSW) who maintains contact with the client after job placement and supports the client in a variety of ways. A 50% simple random sample was taken of all persons who entered the Thresholds Agency between 3/1/93 and 2/28/95 and who met study criteria. The resulting 484 cases were randomly assigned to either the SE condition (treatment group) or the usual protocol (control group) which consisted of life skills training and employment in an in-house sheltered workshop setting. All participants were measured at intake and at 3 months after beginning employment, on two measures of psychological functioning (the BPRS and GAS) and two measures of self esteem (RSE and ESE). Significant treatment effects were found on all four measures, but they were in the opposite direction from what was hypothesized. Instead of functioning better and having more self esteem, persons in SE had lower functioning levels and lower self esteem. The most likely explanation is that people who work in low-paying service jobs in real world settings generally do not like them and experience significant job stress, whether they have severe mental illness or not. The implications for theory in psychosocial rehabilitation are considered.
The Effects of a Supported Employment Program on Psychosocial Indicators for Persons with Severe Mental IllnessOver the past quarter century a shift has occurred from traditional institution-based models of care for persons with severe mental illness (SMI) to more individualized community-based treatments. Along with this, there has been a significant shift in thought about the potential for persons with SMI to be "rehabilitated" toward lifestyles that more closely approximate those of persons without such illness. A central issue is the ability of a person to hold a regular full-time job for a sustained period of time. There have been several attempts to develop novel and radical models for program interventions designed to assist persons with SMI to sustain full-time employment while living in the community. The most promising of these have emerged from the tradition of psychiatric rehabilitation with its emphases on individual consumer goal setting, skills training, job preparation and employment support (Cook, Jonikas and Solomon, 1992). These are relatively new and field evaluations are rare or have only recently been initiated (Cook and Razzano, 1992; Cook, 1992). Most of the early attempts to evaluate such programs have naturally focused almost exclusively on employment outcomes. However, theory suggests that sustained employment and living in the community may have important therapeutic benefits in addition to the obvious economic ones. To date, there have been no formal studies of the effects of psychiatric rehabilitation programs on key illness-related outcomes. To address this issue, this study seeks to examine the effects of a new program of supported employment on psychosocial outcomes for persons with SMI.
Over the past several decades, the theory of vocational rehabilitation has experienced two major stages of evolution. Original models of vocational rehabilitation were based on the idea of sheltered workshop employment. Clients were paid a piece rate and worked only with other individuals who were disabled. Sheltered workshops tended to be "end points" for persons with severe and profound mental retardation since few ever moved from sheltered to competitive employment (Woest, Klein & Atkins, 1986). Controlled studies of sheltered workshop performance of persons with mental illness suggested only minimal success (Griffiths, 1974) and other research indicated that persons with mental illness earned lower wages, presented more behavior problems, and showed poorer workshop attendance than workers with other disabilities (Whitehead, 1977; Ciardiello, 1981).
In the 1980s, a new model of services called Supported Employment (SE) was proposed as less expensive and more normalizing for persons undergoing rehabilitation (Wehman, 1985). The SE model emphasizes first locating a job in an integrated setting for minimum wage or above, and then placing the person on the job and providing the training and support services needed to remain employed (Wehman, 1985). Services such as individualized job development, one-on-one job coaching, advocacy with co-workers and employers, and "fading" support were found to be effective in maintaining employment for individuals with severe and profound mental retardation (Revell, Wehman & Arnold, 1984). The idea that this model could be generalized to persons with all types of severe disabilities, including severe mental illness, became commonly accepted (Chadsey-Rusch & Rusch, 1986).
One of the more notable SE programs was developed at Thresholds, the site for the present study, which created a new staff position called the mobile job support worker (MJSW) and removed the common six month time limit for many placements. MJSWs provide ongoing, mobile support and intervention at or near the work site, even for jobs with high degrees of independence (Cook & Hoffschmidt, 1993). Time limits for many placements were removed so that clients could stay on as permanent employees if they and their employers wished. The suspension of time limits on job placements, along with MJSW support, became the basis of SE services delivered at Thresholds.
There are two key psychosocial outcome constructs of interest in this study. The first is the overall psychological functioning of the person with SMI. This would include the specification of severity of cognitive and affective symptomotology as well as the overall level of psychological functioning. The second is the level of self-reported self esteem of the person. This was measured both generally and with specific reference to employment.
The key hypothesis of this study is:
HO: A program of supported employment will result in either no change or negative effects on psychological functioning and self esteem.which will be tested against the alternative:
HA: A program of supported employment will lead to positive effects on psychological functioning and self esteem.
The population of interest for this study is all adults with SMI residing in the U.S. in the early 1990s. The population that is accessible to this study consists of all persons who were clients of the Thresholds Agency in Chicago, Illinois between the dates of March 1, 1993 and February 28, 1995 who met the following criteria: 1) a history of severe mental illness (e.g., either schizophrenia, severe depression or manic-depression); 2) a willingness to achieve paid employment; 3) their primary diagnosis must not include chronic alcoholism or hard drug use; and 4) they must be 18 years of age or older. The sampling frame was obtained from records of the agency. Because of the large number of clients who pass through the agency each year (e.g., approximately 500 who meet the criteria) a simple random sample of 50% was chosen for inclusion in the study. This resulted in a sample size of 484 persons over the two-year course of the study.
On average, study participants were 30 years old and high school graduates (average education level = 13 years). The majority of participants (70%) were male. Most had never married (85%), few (2%) were currently married, and the remainder had been formerly married (13%). Just over half (51%) are African American, with the remainder Caucasian (43%) or other minority groups (6%). In terms of illness history, the members in the sample averaged 4 prior psychiatric hospitalizations and spent a lifetime average of 9 months as patients in psychiatric hospitals. The primary diagnoses were schizophrenia (42%) and severe chronic depression (37%). Participants had spent an average of almost two and one-half years (29 months) at the longest job they ever held.
While the study sample cannot be considered representative of the original population of interest, generalizability was not a primary goal -- the major purpose of this study was to determine whether a specific SE program could work in an accessible context. Any effects of SE evident in this study can be generalized to urban psychiatric agencies that are similar to Thresholds, have a similar clientele, and implement a similar program.
All but one of the measures used in this study are well-known instruments in the research literature on psychosocial functioning. All of the instruments were administered as part of a structured interview that an evaluation social worker had with study participants at regular intervals.
Two measures of psychological functioning were used. The Brief Psychiatric Rating Scale (BPRS)(Overall and Gorham, 1962) is an 18-item scale that measures perceived severity of symptoms ranging from "somatic concern" and "anxiety" to "depressive mood" and "disorientation." Ratings are given on a 0-to-6 Likert-type response scale where 0="not present" and 6="extremely severe" and the scale score is simply the sum of the 18 items. The Global Assessment Scale (GAS)(Endicott et al, 1976) is a single 1-to-100 rating on a scale where each ten-point increment has a detailed description of functioning (higher scores indicate better functioning). For instance, one would give a rating between 91-100 if the person showed "no symptoms, superior functioning..." and a value between 1-10 if the person "needs constant supervision..."
Two measures of self esteem were used. The first is the Rosenberg Self Esteem (RSE) Scale (Rosenberg, 1965), a 10-item scale rated on a 6-point response format where 1="strongly disagree" and 6="strongly agree" and there is no neutral point. The total score is simply the sum across the ten items, with five of the items being reversals. The second measure was developed explicitly for this study and was designed to measure the Employment Self Esteem (ESE) of a person with SMI. This is a 10-item scale that uses a 4-point response format where 1="strongly disagree" and 4="strongly agree" and there is no neutral point. The final ten items were selected from a pool of 97 original candidate items, based upon high item-total score correlations and a judgment of face validity by a panel of three psychologists. This instrument was deliberately kept simple -- a shorter response scale and no reversal items -- because of the difficulties associated with measuring a population with SMI. The entire instrument is provided in Appendix A.
All four of the measures evidenced strong reliability and validity. Internal consistency reliability estimates using Cronbach's alpha ranged from .76 for ESE to .88 for SE. Test-retest reliabilities were nearly as high, ranging from .72 for ESE to .83 for the BPRS. Convergent validity was evidenced by the correlations within construct. For the two psychological functioning scales the correlation was .68 while for the self esteem measures it was somewhat lower at .57. Discriminant validity was examined by looking at the cross-construct correlations which ranged from .18 (BPRS-ESE) to .41 (GAS-SE).
A pretest-posttest two-group randomized experimental design was used in this study. In notational form, the design can be depicted as:
R O X Owhere:
R O O
R = the groups were randomly assignedThe comparison group received the standard Thresholds protocol which emphasized in-house training in life skills and employment in an in-house sheltered workshop. All participants were measured at intake (pretest) and at three months after intake (posttest).
O = the four measures (i.e., BPRS, GAS, RSE, and ESE)
X = supported employment
This type of randomized experimental design is generally strong in internal validity. It rules out threats of history, maturation, testing, instrumentation, mortality and selection interactions. Its primary weaknesses are in the potential for treatment-related mortality (i.e., a type of selection-mortality) and for problems that result from the reactions of participants and administrators to knowledge of the varying experimental conditions. In this study, the drop-out rate was 4% (N=9) for the control group and 5% (N=13) in the treatment group. Because these rates are low and are approximately equal in each group, it is not plausible that there is differential mortality. There is a possibility that there were some deleterious effects due to participant knowledge of the other group's existence (e.g., compensatory rivalry, resentful demoralization). Staff were debriefed at several points throughout the study and were explicitly asked about such issues. There were no reports of any apparent negative feelings from the participants in this regard. Nor is it plausible that staff might have equalized conditions between the two groups. Staff were given extensive training and were monitored throughout the course of the study. Overall, this study can be considered strong with respect to internal validity.
Between 3/1/93 and 2/28/95 each person admitted to Thresholds who met the study inclusion criteria was immediately assigned a random number that gave them a 50/50 chance of being selected into the study sample. For those selected, the purpose of the study was explained, including the nature of the two treatments, and the need for and use of random assignment. Participants were assured confidentiality and were given an opportunity to decline to participate in the study. Only 7 people (out of 491) refused to participate. At intake, each selected sample member was assigned a random number giving them a 50/50 chance of being assigned to either the Supported Employment condition or the standard in-agency sheltered workshop. In addition, all study participants were given the four measures at intake.
All participants spent the initial two weeks in the program in training and orientation. This consisted of life skill training (e.g., handling money, getting around, cooking and nutrition) and job preparation (employee roles, coping strategies). At the end of that period, each participant was assigned to a job site -- at the agency sheltered workshop for those in the control condition, and to an outside employer if in the Supported Employment group. Control participants were expected to work full-time at the sheltered workshop for a three-month period, at which point they were posttested and given an opportunity to obtain outside employment (either Supported Employment or not). The Supported Employment participants were each assigned a case worker -- called a Mobile Job Support Worker (MJSW) -- who met with the person at the job site two times per week for an hour each time. The MJSW could provide any support or assistance deemed necessary to help the person cope with job stress, including counseling or working beside the person for short periods of time. In addition, the MJSW was always accessible by cellular telephone, and could be called by the participant or the employer at any time. At the end of three months, each participant was post-tested and given the option of staying with their current job (with or without Supported Employment) or moving to the sheltered workshop.
ResultThere were 484 participants in the final sample for this study, 242 in each treatment. There were 9 drop-outs from the control group and 13 from the treatment group, leaving a total of 233 and 229 in each group respectively from whom both pretest and posttest were obtained. Due to unexpected difficulties in coping with job stress, 19 Supported Employment participants had to be transferred into the sheltered workshop prior to the posttest. In all 19 cases, no one was transferred prior to week 6 of employment, and 15 were transferred after week 8. In all analyses, these cases were included with the Supported Employment group (intent-to-treat analysis) yielding treatment effect estimates that are likely to be conservative.
The major results for the four outcome measures are shown in Figure 1.
Insert Figure 1 about here
_______________________________________It is immediately apparent that in all four cases the null hypothesis has to be accepted -- contrary to expectations, Supported Employment cases did significantly worse on all four outcomes than did control participants.
The mean gains, standard deviations, sample sizes and t-values (t-test for differences in average gain) are shown for the four outcome measures in Table 1.
Insert Table 1 about here
_______________________________________The results in the table confirm the impressions in the figures. Note that all t-values are negative except for the BPRS where high scores indicate greater severity of illness. For all four outcomes, the t-values were statistically significant (p<.05).
The results of this study were clearly contrary to initial expectations. The alternative hypothesis suggested that SE participants would show improved psychological functioning and self esteem after three months of employment. Exactly the reverse happened -- SE participants showed significantly worse psychological functioning and self esteem.
There are two major possible explanations for this outcome pattern. First, it seems reasonable that there might be a delayed positive or "boomerang" effect of employment outside of a sheltered setting. SE cases may have to go through an initial difficult period of adjustment (longer than three months) before positive effects become apparent. This "you have to get worse before you get better" theory is commonly held in other treatment-contexts like drug addiction and alcoholism. But a second explanation seems more plausible -- that people working full-time jobs in real-world settings are almost certainly going to be under greater stress and experience more negative outcomes than those who work in the relatively safe confines of an in-agency sheltered workshop. Put more succinctly, the lesson here might very well be that work is hard. Sheltered workshops are generally very nurturing work environments where virtually all employees share similar illness histories and where expectations about productivity are relatively low. In contrast, getting a job at a local hamburger shop or as a shipping clerk puts the person in contact with co-workers who may not be sympathetic to their histories or forgiving with respect to low productivity. This second explanation seems even more plausible in the wake of informal debriefing sessions held as focus groups with the staff and selected research participants. It was clear in the discussion that SE persons experienced significantly higher job stress levels and more negative consequences. However, most of them also felt that the experience was a good one overall and that even their "normal" co-workers "hated their jobs" most of the time.
One lesson we might take from this study is that much of our contemporary theory in psychiatric rehabilitation is naive at best and, in some cases, may be seriously misleading. Theory led us to believe that outside work was a "good" thing that would naturally lead to "good" outcomes like increased psychological functioning and self esteem. But for most people (SMI or not) work is at best tolerable, especially for the types of low-paying service jobs available to study participants. While people with SMI may not function as well or have high self esteem, we should balance this with the desire they may have to "be like other people" including struggling with the vagaries of life and work that others struggle with.
Future research in this are needs to address the theoretical assumptions about employment outcomes for persons with SMI. It is especially important that attempts to replicate this study also try to measure how SE participants feel about the decision to work, even if traditional outcome indicators suffer. It may very well be that negative outcomes on traditional indicators can be associated with a "positive" impact for the participants and for the society as a whole.
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Woest, J., Klein, M. and Atkins, B.J. (1986). An overview of supported employment strategies. Journal of Rehabilitation Administration, 10(4), 130-135.
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