INTRODUCTION — Addressing the employment difficulties of individuals with severe mental illness (SMI) has been a long-standing mental and public health problem. Studies show that only approximately 15 percent of SMI individuals are employed [1-4]. This rate stands in marked contrast to the 65 percent of SMI individuals who express a desire to work as a goal [5-7].
Several different vocational rehabilitation programs have been designed and implemented to bridge this gap. The individual placement and support model of supported employment, a vocational rehabilitation model that focuses on obtaining competitive employment via a rapid job search, has been shown in randomized clinical trials to achieve superior outcomes compared with alternative vocational rehabilitation services focused on prevocational training or noncompetitive work as an initial step.
This topic reviews the context, theoretical foundation, indications, components, and efficacy of supported employment for patients with SMI. Other psychosocial interventions for patients with SMI are reviewed separately. Cognitive-behavioral therapy and other psychosocial interventions specifically for patients with schizophrenia are also reviewed separately. (See "Assertive community treatment for patients with severe mental illness" and "Approach to managing increased risk for cardiovascular disease in patients with severe mental illness" and "Lifestyle interventions for obesity and overweight patients with severe mental illness" and "Psychosocial interventions for schizophrenia in adults".)
SEVERE MENTAL ILLNESS — Supported employment and some other psychosocial interventions have been developed and tested in patients with a “severe mental illness” [8], ie, a mental disorder that has each of the following characteristics:
●Severe symptoms and behavioral impairment
●Pronounced disability in basic life skills
●Prolonged course of illness
Mental disorders most commonly associated with this term include schizophrenia, schizoaffective disorder, recurrent bipolar disorder, and chronic or recurrent psychotic depression [9,10]. Certain personality disorders, posttraumatic stress disorder, and other mental disorders are sometimes included within the category. Variation in the disorders included is seen among US states when the designation is used to determine eligibility for mental health care and other social services [8]. Definitions of severe mental illness typically exclude substance use disorders (as primary disorders), dementia, and intellectual developmental disorder (formerly mental retardation in DSM-IV) [11]. (See "Schizophrenia in adults: Clinical manifestations, course, assessment, and diagnosis" and "Bipolar disorder in adults: Clinical features" and "Unipolar major depression with psychotic features: Epidemiology, clinical features, assessment, and diagnosis".)
OVERVIEW AND CONTEXT — Supported employment is a type of vocational rehabilitation with the aim of assisting individuals with severe mental illness (SMI) obtain a competitive job. There are several types of work readiness programs for individuals with SMI:
●Transitional work experience
●Compensated work therapy
●Incentive therapy
●Sheltered workshops
●Supervised work crews
●Community job programs
Traditional vocational rehabilitation programs include engagement in prevocational training or noncompetitive work (such as transitional work experience) as an initial step towards seeking competitive employment. Vocational rehabilitation programs differ by the type of structured work experience and the amount of staff and other supports provided.
The premise underlying traditional vocational rehabilitation is that prevocational training and experience in noncompetitive, structured, staff supported, work-type settings with other SMI individuals is necessary before assuming the demands of competitive employment and working with individuals from the general population.
Criticisms of this approach include the lack of research supporting the underlying principles, the lack of standardization across programs, not tailoring the prevocational work experience to the SMI individual’s personal interests, and the lack of empirical evidence that these approaches lead to obtaining competitive jobs better than place-train models or other comparison vocational rehabilitation services [12-14].
The origins of the individual placement and support model of supported employment (SE-IPS) date back to the early 1990s. At present, it is the leading evidence-based vocational rehabilitation model, well supported through reviews and meta-analyses of randomized clinical trials [15,16]. There are currently over 500 SE-IPS programs within the United States with programs in Europe, Asia, and Australia as well.
THEORETICAL FOUNDATION — Supported employment under the individual placement and support model (SE-IPS) is based on the premise that competitive work is inherently tied to one’s identity and self-worth and is a core component of recovery from severe mental illness. Competitive work is the goal of SE-IPS. Research shows that competitive employment is associated with improvements in quality of life, and, to a lesser extent, there is evidence for ties to other positive mental health outcomes, including reduced psychiatric symptoms, increased self-esteem, reduced stress, increased positive mood, increased socialization, and reduced stigma [17-21].
Prior to SE-IPS, the prevailing vocational rehabilitation approach was a “train-place” model, which emphasized job training prior to competitive work. Training included participation in work-related job skills and structured work activities with other individuals with severe mental illness prior to seeking competitive employment. In reaction to this approach, SE-IPS proposed a “place-train” model in which the search for competitive employment begins rapidly following entry into the program and then continuous, follow-along support is provided after job obtainment. Although rapid job search was a primary early focus of SE-IPS, research findings over the years have supported inclusion of seven other principles which underlie the model [15]. (See 'Components' below.)
INDICATIONS — Supported employment under the individual placement and support model (SE-IPS) was designed to address the needs of individuals with severe mental illness (SMI) who are interested in competitive employment. There are no clinical, cognitive, or physical limitations that exclude SMI individuals from receiving SE-IPS. (See 'Zero exclusion' below.)
The only requirement is that they want to work at a competitive job. Over the years, there has been an effort to target underserved clinical populations, including SE-IPS applications for recently deployed veterans and individuals with chronic pain, criminal justice backgrounds, recent homelessness, autism, and chronic substance use disorders.
Motivation to work is an important consideration within the SE-IPS model and has been shown to be a significant predictor of employment success [22,23]. It is common for many SMI individuals to express ambivalence about competitive work. The ambivalence may be based on previous work experiences, the anticipated effort involved in seeking and working at a competitive job, the perceived self-stigma that SMI individuals cannot work at competitive jobs, or severity of negative symptoms affecting avolition/asociality [24]. In addition, the job search process can be complicated (eg, filling out job applications, going on interviews) and time consuming.
Working poses additional challenges, which may include transportation issues, adhering to work schedules, maintaining appropriate hygiene and grooming, socialization with non-SMI coworkers, and other requirements. SE-IPS programs assess the degree and nature of their SMI clients’ ambivalence to work and address these issues during the course of providing services.
COMPONENTS — Supported employment under the individual placement and support model (SE-IPS) embodies eight core principles:
Competitive work — The overriding goal of SE-IPS is to assist the severe mental illness (SMI) client in obtaining competitive work. This model bypasses involvement in prevocational training and protective work experiences prior to beginning competitive work. It was postulated that, in addition to the financial benefits of competitive work, integration of the SMI client into a regular work setting with others without SMI might confer mental health benefits as well. The most consistent evidence has been that competitive work is linked to improvements in quality of life with some evidence that it may confer benefits on reducing self-stigma as well. The findings on clinical functioning are more mixed [17-20,25-27].
Zero exclusion — No individual who expresses a desire to work at a competitive job is turned away from SE-IPS. Severity of mental illness, alcohol/substance use, cognitive impairment, physical limitations, or other factors do not prevent SMI individuals from being enrolled in SE-IPS and receiving these services.
Integration with mental health treatment services — It is important to address mental health needs that may interfere with being able to function in a competitive work environment. In conventional mental health clinics with a multidisciplinary treatment team comprised of psychiatry, psychology, nursing, social work, and other disciplines, SE-IPS employment specialists are a bona fide member of the team and interact with other represented disciplines in working to achieve treatment goals involving work outcome. As an example, a psychiatrist may decide to adjust medications with sedating side effects so that they do not interfere with an SMI individual’s ability to be alert and wakeful during working hours.
Job choice based on client preferences — This principle underscores the model’s emphasis on job fit for the SMI individual. The basic premise is that SMI individuals are more likely to be motivated to work at a competitive job that matches their personal interests.
Provision of personalized benefits counseling — Many SMI individuals have financial concerns about returning to work, eg, the fear that returning to work will result in a loss of benefits, such as social security disability or health care insurance. Misperceptions about the impact of competitive work on these benefits can be a strong disincentive. As part of SE-IPS, SMI individuals are provided accurate information about the financial, health care, and retirement benefits associated with their job and how their disability subsidies are affected. See the following link for additional information: www.osece.org/ssissdiworkinc/.
Rapid job search — A search for a competitive job is conducted within 30 days after enrollment into a SE-IPS program. As a first step, an assessment evaluation is conducted to gather information about the SMI individual’s past work history, strengths and weaknesses, and specific job interests to guide job selection. Job obtainment may not be as rapid as the search.
Disclosure — In supported employment, disclosure pertains to the degree of information provided to an employer about one’s disability. According to the SE-IPS model, the employment specialist works with the SMI individual to facilitate an understanding of the advantages and disadvantages associated with different levels of disclosure and then to work with the SMI individual to decide upon the level that is most comfortable for them. For example, an SMI individual with schizophrenia may not want to disclose their psychiatric diagnosis, but may find it desirable for the supervisor to know that he or she has a disability and may benefit from accommodations (eg, more time) to complete certain job assignments.
Continuous, follow-along job supports — SMI individuals generally need continued support after getting a job. The amount and type of support are individualized to the individual’s needs and preferences. SMI individuals are typically provided frequent contact with their employment specialist during the first month or two on a job to help them address the numerous challenges commonly encountered during this period (eg, disclosure decisions, job demands, transportation challenges).
Over time, less frequent contact (eg, one time per month) is generally necessary as the SMI individual client gains familiarity with the job and work-related issues have been resolved.
Standardization — SE-IPS is manualized with training and consultation available from the IPS Learning Community [28]. In efforts to standardize SE-IPS across programs, a 25-item fidelity scale was developed to measure the degree by which programs adhere to and implement the eight SE-IPS principles. Some data exist to indicate that programs with higher fidelity scores yield better work outcomes than lower fidelity programs [29].
EFFICACY
Comparing SE-IPS with a traditional vocational rehabilitation program — Supported employment under the individual placement and support model (SE-IPS) has been found to lead to better work outcomes compared with alternative vocational rehabilitation services. A meta-analysis of 21 SE-IPS randomized controlled trials that included 30 sites from the United States, Canada, Sweden, Germany, Italy, Bulgaria, United Kingdom, Netherlands, Switzerland, Japan, Australia, and Hong Kong found that SE-IPS participants were more likely to obtain a competitive job compared with alternative vocational rehabilitation services (mean risk ratio = 2.31 [95% CI 1.99-2.69]) [30].
As an example, a clinical trial randomly assigned 85 veterans with posttraumatic stress disorder aged 19 to 60 to SE-IPS or a Veterans Health Administration Vocational Rehabilitation Program (VRP) and followed them for 12 months. VRP included the following components:
●Prevocational testing and assessment
●A work regimen with monetary incentives received on a piece-rate basis
●Time-limited transitional work experience
The VRP specialist provided time-limited job search assistance to help the veteran obtain competitive employment. Follow-along support was provided during the period of transitional work experience, but little to no vocational assistance was provided after obtaining the first competitive job. Results showed that more SE-IPS participants obtained competitive employment compared with VRP participants (76 versus 28 percent). SE-IPS participants worked more weeks (21.6 versus 6.8 weeks) and earned higher income ($9264 versus $2601) than VRP participants.
An earlier review of 1063 SE-IPS participants compared with 1117 controls in nine United States studies and six non-United States studies found a higher rate of competitive employment compared with those assigned to alternative vocational rehabilitation services (55.7 versus 22.6 percent) [31]. SE-IPS was found to yield consistently better work outcomes on other indices as well:
●Mean number of days to first competitive job (135.6 versus 204.6 days)
●Mean hours worked per year (284.3 versus 86.1 hours)
●Worked 20 or more hours per week (43.6 versus 14.2 percent)
There was no difference between SE-IPS and alternative vocational rehabilitation services on job tenure as measured by annualized weeks worked for those who obtained competitive jobs (20.0 versus 19.3 weeks). Other reviews have reported similar results [32,33]. This finding is somewhat surprising given the SE-IPS emphasis on continuous, follow-along support, which is designed to address problems that may lead to early job termination.
A consideration here is that many competitive jobs obtained within supported employment programs are short-term, entry-level, part-time jobs that are low paying and have a high turnover rate within the general population. Hence, the relatively brief job tenure, regardless of condition, observed in many studies (eg, less than six months) is not surprising. Another point of consideration is a more recent 2018 finding that social factors are an important determinant to early job termination [34]. SE-IPS programs may not be best suited to address the social difficulties that SMI individuals experience in a competitive work environment. Hence, it may be necessary to augment SE-IPS with other targeted treatments to yield greater improvements in job tenure. (See 'Efficacy of augmented SE-IPS programs' below.)
Studies reporting wages earned from competitive employment in the United States generally show that SE-IPS participants earned less than $10,000 in most studies [12], which is meager but consistently higher than those from alternative vocational rehabilitation services [35-41].
High fidelity SE-IPS and work outcomes — Competitive employment appears to be associated with beneficial effects on nonvocational outcomes, eg, quality of life as measured by scales including Heinrichs-Carpenter Quality of Life and Lehman Quality of Life interview. These findings do not appear specific to SE-IPS, but rather competitive work in general [17,18,20,21]. Some data suggest that competitive employment is associated with reduced negative symptoms, better cognitive functioning, and higher levels of social functioning, though these findings are more mixed [17,19]. Associations with outpatient psychiatric service use and psychiatric hospitalizations have been mixed as well, with the exception that long-term employment may confer benefits against relapse and rehospitalization [19].
As an example, a study evaluated the SE-IPS model as provided to 2639 SMI individuals aged 18 to 64 at 10 community mental health centers. Center fidelity to the SE-IPS model was measured at each site using the SE-IPS fidelity scale, a validated 15-item scale that measures components of supported employment in three categories (staffing, organization, and services). Across the 10 sites, the mean SE-IPS fidelity score correlated with the competitive employment rate (r = 0.76) [29].
Predictors of SE-IPS work outcomes — The principle of zero exclusion – that all SMI individuals can benefit from this model – appears to be largely supported by research on predictors of SE-IPS work outcomes. The observed benefits of SE-IPS do not appear to be limited by client demographic or clinical characteristics [42,43]. As an example, four SE-IPS studies with 296 participants examined predictors of job acquisition and job tenure over an 18-month period:
●Only work history among participants who received SE-IPS predicted job acquisition – not disability income, age, gender, ethnicity, education, marital status, psychiatric hospitalization over the past year, psychiatric diagnosis, thought disturbance, anergia, disorganization, overall symptomatology, substance abuse, study site, or type of disability benefits [44].
●Only receipt of disability benefits by type among participants who received SE-IPS predicted job tenure. This source of disability income accounted for a very small percentage of the variance in job tenure.
Efficacy of augmented SE-IPS programs — Although SE-IPS has been shown to be more effective than alternative vocational rehabilitation services for obtaining competitive work, across studies approximately 40 percent of SE-IPS participants do not obtain a competitive job, and mean job tenure at SE-IPS-acquired jobs ranges from 10 weeks to over a year [45-49]. Thus, there have been efforts to augment the effectiveness of SE-IPS with additional training interventions:
●Combined data from two separate studies examined the effectiveness of a compensatory behavioral training intervention errorless learning, on work outcomes [34]. For the majority of SMI participants, the targets of training were social communication skills. Results showed that augmented SE-IPS yielded longer job tenure and greater improvement on targeted work behavior problems (eg, social skills) than SE-IPS alone. There were no differential benefits on wages earned or hours worked.
●Two cognitive remediation programs added to SE-IPS showed mixed results (one positive, one negative) on work outcomes [50,51].
●Two studies of adding a skills training intervention found mixed results [50,51].
Studies of SMI individuals in the competitive work environment have found that social skills were the weakest area of work behavior relative to other skill areas (eg, work quality, work habits), and explained 18 percent of job tenure beyond cognition, psychiatric symptoms, and work history [34]. Efforts to augment SE-IPS with specialized psychosocial interventions such as social cognition skills training, social problem solving skills training, compensatory behavioral interventions, or possibly pharmacologic interventions that target social behavior may be better able to address this need.
Adverse effects — Although critics of SE-IPS’s emphasis on rapid entry into competitive work postulated that it could lead to adverse mental health consequences (eg, relapse), multiple studies have failed to find any empirical support for such a connection [25,45,52].
SUMMARY
●Supported employment was developed for individuals with severe mental illness (SMI), a mental disorder characterized by severe symptoms and behavioral impairment, pronounced disability in basic life skills, and a prolonged course of illness. (See 'Severe mental illness' above.)
●Supported employment focuses on obtaining competitive employment via a rapid job search and retention, while more traditional vocational rehabilitative programs focused on prevocational training and experience in noncompetitive, structured, staff supported, work-type settings with other SMI individuals as an initial step. (See 'Overview and context' above.)
●The principle of zero exclusion – that all SMI individuals can benefit from the supported employment under the individual placement and support model (SE-IPS) – appears to be largely supported by research on predictors of SE-IPS work outcomes. The observed benefits of SE-IPS do not appear to be limited by client demographic or clinical characteristics. (See 'Predictors of SE-IPS work outcomes' above.)
●Other components of SE-IPS include integration with mental health treatment services, job choice based on client preferences, provision of benefits counseling and continuous, follow along job supports, and consideration of the benefits and risks of disclosure. (See 'Components' above.)
●Individuals with SMI receiving SE-IPS model are more likely to obtain a competitive job compared with those assigned to alternative vocational rehabilitation services in clinical trials. (See 'Efficacy' above.)
●Individuals with SMI receiving SE-IPS generally have better work outcomes relative to individuals assigned to alternative vocational rehabilitation services in clinical trials, eg, on time to first competitive job, hours worked, and wages earned. (See 'Efficacy' above.)
●While SE-IPS’s emphasis on more rapid entry into competitive work compared with traditional vocational rehabilitation had been postulated as having adverse mental health consequences, multiple studies have not found associations between assignment to SE-IPS and adverse effects on psychiatric symptoms or overall mental health. (See 'Adverse effects' above.)
●For individuals with SMI who are nonresponders to SE-IPS (eg, unable to obtain a competitive job, unsatisfactory job termination), augmenting SE-IPS with either cognitive remediation, social skills training, or compensatory behavioral training interventions may be beneficial. (See 'Efficacy of augmented SE-IPS programs' above.)
●There are currently over 500 SE-IPS programs within the United States; programs are also found in Australia and other countries in Europe and Asia as well. SE-IPS is manualized with training and consultation available from the IPS Learning Community. In efforts to standardize SE-IPS across programs, an updated 25-item fidelity scale was developed to measure the degree by which programs adhere to and implement the eight SE-IPS principles. (See 'Overview and context' above and 'Standardization' above.)
