Improving Employment Outcomes for People with Psychiatric Disorders and Other Disabilities. C. Evidence for Improving Employment Outcomes through Supported Employment

04/01/2014

1. There is strong evidence that SE is more effective in helping people with SMI obtain competitive employment than traditional vocational programs. Yet, even with SE, about half of participants did not find competitive work. For those that did, jobs were part-time and of short duration, and earnings were low.

We reviewed reports on 18 randomized controlled trials (RCTs) of SE services (Appendix A, Table A.1 and Table A.2). Sixteen of these studies reported competitive employment rates, defined as working at a competitive job at any time during the study period. In 11 of them, competitive employment rates were significantly higher in the SE groups than in the control-groups. Overall, 27-78 percent of SE participants found competitive employment, compared with 7-40 percent of control participants. Across the high-fidelity SE studies reviewed in Bond et al. (2008), competitive employment rates were 61 percent, on average, among SE participants, compared with 23 percent among controls. Cross-site evaluations of EIDP also found that, compared with those who receive services-as-usual or weaker forms of the intervention, SE recipients were significantly more likely to achieve competitive employment (55 percent versus 34 percent). Employment rates increased over the course of the 24-month study period (Cook et al. 2005b).

Job duration across these studies appears to be short, with participants staying in a given job for an average of only 14-21 percent of the study duration (Twamley et al. 2003), but the durations of most of these studies were two years or less. Employment outcomes are likely to improve over time as participants adjust to work environments and gain work experience. In addition, longer-term program interventions targeting wages and job tenure to the same degree as initial attainment of competitive employment might have led to more positive results.

Part-time work is the norm for both SE and traditional employment programs. Research suggests SE participants work more and earn more, but the evidence is slim. Across EIDP sites, SE recipients were significantly more likely than controls to work 40 or more hours per month (51 percent versus 39 percent) (Cook et al. 2005b). Among participants in the Mental Health Treatment Study (MHTS) who obtained at least one competitive job, both treatment and control-group members worked about 20 hours per week and earned only about $200 per week at the job they held the longest or at which they worked the most hours (Frey et al. 2011).

2. Participants with a variety of characteristics benefit from SE.

Two studies found that SE was more effective than control interventions regardless of the participants' demographic and background characteristics. Frey et al. (2011) analyzed employment for MHTS participants by age, gender, diagnosis, and education. The SE group had significantly higher competitive employment rates than controls in every category. In EIDP, although certain individual characteristics were associated with poorer employment outcomes overall, employment outcomes for people with such characteristics improved significantly with receipt of SE service. For example, although study participants with schizophrenia or who lived in localities with a high unemployment rate had poorer employment outcomes overall, Cook et al. (2006, 2008) found a greater effect of SE for these groups than for those with other diagnoses or living in areas with lower unemployment rates; these results suggest that SE may be particularly effective at ameliorating factors that otherwise serve as barriers to employment.

3. Job-development services and strong integration of vocational and clinical services are key components of SE.

Understanding which specific elements of SE are important for vocational success is vital for replicating and improving SE models. As reported in Cook et al. (2005b), EIDP found that individuals receiving job-development services--defined as tailored job-seeking activities to match jobs to clients--were nearly five times more likely to obtain a competitive position. Without job-development services, participants were very unlikely to gain competitive employment, especially if they had no prior work experience. Notably, ongoing job support was not associated with the total number of hours worked but was associated with significantly longer tenure for a first competitive job. Another analysis of EIDP data found that those receiving services from SE programs with high degrees of integration were over 2.5 times more likely to be competitively employed and nearly twice as likely to work 40 or more hours per month (Cook et al. 2005b). Receiving more hours of vocational services was associated with better employment outcomes, whereas receiving more hours of clinical services was negatively associated with employment outcomes, even when controlling for work history, diagnosis, level of functioning, and receipt of SSA disability benefits.

In sum, there is evidence for the effectiveness of SE, but room for improvement remains. The lack of strong evidence for long-term outcomes may result from the lack of programmatic emphasis on job tenure and economic self-sufficiency. Work disincentives built into Social Security disability and other financial-support programs may also contribute to lower work and earnings levels.

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