In addition to the more rigorously evaluated types of employment supports described in preceding sections, a variety of other services have been postulated by stakeholders to positively affect employment outcomes. We reviewed information on several of these, including social enterprises, self-employment, consumer-provided services (which include peer counseling and other services provided by people with SMI or services provided by agencies staffed by people with SMI), self-determination models, asset-development, financial-literacy, and supported education (Appendix A, Table A.7). Although these interventions are considered promising, few high quality studies have been conducted to assess their effectiveness in comparison to alternatives. The interventions we reviewed have relatively small bases of rigorous evidence, or, in some cases, no rigorous evidence of their effectiveness. However, the evidence that does exist suggests that they can have positive effects on employment and mental health outcomes. More research is needed to establish the effectiveness of self-employment and consumer-run businesses, and on asset-development and financial-literacy programs. It is not immediately obvious how a rigorous study of self-employment could be conducted, although studies of supports for those who already are self-employed or are seeking self-employment would be feasible. Additional research on the efficacy of self-determination models for individuals with psychiatric disorders is needed; when these programs were first introduced, some were skeptical that individuals with SMI were well-suited to participate, so relatively little attention was paid to the outcomes of those who did.
The evidence for consumer-provided services is more substantial, but more work remains to be done to establish the most effective models for such programs. Consumer-provided services, defined as employment supports, peer counseling and other services provided by people with psychiatric disabilities or by agencies managed by people with psychiatric disabilities, are increasingly helping to fill in gaps and shortages in the mainstream mental health workforce, and a substantial percentage of consumer-operated service programs offer specific employment supports, such as resume preparation, job leads, and job seeker's support groups to help people find and retain jobs (Goldstrom et al. 2006). Moreover, these programs have the added advantage of providing direct employment to people with SMI.
The evidence for social enterprises is also growing. Social enterprises, also known as social firms, develop a business model with the goal of employing individuals from disadvantaged groups who would otherwise have a difficult time finding, obtaining, and maintaining a job. General guidelines for these enterprises call for at least 50 percent of revenue to come from sales, and at least 25 percent of employees to belong to a very disadvantaged group (McDermid et al. 2008). They may offer more flexible work conditions, provide targeted supports as an integrated part of the job, or simply encourage a more inclusive and supportive work atmosphere. Although any type of organization can use the social enterprise model, they tend to be established by non-profit organizations, or as free-standing non-profits. Results from one study suggest that social enterprises can increase job tenure, average weekly hours worked, quality of work life, and self-esteem among workers with psychiatric disorders (McKeown et al. 1992).
Evidence is beginning to emerge about the effectiveness of supported education. The evidence-based SE model has been adapted to include supported education; components generally include career planning, academic survival skills, help with enrollment and financial aid, and outreach to campus resource people.6 Research has shown that educational attainment is associated with the ability of people with psychiatric disabilities to obtain competitive employment (Burke et al. 2006), and the fastest-growing occupations are those requiring two-year or four-year college degrees or technical training (Cook & Burke 2002). Yet, few participants in SE programs have college degrees (Blyler 2003). In one study, the SE principle of rapid job search was modified to be a rapid enrollment in or return to relevant schooling for individuals who dropped out of school when they experienced a mental illness. The SE specialist assisted the participant to enroll or re-enroll in school programs consistent with their preferences and interests (Nuechterlein et al. 2008). Supported education appears to have substantial short-term benefits, some of which, like enrollment in education, suggest positive longer-term outcomes, but more research is needed to show that these long-term outcomes actually occur.