COVID-19, Unemployment, and Behavioral Health Conditions: The Need for Supported Employment.

The COVID-19 pandemic has caused massive unemployment, exacerbated pre-existing behavioral health (mental health and substance use) disorders for many people, and created new disorders for others. Although policy changes have increased health care and unemployment benefits, most people want jobs and self-sufficiency rather than handouts. A robust evidence base shows that supported employment can enable unemployed people with behavioral health conditions to find competitive, integrated employment and behavioral health supports. Millions of U.S. citizens may need these services as the pandemic recedes and jobs become available. Government attention to supported employment is necessary now more than ever.

A Tale of Four States: Factors Influencing the Statewide Adoption of IPS.

Evidence-based supported employment has become a core community mental health service in much of the U.S. Although a national learning community has facilitated progress in about half of the states, other states have tried to implement evidence-based supported employment on their own. Many studies have examined site-level factors influencing implementation of supported employment, but few have focused on the role of state agency policies and actions. This study examined four states that have not joined the learning community, comparing two that have implemented with success (adopting states) and two that have faced challenges (non-adopting states). This comparative case study approach compared barriers, facilitators, and strategies in two states adopting IPS to two states that did not. The authors examined quantitative data from public records and conducted content analysis of qualitative and quantitative data from key informant interviews. The two non-adopting states lacked model clarity, funding, focus on people with serious mental illness, and collaboration between state mental health and vocational rehabilitation agencies. The two successful states experienced similar barriers but overcame them following lawsuit settlements that required implementation of evidence-based supported employment. Key strategies for successful implementation were funding, fidelity monitoring, technical assistance, and collaboration between state mental health and vocational rehabilitation agencies. With legal settlements serving as the catalyst, states facing challenges to implementing evidence-based supported employment can achieve success using standard implementation strategies to fund and ensure the quality of services.

Enhancing return to work or school after a first episode of schizophrenia: the UCLA RCT of Individual Placement and Support and Workplace Fundamentals Module training.

BACKGROUND: This study evaluated in a rigorous 18-month randomized controlled trial the efficacy of an enhanced vocational intervention for helping individuals with a recent first schizophrenia episode to return to and remain in competitive work or regular schooling. METHODS: Individual Placement and Support (IPS) was adapted to meet the goals of individuals whose goals might involve either employment or schooling. IPS was combined with a Workplace Fundamentals Module (WFM) for an enhanced, outpatient, vocational intervention. Random assignment to the enhanced integrated rehabilitation program (N = 46) was contrasted with equally intensive clinical treatment at UCLA, including social skills training groups, and conventional vocational rehabilitation by state agencies (N = 23). All patients were provided case management and psychiatric services by the same clinical team and received oral atypical antipsychotic medication. RESULTS: The IPS-WFM combination led to 83% of patients participating in competitive employment or school in the first 6 months of intensive treatment, compared with 41% in the comparison group (p < 0.005). During the subsequent year, IPS-WFM continued to yield higher rates of schooling/employment (92% v. 60%, p < 0.03). Cumulative number of weeks of schooling and/or employment was also substantially greater with the IPS-WFM intervention (45 v. 26 weeks, p < 0.004). CONCLUSIONS: The results clearly support the efficacy of an enhanced intervention focused on recovery of participation in normative work and school settings in the initial phase of schizophrenia, suggesting potential for prevention of disability.

Introducing Individual Placement and Support (IPS) supported employment in Japan.

Individual Placement and Support is a standardized model of supported employment, developed initially for people with serious mental disorders and now applied to people with a range of disabilities. More than two dozen randomized controlled trials around the world show that the approach helps a majority of participants to succeed in competitive employment. Individual Placement and Support is spreading rapidly across the USA and in many other high-income countries, with facilitation by an international learning community.

Sustaining and Expanding Evidence-Based Supported Employment: The Role of State Leaders Participating in a Learning Community.

State leaders often promote implementation of evidence-based practices but have difficulty sustaining and expanding them over time. This paper examines the activities of leaders in 13 states that have successfully implemented, sustained, and expanded evidence-based supported employment, known as Individual Placement and Support (IPS), for 4 to 12 years. We interviewed state leaders from 13 states participating in a learning community regarding the composition of their leadership team, participation in the learning community, interagency collaboration, state policy alignment, financing, training, and monitoring of fidelity and outcome. To assess state-level performance in implementing, sustaining, and expanding IPS services, we obtained measures of sustainment, expansion, program fidelity, and employment in the subsequent year and compared them to a priori benchmarks. The majority of states (between 69 % and 77 %) met benchmarks for sustainment, expansion, fidelity, and employment. States varied widely in specific actions to advance IPS, but all had established leadership teams, participated in the national learning community, and built an infrastructure supporting IPS. Leaders in 13 states participating in a learning community have adopted and maintained multiple strategies to sustain and expand evidence-based supported employment at a high level of fidelity with good employment outcomes.

Prevalence and Quality of Individual Placement and Support (IPS) Supported Employment in the United States.

The individual placement and support (IPS) model of supported employment for people with serious mental illness is an evidence-based practice. Factors including a national learning community promoting IPS and enforcement of the Supreme Court's Olmstead decision have spurred the growth of IPS nationwide. In this study we first evaluated the national prevalence and quality of IPS programs. We then evaluated the impact of learning community membership and Olmstead settlements on IPS program penetration and quality across the United States. We interviewed representatives from 48 state behavioral health agencies and 51 state vocational rehabilitation agencies. Survey questions examined the number of IPS programs in each state, the presence of an Olmstead settlement mandating employment services for people with serious mental illness, and the presence of three indicators of quality in IPS programs: collaboration between state behavioral health and vocational rehabilitation agencies, regular, independent fidelity monitoring, and technical assistance and training for IPS programs. Respondents from 38 (75%) states, including 19 states in the IPS Learning Community and 19 outside the learning community, reported a total of 523 IPS programs nationwide (M = 14, SD = 16). The state IPS program penetration rate (number of IPS programs per 1,000,000 people) ranged from 0.05 to 16.62 (M = 3.61, SD = 3.62) among states with IPS. The penetration rate was similar for learning community and non-learning community states with IPS, but learning community states were much more likely than non-learning community states with IPS to report the presence of each of three quality indicators. Eleven states reported Olmstead or other settlements that positively impacted employment services for people with serious mental illness, but among the 38 states with IPS programs, Olmstead states did not differ from non-Olmstead states in IPS program penetration or on the quality indicators. Nationally, most states provide IPS programs, but the within-state penetration rate and quality of implementation vary widely. While learning community and non-learning community states with IPS do not differ in the prevalence of IPS programs, learning community states are much more likely to report key quality indicators, which may enhance these states' potential for sustaining and expanding IPS. Olmstead settlements have not yet shown a direct impact on the penetration and quality of IPS, but as the Department of Justice continues to enforce the Supreme Court's Olmstead decision, their significance may increase.

Individual Placement and Support (IPS) for Methadone Maintenance Therapy Patients: A Pilot Randomized Controlled Trial.

Individual Placement and Support (IPS) is an evidence-based employment model for people with severe mental illness, but it has not been evaluated for clients enrolled in substance abuse treatment programs. This study evaluated the effectiveness of IPS for people with opioid use disorders enrolled in an opioid treatment program. Within a randomized controlled experiment, 45 patients receiving methadone maintenance therapy were assigned to either IPS or a 6-month waitlist. The waitlist group received IPS after 6 months. The primary outcome assessed over 1 year compared the attainment of a job for the IPS condition to the waitlist comparison group. During the first 6 months after enrollment, 11 (50%) active IPS participants gained competitive employment compared to 1 (5%) waitlist participant (Χ 2 = 12.0, p < 0.001). Over 12 months of enrollment, 11 (50%) IPS participants gained competitive employment compared to 5 (22%) waitlist participants (Χ 2 = 3.92, p = 0.07). We conclude that IPS holds promise as an employment intervention for people with opioid use disorders in methadone maintenance treatment, but larger trials with longer follow-up are needed.

Barriers and Facilitators to Sustainment of an Evidence-Based Supported Employment Program.

Large-scale initiatives to expand evidence-based practices are often poorly implemented and rarely endure. The purpose of this study was to identify the perceived barriers and facilitators to sustainment of an evidence-based supported employment program, Individual Placement and Support (IPS). Within a 2-year prospective study of sustainment among 129 IPS programs in 13 states participating in a national learning community, we interviewed IPS team leaders and coded their responses to semi-structured interviews using a conceptual framework adapted from another large-scale implementation study. Leaders in 122 agencies (95%) that sustained their IPS programs identified funding, prioritization, and workforce characteristics as both key facilitators and barriers. Additional key factors were lack of local community supports as a barrier and leadership and structured workflow as facilitators. Within the IPS learning community, team leaders attributed the sustainment of their program to funding, prioritization, workforce, agency leadership, and structured workflow. The actions of the learning community's leadership, state governments, and local programs together may have contributed to the high sustainment rate.

Is high fidelity to supported employment equally attainable in small and large communities?

Individual Placement and Support (IPS) is an evidence-based model to help people with serious mental illness achieve employment. This study examined variation in model adherence in small and large communities. We compared program-level ratings on a standardized 25-item IPS fidelity scale (range = 25-125) for 79 sites in eight states categorized by local community size. Programs in large and small communities achieved comparable fidelity scores (mean = 100 and 104, respectively). Fidelity-outcome correlations within the two groups were both of moderate size. As a practical guide, the IPS fidelity scale is suitable for use in both small and large communities.

Individual placement and support for young adults: One-year outcomes.

OBJECTIVE: Many young adults who are unemployed and not in school need support achieving employment goals. Individual Placement and Support (IPS) is an evidence-based employment practice for adults with serious mental illness, but its applicability to young adults with mental health conditions has not been well-researched. The present study prospectively assessed IPS effectiveness in a national sample of young adults enrolled in routine practice settings in the U.S. public mental health system. METHOD: Nine community agencies in five states participated in a 1-year follow-up study of young adults (aged 16-24) enrolled in IPS services. The study examined three outcomes: retention in services, employment, and education. State fidelity reviewers examined IPS fidelity using a new fidelity scale, the IPS-Y. RESULTS: In a sample of 111 participants, the mean age was 19.2, 72 (64.9%) had never worked, and 76 (68.5%) had a diagnosis of depressive and/or anxiety disorder. Participants averaged 8 months of enrollment before terminating from IPS services. During follow-up, 51 (45.9%) participants obtained a competitive job (N = 50) or paid internship (N = 1); 14 (12.6%) achieved a new education outcome. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: IPS has promising outcomes for helping young adults with mental health conditions achieve positive employment outcomes, but its effectiveness in helping young adults achieve education goals has not been demonstrated. IPS should be offered to young adults with employment goals. Targeted funding for supported education and training for IPS specialists in delivering educational supports may be necessary to ensure optimal education outcomes in IPS. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A test of the occupational matching hypothesis for rehabilitation clients with severe mental illness.

PURPOSE: This study compared job matching rates for clients with severe mental illness enrolled in two types of employment programs. Also examined was the occupational matching hypothesis that job matching is associated with better employment outcomes. METHODS: The study involved a secondary analysis of a randomized controlled trial comparing evidence-based supported employment to a diversified placement approach. The study sample consisted of 187 participants, of whom 147 obtained a paid job during the 2-year follow-up. Jobs were coded using the Dictionary of Occupational Titles classification system. Match between initial job preferences and type of job obtained was the predictor variable. Outcomes included time to job start, job satisfaction, and job tenure on first job. RESULTS: Most occupational preferences were for clerical and service jobs, and most participants obtained employment in these two occupational domains. In most cases, the first job obtained matched a participant's occupational preference. The occupational matching hypothesis was not supported for any employment outcome. The occupational matching rate was similar in this study to previous studies. CONCLUSIONS: Most clients who obtain employment with the help of evidence-based supported employment or diversified placement services find jobs matching their occupational preference, and most often it is a rough match. Occupational matching is but one aspect of job matching; it may be time to discard actuarial classification systems such as the Dictionary of Occupational Titles as a basis for assessing job match.

Individual placement and support programmes for young adults: Where are they and whom do they serve?

AIM: Individual Placement and Support (IPS), an evidence-based supported employment model developed for adults with serious mental illness, has been recently targeted to young adults with mental health conditions, but little is known about its adoption in this age group in the United States. METHODS: We recruited a volunteer sample of nine IPS programmes in five states serving young adults with mental health conditions aged 16 to 24. IPS team leaders reported programme and participant characteristics and rated barriers to employment and education. RESULTS: Most IPS programmes were located in community mental health centres, served a small number of young adults, and received most referrals from external sources. The study sample of 111 participants included 53% female, 47% under 21 years old, 60% diagnosed with a depressive disorder; 92% had an employment goal, and 40% had an education goal. IPS specialists reported that managing mental health symptoms was the most common barrier to achieving employment and education goals. CONCLUSION: Future research should examine how IPS programmes could best provide services to young adults.

Update on funding IPS supported employment services in the IPS learning community.

OBJECTIVE: Individual placement and support (IPS) is the evidence-based supported employment approach for people with serious mental illness. Because funding is the major barrier for states to implement IPS and increase access, the IPS Learning Community collected information about sources of IPS funding from 24 member states. METHODS: In early 2020, IPS employment leaders from the public mental health authority and the state vocational rehabilitation (VR) authority completed a questionnaire identifying sources of funding for IPS in their states. RESULTS: The main sources of funding were Medicaid, Substance Abuse and Mental Health Services Administration (SAMHSA) block grants, state and county government, the Ticket to Work program, and the federal-state VR programs. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Funding IPS services requires braided funding from multiple sources. This complicated method limits scaling up services statewide. Solving this funding problem would require coordinated action from federal and state agencies. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Growth of IPS Supported Employment Programs in the United States: An Update.

OBJECTIVE: Individual placement and support (IPS), an evidence-based supported employment practice, is a core service in community mental health in the United States. Several factors promote the growth of IPS, including a network of 24 states participating in a learning community devoted to expanding IPS services. This study examined growth of IPS in the United States from 2016 to 2019, comparing growth rates for states within and outside the learning community. METHODS: This national survey included telephone interviews with 70 representatives from state mental health and vocational rehabilitation agencies in 50 states and the District of Columbia, replicating methods of a 2016 survey. The primary outcomes were the number of IPS programs and clients served. The survey inquired about four indicators of state-level support for IPS implementation and sustainment: collaboration between state agencies, independent fidelity reviews, technical assistance and training, and funding. RESULTS: In 2019, 41 (80%) of 50 states and the District of Columbia had IPS services, with 857 IPS programs serving an estimated 43,209 clients. Between 2016 and 2019, the number of programs increased from 272 to 486 in 22 learning-community states and two learning-community counties, and from 251 to 371 in 18 states outside the learning community. State-level support for IPS was significantly greater in learning-community states, compared with non-learning-community states. CONCLUSIONS: IPS services expanded substantially in the United States between 2016 and 2019. Learning-community states had more rapid growth and provided greater implementation support, facilitating implementation, expansion, and sustainment of high-fidelity IPS. Nevertheless, access to IPS remains limited.

Personnel time required for supported employment and education services for individuals in a recent-onset psychosis treatment program.

AIM: Individual Placement and Support (IPS) improves vocational outcomes in first-episode psychosis patients, but policy makers need information on costs (and personnel time required) to conduct effective IPS. METHODS: Using chart records of 42 clients in a first-episode psychosis study, we examined service time for specific activities over 18 months. RESULTS: The IPS specialist averaged 92 (SD = 62) minutes per client per week: 39% of time was spent in direct client contact, 9% in meetings without the client, 14% in meetings with the treatment team, 14% in supervision and 24% on travel time. Time required was significantly higher when participants were seeking work/school placements, decreased over duration of enrolment and was similar for those using work vs school support. CONCLUSIONS: IPS service time covers numerous activities, is reduced when not seeking work/school placements and required less time over enrolment duration. Financing structures should support the full range of IPS services.

Helping People Denied Disability Benefits for a Mental Health Impairment: The Supported Employment Demonstration.

Social Security Administration demonstration projects that are intended to help people receiving disability benefits have increased employment but not the number of exits from disability programs. The Supported Employment Demonstration (SED) is a randomized controlled trial (RCT) of services for individuals with mental health problems before they enter disability programs. The SED aims to provide health, employment, and other support services that help them become self-sufficient and avoid entering disability programs. The target population is people who have been denied Social Security disability benefits for a presumed psychiatric impairment. Thirty community-based programs across the United States serve as treatment sites; inclusion in the SED was based on the existence of high-fidelity employment programs that use the individual placement and support model, the ability to implement team-based care, and the willingness to participate in a three-armed RCT. In the SED trial, one-third of 2,960 participants receive services as usual, one-third receive services from a multidisciplinary team that includes integrated supported employment, and one-third receive services from a similar team that also includes a nurse care coordinator for medication management support and medical care. The goals of the study are to help people find employment, attain better health, and delay or avoid disability program entry. This article introduces the SED.

Creation of a measure to assess knowledge of the individual placement and support model.

OBJECTIVE: This article describes the development and psychometric evaluation of the IPS-Q, a quiz assessing practitioner knowledge of the Individual Placement and Support (IPS) model. METHODS: Using multiple resources, including the IPS Fidelity Scale and publications about the IPS model, a 30-item multiple-choice quiz covering fundamental IPS principles and key components was developed. Ratings by eight IPS experts supported its content validity. To examine the IPS-Q's psychometric properties, 107 practitioners from high-fidelity IPS programs and 59 practitioners from non-IPS vocational programs were administered the IPS-Q via a web-based survey tool. RESULTS: The measure displayed good internal consistency (Cronbach's alpha = .89) and a difficulty level consistent with that of typical job knowledge tests. The IPS-Q did not correlate with demographic variables that were considered extraneous to knowledge of IPS and did correlate with self-reported supported employment familiarity. However, contrary to our hypothesis, the quiz was not significantly correlated with exposure to supported employment. The IPS-Q significantly discriminated between practitioners working in high-fidelity IPS programs and non-IPS vocational programs. Furthermore, supervisors from high-fidelity IPS programs scored significantly higher on the measure than vocational workers from high-fidelity IPS programs. CONCLUSIONS: The IPS-Q is a valid measure of IPS knowledge and might prove useful for assessment, research, and training purposes. Practitioners sometimes assume that they understand a program model when in fact they have misconceptions. The IPS-Q provides an objective way to gauge practitioner knowledge.

Commentary on special issue on individual placement and support (IPS) international.

OBJECTIVE: In this commentary, we identify major themes found in this set of 11 articles, which examine the history of individual placement and support (IPS) adoption within each nation. METHOD: We summarize major barriers and strategies to achieve to IPS adoption and implementation and briefly discuss IPS research conducted in these countries. FINDINGS: Faced with many barriers, countries are developing strategies to promote IPS implementation and dissemination. IPS research has consistently found superior employment outcomes for people receiving IPS compared to usual services. Researchers are evaluating the effectiveness of IPS for new populations. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: IPS is expanding worldwide, aided by strong leadership, national directives, and the International IPS Learning Community. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Growth and Sustainment of Individual Placement and Support.

Many people with serious mental disorders want to work. Individual placement and support (IPS), an evidence-based program that helps such individuals find and maintain jobs of their choice, has spread steadily across the United States (which has more than 1,000 IPS programs) and to at least 19 other countries during the past 20 years. Four factors explain the program's success. First, IPS is client-centered-IPS specialists follow their clients' preferences regarding issues such as type of employment, style of job search, and type of job support needed. Second, research has undergirded IPS's evolution, helping to refine its effectiveness. Third, support from private foundations and federal agencies has helped to foster implementation, research, and dissemination efforts. Fourth, an international learning community has consolidated cooperation among stakeholders and mental health and vocational rehabilitation agencies and has facilitated continuous quality improvement through data sharing and extensive interactions.

First person accounts of long-term employment activity among people with dual diagnosis.

OBJECTIVE: Evidence suggests that many individuals with dual diagnosis of mental illness and substance use disorder can be successfully employed in competitive jobs, though there remain barriers and facilitators to consistent work activity in this population. The purpose of this study is to elicit and examine first person accounts of work activity over a 16-year period from people with dual diagnosis, who were not selected for employment readiness or vocational interests. METHODS: 120 people with severe mental illness and co-occurring substance use disorder participated in this study. Their work activity was self-reported at yearly interviews occurring over a 16-year period. Participants naturally fell into one of four categories: those who (i) never or hardly worked; (ii) worked intermittently; (iii) worked fairly consistently; (iv) worked very consistently. A more in-depth interview occurred at 16 years when participants gave first person accounts of their 16-year work history in answer to open-ended questions. These responses were analyzed using traditional methods of qualitative content analysis, comparing responses across the four categories of work patterns. RESULTS: Five overlapping themes given by participants as strong influences on work activity arose from the data. These are (i) illness management, including use of psychiatric medication and controlling substance abuse; (ii) personal evaluation of the impact of employment; (iii) congruence between job preference and actual employment; (iv) personal motivation and job-seeking assistance, and (v) the conditioning nature of working or not working. CONCLUSIONS: Longitudinal themes of work activity suggest service improvements consistent with evidence-based supported employment.