Hello and welcome. I'm Dr. Benjamin Druss, a Professor of Health Policy and Management and Rosalynn Carter Chair in Mental Health at Emory University, as well as a member of the SMI Advisor Clinical Expert Team. I am pleased that you'll be joining us today for an SMI Advisor webinar, Improving Lives Through Employment and Education. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Deborah Becker. Deborah is Research Senior Associate and Director, International IPS Learning Community, at the IPS Employment Center, the Rockville Institute at Westat. She has more than 33 years of experience developing, researching, training, and consulting on individual placement and support, the evidence-based practice of supported employment. She co-developed the SAMHSA Evidence-Based Practice Supported Employment Implementation Resource Kit. She co-founded and is overseeing the IPS International Learning Community, which is organized to improve access to IPS in 24 states and 6 international countries. She was Director of Supported Employment at the Dartmouth Psychiatric Research Center for over 25 years, and Research Associate Professor of Community and Family Medicine and of Psychiatry, Geisel School of Medicine at Dartmouth, from 2010 to 2016. Debbie, thank you for leading today's webinar. We're looking forward to hearing it. Okay, thank you very much. So let's get started. I'm hoping that by the end of the hour, you will have understood the eight core principles of evidence-based supported employment. You'll understand a little bit of the research behind this practice, and also understand more generally how to support people with severe mental illness and co-occurring substance use disorder in their career advancement through employment and education. So what's the big picture, and what do I want you to really understand? And that is, one, that many people with severe mental illness, including those with a co-occurring substance use disorder, want to work. And many can and do work, and they also go through further education to advance their careers. Now, I use the term individual placement and support, IPS, that's what I'm going to refer to for the next hour, because that is the practice that has the most, by far, research evidence behind it. And it is used as a roadmap for implementation. Supported employment, which is the more general term, was originated in the Rehabilitation Act amendments of 1986. And it was pretty broadly defined as mainstream jobs in the community that pay at least minimum wage, and that there are four people with the most severe disabilities, and ongoing support is provided. And so you can see how that could be, those main points could be taken and implemented very differently. But with IPS, you've got manuals that have been updated, you've got a toolkit, you've got a fidelity scale, and it's been studied to show that the fuller the implementation, the better the outcomes. So that's a little bit of background for you. I always like to start my presentations using the words of people who have received these services and have gone to work. And so the first one is, when you're working, you're part of the real world. You feel connected. Having a job gives me stability. I have something to look forward to every day. The second one, which I think I like the most, or I always think about, is in the past, people might have used labels to describe me, such as homeless, mentally ill, and welfare mother. Now, my titles are financial administrator, college student, and working mom. And I think this quote really reflects why I go to work every day, and probably why many of you do too, that, you know, this is all about recovery and promoting wellness. And I can, I often remember a woman who was in one of our studies who received IPF services and went to work, and I had the opportunity to go back and interview her. And I asked her how life was now, and she said, with a smile on her face, I'm an ordinary person. And she went on to explain that she was no longer the mental patient who went to the day program every day. Instead, she was a community member who had a job, went to work, and lived like everybody else. Okay, so where are we? Approximately 60 to 70 percent of people with severe mental illness say they want to work, and this has been shown in multiple surveys. So about three quarters of the people want to work, but there's a big gap between how many are working, which is around 20 percent, we estimate. And even worse, less than 2 percent are receiving these evidence-based services. And in the U.S., we have a big problem in being able to pay for these services in a simple way. So what are barriers to employment and education for people? And stigma and low expectations are huge, and they may be on the part of the individual, but they also may be on the part of family members. It may be a part of staff and practitioners, providers, focusing on medication management and stability, but in fact, what we've learned over time is having something meaningful, like a job, which may be very part-time for people initially, is what helps people get better and do better. Inadequate finances and funding, and so for paying for these services, but also for people going to school, they may not be able to get the resources to do that. We see other barriers of symptoms that people are not able to manage, or medication side effects, and in general, people who are having little or no support. So key points about IPS, what's the staffing? There's IPS specialists who carry caseloads of up to 20 people. If they're doing supportive education too, their caseloads are a little bit lower than that, since they're doing both. They provide only employment, and I include education as part of that in this. They're not doing case management or other things. They're not running women's groups or men's groups, and they're doing all phases of supportive education and supportive employment. It's a team approach, and what we mean by that is that these services are integrated with a mental health treatment. State Vocational Rehabilitation Partnership is really key, and that varies from state to state, how well that works, but we have learned that it's important, and we want to continue to help states to develop those relationships, because state rehab, along with funding, can bring rich resources of knowing about different jobs in our communities and employers. They know about other disabilities that people may have, and they help with planning, supporting, and as well as purchasing tools or uniforms or other articles that people may need to work. It's a strengths-based approach, all focused on people's preferences, skills, their strengths, and experiences. I am now going to go through eight principles that define IPS. It's open to anyone who wants to go to work or school. The focus is on competitive employment, rapid job search. There is a systematic job development approach. Client preferences guide all decisions. Individualized long-term supports are provided, and this service is integrated with treatment, and benefits counseling is provided. Okay, the first one. We're not going to screen people out based on work readiness criteria, their diagnosis, symptoms, their substance abuse history, psychiatric treatment, their level of disability. We just can't predict, and we know this from research. I can tell you, time and time again, I would help to run a research study, and we'd go a mental health agency, and we would randomly assign people who've raised their hand who say they want to go to work. Time again, the clinician would hear that Sarah got randomized to IPS, and we'd hear, but she can't work. What happens? She goes to work. We really want to encourage everybody, and the only requirement is there's interest in going to school or work, nothing else. We want to give people hope for their futures. Okay, so frontline practitioners, you all on the phone, there are things that you can do, and conversations that you can have with people that you serve to help them think about this. Have they thought about having a job? Have short conversations about work. We're not trying to push people into doing anything, but we are trying to help people expand what they think their options are, and have discussions about the possible benefits and costs of employment. Ask them, what do you want your life to look like in five years? Would you be working? What relationships would you like to have? Ask them what they do on a typical day, and are you satisfied with this? The agency builds a culture of work, and so that includes the agency director who shares how this is a part of the agency's mission and value, people going back to work and going back to school to advance their careers, and that there are other ways that the agency builds a culture of work, and that's sharing back-to-work stories with clients and practitioners. It's so important for people to hear from their peers that they were in a similar position, but they were able to go back to work. It's such a huge motivator. We want the agency to really show that there's a culture of work, so there are posters, and I see I have a typo there, and work brochures, so it's visible. We believe, this agency, that you can think about going to work. The second one is that competitive jobs are the goal. These are jobs that pay at least minimum wage and benefits, same as other people who are in these jobs. They're integrated in mainstream society, owned by the individual. It's not owned by the rehab agency. The person is hired to do that job, and they need to do that, and they'll get the paycheck. It's not set aside for people with disabilities, so this includes part-time, full-time jobs, seasonal jobs, jobs that are part of the natural fabric of the work world in our societies, as well as self-employment. Often, I'm asked for a list of what are competitive jobs that people are going for, and this was just from one of the studies that we were doing. I just grabbed some job titles, and you can see that they're really varied. Some of them are very entry-level, and others are more advanced, because that's where people are in the world. It may be for young adults, they're earlier on in their work career, but with education, they can have higher jobs, as well. Okay, the third principle is that employment services and mental health services are integrated, and this occurs differently in different organizations. So, if you're in a mental health agency where there are mental health services and IPS services, they are integrated together through a team approach. The IPS specialists join the mental health treatment teams to discuss client situations on a regular basis. They help think about those who haven't raised their hand yet about work and school, about how to encourage them. Then, there are other organizations that are not integrated, and these services are, therefore, coordinated. So, it may be a mental health agency that coordinates services with a rehabilitation agency that provides IPS services. The IPS counselors may even have an office at the mental health agency, but they're still working together as a team to provide these services. A vocational rehabilitation counselor is typically assigned to work with that agency or those agencies, and meets at least monthly with them to talk about referrals that may be helpful, may receive help from vocational rehabilitation, and gain helpful services from them, as well. We also want to include families. Families are the people who may have known these people the longest and have a lot to offer in terms of the skills and talents of the individuals, their experiences, what may be most helpful for them. Okay, weekly team meetings communicate outside of these meetings. They often share office space together. We want to think about work as everybody's business, and so it's not just on the shoulders of the employment specialist. It's the whole team, the psychiatrist, the substance abuse therapist. It could be other people, the nurse, that all get to know individuals and get to know what their strengths are and can bring to the table ideas. It's not just the IPS specialist. I'll just quickly tell you a story. I was working with one team, and this was a research project. This was down in South Carolina, and it was Assertive Community Treatment Team. We were there in the morning and having the morning meeting and running through the list. About 15 minutes into the meeting, the nurse comes running into the room apologizing, being late, but she said, I have to tell you, I've come up with the best idea for Rebecca to be able to work. I just visited her, did a home visit for medication, and she had all these cakes that she had been baking in her kitchen. I asked her what they were for and where they were going. She said that she comes from a very large family and that someone was getting married. She is known as the cake maker and had made the cake. I asked her, might you want to do that more regularly, even for a job? She just lit up with a smile. It's just a story to tell you that that nurse was thinking about work and thinking about what that person likes to do. It told me that they really see this as a team approach. The fourth principle is that this is all guided by individual preferences. People have ideas maybe about the type of job they want, what kind of setting they want to be in, outdoors, indoors, maybe want it to be very quiet, how many hours they think they might want to start working. Having the discussion about, do they need to disclose anything to an employer? Now, if certain accommodations might be helpful for the individual, then some disclosure discussion probably will occur. That might be, for example, if somebody is hearing voices but is able to manage that by wearing headphones. That would be an example of an accommodation. The individual will decide if they are going to disclose, is the IPS specialist going to be part of that? Helps to define what the IPS specialist role is and the kinds of support they're going to have. Now, that doesn't mean that they're dictating everything. It doesn't mean if somebody has a history of substance abuse and they say they want to be a bartender, that the IPS specialist has to go get them a job as a bartender. But that it's going to be their job and so we need them to be invested in it. We need to listen to them and what they want to do and help them think about the advantages and disadvantages of what they're thinking about sort of shared decision-making and work together. Fifth one is about work incentives, benefits planning. This is the area that people have the most fear about going back to work is losing any or some of their benefits if they start bringing home a paycheck. And so they need to get good information about what's going to happen if they go back to work. And this is typically by a specially trained staff person that will go over in a comprehensive way what benefits they have now and how certain jobs and amounts of money will impact their benefits. And family members oftentimes want to join in on these kinds of meetings if the individual says that's okay because they have concerns about possibly losing their SSI or Social Security disability check. So if you don't have an IPS program and people are thinking about going back to work, it's good to try and find a benefits counselor. And vocational rehabilitation is also often helpful in having information about where to find that out. Okay. Sixth one, job search starts rapidly. So it's a rapid job search approach, not rapid job placement. We're not guaranteeing that people are going to have jobs in a certain amount of time. But we are honoring these people who said, I want to go to work. I want to think about this. I want to go to school. We're going to help them get out there and start looking where that might be. And some people, within 30 days, and some people have a, they know what they want to do and they want some support with that. Other people may not know what they want to do. And so they are really helped looking at jobs that may be something they want to do, learn the world of work. Okay. Number seven, systematic job development. So there are specific ways to approach employers. And we know that most people are hired from networking. And we also know that many jobs are not advertised. And so IPS specialists conduct meetings with employers to develop relationships. And they want to find out about the jobs that are at a certain business. And they want to know about hiring practices. And so these IPS specialists are making at least six contacts with hiring managers each week. And it can be a repeat person too. It doesn't have to be six completely different contacts. So we think about the employer as being a customer too. So essentially how this works is we help to train people to identify and develop an introductory statement to an employer, basically to get an opportunity to sit down and meet with that employer for 15 or 20 minutes, not to ask for a job today, but to find out what kinds of jobs are there and what kinds of jobs might they not know about and what makes a good employee there to gather information that the IPS specialist uses to figure out, is this going to be a good job match with a person that I had in mind when I went into that employer. And they have return visits. And it may be that they decide this is not going to be a good job match, but it might be for someone else. So they keep going back. And so they don't introduce a job candidate during the first meeting or typically even the second meeting. But this is how they're trying to get good information to make those job matches. Okay, and the last one is individualized job supports are provided. And timing of those supports is, we have learned through studies, is very important. And so having face-to-face contact with the worker right before starting the job is helpful. And even the day of the job, and then having regular weekly contact over time until the person is really settled into working. Sometimes when no support is provided when somebody has started a job, it's not uncommon that the person just doesn't go back the second day, because they may have been confused about something. So all the supports individualized. We look back with the individual, if they've had previous jobs, where did they have difficulty in the past? And how can we avoid that in this situation? We also support the employer if disclosure is part of that. Sometimes if people don't want the IPS specialist connecting with an employer, then they have to do all of this behind the scenes and never connect that they're working with a particular person to get the job. They can still network with employers and gather information and go back and tell someone about it, but they don't have to tell the employer that they're involved. The IPS specialist also helps with career development, help ending jobs and moving on to better jobs, and transitioning out of IPS when they are no longer in need of intensive services. Okay, so now I'm gonna quickly go through some of the research so you're familiar with that. And there are now 27 randomized controlled trials of IPS supported employment. And as you know, the randomized controlled trials are the gold standard in medical research. And that is where one approach is compared to another approach and people are randomly assigned. And in all of these that are, these research studies that have been conducted around the world, 12 are in the US and 15 outside of the US. And 2 3rds of these have at least an 18 month follow up. But we find 26 of the 27 showed a significant advantage for IPS. And so the mean across these studies is 55% of the people in IPS gain competitive employment as compared to the 24% in the controls. And the one I'll just let you know is in a study in mainland China that had borderline significance. So here's Gary Bond's graph on this graph. And if I should say, you'll get our website at the end of this presentation. He has PowerPoints on the evidence if you're interested in more of this. But he keeps track of these randomized controlled trials. You can see, I'll just read a little bit at New Hampshire, Alabama, Illinois, Connecticut, then there's Hong Kong. There was a seven site study in Europe, Sweden, Japan. So the black bar are those who received IPS and their employment rate. You can see that in many cases, it's far above the red bar or the orange bar in the case of Connecticut that received usual services. Okay, I'm now going to briefly talk about the International IPS Learning Community. And this is a large learning community that started very small, but now includes 24 states and six countries. And they're all focused on implementing IPS and they have done it in a similar way, starting small and then expanding statewide in a way that is sustainable. They track quarterly outcomes. They monitor program implementation through the IPS Fidelity Scale. We have an annual meeting that the leaders come to and we have stakeholder calls throughout the year. And this is for, we have a peer committee, we have a family committee, we have a mental health and VR committee or meeting, quarterly meeting. We have a fidelity reviewer meeting. So people are learning together and they're networking together. This project continues to expand. And in the U.S., you can see in this graph that this is our graph of the number of people who have been served and those working. So the gray bars are those served in annualized quarterly outcome reports. And then the red bars are of those who worked a competitive job in the quarter. And you can see the line across shows that really between 40 and 44% of the people in any one quarter in these sites were working. And so we're often asked about benchmarks and what is a benchmark that is reasonable for quarterly employment outcomes. And you can say 40%. It's actually 41% when we looked at it through all the sites in the learning community. But that is reasonable for a program. Okay, I want to briefly mention that we had did, this is a study reporting on six sites that converted their day treatment program to IPS services compared to those that did not. And what happened in those that converted, they discontinued the day program. They still got medication management. They still had case management. But the day treatment counselors converted into IPS specialist positions. And they helped implement IPS. And they all had similar results. There were large increases in employment. Originally when these ideas were proposed, the clients, staff, and families did not like the idea. But as it turned out, all of them did like it. This was after the initial day treatment conversion that was done here in New Hampshire. And there was a resulting in cost savings from these studies. I would like to mention long-term outcome studies. There are three studies I'm showing here where we re-interviewed people eight to 10 years after being in a study. And what we learned was that people usually went through two or three jobs before they became a steady worker and that in these studies, at least half, well, close to 50% worked at least half of the follow-up period. So for the eight-year study, it was four years. And I was lucky enough in one of these to go back to be able to interview people on what happened and really what made it better for them. And there were really three themes that I learned. One was they helped people. Adjusting medications, working part-time. That was in part to fear of losing benefits and also because it's hard to live a life, I think, for many people who are trying to manage their mental illness. And the third was having the support of an IPS specialist who could help them over time. And for example, asking for a raise. And the other thing I saw is that people didn't need IPS after a while, that they learned how to be a worker. Okay, we're now gonna go, well, before we're gonna go up there, we're gonna just, this is really a summary slide to show you that IPS has benefited all these subgroups. And that there, when we've looked at employment rates for IPS sites in urban locations and rural locations, we found no difference. Okay, so now we're gonna go to supportive education. And supportive education is less well-developed. There is really no consensus on one single model. And there are reasons for that. And I think some of them are just because there's limited research, but also it's difficulty to measure, figure out what your outcome measure is for education. And that occurs over time. But that said, supportive education has been described in, similarly, in parallel to supportive employment. So in that sense, what happens is these are, we encourage people to think about mainstream educational settings, getting support from an IPS specialist to be able to go through school and advance their careers. We encourage you to help tie education to employment. And we know that people who have advanced their schooling are going to have better options for financial security. So we want people to think about education when it makes sense to them, and when it's gonna help them with their work lives. So here are some questions that you could ask people to try and tie education to employment. Okay, the IPS specialist's role in education. Similarly, they have these areas and phases to do in employment. They have a parallel phases in education. So they're responsible to help intake, engage people, assess what their background is, who they are, how this might relate to schooling, what area might they wanna study for ideas about jobs in the future, help them select schools, go through the application process, help with financial aid, and help them connect with academic staff. And if they might want extra supports or accommodations, connect with the offices for students with disabilities. So we include working with people in high school. And we know that we want people to get their high school diploma, if possible, or the equivalent. And so IPS specialists will help with GED. And they also help people who have an IEP, Individualized Education Program. And that is for people who, students who qualify, they're eligible when they have one of, out of, I think it's 13 disabilities that affect educational performance and ability to learn. And so there is a plan that is written, and special education teachers come together with the student, with the family, and with the IPS specialist to talk about what is gonna be helpful for this person to be able to graduate and also be in the least restrictive environment. 504 plans are, the eligibility is a bit broader, but it's still about giving people opportunities for accommodations and supports. Post-secondary education, IPS specialists will help people with, to identify their course of study, what schools that they're gonna go into, help them with that FAFSA, Pre-Application for Federal Student Aid. It's an online application, needs to be completed yearly. And help with, help with deciding what courses that they're gonna take. There's always, I think, with many young people, a temptation to, I'm doing fine, and I'm gonna go into school, and I'm gonna take a full course load like my peers. And that doesn't always work. And so if somebody goes ahead and applies and then finds that they're struggling, and they maybe realize that this, you know, having four classes is way too many, the IPS specialist will talk with them about maybe the idea of connecting with the academic dean to see about reducing the course load without penalties, if possible. Some people are interested in more short-term programs, certificate training in community colleges. I have a couple of examples there. And then other training programs people may want to be involved in. So we really encourage IPS specialists to get to know what's available in your community colleges. Can also help people with, you know, these certificate programs that give people skills fairly quickly. Okay, so remember, it's a team-based approach. So we're gonna have team supports, and people are going to help think about, you know, learning challenges that people have, maybe poor attention, poor concentration. How are we going to optimize how people are gonna learn? And it may be that we're gonna have some medication adjustments. It could be that there are issues with substance use going on, and that that needs to be addressed. And just healthy lifestyles of people with their exercise and their diet. There are opportunities for cognitive enhancement training, and as well as technology supports. And, you know, there's something that's called a SmartPen, which students can use to take notes while recording the lecture. So they can go back and put their pen and their notes in the area that they wanna listen to again, which I think can be really helpful for some people. So some more supports. Connecting with a campus office for students with disabilities. That would help with accommodations. We recommend that people do that early, before, as they're getting started with going back to school. Even if they don't think they're gonna need any accommodation, they may at some point. So what are some examples of accommodations? Well, extra time for test taking. Extra breaks during classes. Maybe tutoring. Permission to record lectures. Maybe preferential seating. Being allowed to sit in the front of the room so that will prevent distraction. Help with note-taking. Extended deadlines for projects. And maybe even receiving an incomplete grade to finish the coursework if someone had to be hospitalized. So to sign up with a student with disabilities, they do need some documentation about a disability, but the specific disability is not discussed with the teacher, but the student may need help, or want help, to talk with the teacher about these accommodations. Other kinds of supports. You know, you could imagine, maybe time management. How to, when classes are, when are they going to study? And how to study. Some people benefit from studying in small blocks of time. Family, facilitating family meetings with young adults. So, you know, education, supportive education really can be for people at any age, but we certainly are seeing more of a focus with young adults because we're hoping that they don't have to go through the path of disability. That they can move forward with support and get greater schooling to become employed. So, I've listed here some other supports. I mean, you know, I think a huge one is celebrating success and it's, you know, nothing is too little that can't be celebrated for people. So, what is program success? We have the quarterly employment and educational, education outcomes. There is a quarterly report that we use. It's on our website, and you'll get that website address in a minute. And then sites can use that information to track their outcomes and make changes to improve their services. Most of these sites will have a supported employment fidelity review using the fidelity scale. It's a 25 item scale that measures program implementation. That's also on our website if you're interested. And we have recently developed a fidelity scale for youth, young adults. We're thinking about ages 16 and up, 16 to 24, 25. We're just starting a study for young adults and we will be using this scale. It is not validated yet, but, and it's likely to have changes because we know that we need to learn from studies as well as what happens in the field. So we'll see how that goes. Okay, so I just wanted to mention one person in particular to try to pull this together. And this was an individual who was a young adult in his early 20s, and he had been referred to a day program, and he basically just sort of sat there. And it was not really helping him in his recovery. It didn't appear that way anyway. And then his counselor decided, let's talk to him about work. And so he was referred to IPS and his IPS specialist helped him think about what kind of place he'd like to work and what would he like to do. And they ended up getting him a job in the mailroom at a local bank. And it just boosted his confidence. He just sort of came alive. And following that, he ended up going to community college. He also got his own apartment. And he just looked really different. But it was through the team support and encouragement that helped him with that. So your role as frontline providers, I think that your biggest role is to encourage people to think about employment and education. As I said before, not to push people, but to encourage them to think about it. And it's also helpful for you to understand these principles and the practices and communicate with IPS providers if you can. You also can be enormously helpful around serving people from different populations and different ways people will engage and wanna be supported. Also make sure that people do have access to benefits counseling. And that just helping people identify the positive things that they're doing and what their successes are, even if they seem really small. I just have a couple more slides because I know I'm supposed to end here, but there was a lot to say. IPS is being studied and implemented with new populations. I have them listed here. Early psychosis, transition age youth, post-traumatic stress disorders, welfare recipients, TANF, common mental disorders, common substance use disorders, even with people with spinal cord injuries, autism spectrum disorders, and people with intellectual developmental disabilities. Pain syndromes, poverty, social security disability denials, the justice system, opioid use disorder, and also with new immigrants. And these are studies that are going on around the world. So my last slide, I believe, is giving you my website, our website, which I hope we have lots of materials. I hope you all are interested to look at them and use them in ways that will be helpful to you. We have online courses for practitioners, other kind of training, and as I mentioned before, we have a couple manuals. Our 2013 manual is about to become 2020 because we have updated that. I've listed my email address, and I'm happy for anybody to email me. And we probably should stop for, see if there are any questions. Thanks.

Dr. Benjamin Druss

SMI Advisor

APA

SAMHSA

Deborah Becker

IPS Employment Center

Supported Employment

Serious Mental Illness