Okay, good morning, everybody. We wanted to welcome you to today's webinar, and we hope that you are safe and healthy. The topic today is Strategies to Improve Supported Employment and Education Outcomes in Coordinating Specialty Care for First Episode Psychosis. This webinar is... Let me advance the slide here. This webinar is presented as a partnership between PepNet and the SMI Advisor. SMI Advisor is a SAMHSA-funded project developed by the American Psychiatric Association as part of the Clinical Support System for Serious Mental Illness. Okay, and so to introduce Shirley, Dr. Glenn is a licensed clinical psychologist who received her PhD in Clinical Social Psychology from the University of Illinois at Chicago. In 1987, Shirley joined the UCLA Department of Psychiatry and Biobehavioral Sciences and the VA Greater Los Angeles Healthcare System at West Los Angeles to begin a program of research on psychosocial interventions. Okay, and Shirley has no relationships or conflicts. This is a disclosure agreement. Okay, so let's... We'll turn it over to Shirley. Thank you. Okay. Hello, everybody. I was thinking about this talk, and I'm thinking about the Borges book, Love in the Time of Cholera, and part of me is thinking about C in the Time of COVID-19. And I know that many of you are struggling a little bit because we do so much C work in the community, and many people can't do community work right now. So although I'm going to talk about everything that pertains to these objectives, and Ramsey's here. Hi, Ramsey. I was just talking with Ramsey yesterday. He's one of our C people. Although we're going to talk about everything I wanted to cover, I do have a couple ideas at the end about what C folks can be doing if they have limited community involvement. So I'll try to cover that as well. So what do we want to cover today? We want to talk a little bit about the research on C for first episode of psychosis. I want to share a tool with you that is a brief assessment tool to capture as people are changing their opinions about whether they want to go to work and school if they're in a first episode program. I want to talk a little bit about what we call neat people, people not in employment education or training, the people that we're trying to work with and having a lot of trouble with, and then talking about some strategies that may help with that. So there's a lot here. Please put your questions in the chat, and we'll try to cover them at the end. All right. Next slide, Judith. Okay. So just to tell you a little bit about myself, I've been doing work in supportive employment education for about 20 years now. I've run a number of trials, came first episode about 10 years ago, and have been now doing a lot of work in that area. And when we think particularly about people with first episode psychosis, one of the things we're thinking about is they're living their lives, doing whatever they would be doing. They may be going to school or work. Clearly, they have aspirations and dreams of some kind. Their family may or may not have aspiration for them. We hope they do, but sometimes people don't. And critically, they may have been on a different kind of instrumental role trajectory before they ever got a psychosis. And by that, I mean, some people you're going to get in your programs may have been going to Ivy League schools and doing wonderfully. Other people may be in doing special ed and struggling before they ever got a psychosis. And one of the challenges we have is how do we meet the needs of such a broad group of people? Next slide. Okay. When we think about how psychosis may impact on someone's work or school involvement, I mean, I think it's pretty obvious. If you have positive symptoms, if you have hallucinations or delusions, if you're very paranoid so you can't even ride the bus to get to work, that's a problem. If you think people are talking about you while you're trying to do customer service, that can be a problem. So there's a lot of issues there. Obviously, we talk about negative symptoms. And if you have a lack of motivation, if nothing gives you pleasure so you can't really think about, you know, I might have a good day at work, I might meet a friend, whatever. And then obviously the cognitive problems that people have. Particularly remembering, concentrating, perspective taking. I mean, right now, part of what we're all having to do at work is think about what do our bosses need so we can try to be helpful in this difficult time. If you don't have perspective taking, that's a really hard thing to do. Next slide. All right. Okay. Now, in addition to symptom issues, there's also social issues. People with psychiatric illnesses are often shunned. They may have shame about their situation. They often have impoverished lives. I mean, I'm thinking about people that I want to bring for job interviews. And they don't have enough money to get a good haircut. And so they feel awkward about it. And you can understand why. We all want to present well. So they have limited access. This next point is critical. I've come to understand, having done this for about 10 years now, that there's certain groups of people we work with that their families had aspiration and ambition for them. We also work with people who their families did not have aspiration. Maybe nobody in the family is working at all going out of the house. And so we're not only trying to help the person get a job, we're trying to change the culture for the person. And so there can be many impediments to engagement or success. Next slide, please. All right. In addition, and this is for those of you who've only worked with first episode psychosis people, you probably are golden with this. But we often get people who have been doing IPS. And now they're basically being asked to work. And they worked with long term clients. And now they're having to work with younger folks. And they may sort of not even have be struggling to think what it's like. They may, for example, often our younger folks are living with their parents. So family involvement becomes more important compared to when you're working with somebody who's 40 or 50. Their peer relationships or friendships and the romantic relationships are often important. And those are the relationships that they're thinking about when they think about this, this is a cool job, or what do I want to do with my time? Their goal is, their developmental goal is individuating from their family. But now they're becoming more dependent. And so there's this struggle about this, they have a desire to exert autonomy to do it themselves. And yet, you know, we're sort of, to some extent, trying to give them guidance. And there can be some real tension about that. They have high rates of substance abuse. They may not think psychosis is particularly serious. It's a one time thing. It's because I got some bad drugs. I was overtired from school. They're heavily influenced by social media, which can be good or bad. And this is really critical. They're not socialized since routine medical care. Think of the typical 20 year old male who may be typical in your program. They're often not seeing a doctor at all for anything. And then they develop a psychosis. And we say you need to come to the clinic every, you know, maybe six or seven times a month. So what, you know, and they do and they know show and we get frustrated, but they've never really thought of medical care that way. And we need to sort of help socialize them into that. Next slide. Okay. So now I'm going to talk a little bit about C. C is supported employment and education. And for first episode psychosis, that's what we call C. And just, I'm going to briefly talk about the tenants. If you know IPS, these will be very familiar to you, but just in case it's relatively new to you, the job match is critical. We try to find people jobs they can get. Okay. We want to discover why the consumer wants to work, figure out what their strengths are, and build on them. Much better to get a job people can do with their current strengths than try to, you know, change them, find the right placement. We don't expect consumers to change a lot for jobs. I mean, if their hygiene is poor, maybe they want to work on getting a food service job, but we may also try to think about helping them get a job where hygiene is critical. Provide ongoing support and anticipate problems. And this is critical. Here's another difference from IPS. In IPS, we talk some about career development, but not so much. When you're working with young people, you really want to have your eye on, are they on a career trajectory? Either what they're doing in terms of their schooling, or if they've got a job, occasionally bringing up with them, perhaps every three to six months. Do you want to talk about promotion? How would we talk about promotion? Do you want to talk with your manager? I mean, let's say, if you were, if you're at a DSW and you last for six months selling shoes, you typically qualify to be a, you know, a shift leader or an assistant manager. So keeping that in the eye of people is really, really important. Okay, next slide. All right, I want to just briefly talk about the principles of C. First of all, C services are available to all people in coordinated specialty care. So we're trying to offer it to everybody. And this is really important. Point C, I'll talk about this a little bit. If people say no initially, we want to keep going back to them. Not every month, but perhaps every three months or every six months. People change their minds. In our Navigate program, about half the people who got engaged, got engaged in C six months after the program started. So we want to revisit. We honor people's goals and preferences. We're talking about helping people get meaningful employment. Now I should say we do occasionally allow volunteer worker internships. That's often something different from traditional IPS. I usually say that if 10% of a C person's caseload is in volunteer work, or in internship, that's perfectly reasonable from a fidelity point of view. Next slide. Okay. One thing is benefits counseling. One of the big issues for those people who work with long-term clients and that are moving into first episode is, you know, many of them are on SSI or SSDI and we're spending time talking about what it would be like to go to work or school and how that will impact on their benefits. With first episode folks, of course, we're trying to hope they can recover and that they won't necessarily need to go on disability. The upshot of that, now some people will come to your program, they've already applied for disability, or they're saying that's the only thing I want to do. Okay. If that's the case, that's the case. But I would encourage you not to have your C person involved in helping people apply for disability, because it's really hard to give the message on Monday, let's do the work you can't work. And then on Wednesday, now let's help you find a job. So if people are going to apply for disability, I really encourage the C people not to be the people involved in that. We work with all other CSC services and that should be conjoint meetings. So for example, I've worked with people who have anxiety at work to the point where it impacts on their performance. It's a wonderful thing to have a conjoint person with the, have a conjoint meeting with the individual therapist and everybody learns some anxiety management techniques together that then the C person can bolster. We meet with people when they say they're interested in working or going to school. But unlike traditional IPS, we also try to use a little motivational interviewing. The whole team, keeping that notion of you can have a future more aligned here. You know, a better future as you work on your recovery. Next slide. Okay. We don't do a lot of pre-vocational assessment. You all know that this is a, you know, a basically a place and train model. You know, it takes maybe a month to two months to get people out in the field from when they start working with C, but we don't do a lot of clinic-based work and we offer follow-on supports. People churn in and out of jobs and it's easy to get frustrated as a C specialist about that because you've worked hard on it. But remember developmentally, if you think of 19, 20, 21 year olds, perhaps yourself, when you started initial jobs, people churn. You know, there's a McDonald's where I work. He'll hire anybody to work basically because he knows most people are going to do one or two shifts regardless of whether they have psychosis or not, and then they're not going to finish. They're going to leave. That's not the job for them. So that churning is often part of a developmental issue. Next slide, please. Okay. I want, I'm a psychologist. I have to talk a little bit about research and I do want to talk specifically about one interesting thing. When you read the research and try to compare your outcomes to studies, I'm going to talk, publish studies. I'm going to talk about three trials. Next slide, please. These are all first episode trials. This is the first trial. This is in Kalaki. And I think that, I think that this is the first trial I'm aware of that we said specifically on what they call IPS, but it's basically C. This was done in Australia by Ian Kalaki. You may be familiar with his work. They got consumers with first episode psychosis, randomly assigned them to either IPS, so that's the kind of like C, or regular customary care. Importantly, to get into that study, you needed to say you had an interest in work or school as an outcome. Okay. Next slide, please. This is just describing typical people in their 20s, mostly males. Next slide, please. Okay. The blue is how many people didn't work. The white is how many people worked after six months of the intervention. You see for the vocational intervention group, most got a job. You see in treatment as usual, most did not. This was given as preliminary evidence that we have a pretty good model to work with. Next slide, please. They also had the option of helping people get to school. And when you combine work or school, you see almost everybody in the vocational intervention got a job, and most of the people in treatment as usual did not. This is going to be a recurrent theme through our work. Okay. Next slide. Ann's group just published outcome from 18 months from this same group. And to be honest, the results were not as good. Remember, this is a six-year, excuse me, six-month work program. Most of you, if you're doing OnTrack or Navigate or something, you're offering treatment for two years, which as it turns out is probably good, because as you see, the initial gains, that horizontal access is months of the program. Zero to six, there was a big group difference. You see IPS in the blue did better. That difference was no longer apparent at month 12 or month 18. So this sort of suggests that maybe we need to do longer-term work here, which is great, because most of you probably are. Next slide, please. Okay. There's been a recent study by Keith Nectarline's group. Keith works with us at UCLA. And Luana may even be on this call, and Luana is their head IPS person and has done a wonderful job. So this is young people who developed a non-affective psychosis. Compared to other programs, one thing they did in this program was get people who had been ill for up to two years. So this is people who tended to be ill perhaps longer than many of your first episode programs. But again, just like Kalaki's group, you had to say that you were at least interested in pursuing work or school to join the study. Again, it was a randomized trial, half got IPS and a clinic-based work group. That's called Workplace Fundamentals, or just referral to whatever was available in the community for both rehab and some social skills training. They gave 18 months of treatment, so a longer treatment. Okay. Next slide. All right. So first we see competitive employment. And what you see here is very little difference between the groups in the first six months, but then you see a dramatic impact of being in the IPS, which is great. Okay. This suggests that we have a good model. A little different with school outcomes. So let's see those next. That's the next slide. You see in school that they were a little different initially, and that people got to school sooner in IPS. They had more success earlier. But by the end of the 18 months, the two groups were similar. So perhaps the outcomes for work in school, the trajectory of improvement, may be a little different for the two outcomes. Okay. And then finally, I think, next slide. So I'm going to take a moment. This is the combined outcomes. So this is competitive work or school. So let's just look at this slide. This is a percentage of the group that's working or going to school. Here, again, you see where they were at baseline, where they were at six months, and where they were then at 18 months. And you see IPS is the straight line, and the referrals to voc rehab are the dotted line. And again, what you see is that the groups were a little different at baseline, but even controlling for those baseline differences, the supported employment group, the group that got the supported employment, and the clinic-based weekly or biweekly sessions on work skills, did consistently better to the point, and this is kind of an amazing finding, for them, by the end of the 18 months, 93% of the people had had a work or school experience. So that's pretty amazing. I mean, this is among the most successful trials I know of for work or school and first episode psychosis. And it's a real tribute to them that they had such a great outcome. And it gives us hope that we're doing good work trying to help people get back to work or school. Next slide. Okay, so I'm going to talk a little bit about the RAISE trial. I was involved in the RAISE trial, not so much in supported employment initially, more in family work, but now I do a lot of training in it. Now, what differs about the RAISE trial, and this is going to be important for you to pay attention to, is there was no eligibility requirement that people have to want to go to work or school. So when we saw those great outcomes before, remember, this was already the group who said, I want to go to work or school. And we don't know how big a group that is in the general population. The RAISE trial may give us a good idea about that, insofar as that wasn't a requirement. Most of you who are running a first episode program don't necessarily require people to say they want to go to work or school to get into your program. Those other research trials did. So this is a slightly different population. Next slide. Okay, so just to remind you about RAISE, it's an RCT. Uh-oh, let me go back one. Yeah, it's an RCT. People either got coordinated specialty care or community care, which was whatever. You're going back? I don't know. Keep going. Yeah, stop there. People got at least two years of treatment if they wanted it. Sites were, we had 34 sites. Teams were randomized by site. And all the assessment was done through distance remote stuff, not unlike this. Next slide. This is just showing we had 17 sites in each condition, and this is the number of subjects. So it was people who got the NAVIGATE intervention, which you may have heard of, or community care. Next slide, please. Okay, this is just reminding you about what we offer in NAVIGATE. It's team-based, shared decision-making, emphasis on strength. Uh-oh, we lost the slide again. No, the other way. I think you need to go two slides. No, you're going the wrong way. Keep going, one more. Okay, psychoeducational teaching skills. We try to use MI whenever we can. And then, of course, we have our four components. And probably most of you know, but all the manuals for the psychosocial components are available at navigateconsultants.org, and I have the website at the end of this. Okay, next slide. All right, so this is sort of interesting. Everybody in RAISE was talked to monthly about what kind of services are you getting. So one, so the red is the NAVIGATE people, the blue are the community care. And this is when we asked them, is somebody helping you, some formal professional helping you get a job? All right, and what you see here is early on, about half the people in NAVIGATE said yes. The other people were presumably not interested in getting a job at that point. And then it drops off, because once people get jobs, they may leave the program, or they're doing successfully, or they're going to school, and they say they don't need help, whatever. But you see that, you know, about half the people in the beginning said, yeah, I want some help. I'll meet with you. And the other thing is, look at the blue. This is customary care. Basically, they're getting very little help. So what that means is, people who are just getting community-based care for first episode psychosis, most of them, not all, but most, are not getting a lot of help if you refer them to voc rehab, or whatever. Those are hard systems to penetrate. Next slide. Okay, these are our results. So remember, again, these results are going to be less successful, presumably, than the other two we talked about, because the other two trials we talked about, because people did not have to say in the beginning, I'd like to get work or school here. And what you see is that the blue line is customary care, community care. They only increased 3% in their work over the 24 months of the trial, whereas if you see the red, those are the Navigate people. They started lower. It's a significant difference in terms of whether they were involved in work or school at the beginning. But they increased by, I think it's 17 percentage points, which was over 50% improvement. Again, we want to build on these. I would hope everybody on this call would take this as a baseline and actually think, rather than getting people 45% employed at work or school by the time they leave the program, at some point in your program, that we could really get this up to about 65-70%. And this is the point of this call, what are the ways we can improve outcomes? Next slide, please. Okay. This is just to remind you, there was no requirement of work or school. That's part of why the differences are. And we also were limited. We didn't have full-time C people in Waze, so that, in many sites. And as I said, participants started lower in the Navigate group. That was just random assignment. This next point is important. Two-thirds of the people, 68%, by the end of the Navigate, the two years of Navigate, had met with the C person at least three times, which was sort of our measure of engagement. But this is what's critical. Half of those did that after the first six months of Navigate. So what that means is, you're going to have people in your program, perhaps as many as half, who are going to decline work with the C specialists initially and need to be re-engaged over time. Somebody's got to, wait, one more slide. I mean, go back once. Okay. Finally, people who go on Social Security, here's the shocker, have decreased chances of working or returning to school. Next slide. Okay. So I just want to summarize a little bit about what I've said this morning. Then we're going to talk about hard cases. First of all, running a trial where you have people want to go to school or work seems to have better program outcomes. So when you're reading research or developing a program, you want to think about that. When people have poor outcomes, they're coming into C but not doing well, many folks are now adding a cognitive component to it, either John Felican's cognitive adaptation training, or you may know Kim Muser and Susan McGirt's Thinking Skills for Work. That's going to be in a book coming out. This is a way people are thinking maybe it's cognition that's getting in the way of people being successful. We don't know how long IPS or C should be. We know six months probably isn't long enough. We're just publishing our five-year race outcome stuff, but the first paper won't have work outcomes, so it's still a little unclear. But it does appeal from the Kalaki paper that if you only offer it short-term and then stop, people don't sustain their benefits. Maybe there's a different trajectory for work and school based on the Nectarline results. It may be that school stuff, that work changes happen quicker than school or school quicker than work. We don't really know much about gender or ethnic differences. People aren't really reporting that much. I'm going to talk briefly about that at the end, but there's not too much. And disability may impact on whether people work. We certainly found that in Next slide, please. I want to talk now a little bit more about working with people where either they don't seem to have an interest in work or school or they have an interest, but we're having trouble helping them be successful. And I'm a little reluctant to do this only because I don't have the magic wand here to kind of say, hey, do this, and it's all going to work out great. I think we're all trying to develop new ideas, and you heard me just talk about some people are approaching this as a problem with cognition. We're going to be doing some research and navigate on this now. But there's lots of ways to think about why developmentally somebody somewhere between 17 and, say, 30, when the norm in this society might be getting involved in work or school, why is it that we have this subset of people who are really having trouble with that? How do we understand that? And I'm going to just now present sort of things I've learned, things I've talked about with other people. But again, this is more planting seeds for you all to think about things you might address in your program rather than this is the perfect answer. Next slide, please. Okay. So how do we think about people who come into the coordinated specialty care program? And it doesn't lead to work success. And maybe there are a group of people who tell us initially, I don't want to meet with the employment specialist. I don't want to do that. It's sort of interesting. There's this study, I didn't reference it here, but where they went into the hospital and talked with people who were having a first episode psychosis and asked them, did they want to go to work or school again? And over half of them said, yes. But most of them said, not right now. So, you know, it may be an issue of timing. Okay. That people, maybe they don't, you know, maybe they're in high school and they don't quite feel ready to start college yet, whatever. And so one of the things we have to do is for the entire time we're working with people in a program, we need to continually approach them to ask them, have they thought about work or school? And whoever's meeting with them, and it won't be the C specialist because that person will not be meeting with them, but they have an individual therapist or there's a family person or somebody to really try to help them, help use some motivational interviewing to see if people want to move in that area. And I do have a brief assessment tool we're using. I don't know if you can show it, Judith, or somehow people can get it. I'm not quite sure how that piece is going to work, but hopefully we'll put it in the chat. Because one of the issues people have is, well, the C specialist won't know because this person said, I don't want to meet with the C specialist. So how are we going to really help people understand? How are we going to monitor changes in work or school interest over time? So we have developed a short assessment tool. It can be done in about five minutes, probably part of a treatment team meeting, that sort of we're saying. So you can maybe do it every six months, which would also, some of you have requirements to assess about vocational interest. It's much shorter than a career and education inventory typical big assessment you would do. It's got maybe six or seven questions. And we have, we're encouraging people to use that as their way to monitor progress over time and to keep the idea alive. And somehow I think Judith can get it to you. Okay. Yeah. Somebody's asking for a copy and Judith has it. So hopefully you'll get it. Okay. Next slide. Next slide. I am here. And what we're doing right now is we're posting the document drive and doing a little technology thing here. So hold on. All right. All right. And I should say we developed this tool with the state of Minnesota. I did a lot of training for them and they asked for a tool. How can we kind of quickly assess people over time? So hopefully, okay. Is this now? Yes. And do people have a way they can get the tool? Yeah. I can link on it. Yeah. It should be great. All right. Thanks. Okay. Great. So I also want to talk. So I, so one thing we talked about is people may change their opinions over time and we need to keep that alive. And for those of you who look at that assessment, there's a little bit of a confidence ruler in there from MI. So, you know, there's different ways to approach it. Another issue, I think, when we think about people where there's a hardcore problem of maybe not having interest in work or school is what their trajectory was before they developed a psychosis. Now I want to say an aside before I talk about this slide. I would bet most of you on this call know of a young person who doesn't have psychosis, who's having a hard time launching. Okay. I mean, I know when I talked to family members in my clinical work, like parents, they'll say, you know, I've got a kid. All they do is play video games all day. They're 22. I don't know how to get them out of the basement. So to some extent, this is a societal problem, national problem. I don't know if it's more or less than it used to be, but this is a problem. So some of the stuff I'm going to say, there's a general developmental problem, perhaps that's broader than just psychosis. I just want to preface that. But I think that, you know, when we first developed supported employment education programs, I think we sort of thought of this kind of model that people, this is, you know, time, you know, maybe years in your young adulthood, and we've got optimal role functioning and poor role functioning. And I think that, you know, we thought people, most people coming into the program may have had like at least moderate performance, and then they have a psychosis and it dips. And then our job is to get them back to the trajectory they were on. I mean, I think that's how I thought about this 10 years ago. I didn't really think a whole lot about we may need to change their whole trajectory. And I think, and I don't think I'm alone in that. I think many of us thought this. Okay, next slide. Okay. But now has come the concept of the, which is quite, I think it's a term used more in Europe than in the US, but it's becoming more prevalent in the US. And this is basically talking about young people who are not in employment, education or training. These are the young people, and I'm going to, you know, talk about the group with psychosis. But as I said, it could be a more general problem than the culture right now. These are people who basically, maybe they're getting out of high school, but then they don't seem to be grabbing on to much. And in our folks that also have the psychosis, so that can make it even more difficult. Now, some of the ways I think about this, and we have not a whole lot of data in the US about this group. There's some in Europe, but less in the US, although I know there are a few people studying it. But I sort of want to talk about this. And part of the reason I think this is so important is I gave a talk a couple of years ago, and talking about this, and I talked about, I don't know, something about people didn't have motivation to work. I think that's how I phrased it. And really, a colleague I really trust and think much of, Judith Cook, you know, brought up the concept of, yeah, well, if you talk about their lacking motivation, it sort of implies the problem is them, not our technology, not what we're doing as professionals. And maybe we should rethink that. And that really stuck with me, this notion of, we talk about, hey, they're not motivated. I've given it my best. But maybe we really need to think more deeply about the problem. And this is my attempt to do that. Okay, so first of all, maybe it is that these people have poor pre-morbid history. And that's one thing I think we could get better at assessing. Like, it probably makes a difference. And I think we don't conceptualize this as well as we might. If somebody was in college versus somebody was taking special ed courses in high school. I mean, I think us understanding better what their pre-morbid track was can really help us understand a little bit more who's going to need extra TLC in the C. We also have a group of people where nobody around them may be working. I've been sort of, or going to school. I've been struck by the families, the clients we work with, we go to pick them up. Nobody else in the house is working or going to school. And I think for most of you on this call, you're professionally successful. That's why you're here. And I think as we get to understand, oh, there's a culture of people where that isn't sort of what they've been valuing. And it's become clear to me that we are not only trying to help the person get a job. We may also be trying to change the culture of the family or the social group. Some people really need money quickly. They see disability payments as a way to do this. Maybe other people in their families have this. And we have to sort of weigh and want to apply for disability. But those of us on the call realize disability generally doesn't pay enough to really live on well. So then what do we, you know, are we constraining them to really a life of poverty? They may have no identity as a worker. Maybe they've never worked. And so now we come in and we kind of say, well, you could get a job or you could do this, but they never thought of it this way. And then, and this is an important point I'll get back to, this lack of motivation. We talk about motivation, but maybe the real problem is they've got very legitimate barriers to work. Things that if we had them as people who are then trying to apply for jobs, we might really think, how could we ever do this? I mean, I've been amazed. Transportation difficulties. I think of, we work within Charleston. We work with a community agency in Charleston, South Carolina. There's really no bus service. I mean, people are, they feel lucky that they can get a bike to help people get to work. I mean, just imagine some of us choose to take a bike to work, but many of us are taking cars. They may have limited work history or experience, have no way to think about it. Many of the people we see also have caretaking responsibilities. I'm thinking about one person we worked with. Turned out that they were taking, help take care of an elderly relative, bring them to medical appointments and stuff like that. I mean, that's a person that the elderly relative didn't really want them to go to work. One of the things, the other part is often people come out of the hospital, they still have severe symptoms. And if you've been doing traditional IPS with more long-term clients, I mean, they're often, even if they have high levels of symptoms, are pretty stable. But the people coming out of the hospital that you may pick up in your CSC thing, program may have very severe symptoms and they just may need some time to settle down. Same, they may be on medications where they feel really sedated and that's hard. Again, another reason to approach them at a few times. And then we talked about the cognitive challenges. Next slide, please. So what can we do? I don't know all the tips and tools, but these are the things I think of when I really feel like I'm working with someone, I see they have some potential in my mind, but I'm having trouble kind of lighting that flame with them. As I said, one thing I really want to do is understand their pre-morbid history. Were they on a track where they were doing really well and I just need to bolster that a little bit? Or is it really the case they haven't had success for a long time? Maybe they can barely read, they've been in special ed, they weren't going to school long before psychosis. And so we're developing a whole new pattern in their lives. I really want to understand what the important people in their lives think about work and school. And I'll talk a little bit more about that in a moment. As I said, I really want to distinguish work from disability. That's hard to do, but one way to do it is not have the employment specialist involved in putting in additional applications. As I said, really ask him when you're meeting people first time, particularly if you're going to their home, finding out who else lives there and what do they do. Now, you don't want to appear intrusive. We don't want to appear intrusive, of course, but are other people getting up and going to work? Is there a culture of that or is there not? And then really trying to understand from the person's point of view what would be the obstacles they would encounter going back to work or school. Next slide, please. All right. This is now my understanding about what we're trying to do when we do get people who are not on that trajectory I talked about before, who were doing pretty well and then developed a psychosis and now we're trying to get them on back on track. I think that really what we have is a group of people, and I think it's a sizable group, who really had difficulties in functioning beforehand. They may have been known to your clinic. I mean a lot of times what's happening is people are recruiting in a clinic and they're recruiting people who had been getting services perhaps for years as young people. Now they've developed a psychosis and so now we're going to bring them into their program. We're going to bring them into our CSC program. But they're often on, you know, they were in special ed, they weren't going to college, they had tried jobs, couldn't get jobs, had jobs, got a lot of jobs. How many times have you heard this great person at getting jobs but can't keep any of the jobs? We are not only, and maybe with the psychosis, their functioning hasn't dropped that much because it wasn't that high anyways. And we're trying to improve their functioning above the trajectory it was on. And I think that now as we sort of understand that a little bit, we know there's this group where there's really more heavy lifting required and what do we need to do. Okay, next slide. Okay, one of the things we can do in this situation is really try to understand what's going on with their families. I think we probably, you know, we try in CSC programs to involve families. Here's what I know to be true. Families can make or break whether consumers succeed. If the family wants them to get a job, that's great. If the family has reservations about that, either because of disability, they're afraid somebody's going to get sick again, whatever, that will be problematic. People may be, relatives may be ambivalent and giving ambivalent messages about going back to work or school. This is why, even if you have a family education program, having this seen person make a connection with the family and really sort of be there to help the family understand what is going on, why does we think this is important, and in some ways helping the family understand we're not just discussing the participant today, we're trying to help their future self five or ten years from now, if we're lucky enough to be able to do that. So, you know, obviously adult consumers have to consent, but to the extent we really sort of engage families in the C part, that's really good. Okay, next slide. Okay, I've made this point, I'm not going to kill the, you know, beat a dead horse, but I think with first episode people, you really need to be thoughtful about how you're applying, talking about disability. The number of sites I've done training at, and they're thrilled because what they say to me is, you know, that new Social Security program, SOAR, we've got that here, so we can get our first episode people on, they can access that program, they can get on disability really quickly. I think we want to think carefully, do we want to be routinely giving the message that people are disabled, all right? Some people want that, but, you know, and if people come in and they're applying, that's fine. I mean, you never say don't apply, but you really want to work out your program stance to that. Next slide. Okay, I've talked about people not having an identity as a worker. I mean, you know, when you're 19, 20, 21, you may, I mean, many of us don't have any identity as a worker, but you really have to think, people may have no prior work experiences. They may have no idea what work really involves. They may live with people who aren't going out and work. So for here, there's a couple things you can think about. One is really try to ask people, do they have heroes or mentors or somebody who's done work, who's gotten involved, maybe it's even a sports person, but somebody who actually is instrumentally successful. Do they want to investigate that? Do they want to pursue that? How do they think about that? Another thing you can do and see is informational interviewing, just going out and learning about jobs. If you have somebody who has the most modest interest in something, being a C worker and helping them meet somebody who has that job, so they can just talk about it or watch that person do that job, so they can begin to think about things. And the other thing I wanted to talk about, I don't know how many of you know Jonathan Tellman's work. He's in Boston and he does work with young African-Americans with mental health challenges. And one of the things he's been promoting is that it may be that for some people, and particularly for disadvantaged ethnic groups, that it may be very hard for them to get to the traditional work system. You know, maybe where they live there really aren't that many jobs. I mean, if you go to South Central LA, it's often kind of devastating. There aren't that many jobs there. So one of the things he's talked about is maybe we should be promoting more entrepreneurship of people where it seems like the traditional work groups aren't going to work. Now that's hard if you have a psychosis. I don't generally say rush to helping people get a business up and going. But certainly thinking outside the box, if you've got somebody where it seems like it's going to be very hard for them to do the traditional, you know, to get hired and succeed in the traditional work setting. Okay, next slide. Okay, I mentioned this as well. You know, we talked so much about people don't have lack, they have a lack motivation. And sure, you know, we know a motivation is a negative symptom. People have it. I'm not going to say they don't. But that every time you use that word, those words, with regard to see, you should flip it and say, wait a second, are there obstacles I don't understand? You know, let me really under, let me understand. And I, I don't really want to talk about lack of motivation. I'm going to talk about reluctance or hesitance to go to work. What's your reluctance? What's your hesitance? What's your reluctance to go to school? What's your hesitance? So as I said, the see person may be doing this in a very limited way because the person may not even prefer to see. So can somebody else on the team do this? And, and, and use a lot of curiosity where your only job first is to understand how the person really thinks about it. And maybe what they see about what would be hard. Nobody would hire me, you know, those kind of negative beliefs. I'll never find anything I want to do. What's the point? You know, really trying to understand that. And then using motivational interviewing and problem solving. And finally, for those of you who have a peer program, which is great, they can be wonderful role models, but in terms of talking about their jobs as a peer, but other jobs they've done or schooling they've done. Next slide. Okay, so my third take home point is try to really get in the participant's world if you're trying to deal with reluctance and then engage in some problem-solving together about it. Next slide. Okay, I want to talk a little bit about resources. The, here are three resources you might want to use. You probably know, many of you know, Nev Jones. She and her group have done some nice toolkits for school. Here's a toolkit for students and families, particularly if people are going to do college. Again, that's often the people with the good pre-morbid history, but it's a nice toolkit. And then one actually for colleges and universities. And then I mentioned as well, if you're not a Navigate site, you can see our C manual. You can just Google navigate consultants org and all our manuals are up there. I should say all our manuals are being revised. There should be new manuals up, certainly by the end of April, if not before. And so if you've got one, go back. I'm writing the addendum to see, we're going to have sort of a new part about things we've learned since we did our study. Next slide. Okay, I've only got like two more slides. One, so this is just take-home lessons, all right? Monitor interest, ongoing while people are Navigate. Think carefully about the people who aren't doing well and try to reformulate lack of motivation, lack of motivation as an abundance of perceived obstacles, okay? And thinking carefully, really drilling down and being curious. Okay, next slide. Okay, these are just the references I use. Can you show this and then the other one, Judah? Okay, I want to say, and I've got a piece of paper in front of me, I'm going to say one other thing before we open it up and I think I'll hit it right at 11. I know many of you are on this call, you are either managing C, you're in C, you're project managers, and a lot of places C has gone down because you can't meet people in the community. And so I just, and I've been dealing with that question this week, I want to just tell you what I'm telling people to do is spend maybe the next week or two kind of beefing up their C skills, if you will. You can still use the telephone. I know you're meeting people by telephone, but it's hard, no community work, and telephone calls are usually shorter. And unfortunately, we don't have this in the slide because I just developed it this morning. But the resources I'm telling people to use, and if you want to grab a piece of paper and a pencil or a pen. First of all, if people have downtime in their C, unfortunately most of this isn't billable, but it's things you could do. The manual on IPS for all patients, not just first episode, but it's a great book. It's called A Working Line. It's by Deborah Becker, B-E-C-K-E-R, and Bob Drake. You could order that book and the C person could read it. It's, again, it's not FTP, but it is the granddaddy of this. There is a website called IPSWorks, so I-P-S-W-O-R-K-S- dot-org. That is kind of a companion to A Working Line. It's got loads of videos, handouts, booklets. You could spend some time, a C person could spend some time getting really familiar with what's on that. People could reread or read for the first time the C manual. There's a lot of stuff on YouTube. First of all, people doing C could watch the YouTubes on job interviewing, job applications. You could just Google all that. That's really good, and there's also another one, Adapting IPS to Young People. It's done by Thresholds. If you Google and YouTube Adapting IPS to Young People, the young people have mental health challenges, not necessarily psychosis, but there's some helpful stuff in there. That's from Thresholds in Chicago who does great work. Okay, and then what can you do on your telephone calls? A couple things I can think of. One is a C specialist, maybe shorter calls, probably not 45 minutes or an hour, maybe half an hour, help people get on the schedule. People aren't going to do much job interviewing right now, but people are going back onto online school. One thing I would say is, again, go on YouTube. If you Google in taking online courses successfully, there's four or five nice brief lectures about tips for taking online courses. You could be watching them so you know how to support people who are now moving to all online courses, or you could watch them. You know, you could have your person watch them, your client, and then discuss that, but that's another tool. Okay, I am now going to stop, and I don't know what time it is, but I hope I'm not too late. Oh, two minutes. Okay, great. I think I go to the next slide. What is that, my thank you slide? Yes, this is me. Feel free to reach out to me if you have questions or concerns, and now I'm going to turn it over to Judith. Okay, thank you so much, Shirley, for the great presentation, but yes, if you have any further questions for Dr. Quinn about today's presentation, please contact her at this email address, and at this point, we're going to turn it over to questions and answers. All right, hi, I'm Kate Hardy, and thank you so much, Shirley. It was a fantastic presentation, and there was certainly some questions coming through which I've been making a note of. So one of the questions I think was somebody asking, just for a quick review, about why is it not helpful for the supportive education and employment specialist to assist in disability benefits? Can you just review that again? Yeah, the issue is, think of the person, think of the client, and think of the employment specialist. So the employment specialist's job is to help somebody get a job or go to school. That's what the C specialist's job is, and when they're sitting with someone and they're helping them fill out paperwork, which basically says, I'm incapable of working, and here's all the reasons why, and they're doing that on Monday or Tuesday with them, that when they then go back and say, okay, on Thursday or Friday, do you want to come now and help, you know, and I'll help you get a job or go to school, you can understand that's kind of mind-boggling for the client, and that's mind-boggling for the C specialist. I think with IPS, for those of you who've worked with older consumers who have been on SSI or SSDI and aren't currently applying, the C specialist can be, the IPS specialist knows how to work with that, but when people are making decisions about applying, it's very hard for the C specialist or the client to keep both parallel lines, and that, I think, is why we have the data, part of the reason we have the data showing that once people apply for benefits, they don't, the work involvement drops. Thank you, and then I think you might have touched on this with the website links you're giving, but just where to go, would you recommend getting C training for specialists into the full team and IPS training? Right, so I don't know, I mean, we offer C training with Navigate. I kind of thought maybe somebody wrote in some links there. There's a video, there's a not first episode specific, but a very nice video training, online training. If you go to the IPS Works site, they offer probably three or four times a year, it's $300, it's online, you learn how to do it with a broad category of people, and then you need to think about how you would do it in first episode, and there's some differences, but I would say IPS and C are about 70% consistent, so that's a good place to get training. I think OnTrack has training in C as well, so those are my thoughts, and maybe there's some people on this call who are offering it. Please put it in, if you are. Yes, yes, please do include in the chat, and we might be able to add some links, so some training links when we post these on the PepNet website. A couple of questions, I'm going back to the studies that you summarized. So one, I think it was the Kawaki study, you had to express an interest in workhorse school to be included in the study, and somebody wondered, was there any data on how many in the team, or how many of the clients expressed an interest in workhorse school to then be included in the study? Not that I'm aware of, they just said, I mean they, you're asking, you're asking a really good question. I think the thing is, you can't really tell that, because they're just going out there, they're not asking everybody in the clinic would be my guess. My guess is they're publicizing a study, and then people who want to be part of it do it. So we don't really know. The better, the better way to look at that is in the RAISE trial, where basically over time, two-thirds of the participants wanted, had an interest in workhorse school that they articulated. That means one-third didn't, and some of those people, it's because they were working, but there was a solid group, I bet you 20-25%, who never had an interest. Great, and then speaking of the RAISE trial, there was a question about one of the graphs that you showed, and I think you mentioned that the kind of the drop-off was attributed to the individuals getting a job, and the question was, is that the only attribution, or could it have been that the team was focusing on new enrollees and not kind of following up with people who'd been in the team for a while? Were there other reasons for the drop-off potentially? I'm not sure what you mean by drop-off. That was, I'm kind of, I have to go back somehow, and helpfully I've just lost my screen, that's not very good, but so I'm thinking about the slide, and it was after the first six months, it was like 50%, and then it dropped to people who were interested in going. Yeah, yeah, yeah, I know what you mean, the drop-off and involvement, right? Yeah, yeah, so you guys probably all know this. What happens is, there's a large group of people, once they get a job, they want to kick us to the curb, you know, and one of the biggest challenges a C-specialist has is keeping connected with people once they get a job, and so what happens is, people often fire us when they get a job, and then re-engage when they lose a job, and then so there's churn through the program, but basically what that probably means is, that that drop-off, the most participation was in the first six months, or yeah, and then it slowly dropped off. A lot of people, when they get placements, they don't want to meet with us anymore, or they're leaving the program totally. And a nice follow-on question from that, thank you, was also how often should follow-up supports occur once a person is in work or school? So that depends, if you, the IPS people try to do it a long time. We don't have data on this. I'll tell you what I recommend to people. I recommend that people, that the C-specialist stay involved with someone who's working, if they will let them, for six to nine months, and that is because oftentimes what happens is, you know, the average holding job in IPS is four months. We don't have data like that for separate psychosis yet, but people are going to move in and out of jobs, and you want to be around when they're quitting their job, if they're going to quit. So I say six to nine months. Often, and then what you can do is transfer them back to the case manager, and the case manager is monitoring their work stuff, maybe in monthly meetings. Now that six to nine months does not have to be weekly meetings. Might be weekly for a lot of contact the first month, a lot of contact, because people, you know, if they get sick, they may not know how to call in. They just never go back. You need to really help them initially, but then you can often back off to every two weeks, you know, something like that, if people seem to be making a good adjustment, and I should say it's harder with school. School, you need to keep a closer contact with, because people can get in trouble in a week. You know, they fail a test. They don't know what to do. School, you really need to meet more frequently the whole time they're with you, unless they fire you. I mean that sarcastically, you know, they say they won't be with us. Okay, and then I think maybe just what time for one more question. Do you invite families or significant others to the initial assessment to evaluate if home culture may be interfering with work or school participation? What we do is we, not to the initial assessment, we invite them to the initial orientation on C. So when we're going to say someone's come into the CSC program, and now they said they'll meet with the C specialist, we love to have the family members come in too, and there we can both ask the families a little bit about what's your job, what do you do, do you work, what's going on, and then whatever reservations they have about the person going to work. So it's kind of a twofer, and you develop a relation, you begin to develop a relationship, and hopefully you lay any fears they have. That's what we routinely do with consumer consent, of course. Okay, I guess it's time for us to go. I think so. Thank you so much. That was a lot, you guys. Look at the slides, you know, reach out if that could be helpful. Thank you all for what you do. It's not easy seeing the time of COVID-19. Take care. Stay healthy, everyone, and thank you for joining us today.

Dr. Shirley Glynn

webinar

supported employment

education outcomes

coordinating specialty care

first episode psychosis

challenges

pre-morbid history

perceived obstacles

involving families

resources