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Running Head: SUPPORTED EMPLOYMENT 1/19/2016 11:03 AM

This paper describes the psychosocial effects of a program of supported
employment (SE) for persons with severe mental illness. The SE program involves
extended individualized supported employment for clients through a Mobile Job
Support Worker (MJSW) who maintains contact with the client after job placement
and supports the client in a variety of ways. A 50% simple random sample was taken
of all persons who entered the Thresholds Agency between 3/1/93 and 2/28/95
and who met study criteria. The resulting 484 cases were randomly assigned to either
the SE condition (treatment group) or the usual protocol (control group) which
consisted of life skills training and employment in an in-house sheltered workshop
setting. All participants were measured at intake and at 3 months after beginning

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employment, on two measures of psychological functioning (the BPRS and GAS)
and two measures of self esteem (RSE and ESE). Significant treatment effects were
found on all four measures, but they were in the opposite direction from what was
hypothesized. Instead of functioning better and having more self esteem, persons in
SE had lower functioning levels and lower self esteem. The most likely explanation is
that people who work in low-paying service jobs in real world settings generally do
not like them and experience significant job stress, whether they have severe mental
illness or not. The implications for theory in psychosocial rehabilitation are
considered.

Over the past quarter century a shift has occurred from traditional institution-based 1/19/2016 11:03 AM
models of care for persons with severe mental illness (SMI) to more individualized
community-based treatments. Along with this, there has been a significant shift in
thought about the potential for persons with SMI to be "rehabilitated" toward
lifestyles that more closely approximate those of persons without such illness. A
central issue is the ability of a person to hold a regular full-time job for a sustained
period of time. There have been several attempts to develop novel and radical
models for program interventions designed to assist persons with SMI to sustain
full-time employment while living in the community. The most promising of these
have emerged from the tradition of psychiatric rehabilitation with its emphases on
individual consumer goal setting, skills training, job preparation and employment
support (Cook, Jonikas and Solomon, 1992). These are relatively new and field
evaluations are rare or have only recently been initiated (Cook and Razzano, 1992;
Cook, 1992). Most of the early attempts to evaluate such programs have naturally
focused almost exclusively on employment outcomes. However, theory suggests that
sustained employment and living in the community may have important therapeutic
benefits in addition to the obvious economic ones. To date, there have been no
formal studies of the effects of psychiatric rehabilitation programs on key illness-
related outcomes. To address this issue, this study seeks to examine the effects of a
new program of supported employment on psychosocial outcomes for persons with
SMI.

Over the past several decades, the theory of vocational rehabilitation has experienced
two major stages of evolution. Original models of vocational rehabilitation were
based on the idea of sheltered workshop employment. Clients were paid a piece rate
and worked only with other individuals who were disabled. Sheltered workshops
tended to be "end points" for persons with severe and profound mental retardation
since few ever moved from sheltered to competitive employment (Woest, Klein &
Atkins, 1986). Controlled studies of sheltered workshop performance of persons
with mental illness suggested only minimal success (Griffiths, 1974) and other
research indicated that persons with mental illness earned lower wages, presented
more behavior problems, and showed poorer workshop attendance than workers
with other disabilities (Whitehead, 1977; Ciardiello, 1981).

In the 1980s, a new model of services called Supported Employment (SE) was

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proposed as less expensive and more normalizing for persons undergoing
rehabilitation (Wehman, 1985). The SE model emphasizes first locating a job in an
integrated setting for minimum wage or above, and then placing the person on the
job and providing the training and support services needed to remain employed
(Wehman, 1985). Services such as individualized job development, one-on-one job
coaching, advocacy with co-workers and employers, and "fading" support were
found to be effective in maintaining employment for individuals with severe and
profound mental retardation (Revell, Wehman & Arnold, 1984). The idea that this
model could be generalized to persons with all types of severe disabilities, including
severe mental illness, became commonly accepted (Chadsey-Rusch & Rusch, 1986).

One of the more notable SE programs was developed at Thresholds, the site for the
present study, which created a new staff position called the mobile job support
worker (MJSW) and removed the common six month time limit for many
placements. MJSWs provide ongoing, mobile support and intervention at or near the
work site, even for jobs with high degrees of independence (Cook & Hoffschmidt,
1993). Time limits for many placements were removed so that clients could stay on
as permanent employees if they and their employers wished. The suspension of time
limits on job placements, along with MJSW support, became the basis of SE services
delivered at Thresholds.

There are two key psychosocial outcome constructs of interest in this study. The first
is the overall psychological functioning of the person with SMI. This would include the
specification of severity of cognitive and affective symptomotology as well as the
overall level of psychological functioning. The second is the level of self-reported self
esteem of the person. This was measured both generally and with specific reference to
employment.

The key hypothesis of this study is:

HO: A program of supported employment will result in either no change
or negative effects on psychological functioning and self esteem.

which will be tested against the alternative:

HA: A program of supported employment will lead to positive effects on
psychological functioning and self esteem.

The population of interest for this study is all adults with SMI residing in the U.S. in 1/19/2016 11:03 AM
the early 1990s. The population that is accessible to this study consists of all persons
who were clients of the Thresholds Agency in Chicago, Illinois between the dates of
March 1, 1993 and February 28, 1995 who met the following criteria: 1) a history of
severe mental illness (e.g., either schizophrenia, severe depression or manic-
depression); 2) a willingness to achieve paid employment; 3) their primary diagnosis
must not include chronic alcoholism or hard drug use; and 4) they must be 18 years
of age or older. The sampling frame was obtained from records of the agency.

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Because of the large number of clients who pass through the agency each year (e.g.,
approximately 500 who meet the criteria) a simple random sample of 50% was
chosen for inclusion in the study. This resulted in a sample size of 484 persons over
the two-year course of the study.

On average, study participants were 30 years old and high school graduates (average
education level = 13 years). The majority of participants (70%) were male. Most had
never married (85%), few (2%) were currently married, and the remainder had been
formerly married (13%). Just over half (51%) are African American, with the
remainder Caucasian (43%) or other minority groups (6%). In terms of illness
history, the members in the sample averaged 4 prior psychiatric hospitalizations and
spent a lifetime average of 9 months as patients in psychiatric hospitals. The primary
diagnoses were schizophrenia (42%) and severe chronic depression (37%).
Participants had spent an average of almost two and one-half years (29 months) at
the longest job they ever held.

While the study sample cannot be considered representative of the original
population of interest, generalizability was not a primary goal -- the major purpose of
this study was to determine whether a specific SE program could work in an
accessible context. Any effects of SE evident in this study can be generalized to
urban psychiatric agencies that are similar to Thresholds, have a similar clientele, and
implement a similar program.

All but one of the measures used in this study are well-known instruments in the 1/19/2016 11:03 AM
research literature on psychosocial functioning. All of the instruments were
administered as part of a structured interview that an evaluation social worker had
with study participants at regular intervals.

Two measures of psychological functioning were used. The Brief Psychiatric Rating
Scale (BPRS)(Overall and Gorham, 1962) is an 18-item scale that measures perceived
severity of symptoms ranging from "somatic concern" and "anxiety" to "depressive
mood" and "disorientation." Ratings are given on a 0-to-6 Likert-type response scale
where 0="not present" and 6="extremely severe" and the scale score is simply the
sum of the 18 items. The Global Assessment Scale (GAS)(Endicott et al, 1976) is a
single 1-to-100 rating on a scale where each ten-point increment has a detailed
description of functioning (higher scores indicate better functioning). For instance,
one would give a rating between 91-100 if the person showed "no symptoms,
superior functioning..." and a value between 1-10 if the person "needs constant
supervision..."

Two measures of self esteem were used. The first is the Rosenberg Self Esteem
(RSE) Scale (Rosenberg, 1965), a 10-item scale rated on a 6-point response format
where 1="strongly disagree" and 6="strongly agree" and there is no neutral point.
The total score is simply the sum across the ten items, with five of the items being
reversals. The second measure was developed explicitly for this study and was
designed to measure the Employment Self Esteem (ESE) of a person with SMI. This
is a 10-item scale that uses a 4-point response format where 1="strongly disagree"
and 4="strongly agree" and there is no neutral point. The final ten items were
selected from a pool of 97 original candidate items, based upon high item-total score

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correlations and a judgment of face validity by a panel of three psychologists. This
instrument was deliberately kept simple -- a shorter response scale and no reversal
items -- because of the difficulties associated with measuring a population with SMI.
The entire instrument is provided in Appendix A.

All four of the measures evidenced strong reliability and validity. Internal consistency
reliability estimates using Cronbach's alpha ranged from .76 for ESE to .88 for SE.
Test-retest reliabilities were nearly as high, ranging from .72 for ESE to .83 for the
BPRS. Convergent validity was evidenced by the correlations within construct. For
the two psychological functioning scales the correlation was .68 while for the self
esteem measures it was somewhat lower at .57. Discriminant validity was examined
by looking at the cross-construct correlations which ranged from .18 (BPRS-ESE) to
.41 (GAS-SE).

A pretest-posttest two-group randomized experimental design was used in this study. 1/19/2016 11:03 AM
In notational form, the design can be depicted as:

ROXO

ROO

where:

R = the groups were randomly assigned

O = the four measures (i.e., BPRS, GAS, RSE, and ESE)

X = supported employment

The comparison group received the standard Thresholds protocol which emphasized
in-house training in life skills and employment in an in-house sheltered workshop.
All participants were measured at intake (pretest) and at three months after intake
(posttest).

This type of randomized experimental design is generally strong in internal validity. It
rules out threats of history, maturation, testing, instrumentation, mortality and
selection interactions. Its primary weaknesses are in the potential for treatment-
related mortality (i.e., a type of selection-mortality) and for problems that result from
the reactions of participants and administrators to knowledge of the varying
experimental conditions. In this study, the drop-out rate was 4% (N=9) for the
control group and 5% (N=13) in the treatment group. Because these rates are low
and are approximately equal in each group, it is not plausible that there is differential
mortality. There is a possibility that there were some deleterious effects due to
participant knowledge of the other group's existence (e.g., compensatory rivalry,
resentful demoralization). Staff were debriefed at several points throughout the study
and were explicitly asked about such issues. There were no reports of any apparent
negative feelings from the participants in this regard. Nor is it plausible that staff
might have equalized conditions between the two groups. Staff were given extensive
training and were monitored throughout the course of the study. Overall, this study
can be considered strong with respect to internal validity.

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Between 3/1/93 and 2/28/95 each person admitted to Thresholds who met the 1/19/2016 11:03 AM
study inclusion criteria was immediately assigned a random number that gave them a
50/50 chance of being selected into the study sample. For those selected, the
purpose of the study was explained, including the nature of the two treatments, and
the need for and use of random assignment. Participants were assured confidentiality
and were given an opportunity to decline to participate in the study. Only 7 people
(out of 491) refused to participate. At intake, each selected sample member was
assigned a random number giving them a 50/50 chance of being assigned to either
the Supported Employment condition or the standard in-agency sheltered workshop.
In addition, all study participants were given the four measures at intake.

All participants spent the initial two weeks in the program in training and orientation.
This consisted of life skill training (e.g., handling money, getting around, cooking and
nutrition) and job preparation (employee roles, coping strategies). At the end of that
period, each participant was assigned to a job site -- at the agency sheltered
workshop for those in the control condition, and to an outside employer if in the
Supported Employment group. Control participants were expected to work full-time
at the sheltered workshop for a three-month period, at which point they were
posttested and given an opportunity to obtain outside employment (either Supported
Employment or not). The Supported Employment participants were each assigned a
case worker -- called a Mobile Job Support Worker (MJSW) -- who met with the
person at the job site two times per week for an hour each time. The MJSW could
provide any support or assistance deemed necessary to help the person cope with
job stress, including counseling or working beside the person for short periods of
time. In addition, the MJSW was always accessible by cellular telephone, and could
be called by the participant or the employer at any time. At the end of three months,
each participant was post-tested and given the option of staying with their current
job (with or without Supported Employment) or moving to the sheltered workshop.

There were 484 participants in the final sample for this study, 242 in each treatment.
There were 9 drop-outs from the control group and 13 from the treatment group,
leaving a total of 233 and 229 in each group respectively from whom both pretest
and posttest were obtained. Due to unexpected difficulties in coping with job stress,
19 Supported Employment participants had to be transferred into the sheltered
workshop prior to the posttest. In all 19 cases, no one was transferred prior to week
6 of employment, and 15 were transferred after week 8. In all analyses, these cases
were included with the Supported Employment group (intent-to-treat analysis)
yielding treatment effect estimates that are likely to be conservative.

The major results for the four outcome measures are shown in Figure 1.

_______________________________________

Insert Figure 1 about here

_______________________________________

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It is immediately apparent that in all four cases the null hypothesis has to be accepted
-- contrary to expectations, Supported Employment cases did significantly worse on
all four outcomes than did control participants.

The mean gains, standard deviations, sample sizes and t-values (t-test for differences
in average gain) are shown for the four outcome measures in Table 1.

_______________________________________

Insert Table 1 about here

_______________________________________

The results in the table confirm the impressions in the figures. Note that all t-values
are negative except for the BPRS where high scores indicate greater severity of
illness. For all four outcomes, the t-values were statistically significant (p<.05).

The results of this study were clearly contrary to initial expectations. The alternative 1/19/2016 11:03 AM
hypothesis suggested that SE participants would show improved psychological
functioning and self esteem after three months of employment. Exactly the reverse
happened -- SE participants showed significantly worse psychological functioning
and self esteem.

There are two major possible explanations for this outcome pattern. First, it seems
reasonable that there might be a delayed positive or "boomerang" effect of
employment outside of a sheltered setting. SE cases may have to go through an initial
difficult period of adjustment (longer than three months) before positive effects
become apparent. This "you have to get worse before you get better" theory is
commonly held in other treatment-contexts like drug addiction and alcoholism. But a
second explanation seems more plausible -- that people working full-time jobs in
real-world settings are almost certainly going to be under greater stress and
experience more negative outcomes than those who work in the relatively safe
confines of an in-agency sheltered workshop. Put more succinctly, the lesson here
might very well be that work is hard. Sheltered workshops are generally very
nurturing work environments where virtually all employees share similar illness
histories and where expectations about productivity are relatively low. In contrast,
getting a job at a local hamburger shop or as a shipping clerk puts the person in
contact with co-workers who may not be sympathetic to their histories or forgiving
with respect to low productivity. This second explanation seems even more plausible
in the wake of informal debriefing sessions held as focus groups with the staff and
selected research participants. It was clear in the discussion that SE persons
experienced significantly higher job stress levels and more negative consequences.
However, most of them also felt that the experience was a good one overall and that
even their "normal" co-workers "hated their jobs" most of the time.

One lesson we might take from this study is that much of our contemporary theory
in psychiatric rehabilitation is naive at best and, in some cases, may be seriously
misleading. Theory led us to believe that outside work was a "good" thing that would
naturally lead to "good" outcomes like increased psychological functioning and self

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esteem. But for most people (SMI or not) work is at best tolerable, especially for the
types of low-paying service jobs available to study participants. While people with
SMI may not function as well or have high self esteem, we should balance this with
the desire they may have to "be like other people" including struggling with the
vagaries of life and work that others struggle with.

Future research in this are needs to address the theoretical assumptions about
employment outcomes for persons with SMI. It is especially important that attempts
to replicate this study also try to measure how SE participants feel about the decision
to work, even if traditional outcome indicators suffer. It may very well be that
negative outcomes on traditional indicators can be associated with a "positive"
impact for the participants and for the society as a whole.

Chadsey-Rusch, J. and Rusch, F.R. (1986). The ecology of the workplace. In J. 1/19/2016 11:03 AM
Chadsey-Rusch, C. Haney-Maxwell, L. A. Phelps and F. R. Rusch (Eds.), School-
to-Work Transition Issues and Models. (pp. 59-94), Champaign IL: Transition
Institute at Illinois.

Ciardiello, J.A. (1981). Job placement success of schizophrenic clients in sheltered
workshop programs. Vocational Evaluation and Work Adjustment Bulletin, 14,
125-128, 140.

Cook, J.A. (1992). Job ending among youth and adults with severe mental illness.
Journal of Mental Health Administration, 19(2), 158-169.

Cook, J.A. & Hoffschmidt, S. (1993). Psychosocial rehabilitation programming: A
comprehensive model for the 1990's. In R.W. Flexer and P. Solomon (Eds.), Social
and Community Support for People with Severe Mental Disabilities: Service
Integration in Rehabilitation and Mental Health. Andover, MA: Andover Publishing.

Cook, J.A., Jonikas, J., & Solomon, M. (1992). Models of vocational rehabilitation for
youth and adults with severe mental illness. American Rehabilitation, 18, 3, 6-32.

Cook, J.A. & Razzano, L. (1992). Natural vocational supports for persons with severe
mental illness: Thresholds Supported Competitive Employment Program, in L. Stein
(ed.), New Directions for Mental Health Services, San Francisco: Jossey-Bass, 56,
23-41.

Endicott, J.R., Spitzer, J.L. Fleiss, J.L. and Cohen, J. (1976). The Global Assessment
Scale: A procedure for measuring overall severity of psychiatric disturbance. Archives
of General Psychiatry, 33, 766-771.

Griffiths, R.D. (1974). Rehabilitation of chronic psychotic patients. Psychological
Medicine, 4, 316-325.

Overall, J. E. and Gorham, D. R. (1962). The Brief Psychiatric Rating Scale.
Psychological Reports, 10, 799-812.

Rosenberg, M. (1965). Society and Adolescent Self Image. Princeton, NJ, Princeton

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University Press.

Wehman, P. (1985). Supported competitive employment for persons with severe
disabilities. In P. McCarthy, J. Everson, S. Monn & M. Barcus (Eds.), School-to-Work
Transition for Youth with Severe Disabilities, (pp. 167-182), Richmond VA: Virginia
Commonwealth University.

Whitehead, C.W. (1977). Sheltered Workshop Study: A Nationwide Report on
Sheltered Workshops and their Employment of Handicapped Individuals. (Workshop
Survey, Volume 1), U.S. Department of Labor Service Publication. Washington, DC:
U.S. Government Printing Office.

Woest, J., Klein, M. and Atkins, B.J. (1986). An overview of supported employment
strategies. Journal of Rehabilitation Administration, 10(4), 130-135.

Table 1. Means, standard deviations and Ns for the pretest, posttest and gain scores
for the four outcome variables and t-test for difference between average gains.

BPRS Mean Pretest Posttest Gain
Treatment sd 3.2 5.1 1.9
N 2.4 2.7 2.55
Control Mean 229 229 229
sd 3.4 3.0 -0.4
t= N 2.3 2.5 2.4
GAS 9.979625 233 233 233
Treatment p<.05
Mean Posttest Gain
Control sd Pretest 43 -16
N 59 24.3 24.75
t= Mean 25.2 229 229
RSE sd 229 63 2
Treatment N 61 22.1 24.4
-7.87075 26.7 233 233
Control 233
Mean p<.05 Posttest Gain
t= sd 31 -11
ESE N Pretest 26.5 26.8
Mean 42 229 229
sd 27.1 43 2
N 229 25.9 27.05
-5.1889 41 233 233
28.2
233 Posttest Gain
p<.05

Pretest

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Treatment Mean 27 16 -11
Control sd 19.3 21.2 20.25
t= N 229 229 229
Mean 25 24 -1
sd 18.6 20.3 19.45
N 233 233 233
-5.41191 p<.05

Figure 1. Pretest and posttest means for treatment (SE) and control groups for the
four outcome measures.

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Please rate how strongly you agree or disagree with each of the following statements.

Strongly Disagree Somewhat Disagree Somewhat Agree 1. I feel good about my work on the
Strongly Agree job.

Strongly Disagree Somewhat Disagree Somewhat Agree 2. On the whole, I get along well
Strongly Agree with others at work.

Strongly Disagree Somewhat Disagree Somewhat Agree 3. I am proud of my ability to cope
Strongly Agree with difficulties at work.

Strongly Disagree Somewhat Disagree Somewhat Agree 4. When I feel uncomfortable at
Strongly Agree work, I know how to handle it.

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Strongly Disagree Somewhat Disagree Somewhat Agree 5. I can tell that other people at
Strongly Agree work are glad to have me there.

Strongly Disagree Somewhat Disagree Somewhat Agree 6. I know I'll be able to cope with
Strongly Agree work for as long as I want.

Strongly Disagree Somewhat Disagree Somewhat Agree 7. I am proud of my relationship
Strongly Agree with my supervisor at work.

Strongly Disagree Somewhat Disagree Somewhat Agree 8. I am confident that I can handle
Strongly Agree my job without constant assistance.

Strongly Disagree Somewhat Disagree Somewhat Agree 9. I feel like I make a useful
Strongly Agree contribution at work.

Strongly Disagree Somewhat Disagree Somewhat Agree 10. I can tell that my co-workers
Strongly Agree respect me.

Copyright �2006, William M.K. Trochim, All Rights Reserved
Purchase a printed copy of the Research Methods Knowledge Base
Last Revised: 10/20/2006

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