Predictors of on-site vocational support for people with schizophrenia in supported employment

Contents and Intensity of Services in Low- and High-Fidelity Programs for Supported Employment: Results of a Longitudinal Survey

OBJECTIVE

Little is known about the association between service intensity and fidelity scale score in supported employment programs. This study compares service contents and intensity in low- and high-fidelity programs and examines the validity of the Japanese version of the individualized Supported Employment Fidelity Scale.

METHODS

The vocational outcomes and service provision data for 51 individuals with schizophrenia in 13 supported employment programs were collected over a 12-month study period. Outcomes, service contents, and service intensity were compared between the low-fidelity group (seven programs; N=29) and the high-fidelity group (six programs; N=22).

RESULTS

In both groups, 70% of the total services (hours) were provided in the first 6 months. The high-fidelity group, which was associated with better vocational outcomes than the low-fidelity group (employment rate, 68% versus 38%, respectively), made the greatest effort in job development outside of the agency, whereas the low-fidelity group spent more time on group services. In addition, before the client obtained a job, high-fidelity programs provided outreach services (B=7.2, p=0.043) and agency-based individual services (B=5.7, p<0.001) at greater intensity than did low-fidelity programs. However, no significant between-group difference was found in service intensity once clients were employed.

CONCLUSIONS

Supported employment programs with a high fidelity score focus more intensely on providing individual services in and outside of the agency, particularly before clients obtain a job. However, clarification of the relationships among service quality at the structure level, amount of follow-up services, and individual needs in supported employment programs is a future issue.

Client, Contextual and Program Elements Influencing Supported Employment: A Literature Review

Supported employment is an evidence-based practice with a well-established research base. Most studies track such outcomes as employment rates, time to employment and wages earned. Few studies address client and contextual factors that impact outcomes or consider program elements beyond those that comprise the individual placement and support model. This paper reviews existing literature to shed light on the following questions: (1) What impact do labour market trends have on the effectiveness of SE? (2) How lasting are the effects of SE and what factors influence longevity of SE effects? (3) What levels and types of employment are targeted by SE? (4) What are the characteristics of people who benefit from SE? (5) What is the role of peer support in SE? and (6) What are the barriers to effective SE implementation? Research findings are synthesized and suggestions for service enhancements are offered so that the model can continue to evolve.

Imagining the future: degraded representations of future rewards and events in schizophrenia

Over the course of life, most people work toward temporally distant rewards such as university degrees or work-related promotions. In contrast, many people with schizophrenia show deficits in behavior oriented toward long-term rewards, although they function adequately when rewards are more immediately present. Moreover, when asked about possible future events, individuals with schizophrenia show foreshortened future time perspectives relative to healthy individuals. Here, we take the view that these deficits are related and can be explained by cognitive deficits. We compared the performance of participants with schizophrenia (n = 39) and healthy participants (n = 25) on tasks measuring reward discounting and future event representations. Consistent with previous research, we found that relative to healthy participants, those with schizophrenia discounted the value of future rewards more steeply. Furthermore, when asked about future events, their responses were biased toward events in the near future, relative to healthy participants' responses. Although discounting and future representations were unrelated in healthy participants, we found significant correlations across the tasks among participants with schizophrenia, as well as correlations with cognitive variables and symptoms. Further analysis showed that statistically controlling working memory eliminated group differences in task performance. Together these results suggest that the motivational deficits characteristic of schizophrenia relate to cognitive deficits affecting the ability to represent and/or evaluate distant outcomes, a finding with important implications for promoting recovery from schizophrenia.

Impact of follow-along support on job tenure in the individual placement and support model

Individual Placement and Support (IPS) effectively helps clients with severe mental illness to obtain competitive jobs. However, one IPS model component, ongoing support for clients who obtain employment, has not been empirically validated. We hypothesized that frequency of employment specialist contact would be associated with job tenure. IPS employment specialists provided monthly data on 142 clients who had obtained employment, recording client contacts and competitive employment outcomes over a 2-year follow-up. Prototypically, employment specialists made weekly contact immediately after a job start, within a few months reduced this to monthly, and maintained this frequency thereafter. Frequency of contact was positively correlated with months of work during follow-up (r = 0.27). IPS typically provides support for 1 year or more after clients begin the job. Ongoing IPS support from employment specialists promotes continued employment. Future research should identify characteristics of effective employment specialist interventions and examine other sources of support.

Predictors of competitive employment among patients with schizophrenia

PURPOSE OF REVIEW

Recently published studies examining predictors of competitive employment for patients with schizophrenia are reviewed.

RECENT FINDINGS

Researchers continue to examine predictors of employment among three types of variables: patient characteristics, environmental factors, and interventions. Provision of supported employment is the strongest predictor of competitive employment in this population, while patient predictors continue to show modest associations with outcomes. Environmental factors, including societal and cultural influence, local economy, labor laws, disability policies, and governmental regulations, are presumed to have major influences on employment, but these factors have been little studied.

SUMMARY

Given the strong and consistent evidence base for the effectiveness of supported employment in helping individuals with schizophrenia achieve competitive employment, mental health planners should make access to this practice a high priority. Barriers to implementation of supported employment, including finance, organization, integration, training, and supervision, need to be systematically addressed. The field currently lacks an adequate understanding of the role of societal, cultural, and regulatory factors in facilitating and hindering employment outcomes; such research is much needed.