REHAB Bringing Research into
BRIEF Effective Focus
Vol. XIV, No. 3 (1992) ISSN: 0732-2623
NATIONAL INSTITUTE ON DISABILITY AND REHABILITATION RESEARCH
OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES
DEPARTMENT OF EDUCATION * WASHINGTON, D.C. 20202
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New Directions In Supported Employment
Supported employment (SE) was originally conceived to effect the transition
of clients with severe developmental disabilities into work. Rehab BRIEF Vol.
10, No. 1, 1987, "Supported Employment," addressed the then rather new ideas
about SE and highlighted some of the philosophies and trends of the first few
years of the concept.
Since the publication of that Rehab BRIEF, supported employment has "taken
off." According to the late Robert McDaniel, former Director of Rehabilitation
Administration Training Programs, University of San Francisco, "Quality
supported employment services are being delivered in local communities in
nearly every state ... Innovations are occurring at all levels in the
implementation of supported employment."
This Rehab BRIEF focuses on supported employment as it is now being
successfully applied to a number of new populations. It features also an
active movement toward consumer-driven supported employment.
APPLICATIONS OF SUPPORTED EMPLOYMENT TO NEW POPULATIONS
* In 1989, the Texas Commission for the Blind began to purchase SE
services for its blind and visually impaired consumers.
* The Richmond (Virginia) Vocational Training and Employment Services
is a SE program that serves adolescents and adults with a wide
variety of physical disabilities.
* Many United Cerebral Palsy chapters have supported employment
specialists who provide SE services to consumers.
* The New England Center for Autism in Southborough, Massachusetts,
carries out a SE program.
Following are descriptions of how SE is being applied to people who have
psychiatric disabilities and people who have had traumatic brain injuries.
SE and Clients With Psychiatric Disabilities
The Rehabilitation Amendments of 1986 (P.L. 99-506) specifically supported
funding and activities designed to help states provide services to people with
severe psychiatric disabilities. The supported employment option was outlined
in those amendments. As a result, people with mental illness are now being
involved in SE schemes and obtaining work experience in community settings.
In SE, the train-place model of traditional vocational rehabilitation-in
which clients in day centers and sheltered workshops were trained to "get
ready" for competitive employment before being placed but often had difficulty
transferring skills to mainstream workplaces has given way to a model that can
be characterized as place-train. In this model, the client is placed in a
competitive employment setting and then learns work skills in that setting.
Karen Danley, Director of the Supported Work Initiative, Center for
Psychiatric Rehabilitation at Boston University, has done extensive work on a
variation of this place-train model that she and her colleagues feel is even
more appropriate for people with psychiatric disabilities-the choose-get-keep
model. According to Danley and Anthony (see Sources), there should be a strong
emphasis on client involvement in decision making. This involves far more than
merely obtaining infor- mation about workers' skills and past performance;
clients' preferences and personal aspirations are vital to any decisions about
employment.
Because of the stronger emphasis on client choice in the choose-get-keep
model, the preemployment phase may be longer than in the place-train model.
Then follows the "get" phase, in which specific employers are located,
contacted, and interviewed; this phase results in the client obtaining
employment. Finally, in the "keep" phase, the client applies appropriate job
behavior skills as well as technical abilities at the level needed to do the
job.
According to Anthony and Blanche (see Sources), the new SE initiatives
reflect a new set of beliefs about the capacity of seriously disabled people
to work. SE assumes that most people can do meaningful, produc- tive work in
mainstream settings, if that is what they choose to do and if they are given
the necessary supports.
Research at the Center for Psychiatric Rehabilitation, Boston University,
indicates that the basic assumptions and philosophy of SE cut across all
disability groups; however, operational differences may be necessary when
applying them to different groups. Anthony and Blanche stress the following
points for applying SE principles to people who are psychiatrically disabled.
(Note that many of these principles are important when working with any
population.)
* People with psychiatric disabilities need to select their own jobs,
not be "matched" to jobs. SE must be done with them, not to them.
* The SE process must focus on workers' goals and interests, not merely
their skills.
* There may need to be a lengthier preemployment phase than with other
SE populations, so that consumers can be more involved in job
placement decision making.
* The range of supported work slots must include skilled jobs and
entry-level jobs with the possibility of advancement.
* Because stigma against people with mental illness is often greater
than for other disability groups, marketing and job development are
sometimes more difficult.
* Many psychiatrically disabled people prefer not to be identified as
disabled in the workplace; this may require alteration in the role of
the employment specialists.
* Many people with psychiatric disabilities learn skills quickly but may
need interventions that focus on appropriate job behaviors.
Mark Kirszner (see Sources) reports a recent study by the
Philadelphia-based Matrix Institute on employer involvement in SE for people
with long-term. mental illness. The researchers found the following:
* Most employers who have hired workers with psychiatric disabilities
found these workers had no problem in becoming integrated into the
work force.
* If forced to reduce staff, over 80 percent of employers said they
would not automatically fire a supported-employment worker.
* Eighty-four percent said they would hire another individual with
mental illness.
It is a premise of most vocational rehabilitation efforts that employment
enhances a person's self-esteem and contributes to increased quality of life.
However, most of the available SE outcome studies focus on quantitative
results, such as wages, employment tenure, and cost-benefit analysis. Under a
grant from the National Institute on Disability and Rehabilitation Research
(NIDRR), Ellen Fabian (see Sources) studied the impact of SE on
quality-of-life outcomes for individuals with severe mental illness. Quality
of life was measured by an interview instrument that assesses life experiences
across eight domains: living situation, family, social relations, leisure
activities, physical and mental health, safety, work, and finances.
Results indicate that there are some clear differences in quality of life
for individuals participating in SE compared with those not working,
especially in categories such as job satisfaction and finances. Employment
tenure was found to be associated with higher quality of life. The longer a
person stays in work, the higher the quality-of-life score. However, during
initial months of employment, people with severe mental illnesses appear to
experience a transition effect that may negatively affect all areas of their
lives. Quality-of-life scores for the group studied during the first 6 months
were even lower than for people not in work. This suggests that stress during
the transition period may for some clients seem to outweigh the benefits of
employment and potentially lead to job loss. Employment specialists may need
to - address the stresses being experienced by individuals, especially at this
stage. If a worker successfully negotiates this phase of return to work, then
improved quality of life becomes more likely.
SE and Clients With Traumatic Brain Injuries
Work by Wehman et al. (see Sources) indicates that many individuals do not
return to work after brain injuries. Of those who do, many lose their jobs or
experience difficulties on the job that are attributable to their brain injury
disabilities. As part of the recovery process, a person may want to return to
the same job held prior to the injury. If the person's new ability levels are
no longer sufficient to meet the demands of the previous job, this does not
have to preclude alternative successful employment.
Under a 1987 grant from NIDRR, supported employment programs were
established for people whose employability has been reduced by traumatic brain
injuries. The Minnesota Department of Jobs Training, Division of
Rehabilitation Services, in cooperation with the Minnesota Head Injury
Association, initiated these specialized SE programs.
The project, directed by Allan Lunz (see Sources), developed two models to
provide SE services. Both models had four characteristics common to most SE
programs: diagnostic assessment; job development, or placement; job training
(on-the-job training); and followup, or long-term support.
Fifty percent of the placements that occurred were with people who would
traditionally be considered too severe to benefit from vocational
rehabilitation services. Results of a 3-year study of the two programs
indicate that employers had to make almost no major modifications to their
work areas to accommodate employees with disabilities related to traumatic
brain injuries; accommodations made were minimal and without cost. However,
these employees (like psychiatrically disabled employees) benefited from more
intense job coaching initially than is typical with other disability groups in
SE.
An important finding of this project was that consumer satisfaction was
higher for people in SE than for those in in-house work programs. When
interviewed, the participants viewed SE as a "real job," while they viewed
in-house programs as merely rehabilitation services or training programs.
In a counselor guide developed in cooperation with an RSA demonstration
project, Best Practices for Serving Persons With Traumatic Brain Injury in the
Vocational Rehabilitation Program (see Sources), the following points are made
about supported employment with consumers who have disabilities related to
traumatic brain injuries.
* While early referral and intervention are important, referral can be
too early. Vocational rehabilitation services are likely to be
inappropriate for people not yet oriented to time and place, and if
the person has not yet developed at least superficial insight into the
disability.
* Counselors often find they need to modify their interview techniques.
It may be more effective to ask specific, rather than open-ended,
questions.
* Counselors should be aware that certain disability groups have a high
incidence of traumatic brain injury as a secondary disability (e.g.,
chemical dependency, mental illness, epilepsy, and spinal cord
injury). Brain injury also is often present in individuals with
histories of domestic abuse or involvement in criminal activities. It
is common for such consumers to be referred to vocational
rehabilitation without any identification of their previous brain
injuries.
* Medical terminology may refer to severe, moderate, or mild levels of
injury. This should not be confused with the VR concept of a severe
vocational handicap. The VR concept of severity is based on a
counselor's determination of an individual's functional capabilities.
In contrast, medical professionals measure severity of brain injury
by length of time in and depth of coma.
CONSUMER-DRIVEN
SUPPORTED EMPLOYMENT
The concept of independent living is rooted in the belief that control over
one's own life is important and that personal independence can be increased by
managing one's own affairs, participating in day-today life in the community,
and fulfilling a variety of social roles. For many people who have
disabilities, work is an important goal; but because of barriers-both physical
and attitudinal-in the workplace and in society, productive work in
competitive work environments has often been denied them.
The independent living movement and the initiative of SE have begun to join
forces. Taken together, the respective philosophies and outcomes of
independent living and SE offer opportunities for people with severe
disabilities to take on productive, paid employment and benefit from full
community integration in settings that are client-directed.
How is Consumer-Driven SE different?
According to Westbrook and Lumbley (see Sources), consumer-driven SE
emphasizes the role of the consumer-the client with a disability-in all the
phases of the SE process (assessment, plan development, job placement,
training, ongoing support, and periodic assessment). At first, the SE concept
was perceived as an antithesis to the independent living philosophy. Many who
worked for independent living feared that any kind of "supported" work scheme
would detract from true independence and from their goal of individual
empowerment. However, it has become clear that by allowing people to access
employment situations previously denied because of lack of employment or
transition skills, SE contributes to rather than detracts from independent
living goals. Also, SE provided in the context of independent living programs
allows for a more holistic approach, integrating work with other aspects of
life. Because the emphasis is on consumers' desires and goals rather than on
assessment of present skills, consumers are said to sense greater fulfillment
in work. And because consumer-driven SE works by consultation and agreement
with a rehabilitation professional rather than a more passive acceptance of a
professional's decision, it enhances autonomy and independence.
National Model for Supported Employment and Independent Living
In a 3-year effort funded by NIDRR, begun August 1988, the Southwest
Educational Development Laboratory in Austin, Texas, has been investigating
the potential for independent living centers to expand their range of
activities to include SE initiatives. They have developed the first National
Model for Supported Employment and Independent Living (NMSEIL) at the Austin
Resource Center for Independent Living. The project emphasizes independent
living activities for people who may have been relatively underserved in the
past, including people with long-term mental illness, severe mental
retardation, and sensory impairments, as well as mobility-limiting
disabilities.
Independent living programs are typically consumer-controlled and operated.
NMSEIL director John Westbrook says that allowing potential workers with
disabilities to choose and plan their own career paths-as any other service
consumers might-not only empowers employees but satisfies employers and
ensures longer lasting job placements.
As part of its training and information dissemination effort, NMSEIL has
developed three manuals for use by independent living staff involved in SE
activities:
* Supported Employment and You is designed for direct use by people with
severe disabilities who may be interested in SE. The booklet includes
information on the concept and describes the potential benefits of
employment. There is also a discussion of the special supports that
are provided in SE.
* Supported Employment and the Family covers topics such as functions
of independent living centers, explanation of SE, resources for
families, and Social Security benefits.
* Supported Employment and the Employer can be used by an independent
living center in making a presentation to an employer. It contains
information about the benefits to the workplace, potential concerns
of employers, and the perceptions of employers who have already become
involved in SE.
* Supported Employment in Your Independent Living Center is a guide
developed for use by independent living center executive directors and
members of boards of directors to facilitate organizational decisions
about providing SE services. Information about determining community
need, staff considerations, organizational placement, funding, and SE
service options is included.
According to Westbrook, "Supported employment can be bettered by
allowing those it 'serves' to be more directive of what happens." This
is the goal of the NMSEIL project.
RESOURCES
For rehabilitation professionals interested in teaming more about supported
employment, the following are useful resources:
* APSE-The Association for Persons in Supported Employment.
APSE is a national organization which represents individuals and
organizations interested in supported employment. Its membership is
now over 1,600. Its goals are to provide advocacy and information to
the recipients and implementors of SE; to address issues and barriers
that impede the growth of integrated employment services; to improve
SE practice; and to promote national, state, and local policy
development that enhances the social and economic inclusion and
empowerment of all people with severe disabilities. For information
on how to join APSE and to receive its publication, The Advance, call
or write the Association for Persons in Supported Employment, 5001
West Broad Street, Suite 34, Richmond, VA 23230, (804) 282-3655.
* InfoLINES-a publication of the Training Resource Network (TRN). TRN's
goal is to "provide consultation and training to agencies, families,
and individuals to better support persons with disabilities in valued
community roles." To receive InfoLINES, contact Training Resource
Network, 20 Beech Street, Keene, NH 03431, (602) 357-1791.
SOURCES
Anthony, W.A., & Blanch, A. (1987, October). Supported employment for
persons who are psychiatrically disabled; An historical and
conceptual perspective. Psychosocial Rehabilitation Journal,
11(2), 5-23.
Danley, K.S., & Anthony, W.A. (1987, October, November, December).
The choose-get-keep model: Serving severely psychiatrically
disabled people. American Rehabilitation, pp. 6-11.
Fabian, E. (no date). Supported employment and the quality of life:
Does a job make a difference? (Draft). Funded by grant
#133C90116 from the National Institute on Disability and
Rehabilitation Research, U.S. Department of Education.
Kirszner, M. Employer involvement in supported and transitional
employment for persons with long-term mental illness. Matrix
Research Institute, Kenilworth 106, 2979 School House Lane,
Philadelphia, PA 19144.
Lunz, A. (Project Director). Supported employment for persons with
traumatic brain injury: A three-year study of two programs,
Final Report (CFDA 84.133A. Award No. G008720133). State of Min-
nesota, Department of Jobs and Training, Division of Rehabilita-
tion Services, 390 North Robert Street, St. Paul, MN 55101.
McDaniel, R.H. Innovative approaches in supported employment.
Unpublished paper prepared for Southwest Educational Development
Laboratory, Regional Rehabilitation Exchange Conference, Dallas,
TX, February 24, 1988.
National Model for Supported Employment and Independent Living.
Annual report, August 1, 1989 through July 31, 1990. Southwest
Educational Development Laboratory, 211 East Seventh Street,
Austin, TX 78701. (Developed under a grant from the National
Institute on Disability and Rehabilitation Research, Department
of Education, Cooperative Agreement #H133D80001.
Traumatic Brain Injury Work Group. (1989, November). Best practices
for serving persons with traumatic brain injury. Division of
Rehabilitation Services, 390 N. Robert Street, St. Paul, MN
55101.
Wehman, P. et al. (1989). Employment outcomes of persons following
traumatic brain injury; Pre-injury, post-injury, and supported
employment. Brain Injury, 3(4), 397-412.
Westbrook, J.D., & Lumbley J. (no date). Consumer-driven supported
employment. National Model for Supported Employment and
Independent Living, Southwest Educational Development
Laboratory, 211 East Seventh Street, Austin, TX 78701.
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We welcome your comments on this BRIEF and on BRIEFs put out during the past
year, as well as your suggestions for topics and for improving this
publication of PSI International, Inc.
Prepared by PSI International, Inc., P.O. Box 5186, Arlington, Virginia 22205
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