Year: 2017
Type: article
Abstract: In the era of deinstitutionalization, employment was an uncommon outcome for people with schizophrenia and other severe mental illnesses living in the community.1 Mental health and vocational rehabilitation professionals initially offered little help, perhaps because they believed that people with severe mental illnesses were unable or unlikely to work competitively. Instead, professionals referred people coming out of hospitals to sheltered settings, such as day programs and sheltered workshops, where they could be monitored closely and trained to work in a slow, step-wise fashion. Even the Program for Assertive Community Treatment2—a pioneer in community integration in the 1970s and 1980s—initially endorsed sheltered work. People with psychotic and other severe mental disorders nevertheless struggled to find competitive employment, gathering to support one another in finding and keeping jobs.3 The psychiatric rehabilitation (originally psychosocial rehabilitation) movement strongly endorsed their employment goals,4 but an effective employment approach did not exist5 until supported employment for people with severe mental illnesses emerged in the 1990s.6,7 Supported employment, standardized in the Individual Placement and Support (IPS) model, involves a fundamental shift from train-and-place approaches to a place-and-train approach. In other words, IPS supported employment eschews pre-employment training and instead uses a rapid job search based on patient choice regarding jobs that match interests and skills combined with individualized job development. A multidisciplinary mental health and employment team facilitates job finding and provides ongoing supports as needed. Over the past 20 years, IPS supported employment has continued to gain empirical support; more than 2 dozen randomized controlled trials show, with moderate or large effect sizes, that most people with schizophrenia and other severe mental disorders who want to work can in fact succeed in competitive employment.8 IPS supported employment has steadily spread across the United States9 and other high-income countries.10 For many people with schizophrenia and other severe mental disorders, employment symbolizes a normal life and provides functional recovery, helping them to achieve self-esteem, gain meaningful integration in society, discard the stigmatized identity of a mental patient, and become more independent.11 Employment is now a realistic goal for the majority of people with schizophrenia and other severe disorders, not just a future goal for a small minority. Furthermore, supported employment gives psychiatry and vocational rehabilitation an effective intervention to improve functional outcomes. Progress engenders new frontiers of course, and this special section on “Employment and Schizophrenia” showcases 3 areas of current research. The first involves environmental influences on employment. As supported employment disperses across high-income countries, many of which have similar concerns regarding rising disability rolls but very different economic, workforce, and regulatory conditions, questions about these environmental factors have become salient. From a policy perspective, the concerns focus on costs of disability. Health leaders around the world are witnessing increasing rates of disablement8 and cannot continue to support the numbers of people who develop mental disorders at a young age and remain on disability pensions for decades. For people with mental disorders in the United States, federal disability programs confer a life of poverty, inactivity, and low self-esteem, along with the problematic behaviors that often accompany these traits. Policy makers and researchers hope that earlier intervention, including supported education and employment, may change the functional trajectory of people with schizophrenia and other severe mental disorders by enabling some of them to work substantially and avoid disability.12 But what are the economic, workforce, and regulatory environments that would allow these changes to occur? The first paper in this series, by Metalfe and colleagues,13 addresses this issue through a meta-analytic study of 23 randomized controlled trials of IPS supported employment around the world. This paper provides the first comprehensive analysis of environmental influences on employment and tests several hypotheses. For example, many believe that unemployment and government protections for workers strongly influence the employment of people with disabilities. But are these assumptions correct? The next 2 papers switch from environmental to clinical issues. Although a majority of participants with severe mental illnesses benefit from IPS supported employment, some participants fail to achieve steady competitive employment. Cognitive deficits, rather than psychiatric symptoms or other clinical and demographic factors, seem to be the strongest clinical predictors of a poor response to supported employment.14 Several investigators have therefore endeavored to improve employment outcomes by enhancing cognitive functioning. The studies in this section by McGurk and colleagues15 and Kern and colleagues16 examine distinctly different innovations: one uses cognitive exercises, and the second uses errorless learning. By comparing learning theory models and techniques, these studies should be of great interest to cognitive researchers and theoreticians as well as clinicians. Real-world implementations of these innovative cognitive strategies will probably be deferred, however, because clinical programs have difficulty paying for basic supported employment.17 The latest estimate of penetration indicates that only 2% of people in community mental health programs in the United States have access to evidence-based supported employment,18 largely due to the lack of a simple payment mechanism.8 Nevertheless, research on cognition likely presages future programming. The opportunity to work and become integrated in one’s community has become a social justice issue in the United States.19 Rapid increases in the use of IPS supported employment create hope for different stakeholders. People with schizophrenia want a meaningful life. Businesses strive to build a diverse workforce. Policy makers need a mechanism to relieve crowding in treatment centers and perhaps to reduce disability roles. Researchers can take advantage of the opportunity to study the economic, psychological, social, and neurocognitive effects of employment.
Source: Schizophrenia Bulletin
Author: Robert E Drake
Language: English
Subfield: Safety Research
Field: Social Sciences
Domain: Social Sciences
Open Access status: bronze
OpenAlex ID: W2775725562