Limitations and future research
Limitations and future research
Abstract and Keywords
By improving vocational outcomes for many people, enhancing recoveries from serious mental illness, and perhaps preventing some amount of disability, Individual Placement and Support (IPS) has inspired optimism in many parts of the world. However, IPS does not benefit everyone with mental illness. This chapter enumerates several limitations of IPS and discusses potential solutions.
By improving vocational outcomes for many people, enhancing recoveries from serious mental illness, and perhaps preventing some amount of disability, IPS has inspired optimism in many parts of the world. Of course IPS does not benefit everyone with mental illness (Drake & Bond, 2008), and in this chapter we enumerate several limitations of IPS and discuss potential solutions.
Not all persons with psychiatric disabilities are motivated to pursue work (Mueser, Salyers, & Mueser, 2001; Rogers, Walsh, Masotta, & Danley, 1991). Some have adopted meaningful roles other than competitive employment, but others avoid work because they fear losing benefits (MacDonald-Wilson, Rogers, Ellison, & Lyass, 2003), lack confidence (Westermeyer & Harrow, 1987), receive little encouragement from their counselors and psychiatrists (West et al., 2005), or cannot access appropriate help (Drake & Essock, 2009; Hall, Graf, Fitzpatrick, Lane, & Birkel, 2003). Perhaps changes in societal stigma, insurance and health care regulations, and the culture of mental health care may help many people to increase their aspirations and try employment rather than accept a life of poverty and disability. As we discuss below, researchers are studying efforts to put more information and decision-making in the hands of clients.
Approximately one-third of those who enter IPS are unsuccessful in finding a competitive job (Bond, Drake, & Becker, 2008). Some of these individuals decide not to pursue work when they receive benefits counseling and understand fully the potential loss of benefits, but others encounter difficulties related to psychiatric illnesses, cognitive deficits, medical problems, inadequate services, and (p.125) other barriers (Frey et al., 2011). As described below, researchers are attempting to address these specific barriers.
Some of the people who obtain competitive employment have limited success, such as short-tenured jobs or negative job endings (Becker et al., 1998; Mueser et al., 2005). Fears of losing insurance, performance problems, episodes of illness, cognitive difficulties, and other barriers impede their efforts to work (Johannesen, McGrew, Griss, & Born, 2007). Many clients nevertheless go on to succeed in subsequent jobs, but researchers are attempting to address the specific barriers that underlie their difficulties.
Among those clients who become steady workers, few leave the disability system entirely (Becker, Whitley, Bailey, & Drake, 2007; Salyers, Becker, Drake, Torrey, & Wyzik, 2004). Their movements toward independence may be constrained by disability and insurance regulations, but many people report that working part-time is optimal for a variety of reasons (Strickler, Whitley, Becker, & Drake, 2009). Researchers are attempting to understand the types, amounts, and environments of employment that constitute optimal fits. All clients should be able to increase their incomes above poverty levels by working.
Another open question is whether IPS can be used to help other populations. Research to date has focused almost entirely on people with severe and persistent mental illnesses. But many other populations, such as people with primary substance use disorders or traumatic brain injuries, are in need of vocational services. Can IPS, perhaps with appropriate adjustments, help any of these other groups?
Finally, as a result of the well-recognized science-to-service gap in the U.S. health care system, the adoption of evidence-based supported employment across the country is progressing slowly (Institute of Medicine, 2006; NAMI, 2006; New Freedom Commission on Mental Health, 2003). The 15% employment figure for people with serious mental illness is unlikely to improve significantly until a larger portion of people have access to high-quality IPS (Drake, Skinner, Bond, & Goldman, 2009). We discuss these policy issues in Chapter 12.
The future of IPS depends, in part, on continued research. As we have emphasized throughout, the IPS model is not intended to be static. We consider several near-term possibilities next.
Client-centeredness. The crux of recovery-oriented services is client-centeredness: honoring the aspirations, goals, and journeys of people with mental illnesses (Davidson, Drake, Schmutte, Dinzeo, & Andres-Hyman, 2009; Slade, 2009). The voices of mental health system users have determined the development of IPS from the beginning, and IPS prescribes careful individualization based on informed choices by users (Swanson & Becker, 2010). As recovery enters the lay literature, (p.126) people’s recovery stories continue to emphasize the importance of mainstream employment (e.g., Carter, Golant, & Cade, 2010). By contrast, some professionals continue to emphasize that many people cannot work and need to be protected in sheltered settings (Hoffmann & Kupper, 2003; Warner & Mandiberg, 2006; Watzke, Galvao, & Brieger, 2008). These latter beliefs recapitulate arguments for long-term institutionalization in the 1970s and, like those previous positions, may diminish over time as more people are in recovery and as public attitudes change.
In the meantime, several lines of current research emphasizing mental health service users’ perspectives are emerging. Some of the most promising approaches involve empowering mental health clients to demand effective services by creating client-directed service accounts, incorporating IPS training within peer-run organizations, providing electronic decision support systems to enhance knowledge and shared decision making, and employing peers as employment specialists. A few examples illustrate the possibilities. Andrews, Drake, Haslett, and Munusamy (2010) are developing web-based applications that clients and families can use to access accurate information about IPS and other vocational services, to have greater input into planning their own vocational services, and to participate actively in documenting their needs and progress. Swarbrick and colleagues (2009) have been developing employment services that incorporate IPS training within peer-run programs. Swendsen, Ben-Zeev, and Granholm (2012) and many other investigators are developing mobile applications that can be used to enhance functioning throughout the day, including on jobs. Ongoing research in each of these areas is likely to enhance client-centeredness.
Families. For years, families have understandably advocated for long-term supports and economic security for their relatives. More recently, they have embraced the crucial role of regular employment in the recovery process and have begun advocating for employment services. Family organizations in several states are leading the advocacy for IPS programs (Swanson et al., 2011).
Research on families and employment is meager. In one study of IPS, families of Latino clients were successfully involved in making vocational decisions, illustrating adaptation of the model for cultural reasons (Alverson & Vicente, 1998). Another study of supported employment recruited families to aid in developing jobs, but family involvement did not improve vocational outcomes (McFarlane, 2002). Nevertheless, families are often involved in creating expectations, in arranging informal employment, and in making decisions regarding work and disability. More research on their involvement is clearly needed.
Workforce. Few professionals learn IPS skills in graduate school because few universities offer training in IPS. Training the existing workforce has therefore been critical for dissemination, implementation, and sustainability (Becker et al., 2011). Several states, including Kansas, Maryland, Ohio, Oregon, New York, and Vermont, have established technical assistance centers on IPS (p.127) (Rapp, Goscha, & Carlson, 2010). These centers provide various combinations of training, technical assistance, and fidelity reviews; Dartmouth backs them up with educational resources, train-the-trainer seminars, and on-line courses (Becker et al., 2011).
Beyond formal coursework, current approaches to improving IPS skills include field mentoring, outcome-based supervision, and collaborative learning groups (Becker et al., 2011). Each of these needs systematic study to determine the optimal means to achieving an effective workforce. One current research strategy is to identify what successful employment specialists do in hopes that these skills can be codified and taught to others (Glover & Frounfelker, 2011a, 2011b; Kostick, Whitley, & Bush, 2010; Taylor & Bond, submitted).
State vocational rehabilitation counselors are essential partners in the development and maintenance of IPS services. Research on the role of these counselors emphasizes the importance of a collaborative relationship with IPS employment specialists (Oulvey, Carpenter-Song, & Swanson, submitted). Working as a team, they can provide a wide range of material resources as well as practical and emotional supports. Operating principles emanating from the Rehabilitation Act and its amendments are sometimes interpreted as conflicting with IPS principles, but many Departments of Vocational Rehabilitation and individual counselors have become IPS champions, as described by Swanson and colleagues (2011).
Progress in offering recovery-oriented care generally and IPS in particular also depends on changing the attitudes and training of mental health professionals (Slade, 2009). IPS requires a team approach (Swanson & Becker, 2010), and clients often report that they went to work because their doctor told them that they could (Becker et al., 2007). In general, mental health professionals of all disciplines need to emphasize strengths, functional behaviors, and optimism (Rapp & Goscha, 2011).
Process. Within the IPS model, many clinical issues warrant further study. What are the best techniques for activating clients, for developing jobs, for supporting people in jobs, and for helping them to make transitions from one job to another? How should clients handle disclosure? How should job applicants approach the issue of involvement with the justice system? Each of these topics needs more research (Glover & Frounfelker, 2011a; Jones, 2011; Swanson, Langfitt-Reese, & Bond, in press).
One future goal for IPS is to move toward individualizing services based on specific client characteristics—what is now termed personalized medicine (Drake, Cimpean, & Torrey, 2009). For example, specific cognitive strategies might be tailored for people with problems maintaining attention, for people with residual psychotic symptoms, or for people with social anxiety. Other strategies might be optimal for people who want to pursue school before employment, for those with physical health limitations, and for those with other social problems.
(p.128) Employers. Improving employment opportunities for people with disabilities involves employers as well as employees. The optimal techniques for motivating employers to hire people with disabilities are, however, unclear. Should this be done through general antidiscrimination campaigns (Thornicroft, Brohan, Rose, Sartorius, & Leese, 2009)? Should it involve reaching out to employer organizations and having employers share their experiences with other employers? Are special tax incentives or other financial strategies effective?
One first step may be a better understanding of the perspectives of employers, a largely neglected area of research (Biggs, Hovey, Tyson, & MacDonald, 2010). For example, some large companies have a set policy of not hiring people with a justice system record (Rodriguez & Emsellem, 2011), while others are flexible in their willingness to hire people with both mental illness and a justice history, provided they are convinced that applicants can perform the work and have made amends for crimes (Swanson, Langfitt-Reese, & Bond, in press). Effective employment specialists often develop jobs by learning the needs and conditions of individual employers, one business at a time, but technology may enable greater efficiency.
Communities. How the characteristics of local communities influence employment of people with psychiatric disabilities is also poorly understood. In the absence of systematic research, expert opinion prevails but is often wrong. For example, many experts believe that jobs are harder to obtain in rural communities, but this belief has not been supported empirically (Haslett, Bond, Drake, Becker, & McHugo, 2011). Similarly, the local unemployment rate is assumed to affect IPS employment outcomes (Bond & Drake, 2008), but the size of the association is often overestimated. Other community factors, such as the diversity and flexibility of jobs, free bus service, community action programs to hire people with disabilities, and business leadership, deserve study.
Programs and Systems. At the program level, many administrative issues are pertinent: organization, financing, implementation, clinical records, fidelity, and sustainability, to name a few. One essential issue is developing strategies for integrating rehabilitation with clinical services. Research robustly supports integration (Cook et al., 2005), but the mechanisms for achieving this are unclear. Maryland developed a unique approach that involves paying providers directly for integrating mental health and rehabilitation services (Becker et al., 2007). Helping programs to achieve fidelity is another critical issue. IPS fidelity strongly predicts outcomes (Bond, Becker, & Drake, 2011), but fidelity visits by experts and related technical assistance strategies are expensive. How to monitor and enhance fidelity on a large scale is unclear. One proposed strategy is to bypass fidelity assessments for sites with exemplary employment outcomes, using benchmarks developed in a large longitudinal data base of IPS programs (Becker, Drake, & Bond, 2011).
Connecting with Mainstream Vocational Research. To some degree, vocational research on people with psychiatric disabilities has developed independently (p.129) from vocational research on the general public, often emphasizing counseling, skills training, and mental health deficits. Large issues in mainstream vocational research, such as the role of employee assistance programs, concerns regarding absenteeism and presenteeism, workplace morale, and the quality of specific jobs, have been relatively ignored in the research on psychiatric rehabilitation. Now that people with mental illnesses have established clearly that most want to work and can do so, these parallels with the mainstream workforce need to be studied.
Improving IPS. Efforts to amplify and expand IPS, both for new populations and for clients who have not succeeded IPS programs, are in progress. We first consider new populations, for whom the IPS model may need modifications.
Two recent randomized controlled trials have shown that adding supported education to IPS is effective for people experiencing a first or early episode of psychosis, because many young clients have educational goals as well as vocational goals (Killackey, Jackson, & McGorry, 2008; Nuechterlein et al., 2008). This adaptation to create IPS supported education/employment represents another example of listening carefully to mental health service users. Another recent randomized controlled trial demonstrated that IPS helped military veterans diagnosed with posttraumatic stress disorder to obtain competitive employment (Davis et al., 2012). Still another randomized controlled trial underway is designed for people who have justice system records as well as serious mental illness (Bond, work in progress). Researchers are studying IPS with other populations, including people with less severe mental disorders, primary substance use disorders, traumatic brain injuries, or spinal cord injuries.
What about the clients with serious mental illness who do not currently benefit from IPS? As we reviewed earlier, IPS employment outcomes have been robust across different subgroups of people with serious mental illness, such as those with co-occurring substance use disorders and people from minority backgrounds (Campbell, Bond, & Drake, 2011). But in most studies at least one-third of the participants do not achieve vocational success. One approach to enhance outcomes for potential nonresponders has been to supplement services for nonresponders with specific enhancements. Examples include adding motivational interviewing, social skills training, cognitive training, or other cognitive strategies to IPS. Adding motivational interviewing has thus far not enhanced success (Drebing, Rosenheck, Drake, Penk, & Rose, 2009). Similarly, adding social skills training has been tried with mixed outcomes (Mueser et al., 2005). On the other hand, a variety of approaches to enhancing cognition have shown some success (McGurk & Wykes, 2008). Cognitive enhancements typically include several components: educating employment specialists to be aware of such problems and to look for appropriate job matches, emphasizing compensatory strategies on the job, and practicing cognitive tasks to improve performance. Whether these improvements are due to attention, building (p.130) cognitive skills, or compensating for deficits remains unclear, but this is an active area of research.
Other barriers warrant similar attention. For example, the recent Mental Health Treatment Study included many clients with comorbid medical illnesses that affected employment outcomes (Frey et al., 2011). IPS specialists in this study often struggled to coordinate with medical specialists and to develop jobs for some clients with very limited mobility. Similar issues involve justice system involvement, symptoms of posttraumatic stress disorder, limited education, and so on.
The goal of continued IPS research is clear: to ensure that every client with mental illness who wants to work has access to effective services and has opportunities to work in appropriate settings at appropriate amounts. To a large extent, success will require policy changes, which we discuss next.