Rehab Rounds: Supplementing Supported Employment With Workplace Skills Training

Abstract

Introduction by the column editors: Supported employment, as designed for persons with serious and persistent mental illness, has been termed individual placement and support. In two randomized controlled trials (1,2), clients who received individual placement and support services were more likely to obtain at least one job in the competitive sector, to work more hours, and to have a higher total income than their counterparts who received more traditional types of vocational rehabilitation. However, individual placement and support did not improve the length of time the employed participants kept their jobs. An adjunctive or additional element of individual placement and support, aimed at improving the job tenure of individuals with mental illness, would be a constructive contribution to the vocational rehabilitation for this population. In a previous Rehab Rounds column, Wallace and colleagues (3) described the development of the workplace fundamental skills module, a highly structured and user-friendly curriculum designed to teach workers with mental illness the social and workplace skills needed to keep their jobs. The workplace fundamental skills module supplements individual placement and support by conveying specific skills that enable workers to learn the requirements of their jobs, anticipate the stressors associated with their jobs, and cope with stressors by using a problem-solving process. The earlier report described the production and validation of the module's content. The purpose of this month's column is to present the preliminary results of a randomized comparison of the module's effects on job retention, symptoms, and community functioning when coupled with individual placement and support. To enable wide generalization of the findings of the study, the program was conducted in a typical community mental health center.

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PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ May 2004 Vol. 55 No. 5
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Introduction by the column editors:
Supported employment, as de-
signed for persons with serious
and persistent mental illness, has
been termed individual placement
and support. In two randomized
controlled trials (1,2), clients who
received individual placement and
support services were more likely
to obtain at least one job in the
competitive sector, to work more
hours, and to have a higher total
income than their counterparts
who received more traditional
types of vocational rehabilitation.
However, individual placement
and support did not improve the
length of time the employed par-
ticipants kept their jobs.
An adjunctive or additional ele-
ment of individual placement and
support, aimed at improving the
job tenure of individuals with
mental illness, would be a con-
structive contribution to the voca-
tional rehabilitation for this pop-
ulation. In a previous Rehab
Rounds column, Wallace and col-
leagues (3) described the devel-
opment of the workplace funda-
mental skills module, a highly
structured and user-friendly cur-
riculum designed to teach work-
ers with mental illness the social
and workplace skills needed to
keep their jobs. The workplace
fundamental skills module sup-
plements individual placement
and support by conveying specific
skills that enable workers to learn
the requirements of their jobs,
anticipate the stressors associated
with their jobs, and cope with
stressors by using a problem-solv-
ing process. The earlier report
described the production and val-
idation of the module’s content.
The purpose of this month’s col-
umn is to present the preliminary
results of a randomized compari-
son of the module’s effects on job
retention, symptoms, and com-
munity functioning when coupled
with individual placement and
support. To enable wide general-
ization of the findings of the
study, the program was conduct-
ed in a typical community mental
health center.
L
ike all the skills training modules
produced in the social and inde-
pendent living skills series of the Uni-
versity of California, Los Angeles (4),
the workplace fundamental skills
module is a self-contained curriculum
that teaches participants the skills of a
major domain of functioning, in this
case the workplace skills depicted in
Table 1. It should be emphasized that
the module is not focused on helping
participants find a job. It does not
teach skills such as obtaining job
leads, producing a résumé, and par-
ticipating in a job interview. These
skills are covered in supported em-
ployment or other job-finding servic-
es; the workplace fundamental skills
module complements these services
but does not supplant them.
Operation of the module
As with all the modules, each skill in
the workplace fundamental skills
module is taught with use of seven
“learning activities,” administered in
the following sequence: introduction,
videotaped demonstration, role-play
practice, generation and evaluation of
solutions to resource management
problems, generation and evaluation
of solutions to outcome problems,
completion of in vivo assignments,
and completion of homework assign-
ments. The sequence has participants
acquire and practice the behaviors,
overcome the obstacles that could
prevent them from performing the
skill, and then practice the skill out-
side the training environment.
To ensure that the training is faith-
fully conducted across settings, staff,
and participants, each module is pro-
duced and distributed with three
highly structured components: a
videotape, a trainer’s manual, and a
participant’s workbook. The video-
tape provides clear, graphic, and an-
notated peer modeling of the behav-
iors to be acquired. The trainer’s
manual specifies the lesson plans that
are used to implement and evaluate
each session. The workbook—“Job
Organizing Book,” or JOB—consists
of work sheets and checklists that in-
volve participants in an active learn-
ing process that highlights the “fit”
between the person’s characteristics
and the job’s demands. This process
enables the clinician and the partici-
pant to engage in problem solving by
learning requisite skills for meeting
the expectations of the job or making
needed accommodations to improve
Supplementing Supported Employment
With Workplace Skills Training
CChhaarrlleess JJ.. WWaallllaaccee,, PPhh..DD..
RRoobbeerrtt TTaauubbeerr,, MM..AA..
Dr. Wallace is adjunct professor of med-
ical psychology and Mr. Tauber is re-
search associate in the department of
psychiatry of the University of Califor-
nia, Los Angeles, Neuropsychiatric In-
stitute. Send correspondence to Dr. Wal-
lace at Psychiatric Rehabilitation Con-
sultants, Box 2867, Camarillo, Califor-
nia 93012 (e-mail, cwall886@concentric.
net). Alex Kopelowicz, M.D., and Robert
Paul Liberman, M.D., are editors of this
column.
RReehhaabb RRoouunnddss

the individual’s functioning and satis-
faction at work. The completed JOB
constitutes an individualized action
plan that can be reviewed and revised
by the participant and his or her sup-
port staff at any time.
Because the workplace fundamen-
tal skills module is focused on the
skills needed to keep a job, it is par-
ticularly relevant for people who are
engaged in a job search or those who
have just been hired. However, if a
participant is ambivalent about ob-
taining a job, participation in the
module may serve as a preview of the
requirements, expectations, and re-
wards that might be encountered in a
workplace. Thus a positive learning
experience with the module can de-
sensitize individuals who have appre-
hension or concerns about the conse-
quences of working, thereby promot-
ing readiness for rehabilitation. Even
if a participant has been employed for
some time, and there is no evidence
of pending difficulties or termination,
participation in the module can rein-
force and illuminate the skills cur-
rently being used in the workplace.
Evaluation
An evaluation of the workplace fun-
damental skills module was conduct-
ed in collaboration with the Santa
Barbara County Department of Alco-
hol, Drug, and Mental Health Ser-
vices. The aim was to determine
whether the module helped workers
keep their jobs by comparing the out-
comes achieved by workers who were
exposed to both individual placement
and support and the workplace fun-
damental skills module with those of
workers who engaged in individual
placement and support services only.
The selection of participants began
by the project staff’s meeting with
the county’s case management teams
and asking them to review their ros-
ters of clients to identify eligible par-
ticipants. Those who were eligible
had a diagnosis of a schizophrenia-
spectrum or mood disorder on the
basis of DSM-IV criteria, were con-
sidered occupationally disabled, had
a disabling disorder of at least two
years’ duration, did not have a pri-
mary diagnosis of substance abuse,
had no inpatient treatment during
the previous three months, were
aged 18 to 70 years, expressed an in-
terest in obtaining competitive em-
ployment within six weeks of enroll-
ment in the study, and had at least
two unsuccessful job experiences
with terminations in the previous
three years. The eligibility criteria
were crafted to recruit persons
whose background characteristics
and problematic work histories sug-
gested that they might benefit from
the workplace fundamental skills
module.
Once prospective participants
were identified, a project staff mem-
ber joined the next regularly sched-
uled meeting of the individual with
his or her case manager to explain the
project in detail and to answer any
questions asked by the potential par-
ticipant. If the person agreed to par-
ticipate, he or she signed an in-
formed consent form, and an ap-
pointment was scheduled for admin-
istration of the baseline assessments.
Forty-two individuals participated
in the study, 50 percent of whom
were men. Fifty-four percent had
schizophrenia, 43 percent had bipo-
lar disorder, and 3 percent had an-
other psychotic disorder. Sixty-two
percent had never been married, 1
percent were married, and 28 per-
cent were divorced. The participants’
average education level was 13.9
years. The participants were random-
ly assigned to receive either individ-
ual placement and support only or in-
dividual placement and support plus
the workplace fundamental skills
module. An employment specialist
who worked half-time and whose
task was to conduct assessments and
match participants with appropriate
jobs staffed each group.
For the clients who received indi-
vidual placement and support only,
two part-time job supporters provided
ongoing supportive contacts, helped
them overcome job-related obstacles,
and, when desirable, consulted with
their employers and workplace super-
visors. For clients who received both
modalities, the same two job support-
ers provided similar supports and
problem solving but also assisted par-
ticipants in using the skills they
learned during training sessions. Both
the employment specialist and the job
supporters exchanged clinical infor-
mation and progress reports weekly
with each participant’s multidiscipli-
nary team, regardless of the client’s
treatment condition.
The two-hour fundamental skills
sessions were conducted on a twice-
weekly schedule by either of the two
job supporters. The duration of train-
ing was three months, and individual
make-up sessions were provided as
needed. Only five participants
dropped out of the study, for a variety
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TTaabbllee 11
Skill areas of the workplace fundamentals module for persons with serious mental illness
Skill Module content Generic skills
1. How work changes your life General benefits and costs of work Develop and apply a
2. Learning about your workplace Specific details of your job knowledge base (skills
3. Identifying your own stressors Identifying what specific details will be a problem 1 to 3)
4. General problem solving Learning a seven-step method for solving problems Problem solving (skills 1 to 9)
5. Managing symptoms and medications Solving problems with symptoms and medications
6. Managing health and hygiene Coping with physical health issues and drug abuse
7. Interactions to improve your job Interacting with your supervisor to obtain feedback
8. Appropriate socialization Workplace culture and interactions on and off the job
9. Supports and motivation Knowing who can help; countering “demotivators”

of reasons—for example, moving out
of the area or being arrested and
jailed. However, no significant differ-
ences were observed between the
two treatment conditions in the num-
ber of participants who dropped out
nor on any of the pretest measures or
demographic factors. The fidelity of
both conditions was assured by
checklists based on optimal delivery
of each intervention (5,6).
A total of 34 participants—17 in
each group—were employed during
the duration of the project. No signif-
icant differences were found between
the groups’ total earnings ($4,239 in
the group receiving individual place-
ment and support only and $3,002 in
the group receiving both individual
placement and support and the work-
place fundamental skills module) or
hours worked (597 in the individual
placement and support group and 427
in the group receiving both modali-
ties). However, the individual place-
ment and support group held signifi-
cantly more jobs than the other group
(1.9 compared with 1.2), indicating
that there was significantly more job
turnover in the group that received in-
dividual placement and support only.
Furthermore, the members in this
group were significantly less satisfied
with their jobs than those in the group
receiving both modalities (4.4 com-
pared with 5.4, scored on a 7-point
scale on which 7 represents the high-
est level of satisfaction). For the meas-
ures of psychopathology and social
functioning, no significant differences
between the groups were observed on
any measure.
Afterword by the column editors:
The most noteworthy finding from
this preliminary comparison be-
tween two types of vocational reha-
bilitation was the greater job reten-
tion among the participants who re-
ceived the combination of individual
placement and support and the
workplace fundamental skills mod-
ule. The greater tenure in a job for
the combined treatment condition
provided support for the initial hy-
pothesis about the module’s additive
value in improving job retention
among clients receiving individual
placement and support. The ability
to hold on to a job may have been
gained because of the specialized
and focused training that partici-
pants in the combined condition re-
ceived in identifying and coping with
stressors on the job.
One might consider the possibility
that increased job turnover is actually
favorable in enabling clients to try dif-
ferent jobs until they find one that is
a better match and provides greater
satisfaction. However, the fact that
the clients who received both modal-
ities reported significantly greater job
satisfaction belies this explanation.
Taking the findings as a whole, the
supplementary skills training in work-
place fundamentals may be a useful
adjunct to supported employment
given that job turnover can be demor-
alizing for mental health clients and
an obstacle to their mastery of job op-
portunities and the establishment of
new social relationships.
The generalizability of these find-
ings to other mental health programs
was enhanced through implementa-
tion of the study in a typical mental
health center staffed by a standard
mix of nonacademic, multidiscipli-
nary professionals and paraprofes-
sionals. Both the workplace funda-
mental skills module and individual
placement and support are manual-
based treatments that facilitate dis-
semination of the procedures to a di-
verse array of practitioners working
in most psychiatric facilities. The
methods of both services can be
adopted by neophyte paraprofes-
sionals who have limited experience
working with persons with severe
mental illness as well as by more ex-
perienced clinicians who can put
their own professionally informed
stamp on the techniques.
A more complete report of this
project will be published in the fu-
ture, including the research design,
quantitative results, and statistical
analysis. In addition, two randomized
controlled trials of individual place-
ment and support in conjunction with
the workplace fundamental skills
module are under way at the Univer-
sity of California, Los Angeles, and
the New Hampshire –Dartmouth
Psychiatric Research Center among
individuals with recent-onset schizo-
phrenia as well as those with more
chronic forms of schizophrenia. ♦
Acknowledgment
This work was supported by grant MH-
57029 from the National Institute of
Mental Health to Dr. Wallace.
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