Augmenting vocational outcomes of supported employment with social skills training. (Vocational Outcomes of Supported Employment).

Work has long been regarded as a potential contributor and a tool for the treatment of mental illness (Ekdawi, Conning, & Campling, 1994). It is an important part of a cultural role, filling much of an individual's time, supplying a source of income, providing a source of identity, and contributing to one's physiological and psychological well-being in societies (Dawis, 1987; Mowbray, Bybee, Harris & McCrohan, 1995; Osipow, 1968). Unemployment, on the other hand, has demonstrated adverse effects on health caused by poverty, poor housing, and rejection by society (Brenner, 1987; Smith, 1987). While work serves an important function in a person's life, not every person can manage this important aspect of life, particularly those suffering from schizophrenia and other major mental disorders. Difficulties in choosing, getting, and keeping a job in the community are common among persons with mental disorders (Anthony, Howell, & Danley, 1984; Massel et al., 1990). Studies show that the employment rates of persons discharged from psychiatric hospitals ranged from 15 to 30% (Dion & Anthony, 1987; Unger & Anthony, 1984). With the introduction of supported employment, more promising findings were reported. The employment rate among those with serious mental illness could be as high as 50% following the Individual Placement and Support (IPS) model of supported employment developed by Drake and his team (Drake & Becker, 1996). Although supported employment has been shown to be effective in boosting the rate of job acquisition, a major limitation is that it showed no advantage over traditional vocational rehabilitation services in helping workers retain their jobs (Wallace, Tauber, & Wilde, 1999). As discussed by Drake, Becker, Clark, and Mueser (1999), available evidence only demonstrates that IPS can improve short-term rates of competitive employment. Nevertheless, the long-term course of jobs and vocational careers in relation to IPS remains an unknown. Many individuals move on to other jobs (Tsang, Ng & Chiu, 2002), but little is known about the underlying reasons and their subsequent vocational patterns.

In this article, the author attempts to trace the development and evidence related to the effectiveness of supported employment, reviews the role of social functioning in employment outcome, and argues that the vocational outcomes in terms of job retention using supported employment can be improved with the addition of a social skills training program specially designed and developed for job tenure.

The Supported Employment Approach

Current interest in vocational rehabilitation among people with mental illness brings the development of several innovative vocational rehabilitation strategies with promising results. The most promising and evidenced-based one is the supported employment approach, particularly the Individual Placement and Support (IPS) model (Drake & Becker, 1996). This model can be regarded as a specific model of supported employment for consumers with long-term impairments due to severe mental illness. As defined by Bond et al. (2001), supported employment is a well-defined approach to helping people with disabilities participate as much as possible in the competitive labor market, working in jobs they prefer with the level of professional help they need. Typically, the clients work for pay, are in regular contact with non-handicapped workers, and receive ongoing support (Bond, Drake, Mueser, & Becker, 1997).

The central theme of this model is integrating employment specialists into case management or mental health team to provide consumers with practical assistance in finding and maintaining competitive employment. There are six principles for the IPS model (Drake & Becker, 1996):

* Rehabilitation as an integral component of mental health treatment

* Goal is competitive employment in work settings integrated into a community's economy

* Participants are expected to obtain jobs directly, rather than following lengthy pre-employment training

* Services are continuous and based in real work experiences in the community

* Follow along support should be time-unlimited

* Services are based on consumer's preferences and choices, rather than providers' judgment

As described by Drake et al. (1999), supported employment represents a fundamental paradigm shift from the traditional vocational services of "train-and-place" to a "place-and-train" approach. It has been demonstrated to be effective in numerous research projects. The first piece of evidence came from an experiment in New Hampshire in converting the rehabilitative day program by an IPS supported employment program. The employment outcomes of day treatment patients following IPS model jumped significantly from 33% to 56% while the comparison day center showed no significant improvement (Drake et al., 1994). In a comprehensive review by Bond, Drake and Mueser, and Becker (1997), there were six randomized controlled trials on the effectiveness of supported employment published from 1994 to 1996. The results have been consistent, with a mean of 58 percent of supported employment clients achieved competitive employment over a 12 to 18 month follow-up period, which were significantly better than 21% in the controlled group participants. The outcomes tended to favor time employed and employment earnings. No evidence was found that supported employment led to increased stress levels precipitating higher re-hospitalization rates. Two other features related to the outcomes are that the programs adhered to ongoing support and attention of client preferences. A more up-to-date study by Lehman et al. (2002) compared the effectiveness of IPS to traditional vocational or psychosocial approach and reported similar result that IPS group participants (42%) were more likely to obtain competitive employment than the participants in the comparison group (11%).

Job Tenure and Social Competence

Limitations of the Supported Employment Approach

Although the success rate of the IPS clients is shown to be impressive based on available research results, there were still nearly half of the participants who failed in the process of securing competitive employment. It has been reported that persons with severe mental illness had problems in maintaining jobs (Cook, 1992; MacDonald-Wilson, Revell, Nguyen, & Peterson, 1991; Xie, Dain, Becker, & Drake, 1997). In discussing the results of a randomized clinical trial comparing IPS and enhanced vocational rehabilitation (EVR) (Drake, et al., 1999), the researchers claimed only that IPS was more successful than EVR in helping persons with severe mental illness to obtain competitive employment. The IPS participants showed no advantage over EVR participants in terms of the wages they earned, job satisfaction, and non vocational outcomes.

In discussing the role of social functioning in vocational rehabilitation, Bond, Drake, and Becker (1998) commented that the job acquisition process includes locating available jobs, successfully interviewing for a job, and acclimating to an unfamiliar setting whereas job retention also requires skills in getting along with others for an extended period of time. Based on this basic understanding, failures of people with severe mental illness in getting and maintaining their jobs may be due to problems related to their social functioning. In a study to identify masons for job terminations among persons with severe mental illness participating in supported employment, it was found that interpersonal difficulty was the most frequently reported job problem (58%) that may lead to job termination (Becker et al., 1998). This is in line with available evidence in the literature (Cook & Razzano, 2000; Tsang, Lam, Ng, & Leung, 2000) which has shown that social competence is one of the most significant predictors of employment outcome among individuals with mental illness.

Relationship between Social Competence and Job Tenure

Social competence plays a significant role in vocational functioning and employment outcomes among people with mental illness. In a review of previous cross-sectional and longitudinal studies, it is concluded that the relationship between social and vocational functioning is well established (Bond, Drake & Becker, 1998). It is however surprising to find that theoretical models in linking the relationship between social and vocational functioning of persons with severe mental illness are limited.

There are at least two reasons for this. First, there is the neglect of the fact that accommodation in the workplace is a social process (Gates, 2000). Most of the traditional vocational rehabilitation approach views accommodation as technical changes to job tasks, job routines, or the physical environment. The interpersonal aspect of the accommodation is largely neglected. Examples include how to deal with customers, how to deal with criticisms from supervisor, and how to deal with stigmatizing attitude from co-workers. Second, there is little attempt to conceptualize social skills needed for job acquisition and retention among people with mental illness. A recent attempt is a three -tier framework proposed by Tsang and Pearson (1996) which conceptualized those specific social skills necessary for job search and job tenure in a three-tier hierarchical structure. A person masters concepts and skills sequentially in each tier before proceeding to the next stage. The first tier is comprised of basic social skills and basic survival skills on the job. The second tier is comprised of two clusters of core skills needed to handle both general and specific work-related situations. The third tier of the program encompasses the goals for which the basic and core skills had prepared participants; that is, learning the benefits that a person can obtain by possessing these skills. These benefits are the consequences of getting a job, such as salary, social contacts, structure for one's time, and a sense of achievement and satisfaction from working.

Social skills play a crucial role in the process of job search and retention among people with severe mental illness. Although social skills training is a well established treatment modality for people with schizophrenia which helps to improve their social competence (Penn & Mueser, 1996), its potential benefit to augment the vocational outcome of supported employment has not been explored. A possible reason may be that prolonged training of consumers in the treatment setting leads to a delay of the job search process. This may easily be solved by using a training program that is short, effective for job search and retention, and evidence-based. In most of the studies that compared the effectiveness between supported employment (experimental) and skills training (comparison), the comparison group was not based on an effective and evidence-based training module geared towards job search and job maintenance of people with mental illness. This may be due to the fact there have been only a few programs of this kind available in the literature (Jacobs, Wissusik, Collier, Stackman, & Burkeman, 1992; Corrigan, Reedy, Thadani, & Ganet, 1995; Kelly, Laughlin, Claiborne, et al., 1979). These attempts mainly studied the short-term effect of training on job seeking skills. Studies on skills for job maintenance are even more limited. One study based on the single case study approach was reported by Mueser, Foy, and Carter (1986). A recent and more systematic attempt to adopt the skills training approach to help persons with serious mental illness maintain their jobs is the "Workplace fundamentals" developed by Wallace, Tauber, and Wilde (1999). The reason for developing this module was that supported employment had demonstrated no advantage over traditional vocational rehabilitation services in helping workers retain their jobs. The skill areas covered in the module include identifying how work changes participants' life, using problem solving to manage symptoms and medications at the workplace, learning how to interact with supervisors and peers to improve job task performance, and using problem solving to recruit social support on and off the job.

A training module designed to improve the social skills necessary for getting and keeping a job based on a conceptual framework put forward and validated by Tsang & Pearson (1996). The Tsang's module applied the basic principles of social skills training developed by Liberman, DeRisi, and Mueser (1989). The training program or module for finding and keeping a job has been outlined elsewhere (Tsang, 2001). It consists of 10 weekly sessions, of 1-1/2 to 2 hours each, thus fitting into the clinical workload of most psychiatric rehabilitation professionals. The curriculum can be delivered to individual clients or in a group format. Although it is preferable that participants in this program should first be equipped with training in basic social skills, this ideal scenario is not always possible.

Towards an Integrated Approach

Although social skills training (Penn & Mueser, 1996) and supported employment (Bond, Drake, Mueser, & Becker, 1997) have been widely accepted as effective treatment modalities to improve social and vocational outcomes of persons with severe mental illness, they are in general seen as two unrelated and sometimes even conflicting strategies. Limited effort has been made to combine these two techniques in producing a better vocational outcome. There is a recent trend to apply social skills training in the vocational context. Controlled trials of IPS on the average showed that about 50% participants were competitively employed at the follow-up periods. Results of the vocational social skills training reported a figure of about 40% (Tsang & Pearson, 2001). The preliminary results of Tsang's study suggest that social skills training and vocational rehabilitation are not two separate entities for the rehabilitation of people with schizophrenia and other persistent mental illness. Social skills training should become an integral part of vocational rehabilitation programs for people with schizophrenia and other persistent mental disorders, whether in psychiatric hospitals, psychiatric day facilities, and community facilities such as the Assertive Community Treatment, so that clients' chances of being gainfully employed in the community are enhanced. Social skills training in the vocational context is particularly compatible to the IPS model. The module may form an integral part of the IPS program from vocational assessment to on-going support provided by the employment specialist so as to help clients with severe mental illness to get and keep their jobs.

If any of the social skills training modules (either Wallace's workplace fundamentals module or Tsang's module) are used together with IPS to form an integrated model, it is expected that the vocational outcome would even be better. It is suggested that this combined strategy may become a new model for psychiatric facilities to improve employment opportunities for people with mental illness. The remaining parts of this article describe a preliminary service protocol and a hypothetical case to illustrate the run down of this integrated approach.

A Preliminary Service Protocol

The service protocol consists of two basic intervention components: individual placement and support (IPS) and social skills training (SST). The actual implementation follows the steps of a typical IPS program (Becker & Drake, 1993):

* Referral

* Building a relationship

* Vocational assessment

* Individual employment plan

* Obtaining employment

* Follow-along support

Vocational Assessment

Skills training begins to be an integral part of the treatment during the step of vocational assessment. Individual and Placement Support model emphasizes tracking experiences in competitive jobs. The goal is to find out how well the client does in a competitive job out in the community. Assessment should cover work background, current adjustment, work skills, and other work-related factors. Assessment on social skills necessary for seeking and maintaining a job should be incorporated into the above. The Vocational Social Skills Assessment Scale (VSSAS; Tsang & Pearson, 2000) may be used for this purpose. The scale consists of a 10 item self-administered checklist and a role-play exercise. The self-administered checklist aims at tapping the participants' perception of their own social competence and the role-play exercise assesses the participants' skills under simulated social situations. Validation studies showed that the scale had (.80 for the self-administered checklist and .96 for the role-play exercise) very good to excellent internal consistency. Meanwhile, the self-administered checklist had acceptable to good test-retest reliability (.35 to .78) while the role-play exercise had good to very good inter-rater reliability (.77 to .90). The concurrent validity was also statistically acceptable using the method of contrasted groups. In addition, observation checklists using the situational assessment principle will provide useful information about the clients' problems and needs.

Individual Employment Plan

In the stage of formulating an employment plan, a course of action after taking into account everything that the treatment team knows about the client related to the client's ability to get and hold a job should be worked out. As suggested by Becker and Drake (1993), the plan should consist of five sections: client's vocational goals, his/her related strengths and weaknesses, objectives enabling the client to meet his/her goals, the type of support the client wants from the employment specialist, and people/services/supports that will help the client achieve the objectives. In the proposed integrated approach, an emphasis should be given to the role social skills play in the individual employment plan. We should be fully aware of social skills needed by jobs that fall into the client's vocational plan. For instance, we should bear in mind that the client has to know how to handle complaints from customers if he/she plans to be an sales assistant in a department store. The social competence required would then become one of the objectives. Services or programs that improve the client's capability in this aspect should also be considered.

Obtaining Employment

Before the process of obtaining employment, services or programs mentioned above that help the client to upgrade his/her level of social competence in attending job interviews and the workplace should be given. A typical example will be the social skills training module described above by Tsang (2001). In fact, the content of the module is flexible especially the core skills which are specific to the particular kind of job. This part should be tailor-made to suit the needs of the client. As described above, the program should not be prolonged. The program can be completed within a month. The client will then be guided by the employment specialist to enter a rapid job search program. This can be done by following employment advertisement, contacting the employers directly, using the consumer's social network, and job shadowing as suggested by Becker & Drake (1993).

Follow-along Support

Perhaps the most important process is the step of follow-along support. As mentioned by Becker and Drake, clients would not be able to maintain a job successfully without ongoing help. The IPS program offers clients a complete set of supports, from 24-hour emergency services to peer support groups, employment counseling, benefits planning, and reliable transportation. With this integrated approach, ongoing support includes special emphasis on providing assistance to the clients how to develop and maintain good and cooperative working relationship with their fellow-workers, supervisors, and customers. This process can be conducted individually and in group. It can be conducted in the workplace, at clients' home or the psychiatric facility. Contents covered in the module are revised with the clients. Emphasis should be given to the generalization of the skills taught. A problem solving approach should be used to help clients to handle their interpersonal conflicts.

Case Vignette 

Mr Cheung is a 32 year old single man. He came to Hong Kong from the Chinese Mainland at the age of 15 with his family. His father died five years ago. He used to live with his mother who was overprotective and treated him like a child. His mother was now 65 years old, suffering from high blood pressure and subsisted on public assistance. Mr. Cheung was very dependent on his mother. Mr. Cheung completed primary school in China. After he came to Hong Kong, he studied one year in a secondary school with very poor results and had frequent conflicts with his classmates.

Mr. Cheung was described by his mother to be an introvert. He liked to stay at home and read books while he was in China. Nothing abnormal was observed. After migrating to Hong Kong, he started to have some abnormal behaviors which included talking to himself and saying that triad society members were following him. Also, he did not like going to school because his schoolmates were teasing him. He then left school and worked as a restaurant worker. Yet he was dismissed after only working for a few weeks because of poor performance and conflicts with colleagues. He had never been gainfully employed since. He also developed the obsessive compulsive feature of checking over the past two years. His mother took him for medical consultation because his personal hygiene deteriorated significantly for a year and his checking behaviors occurred more frequently. He was subsequently receiving treatment in a supported employment team affiliated to a community-based psychiatric facility. His mental state was now more stable. After meeting the employment specialist in the team a couple of times, he began to have trust in the employment specialist and talked about his unpleasant experiences associated with his previous work experiences. He revealed that he had frequent conflicts with his fellow workers because of discrimination. Despite failures in the past, Mr. Cheung was still keen to get a job but he expressed that he did not know how to make this happen. The employment specialist then arranged a comprehensive vocational assessment for Mr. Cheung. In addition to the work sample and situational approaches, the specialist used the Vocational Social Skills Assessment Scale (VSSAS) to assess Mr. Cheung's social competence in getting and holding job. In the self-administered part, he rated himself from 3 (sometimes difficult) to 1 (always difficult) in most of the 10 items. Items that he ranked himself "always difficult" included "participate appropriately in a job interview", "resolve a conflict with supervisor" and "resolve a conflict with a colleague". During the role play exercise, he appeared to be very nervous and uncomfortable. When being asked about his work experience, he had a lot of pauses and hesitations.

Based on the assessment results, the therapist discussed with Mr. Cheung his likes, dislikes, and job preferences and formulated the employment plan for Mr. Cheung. They decided that being a cleaning worker in a restaurant would be the first choice. As social competence was a major problem of Mr. Cheung, he was referred to a vocational social skills training group which lasted for about one month. At the same time, the specialist met with Mr. Cheung regularly to give psychological support and practical advice about how to look for a job. Two weeks after the completion of the training program, Mr. Cheung was successful in securing a job as a cleaner in a fast-food shop.

One week after Mr. Cheung had started his job, the employment specialist met him in the workplace and had lunch together. Mr. Cheung looked sad and complained that his fellow-workers did not talk to him. The specialist reassured him that the situation would improve if he took more initiative in a socially skilled manner. They went through the skills Mr. Cheung learned in the social skills training program and did some role play exercises with him. Mr. Cheung then took initiative to greet and initiated conversation with his colleagues. After three months, Mr. Cheung said that the situation had eventually improved. He now had a good friend in his workplace. Although there were new interpersonal problems, he tried to discuss these with the employment specialist and find a solutions for each problem.

For the next 12 months, the employment specialist and Mr. Cheung met regularly. During the meeting, they talked about everything that Mr. Cheung felt important, including his jobs, leisure, and finances. Whenever Mr. Cheung had problems with his colleagues or supervisor, the specialist reminded him of the social and problem-solving skills learned in the vocational social skills training group. When Mr. Cheung did not know how to apply materials learned previously to his day-to-day interpersonal problems, the specialist provided additional assistance to him so that he could bridge the gap in generalizing the skills to his job context. This strategy worked successfully for this year. Mr. Cheung settled well in his job and had no plan for changing his job anymore.

Conclusion

The above case shows that IPS goes smoothly together with the skills training approach. As the duration of the skills training module lasts only for one month, it does not contradict the "place-then-train" approach of supported employment (Wehman, 1986). On the other hand, it acts as a supplement to IPS especially for clients who have obvious deficits in social skills that hinder their process of getting and holding a job. The above protocol is formulated at a theoretical level and based on indirect evidence available in the literature. A randomized clinical trial funded by the Health Services Research Committee is now underway in Hong Kong to see if evidence matches with the above analysis.

Acknowledgement

This study was supported by the Health Services Research Grant H-ZK12 in Hong Kong. I would like to give my sincere thanks to Dr. Gary Bond and Ms. Debbie Becker for their comments in revising the manuscript leading to publication of this article in the Journal of Rehabilitation. I am also grateful to Wai Ming for her support.

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Hector W. H. Tsang, Ph.D., Associate professor, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong. E-mail: [e-mail]