CLINICAL HANDBOOK OF SCHIZOPHRENIA

264 IV. PSYCHOSOCIAL TREATMENTapproaches, psychosocial rehabilitation, brokered vocational services, and skills training.Overall, there was a threefold difference in employment outcomes (60 vs. 24%, respectively).Research has shown that competitive employment outcomes are higher in supportedemployment than in comparison programs, regardless of gender, age, diagnoses, minoritystatus, work history, and urban and rural locations. A monthly employment rate of 40%for people participating in supported employment services is achievable. With increasedattention on outcome results, agencywide employment data are recommended.Most clients in supported employment programs work in part-time jobs. Starting ajob at 10 hours per week and gradually increasing the number of hours is not uncommon.Jobs are typically entry-level positions and are consistent with the person’s experiences.People report more job satisfaction and have longer tenure when they work in jobsthat are consistent with their preferences. Ending a job by quitting, without having securedanother job, or being fired, has been associated with interpersonal difficulties atwork. People with schizophrenia often transition through two or three jobs before workinga job long term, similar to people without disabilities.Most studies have been short term (i.e., 18–24 months). At least three supported employmentresearch studies with long-term follow-up (i.e., 8–12 years) have shown thatpeople with serious mental illness are developing work careers. In two of these studies,71% of the people had worked over half the follow-up period, and 47% were working ina competitive job at the time of the follow-up interview.The effects of work on nonvocational outcomes are less clear. There is some evidencethat people working in competitive jobs have higher ratings of self-esteem, satisfactionwith finances and leisure, and better symptom control than people who work in shelteredsettings, or who work minimally.PRACTICE GUIDELINES FOR SUPPORTED EMPLOYMENTThere are seven principles of evidence-based supported employment.1. The client determines eligibility. No one who wants to work is excluded. Clientsoften overcome barriers when they identify competitive employment as their goal. Practitionerssometimes are surprised when people for whom they had no work expectationshave successful job experiences.Setting up a simple referral system encourages all people to consider work in theirlives. Client access to informational brochures in waiting areas makes work visible in themental health agency. Working clients are invited to speak with other clients and practitionersabout their experiences.2. Benefits counseling is part of the employment decision-making process. Individualizedbenefits planning gives people the information needed to make informed decisions.In two studies (D. Bailey, personal communication, March 3, 2005; Tremblay, Xie,Smith, & Drake, 2004), people who received benefits counseling worked more andearned more money compared to people who did not receive benefits counseling. Fear oflosing benefits (e.g., Social Security Income, Social Security Disability Insurance, Medicaidhealth insurance) is the most common reason that people with serious mental illnessare reluctant to start a job. In most cases, people are better off financially if they workand take advantage of work incentives. Setting up such a system allows all clients to accessbenefits counseling when they consider working.3. Supported employment is integrated with treatment. Rehabilitation is an integralcomponent rather than a separate service of mental health treatment. Good communicationis the key to provide seamless services. Employment specialists join treatment teams