We interviewed Dr. Robert E. Drake, co-developer of the supported employment model Individual Placement and Support (IPS), before COVID-19 hit, with absolutely no idea what was in store for us. A global pandemic that, for many people, has impacted day-to-day life. In April, unemployment in the U.S. spiked to 14.7%. It has since decreased by 4.5% but is still far higher than before. Thanks to federal and state support and innovative programs, mental health pivoted quickly to adapt to physical distance regulations and shed the last remaining hurdles to telehealth. During the pandemic, IPS programs also rapidly shifted to provide supported employment services remotely by phone, video chat, email, and text message. Dr. Drake shared with us in an email that people with serious mental illness and other disabilities are highly vulnerable to the pandemic and associated mandates, pointing out that “their safety and economic security should be high on our list of priorities.” IPS specialists, he notes, are working diligently to help. In the below article, Dr. Drake explains how the IPS model developed and why it works.
Health researcher Robert E. Drake, M.D., Ph.D., co-developed Individual Placement and Support, a supported employment model for people with serious mental illness. He says he began looking at employment methodology in the late ‘80s after the director of mental health in New Hampshire told him, “What clients say every year is that their first goal is to get a job, but we don’t know how to help them do so.” Dr. Drake didn’t have high expectations but started examining various programs and conducting small studies and randomized trials. “The model that consistently did better than others was supported employment, which originated in the developmental disabilities field.” He says the supported employment model was different in that the services avoided extensive pre-employment training, practice, and evaluation. Instead, the idea was simple and straightforward: helping clients find jobs they like and providing training and support as needed on the job. “It’s a much more direct model in terms of criterion and outcome, and it’s consistently more effective than skills training or sheltered workshops [also called work centers], which were popular at the time.”
Clients weren’t interested in learning skills or participating in programs that, at best, were indirect stepping stones to actual employment. The result was high dropout rates. Dr. Drake said that mental health professionals attributed the plummeting participation to patients not knowing what they wanted. “Professionals made a lot of incorrect assumptions. One expert told me, ‘Clients don’t know what the heck they want to do; it takes at least nine months of counseling to help them figure it out.’ He was wrong.” In fact, Dr. Drake and his colleagues interviewed a sample of clients and discovered that 90% knew exactly what kind of job they wanted. The misconception among experts was reflective, says Dr. Drake, of the mental health system at the time. “It was paternalistic. The assumption was that people with mental illness were confused and not capable of confident decision-making and that we professionals knew better. Unfortunately, this is still a problem. We haven’t been good, over the years, at listening to people and helping them with what they want.”
In the early ‘90s, Dr. Drake and employment researcher Deborah R. Becker, M.Ed., CRC, adapted supported employment for people with serious mental illness, calling it Individual Placement and Support (IPS). They conducted multiple small studies and two large randomized trials in New Hampshire and Washington D.C. Participants in the latter trial were experiencing homelessness, mental illness, and addiction. There’s often a misconception that people can’t obtain employment if they are homeless, but that’s not true. What Becker and Dr. Drake discovered in the D.C. study is that IPS was successful even among this particularly marginalized population experiencing homelessness and co-existing mental illness and substance use disorder. “What we found is that we could get people jobs, and having an income helped them to get sustainable housing.” Dr. Drake and his colleagues have continued to study and develop IPS. What the research has solidified, he says, is that employment is one of the most, if not the most, critical intervention because “it allows people to become self-reliant.” He says that the mental health field has historically underestimated the power of autonomy in crisis prevention and recovery. When people earn an income and can make decisions about their life, the benefits are striking. “Long-term studies show that once people are employed, they stop hanging around hospitals and community mental health centers. They get on with their lives.” As a researcher, he says it was amazing to see how employment was such a powerful intervention, “more so than medication, psychotherapy, and other treatments we were studying.”
Individual Placement and Support is person-centered and follows clients’ choice about when they look for work, what they want to do, and how many hours they want to work. Like everyone else, people with mental health challenges want to be independent. Yet, says Dr. Drake, healthcare and financial systems often socialize them into disability, “conveying the message to patients that they are broken, not competent, and can’t succeed in life.” Patients become hopeless in the same way that people who live in hospitals or jails for decades do. We call that institutionalization. “Living in a stagnant environment causes social and cognitive decline and also instills the belief in people existing under those conditions that they can’t possibly survive outside of the institution.” Even so, people struggling with serious mental illness consistently state they want to be employed, though less so the longer they’ve been unwell. “If you look at young people in the early years of illness, about 90 percent of them have employment as a top goal. Then when you look at people who have been ill for many years, and they have been beaten down by the system, 60% of them still list employment as a top priority.”
Lisa Dixon, M.D., M.P.H., a professor of psychiatry at the Columbia University Medical Center, told us in October that the longer a person experiences untreated psychosis, the worse the outcome over the short and long term. Similarly, says Dr. Drake, the longer a person with a serious mental illness is outside of the employment sphere, the more difficult it is to engage. Across all the research studies, the only consistent predictor of who is going to do better with supported employment is how much they have worked in the past. That’s why it’s essential to help people keep functioning in their day-to-day lives, instead of removing them from functional activity. “Previously, we told people to stay in the hospital for six months or stay at home for two years to recover, but that has all kinds of harmful effects. If we can get people out working or finishing their education, it builds resilience that will benefit them throughout their lives.”
To date, 27 randomized control trials have examined IPS, and they all show that people do better in supported employment than they do with a whole range of other interventions. One of the surprising findings, says Dr. Drake, is that once people are launched in an employment trajectory, the benefits continue even without services and support. “That’s different from everything else we are doing now in mental health where if you take away the therapy, medication, or support, people tend to decline and go back to their baseline.” He says that’s not true for employment. Once people with serious mental illness start working, they have more self-confidence, develop friends in the community, participate in activities, experience financial stability, and “many get promoted over time or get some education so they can get a better job.” “I’ve never seen any other kind of intervention where people actually recover to such a great degree.”
Since the ‘90s, senior researcher Deborah R. Becker has continued to improve upon the intervention so that it works for people experiencing co-existing conditions, who have been in the criminal justice system, or are disadvantaged in some other way. Twenty countries use the IPS model, and some have better infrastructures for maximizing the potential benefits. In the United States (U.S.), says Dr. Drake, the biggest barrier is that health insurance companies don’t want to pay for supported employment. “Vocational Rehabilitation doesn’t have much money, and the Department of Labor doesn’t want to deal with people who have a mental illness, and Medicaid only pays partially for employment services.” For the most part, programs and states weave together funding from several sources, which means only a small proportion of people who need supported employment have access to it. He says that in some other countries, like the United Kingdom, supported employment is simply part of the health policy for people treated with serious mental illness, though there are consistent administrative and implementation challenges. “The simplest solution in the U.S. would be if Medicaid had a code or would pay for a package of services that would include supported employment for people with serious mental illness.” That requires a major shift, he notes, because U.S. healthcare systems tend to over medicalize problems and underemphasize social services. “It has been hard to get them to incorporate vocational services, but people are going to keep having crises until you help them access a decent life.” They need a pathway out of dependence on the mental health system.
Over time, Dr. Drake and colleagues discovered that people who are employed are less likely to experience mental health hospitalization, even among the most severely ill and crisis-prone. This is a benefit to participants and to the mental health system as a whole. “Their healthcare costs go down year by year over 10 years to almost nothing.” He has treated some patients for two decades, seeing them once a year for a medication renewal. They had once been frequently in and out of the hospital or day programs when he first started working with them. Now, if they walked into their local mental health center, no one would have any idea who they are. “Their identity isn’t as a patient.” He says in mental health, it’s time to transition to interventions that tap into people’s strengths, competence, and capacity for recovery, “rather than dealing with people as damaged goods.” Supported employment, he notes, is central to recovery.