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Autumn 2009 | Vol 13 No 1

Myth busters

Working out myths about supported employment

William A. Anthony

In the Winter 2005/06 issue of CrossCurrents, William A. Anthony, executive director of the Center for Psychiatric Rehabilitation at Boston University, challenged the following six myths that for decades impeded the development of the psychiatric vocational rehabilitation field.

1. People with psychiatric disabilities really do not wish to work.
2. People with psychiatric disabilities do not wish further education.
3. Psychiatric symptomatology and psychiatric diagnoses predict capacity to work.
4. Intelligence, aptitude and personality tests are a good predictor of future work performance.
5. Vocational performance in the community can be predicted from performance in other settings.
6. People with psychiatric disabilities lose their jobs because of their inability to perform the job tasks.

Four years later, CrossCurrents asked Anthony to tell us what has changed and what hasn’t. Here is what he told us:

Research developments in the field of psychiatric vocational rehabilitation have relegated these six myths to history. The evidence base that has accrued around the field of supported employment has contributed to their demise. However, new myths have developed about how best to practice supported employment. Have some of the myths below crept into your thinking and your agency’s use of supported employment practices?

Myth: Supported employment as presently practiced is for everyone.
Fact: In a recent issue of the Psychiatric Rehabilitation Journal, Robert Drake and Gary Bond report that many people do not wish to enter supported employment program for a variety of reasons, and still others (about one third) who enter supported employment do not become competitively employed. There is still much creative work that needs to be done to improve supported employment services.

Myth: Professionals can predict a person’s readiness to engage in and profit from supported employment services.
Fact: Just as professionals cannot predict very well who can and cannot work, they also are poor at predicting who should receive supported employment services. Rather than attempting to predict vocational rehabilitation readiness, Marianne Farkas has developed a rehabilitation readiness technology that practitioners can use to help people determine their own rehabilitation readiness and also helps them to get ready for rehabilitation. According to Farkas, readiness assessment helps individuals “judge for themselves” whether or not it makes sense to them to engage in vocational rehabilitation services. Readiness for rehabilitation is an indication of people’s self-determined commitment and interest in rehabilitation, not an assessment of their capacity to achieve rehabilitation success. People differ in their vocational rehabilitation readiness just as they vary in terms of their readiness for any possible change, such as college, marriage, a vacation or a physical exercise program. Like all types of people, they can be helped to improve their readiness.

Myth: Supported employment practices require rapid job placement without much attention to people’s job preferences.
Fact: A hallmark of psychiatric vocational rehabilitation is that service recipients exercise their preference with respect to an employment position. I was a co-investigator in one of the first successful randomized clinical trials of supported employment and personally interviewed each of the supported employment practitioners. All of these practitioners indicated that they helped people receiving
supported employment services explore their vocational goals. The focus on rapid job search counteracts the previous misconception that people needed such interventions as sheltered workshops to get ready for work. Supported employment practices begin the job search process more quickly, but the actual job placement should be based on people’s preferences.

Myth: The particular supports used in supported employment are well known.
Fact: The particular supports helpful in supported employment practices vary from individual to individual. The use of supports must be identified based on the individuals’ employment goals. While it may be possible to categorize various supports, such as supportive people (a family member to drive), places (a location to store medication), things (a bus pass) and activities (a workplace exercise group), there are as many variations of supportive people, places, things and activities as there are individuals. The practitioner must pay as much attention to the kind of support as to engaging the individual in exploring goals. Furthermore, I have stressed to practitioners that supported employment provides the opportunity for ongoing support, not the provision of ongoing support. What individuals need to know is that support is accessible, but will not be provided intrusively when the individual neither needs nor wants it. Support in supported employment is available but not intrusive.

Clearly, the evidence base that has developed around supported employment is impressive. As I pointed out in a recent issue of the Psychiatric Rehabilitation Journal, there is significant similarity between the principles underlying the entire psychiatric rehabilitation field and the practice of supported employment. Common to psychiatric rehabilitation and supported employment are principles focusing on competitive employment as a rehabilitation goal, consumer preference with respect to choice of service and choice of employment position, and opportunities for support for as long as needed. So while the principles of supported employment are familiar and perhaps comforting to practitioners of psychiatric rehabilitation, new myths specific to supported employment have emerged. As noted above, misconceptions exist about the universal application of supported employment, the meaning of rapid job search, the value of trying to predict supported employment readiness and the nature of employment support. Similar to the six vocational rehabilitation myths I wrote about four years ago, these current supported employment myths must be rejected for the practice of supported employment to remain effective and innovative.