Why Not Implement Supported Employment?

Several facts are clear. Most people with serious mental illnesses want to work in competitive jobs. They want to be productive, have a role in their communities, and pay taxes. They see employment as an essential aspect of recovery. Evidence-based supported employment, also called individual placement and support or IPS, can help about two-thirds of them to succeed: 17 randomized controlled trials confirm the effectiveness of IPS supported support. Those who are working reduce their use of mental health services and reduce their disability benefits in keeping with the rules governing the amount of work they perform. Furthernore, close personal contact in the workplace is arguably the most successful strategy to overcome stigma.

Therefore, we ask ourselves these questions every day: Why do federal and state governments espouse a recovery philosophy but ignore employment? Why do they spend hundreds of millions of dollars each year funding day centers, sheltered workshops, and other ineffective programs rather than IPS supported employment? Why are less than 2% of those in need able to access IPS supported employment?

Is the problem resistance by the workforce? In an article in this issue Pogoda and colleagues make several excellent points regarding barriers that impede the dissemination and implementation of evidence-based supported employment within the Department of Veterans Affairs health care system. We have encountered similar barriers within the federal-state public health care systems. Hardworking clinicians believe in what they do every day and are reluctant to change as new interventions arise. But providers also want to help their clients recover. Our experience has been that providers readily embrace IPS supported employment and master new skills as soon as they see their clients working and recovering. Leadership, persistence, and good intentions generally prevail.

Unfortunately, a much larger barrier prevents the adoption of evidence-based supported employment. The crux of the matter is our failure to develop a clear, simple, direct funding mechanism. No single agency funds IPS supported employment, and providers must cobble together funding from multiple sources. And as several state mental health directors have said to us, “I hate to waste money on daycare programs, but that's what Medicaid pays for.” Why hasn't this problem been solved? At the federal and state levels, leaders protect their bureaucracies, funding silos, and organizational barriers. In doing so, they block the adoption of evidence-based practices, subvert recovery, hold people with disabilities hostage, neglect the basic human right to social inclusion, and impede society's efforts to overcome stigma. We can only hope that good sense, humanism, and science will eventually win out.