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Strategy began small, is now a national model

Thirty years ago, psychiatrists advised their patients who had severe mental illnesses—like schizophrenia, major depression, or bipolar disorder—not to work.

"We were all taught in training that work is stressful, and we should try to help people decrease stress in their lives so that they can manage their illnesses," says DMS psychiatrist Robert Drake, M.D., Ph.D. He's singing a different tune these days. "It turns out that there are now numerous studies to show that not working is more stressful than working," he says. "People do much better when we help them get into a job, particularly if it's the right kind of a job."

Drake coauthored a study, recently published in the American Journal of Psychiatry, that followed 1,273 people with severe mental illness at sites in Maine, Connecticut, Massachusetts, Maryland, South Carolina, Texas, and Arizona. The researchers found that those who received integrated psychiatric and vocational support, a model known as supported employment, were more than twice as likely to be competitively employed and almost one and a half times as likely to work at least 40 hours a month. Over a dozen other studies, including ones that have followed patients for as long as 12 years, con- firm that supported employment works.

Jobs: The story of how the mental-health system stumbled upon this successful strategy began in Lebanon, N.H., in the late 1980s. Drake credits Deborah Becker, M.Ed., who was then a vocational counselor at West Central Services, with the innovation. She managed to place people with mental illness in mainstream jobs when no one else could. In those days, people with mental illness, if they did work, did so under the supervision of mental-health professionals in sheltered settings with other mentally ill people, doing administrative, janitorial, or food service jobs. But few developed the confidence to make the transition to real-world jobs, even if they got vocational counseling. Unless the counselor was Deborah Becker.

Becker led her clients through an individualized process of matching their skills, interests, and experiences to suitable jobs. Then she coached them in job-hunting techniques; helped them review employment ads; talked to employers to find opportunities that might not be advertised; accompanied them to interviews; even talked to employers on her clients' behalf if they wanted her to.

She believed that her clients could thrive in standard workplaces, as long as vocational and psychiatric services were integrated, so clients could get appropriate counseling and support—sometimes even modification of their medication dosages.

Officials at New Hampshire's Division of Mental Health became impressed with Becker's results and "asked us to help them get

Becker, right, had an idea that ran counter to conventional psychiatric wisdom, and Drake, left, proved it works.

more people into jobs," says Drake, who has been director of the New Hampshire-Dartmouth Psychiatric Research Center since 1987. Drake's research confirmed, he says, that Becker's "approach . . . was better than any of the other approaches."

Drake's team may have merely recognized a good thing rather than actually originating it, but his group was the first to formalize and study supported employment. "Most people credit it with starting here," says Drake. "To me, it's just amazing that what started out as a little program in Lebanon is now used all over the world."

Drake, DMS's Andrew Thompson Professor of Psychiatry, and Becker, now a research assistant professor of community and family medicine, have been refining and testing the model ever since, as well as teaching others how to use it. They currently have funding from Johnson & Johnson for a demonstration project to help 10 other states develop supported- employment programs.

Real: In most areas without such programs, fewer than 10% of people with mental illness are employed. But with supported employment, "we've been able to get the rate up to more like 40% or so," Drake explains. "When you put people in real job settings, they're much more successful than any of us believed that they would be.

"They flower once they're in a setting where they're around everyday people who don't have disabilities," he says. That one thing "helps people change their self-image and move out of the dependent mental patient role."

Laura Stephenson Carter

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