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Work as a Priority: A Resource for Employing People who have Serious Mental Illnesses and are Homeless

Approaches to Employment for People with Serious Mental Illnesses^[1]

A recent report documented and described program-level factors affecting outcomes in various types of employment program models that serve people with severe mental illnesses.^[2] Five major factors related to employment success cut across all program types: (1) organizational climate and culture that support work; (2) facilitation of employment; (3) emphasis on consumer preferences and strengths; (4) ongoing, flexible, individualized support; and (5) re-placement assistance.

This chapter provides an overview of the most frequently utilized employment approaches to help people with mental illnesses obtain and maintain employment. While many mental health consumers acknowledge that, at some point in their recovery, a structured/sheltered work setting was needed, the merits and disadvantages of sheltered employment are not discussed in this volume. Rather, this discussion begins with the premise that long-term worker role recovery is possible through integrated employment that provides work at competitive wages, offers the opportunity to work with non-disabled co-workers, and offers long-term, post-placement support.

When deciding to adopt a particular employment program, agencies must consider how the particular model chosen is relevant to the needs, interests, and cultural values of their constituency; whether a particular strategy will work in both urban and rural settings; and whether types of funding and staff expertise required match agency capacity. The strength and diversity of the local employment or business market and its ability to meet the job placement and job creation objectives of the agency, also should be evaluated. Finally, the culture of the agency and the importance it places upon employment must be evaluated. Valuing work as a priority may represent a significant change in an agency’s culture.

Some agencies may find that the local employment market is sufficiently strong, that their Board of Directors or staff has established networks with employers, and that their constituency prefers a supported employment option. They may decide that a "place/train" strategy would be most appropriate. Another agency may have a history of risk-taking and entrepreneurship, in which case social enterprise development might be more consistent with their orientation.

The goals of each of the employment approaches in this chapter are summarized in Table 3.1. Many providers have recognized that job and career growth is tied inextricably to job training and education. It therefore is worth noting that job training and education are essential components in the array of employment-related services. This includes helping individuals obtain their GED, college diploma, or certification through a trade school; and providing or linking individuals to appropriate educational services, including supported education, described briefly at the end of this chapter.

Transitional Employment

Fountain House Foundation in New York City implemented the first Transitional Employment Program (TEP) in 1964.^[3] Fountain House developed a Clubhouse Model, offering day treatment based on a specific psychosocial rehabilitation approach. Today, TEPs remain one of the primary vocational services offered to their members by psychosocial clubs in the Nation. In addition to providing organized individual and group activities, psychosocial clubs afford community members the opportunity to socialize, support, and advise each other.

Often the setting for job clubs, temporary labor, and work readiness services (e.g., resume writing, job searches, visiting speakers, etc.), psychosocial clubs provide safe environments for consumers to begin exploring the notion of returning to work.

TEP participants work in a series of time-limited, competitive jobs to gain employment experience and skills, and to identify job preferences. The jobs, usually entry-level, are developed through an agreement between the rehabilitation agency and one or more private businesses. The agency commits to filling the job slots with trainees on a continuing basis, while the business commits to providing the slots. The designation of a specific staff liaison by the agency can help assure the employer that the agency is reliable.^[4] On- and off-site job coaching is provided to participants by club staff. Trainees usually participate on a part-time basis for four to six months, after which they are transferred to another job placement.

While the desired outcome is the eventual acquisition of either full- or part-time permanent employment, the results are mixed with regard to the effectiveness of TEPs in helping individuals achieve permanent, competitive employment. Although evidence exists that TEPs can have a significant impact on employment outcomes as length of the follow-up or job coaching period increases,^[5] a recent study found that longer involvement in TEPs actually can result in lower rates of competitive employment.^[6] TEP participation can be a useful form of situational assessment for many people with serious mental illnesses, and can help some individuals establish an integrated work experience, test work goals, and develop interaction skills with coworkers who are not disabled—often the most difficult challenge faced by trainees.

Table 3.1 Overview of Employment Program Approaches

Type of Employment Approach
Approach	Transitional Employment programs. (TEP)	Supported Employment.	Program of Assertive Community Treatment. (PACT)	Individual Placement and Support.	Social Enterprises.	Self-Employment.
Characteristics	Time-limited placements in competitive jobs. Agency commits to keeping job slots filled. Often clubhouse-based.	Direct placement into integrated competitive jobs with follow-along supports.	Integrates both clinical and rehabilitative services within a continuous or assertive community treatment team.	Emphasizes rapid job search. Continuous and comprehensive assessment that continues throughout employment. Time-unlimited supported.	Agency-sponsored businesses that provide affirmative employment.	Consumer-owned business (sole proprietorship/ partnership/ cooperative).
Objective	Build experience, competence, and job goals with the objective of attaining a permanent job.	Part- or full-time employment at prevailing wage.	Work as a long-term process to aid in recovery. Individualized assessment, placement, follow-along, and reassessment.	Replace traditional day treatment programs with those focused on work to achieve better vocational outcomes.	Job goal and skills development, work experience, transitional/career employment.	Employment as full-time/part-time self- employed business owner.
Possible Funding Sources	State VR, HUD, MH, Foundations.	State VR, MH, HUD, DOL (wage subsidies, employer hiring incentives), foundations.	MH, State VR, Medicaid/Managed Care.	State VR, MH, Medicaid.	VR, MH, business revenue, economic development, HUD, foundations.	VR, SSA, MH Federal, SBA, State community business lenders, private capital.
Staff Expertise Required	Skills teaching, job development, placement, support, ability to perform job in consumer’s absence.	Skills teaching, job development, placement, intensive/extended support, re-placement.	Interdisciplinary treatment team with vocational specialist.	Employment specialist to coordinate services with case management or mental health treatment team.	Business/ production experts, training/job coach staff, job development placement staff.	Business-related TA/support, MH support.
Advantages	Basis for establishing links with employers. Builds credentials, experience, and resume.	Employee hired by the employer, not by the MH program. Works with non-disabled co-workers. Salary, growth potential like co-workers.	Work as an important and integral component of clinical treatment.	Integrates mental health and rehabilitation services through regular meetings between MH clinicians and employment specialists.	Adds to the available jobs in a community. Has economic development potential. Agency "owns" jobs.	Responsibility for success relies upon the individual. Independence, control.
Disadvantages	Time limitations not always congruent with consumer preference. Staff may need to fill in for absent worker. Unclear outcomes re: how TEP facilitates competitive employment.	Clash between long-term job coaching needs and short-term VR support, individual’s discomfort with being coached on the job.	Direct placement approach contains similar disadvantages as supported employment; e.g., funding for long-term follow-along and re-placement assistance.	Providing time-unlimited supports contains similar disadvantages as noted for PACT and supported employment, e.g., funding for long-term follow-along and re-placement assistance. Need support for people who cannot or do not find jobs through IPS.	Requires sound business planning. High business risk factor. Start-up capital needs.	Responsibility for success relies upon the individual. High financial risk factors. Requires sound business planning.

Using a Transitional Employment Approach Community Access, Inc. has been providing supportive housing to people discharged from psychiatric hospitals in New York City since 1974. Over the past 25 years, Community Access has continued to expand its residential services while adding case management, social clubs, advocacy, consumer-operated programs and services, and employment and education services. The Cooper Employment and Training Center is one of two psychosocial clubs the organization operates. Begun in 1995, the Center specializes in services leading toward employment, including GED and college preparation, computer skills, job readiness, benefits counseling, on-site internships and volunteer positions, and on-site transitional and permanent employment placements. The Center’s 250 members are people with serious mental illness, the majority of whom are single, African-American adults, approximately 50% of whom have recently been homeless. Members take job readiness classes for five weeks and then volunteer in various club positions. At the end of 12 weeks, a determination is made for continued job readiness, entry into a transitional employment slot, or a permanent employment opportunity. The Center works to place members with various employers in the business community with on- or off-site job coaching provided as necessary.

Supported Employment

Supported employment became popular in the mid-1970s as a way to improve the employability of people who historically had experienced high unemployment rates, particularly people with physical or developmental disabilities.^[7] It also was developed as an alternative to sheltered workshops. Supported employment is defined by Federal statute as "competitive employment in an integrated setting with ongoing support services for individuals with the most severe disabilities."^[8] The purpose of supported employment is to provide employment success and integration using a wide array of short- and long-term supports after placement. From the beginning, this "place, then train" approach has differed significantly from the pre-employment testing and pre-vocational work that were previously widely used for people with disabilities.

Increasingly, supported employment principles and practices have been adapted to meet the needs of a wider population with disabilities. Adaptations to the original program model are evolving to address the specialized needs of people with serious mental illnesses.^{[9],[10],[11],[12]} An important modification acknowledges that many people with mental illnesses need assistance to establish job preferences and career goals, and both get and keep jobs.^[13] As the field expands, a wide variety of strategies have been adopted to modify this approach and increase job success for people with severe mental illnesses. Some of the most common adaptations include:

• Active consumer involvement in identifying personal job goals;

• More time educating employers and coworkers;

• Recognition that some consumers choose not to disclose their disability;

• Increased training in emotional-interpersonal skills development;

• Increased levels of support;

• Re-placement services;

• Wider variety of jobs, with greater emphasis on professional/technical options; and

• Emphasis on career and opportunities for advancement.

The effectiveness of supported employment has been demonstrated by evidence from eight randomized controlled trials and three quasi-experimental studies and fidelity measures.^[14] Supported employment programs demonstrated improved employment outcomes across a range of client characteristics and community settings. A recent study demonstrated a strong correlation between overall program fidelity and higher rates of competitive employment outcomes compared to non-supported employment approaches.^[15] However, a prime barrier to its use was a lack of access and availability. Further, fewer than 25% of people with severe mental illness receive any vocational assistance; only a fraction had access to supported employment.^[16]

The PACT Vocational Model

The Program of Assertive Community Treatment (PACT) was established in 1984 to provide comprehensive, community-based clinical and rehabilitative services for discharged state hospital patients identified by outpatient mental health centers as requiring extensive and intensive support.^[17] PACT addresses these needs with a continuous treatment team approach that has a low staff-to-client ratio. The team includes nurses, social workers, psychiatrists, peer specialists, substance abuse counselors, and employment specialists who provide community-based symptom monitoring and management, 24-hour crisis intervention, and assistance in areas of improved functioning in critical life skills areas, including work.^[18]

Though few PACT programs include vocational or employment specialists on their teams, the PACT approach recognizes work as integral to the treatment process. It also helps to promote a positive self-concept as a worker or valued and productive member of society. PACT programs that address employment emphasize helping people get jobs as an individualized, long-term process built through trial and error. There are no readiness prerequisites; individualized assessment, placement, follow-along and reassessment services are provided on an as-needed, ongoing, basis. One of the major distinctions between PACT and step-wise employment programs is PACT’s perspective that the best way to address people’s strengths and limitations is within a normalized work setting. The PACT model emphasizes rapid placement into competitive work rather than extended involvement in pre-employment testing and assessment. Assessment is ongoing; growth and job stability are outcomes, and "failure" can be one of the keys to success.^[19]

Individual Placement and Support

One of the most recent and well-studied adaptations of supported employment is the Individual Placement and Support Program (IPS), developed and researched at the New Hampshire-Dartmouth Psychiatric Research Center and Dartmouth Medical School.^[20] IPS makes employment a high priority in the consumer’s treatment and rehabilitation plan by including employment specialists, who assist with rapid job searches, as part of the case management or mental health treatment team.^[21]

Drawing from the PACT vocational model, IPS emphasizes the integration of vocational and clinical services, minimal preliminary assessments, rapid job searches, normal work settings, matching consumers with jobs of their choice, and ongoing support. Work is considered treatment, in which employment outcomes and vocational rehabilitation become vital components of a client’s ongoing treatment regimen.^[22]

Elevating work to the same priority as mental health services can change the way clinicians and employment specialists view their roles. In a New Hampshire study, IPS was compared to step-wise employment services provided by a day-treatment provider. The results were dramatic. The competitive employment outcomes of people attending IPS improved significantly (33%-56%), while people attending day treatment showed no significant change in employment outcomes (9%-14%).^[23] Furthermore, IPS clients obtained competitive employment faster, were more likely to be employed every month of the 18-month study, worked more total hours, and earned higher wages than those in the rehabilitation agency program.^[24] Key program principles identified as related to better vocational outcomes include:^[25]

• Competitive employment as a primary goal;

• Integration of rehabilitation with mental health services;

• Rapid job searches;

• Continuous assessment; and

• Unlimited support.

The emerging PACT and IPS employment approaches recognize the complex, ongoing support requirements of people with mental illnesses and the need to address those requirements simultaneously to achieve work success. Consumers have expressed their preference for rapid work placement to respond to their work needs and interests rather than pre-vocational services where they may spend years without ever working at a real job. IPS recognizes and incorporates those preferences as an underpinning of its approach. In randomized, controlled trials in a limited number of test sites, IPS showed better employment outcomes with 58% of participants, compared to 21% achieving similar outcomes through traditional programs.^[26] Adoption and testing of the IPS approach is occurring throughout the country, including a number of projects funded through the Federal Community Action Grant Program supported by SAMHSA. The results of those programs should help increase knowledge of how IPS can be even more effective in assisting consumers to get, keep, and advance in employment compared to more traditional step-wise options.

Social Enterprises and Affirmative Businesses

A social enterprise is a business venture created specifically to provide employment and career opportunities for people who are unemployed, disabled, or otherwise disadvantaged. Social enterprises seek to achieve social change through the economic empowerment of individuals and groups who have been disenfranchised. While the term "social enterprise" is used throughout Canada and Europe, in the United States, the term "affirmative business" is used when the business primarily employs people with disabilities.

Each year, new social enterprises are created throughout the United States and in other parts of the world. An increasing number are being developed with the express purpose of employing people who previously were homeless.^{[27],[28],[29],[30],[31],[32]} A social enterprise has a dual purpose: to operate a viable, sustainable business and to help people who face multiple barriers to achieve success and satisfaction in a real work setting. To operate as a viable business, a social enterprise must adopt standard business practices, employ experts, and expect all employees to practice the technical skills that will enable the business to offer a competitive product or service.

Current or former recipients of mental health services also own or manage and operate social enterprises formed as worker cooperatives, a model more common in Canada.^[33] Examples include ABEL Enterprises in Simcoe, Ontario, and Fresh Start Cleaning in Toronto. These businesses receive some government subsidy and provide permanent part-time employment to individuals with serious mental illnesses, some of whom also have histories of homelessness.

Social enterprises should look like businesses, act like businesses, and provide products and services of comparable price and quality as those of other businesses. If these goals are achieved, the potential exists to overcome the stigma and misconceptions faced by people with mental illnesses in their communities. They can be seen, not as patients in a treatment program, but rather as workers in a local business. In addition, these businesses can contribute to the local economy and demonstrate how people with mental illnesses can provide quality products and services when given the opportunities to do so.

Realistically, not every mental health provider has the commitment or capacity to develop an effective social enterprise. Similarly, not every person with a mental illness who has been homeless may choose employment in a social enterprise. However, a social enterprise can add to the jobs available within a locality without relying on the existing job market to meet the employment needs of consumers.

For a social enterprise to be successful, certain key elements beyond financial viability must be in place:^[34]

• Capacity: What compels the organization to go into business? What organizational strengths, assets, and experiences will prepare the agency to become social entrepreneurs? What are the organization’s weak points? What are the indicators of success?

• Fit: Is this business compatible with the agency’s goals, needs, interests, values, risk tolerance level, and other organizational/program criteria?

• Viability: Can the proposed business provide quality products or services at competitive prices to an identified group of purchasers who can afford to purchase these products/services at the price the agency must charge?

In essence, the rigorous business planning process for social enterprises involves a thorough assessment of the organization and the business, and the potential interrelationship between the organization and the business and the business and its market environment.

While there is no one social enterprise program model, those that have successfully blended economic development and social service aspects can serve as examples of "best practices." They often exhibit the following characteristics:

• Are market- and profit-oriented;

• Access technical expertise and capital resources;

• Establish linkages with individual support services for employees;

• Involve participants in the establishment and/or management of the enterprise;

• Utilize a business planning approach;

• Are driven by the provision of quality products/services to their customers;

• Provide competitive wages and fringe benefits;

• Achieve a social purpose by hiring, training, and employing people who have been typically unemployed or underemployed as a result of a disability or other disadvantage;

• Consider workers as employees, not clients; and

• Provide either an integrated workforce or a community-integrated setting.

Self-Employment

Though often overlooked as an option for people with serious mental illnesses, self-employment—or entrepreneurship—is firmly embedded in the American dream, and, for many, can be a successful step toward self-sufficiency. Many people who have experienced a major mental illness have developed or operated a small business at some time in their lives. Despite the obstacles, self-employment is becoming an increasingly desired work option for many individuals with disabilities. Self-employment provides a high degree of independence and control over one’s economic future, and satisfies a personal work objective. For individuals with disabilities who believe that traditional vocational programs promote "learned helplessness," self-employment can be an opportunity to control their own vocational future, independent of the vocational service system.

Small business development is a blend of art, science, and passion. To be successful, a business must be economically viable, meet its business operating expenses (e.g. salaries and fringe benefits, rent, utilities, production costs) through sales revenue, and generate a return on investment for its owners. Not everyone, however, has the capacity to build an enterprise with the characteristics necessary to be a sustainable business. Among the personal attributes needed to create and sustain a business venture are creativity, dedication, self-sacrifice, business acumen, technical and marketing skills, and a desire to be self-employed.

Utilizing one’s inherent skills, motivation, and talents to develop a meaningful and rewarding career reflects the cornerstones of recovery—hope, willingness, and responsible action.^[35] InCube, Inc. was an early pioneer in efforts to help consumers develop their own businesses. Established in 1990 in New York City, this consumer-managed and staffed organization helped more than 30 small business enterprises that provided full or part-time employment to more than 70 consumers.

InCube’s work inspired similar efforts throughout the country and worldwide. The organization helped aspiring entrepreneurs assess their skills, interests, experiences, financial resources, and family and collateral supports. People received help to develop a business plan, obtain start-up funds, acquire equipment, access training needs, and market their products or services. The InCube strategy tightly linked business development assistance to peer and self-help supports to help people balance and strengthen both their recovery and their self-employment priorities. While InCube has reduced its services in recent years, its founder remains active in both national and international forums promoting the possibilities and best practices of supported self-employment and inspiring consumers to take charge of their own economic futures through entrepreneurship.

In rural locations, where both employers and jobs may be scarce, self-employment may be a viable work option where few large employers exist.^[36] However, vocational rehabilitation (VR) support for self-employment varies throughout the country. In 1988, for example, only 2.6% of all successful VR case closures were to self-employment. A more recent study suggests that the variation across state VR policies is one reason for low utilization of the self-employment option.^[37] However, with the 1998 amendments to the Vocational Rehabilitation Act that reaffirm the value of self-employment as a viable employment goal, this trend may begin to change.

While no single approach to supported self-employment exists, currently successful methods and their implementation have been described, including those related to helping people own equipment, computers, etc., needed to start and operate their business.^[38] In addition, rehabilitation staff must acquire new skills and assess their own personality traits in order to help people with disabilities achieve success as small business owners.^[39]

A Note about Supported Education

Mental illness often manifests itself in late adolescence and early adulthood, critical years when important decisions concerning education and careers are made. People whose jobs and career development have been interrupted by serious mental illnesses must have opportunities to regain exposure and experience in the world of work. Similarly, people whose education is interrupted must obtain assistance to reconnect and continue with their educational development.^[40]

Through supported education, people receive help to define their educational objectives, such as getting their high school GED or a post-secondary degree. Support and assistance for education can be provided in a number of ways. For example, some programs use on-site support in which people receive individual counseling, college placement, and support from an educational coach who provides ongoing assistance both on- and off-campus. Other programs utilize a mobile team similar to the on-site model except that services are provided at more than one post-secondary site by a mobile team, usually from the community mental health center. Another strategy is to provide remedial education and educational readiness services in on-campus, self-contained classrooms to ease the re-entry into the college mainstream.

Two Federal statutes—the Individuals with Disabilities Education Act (IDEA) and the Carl D. Perkins Education Applied Technology Education Act—have language addressing the coordination of vocational and educational planning for people with disabilities. Educational institutions maintain an Office of Disabled Student Services (ODSS) which handles issues related to accommodations under the Americans with Disabilities Act (ADA) and can be a valuable partner in a supported education program. ODSS often has contact information for mental health treatment services, as well as for counseling services to help with adjusting to college life. These offices also work with academic staff to raise awareness about disabilities and provide support and accommodations to help students meet classroom requirements.

Support needs of consumers re-entering school can be similar to those for people acclimating to a competitive work environment. That is, consumers may have greater difficulty managing and negotiating the interpersonal relationships at school than they do in meeting their class requirements. Helping people accept praise and criticism, attend to tasks, work with classmates and instructors, and identify and acquire natural supports, are often critical skills needed for success. Mainstream public and private sources, as well as state departments of vocational rehabilitation, can provide tuition assistance, and mental health departments often support case management and educational counseling. The challenge is to coordinate all the funds needed to pay tuition, provide support while in school, ensure a safe, affordable place to stay and study, and offer ongoing support as needed.

Barriers to supported education, in many respects, are similar to those for supported employment. The stigma associated with mental illness, the side-effects of medication that affect concentration and functioning, poor support systems, the need to manage a job and one’s recovery process, in addition to school demands, are among the barriers faced by consumers. Since many people were in school or about to enter school when their mental illness began, there may be the corresponding fear and lack of confidence in resuming a path that may be associated with the onset of the illness. Still, supported education may be an essential element to address for many consumers who are attempting to achieve their employment goals.

Chapter Summary

During the past two decades, a number of best practices have been developed to increase employment success for people with serious mental illness. While particular approaches may differ, the essential and common elements include a focus on helping people meet their stated goals for employment and/or education, and providing the ongoing support to grow and sustain their efforts. Individuals may require different services at different times, with varying levels of intensity. Whether a person participates in employment goal-setting, rapid job placement, or addresses worker role recovery through return to school, the right to choose and participate in planning one’s own employment future must be respected and nourished. It is recommended that this person-centered and recovery-focused approach be the foundation for whatever type of employment service is developed and offered.

Chapter 3 Notes

^[1] This Chapter contains material adapted from: Shaheen, G., Bianco, C., and Falco, A. "Employing people with mental illness who are homeless: Surveying the field." Paper prepared for the CMHS Sponsored Employment and Vocational Rehabilitation for Homeless People with Serious Mental Illnesses Workshop, Washington, DC, September 1999; and Bianco, C. and Shaheen, G. Employing Homeless People with Mental Illness: Principles, Practices and Possibilities. Unpublished draft prepared for the CMHS PATH Program. Albany, NY: Advocates for Human Potential, July 1999.

^[2] Ridgeway, P., and Rapp, C. The Active Ingredients in Achieving Competitive Employment for People with Serious Mental Illness: A Research Synthesis. Lawrence, KS: University of Kansas School of Social Welfare, 1998.

^[3] Beard, J.H., Probst, R.N., and Malamud, T.J. The Fountain House model of psychiatric rehabilitation. Psychosocial Rehabilitation Journal 5(1):47-53, 1982.

^[4] Black, B.J. Work as therapy and rehabilitation for the mentally ill. Altro Institute for Rehabilitation Studies, Professional Monograph Series: Volume I, New York, NY 1986.

^[5] Anthony, W., Cohen, M., and Farkas, M. Psychiatric Rehabilitation. Boston, MA: Center for Psychiatric Rehabilitation, 1990.

^[6] Ridgeway and Rapp, op.cit. p. 29.

^[7] Wehman, P. and Moon, M.S. Vocational Rehabilitation and Supported Employment. Paul H. Brookes Publishing Company, 1998.

^[8] Rehabilitation Act Amendments of 1986 PL 99-506, 1986 and PL 102-569, 1992.

^[9] Bond, G.R., Drake, R.E., Mueser, K.T., and Becker, D.R. An update on supported employment for people with severe mental illness. Psychiatric Services 48(3): 335-46, 1997.

^[10] MacDonald-Wilson, K., Revell Jr., W.G., Nguyen, N., and Peterson, M.E. Supported employment outcomes for people with psychiatric disability: A comparative analysis. Journal of Vocational Rehabilitation 1(3): 30-44, 1991.

^[11] Becker, D.R., and Drake, R.E. A Working Life: The Individual Placement and Support (IPS) Program. Concord, NH: New Hampshire-Dartmouth Psychiatric Research Center, 1993.

^[12] Bianco, C., and Shaheen, G. Employing Homeless People with Mental Illness: Principles, Practices and Possibilities. Unpublished draft prepared for the CMHS PATH Program. Albany, NY: Advocates for Human Potential, July 1999.

^[13] Danley, K.S., and Anthony, W.A. The Choose-Get-Keep Model: Serving Psychiatrically Disabled People. Boston, MA: Boston University Center for Psychiatric Rehabilitation, 1988.

^[14] Bond, G.R., Becker, D.R., Drake, R.E., Rapp, C.A., Meisler, N., Lehman, A.F., Bell, M.D., and Blyler, C.R. Implementing supported employment as an evidence-based practice. Psychiatric Services 52(3): 312-322, 2001.

^[15] Ibid.

^[16] Becker, D.R., Smith, J., Tanzman, B., Drake, R.E., Tremblay, T. Fidelity of supported employment programs and employment outcomes. Psychiatric Services, 52: 834-836, 2001.

^[17] Edgar, E. The Role of PACT in Recovery. Arlington, VA: National Alliance for the Mentally Ill, 2000.

^[18] Russert, M. G. and Frey, J. L. The PACT vocational model: A step into the future. Psychosocial Rehabilitation Journal, 14(4), 7-18, 1991.

^[19] Ibid.

^[20] Drake, R. A brief history of the individual placement and support model. Psychiatric Rehabilitation Journal 22(1): 3-7,1998.

^[21] Drake, R.E. and Becker, D.R. The individual placement and support model of supported employment. Psychiatric Services, 47(5): 473-475, 1996.

^[22] Becker, Drake, op.cit., p. 29.

^[23] Torrey, W.C., Becker, D.R., and Drake, R. Rehabilitative day treatment vs. supported employment: Consumer, family and staff reactions to a program change. Psychosocial Rehabilitation Journal 18(3): 67-75, 1995.

^[24] Drake, R., Becker, D., Clark, R., Mueser, K. et al. Research on the individual placement and support model of supported employment. Psychiatric Quarterly 70(4): 289-301, 1999.

^[25] Ibid.

^[26] Bond, G.R., Drake, R.E., Mueser, K.T. An update on supported employment for people with severe mental illness. Psychiatric Services 48: 335-346, 1997.

^[27] Emerson, J., and Twersky, F. (eds). New Social Entrepreneurs: The Success, Challenge and Lessons of Non-Profit Enterprise Creation. San Francisco, CA: Roberts Foundation Homeless Economic Development Fund, 1996.

^[28] Fleischer, W. Work in Progress: An Interim Report From The Next Step: Jobs Initiative. New York, NY: Corporation for Supportive Housing, 1997.

^[29] Granger B., Baron, R., and Robinson, S. Findings from a national survey of job coaches and job developers about job accommodations arranged between employers and people with serious mental illness. Journal of Vocational Rehabilitation 9: 235-251, 1997.

^[30] Proscio, T. Work in Progress 2: An Interim Report on Next Step: Jobs. New York, NY: Corporation for Supportive Housing, 1997.

^[31] Whiting, B. Employing the Formerly Homeless: Adding Employment to the Mix of Housing and Services. New York, NY: Corporation for Supportive Housing, 1994.

^[32] Bianco, C., Shaheen, G., and Golden, T. Integrated Employment for People with Serious mental illness: A Rehabilitation and Recovery-Based Approach. Ithaca, NY: Cornell University, 1997.

^[33] Church, K. Build Your Own Boat. Presented at Navigating the Waters, Canadian Association of Independent Living Centers, Ottawa, Canada, September 2000.

^[34] Bianco, Shaheen, Golden, op.cit., p. 30.

^[35] Deegan, P. Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal 11(4): 11-19, 1988.

^[36] Raveloot, C., and Seekins, T. Rehabilitation counselors’ attitudes toward self-employment as a rehabilitation strategy. Rehabilitation Counseling Bulletin 39(3): 189-201, 1994.

^[37] Arnold, N.L., and Seekins, T. Self-employment as a vocational rehabilitation closure in urban and rural areas. Rehabilitation Counseling Bulletin 39(2): 94-106, 1995.

^[38] Hammis, D. Steps to success: Supported self-employment. In Future Designs: The Annual Monograph of the Montana Consumer Controlled Careers Project. Montana Affiliated Rural Institute on Disabilities, 1999.

^[39] Griffin, C. Supporting entrepreneurs with disabilities: Vital characteristics for rehabilitation personnel. Rural Exchange Newsletter 12(2), 1999.

^[40] Unger, K. Supported post-secondary education for people with mental illness. American Rehabilitation, Summer: 10-33, 1990.

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