Supported Employment

Supported employment is an individualized rehabilitation approach developed as a means of addressing the inadequacies of traditional employment methods. Originally developed to assist persons with psychiatric and intellectual disabilities, supported employment was adapted in the early 1980s for use with persons with brain dysfunction. Supported employment has become the standard of practice for many vocational rehabilitation professionals. The approach to vocational rehabilitation is well suited to illustrate the benefits of real-world cognitive rehabilitation efforts and the use of compensatory strategies. Despite progress in rehabilitation program development, return to work remains a formidable challenge, especially for persons with severe cognitive impairments. In many societies, employment is the basis of an adult's personal identity, with higher paying and more prestigious occupations affording higher levels of social recognition. Consequently, many unemployed persons with brain dysfunction view their recovery as incomplete or insignificant.

There are many variations of supported employment. Services are provided by job coaches or employment specialists. In contrast to traditional programs, which focus on job acquisition, emphasis is placed on helping people maintain jobs. Characteristics of the successful model include the following:

* Community placement and integration: Clients are helped to find and keep jobs in their home community by working in local businesses. In an effort to avoid segregation and promote widespread community integration, one to four clients work alongside nondisabled coworkers.

• Competitive hiring, wages, and benefits: Clients are hired through the same competitive process as other employees, such as by completing the employer's standard application form and attending an interview. Often, employment specialists help clients complete job applications, provide transportation, or prepare the client for an interview using role-playing techniques. Furthermore, workers with disabilities receive the same pay and benefits as coworkers.

• Emphasis on inclusion: Rather than excluding clients on the basis of mental health or behavioral or medical problems, an interdisciplinary team follows the client to meet needs for rehabilitation, medical care, and mental health services before and after placement.

• Holistic assessment of the client, home environment, and workplace: Assessment often includes a series of questionnaires completed by the client and family members; center-based and community-based interviews with clients, family, employers, and cow-orkers; and a comprehensive neuropsychological evaluation. Additionally, a job analysis is conducted in which the job coach visits each potential employment site and evaluates the characteristics of the workplace. A special effort is made to understand the exact nature of job responsibilities, the degree of interpersonal interaction with customers and cow-orkers, safety risks, and level of available supervision.

• Emphasis on choice and job matching: People, regardless of disability, are less likely to succeed at a job that is demeaning, meaningless, or boring. Although the client has the final choice regarding which job to apply for, the job coaches strive to match clients' goals, interests, and abilities with appropriate employment settings based on job analysis.

• Emphasis on intervention after placement: On average, 32-36 hr of intervention time occur prior to placement, whereas 240-260 hr occur within the first 6 months following placement. Ongoing behavioral and cognitive rehabilitation techniques are utilized within the workplace. Problems with memory are common after brain injury and severely limit generalization from preplacement training. Strategies such as self-monitoring, rehearsal, and reinforcement are used to teach and help generalize skills.

• Coworker and employer education: To alleviate negative attitudes, prior to placement the job coach provides the employer and coworkers with educational materials regarding the effects of brain injury and information concerning the client's positive attributes. After placement, the job coach acts as a liaison between clients, coworkers, and employers, maintaining communication between all parties.

• Long-term follow-up: After placement, the client may face many difficult situations that all people face during employment. For example, there may be changes in personnel or job responsibilities. External life stresses may interfere with productivity. Job support and intervention fluctuate as new problems are encountered and resolved. Feedback from the client, supervisor, and rehabilitation team is considered in the determination of follow-up intensity. Early on, the employment specialist may spend the entire workday with the client to identify problems, develop methods of resolution, provide direct feedback, and reduce the client's stresses. With job mastery, the employment specialist "fades," reducing direct intervention time. After employment stabilization (e.g., 6 months following placement), follow-up may require 2 or 3hr per month.

• Job completion guarantee: Prior to employment, job coaches assert that clients will meet work responsibilities. A system of checks and balances is employed by the coach, including having the job coach work alongside the client to make certain job goals are met.

• Intensive ongoing analysis of program outcome: To ensure efficacious supported employment programming, ongoing data collection and analysis are essential. Program data include typical information such as injury severity, age, time elapsed since injury, employment status, and wages. In addition, the following information is collected: hours and types of intervention, employers' and clients' performance and satisfaction ratings, reasons for job separation, factors promoting successful work outcome, and level of employment stability.

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