“Work can be a very powerful antidepressant,” says Rick Martinez, medical director of corporate contributions for Johnson & Johnson in New Brunswick, N.J. “It gives a huge lift to self-esteem.”

Though Martinez’s words may ring true for many people, he is talking specifically about people with serious mental illnesses. Studies from the New Hampshire-Dartmouth Psychiatric Research Center (PRC) suggest that although the majority of people with serious mental illness want to work, only a fraction of them are employed. “Their goals are no different from someone without a psychiatric disability,” says Larry Abramson, director of vocational rehabilitation at St. Luke’s House in North Bethesda, Md. But his clients—adults with serious mental illness such as schizophrenia or bipolar disorder—“need some supports,” he says.

Enter the Johnson & Johnson-Dartmouth Community Mental Health Program. Since 2001, Johnson & Johnson executives have worked with researchers from Dartmouth Medical School to offer a type of employment service called individual placement and support (IPS). IPS is an evidence-based approach to helping people with mental illness find and retain good jobs. As part of the Johnson & Johnson program, a participating site—typically a community mental health clinic—will assign clients an integrated mental health treatment team. The team may include a psychiatrist, psychiatric nurse, and case manager as well as an employment specialist from the site, trained by Dartmouth, and a state vocational rehabilitation counselor.

The team helps to identify a job that meets a client’s needs, strengths, and job preferences. As a result, two to three times more people with mental illnesses find and maintain employment through IPS than through other employment services, says Deborah Becker, an assistant professor of community and family medicine at Dartmouth Medical School.

With Robert Drake, director of the PRC, Becker first described and defined IPS in the early 1990s. Two of the service’s big ideas have been to bundle proven practices that help mentally ill clients find jobs and to guide clients to competitive jobs that pay at least minimum wage, rather than to ones designed for people with mental illness. This integration approach, program leaders say, has helped clients avoid boredom, isolation, low self-esteem, and discrimination. Unlike other programs of its kind, IPS does not require clients to complete drawn-out vocational training before they can apply for a job.

The PRC requires that clients receive mental health services as part of the IPS model. Once clients are on the job, employment specialists and psychiatrists—with the client’s approval—work together to discuss symptoms, medications, and accommodations that will help clients succeed at work. Meanwhile, employers are reassured to know that clients will continue to receive support from both employment specialists and mental health professionals.

“People who are symptomatic can still be good workers,” says Howard Goldman, a professor of psychiatry at the University of Maryland School of Medicine and a member of the Johnson & Johnson-Dartmouth advisory board. “You don’t have to be 100 percent well to be 100 percent employed.” Something as simple as, say, wearing a headset to drown out auditory hallucinations can help a client work effectively.

A PRACTICAL PARTNERSHIP

In the late 1990s, senior management at Johnson & Johnson began exploring how the company might do something in the area of mental health, says Martinez. Although Johnson & Johnson owns a company that does mental health research, it “had never given money away in the area,” says Becker. The National Alliance on Mental Illness and the National Institute of Mental Health steered Johnson & Johnson toward employment programs, eventually leading the company to the Dartmouth Supported Employment Center (DSEC), part of the PRC. After visiting the center, reviewing studies, and talking with the Dartmouth researchers, Johnson & Johnson signed on to fund a pilot program in which the PRC would help states implement the IPS model.

“We function as a donor, so finding a partner that knows its subject matter was our first step,” says Martinez. The published evidence affirming IPS’s effectiveness “signaled to us that here was an idea that was successful and accepted by peers.”

The pilot program began in 2001 with one site in each of three states: Connecticut, South Carolina, and Vermont. Nine years later, the program has expanded to 12 states and a total of 115 sites. Although not every site is a mental health center, all must connect clients to mental health services as part of the IPS model. Without effective IPS services, “only about 10 percent of people with serious mental illness are able to work in competitive jobs,” says Martinez. “We were able to convert that into 40 percent to 50 percent at some sites.”

Before a state begins the program, Dartmouth gives the state’s mental health authority and department of vocational rehabilitation an application, which the two agencies must complete together. “We learned that we need to talk with the state leadership team right from the beginning and have clear expectations,” says Becker. To participate in the program, the state needs to demonstrate interest, commitment, and a willingness to work with Dartmouth to develop state-level funding and support for the IPS model.

In Maryland, where funding has shifted from Johnson & Johnson to public sources, sites earn more if they show high fidelity to the model. If a local site is not following the IPS model, it receives technical assistance to get back on track. For example, a site may break its connection to a mental health center so that clients are no longer receiving mental health services, notes Goldman. In this case, the program would help reconnect the provider to a mental health center, as well as warn the provider that it needs to return to the model or risk losing its funding. In one case, a site eventually lost funding from Johnson & Johnson-Dartmouth because it “didn’t meet fidelity requirements and was not going to work toward good fidelity,” says Becker.

Like Maryland, South Carolina no longer receives funding from Johnson & Johnson. Yet “the Johnson & Johnson-Dartmouth Community Mental Health Program continues to be an integral component of the IPS program in South Carolina,” says Alfreda King, director of community and client relations for the South Carolina Vocational Rehabilitation Department. Because the IPS program has worked so well to assist clients with mental illness, South Carolina is now using similar techniques to help clients who are deaf and hard of hearing, clients with brain and spinal cord injuries, and youths transitioning from school to work. The South Carolina IPS teams also “have access to the best and most current technical assistance and training” from the PRC, adds King.

SHARED INTERESTS, SHARED FUTURE

As IPS gains momentum, many different stakeholder groups reap the gains. Employers benefit because employees with mental illness receive the support they need to be consistent and effective workers. People with mental illness who find employment earn self-esteem, self-reliance, and a place in the community. They also may achieve greater mental health, as they “are motivated to stay well, to take their medications,” says Martinez. “They know if they don’t stay well, they won’t be able to work.” Sally, an IPS client , was able to land a job as a dog groomer and now runs her own dog grooming business. “I enjoy working with customers and educating them about their dogs,” she says. “When people are independent and active with the public, it takes their mind off their disability.”

In addition, states save money because “people in IPS are less likely to need hospitalization and less likely to visit emergency rooms,” notes Martinez. States also save on Social Security benefits, Abramson points out. As people with mental illness find employment, he says, “they not only reduce the amount of Social Security they take out of the system, they actually put money into the system.” Abramson adds that there is “no partisanship. Republicans, Democrats, everybody loves supported employment.”

Although Johnson & Johnson may not devote funds to support IPS employment indefinitely, many people hope that the gains made through the Johnson & Johnson-Dartmouth program will be sustainable, outlasting the program itself and persisting despite government cutbacks. “We need continuing education, refresher courses, educational opportunities for new specialists,” says Martinez. Especially important is ensuring that states understand the importance of IPS and continue to reward sites following evidence- based practices. Becker describes a yearly meeting organized by Dartmouth and attended by people from each state participating in the program. “[We are] learning collaboratively,” she says, “trying to focus on sustainability, so that in these times of budget cuts, evidence-based employment services are not taken away.”

Laura Gehl writes about science and medicine for adults and children. She is senior editor of Science Weekly, which offers interactive, educational science content.

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