Deborah (Debbie) R. Becker, MEd, CRC - Senior Research Associate with Individual Placement and Support speaks about the gold-standard, evidence based method of supported employment for individuals with serious mental illness, which brought hard research into the supported employment world. Debbie speaks about early research, key parts of the method, and the international IPS learning community, which includes 24 states and six countries/regions outside of the United States.
Welcome to the landscape. A podcast to shed light on the people, programs and businesses that are changing the landscape for individuals with any type of disability. I'm your host. No avail. Dar Today's episode will feature Debbie Becker, a senior research associate with Individual Placement Support, which is the gold standard, research based method of support employment for individuals with serious mental illness. The method also ripples beyond service providers as they are a model for the power of local and international collaboration. We start with Debbie speaking about how they decided to research employment.
Actually, um, our team had been researching other topics. Bob Drake, who is our leader and was our leader at the Dartmouth Psychiatric Research Center. Ah was very interested in dual diagnosis, and so had been working in that area with his research. But then he was asked to collaborate on a research grant with Bill Anthony, actually from Boston University, and, ah, Bill wanted to research a program in New Hampshire that did something close toe what they do the choose get keep. And so, Bob, um knew me from working at our local mental health center together, and so he actually recruited me to help with this Grant. And we developed I ps for that grant is what happened. I ps, as you know, stands for individual placement and support. So it was It was a randomized controlled trial where I P s was compared to this other model. And so Bob has always been interested in service is for people with serious mental illness. So, of course, employment, um, was one of those areas, and so he wanted to do it, and and it just ah became the focus of my career. But but also in large part are our center.
So can you explain very briefly, what is randomized trials and why they're important?
Yeah. Okay, so a randomized controlled trial is used to test two or three different interventions to see which one is most effective. And so when we did, um, they sometimes call them are Seti's for short, a randomized controlled trial for employment. We would go into a mental health center and ask people clients being served. Would you be interested in being part of a study to learn which to employment interventions are more, Which one is more effective? And so it's like a flip of a coin. People who say yes, I want to be part of this study. I understand. Intervention A I understand intervention. Be, um I will sign up. And so, by a flip of the coin, they would get one of the two interventions which they would then participate in. And then all things being equal, we would see which intervention had better employment outcomes.
Right? And so what were the findings? Year one. What should have been 1996 Correct.
Yeah. So we don't look at the findings till the end of the study is a three year study, and I p s ah, had many more people go to work then the other intervention, and that's really been replicated. Now, in 26 of 27 studies worldwide, the only one, um, that was not ah, that was borderline significant. Meaning borderline. Um, close to making. Being significantly different was in mainland China, but otherwise I p s has been studied in These are SETI's around the world.
And so what are some of the elements that make I p s different from these other methods?
Okay, So traditional employment service is were more stepwise. The thinking Waas. We need to help people prepare for going toe work, so that might be in a sheltered workshop where they would practice going toe work on time and staying on task. They might be asked to go to be on a work crew after that out in the community, or they might be asked to volunteer to show that they can be successful working. But I PS individual placement and support took a different tack that that people didn't really need that what was important was to understand who the individual is, what their skills are, what they've done in the past. What do they want to do and try to figure out where that ISS out there in the work world? And so, um, people didn't drop out of these, you know, I ps, they wanted to stay in. They wanted to get work. They didn't want to have it postponed while they were doing supposed to do vocational assessments, occasional evaluations. And I think that's what's helped to make it successful is because we're honoring what people want. They want to goto work, and so and we're listening to what they want to do. So, um, people's preferences are extremely important for the type of work the kinds of jobs supports that they have. And so I think you know that that is a huge difference. Another big difference is that it's really a team approach. And so the D. I PS specialists, they connect with the mental health treatment team, and so they're part of the team, and they they plan together. And they, um, proposed ideas toe suggest to the individual about going to work. They know that what their skills are and and previously really had they were not integrated. Service is the thinking was that employment service is our better separate, but that didn't turn out to be the case.
It's interesting because so you have a Fidelity fidelity model, um, and then But you also on top of the fidelity, you have eight principles and out I was reading over those toe refresh my memory and on, and I picked the two that you named because I said if there were two game changers, from what I saw, that just really challenged peoples. Um, really, everything that ever been taught one was zero exclusion, Um, because, as you know, a soon as you say it. People look at you like you're you know, you're just doing the wrong thing. Um and so can you talk a little bit about zero exclusion? And was that implemented from the very beginning?
It wa ce we started, I think with six principles, we now have eight. Um and that was one of the six. And the the ideas that we're not going to screen people out who have had problems with the justice system, people who were using alcohol and drugs. That's a big one, huh? Ah, a lot of clinicians and other agencies, they don't think people should be able to, ah, use thes service's and goto work successfully. But the thing is, is that people need a reason to not use right. And so work becomes, um, you know, a motivator for people to not USA's much or to figure out when they're gonna use and have it not having interfere with work. So the zero exclusion is a tough one for a lot of people. A lot of clinicians, because they think they can predict who's gonna goto work and who's not gonna goto work. And I can remember being a project director for several of these studies, and I would go in, um, and tell the consumers about the possible study. And then clinicians would hear that they were randomly assigned to I. P s and they'd say, Oh, it's never gonna work. John's not going to go to work. And guess who was the 1st 1 to go to work with I PS. It was John
John, right? Exactly. You know, it was a huge challenge for our vocational rehabilitation because they had a policy that if somebody was recently released from the hospital or if somebody was actively drinking, for example, that they would not serve them. And so I ps became their Onley letter of agreement, which is what we call it here in Tennessee. I don't know if it's called that everywhere that allows for those individuals to be admitted like you cannot turn anybody down. And I will say, whenever I'm around v R counselors in a meeting in I P. S comes up, they cheer because they have such good outcomes from it. I know you kind of downplayed to the little, but, you know, in some cases you doubled and tripled the outcomes of people who were goingto work
right? Absolutely. And and today there are still people in ST vocational rehabilitation who haven't been exposed a lot toe I ps and still question whether this makes sense. But how it comes to make sense is that they see that I ps is gonna help them get their better outcomes and and see people doing better. But, um, it's it's ah, shift in thinking, really,
it is. And there was a therapist on a team, and and she became one of the biggest cheerleaders because she thought we were absolutely going to be a train wreck. Right? Like that. This person's gonna goto work, or these individuals are gonna goto work that aren't quote unquote stable, um, and and they're gonna lose their job. And it took, you know, one or two successes for her to realize Oh, my gosh, the research is correct.
Yeah, yeah, well, and it's also I think it's worth mentioning that people tend to go through two or three different jobs before they may settle in tow one. And so, um, you know, we can't expect that people, as we all did right in her work careers that, um you know, the people may end up going through a couple of different jobs before they really figure out what? What's the right one for them?
And is it just the percentage of people that found a job that increased her that Were there other data points that increase like ours worked or income or anything like that?
Well, because more people went toe work, those those data points increased as well. But there were fewer dropouts in I. P s programs compared to the other interventions that have been studied and that they work more hours, earn more money. Um, and they're more satisfied.
So one of the reasons, like if you're reading about it, is this concept of recovery from mental illness and so people that don't work in the field I have no idea what that means. So can you speak a little bit about what is recovery for mental illness?
Yeah, So recovery doesn't mean that all symptoms are necessarily gonna cease, but it's really that people are gonna go past that in their lives, and they're gonna have functional lives, and they're going to have a work life or they are going to live. Maur independently than they have in the past. So the focus is not on the disability and what are the barriers? But it's going forward. And having a life and having a life for most people includes having some kind of a meaningful employment. And it may be going to school as well to have, um, career advancement, but and and living independently and in having some kind of social, ah network that's important to them. And so, um, people, I think I ps really what has been successful around because of the timing. And it was at the time that sort of strength based service is Charlie Rap started writing about and and the recovery movement in which people said people with a lived experience, that we want more and we want to make decisions and we don't want the practitioners telling us what to do.
Imagine that, um, and one of the things that I was drawn to, I P s where immediately was the fact that it was researched base because, like you said, our intuition with the disability community has been pretty terrible. When you think about it, like we we think they can't or they should be in. Like you said, Enclaves are or mobile work crews or things like that, and very little has been done toe. Take what they wanted into consideration and then to see. Are we right or are we wrong? And so that's that was, That's the beauty of research and it's just it's just lacking. Is there? Is there any other populations that you're looking at besides individuals with severe, persistent mental illness?
Oh yes, I PS is spreading to lots of different populations, even people with physical disabilities. So people with spinal cord injuries and this is being studied in the Veterans Administration, but also in Europe. They're studying people with common mental disorders. And so, um, they're they're studying i ps with refugees. And so people with intellectual disabilities autism spectrum disorder. So there's there's really been, ah, a spread over many different populations and and vocation. You mentioned state vocational rehabilitation that's occurring in a number of states, and, um, Illinois, for example, are is spreading. I ps vary widely across different populations.
Interesting. I know Here in Tennessee, we are piloting some programs with, um, the dual diagnosis of intellectual developmental disability with a mental illness um And so that's something where it's a very astute population that that is often doesn't have specialized service is for them, like they want to give them one or the other. So we're very excited just to see what the outcomes will be for that.
Yeah, I think what? What makes that, um, easily applied to different populations is that I P s is a very practical approach, and it's very individualized. So we, um you know, if you look at the fidelity scale, we have a 25 item fidelity scale, and they'll talk about integrating with mental health treatment. Well, if they're going to be serving a different population, you can still use the scale. You can still use the principles. You would just change the word mental health treatment team to the team of people that are serving that population.
Right? Right. Um, how do you validate somebody scoring the fidelity scale? How do you oversee that?
So Gary Bond has done tremendous work in terms of validating fidelity scales, and he helped to validate the 15 item Ah, I PS scale. And as we learned more, that's another thing about I PS Is that as we learn, we change things, we add things. And so we have the 25 items scale that he validated. So what that means is that the higher your score, the better your score on the scale. The total scale score, the better employment outcomes that you're gonna have is what he found.
OK? And who is it? A self assessment?
No, no, no, no. We don't self assess very well. And we have found that that some sites will think they're doing fabulous where outside objective reviewers would not agree with that or we fan sites that have tried these self assessments that are just really hard on themselves, and that doesn't work either. So we, um, try to train the sights and states to have trained Fidelity reviewers who can objectively come in and score. They visit a site for a day and 1/2 to 2 days to look a activities and documentation that's used to score the 25 items. Now, not all states may have enough Fidelity reviewer, so it may be that, um, somebody in Q eh? Or ah, within it, a large agency could be trained. We recommend having to ah Fidelity reviewers for a review.
Okay, Now, one thing I was surprised about is so my program, we wanted to go off fidelity a little bit. So part of part of the fidelity is that one person does all the service is for an individual. So it's not. Nobody's handing off for different times in my program. Wanted to try having a job developer, a standalone job developer. That's all they're gonna do is go into the community. And John developed. And And so I wrote you guys and you gave us permission. You said, Yeah, OK, give it, give it. Of course, it would impact our fidelity score, but you didn't say no, Not they don't do that. Um, but lo and behold, you know, a year later, we were like, yeah, should have tried that. I should have just listened to what the fidelity said. But that brings us to job development, because I will tell you, and I don't know if you're aware of this. Um, So you have a very specific model of how to job develop, and that is a huge game changer. So it has nothing to do with the population. So I currently work with individuals with the intellectual developmental disability. So I have used is caught three cups of tea. I'm gonna let you talk about it. I have trained three cups of tea to our providers with that population across the state, and it is hands down. The training that they were like this changed my professional life. It is because there are no other methods. There's, like suggestions and theirs. But you have a very specific do A B. You have a book that goes with it. So can you tell us a little bit about one? The method very briefly. And then how you even came up with it?
Yeah, Well, actually, we need to give credit to Sarah Swanson because she used that name three cups of tea and outlined the method. And the thinking of three cups of tea is that it takes really three cups of tea to get to know somebody and have a relationship. And the The idea behind this method is that networking and getting to know employers and what they're looking for in who they hire is key. Many jobs are not advertised, so going to the want ads or online, you're not going to one developed that relationship with the employer. And, no, really, what's out there? So three cups of tea, the first cup of tea is at I. P s specialists will go ask ah, hiring manager or an employer if they could meet with them for 15 20 minutes to learn more about the business, the kinds of people that they hire, who does well there. And, um, and not even ask for jobs. I mean, it's well, we tell people, don't ask for a job, because if he asked for a job and they say, Well, we don't have any than that ends the conversation. So, um, the second cup of tea is when you have that 15 20 min minute conversation with a hiring manager and start getting them talking about their business and their hiring practices. And what are the different jobs that they have in the business? And so it's all about learning. It's all about getting the employer talking and excited. And then the third cup of tea and fourth and fifth are just continuing that relationship. And the the I PS specialist is thinking, um, all along they have somebody in mind, which is why they went to that employer in the first place. And they may decide. You know what? This is not the spot for Peter. Um, and that's fine. They may continue to groom that relationship with the employer because there may be somebody else who's gonna come along who has same kinds of interests in and skills. But I think what happens is that people, um they're kind of scared about job development because they don't know what to say. They don't have the questions, they don't have an introductory statement. And so this method tries to give people the tools so they can feel confident and people get more confident the more they do it. So if you just have that loan job developer, the other people are gonna safe. Glad I don't have to do that. But, you know, they're gonna miss out on all those all those jobs,
right? And it's so really, it's based on psychology. When I train it, I tell people, you know, this could be used for any thing you will ever ask for. And I give the example. So, you know, I had a mentor, and the first time I met, I met with him to say, Will you be my mentor? And he was like, Yeah, absolutely. In the second time, we got coffee ironically, um, and we just sat down and talked about our professional paths up to that point and kind of got to know each other better. And then the third time we met. And this is I am not making this up. All the third time we met were in his office, and he's like, So what are some projects you're working on? And I was and I told him and he goes, What can I do to help you? Right? And so it and that's that moment that third time to somebody's meet you, that they feel like I know you. I trust you. What can I do for you are how can I help you? If I had asked him for help the first time I met, he would have been like, Who are you and why are you talking to me? Hey, it's so I was like, That's That's three cups of tea right there. So it's something that's, um, they could be used in our day to day life. A swell, great example um So you mentioned previously Education and I P s How does education fit in If somebody wants toe, go to trade school or go to college or
Yeah, you know, when we first developed I ps, we focused on employment. But then over time, clearly, education is a part of it, and it's more likely apart for younger people, right? And and so that's what they're there. Piers were doing as well. And so education needs to be a part of I ps. And we're actually we're doing a study now of young adults, and we've, um We've gotten to know a lot of programs that serve young adults, and we find that many of these people are going to school and have a job and so so education. We we know that people, the more education they have, the better their salaries gonna be in their life. And so we want people to graduate from high school. You know, we need I ps specialists talking to people about that and then going forward, you know, um, training school certificate programs. They're always that people can move ahead in their careers. And we want we want I PS specialists to offer options to people, and so education really is is extremely important. And I'm I'm glad it's clearly now, so much a part of I ps, um, more so than we started, you know, back in the 19 nineties.
And do you find that young adults are very different from older adults in this population and outcomes or goals or anything like that?
Yeah. You know, I think, um, they sometimes change their minds a lot, you know? Really? Yeah. One day they want to do this the next day. They want to do that, and they've got their social life, and, you know, they're not, um they're not easily contacted by a telephone. You know, we know we got to be texting these young people, and we we need to be interested in what, What's going on in their life, too, for engaging young people. But they do want to work, and they want to go to school. And, um and they are doing those things. So I think I think the education piece we haven't had a a good track record of research on that. And it's hard to, you know, what is the outcome that we're measuring completion. You know of a whole program, or is it of a course or so, um, we're tryingto think about that more. But we do have a fidelity scale for we develop it for young adults. And so it has a component now for supported education. It's up on our website. Um, if people want to see that I ps works dot or GE and, um so hopefully that will help people. And we also have, Ah, a manual that we wrote a couple of years ago about helping young adults. But there's a big focus in that manual on education, anybody can go back to school. I mean, you don't have to be a young adult to do that, but we know most people are focused on that.
Yeah, we talked about changing times. I mean, when you think of I'm almost 50. When you think of people my age and older, um, families, I think didn't have a lot of expectations. It was common to put people in day treatment programs where they went all the time. But this younger population, them and their families have much higher expectations.
So, um, yes. Thank goodness. Um Can you talk to me a little bit about the learning Collaborative? What does that mean and who belongs to it.
Okay, so, um, it was initially the i PS learning community, but now it's the International I PS learning community that currently includes 24 states in this country and six other countries. This got started, um, decades ago, actually through ah, philanthropic gift of Johnson and Johnson. And, um, that's very separate from their companies and their pharmacies and pharmaceutical companies. But they had never given um before to anything in mental health and decided through the recommendation of the National Alliance on Mental Illness. And I am h that they should come talk to us, and they did, and they asked us tow demonstrate that I ps is gonna help people. So we did a small demonstration in three states. Um, Connecticut, Vermont? In South Carolina, they had good outcomes. We made a video, and so they, um, funded us through. Ah, 2000. I think it was 14. The funding us for 15 years. And then, um and so what? We did waas. They said, you know, you figure out what you want to dio um and we will provide the money for that. And so we think we wanted a model of that was going to help expand I ps across our country as well. A sustained the program. So we gave incentive money. Two states just a few at a time, and we helped them with training. We help them figure out what's the infrastructure to make this happen in in your state. So we did that with Tennessee, right? And, um, you developed a state I. P s team, and we ask that you have a partnership between the state mental health authority and state vocational rehabilitation. That was very intentional because we felt that that was a way to launch this and sustain it over time that they're they're funding sources. But also, um, you know, vocational rehabilitation. They know about jobs in the world of work. That's what they dio. They also know about a lot of different kinds of disabilities. So people with mental illness may have other illnesses going on, so it's good to have that expertise and then they help with, um, planning. And they also have resource is that people may need for supplies at work tools uniforms those kinds of things. So these two systems partner together to identify local sites 3 to 6 and have a trainer. They provide training. They collect simple outcomes that are part of the learning community. Um, it's up on our website. You can see the U. S. Outcomes and, um, we we make sure that fidelity reviews are conducted and it just has continued to expand. Ah, a number of years ago. Johnson and Johnson said, Well, we have companies all over the world, So let's let's go international with this. And so that's when we then, um, Italy, Spain and the Netherlands came on board. But, um, we also have, um, New Zealand and Canada. And so, um, parts of Montreal, um, we've tried thio keep expanding it. It's a big network, and and I guess in my career, that's what I'm most proud of. That that I've been able to help, um, help people communicate with each other and, um, and move forward through that vehicle.
I have to I don't know. I don't have to, but I'm going to pause and let you know how much I PS impact it. My professional career want it opened my mind to to you know, my own biases and things like that Because, like I said, 20 exclusion child, I think the first time you hear it like that challenges everybody. And then the other part was, um, part of your fidelity scale is having a variety of jobs. And I found that, like most teams, I think before they start something like I ps, we tend to funnel people into employers that are friendly to hiring individuals with disabilities. Um, and you actually get scored low if you have too many people working at one place so that the our program usually placed, I don't know between 40 and 55 people a year, and at the end of the year, we have, ah, banquet. And on the back of our program, we would have all the employers where our members were working and, like, you know what? When I first started, we had, I don't know, 8 10 employers, and in a couple of years in to do an I p. S, we would have, like 35 employers, and it's just a symbol of we were unknowingly not being person centered, right, cause not everybody didn't wanna work at those same, you know, big employers. So So that really impacted me, you know, working with you guys. So So anyway, it's just I get, uh, nostalgic. I miss I p s. I don't work with it much much, although I'm still in contact with it in some ways. Um, you guys also seemed tohave and I don't know if you're aware of why, but you have a pretty strong relationship with Samsa, which is the Substance abuse and Mental Health Service's administration. Ah, lot of their grants require I ps is a component. I was wondering that they approach you or did. How did that happen?
How did that happen? I'm not exactly sure how that did happen. I mean, we've worked with people from Samsa and, um, they, you know, we have an annual meeting, and so I think they became educated about it and saw that there that I ps has good outcomes and that this is you know, work is what people really want, and it it helps with their recovery. And so I think that many people at SAMHSA saw that and wanted to promote it, which has been extremely helpful for states.
Yes. Yes, because it gives additional funding for I. P s programs or staff people. Um, do you have any new strategies? Are you still evolving?
I would like to think we're still evolving. Um, you know, I think it's, ah important a part of our center that we're always trying to learn from our research. I mentioned that we have just started a study for I p s for young adults. We're gonna learn what works there. How much is different than the serving older individuals? Um, we were currently in a ah, in the midst of a social Security demonstration called the Supported Employment demonstration. And that's serving people who had had an initial denial, Um, for a, um, social security application for an alleged mental illness. And so were were dealing with, ah, different population, really, And learning about that population. So, uh, we're always learning. I think we're expanding the populations that are using I ps and are part of ah studying those different populations. So I I hope we are always continuing toe learn and well, um, modify and expand things as we do,
and that is the end of the formal part And now I'm gonna ask you some personal questions. Always end with a few personal question. Okay, Um, the first. Have you had mentors? I mentioned one earlier. I just Ice is always strongly believed in mentors. Did you have any Even, like, going back to high school? College?
Oh, boy. Um, well, there are people that I looked up to. Ah, my father was one. He was Ah, internist. Physician. Um, he was a hard worker and, um, dedicated to helping people. And I seem to have inherited some of those jeans. I think, um, and and then, ah, you know, in graduate school, there were professors that I, ah admired. And then, really, my long term mentor and, um colleague is, well, a CZ partner, Bob Drake. Um, you know, had high expectations for me, and so I I don't think I would have been able to do all the things that I have been able to do overtime without his encouragement and support. So, um, he, I guess, filled a lot of shoes for me.
Yeah. Um, you mentioned how we all tend to change jobs or change our minds over years. When you were starting school um, did you think you will be working in this field or working with the research? Was that always your intent?
No. No. You know, in college, I, um, studied English in history, you know? Then I graduated and thought, Now what am I gonna D'oh! And I went and a waitress for it lasted a month. That was a long as it went. Um, I can remember serving the person French onion soup. That was cold. I had forgotten to microwave it. It was not a good scene. So I stopped that. And and then, um, I got a job working at a state institution for people who have mental retardation. And, ah, Then I realized I needed to go back to school. Thio do something other than that. And ah, friend of mine had gone into a program for rehabilitation counseling. And at the time, it was only one year, and I thought, That's perfect, You know, I want to get through and cause I I guess I've always been one toe, um, learn through doing and working. And so that's what that's how it all evolved. Um, You know, I used to like to keep track of um, data and numbers when I was an employment specialist, but, um, maybe that gently led me toward working at the research centre, but it's it's been a good fit for me.
Uh, well, we're glad you landed there, that's for sure. Um, and the last one, Do you have any pets?
Do I have my I have two dogs. Oslo who you can see on our website under staffing. He comes to work with me every day. His brother stays at home because his brother is grumpy and we're not supposed to leave them alone together. So but they, um a slow it brightens many lives in this office. I think that we have fun with him.
Yes. Before we started taping, told us on the Web site that he's like a research assistant in training. Or so some title you get. It's like he's not just on the Web site, but he has a title. So I didn't do that. Somebody else. For more information on individual placement support, please visit their website at I. P s works dot org's, That's I PS works one word dot org's. Make sure to follow the podcast on Facebook. Instagram lengthen and YouTube under the landscape podcast. If you like to leave a comment or suggestion, please email us at comments at the landscape podcast dot com and finally subscribed to the podcast through iTunes. I heart radio Spotify or wherever you listen to podcasts and make sure to leave a review. See you next time.