238 May/June 2009, Volume 63, Number 3

Case Report of Integrated Supported Employment

for a Person With Severe Mental Illness
KEY WORDS
employment, supported
interpersonal relations
mentally ill persons
rehabilitation, vocational
social adjustment
Ashley S. M. Chan, MPhil, HKROT, is Occupational
Therapist, Department of Rehabilitation Sciences,
The Hong Kong Polytechnic University, Hung Hom,
Hong Kong.
Hector W. H. Tsang, PhD, OTR, is Associate
Professor, Department of Rehabilitation Sciences,
The Hong Kong Polytechnic University, Hung Hom,
Hong Kong; rshtsang@inet.polyu.edu.hk
Sally M. Y. Li, HKROT, is Occupational Therapist,
Department of Rehabilitation Sciences, The Hong Kong
Polytechnic University, Hung Hom, Hong Kong.
OBJECTIVE. We illustrate the implementation of an integrated supported employment (ISE) program that
augments the individual placement and support model with social skills training in helping people with severe
mental illness (SMI) achieve and maintain employment.
METHOD. A case illustration demonstrates how ISE helped a 41-year-old woman with SMI to get and keep a
job with support from an employment specialist. An independent, blinded assessor conducted data collection
of employment information, including self-efcacy and quality of life, at pretreatment and at 3-month, 7-month,
11-month, and 15-month follow-up assessments.
RESULTS. The participant eventually stayed in a job for 8 months and reported improved self-efcacy and
quality of life.
CONCLUSION. The case report suggests that ISE could improve the employment outcomes of people with
SMI. Moreover, changes in the participants self-efcacy and quality of life were shown to be driven by the
successful employment experience.
Chan, A. S. M., Tsang, H. W. H., & Li, S. M. Y. (2009). Case report of integrated supported employment for a person with
severe mental illness. American Journal of Occupational Therapy, 63, 238244.
Ashley S. M. Chan, Hector W. H. Tsang, Sally M. Y. Li
E
mployment plays an important role in the rehabilitation of people with severe
mental illness (SMI). Apart from generating income, work is associated with
positive mental health because it provides opportunities for skills development,
social contacts, and participation in the community (Ruesch, Graf, Meyer, Rossler,
& Hell, 2004). People with SMI are known to have a diminished self-concept and
a distorted sense of self-efcacy (Davidson & Strauss, 1992). Strong (1998) found
that the act of working is powerful in creating and facilitating change in a persons
self-concept and self efcacy. Strong (1998) concluded that one way to facilitate
recovery is to help people with mental illness link meaningful occupations and
experience challenges and successes in the context of meaningful work. Obtaining
and maintaining employment are difcult for people with SMI, however, as reected
in ndings that only 15% to 30% of adults with SMI are employed (Anthony,
Cohen, Farkas, & Gagne, 2002; Equal Opportunities Commission, 1997;
Rosenheck et al., 2006). The individual placement and support (IPS) approach, a
specic model of supported employment, is an evidence-based vocational rehabilita-
tion approved for people with SMI (Bond, 2004; Crowther, Marshall, Bond, &
Huxley, 2001; Drake & Becker, 1996; Drake, McHugo, et al., 1999; Lehman et
al., 2002). This approach assists people with psychiatric disabilities with rapidly and
directly obtaining competitive employment (Drake & Becker, 1996). With the
introduction of IPS, the employment rate of people with SMI was reported to reach
56% (Bond, 2004). IPS, however, has limitations in helping employed participants
sustain their jobs (Drake, Becker, Clark, & Mueser, 1999; Tsang, 2003; Twamley,
The American Journal of Occupational Therapy 239
Jeste, & Lehman, 2003; Wallace, Tauber, & Wilde, 1999).
Researchers have suggested that further improvements
should be made so that IPS will result in more positive out-
comes and long-term employment (Cook et al., 2005;
McGurk, Mueser, & Pascaris, 2005; Twamley et al., 2003;
Wallace et al., 1999).
Integrated Supported Employment
Approach
People with schizophrenia and other forms of SMI have
decits in social functioning (Bond, Drake, & Becker, 1998).
The literature has documented that social competence is one
of the most signicant and consistent predictors of employ-
ment outcome among people with mental illness (Tsang,
Lam, Ng, & Leung, 2000). Moreover, problems with job
retention have been found to be related to social functioning.
Studies have shown that interpersonal difculty is the most
frequently reported job problem (58%; Becker et al., 1998;
Mak, Tsang, & Cheung, 2006). Tsang (2003) therefore
developed the integrated supported employment (ISE)
approach to help people with SMI acquire the social skills
necessary in the workplace and also to support them in
obtaining and maintaining competitive employment. The
service protocol consists of two basic intervention compo-
nents: IPS and work-related social skills training (WSST;
Tsang & Pearson, 1996).
In a randomized controlled trial, Tsang (2007) found
that signicantly more ISE participants (78.8%) than IPS
participants (53.6%) obtained competitive employment. In
addition, ISE participants worked longer than IPS partici-
pants (25.12 weeks vs. 11.95 weeks, respectively) after 15
months follow-up service. This study bolstered our hypoth-
esis that ISE participants would have better vocational out-
comes than IPS participants. Because ISE has been shown
to be effective in developing social skills and improving voca-
tional outcomes, it likely exerts a positive impact on the
recovery process of people with mental illness.
ISE Protocol
The implementation of ISE follows the steps of a typical
IPS program (Becker & Drake, 1993). WSST is provided
to ISE participants before they obtain employment. In addi-
tion to the WSST sessions, a skills generalization approach
is used throughout the follow-up process. The skills gener-
alization approach places special emphasis on providing
assistance to participants in developing and maintaining
good and cooperative working relationships with their
supervisors, fellow workers, and customers. The ISE proto-
col is shown in Figure 1.
Although ISE has been empirically tested (Tsang, 2007),
this testing does not mean its innovative protocol translates
automatically into clinical practice. This article illustrates
with a case vignette how an employment specialist helped a
participant go through different stages of the ISE service and
supported her in obtaining and maintaining competitive
employment. We hope this article serves as an exemplary
case that rehabilitation professionals such as occupational
therapists, psychologists, and social workers will consult
when applying ISE in their settings.
Case Description
Ms. L was a 41-year-old woman who had experienced
depression since 1990. She came from a highly educated and
middle-income family.
Assessment
An independent assessor unaware of the details of the case
conducted data collection. Assessment was conducted at
pretreatment, and follow-up assessments were conducted 3,
7, 11, and 15 months after Ms. L participated in ISE service
(the protocol has been described in Tsang, 2007). Assessment
included the Vocational Social Skills Scale (Tsang & Pearson,
2001), the Chinese Job Stress Coping Scale (Tsang, Chan,
Wong, & Liberman, in press), the Personal WellBeing Index
(Lau, Cummins, & McPherson, 2005), and the Chinese
General Self-Efcacy Scale (Zhang & Schwarzer, 1995). The
10-item Vocational Social Skills Scale measures participants
perceived competency in handling work-related situations.
This checklist has demonstrated good internal consistency
(.80) and moderate to very good testretest reliability (.35
to .78; Tsang & Pearson, 2001). The 21-item Chinese Job
Stress Coping Scale assesses participants coping strategies
when faced with job stress using a 5-point response scale
ranging from 1 (hardly ever do this) to 5 (almost always do
this). The 9-item Personal WellBeing Index measures par-
ticipants subjective well-being. This scale has good internal
consistency (.80) and structural validity (Lau et al., 2005).
The 10-item Chinese General Self-Efcacy Scale assesses
participants general self-efcacy and has good internal con-
sistency (0.920.93) and testretest reliability (0.750.94;
Zhang & Schwarzer, 1995).
Treatment
Referral. Ms. L was referred to the ISE service of our
research team at the Hong Kong Polytechnic University by
a nongovernment organization in 2005. On admission, Ms.
L had been unemployed for more than 10 years. She did not
know how to obtain a job and what kinds of jobs would be
suitable for her.
240 May/June 2009, Volume 63, Number 3
Figure 1. Protocols of integrated placement and support (IPS) and integrated supported employment (ISE).
Note. WSST = work-related social skills training.
Building a Relationship. In the rst meeting, the employ-
ment specialist introduced the purposes of ISE service and
her role in the service protocol. She explained how ISE could
help Ms. L in job hunting and dealing with her difculties
in the workplace.
Vocational Assessment. The employment specialist initi-
ated assessment to nd out how well Ms. L could work in a
competitive job in the community. She focused on under-
standing Ms. Ls educational background, work history,
work skills, strengths and weaknesses, and preference. In
addition, the employment specialist assessed Ms. Ls social
competence in getting and holding a job. According to Ms.
L, she had worked as a secretary in a law rm for 2 years after
graduation from a university and had no employment record
afterward. In this previous job, her main duty was to assist
her supervisor in preparing documents. Although she was
The American Journal of Occupational Therapy 241
able to cope with her job duties, she had a poor relationship
with her coworkers and high anxiety when interacting with
them. She often requested urgent leave, which might be
interpreted as avoidance behavior, and nally quit her job
because of her poor mental state.
The employment specialist also obtained information
on Ms. Ls likes, dislikes, and job preferences. Ms. L expressed
that she felt easily fatigued and was therefore unable to cope
with jobs requiring long working hours and a heavy work-
load. She liked following others instructions, and she
described herself as a hard-working person, but she disliked
communication with strangers. She had mastered basic com-
puter skills and hoped to nd a clerical job. On the Vocational
Social Skills Scale, she gave herself ratings ranging from 3
(sometimes difcult) to 1 (always difcult) on most of the 10
items. Items that she rated as always difcult included
participate appropriately in a job interview, resolve a con-
ict with supervisor, and resolve a conict with a col-
league. Her total score on the self-administered checklist
was 20, which reected that she had high social anxiety when
talking to others. During the role-play exercise, Ms. L
appeared to be nervous and uncomfortable. She paused and
hesitated frequently when asked about her work experiences.
Ms. Ls total score on the role-play test was 59, suggesting
that she had insufficient interpersonal skills in the
workplace.
Individual Employment Plan. The employment specialist
then formulated an individual employment plan for Ms. L.
First, WSST was provided to enhance her social skills. Ms.
L expressed that she wanted to obtain a part-time clerical
job. The ultimate goal of the individual employment plan
was to maintain employment and prolong job tenure.
WSST. Ms. L lacked the necessary social skills and social
competence to get and keep a job (Cook & Razzano, 2000;
Tsang, 2003; Tsang & Pearson, 2001). Before her job search,
Ms. L participated in the manualized WSST (Tsang, 2001)
to enhance her ability to seek and maintain employment.
WSST consisted of 10 sessions, each lasting from 1.5 to 2
hr, covering basic social and social survival skills, interview
skills, and communication skills with supervisor, coworkers,
and customers. Each WSST session included warm-up activ-
ities, instruction, demonstration, role-playing, feedback, and
homework.
Ms. L was attentive and cooperative throughout the
WSST. However, she was usually quite passive and did not
comment on or join in the discussion with other partici-
pants. In the job interview skills session, Ms L was required
to look for a job advertisement according to her preference
and role-play a job interview exercise. Throughout the pro-
cess, Ms. L gradually came to better understand the require-
ments of clerical work in the competitive job market. She
nally found a job advertisement for a part-time ofce assis-
tant for which she met all job requirements. Through dem-
onstration and modeling, Ms. L was equipped with appro-
priate job interview skills and work-related social skills. Ms.
L then practiced these skills with the employment specialist
so that her social skills could be consolidated and generalized
from the WSST sessions to her workplace. Appreciation and
encouragement were given to Ms. L after the role-play exer-
cises to establish the motivation for learning and applying
the skills. Also, the importance and value of work, including
better quality of life and a larger social network, were dis-
cussed in WSST.
After 10 WSST sessions, Ms. Ls social skills had signi-
cantly improved. Her total score on the self-administered
Vocational Social Skills Scale after 10 sessions increased from
20 to 34. She gave herself ratings ranging from 4 (occasionally
difcult) to 3 (sometimes difcult) on most of the 10 social
skills items. The total score of the role-play test for Ms. L
jumped from 59 to 85, signifying improvement in her social
competence in the workplace.
Obtaining Employment. The employment specialist regu-
larly accompanied Ms. L to the Labor Department to search
for job vacancies and encouraged her to apply for jobs in
which she was interested. Generalization of the skills learned
in WSST was applied to the process of obtaining employ-
ment, following the steps set out in Figure 1. She encouraged
Ms. L to prepare herself before each job interview by review-
ing WSST content regarding job interview skills. Ms. Ls
preference was a part-time ofce assistant position. The
employment specialist discussed this preference with Ms. L
and set a behavioral goal of performing well during the inter-
view and obtaining the job. Through several guided prac-
tices, Ms. L became more familiar with the interview
process.
Unfortunately, the rst interview ended in failure, so
Ms. L reviewed her performance with the help of the employ-
ment specialist. Ms. L thought the main problem was that
she did not know how to respond to the interviewer when
asked about her employment history. The employment spe-
cialist discussed with her how she could better handle this
question and did a behavioral rehearsal with Ms. L.
Six months later in the job-hunting process, Ms. L
sought a job as a part-time ofce assistant. With the job
interview skills she learned in WSST and the experience she
gained in previous job interviews, she performed well this
time, especially when explaining her employment history to
the interviewer.
Follow-Along Support. An important task for the employ-
ment specialist at this stage is to help clients generalize the
social skills learned in WSST and improve their relationships
with supervisors and coworkers. This task constitutes one of
242 May/June 2009, Volume 63, Number 3
the most important differences between ISE and IPS and
accounts for ISE participants longer job tenures (Tsang,
2007). The following sections illustrate how the employ-
ment specialist helped Ms. L cope with her interpersonal
difculties in the workplace.
Helping Ms. L Improve Her Relationship With Her
Supervisor. Ms. L was perplexed by the interpersonal difcul-
ties she had with her supervisor. For example, she was unable
to nish her job duty because her computer was out of order.
Ms. L was so stressed that she cried helplessly in front of the
employment specialist and thought of quitting. During their
regular meetings, which usually took place at restaurants or
parks near Ms. Ls work site, the employment specialist
taught her how to report her problem to her supervisor using
the social skills acquired in the WSST sessions. The employ-
ment specialist rst reminded Ms. L of the WSST content
regarding communicating with ones supervisor. She then
discussed communication with Ms. L and set a behavioral
goal for her to successfully seek the supervisors advice. The
employment specialist also discussed with Ms. L any appro-
priate behavior that would help her achieve the behavioral
goal and helped her perform the appropriate behaviors
through role play and performance appraisal. After complet-
ing guided exercises on several occasions, Ms. L was able to
master the social skills to report problems to her supervisor
and seek necessary help.
During the follow-along contact, Ms. L reported to the
employment specialist that her supervisor understood her
difculties and assigned her to another job duty, thus solv-
ing the problem.
Helping Ms. L Improve Her Relationship With Coworkers.
To improve her relationship with her coworkers, the employ-
ment specialist suggested that Ms. L join them regularly for
lunch. She rst reviewed the WSST content regarding com-
municating with coworkers, then worked with Ms. L to set
a behavioral goal of improving her social relationships with
coworkers. On the basis of the problems Ms. L faced in the
working environment, the employment specialist and Ms. L
discussed and identied appropriate behaviors to improve
her relationship with coworkers, such as inviting her cowork-
ers for lunch.
The employment specialist encouraged Ms. L to imple-
ment the social skills learned in the WSST sessions by pro-
viding behavioral and performance appraisal. Ms. L expressed
that her main problem was that she had no common topics
to talk about with her coworkers. The employment specialist
suggested that Ms. L could explore some topics to discuss
with her coworkers, including interests, leisure activities, and
TV programs. Through guided practice and feedback, Ms.
L was able to perform the social skills well. During the
follow-up contact, Ms. L expressed that her relationship with
coworkers had improved.
Evaluation of ISE Program
After 7 months of the ISE program, Ms. L successfully
obtained competitive employment. More important, she was
able to work in the same job for 8 months continuously with
follow-up support until the ISE was terminated according
to our research protocol. Ms. L was satised with her job and
expressed that she was able to maintain a good relationship
with her supervisor and coworkers. Moreover, Ms. L reported
that her self-efcacy and personal well-being improved after
working as a part-time ofce assistant. We believe the
improvements were supported by changes in the outcome
measures (Table 1). Ms. Ls scores suggested that she per-
ceived improvement in her job stress coping, personal well-
being, and self-efcacy after completing the ISE program.
It is interesting that Ms. Ls personal well-being and
self-efcacy improved after she attended the WSST. We
believe this improvement was associated with her improved
work-related social skills. Ms. L perceived herself as having
higher competence in real-life situations. However, Ms. L
reported low personal well-being and self-efcacy before she
obtained her job in the 7th month, data suggesting that
unemployment had adverse effects on her personal well-
being and self-efcacy. Because Ms. L had not successfully
obtained a job after 4 months of searching, continuity of
unemployment might have led to the deterioration of her
mental health. Ms. Ls personal well-being and self-efcacy
improved after she obtained employment as a part-time
ofce assistant. The job stress coping results are reported at
the 11-month follow-up when Ms. L worked as an ofce
assistant. We think the results are accounted for by skills
generalization during the ongoing support period that
focused on solving Ms. Ls relationship problems with her
supervisor and coworkers. This work, in turn, reduced her
stress in dealing with interpersonal difculties in the
workplace.
Table 1. Comparison of the Scores at Pretreatment and Follow-Along
Measure Pretreatment 3rd Month 7th Month 11th Month 15th Month
Chinese Job Stress Coping Scale 3.14 2.81 3.19 3.52 3.23
Personal WellBeing Index 6.11 7.33 6.44 7.33 7.44
Chinese General Self-Effcacy Scale 2.20 2.40 2.30 2.60 2.40
The American Journal of Occupational Therapy 243
Conclusion
We demonstrated how ISE was associated with the success of
a person with SMI in obtaining and sustaining employment.
Although Ms. L had been unemployed for more than 10 years,
our innovative ISE approach helped her achieve continuous
employment as a part-time ofce assistant for 8 months.
We propose that the major factor contributing to her
successful job search was improved job interview skills, which
were essential for getting a job. Participants learned interview
skills during the WSST sessions, and Ms. L practiced these
skills before attending job interviews. Joining the WSST may
also have improved her motivation to gain competitive
employment. This nding is consistent with Tsang and
Pearsons (2001) report regarding technical guidance during
follow-up services after WSST and its role in helping par-
ticipants defuse the potential difculties and obstacles that
reduce job-seeking attempts.
Ms. L stayed in the job for 8 months before she was
discharged from our study. Although we do not have fur-
ther follow-up data, it is possible that she may have
remained in the job for a longer period of time. This out-
come represents a job tenure longer than that reported by
other vocational programs (Drake, McHugo, et al., 1999;
Wong, Chiu, Tang, Chiu, & Tang, 2006). The ISE pro-
grams strength in this aspect was that WSST and efforts
targeted at skills generalization throughout the entire
follow-up process enhanced participants job-retaining
social skills. Participants received social skills training,
including training in maintaining a good working relation-
ship with ones supervisor and coworkers (Tsang, 2003).
These skills equipped participants to cope with interper-
sonal conicts in the workplace that might have caused
them to leave their jobs. In the case of Ms. L, follow-up
support focused on solving her relationship problems with
her supervisor and coworkers. Because ISE lls this post-
employment support gap, she was able to get through the
problems and keep her job for 8 months.
Although the ISE program is associated with positive
benets, it is still not widely used as a program for people
with SMI. The principles that contribute to its success
seem simple and clear. However, implementing the pro-
gram well involves the employment specialists practicing
a wide range of clinical skills. An effective learning package
with specic implementation guidelines and demonstra-
tions is thus urgently needed to equip health and rehabilita-
tion professionals with the clinical skills to implement and
master ISE. In view of this need, our group is now develop-
ing an online e-learning package that will focus on case
management concepts and techniques required by employ-
ment specialists. We hope that with this package, the ISE
approach may be better disseminated to and implemented
by clinicians and therapists to further improve their voca-
tional outcomes. s
Acknowledgment
This study was funded by the Health Services Research
Fund, Health, Welfare and Food Bureau, Hong Kong
Special Administrative Region (Project No. S121014). We
are grateful to the Baptist Oi Kwan Association of Hong
Kong from which we recruited our participants.
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