Access,retention,and effectiveness of Individual Placement and Support in the U.S.: Are there racial or ethnic differences?

1 Introduction

A large body of research documents the profound and negative effect centuries of structural racism in the United States has had on racial and ethnic minorities, including disparities in health coverage, chronic health conditions, mental health, and mortality (Bignall et al., 2019; Braveman et al., 2022; Churchwell et al., 2020; Kalin, 2021; Yearby et al., 2022). Healthcare disparities include “inequities in the delivery of healthcare [which] are unjust differences between populations in the access, use, quality, and outcomes of care” (Institute of Medicine, 2003). Healthy People 2020 defines health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion” (U.S. Department of Health and Human Services, 2008).

Numerous studies show mental health care disparities for Blacks and Hispanics (Cook et al., 2017; Creedon & Cook, 2016; Maura & Weisman de Mamani, 2017; Mongelli et al., 2020). For example, studies have found that Black clients have higher treatment disengagement rates (Fischer et al., 2008; Fortuna et al., 2010) and poorer functional outcomes after receiving treatment (Eack & Newhill, 2012; Phillips et al., 2001) than White clients. Factors contributing to these disparities include poverty, patient distrust, treatment expenses, and distance of medical services from the communities where many historically underserved groups live (Bignall et al., 2019; Maura & Weisman de Mamani, 2017).

Mental health policymakers recognize employment as a central social determinant of health (Drake & Wallach, 2020; Pinto et al., 2018). Yet people with serious mental illness have much poorer employment outcomes than the general adult population. Less than 15%of people with schizophrenia and 40%of people with bipolar disorders maintain competitive employment over their lifetime (Hakulinen et al., 2020). Employment outcomes are even poorer for Black and Hispanic clients with mental illness (Ehntholt et al., 2022), mirroring labor force participation in the general population (BLS, 2022). Regardless of race or ethnicity, people with mental illness who want to work should have access to effective employment services (Drake & Wallach, 2020).

A handful of studies have examined racial and ethnic disparities in vocational rehabilitation, including a recent national study of the federal-state vocational rehabilitation (VR) system, which found that Whites were less likely to apply for VR services than were their Black, American Indian/Alaska Native, and Hispanic counterparts (Shaewitz & Yin, 2021; Yin et al., 2022). However, among those who applied, disproportionately more Whites were found eligible for services than the other three subgroups. Further, among those found eligible, Whites received more employment services and had better outcomes than the other three groups (Shaewitz & Yin, 2021; Yin et al., 2022). Other large-sample studies of VR clients have similarly found poorer competitive employment outcomes for Black clients than for White clients (Lukyanova et al., 2014; Salzer et al., 2011). Disparities are especially pronounced for young Black men with mental health conditions (Delman & Adams, 2022; Vryhof & Balcazar, 2020). Racial and ethnic disparities in access to vocational programs are not attributable to a disinterest in receiving help; one study of a homeless population found that non-Whites were more likely than Whites to seek referrals for employment services (Brown et al., 2019).

None of the cited studies, however, examined differences for clients receiving evidence-based employment services. Extensive research has established that people with serious mental illness can hold competitive jobs if they receive appropriate help (Bond et al., 2020). The Individual Placement and Support (IPS) model of supported employment is an evidence-based practice that increases competitive employment for people with mental health conditions (Drake et al., 2012). Initially developed and researched in community mental health centers in the 1990s, IPS has become a standardized model of supported employment for people with serious mental illness, such as schizophrenia and bipolar disorder (Drake et al., 2012). IPS incorporates eight core principles: (1) Focus on the goal of competitive employment. Agencies providing IPS are committed to regular jobs in the community as an attainable goal for clients seeking employment. (2) Zero exclusion/eligibility follows client choice. Every client who wants to work is eligible for services regardless of “readiness,” work experience, symptoms, or any other issue. (3) Attention to client preferences. Services align with clients’ preferences and choices, rather than practitioners’ expertise or judgments. IPS specialists help clients find jobs that fit their preferences and skills. (4) Rapid job search. IPS programs help clients look for jobs soon after a client expresses interest in working, rather than providing lengthy pre-employment assessment, training, and counseling. (5) Targeted job development. Based on finding jobs that align with clients’ interests, IPS specialists build relationships with employers through ongoing contact, learning about the business needs of employers and introducing employers to qualified job seekers. (6) Integration of employment services with mental health treatment. IPS programs closely integrate with mental health treatment teams. (7) Personalized benefits counseling. IPS specialists help clients obtain personalized, understandable, and accurate information about how working may impact their disability benefits and other government entitlements. (8) Individualized long-term support. Individualized, follow-along supports that match clients’ preferences continue for as long as the client wants and needs the support to keep a job or advance career opportunities.

The foundational IPS principle of client choice means that anyone interested in competitive employment, without regard to race or ethnicity, should be eligible for services. Despite this aspiration, the potential pool of IPS participants is subject to several stages of selection, each of which is subject to potential disparities. With the current federal emphasis on racial equity (Executive Order 13985, 2021), research on disparities in IPS for historically underserved groups should be of particular interest to federal, state, and local leaders responsible for planning and implementing evidence-based services. While disparities are well established throughout health care, researchers have given little attention to disparities in IPS services based on race and ethnicity.

2 Methods

3 Results

IPS research has found that adults with serious mental illness from two historically underserved groups (Blacks and Hispanics) have similar retention rates and employment outcomes in IPS services as Whites. All studies found better retention rates and employment outcomes for IPS clients regardless of race or ethnicity.

The findings were mixed for comparisons of access rates for Blacks, Hispanics, and Whites. Several factors complicate the interpretation of the access rate comparisons. First, access, as defined in this review, refers to receipt of services. Lack of access could result from a multitude of client, program, insurance, cultural, and community factors, including a lack of client awareness, limited IPS program capacity, a lack of client interest, geographic or other logistical barriers, or service provider discrimination. Second, the denominator problem also remains unsolved: To which target population should researchers compare the group receiving services? Discrimination could occur at many levels.

The comparators used in the studies examining access all contained serious selection biases. Population could be defined as all people with a mental health condition who need or want employment services, among whom prevalence, diagnostic bias, insurance, and general access to mental health care may differ across ethno-racial groups. Existing studies only address those who are already insured, already in care, or counted in the U.S. Census, thus ignoring those lacking access to insurance or community mental health centers. Employment, insurance, and mental health care among working-age people with serious mental illness may differ substantially across ethno-racial groups. Thus, studies that do not adjust for these confounds cannot rule out disparities in access among different ethnoracial groups, even if the statistical comparisons show no differences. Ideally, disparity research should consider populations of those who could benefit from IPS. For example, if Blacks with serious mental illness have a much higher rate of unemployment (relative to Whites), they should have a much higher rate of participation in IPS services to prevent disparity. Even an equal participation rate may indicate a significant disparity.

Although these studies mostly found no statistical differences in rates for different racial and ethnic groups, statistical equivalence is not synonymous with equity. Diversity and inclusion of the service population may not address greater needs, a lack of equity, and self-selection. In other words, historically underserved groups may have greater need related to years of poverty and educational, employment, and economic bias resulting in the need for greater or different supports to achieve equity, which connotes creating similar opportunities for success rather than just providing equal access to services (Culyer & Wagstaff, 1993). A critical issue in studying racial and ethnic disparities is differences in need rather than in subpopulation size. For example, if twice as many Blacks as Whites in an area are poor, unemployed, and disabled by a mental health condition, Blacks should have twice the access rate rather than a similar access rate.

A further consideration is that Blacks and Hispanics also have long histories of mistreatment and avoidance of mental health services, which is where IPS services are most often available, and these trends have continued even after the passage of the Affordable Care Act, which was intended to reduce barriers to health care (Cook et al., 2017; Creedon & Cook, 2016). Promoting equity in IPS availability and economic opportunity may require outreach to non-psychiatric settings such as supportive housing programs, justice-system programs, and religious organizations; more diversity of professionals in mental health (Miranda et al., 2008); and greater involvement of peers with lived experience and similar racial and ethnic backgrounds.

While we found minimal evidence of racial or ethnic differences in access to IPS services, all groups have inadequate access. Like other evidence-based practices, IPS is available to only a small fraction (approximately 2%) of mental health clients who could benefit (Bruns et al., 2016). Moreover, the studies of IPS access examined in this review did not compare their findings to racial and ethnic statistics for adult residents of the local community. Many communities with a disproportionately high proportion of people from racial and ethnic minorities lack access to affordable outpatient mental health services (Cook et al., 2007) and many from historically underserved groups avoid mental health services due to stigma or distrust. The distribution of IPS programs by geographic location has not been systematically documented, but greater travel time to IPS programs for racial and ethnic minorities seems likely (Miranda et al., 2020). On the other hand, the literature provides several examples of successful IPS programs located in predominantly Black communities (Bond et al., 2007; Drake et al., 1999; Gold et al., 2006; Lehman et al., 2002). With respect to retention in IPS services, we found no evidence of racial or ethnic differences. Moreover, IPS has far higher retention rates than other vocational services regardless of race or ethnicity, a robust finding across IPS RCTs (Bond et al., 2012).

Our review focused on the U.S. with its unique history of racism and exclusion of ethnic groups. Ethnic and racial conflicts exist everywhere, though in different forms. For example, in the UK, researchers have found inequalities in the pathways to care particularly affecting Blacks (Halvorsrud et al., 2018). Outside the U.S., IPS researchers also have generally not examined disparities among racial and ethnic groups. One exception is a British study examining 779 clients served in two IPS programs that compared IPS enrollment rates for Blacks and other historically underserved racial groups to rates of receipt of mental health services in the corresponding service areas (Perkins et al., 2021). The proportion of Black clients enrolling in IPS was more than 50%greater than the proportion of Black clients receiving mental health services. Another exception was a New Zealand IPS pilot, which showed modest progress toward achieving equity of engagement and outcomes for indigenous Māori people (Priest & Lockett, 2020).

This review has several limitations. We identified few studies of race and ethnicity and limited data within studies. To understand disparities and develop strategies to address equity, we need more studies, larger samples, more relevant comparison groups, and longer follow-ups. We also need to design studies prospectively rather than relying on post hoc analyses of studies designed to answer different questions. For example, several studies included in this review were conducted within racially or ethnically homogeneous communities, which provide limited information regarding disparities in accessing services. We also need to develop research designs that evaluate equity and not simply statistical equivalence; such designs have not yet been adequately formulated.

Despite the limitations of existing research, few racial and ethnic differences have been found for IPS employment services, unlike for most of health care. Equitable health care is of great concern to policy makers, practitioners, clients, and family members. Systematic documentation of IPS access, retention, and outcomes are of paramount importance to ensure that diversity, equity, and inclusion are realities throughout our service systems.

5 Conclusion

IPS services could help people in historically underserved groups with psychiatric disabilities to escape poverty and achieve a meaningful, productive life that enhances self-esteem, autonomy, and community integration. More research on social determinants of health could clarify needed adjustments to the IPS model to promote equity.