Supported employment and customized employment: How effective are these interventions and what has been their impact on the field?
1Introduction
In the last 20 years, Customized Employment (CE) has joined Supported Employment (SE) which has its roots traced back to approximately 1980, as a popular employment intervention. SE became codified originally in the Rehabilitation Act of 1986 through Title 6 C, dedicated exclusively to funding SE, along with the primary source of all rehabilitation funding, Title 110, for basic employment services. CE began to receive much more attention when the Workforce Innovation and Opportunity Act (2014) was passed by Congress and CE was codified along with SE and numerous other priorities.
We are writing this editorial because there has been increasing amounts of confusion and debate among rehabilitation and other disability policy makers and practitioners, as well as advocates and clients, as to how these interventions differ; how effective each is; how much overlap exists between them, if any; cost associated with each; and, above all, the research evidence supporting each. This will be a bit of an unusual editorial in that we will not pose only opinions but do our best to highlight evidence based research that we think may help in the overall thought process when evaluating the two interventions.
2Background and historical context
Around 1980, several researchers in Virginia, Oregon, Vermont, Montana, and elsewhere began to develop a program that focused on providing applied behavior analysis techniques and systematic instruction to help place individuals with moderate and severe intellectual disabilities into competitive employment, or— real work for real pay (Wehman, 1981). The Oregon group focused on systematic instruction and placement of individuals with significant disabilities into industries making medical devices (e.g., Rhodes & Valenta, 1985); the Virginia group focused more on what is now known commonly as the individual placement model, whereby a person who has significant intellectual disabilities was placed into competitive employment in different companies (Wehman, 1981). The client received onsite training by an employment specialist who was skilled in systematic instruction using techniques like task analysis, job analysis, and behavioral training techniques. The critical aspects of this model, which came to be called SE, was a) rapid placement after a person centered planning approach; b) placing into a paid job by the employer immediately and then training onsite with careful daily monitoring until the individual’s competence level was meeting the employer’s threshold for success; and c) following along (usually) permanently to verify to the client and employer the depth of the support system.
This individualized system was written about frequently, and at the times critically, (e.g., Mank, 1994; Wehman, Sale, Parent, 1992; Wehman, 1988) but ultimately it was manualized in 1997 (Brooke, Inge, Armstrong, & Wehman, 1997). This manual is in the process of being updated at VCU as a supported employment curriculum which will be available in the Fall of 2023. Eventually Medicaid waiver status was granted by CMS also in 1997 since SE was found to be so highly effective and useful.
From mid-to-late 1980 the Virginia group began collecting significant amounts of data on each placement so that vendors for services and state vocational rehabilitation agencies would be able to determine what rates could be reasonably charged for services to vocational rehabilitation and ultimately Medicaid for the Medicaid waiver. In 1990 National APSE was formed and in 2000 the European APSE was also formed as the model grew internationally. Both the group model and individual model were seen as effective but the latter grew in popularity due to interest in higher level and quality of workplace integration.
The CE model arose in the early 2000s with the forward thinking leadership in the U.S. Department of Labor Office and several other consultants who were looking for more than what SE offered. Key aspects of CE were: much more attention given to the clients’ interests, needs, and aspirations; which were ultimately identified as, “Discovery.” Additionally, there was concern that more attention should be paid to the labor market and job analysis using a term of informational interviewing. Numerous demonstrations occurred of CE (Inge et al., 2018; Riesen et al., 2015) and many people newer to the field began to draw on the strengths of this model.
3Further developments
It is noteworthy, as we close out this admittedly very brief overview, that a much more sophisticated version of SE was being developed for individuals challenged with severe psychiatric disabilities by Robert Drake, Deborah Becker, Judith Cook, Gary Bond, and others. Their work, though modeled after the SE approach, was from the start a higher quality of evidence-based research using randomized clinical trials for definitive proof of concept— and ultimately— proof of scale (Drake et al., 1999; Drake et al., 2012; Drake et al., 2016). It became rapidly popular in the psychiatric circles and would go on to become part of the Institute of Medicine Best Practices.
The discussion of this editorial does not include this model or what would become known as the Individual Placement and Support (IPS) model since the SE vs. CE discussions in the field and APSE seem to enter much more around those with intellectual and developmental disabilities. However, the IPS model elevated the level or bar for which all integrated employment researchers should aim to emulate.
4A paradigm shift
While this historical context is primitive in its brevity, it should be noted that in 1980 there were few or no programs nationally that offered those with severe employment challenges a competitive employment alternative (Rusch, 1986; Wehman, 1981). These folks were considered, “too hard to place,” and were ushered into sheltered work or day habilitation programs, usually for the rest of their lives at great loss of client and human development, and at a great cost to the government due to the expense of a segregated program and loss of taxes which people with disabilities would give to the government. All three programs described above focused on immediate movement into the competitive workplace with support, not long-term lifelong placement in segregated settings. This was a profound paradigm shift consistent with the deinstitutionalization movement of the 1970 s (Wolfensburger, 1972) and dignity of risk (Perske, 1972).
5Body of evidence for supported employment
Supported employment (SE) gained momentum in the 1980 s because it provided a way for individuals with even the most significant cognitive disabilities to participate in competitive employment rather than segregated or non-work alternatives (Kregel, 1995; Wehman et al., 2020). Research and practice on SE have evolved significantly since its inception decades ago. Implementation of SE has gradually gained widespread adoption both nationally and internationally, and has also been scrutinized by increasingly more intensive levels of scientific inquiry over the years investigating its efficacy as an employment intervention (Wehman, Taylor, et al., 2020). These initiatives have culminated in over 40 years of empirical research on SE as a successful pathway to integrated community employment. Today, the extant literature on SE is extensive and therefore beyond the scope of this editorial to review in its entirety. However, providing a detailed summary of the breadth of SE research over the past four decades is intended to provide a comprehensive picture of the impact of SE on the lives of individuals with disabilities.
The foundation of SE was laid by early demonstration projects, case studies, and progressive textbooks (Murphy & Rogan, 1995) that reported securing competitive employment positions. The early SE material was mainly directed for individuals with intellectual and developmental disabilities ([IDD]; Bates, 1986; Flynn et al., 1991; Kregel et al., 1989; Lagomarcino et al., 1986; Moss et al., 1986; Nietupski et al., 1993; Storey & Garff, 1997; Vogelsburg, 1986; Wehman, 1986; Wehman, Taylor et al., 2020). These initial reports on SE were especially notable because rather than describing individuals who were mildly impacted by their disability, numerous examples showcased job seekers with high support needs becoming gainfully employed (Mank et al., 1998; Nietupski et al., 1993; Wehman et al., 1982; Wehman & Kregel, 1990; Wehman & Kregel, 1988). Through the SE process, service providers could address the specific needs of each job seeker in a variety of functional domains, including cognitively, behaviorally, socially, and communicatively, using real work settings as a metric for success (Grossi et al., 2019; Grossi et al., 2020; Wehman & Kregel, 1988; West, 1994). In many instances, the same individuals who were competitively employed using the SE model were previously deemed “unable to work” and excluded from non-sheltered employment options (Kregel, 1995; Wehman et al., 1998; Wehman et al., 1982; Wehman et al., 1979; Wehman & Kregel, 1988; Wehman & Kregel, 1990; West et al., 1994). While early studies comprised relatively small sample sizes, they also documented markedly high rates of CIE among service recipients ranging from 67% to 100% (Bates, 1986; Flynn et al., 1991; Lagomarcino, 1986; Lynch, 1996; Moss et al., 1986; Riddell & Wilson, 1999; Storey & Garf, 1997; Verdugo et al., 1998; Wehman, 1986; Wehman et al., 1979; Wehman et al., 1998; Wehman & Kregel, 1990; Wehman & Revell, 1996; West et al., 1994). For comparison, even today only about 20% of adults with IDD are competitively employed (Winsor et al., 2021).
The improved employment outcomes associated with SE resulted in U.S. federal policy initiatives that made funding available to provider agencies to offer SE as a service option (e.g., The Rehabilitation Act Amendments of 1986, Workforce Innovation and Opportunity Act, 2014). In turn, the application of SE was expanded to broader populations. Today, SE has been successfully applied to a wide range of disability types including IDD (Morgan et al., 2010; Wehman et al., 2012), learning disabilities, physical disabilities (Cotner et al., 2019; Dutta et al., 2008; Ottomanelli et al., 2012; Ottomanelli et al., 2014; Wehman & Revell, 1996), sensory impairments (Dutta et al., 2008; Wehman & Revell, 1996), and psychiatric disabilities (Becker et al., 2011; Bond et al., 2007; Cook et al., 2006; Davis et al., 2018; Davis et al., 2022; Frederick & VanderWeele, 2019; Larson et al., 2007). SE success rates for individuals representing multiple disability categories is high (Wehman et al., 2012; Wehman, Taylor et al., 2020). Individuals with spinal cord injury are more than twice as likely to find competitive work using SE compared to other treatment-as-usual options (Ottomanelli et al., 2012). More than 50% of veterans with a polytrauma/traumatic brain injury find employment within three months of receiving SE regardless of additional challenges such as previous incarceration or homelessness (Pogoda et al., 2022). Transition age-youth with autism spectrum disorder who participate in an SE based internship program yield competitive employment outcomes ranging from 51% to 90% (Avellone et al., 2023; Christensen & Richardson, 2017; Christensen et al., 2015; Wehman, Schall et al., 2014; 2017; 2020; Whittenburg et al., 2020). On average, employment outcomes for individuals with IDD who receive SE through Vocational Rehabilitation services is 7% higher than those who do not participate in SE (Chan & Kregel, 2019). To date, there are at least 27 randomized control studies substantiating the significant impact of the IPS model of SE for individuals with mental illness (Bond et al., 2020) and evidence of the efficacy of the IPS model for young adults with mental illness who also experience homelessness (Ferguson & Glynn, 2012).
The benefits of SE go beyond simply securing a job. A quality employment outcome must consider factors such as wages, hours, fringe benefits, cost of services, the types of industries accessible to job seekers who use SE services, and length of job retention. This line of inquiry has also been extensively addressed in SE research. In addition to being more likely to obtain competitive work, those who receive SE services earn more money and work more hours than those who do not receive SE (Wehman, Taylor et al., 2020). The positive impact of SE on wage and hours has been observed among transition-age youth and adults with intellectual disability (Boeltzig et al., 2008; Cimera, 2017; Grossi et al., 2019; Iwanaga et al., 2023; Kregel et al., 1989; Seward, 2022; Wehman, 1986; Wehman et al., 1989), veterans with psychiatric disorders (Davis et al., 2022), adults with autism (Martin & Lanovaz, 2021), youth with autism (Whittenburg et al., 2020), and individuals with co-occurring mental illness and substance use disorders (Mueser et al., 2011).
While the number of hours a person desires to work is variable, SE can effectively be used to secure both part-and-full-time employment positions. Numerous studies describe SE recipients who have achieved part-time (averaging at least 20 hours per week) and full-time (40 hour) work weeks (Boeltzig et al., 2008; Christensen et al., 2015; Fabian, 2007; Flynn et al., 1991; Kaehne, 2016; Lagomarcino, 1986; Luecking & Fabian, 2000; Mank et al., 1998; Moss et al., 1986; Wehman et al., 2019; Wehman & Kregel, 1988; Wehman & Kregel, 1990; Wehman et al., 2012; Wehman et al., 1989; Wehman & Revell, 1996; Whittenburg et al., 2020).
Employment outcomes are observed in both large and small businesses across a diverse set of industries (Lynch et al., 1996; Mank et al., 1998; Wehman, Schall et al., 2020; Whittenburg et al., 2020). Findings indicate that not only do SE service recipients secure employment, but they maintain employment for extended periods of time (Brooke et al., 2018). Longitudinal data on supported employees have tracked retention rates at a variety of checkpoints including as far as 10 months (Kaehne, 2016), 12 months (Wehman, Schall et al., 2020; Wehman & Kregel, 1990), 15 months (Wehman, 1986), 18 months (Brooke et al., 2018), 32 months (Mank et al., 1998), nine years (Moss et al., 1986) and even the late Lou Brown’s paper 35 years (Brown et al., 2021)— Dr. Brown was noted as the major international leader of education for children with severe disabilities. SE also provides an economic return to taxpayers (Cimera, 2009). Cimera (2009) found SE to be cost-efficient for nine disability categories including sensory, physical/mobility, intellectual, traumatic brain injury, autism, mental illness, communication, other health impaired, and other learning disabilities. Use of SE for individuals with multiple disabilities is also just as cost-effective as for those with one disability (Cimera, 2009).
The SE model is now used by service providers all over the world to help individuals with disabilities secure meaningful working within their communities. Implementation of SE is as widespread as North America (Wehman, Taylor et al., 2020), Europe (Kahne, 2016; Lynch et al., 1996; Riddell & Wilson, 1999; Spjelkavik, 2012; Verdugo et al., 1998), Australia (Janero et al., 2002), South America (Janero et al., 2002), Africa (Engelbrecht, 2022) and Asia (Chandrasekaran, 2021). The IPS model of SE has been used in at least 20 countries (Bond et al., 2020). The momentum of SE as a means to higher quality employment outcomes has been met over the years by growing policy and cultural initiatives to prioritize competitive employment outcomes over segregated alternatives (Association of People Supporting Employment First, 2023; Rogan and Rinne, 2011; WIOA, 2014). As SE enters its fifth decade of research and practice, it continues to be an effective and economically efficient pathway to meaningful competitive employment for a wide range of individuals regardless of disability type or severity.
6Customized employment evidence of research
Customized Employment (CE) was first developed around 2001 as a flexible process for individualizing the relationship between a job seeker with a disability and a business in such a way that meets the needs of both (Office of Disability Employment Policy [ODEP], 2023).
While CE has existed for a much shorter period of time than Supported Employment (SE), it is following a similar path in its progress toward becoming an evidenced-based practice. Like SE, the earliest information on the benefits of CE were derived from model demonstration programs which reported favorable outcomes in CIE settings for individuals who previously struggled to secure or maintain employment (Inge et al., 2018; Riesen et al., 2015). As a result, CE received increased attention among researchers, policy makers and practitioners, and was formally added to Title IV of WIOA under the definition of SE in 2014 (ODEP, 2023).
While CE has no doubt emerged as advantageous in the effort to improve employment outcomes for individuals with disabilities, it has also experienced some confusion over its current standing as an evidenced-based practice (Inge et al., 2018; Riesen et al., 2023). An evidenced-based practice approach has long been used by the medical community to guide ethical decision-making for treatment selection and to maximize patient outcomes (Li & Rai, 2007). The same model for intervention delivery has been adopted by other service fields including education, counseling, and vocational rehabilitation (Leahy et al., 2018).
Articles on CE have appeared in the peer reviewed literature base since the early 2000s but the type and methodological rigor of this research has resulted in the need to establish further support for CE as an evidenced-based practice. For example, Tim Riesen, who has been a prolific and leading CE researcher with his colleagues (2015) conducted a literature review between 2001 and 2015, and found that only 10 of 25 published articles on CE interventions contained outcome data for participants (Citron et al., 2008; Elinson et al., 2008; Fesko et al., 2008; Harvey et al., 2013; Heath et al., 2013; Luecking et al., 2006; Luecking, Cuozzo et al., 2008; Luecking, Gumpman et al., 2006; Luecking & Luecking, 2006; Rogers et al., 2008).
In contrast, the majority of published articles on CE were descriptive in nature and focused primarily on summarizing implementation procedures without including a research design or participant data (Brown, 2009; Callahan et al., 2011; Certo & Luecking, 2006; Condon & Callahan, 2008; Griffin et al., 2008; Jorgensen et al., 2015, Inge, K. 2006; 2007; 2008; Inge & Targett, 2006; Inge & Target, 2008; Nicholas et al., 2006; Phillips et al., 2009; Revell & Inge, 2007; Targett et al., 2007).
In a recent update to this review, Riesen and colleagues (2023) included an additional 8 data-based articles on CE (Inge et al., 2018; Jones et al., 2020; Riesen et al., 2019: Riesen et al., 2018a; Riesen et al., 2018b; Riesen & Morgan, 2018; Shogren et al., 2017; Smith et al., 2019). The full collection of 18 data-based articles (i.e., 2001 through 2021) was then examined for level of scientific documentation pointing to CE as an evidenced-based practice. Results indicated that, as of yet, there are no experimental studies reporting outcome data associated with CE as an intervention and only one identifying a correlational relationship (Riesen et al., 2023). However, these findings should not undermine the value and utility of CE as an employment intervention. The existing body of CE literature certainly describes positive CIE achievements and has highlighted several important areas for future research to address on the path to establishing CE as an evidenced-based practice (Riesen et al., 2015; Riesen et al., 2023).
Most prominently, there is still a need to establish fidelity of implementation, incorporate more varied and rigorous methodology into research designs, and report more detailed descriptions on CE intervention participants in published materials (Riesen et al., 2023). Some efforts to address these particular concerns are already in progress. At least nine states are actively using both the Discovery Fidelity Scale and Job Development Scale (i.e., California, Florida, Iowa, Michigan, Missouri, Rhode Island, South Dakota, Utah, Virginia) which were developed to promote more consistent implementation of CE’s major facets (Crandall & Keeton, 2022; Hall et al., 2018; Hall et al., 2019). These fidelity scales are additionally being used in two countries outside the United States, including Spain and Australia (Crandall & Keeton, 2022). While more research on CE is needed before it can be properly classified as an evidenced-based practice, the cumulative reports on CE success over the years clearly signal that it is a beneficial intervention worthy of continued scientific examination. Future research on CE will further refine its processes, and continue to provide a better understanding of how those processes can best be used to help individuals with disabilities become employed in competitive jobs that match their skills and interests.
7What are the similarities and differences between supported employment and customized employment?
It is important for employment specialists to know the differences in these models for implementation purposes. It is also important for Vocational Rehabilitation state agencies and Medicaid waivers vendors to know the differences in what they are investing. State Vocational Rehabilitation directors under Medicaid waivers as well as local programs need to understand what services they are providing and investing their funds in to realize the maximum return on investment. Families, advocates, and consumers also need to know how to advocate clearly in order to keep expectations and aspirations aligned. Finally, researchers and other scholars should have a clear understanding of how these two models differ as they write, present and communicate.
Inasmuch as this is an editorial and not a research paper, we will only summarize our perceptions using the research and other peer reviewed nonempirical papers to guide us as we look at these differences:
1. SE has over 40 years of steadily increasing empirical research evidence as well as statistical case control studies (Seward, 2022; Iwanaga et al., 2023; Wehman, 2014) through the RSA 911 database. CE does not have this evidence or is very limited.
2. SE has cost benefit data for implementation and outcomes clearly showing its efficacy. CE does not or very limited.
3. SE has been manualized (Brooke, V., Inge, K.J., Armstrong, A.J., & Wehman, P., 1997) for purposes of facilitating replication. There is no detailed manual that we are aware for CE.
4. SE provides for four distinct phases: consumer choice, job development, job site training, intervention, and long term follow along. CE presents only preplacement activities (see page 6 of Supported and Customized Employment: Side by Side Referral Decision Guide, 2023).
This is a very significant difference.
5. Supported document efficacy has been documented through the peer reviewed literature in outcomes for multiple disabilities ie., ID, DD, TBI, SCI, and autism. SE has also provided the foundation for easily the best experimentally controlled employment model, the Individual Placement System which has approximately 30 randomized clinical trials and has been increasingly scaled up nationally and internationally. The IPS model has been used predominantly with those with severe psychiatric challenges (Drake et al., 2016).
6. SE has been the treatment of choice by the U.S Department of Justice as it has negotiated with different states to close their sheltered workshops e.g., most recently in Oregon (Lane v. Brown, 166 F.Supp.3d 1180 [Dist. Court., D. Oregon, 2016]) and followed by a Memorandum of Understanding (MOU), which was recently signed by the North Carolina Secretary of Health and Human Services.
7. SE has as an underlying value that rapid placement and not prolonged preplacement activities is of greater value through avoidance of longer segregation from real work. This has not been researched head to head between CE and SE, however in terms of outcome.
8. CE provides for a much greater in depth analysis of analysis of the job seeker through a term called, “Discovery” which is typically much longer than consumer choice activities and interviews that supported employment presents. Once again this is an empirical research question to determine if one is better than the other in terms of outcome.
9. SE is a model that engages in jobs that are posted and or listed as available, while CE not only engages in these job development activities but also in job creation through employer/informational interviewing. Hence job development will often result in jobs that were previously not posted or available, an attractive feature of CE.
10. SE has demonstrated the test of time internationally across many countries, especially the Nordic countries, Ireland, UK, South Africa, Australia, Spain, and Portugal as well as others. CE has not been tested internationally.
8Summary and implications
In summary, while there are many differences between the two models, it is clear to us that SE has much more definitive evidence to support its efficacy than CE. It is equally clear to us that CE has great promise but needs to be: a) manualized to facilitate replication and clarify its role in post placement job site training/accommodations and follow along support activities; b) needs much more research, ideally head to head with SE, but at a minimum to support issues of time to placement, employment outcomes, cost of services and value of lengthy discovery process. Both models need higher quality of service implementation.
There are other impressions that we cannot help to miss after 40 years in the field. For example, we see a great deal of overlap in some of the activities in each model which the “Side by Side Referral Decision Guide” seems to reinforce. This overlap has significantly helped to create confusion, we believe, among new professionals coming into the field as well as seasoned policy makers. We know, for example, that even though there is more research that demonstrates efficacy on SE that it is not necessarily being executed any better than CE due to lack of training and technical assistance which we have pointed out in earlier writings as a challenge to the field (Wehman et al., 2018). The efforts by the U.S. Rehabilitation Service administration to enhance state by state technical assistance and demonstrations are to be highly commended.
9Final questions
As we close this editorial we will leave readers with three thoughts to ponder:
1) Are we perhaps asking the wrong question: i.e., “Which model is better?” And instead should we be asking: “Which model is a better fit for which populations of people with disabilities and how much does severity of disability play a role in success?” Again only high quality research over time can answer that.
2) And the second question is: Ultimately as a field do we do ourselves a disservice when we are trying to compare one model to another when there is significant overlap and most observers would agree we all want the same outcome, that of competitive integrated employment. We wonder if we should be looking for a “merger of thoughts” that might result in some term such as “Supported Customized Employment” to which we are integrating the best of both models.
3) The third question which comes to our mind and has been raised before (Wehman, 2018) is: Do we just need to do a higher quality job of implementing all of these models to secure richer outcomes that can have greater sustainability?
The good news is that we have multiple employment models that provide a meaningful paradigm shift to CIE and avoid segregation. The bad news is we cannot seem to overcome confusion between the models and how they so significantly overlap in places. It is up to our researchers, policy leaders, and leadership in the field like APSE, to work through these issues. It is a big challenge but one we are all up to if we choose to work together. To not do so will leave even the most well intentioned providers in a continual state of confusion about the efficacy and effectiveness of each model.
Acknowledgment
The author wants to thank and acknowledge Dr. Lauren Avellone, who provided an independent development and review of the SE and CE research evidence sections. This is excellent work and provides much of the foundation for which this editorial was written, and the conclusions drawn. The author also wants to thank Carina Rumrill for her excellent technical assistance, especially in getting references organized, and also Dr. Tim Tansey of the University of Wisconsin-Madison and APSE Executive Director, Julie Christensen for their encouragement of the development of this editorial.
Funding
This editorial was partially supported by grants numbered #90RTEM0003-04-00, #90RTEM0002-04-00, and #90DP0085-05-05 by the National Institute on Disability, Independent Living, and Rehabilitation Research.
Conflict of interest
None to report.
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