In the field of vocational rehabilitation, the types of services made available and, in fact, the determination as to who will receive services are influenced by the meaning and value ascribed to work. Traditionally, the vocational rehabilitation system has attempted to find paid work for individuals considered to have mild disabilities. People labelled severely disabled were considered "unemployable," and offered day activity or day treatment/habilitation programs. A new approach--supported work--attempts to reconceptualize and restructure the way services have traditionally been provided.

PROBLEMS WITH THE TRADITIONAL APPROACH

Sheltered Services

One traditional way of providing vocational services to people with disabilities has been to offer services in sheltered, segregated settings--that is, in settings where people with disabilities are congregated together and supervised or trained by nondisabled people. A number of serious problems with this model of service provision have been discussed in the literature (Bellamy, Rhodes, & Albin, 1986; Brown, et al., 1984; Brown, Nietupski, & Hamre-Nietupski, 1976; Bellamy, Horner, & Inman, 1981).

1. Sheltered services are based on a continuum concept whereby people are supposed to move from one level (e.g., day activity center) to the next (e.g., sheltered workshop) and finally, to graduate to competitive employment. Studies have repeatedly shown, however, that a mere 3-5% of all people in sheltered settings actually do move into the next level in any given year (Bellamy, Rhodes, & Albin, 1986).
2. Sheltered settings typically offer a combination of piece-work and make-work. When no subcontract work is available, people perform simulated tasks, have down time when they do no work at all, or are sent home.
3. Because sheltered settings rely primarily on subcontract work, the kinds of work available rarely resembles actual jobs in the community.
4. Sheltered workshops have a built-in conflict of interest: the best workers are often needed to perform subcontract work. Thus, placement of good workers in the community could mean loss of income for the workshop.
5. Typically, people in sheltered settings are required to demonstrate "readiness" before efforts are made to place them in community jobs. The skills required to demonstrate readiness are usually based on arbitrary criteria selected by the sheltered setting.

Competitive Employment

The ultimate goal of the vocational rehabilitation system is "competitive employment." In the traditional approach, staff provide time-limited services to the prospective worker which may include assistance in locating a job, "matching" the job to a prepared or "job-ready" individual, and short term training and supports (Rood, 1985; Wehman, 1982). Workers receive a minimum wage or better and are expected to match production rates set by typical workers and require no extra supervision. An individual's case is usually "closed" after the maximum term of service delivery is reached (e.g., sixty days). If the individual requires additional assistance at a later date, she or he must re-enter the service system and repeat the above process.

This approach is neither successful nor appropriate for many individuals, especially those with severe disabilities, for several reasons:

1. Many individuals require ongoing support to succeed (Hill, Revell, et al., 1985) and are therefore unlikely to achieve total independence from the service system (Melia, 1986; Wehman, et al., 1985).
2. Many people able to learn specific job tasks often need a variety of job-related supports in areas such as getting to and from work, communicating and getting along with others while on the job, using money handling and time telling skills, etc. (Bellamy, Rhodes, & Albin, 1986; Callahan, 1986).
3. People with severe disabilities demonstrate difficulty in generalizing from a sheltered training site to the actual work site and are often not considered "job-ready" (Brown, Nietupski, & Hamre-Nietupski, 1976; Rudrud, Ziarnik, Bernstein, & Ferrara, 1984).
4. Completing all of the required job tasks at a competitive rate may not be possible by those with the most severe disabilities, but this should not mean that they must be excluded or placed in a segregated setting.
5. People learn best in actual community jobs (Brown, Nietupski, & Hamre-Nietupski, 1976).

The traditional model of service delivery excludes people with severe disabilities from meaningful and valued work opportunities (Bellamy, Rhodes, & Albin, 1986). Relegated to sheltered work or non-work oriented day activity programs, they experience minimum earnings and must rely on family support and governmental supports such as SSI. As a result, the majority of people with severe disabilities are poor (King's Fund Centre, 1984).

Individuals with severe disabilities experience little contact with non-disabled people in sheltered settings (Callahan, 1986). Often the only contact they have is with family and paid staff members. Such segregation denies them the chance to participate in the daily life of their neighborhoods and cuts them off from others who might willingly become involved in their lives (Brown, et al., 1984).

Continued containment in sheltered day programs reinforces the belief that these facilities are the best places for people with severe disabilities (King's Fund Centre, 1984). The practice of segregation fosters the image of people with severe disabilities as unable to contribute in a meaningful way to society (Wolfensberger, 1972). However there are numerous examples of people with severe disabilities who are contributing through their work in integrated jobs.

Supported employment is an alternative to traditional sheltered and competitive employment approaches. It is an attempt to meet the specific needs of individuals with severe disabilities and is based on fundamentally different principles and assumptions. The supported work model assumes that all individuals, regardless of the nature or extent of their disabilities, should have the opportunity and support to work in the community. There are no pre-requisite skills needed for community job success. The task, therefore, is not to identify and place "work ready" individuals, but rather to locate and/or modify meaningful jobs in the community and provide training and supports at the job site.

Background of the Supported Work Model

The principles and assumptions of supported work are based upon both technological advancements and a radical shift in values. The work of Marc Gold, Lou Brown and others amply demonstrated the capabilities of people with severe disabilities to perform a variety of complex tasks (Gold, 1980). In addition, the principle of normalization gained recognition and acceptance (Wolfensberger, 1972). This principle calls for maximal integration and involvement between individuals with and without disabilities in daily activities. As a result of these advancements, people with severe disabilities have gained access to a wide variety of community environments and activities, including integrated work settings (Rudrud, Ziarnik, Bernstein, & Ferrara, 1984). Community-referenced instruction, for example, overcame the difficulties associated with teaching students with severe disabilities by providing instruction in actual community settings. School teachers and professionals in vocational rehabilitation started to look seriously at supporting individuals with severe disabilities in the regular work force (Gold, 1980; Snell & Browder, 1986).

Despite the fact that supported work has been accepted by many as a preferred outcome of vocational services, there is not yet consensus on a definition that can be translated into clear service practice.

Legislative Definitions

The 1984 amendments to the Developmental Disabilities Act (P.L. 98-527) define supported work as:

Paid employment which (i) is for persons with developmental disabilities for whom competitive employment at or above the minimum wage is unlikely, and who, because of their disability, need intensive, ongoing support in a work setting; (ii) is conducted in a variety of settings, particularly work sites in which persons without disabilities are employed; and (iii) is supported by any activity needed to sustain paid work by persons with disabilities, including supervision, training and transportation. (Federal Register, 1984).

The 1986 reauthorization of the Rehabilitation Act of 1973 (P.L. 99-506) also defines the term "supported employment." For the purposes of this Act, it means:

...competitive work in integrated settings (A) for individuals with severe handicaps for whom competitive employment has not traditionally occurred, or (B) for individuals for whom competitive employment has been interrupted or intermittent as a result of a severe disability, and who, because of their handicap, need ongoing support services to perform such work.

Combined, these pieces of legislation outline the key features of the supported work model. As Laski (1986) notes, this legislation mandates a new definition of "employability." Everyone possesses the potential to work. Thus, an emphasis on the long term support of people with severe disabilities in regular jobs was a key component of the legislation.

Key Elements of Supported Employment

Callahan (1986) advocates a strict interpretation of the relevant legislation when defining the key elements of supported employment. These are: integration, paid work, individualized services, and a wide variety of ongoing supports for each person.

Integration. A person with severe disabilities must be integrated at work. That is, the person should be a regular employee of the business or industry rather than an employee of the rehabilitation agency and should work next to and interact regularly with non-disabled coworkers. Further, there should be no more than two individuals with disabilities in any one work area. This general policy is intended to maximize opportunities for integration and minimize the stigma inherent in grouping people with disabilities (Brown, et al., 1984; Callahan, 1986; Rood, 1985).

Paid work. Individuals should receive commensurate pay for work performed. Optimally, payment would begin immediately upon employment and should be based on productivity and work quality (Hagner, Nisbet, Callahan, & Moseley, 1987).

Individualized services. All aspects of supported employment should be tailored to the needs and capabilities of each person, such as job procurement, matching the job to the individual, and providing training and supports (Hill, et al., 1985).

Ongoing supports. Comprehensive supports such as transportation, money and time management, advocacy, and strategies for managing social and communication issues must be available for each person who needs them. Adapting or restructuring a job to suit an individual may also take place. Co-workers should be encouraged to become involved to the maximum extent possible. Rehabilitation agencies must be flexible in order to provide services based on the needs of the individual and to increase or decrease the supports each person needs over time. All of these supports must be available as long as the person requires them (Brown, et al., 1984; Wehman, et al., 1985; Wehman & Kregel, 1985).

While the advantages of supported employment may appear obvious, controversy still exists. Which approaches within supported employment are most consistent with the four elements outlined above? How can financial disincentives to employment be eliminated?

Approaches Within Supported Employment

Many people talking about supported employment today speak of four types of vocational services: work stations in industry or enclaves, work crews, small businesses comprised of workers with and without disabilities, and individually supported placements.

Enclaves. Enclaves typically consist of a group of individuals with disabilities working together under the supervision of an agency employee in a community business or industry. There is a contractual relationship between the business and the agency, and the agency pays the workers with disabilities either by a piece rate, a straight subminimum wage, or by pay commensurate with production.

Job crews. Job crews are agency sponsored groups of individuals with disabilities who travel together to various work sites in the community. Janitorial and maintenance tasks are the most common activities performed by work crews. Methods of payment are similar to those used in the enclave approach.

Small businesses. Small businesses are agency operated work sites organized as businesses. A number of nondisabled employees may be employed at minimum wage or better, but the methods of payment to the workers with disabilities are like those used in the enclave approach. Examples include restaurants, benchwork industries, and other types of businesses which produce goods or services.

Individual placement. Individual placement means locating community jobs for specific individuals. The worker's preference and abilities are considered along with the job requirements. Payment is generally based on productivity, although other methods may be used. The company employing the individual usually pays the person directly. Although more than one person with a disability may work at the same site, this practice stresses finding the most suitable options for each individual. This personalized approach is essential for the success of people with the most severe disabilities (Callahan, 1986.)

While work enclaves, work crews and small businesses may possess advantages for rehabilitation agencies, they present disadvantages for individuals with severe disabilities. The rehabilitation agencies, now with business interests, "own" these jobs and are obligated to maintain their contracts. For the workers with disabilities, these approaches may become dead end programs that prevent them from obtaining their own jobs, as decisions regarding what is best for the business override individual needs and benefits. Ironically, these approaches may form a new continuum of services in vocational rehabilitation.

The adoption of enclaves, job crews and/or small businesses may increase integration in comparison to sheltered settings, but not maximize it (Brown, et al., 1984). In fact, such programs may continue to isolate, label and stereotype workers with disabilities. Job crews often conduct their business in the evenings or outdoors (janitorial or lawn work) where typical workers are not present. Work enclaves may develop separate or dissimilar routines from the host company. Contact with typical people may be limited in a small business set up by an agency. Since workers are not being paid as employees of the business, employers and coworkers may not consider the workers as true employees.

Integration is more than mere physical presence at a work site. It includes individuals with and without disabilities working with and next to each other, sharing work breaks and after hours social activities. The individual placement of people with severe disabilities into the regular work force can best promote the development of relationships and true personal social integration.

Payment Mechanisms and Financial Disincentives

While many supported employment programs have found ways of working around the financial disincentives built into federal and state laws and regulations governing the work and benefits of people with severe disabilities, many changes in these laws and regulations are still necessary for full implementation.

Some disincentives have to do with funding mechanisms. Most states' systems provide substantial sums of money on an ongoing basis to sheltered workshops, segregated employment and day settings, yet these monies cannot be used to support people in integrated settings. Many agencies, including already-established vocational services and "new" providers, are eager to support people in this way but cannot obtain funding to do so or use existing funding for this purpose. Other vocational service providers may need additional incentives to encourage them to begin to engage in supported work. States must make sufficient funds available for supported employment programs. This, along with other incentives, would reward those who are eager to provide these services and would entice additional providers to convert existing programs to supported employment services. Additionally, Medicaid regulations, which currently limit expenditures for work or work-related activities, must be changed--or states must forgo use of Medicaid monies for day programs (Laski & Shoultz, 1987).

Other financial disincentives involve individual benefits such as SSI, SSDI, and Medicaid. Although the increased levels of income allowed under federal provisions known as Section 1619a and 1619b do not, in most instances, jeopardize SSI and Medicaid eligibility, inequities remain. For example, individuals in states which do not link Medicaid and SSI eligibility may lose Medicaid benefits if their income increases too much. Individuals receiving SSDI are not affected by Sections 1619a and 1619b. Thus, they may lose all their benefits if their income increases.

Much-needed reforms are occurring. We must heed the cautionary statements of advocates about the necessity of including people with the most severe disabilities in these reforms (Ferguson & Ferguson, 1986), even as we work to ensure that the changes in systems adhere to progressive principles. We know that with proper supports, individuals with even the most severe disabilities can successfully hold jobs in the community. In order to make this happen, the following needs to occur:

1. Agencies and advocates (including parents, people with disabilities themselves, and other interested parties) must seek the highest degree of social integration possible for each person. Job training and placement must take place in the community. Agency personnel should support interactions between the worker with disabilities and his/her nondisabled peers. Supervisors and co-workers should be encouraged and supported in their efforts to become involved with workers with disabilities.

2. People should be paid according to the quality and quantity of their overall work, with earnings based on the prevailing wage for the job. Whenever possible, individuals should receive pay during training and the initial placement period, with the potential for wage increases after the job is mastered.

3. Regardless of the income earned by the individual, all employees with disabilities should be eligible for the ongoing and individualized supports listed in the federal legislation. The individual's value should not be in any way tied to his/her productivity.

4. Supports should be individualized, so that each employee receives what he or she needs to be successful on the job, and should be available for as long as the person needs them. Supported employment, though a relatively new concept, is changing the type and quality of services received by individuals with disabilities across the country. States are changing their practices and structures, and agencies are now providing supported employment services that truly foster the inclusion of individuals with severe disabilities in all aspects of typical community life.

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