The Need for a Specialized Approach
Connie J. McReynolds, Ph.D., Licensed Psychologist
Rehabilitation Counseling Program, Center for Disability Studies
Department of Educational Foundations and Special Services
Kent State University
McReynolds, C. (2002) Psychiatric Rehabilitation: The Need for a Specialized
Approach. International Journal of Psychosocial Rehabilitation. 7, 61-69.
Contact: Connie J. McReynolds, Ph.D., Licensed Psychologist, Rehabilitation Counseling Program, Center for Disability Studies,Department of Educational Foundations and Special Services, Kent State University, 405 White Hall, Kent, OH, USA 44242-0001,Phone: 330-672-0602; Fax: 330-672-2512; firstname.lastname@example.org.
Many rehabilitation professionals are neither aware nor appropriately prepared to provide the level of services that are needed by individuals with psychiatric disabilities to re-enter the community and function in the workplace. This article discusses the complexities of psychiatric disabilities, the significance of work for individuals with psychiatric disabilities, and intervention approaches that have been found effective in assisting individuals with psychiatric disabilities enter the world of work for the first time or re-enter after acquiring a psychiatric disability.
__________________________________________________________________________More than two thousand years ago, Hippocrates’ observation that our own well-being is affected by our settings established a fundamental cornerstone for Western medicine (Gallagher, 1993). There appear to be many sociological factors that can affect a person’s adjustment to disability. People with any disabling condition must face the task of adjusting to their conditions, disabilities, and to their environment. According to Lazaras and Folkman (1984), psychological stress results from a particular relationship between the person and the environment, one that persons with disabilities often may perceive as either taxing or exceeding their resources and endangering their well-being.
It is estimated that more than 40 million people in the United States have psychiatric impairments; of that number, 4 to 5 million adults have a severe psychiatric disability (National Institute on Disability and Rehabilitation Research, 1993). Severe psychiatric disabilities are described as persistent mental or emotional disorders that significantly interfere with a person’s ability to carry out such primary aspects of daily life as self-care, household management, interpersonal relationships, and school or work (Task Force on the Homeless and Severe Mental Illness, 1992). Primarily, these psychiatric diagnoses include schizophrenia, affective disorders, and anxiety disorders (Bond, 1995).
The treatment of mental illness underwent a dramatic shift in the United States during the 1960‘s and the 1970‘s with the introduction of psychotropic medications. Before the development and introduction of these medications, individuals with psychiatric disabilities were institutionalized for decades, with many individuals living out their lives in institutions (Smart, 2001). The passage of the Mental Health Centers Act of 1963 (P.L. 88-164) caused a major shift in the type of care provided for people with psychiatric disabilities. Subsequent amendments defined the specific services that mental health centers were required to provide (Peterson et al., 1996) serving as the catalyst for more movement toward the development of a decentralized community-based treatment system. However, many individuals with psychiatric disabilities were released from state hospitals after years of institutionalization prior to the establishment of necessary community support systems. The deinstitutionalization effort ultimately resulted in the discharge of many thousands of people with psychiatric disabilities into communities that were neither prepared nor willing to accept them (Gerhart, 1990; Rogers, Anthony, & Jansen, 1991).
The new directions in psychiatric rehabilitation include a variety of strategies to increase the community integration and independence of people with psychiatric disability. Unfortunately, many rehabilitation professionals are neither aware nor appropriately prepared to provide the level of services that are needed by individuals with psychiatric disabilities to re-enter the community and function in the workplace. To this end, this article will discuss (a) the complexities of psychiatric disabilities, (b) the significance of work for individuals with psychiatric disabilities, and (c) intervention approaches.
People with psychiatric disabilities experience numerous limitations in everyday functioning, some of which include difficulties with interpersonal situations, (e.g., misinterpreting social cues, inappropriate responses to situations), problems coping with stress (including minor hassles, such as finding an item in a store), difficulty concentrating, and lack of energy or initiative (Bond, 1995). Whether persons with psychiatric disabilities have never learned social skills or have lost them, most of these individuals have marked skill deficits in social skills and interpersonal situations (Bond, 1995). Traditionally, medication and psychotherapy were the two major treatment approaches for people with psychiatric disabilities, with little attention given to preventing or reducing functional limitations or handicaps to social performance. Traditional approaches such as medications, hospitalization, and dynamic psychotherapy have had limited effectiveness when applied to the socialization and work aspects of individuals with psychiatric disabilities (Chan et al., 1998).
Complexities of Psychiatric Disabilities
Rather, the preferred modes of intervention include strengthening both the client’s skills and the level of environmental supports. Client skill strengthening approaches involving social and independent living skills training, symptom management, and job finding clubs have been recognized as having a strong positive effect for individuals with psychiatric disabilities. Critical environmental support strengthening approaches include family behavior management and the use of peer groups in the transition to community living. Supported employment has been cited as a crucial service component that places equal emphasis on the strengthening of client skills and environmental supports (Xie, Dain, Becker, & Drake, 1997).
According to the Task Force on the Homeless and Severe Mental Illness (1992), community treatment of the person who has a psychiatric disability needs to include a focus on teaching coping skills that are necessary to live as independently as possible in the community. It is the presence or absence of such skills that is often the determining factor related to rehabilitation outcomes, rather than the client’s actual psychiatric symptoms. Rehabilitation programs must encompass the development of learning or relearning of skills and competencies required for successful interpersonal and social functioning as well as those needed for specific vocational pursuits.
According to Anthony, Cohen, and Farkas (1990), the preferred method of increasing a client’s capacities in social situations is a skills-training approach. In such an approach, the intent is to identify those specific client skill deficits that are preventing the person from functioning more effectively in his or her living, learning, and/or work community. For example, clients may need help in learning social skills, interpersonal skills, coping skills, personal hygiene, and self-care, as well as symptom management (Corrigan, Rao, & Lam, 1999). Bellack, Mueser, Gingerich, and Agresta (1997) described social skills as interpersonal behaviors that are normative and/or socially sanctioned. They include such elements as dress and behavior codes; rules about what to say and not to say; and stylistic guidelines about the expression of affection, social reinforcement, interpersonal distance, and so forth. Deficits in these areas can make it quite difficult for a person with a psychiatric disability to establish and maintain relationships that are necessary for social integration
Like other people, individuals with psychiatric disabilities wish to lead normal lives and view work as a signifier of normal adult life (Becker & Drake, 1994). In Western culture, work is highly valued and is considered a socially integrating force; however, many persons with severe psychiatric disabilities have been excluded from the world of work (Ahrens, Frey, & Senn Burke, 1999). In fact, estimates of unemployment are at a rate of 85 percent for working-age members of this population in the United States (National Institute on Disability and Rehabilitation Research, 1993). Despite a strong desire to work, functional competencies, and educational qualifications, many of those who have severe and persistent psychiatric disabilities have no long-term attachment to the labor market (Garske, 1999). Even when persons with psychiatric disabilities seek vocational services, they have success rates only about half of those persons with physical disabilities (Marshak, Bostick, & Turton, 1990).
Significance of Work for Individuals with Psychiatric Disabilities
Employment can serve as a normalizing factor since individuals who are unemployed and lack alternative societal roles are often stigmatized. Through work, individuals can obtain daily structure and may also develop a network of interpersonal contacts (Bond, Drake, & Becker, 1998). Involvement in work can help combat negative symptoms by facilitating a higher level of self-esteem and perceived quality of life (Fabian, 1992; Van Dongen, 1996). Therefore, the mission of psychiatric rehabilitation is to assist persons with long-term psychiatric disabilities increase their functioning so they are successful and satisfied in the environments of their choice with the least amount of ongoing professional assistance (Anthony, et al., 1990). Comprehensive psychiatric rehabilitation programs combined with effective medication management help such individuals meet the challenges of managing their disability (Liberman, Corrigan, & Schade, 1989).
Psychiatric rehabilitation programs have sought to develop strategies to increase the community integration of people with psychiatric disabilities, including schizophrenia. To help people with psychiatric disabilities become and remain integral members of society, rehabilitation, vocational training, and assistance in work settings are essential. However, in many communities, the majority of people with psychiatric disabilities have only two options: to be unemployed or to work in entry-level positions with low pay and little chance of advancement (Carling, 1995). Work is a key component, some would argue the most important component, of services designed to achieve community integration. In the context of psychiatric rehabilitation, work can be seen both as an outcome and as a highly effective treatment modality in enhancing meaningful community integration (Ahrens, et al., 1999).
Psychiatric rehabilitation can be a complex and formidable task. Without proper training and exposure to effective psychiatric rehabilitation strategies, the unprepared rehabilitation professional will easily be overwhelmed and may have difficulty contributing to successful intervention planning with individuals who have psychiatric disabilities. Moreover, the rehabilitation professional may lack the skills necessary to effectively negotiate important adaptations for the individual with the psychiatric disability on the worksite, with co-workers and employers alike (McReynolds & Garske, 2002). The current unemployment rate for individuals with psychiatric disabilities is more than 85 percent (Nobel, Honberg, Hall, & Flynn, 2001), in part because individuals with psychiatric disabilities often struggle with a wide variety of challenges and needs which likewise challenge the rehabilitation professional. Strategies for helping people with psychiatric disabilities obtain meaningful work have changed significantly in recent years. Successful work assistance approaches appear to have a number of common characteristics and include individualized career planning, help with job access, and aid in job retention; peer support; coordination with other social services and benefits; and assurances of confidentiality (Carling, 1995).
The recovery model, as described by Pratt, Gill, Barrett, and Roberts (1999) and as touted by Deegan (1988) and Anthony (1993), is a fundamental shift in perception regarding individuals with psychiatric disabilities. Recovery is viewed as a "reformulation of one’s life aspirations and an eventual adaptation to the disease" (Pratt, et al., 1999, p. 91). Within this concept of recovery lies the belief that individuals with psychiatric disabilities can and do adjust to psychiatric disabilities by a process of acceptance of the disability and the development of a positive self-image. Further bolstering the recovery model are developments in improved medications, the use of supported employment, and the debunking of long-held myths perpetuating stigma and discrimination of individuals with psychiatric disabilities.
According to Bond (1995), psychiatric rehabilitation provides individuals with psychiatric disabilities the opportunity to work, live in the community, and enjoy a social life, at their own pace, through planned experiences in a respectful, supportive, and realistic atmosphere. Psychiatric rehabilitation typically involves helping individuals to gain or improve necessary interpersonal skills and provides a level of support required for clients to obtain their goals. The mission of psychiatric rehabilitation, therefore, is to assist persons with long-term psychiatric disabilities increase their functioning so they are successful and satisfied in the environments of their choice with the least amount of ongoing professional intervention (Anthony et al., 1990).
According to Lamb (1988), no part is more important than giving clients a source of mastery over their internal drives, their symptoms, and the demands of their environments. Various models have been developed in the United States that have provided individuals with psychiatric disabilities opportunities of community integration that were heretofore not possible and are discussed as follows:
The Clubhouse Model is a comprehensive group approach that focuses on practical issues in informal settings (Bond, 1995). Clubhouses are community-based rehabilitation programs for people with psychiatric disability offering vocational opportunities, planning for housing, problem-solving groups, case management, recreational activities, and academic preparation. Individuals can learn or regain skills necessary to live a productive and empowering life. The Clubhouse Model provides for the societal, occupational, and interpersonal needs of the person as well as medical and psychiatric needs (Fountain House, 1999).
Developed at the Fountain House in New York, transitional employment (TE) is an integral part of the Clubhouse approach. Clients, or members as they are called, are placed in part-time entry-level positions for three to nine months and are supervised by one another and/or rehabilitation professionals. Members work at a place of business in the community and are paid the prevailing wage rate by the employer. The placements are part-time and limited generally to 15 to 20 hours a week. The program is designed to develop a client’s self-confidence, current job references, and improve work habits necessary to secure permanent employment (Anthony et al., 1990). TE continues to be an effective rehabilitation strategy in many mental health systems (Bond, 1995).
Individual Placement and Support (IPS)
The Individual Placement and Support (IPS) program was developed at the New Hampshire-Dartmouth Psychiatric Research Center (Becker & Drake, 1993). The IPS Model recognized that "work is so many things to so many people, we might define it simply as a structured, purposeful activity that we usually do in exchange for payment" (p. iii, Becker & Drake, 1993). The model draws from several psychiatric rehabilitation intervention models (e.g., ACT, choose-get-keep) in which clients choose from a range of work possibilities including full-time to various levels of part-time work to pre-vocational activities. Competitive employment is generally encouraged; however, non-paid employment options are likewise given consideration when deemed most appropriate for the particular individual’s needs.
The vital component of the IPS model incorporates the success-driven concept of follow-along support provided by a core group of people who function as a team. The team generally consists of employment specialists, rehabilitation counselors, psychiatrists, and other mental health staff as needed. The treatment team approach provides a more seamless method of service delivery versus receiving separate services from various professionals in a non-coordinated manner. Clients are encouraged to be active and fully involved in the job-search process and are then supported through their employment with on-going follow-along (Becker & Drake, 1993).
Community Support System
The National Institute of Mental Health (NIMH) began the community support system (CSS) initiative in 1977. The intent was to assist states and communities in developing a broad array of services to assist people with psychiatric disability. This initiative eventually became known as the NIMH Community Support Program, with case management as one of the essential services (Anthony et al., 1990).
One of the leading models of CSS is the assertive community treatment (ACT) approach that works with clients on an individual basis providing services primarily in the client’s home and neighborhood rather than in offices. ACT programs are staffed by a group of professionals who work as a treatment team in the community (Bond, 1995). In most ACT teams, staff provide a range of serves to clients in their natural surroundings which include, but are not limited to, assisting with social service agencies, medication management, housing, employment, family issues, and teaching clients coping skills (Chinman et al., 1999). ACT, first developed in Madison, Wisconsin, has spread throughout the United States in recent years, especially in the Midwest (Bond & McDonel, 1991). The ACT team maintains frequent contact with clients and assists with client’s concerns around activities of daily living (i.e., budgeting money, shopping, housing, taking medication, employment, problem solving on the job).
Community-based treatment of persons with psychiatric disability, as provided in the ACT model, focuses primarily on the teaching of basic coping skills necessary to live and function as autonomously as possible in the community. These coping strategies consist of activities of daily living, vocational skills, leisure time skills, and social or interpersonal skills (Bond, 1995). Several characteristics of the ACT approach make it distinctive. The first of these is assertive outreach in which staff members initiate contacts rather than depending on clients to keep appointments. A second characteristic of ACT is its emphasis on continuity and consistency whereby care is ongoing and the services are integrated. Finally, ACT programs combine treatment and rehabilitation in a comprehensive and interdisciplinary approach (Bond, 1995). This case management approach has been widely adopted across the United States, especially for persons with psychiatric disability.
Supported employment (SE) is another promising approach to helping people with psychiatric disability to succeed in the community. SE is one of the models of vocational rehabilitation that has been successful in helping individuals with psychiatric disability secure competitive employment (Ahrens, et al., 1999). It emphasizes direct placement in a community job, assistance in locating the job with the consumer, and ongoing job-related problem-solving and support after consumers obtain work. Individual placement is the key vocational strategy nationwide (Wehman & Revell, 1996). An evaluation of an SE program for persons with psychiatric disabilities found that clients were able to exercise more control over their career choices due to the client-centered approach used in SE programs (Block, 1992). By 1995, a national survey had identified 36,000 persons with mental illnesses who were employed in SE jobs (Wehman, Revell, & Kregal, 1997).
Although long overdue, another vocational improvement for people with psychiatric disability is in the area of education. Supported education programs have surfaced and expanded in the last few years, partly in response to problems experienced by people with psychiatric disability in more traditional vocational rehabilitation approaches (Moxley, Mowbray, & Brown, 1993). Like supported employment and supported housing, supported education takes a rehabilitation approach in providing assistance, preparation, and advocacy to individuals with psychiatric disabilities who desire to pursue post-secondary education or training (Mowbray, Bybee, & Shriner, 1996).
Supported education as a program model has been nationally recognized as a promising method to improve employment rates (Anthony, 1994). A variety of supported education approaches have been identified, of which two of the most common are the structured classroom and on-site support (Mowbray, Moxley, & Brown, 1993). In the structured, or self-contained classroom, students attend classes with other students with psychiatric disability. In the onsite support model, students attend regular classes. Support is provided by the staff of the educational facility (Unger, 1990) and according to Mowbray and Megivern (1999), supportive education programs can and do work.
Individuals with psychiatric disabilities have many of the same desires as other individuals in society – namely, to feel a part of the larger community. Work can, in many ways, help individuals with psychiatric disabilities achieve integration by providing a means to develop valued societal roles, reduce stigmatization, increase social connectedness, and serve as a normalizing factor. Rehabilitation professionals can play an integral and valuable part in the lives of individuals with psychiatric disabilities by integrating and implementing a variety of strategies designed to increase the community integration and independence of people with psychiatric disabilities through successful employment outcomes.
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