An Individualized Job Engagement Approach for Persons with Severe Mental Illness.

Work is highly valued and is considered a socially integrating force in Western culture; however, many individuals with psychiatric disabilities are excluded from the world of work. The National Institute of Mental Health estimates employment rates of between 10% and 30% for persons with severe and persistent mental illness (as cited in NAMI, electronic data www.nami.org/helpline/factsheet.htm). Studies reported by Anthony, Cohen, and Danley (1988) suggest employment rates for persons with severe and persistent mental illness of between 0% and 15% for full- or part-time competitive employment, indicating that a majority of persons with mental illnesses have minimal or no earned income and rely heavily on entitlement programs. The economic burden of mental illness to society is further increased by loss of tax revenue and the cost of care for persons with severe and persistent psychiatric disabilities, resulting in an immense overall cost to society (Rupp & Keith, 1993; Wyatt, 1995).

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 (Frey and Godfrey, 1991; Mueser, Becker, Torrey, Xie, Bond, Drake, & Dain, 1997; Russert and Frey, 1991). For the individual with a mental illness, inability to find or maintain employment can lead to marginalization within society, lack of financial resources (Robins & Regier, 1991), social isolation, and stigmatization (Berven & Driscoll, 1981; Farina & Felner, 1973; Trauer, Duckmanton, & Chiu, 1998). Many authors acknowledge the positive impact of employment on self-esteem and the socially integrating function of work (Anthony & Blanch, 1987; Neff, 1988; Perese, 1997; Trotter, Minkhoff, Harrison, & Hoops, 1988; Van Dongen, 1996; Wart, 1983). Conversely, unemployment among persons with mental illness has been associated with lower self-esteem and higher levels of psychiatric symptoms (Bell, Lysaker, & Milstein, 1996; Bell, Milstein, & Lysaker, 1993; Perese, 1997; Westermeyer & Harrow, 1987).

Despite extensive legislative efforts to improve vocational rehabilitation services to persons with psychiatric disabilities, employment rates for persons with a history of mental illness have remained low. In 1979, the National Institute of Handicapped Research (NIHR) reported that clients with mental illnesses constituted the largest target population for vocational rehabilitation services, yet they had the lowest probability of success. Based on a review of 1,000 cases at the Pennsylvania Office of Vocational Rehabilitation, Marshak, Bostick and Turton (1990) concluded that persons with psychiatric disabilities were only half as likely to achieve positive vocational outcomes as persons with physical disabilities. On a national level, Rutman, McGurrin, and Manderscheid (1994) reported successful rehabilitation rates of 56% for persons with mental illness between 1984 and 1988 versus 69% for persons with other disabilities. Noble (1998) reported that the federal-state vocational rehabilitation system currently spends an estimated $490 million annually on time-limited services to consumers with mental illness, without producing long-term employment outcomes. He suggested that the same amount of money spent on more appropriate, integrated service models could provide stable annual rehabilitation funding for 62,000 to 90,000 consumers.

Supported employment is one of the models of vocational rehabilitation that has demonstrated success in securing competitive employment for people with severe and persistent mental illness. Based on a review of the supported employment literature, Bond, Drake, Mueser, & Becker (1997), concluded that in experimental studies, a mean of 58% of clients participating in supported employment achieved competitive employment, compared to 21% of controls. Furthermore, their review found support for the integration of mental health and vocational services within one service system, but not for preplacement training (Bond et al, 1997). Within supported employment programs, Drake, McHugo, Becker, Anthony, & Clark (1996) provided evidence of the effectiveness of individual placement and support services over group skills training. However, despite growing empirical evidence documenting the effectiveness of supported employment approaches with people with severe and persistent mental illness, Fabian (1992) found that only 14% of participants in a supported employment program were consumers with mental illness.

This study evaluated the effectiveness of an individualized job engagement and placement approach developed at the Program of Assertive Community Treatment (PACT) to serve clients with severe mental illness. This project was designed to provide intensified vocational services to clients who were experiencing long-term unemployment or underemployment despite ongoing rehabilitation efforts. The underlying investigation was conducted over the course of five years.

Program Description

The PACT program (also referred to in the literature as the Training in Community Living Model), served as the site for this investigation. This model of comprehensive community care was developed by Marx, Test and Stein (1973) at Mendota Mental Health Institute in Madison, Wisconsin. A key characteristic of this approach was the provision of services by a core team of professionals who provided almost all biopsychosocial services for a defined group of clients (Test, Knoedler, Allness, Kameshima, Senn Burke, & Rounds, 1994). The team was composed of professionals in a variety of disciplines who provided mobile outreach and highly individualized services to persons with severe and persistent mental illness in the community. Admissions to PACT were limited to persons with a diagnosis of schizophrenic, schizoaffective, bipolar, or major depressive disorders.

Vocational rehabilitation services at PACT have been described by Frey and Godfrey (1991) and Russert and Frey (1991). They were incorporated within the biopsychosocial services provided by the core team of interdisciplinary clinicians and followed the same principles of mobile outreach and individualization as described above. Vocational rehabilitation services were offered to all PACT clients throughout their participation in the program. Thus, clients were not required to meet internal screening or selection criteria (i.e., for "work readiness"). Rather, vocational goals evolved within the clinical relationship between counselor and client. Services generally followed an individualized placement approach (Frey & Godfrey, 1991) in conjunction with long-term support (Frey & Godfrey, 1991; Frey, 1994). In contrast to traditional supported employment services, however, the majority of vocational support services were provided outside the job site. This modification was believed to maximize the normalizing effect of work and to encourage clients' use of natural supports on the job (Frey & Godfrey, 1991). The integration of clinical and rehabilitation services within the team gave the vocational rehabilitation (VR) specialist detailed knowledge of each client's mental status and functional capacity. This knowledge facilitated the job matching process and greatly enhanced the opportunities to use work as a treatment modality. Addressing both clinical and career development considerations, the VR specialist provided a wide array of services including vocational assessment, job development, placement, benefits counseling, ongoing job follow-along, and consultation to clients and employers regarding job accommodations. Job coaching was provided to clients if needed, but was typically used briefly during periods of transition. Funding from the Division of Vocational Rehabilitation (DVR) was sought as necessary to enhance the clients' career development (i.e., funds for on-the-job-evaluation, training), but services (i.e., job development and placement) continued to be provided by PACT staff. Vocational goals were based on an ongoing assessment of each client and revised every six months. As clinical and vocational interventions were based on individual need, their nature and intensity varied greatly from client to client and for individual clients over time.

Time-limited, controlled studies on the efficacy of the PACT model (Stein & Test, 1980) have consistently demonstrated a significant reduction in hospitalizations and gains in independent living for PACT clients versus controls (Bond, Witheridge, Dincin, Wasmer, Webb & De Graaf-Kaser, 1990; Hoult, Reynolds, Carbonneau-Powis, Weekes & Briggs, 1983; Morse, Calsyn, Allen, Tempelhoff & Smith, 1992; Muijen, Marks, Connolly & Audini, 1992). Improvements in work and social functioning have been found less consistently and appear modest (Stein & Test, 1980). In addition, post-discharge follow-up of clients involved in short-term studies has shown that gains are not sustained when services are discontinued.

Purpose of the Current Investigation

Consistent with the findings of earlier research described above, unpublished results of internal Quality Assurance (QA) monitoring data for two twelve month periods (1989/99 and 1991/92), suggest that between 36% and 43% of clients remained unemployed for an entire twelve-month period despite receiving ongoing vocational services. Approximately 37% of clients spent six or more months of the year competitively employed, and between 20% and 27% of clients were competitively employed for periods ranging from a few days to 5 months per year. These results were based on a 50% sample of clients served. This study was designed to improve services to and outcomes for the group of clients who were either continuously unemployed (36% to 43%) or underemployed (20% to 27%).

Method

Subjects

After reviewing the above outcomes, PACT vocational counselors met in the fall of 1992, to review the total clinical caseload of one hundred and twenty-five clients receiving services at that time. Based on group consensus, vocational staff identified sixty-two clients (49.6% of the caseload) as in need of intensified vocational services to secure competitive jobs. Additionally, five persons identified by the 1991/92 QA data, but not by staff ratings, were included in the initial target group of sixty-seven persons. Over the five-year course of the investigation, staff identified an additional twenty-three clients as needing intensified vocational services. These included seven persons who were admitted after the investigation began. The final target group for intensified vocational services available through this grant included ninety of the one hundred and forty four persons (62.5%) served over the five-year course of this investigation.

Of the 90 persons identified as appropriate for expanded vocational services, 67 were opened for services over the five years of the DVR Third Party Progressive Work Opportunities Grant. DVR services were terminated for four of the 67 for the following reasons: (a) death (natural causes; n-1); (b) a marked increase in psychotic symptoms resulting in long-term hospitalization (n=1); (c) unwillingness to participate in a vocational plan (n=1); and (d) a marked increase in substance use (n-1). Results are presented for the group of sixty-three clients who participated in services under the grant on an on-going basis.

Demographic characteristics of the clients who received intensified vocational services under the Progressive Work Opportunities Grant (N-63) are summarized in Table 1. Clients ranged in age from 19 to 61 at the time their case was opened, the mean age at the time of opening being 37 years. Fifty-nine percent of clients were male; forty-one percent were female. Clients were predominantly Caucasian (92%). Five percent were African American and two percent were Native American. Fifty-six percent had never been married and 44% were currently or had previously been married.

Table 1 Demographic Characteristics of Clients Who Received Intensified Vocational Services Under Grant (N=63)

                               All Clients Served Under Grant,(a)
                                              N=63

Demographic Characteristic       N (%)         M (Range)       SD

Age (years)                        --       36.95 (19-61)    8.75

Gender
 Male                          37 (58.7%)         --           --
 Female                        26 (41.3%)         --           --

Race
 Caucasian                     58 (92.1%)         --           --
 African American               3 (4.8%)          --           --
 Asian                          0 (0.0%)          --           --
 Native American                1 (1.6%)          --           --
 Hispanic                       1 (1.6%)          --           --

Marital status Single, never   35 (55.6%)         --           --
married

Married, currently or          28 (44.4%)
previously

(a) Does not include data for four clients who were initially opened under the grant but subsequently terminated due to 1) death (natural causes), 2) long-term hospitalization, 3) unwillingness to participate and 4) a marked increase in substance use.

As reported in Table 2, the vast majority of clients who received intensified vocational services met DSM IV diagnostic criteria for schizophrenia or schizoaffective disorder (95%). Five percent of the clients were diagnosed with non-schizophrenic disorders, including bipolar II disorder (n=2) and delusional disorder (n=1). Forty-three percent had a concurrent diagnosis of an active alcohol or substance abuse disorder (AODA). The mean age at onset of illness for this group was 19.49 years (SD=5.06) with a range from 4 to 33 years of age. On average, clients had spent 11.7 years in PACT prior to receiving intensified vocational services under the grant. With regard to education, 25% of clients had not completed high school. Fifty-one percent had achieved a high school diploma, completed an equivalency exam, or were currently enrolled in an educational program (i.e., high school, technical school, or college). Twenty-four percent had completed some level of higher education. As a group, clients served under the grant had spent an average of 88% of the year prior to opening unemployed (SD 20.9%).

Table 2 Clinical and Vocational Characteristics of Clients Who Received Intensified Vocational Services Under Grant (N=63)

                              All Clients Served Under Grant,(a)
                                            N=63

Clinical/Vocational            N (%)         M (Range)        SD
Characteristic

Diagnosis
 Schizophrenic disorders     60 (95.2%)         --            --
 Non-schizophrenic           3 (4.8%)           --            --
 disorders

Concurrent AODA Diagnosis
 Present                     27 (42.9%)         --            --
 Absent                      36 (57.1%)         --            --

Onset Age of Mental                       19.49 (4-33)       5.06
Illness

Years in PACT before
opened under grant                        11.3 (0.3-21.41    6.36

Education
 No high school diploma      16 (25.4%)         --            --
 High school diploma,
 equivalence, or currently   32 (50.8%)         --            --
 enrolled

Higher education             15 (23.8%)         --            --
Percent of year prior to
 opening spent unemployed        --            88.4%        20.9%

(a) Does not include data from four clients who were initially opened under the grant but subsequently terminated due to 1) death (natural causes), 2) long-term hospitalization, 3) unwillingness to participate and 4) a marked increase in substance use.

Interventions

Funds available under this initiative were used to hire one additional vocational counselor and to provide work incentives for clients. Clients receiving services under this initiative were also eligible for additional funds from DVR for work related expenses such as clothing and transportation. In addition, a DVR counselor was assigned to the group of clients targeted under the grant with the agreement that they would receive accelerated access to services (i.e., case opening, funding). Finally, progress toward vocational goals was reviewed on a monthly basis for each client targeted under the grant. This case review involved a 1-2 hour meeting between all PACT vocational staff and the designated DVR counselor to identify progress, problem-solve, and initiate additional funding or services as necessary.

As described above, the nature and intensity of services varied from client to client and over time. Although interventions are described in a linear sequence, clients received only the services they needed and their progression through services was typically non-sequential. In keeping with a philosophy of long-term support, clients remained eligible for services throughout the course of the Progressive Work Opportunities Grant. Ongoing eligibility allowed for continuous services over an extended period of time, as well as for repeated case opening and closure with DVR as needed by the client.

Functional assessment. Vocational assessment addressed clients' work interests and needs (i.e., need for structure, social interaction, financial rewards, prestige) as well as their capacity for work (i.e., level of energy, anxiety, and concentration; impact of sleep/wake cycle on daily structure; tolerance for environmental stimulation and social interaction). Assessment was ongoing throughout the treatment process.

Interpersonal Engagement: Since many of the targeted clients were socially withdrawn and experienced extreme social anxiety, interventions focused on fostering interpersonal engagement allowing for an extended period of time to build rapport with the VR specialist if needed. In such cases, one-on-one contacts and recreational activities were used both to build trust and to provide exposure to new people, environments, and interests. This gradual exposure assisted in desensitizing clients to anxiety-producing social situations and helped introduce an element of structure into their lives (i.e., weekly meetings and activities). Social groups (i.e., dinner group, women's group, sports group, art therapy group) were offered for clients who could tolerate and desired group situations to continue the socialization process.

Individualized Goal Setting. Based on the results of ongoing functional assessment, the VR specialist developed individualized vocational goals which took into account the client's current level of psychiatric symptoms and identified the interventions to be utilized with each client. This plan was integrated into each client's overall clinical treatment plan. Implementation was monitored on an ongoing basis and the goals were revised together with the clinical treatment plan at six-month intervals.

Prevocational Skills. With some clients, emphasis was placed on teaching general work competencies, increasing work motivation, and decreasing disincentives to work. Beyond the normalizing and structuring effects of social contacts and joint activities, these interventions were designed to enhance clients' self-esteem. As a natural consequence of increased activity and social engagement, clients were expected to develop a more complex need structure, including a greater need for financial resources and social approval, which were seen as important motivators for vocational involvement. When appropriate, incentive money was provided for participation in structured activities with the goal of raising expectations regarding attendance, timeliness, and interactions with peers. At the same time, disincentives to work were addressed, for example by educating clients' families about the rehabilitative value of work, time-structuring activities, and reducing financial support from families where appropriate, or by providing transportation to structured activities. Treatment modalities included individual, group and family interventions.

Social and Independent Living Skills. Interventions in this category focused on expanding individual clients' repertoire of social and independent living skills. Generally, this involved training in areas such as shopping, cooking, budgeting, laundry, and self-care. Interventions related to work included teaching and feedback on grooming, training in the use of public transportation, training in problem solving, time management, and group participation to improve social skills.

Work Hardening Activities. These activities emphasized training in specific work competencies through exposure to the world of work. Interventions included volunteer placements or supported employment to build skills and/or to develop work references. As needed, clients were offered grooming prompts, situational assessments, job coaching, work reviews, and group participation for peer and staff support. Staff continued to assist in clarifying clients' interests and values related to work in individual and/or group contacts. They also provided pre- and post-work support to address psychiatric symptoms (e.g., anxiety, conceptual disorganization, delusional thinking, emotional withdrawal and blunting) and their impact on work.

Individualized Job Development and Placement. Based on the ongoing functional assessment of work capacity, skills, interests, and clients' needs, the VR specialist identified or developed a job for each client individually. Placement activities included assistance with developing resumes, practice interviews, and assistance with job applications. Staff accompanied clients to interviews to provide information and/or support and assisted clients in obtaining or filling out work related documents (i.e., social security cards, tax forms, and insurance forms).

On-going Support. Services in this category focused on assisting clients to retain jobs. Specific interventions included regular support contacts to help clients sustain their work motivation and ongoing monitoring of symptoms and their impact on work. Also provided were regular feedback to clients regarding job performance; teaching of self-monitoring techniques; and negotiating job and/or work schedule modifications during periods of exacerbation in illness.

Results

Of the clients served, 35 (55.6%) worked competitively for the minimum period required by DVR as meeting the criteria for successful closure (60 or 90 days). Twenty-eight clients (44.4%) did not meet the criteria for successful case closure.

Case Closures

Demographic characteristics for those clients who were successfully closed (status 26) under the grant (n=35) are presented in Table 3; clinical and vocational characteristics are reported in Table 4. In keeping with our philosophy of long-term support, clients remained eligible for and received services as needed throughout the course of the Progressive Work Opportunities Grant. Ongoing eligibility allowed for continuous services over an extended period of time, and/or for repeated case opening and closure with DVR, as needed. Thus, four clients had an open case with DVR at two different time points within the five-year course of the grant and each achieved two closures. Only the first closure is included in the current analysis. Clients whose case was successfully closed received intensified services for an average of 383 days (SD=322 days) prior to closure. Length of intensified services ranged from 71 days to 1,305 days, with a median of 310 days of participation in services under the grant.

Table 3 Demographic Characteristics of Cases Closed by DVR (n=35) Under the Grant

                              Cases Closed, n=35(a)

Demographic Characteristic     n (%)        M      SD

Age (years)                      --       37.43   9.08

Gender
 Male                        21 (60.0%)    --      --
 Female                      14 (40.0%)    --      --

Race
 Caucasian                   33 (94.3%)    --      --
 African American            2 (5.7%)      --      --

 Asian                       0 (0.0%)      --      --
 Native American             0 (0.0%)      --      --
 Hispanic                    0 (0.0%)      --      --

Marital status
 Single, never married       28 (80.0%)    --      --
 Married, currently
 or previously               7 (20.0%)     --      --

(a) Includes the first case closure only; four clients were served and closed twice

Table 4 Clinical and Vocational Characteristics of Cases Closed by DVR (n=35) Under the Grant

                                   Cases Closed, n=35(a)

Clinical/Vocational
Characteristic                    n (%)       M (Range)      SD

Diagnosis
 Schizophrenic disorders       35 (100.0%)        --         --
 Non-schizophrenic disorders   0 (0.0%)           --         --

Concurrent AODA

Diagnosis
 Present                       16 (45.7%)         --         --
 Absent                        19 (54.3%)         --         --

Onset Age of Mental Illness        --        20.17 (8-33)   4.73

Education
 No high school diploma        7 (20.0%)          --         --
 High school diploma,
 equivalence, or currently     20 (57.1%)         --         --
 enrolled
 Higher education              8 (22.9%)          --         --

Years in PACT before opened        --        12.18
 under grant                       --        (0.3-20.3)     6.1

Percent of year prior to
opening spent unemployed           --        86.7%          18.9%

(a) Includes the first case closure only for four clients, each of whom was served and closed twice

Cases that were closed at least once (n=35) and those that were never closed (n=28) were compared using t-test (p [is less than] 0.05, two-tailed) or Chi-square analysis, as appropriate. No significant differences were found with regard to demographic, clinical, or vocational characteristics including age, race, gender, marital status, diagnosis, age of onset, concurrent AODA diagnosis, years in PACT before opening, education, and the percent of the year prior to opening spent unemployed.

Conclusions

A number of the demographic, clinical, and vocational characteristics described above suggest that, as a group, clients who received intensified vocational services (N=63) faced multiple challenges to their vocational success. Many characteristics of this group are identified as risks to vocational success in research addressing employability in the general population or the vocational capacity of people with severe and persistent mental illness. Risk factors for this sample included being middle aged (M=36.95, SD=8.75 years of age), having a diagnosis of schizophrenia or schizoaffective disorder (96.8%), an early onset of mental illness (M=19.49, SD=5.06 years of age), being unemployed for approximately three quarters of the year prior to receiving intensified services (M=88.4%), having received services at PACT over an extended period of time prior to receiving intensified vocational interventions (M=11.30, SD=6.36 years), and having a concurrent diagnosis of active alcohol or substance abuse (42.9%).

Studies suggest that employers are reluctant to consider older candidates for semiskilled or lower level positions (Haefner, 1977, Singer and Sewell, 1986, Triandis, 1963). This could present a substantial obstacle for a middle-aged person with a mental illness whose career development has been delayed by frequent job interruptions and/or extended periods of unemployment and who is applying for an entry level position. Although previous research has failed to identify a relationship between psychiatric diagnosis and vocational capacity (Anthony & Jansen, 1984), Fabian (1992) found that persons with schizophrenia or schizoaffective disorder had the lowest longevity rates when compared to clients with affective disorders or personality disorders who participated in a supported employment program. The vocational difficulties experienced by people with severe and persistent mental illness have been further attributed to lack of work experience (Anthony & Jansen, 1984), frequent job changes, and unsatisfactory job terminations (Becker, Drake, Bond, Xie, Dain, & Harrison, 1998), substance abuse (Becker, et al, 1998), deficits in social skills (Lysaker, Bell, Milstein, Bryson, Schestopal, & Goulet, 1993), and severity of symptoms (Bell & Lysaker, 1995). From the perspective of a stress-vulnerability model, the confluence of and interaction between multiple risk factors for poor vocational functioning is likely to have a cumulative effect (Garmezy, 1991), which contributes to the challenge of vocational rehabilitation for this group.

Despite the accumulation of multiple risk factors for poor vocational outcomes, over half the clients (55.6%) who received intensified vocational services under the Progressive Work Opportunities Grant were able to benefit in terms of securing and maintaining competitive work, resulting in closure status (Status 26) with DVR. These findings suggest that innovative vocational interventions can affect successful work outcomes for people with severe and persistent mental illness, even in the presence of multiple risk factors. Although further research is necessary before these findings can be generalized, the results may have implications for the state/federal vocational rehabilitation system. For example, state vocational rehabilitation agencies may be able to improve the traditionally poor closure rates for persons with mental illness by contracting with mental health agencies that incorporate vocational rehabilitation services (Noble, 1998).

Furthermore, the closure rate achieved in this project lends support to the use of individual placement approaches in providing vocational rehabilitation services to people who are affected by severe mental illness, especially in combination with a therapeutic focus on engagement and long-term job support (Frey, 1994). Again, implications for the state/federal vocational rehabilitation system may include reallocating funds for long-term, vocational support (Noble, 1998). The relatively high rate of successful closures in a group of clients with a traditionally poor prognosis also tends to validate the PACT policy of offering vocational services to all clients, without an internal screening or selection process.

On average, closure was achieved alter 383 days of intensified services, with a median length of 310 days of service prior to closure. On the surface, these findings seem to support the effectiveness of intensive services within a one year time frame. These statistics will become more meaningful, once they are examined in the context of (a) the cost of intensified services under the Progressive Work Opportunities Grant, (b) quantification of the type and intensity of services, and (c) the long-term employment outcomes for clients served under the grant. Analyses addressing these aspects of the project are currently in the planning stages.

In summary, the results of this project suggest that innovative vocational interventions can affect successful work outcomes for people with severe and persistent mental illness, even in the presence of multiple risk factors for poor vocational outcomes. If substantiated by further research, these results have implications for psychiatric rehabilitation programs and approaches in the state/federal system as well as other systems with a vocational focus.

Authors Note

This project was funded in part by the Mendota Mental Health Institute and through a five-year Progressive Work Opportunities contract with the Wisconsin Division of Vocational Rehabilitation (CFDA#84.126). The authors extend special thanks to Michael Greco, District Director, Wisconsin Division of Vocational Rehabilitation, for his interest in and support of this project.

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Christine S. Ahrens, Ph.D., Mendota Mental Health Institute, Program of Assertive Community Treatment (PACT), 108 S. Webster Street, Madison, WI 53705. Email: [e-mail]

Jana Lane Frey

Suzanne C. Senn Burke

Program for Assertive Community Treatment (PACT)