Meeting the vocational needs of individuals with psychiatric disabilities through supported employment.

This article discusses how the supported employment model can meet the vocational needs of individuals with psychiatric disabilities. included in this discussion are the Federal Register's definition of supported employment, the components of supported employment, and the types of supported employment as outlined by the President's Committee on Employment of People with Disabilities. The vocational needs of individuals with psychiatric disabilities are outlined through examination of the elements of vocational success and a discussion of the Fountain House model and Boston University's psychiatric rehabilitation approach. Finally, the author provides guidelines for integrating the supported employment model into existing vocational services.

Although mentally disabled clients make up the largest number of cases eligible for vocational rehabilitative services, they have the least probability of success before and after rehabilitation (NIHR, 1979). Historically, the success rate for assisting individuals with psychiatric disabilities in returning to work has not been optimistic. The Rehabilitative Services Administration (RSA) began to serve individuals with mental handicaps nearly 23 years after its inception in 1920. Since then the number of individuals served has risen dramatically. In 1977, the number of individuals with mental illness who received vocational rehabilitation services reached 61,000. This increase, however, is not so dramatic when considering that the RSA estimates that there are at least two million individuals with psychiatric disabilities who could benefit from vocational rehabilitation services (Skelley, 1980).

The increase in numbers of individuals served is also deceiving when considering the numbers of individuals successfully rehabilitated. The rate of those "successfully rehabilitated" with psychiatric disabilities has not increased proportionately over the past 10 years: the success rate for the population is 20% lower than the general disabled population (Rutman, 1985). Moreover, Anthony, Cohen and Vitalo concluded that the unemployment rate among individuals with severe psychiatric disabilities ranges from 75 to 85 percent (Anthony, Cohen & Vitalo, 1978).

As awareness grew regarding the unmet vocational needs of individuals who are psychiatrically disabled, resources were created. In 1974, Fountain House, a New York psychosocial rehabilitation agency, received the first of its grants from RSA to further develop the Transitional Employment Program (TEP) model (Rutman, 1985). Other psychosocial rehabilitation agencies began to utilize the TEP model - each modifying the concept to fit individual and agency needs. Vocational resources were created by the National Institute for Mental Health (NIMH) and RSA when in 1978 they signed a collaborative agreement for the purpose of developing new strategies for meeting the vocational needs of the psychiatrically disabled. This agreement led to research, training, program development, and counterpart agreements at the state and local levels of NIMH and RSA (Anthony & Blanch, 1987 and Rutman, 1985).

Today, mental health professionals are once again being given an additional resource to assist the individual who is psychiatrically disabled in returning to work. The 1986 Amendment to the Rehabilitation Act of 1973 "provides grants to assist States in developing and implementing collaborative program....leading to supported employment for individuals with severe handicaps" Federal Register, 1987). In addition to these Federal funds, the Office of Special Education and Rehabilitative Services (OSERS) has awarded five-year Supported Employment Demonstration grants to 27 states to assist in the movement toward supported employment services. The psychiatrically disabled are included among the populations served Will, 1987).

The purpose of this article is to discuss how the supported employment model can meet the vocational needs of the psychiatrically disabled. This discussion will include: 1) definition and models of supported employment, 2) vocational needs of the psychiatrically disabled, and 3) integration of the supported employment model into existing vocational programs.

Understanding Supported Employment Definitions of Supported Employment

The 1986 Amendment to the Rehabilitation Act of 1973 defines supported employment as:

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. Also included for the first time in supported employment legislation is "transitional employment for individuals with chronic mental illness." The statute also recognizes that individuals with chronic mental illness are not required to receive on-site job training bi-monthly and may receive other support services instead Federal Register, 1987).

Supported employment has been a defined part of the mental retardation movement since the early 1980s when services were needed to help transition developmentally disabled students into community-based employment (Anthony & Blanch, 1987). Studies showed that traditional placements (i.e. sheltered workshops) did not aid individuals who are mentally retarded: the majority did not move on to competitive employment, low earnings left workers dependent on government subsidy, and skills that were learned in the workshop did not transfer into utilization in competitive employment Revell, Wehman, & Arnold, 1984; Wehman & Kregel, 1985). From this movement to provide better vocational services to the mentally retarded emerged a definition of supported employment as paid, competitive employment that occurs in integrated work settings and requires on-going support (Wehman & Kregel, 1985). Components of Supported Employment

As described by Wehman, there are four components in the supported employment model (Wehman & Kregel, 1985; Wehman, 1986; Revell, Wehman & Arnold, 1984; Wehman, 1982). The first component is job placement. This phase is two-fold: 1) a comprehensive assessment of job requirements and client abilities which results in a job match, and 2) an active approach in handling "non-work related factors" such as travel, parental support, and assistance in entitlements. The second component, job-site training and advocacy, refers to the application of behavioral strategies to teach job skins on-site. Advocacy includes facilitating communication between employer and client. Also included in this second stage of supported employment is fading - the systematic reduction of on-site staff assistance.

The third and fourth components of supported employment are ongoing monitoring and job retention, respectively. Ongoing monitoring is the assessment of the client's behavior through the collection and analysis of subjective data from employer and client. Job retention refers to long-term activities (e.g. phone calls to employers, review of evaluations) intended to maintain the client's level of work performance by providing ongoing support. Approaches to Supported Employment

There are several approaches to supported employment which share the four components described above. A task force of the President's Committee on Employment of People with Disabilities (1987) describes three kinds of supported employment: individual, enclave, and mobile crew. Similarly, the Office of Supported Employment of the Commonwealth of Virginia's Department of Mental Health, Mental Retardation, and Substance Abuse (1987) identifies four models of supported employment: entrepreneurial, enclave, job coach, and mobile crew. Additionally, Wehman includes competitive employment as a type of supported employment (Wehman, 1986).

The job coach, individual placement and competitive employment models of supported employment are essentially the same. All describe individual client-job matches where full-time support is given by a staff person (sometimes called a job coach) on the job site. Training and advocacy is gradually faded as a client's independence increases. This model assumes, as is implicit in the Federal Register's definition of supported employment, a 20-hour work week. Client,s pay is usually minimum wage or above. An example of this individual placement model at work for mentally retarded adults is Project Transition, a competitive employment program in Northern Virginia Revell, Arnold, Taylor & ZaitzBlotner, 1982). During its first year, this program successfully placed 20 individuals into competitive employment. The remainder of the models of supported employment entrepreneurial, enclave, and mobile crew - aU share a group placement philosophy. The enclave model can be defined as a group of individuals with handicaps who are working with special training or job supports within a normal business or industry" (Rhodes & Valenta, 1985). Job supports include an on-site trainer which usually remains with the individuals throughout their length of employment. Hours worked, again, are 20 hours a week or more. Client wages are minimum wage or based on productivity according to the Department of Labor guidelines (Office of Supported Employment, 1987). The number of workers ranges from three to eight, and the level of supervision needed by clients is much greater than in the individual placement approach. The enclave approach is being utilized by Trillium Employment Services. Eight of their clients with severe mental retardation work as electronic assemblers for Physio Control Corporation in Redmond, Washington (Rhodes & Valenta, 1985). The mobile crew model of supported employment is an "enclave on wheels": a crew of three to eight workers who provide services to various contract sites in the community. Transportation, training, equipment, and continuous on-site support are essential elements of this model. The wages, again, are paid at a competitive wage or in compliance with the Department of Labor standards. Although many psychosocial programs have active, successful mobile crews, many do not meet an essential criterion of supported employment: each worker must work a minimum of 20 hours per week. The last and rarest of types of supported employment is the entrepreneurial model. This model is essentially a small business for profit or non-profit designed to provide employment opportunities for individuals with severe handicaps. In keeping with the supported employment regulations, integration must take place through the hiring of individuals who are non-disabled. Wages and the number of hours worked is consistent with the other models presented. Support is provided on an ongoing basis.

Understanding the Vocational Needs of

Individuals Who Are Psychiatrically

Disabled

In order to understand how supported employment may fit into existing vocational services for those who are psychiatrically disabled, it is essential to first understand the vocational needs of this population. Needs may be defined in two ways: through examination of the elements of vocational success and through the discussion of current vocational service providers and their programs. Predicting Vocational Success

The task of predicting which variables guarantee vocational success for individuals with psychiatric disabilities has been an elusive one. For researchers, it seems far easier to find poor predictors of vocational success rather than positive variables. Anthony and Jansen (1984) gave the following as poor predictors of vocational outcome: diagnosis, psychiatric symptomatology, ability to function in one environment as predictive of another, and intelligence, aptitude and personality tests. Similarly, Douzinas and Carpenter (1981) found that inpatient behavior and prognosis are poor predictors of community-based performance. Also stated was that race is not a decisive factor in predicting vocational success. One positive variable associated with post-hospital success is living arrangement. Individuals with psychiatric disabilities function optimally when married or in a living arrangement with definite responsibilities (Douzinas & Carpenter, 1981). The most common positive predictor stated in the literature however, is the assessment of work behaviors. In a study of those clients chosen for services by rehabilitation counselors, it was found that clients were "ferreted out" on the basis of less behavioral disturbances (Green, Miskimins, & Keel, 1968). Such kinds of work behaviors include attendance, appearance, punctuality, accepting supervision, and interacting with co-workers. Another study concluded that behavioral observations of such work behaviors "are by far the most predictive of vocational success" (Nelson, Berry, & Miskimins, 1969). More recently, Anthony and Jansen (1984) stated that the "best clinical predictor of future work performance are ratings of a person's work adjustment skins made in a workshop setting or sheltered work site" (p. 540). The ability to get along with co-workers and supervisors and to be dependable (i.e. punctuality, attendance, completing work tasks) were found to be most strongly related to work performance. In a study of the use of situational assessments in predictive validity, Bond and Friedmeyer (1981) also concluded that staff ratings of work adjustment are predictive of future employment for individuals with psychiatric disabilities. It would seem logical that predictors of vocational outcome would influence the delivery of services meant to fulfill the vocational needs of the psychiatrically disabled. Equally influential, however, is the philosophical orientation of the service provider. Two examples are Fountain House, a psychosocial program in New York City, and The Center for Psychiatric Rehabilitation at Boston University. Both are leaders in providing vocational services to individuals who are psychiatrically disabled. In addition, both base program methodology from a core of philosophical principles. The Fountain House Model and Vocational Need

Fountain House, founded in 1948 by John Beard, was the first clubhouse approach for individuals with psychiatric disabilities. The basic tenets of this model are that : 1) each participant is a contributing member of the clubhouse, 2) their presence is expected and welcomed, 3) their contributions are wanted, and 4) their contributions are needed in order to keep the clubhouse alive. Additionally, there are four closely related beliefs: 1) the belief in productivity of every member, 2) the belief that work is a central ingredient of the model and clubhouse, 3) the belief that men and women require opportunities to socialize, and 4) the belief that a program is incomplete unless it offers opportunities for adequate housing (Beard, Propst, & Malamud, 1982).

Particularly important in determining vocational needs is the belief that work is a motivating force in every member as well as within the clubhouse. Involvement in clubhouse activities is considered preparation for employment in the community. The most profound part of this belief is Fountain House's guarantee that every member will be given the opportunity to work in their Transitional Employment Program (TEP) (Beard, Propst, & Malamud, 1982). Thus, ideally, in addition to feeling wanted and needed in the clubhouse environment, each member must also feel vital in the work community. The vocational needs emerging from these principles for Fountain House members are the need to feel a member of the workforce, the need to feel wanted and needed in the workforce, and the need to have a guaranteed opportunity to be a part of the workforce.

TEP jobs seem to be geared toward the Fountain House philosophy that every member regardless of the severity of the psychiatric impairment deserves the right to work. Positions are part-time, entry level positions requiring little skill. Members are not required to be able to pass an employment interview or "have sufficient motivation to seek employment independently." Successful completion of work adjustment training is not necessary. In fact, TEP sites provide a place in the community to assess such skills. TEP jobs are temporary - lasting from three months to one year. Job failures are considered an essential learning experience (Beard, Propst, & Malamud, 1982). It would appear from these TEP characteristics that the need for individuals who are psychiatrically disabled to experience work in the community outweighs the need for development of work skills prior to placement. Psychiatric Rehabilitation and Vocational Need

In 1978, the Center for Psychiatric Rehabilitation at Boston University was founded by William Anthony. Like the Fountain House Model, the psychiatric rehabilitation approach that emerged from this Center is based upon certain philosophical principles. The psychiatric rehabilitation principles were adapted from the practice of physical rehabilitation and the practice of psychotherapy. From the model of physical rehabilitation, psychiatric rehabilitation takes the concept that individuals with disabilities need a combination of skills and supports in order to function in their choice of living, learning, and working environments. From the constructs of Carkhuff's psychotherapeutic approach, psychiatric rehabilitation places emphasis on client involvement in the rehabilitation process. This client involvement includes the development of the client's rehabilitation goal, the discussion and acceptance of a rehabilitation diagnosis (i.e. information on level of skills and resources relevant to achieving goal), and the creation of a plan to identify what interventions will be needed to help the client achieve their rehabilitation goal (Anthony, Cohen, & Cohen, 1983).

The nature of the psychiatric rehabilitation approach is further defined by eight principles. These principles are: 1) The primary focus of psychiatric rehabilitation is on improving capabilities and competencies, 2) The benefit for clients is behavioral improvement in their environment of needs, 3) Psychiatric rehabilitation is eclectic and atheoretical, 4) A central focus is improving vocational outcomes, 5) A central ingredient of the rehabilitation process is hope, 6) An increase in client dependency can lead to an increase in client independence, 7) The client is actively involved in the rehabilitation process, and, 8) Two fundamental interventions of psychiatric rehabilitation are client skill development and environment resource development (Anthony, Cohen, & Cohen, 1984). These principles tic directly to the research cited earlier on predictors of vocational success by focusing on the acquisition of the necessary work behaviors needed for the working environment. Clearly, other vocational needs for individuals with psychiatric disabilities emerge from the psychiatric rehabilitation principles. First, the need for the client to determine appropriate goals and guide the rehabilitation process. Second, the need for the client to learn specific skills (work behaviors or job skills) to achieve their goal. Included are those skills clients need in order to choose a job (e.g. exploration of values, interests and skills), get a job (e.g. writing a resume, interviewing), and keep a job (e.g. getting along with co-workers). A third need of individuals with psychiatric disabilities is support. Support can take the form of a person or environment that allows the client to meet his/her vocational goal. For example, finding a job that meets exactly the client's values, interests, and skill level is one kind of environmental support. Fourth, clients may need to depend on others for assistance and support in order to eventually achieve vocational independence.

integrating the Supported Employment

Model into Existing Vocational Programs

Although the Fountain House model and the psychiatric rehabilitation approach may differ in some of their philosophical principles, the belief that individuals with psychiatric disabilities have a right to vocational services to meet their changing needs is fundamental. Supported employment can assist service providers in meeting those needs: the need to acquire appropriate work behaviors, the need to experience meaningful work in the community, the need to be integrally involved in the rehabilitation process, the need for various supports to acquire and maintain employment, and the need to learn new skills in relation to job requirements. In integrating the supported employment model into existing vocational program, service providers must ask themselves two questions: First and foremost, are the present vocational services meeting the needs of the individuals it intends to serve? Secondly, do the services provided meet the definition and guidelines of supported employment?

The following guidelines are meant to assist vocational programs in integrating supported employment in order to better serve the needs of individuals who are psychiatrically disabled. 1. Provide a period of work adjustment training prior to placement.

It is clear from the research stated earlier in this article that assessment of work adjustment skills is the best predictor of vocational success. For, in addition to individuals having the right to experience work in the community, they also have the responsibility to learn the skills necessary to perform and keep that job. Work adjustment training can aid aH clients - from those who need a short period of assessment before placement to those who may need more intensive preparation. Work adjustment training need not take place solely in a sheltered workshop. Environments of preference are those that can be structured similarly to a work setting with the same employee expectations imposed. Examples of such environments are volunteer placements or employer-based work adjustment training. 2. Provide opportunities to explore occupational interests.

The Fountain House model allows for clients to experience different kinds of jobs by transitioning from one TEP job to another. Although this "hands on" career exploration is invaluable experience in some respects, it also may be detrimental to clients who experience high levels of stress with transition or who cannot see value in the face of a failed job experience. Many individuals who are psychiatrically disabled first become ill during adolescence - a valuable period in terms of career development. It is essential then that vocational service providers provide activities to encourage career exploration. Such activities could include site-visits to various employers, guest lecturers, informational interviewing, and, utilization of traditional career counseling techniques (e.g. interest inventories, Occupational Outlook Handbook). 3. Teach how to identify a "job match."

The job match is an essential element of supported employment. Clients who are able to identify their occupational interests, job skills, and job requirements will be able to choose a job that fits." Teaching a client how to choose his/her job facilitates maximum client involvement in the rehabilitation process by taking the responsibility of job matching from the hands of the rehabilitation practitioner and putting it into the hands of the client. This process enables the client to actively choose his/her "ideal job" as opposed to the assignment of a fixed TEP slot. Teaching clients the elements of choosing a job can occur in individual or group career counseling sessions during the work adjustment training period. This essential information can be passed onto the job placement person to develop an individual supported employment placement or compared to the program's supported employment opportunities to determine the closest job-client match. 4. Provide a variety of supports necessary for vocational success.

As previously cited, another key ingredient in the supported employment model for the mentally retarded is active involvement in provision of support services. Supports are essential in fulfilling the vocational needs of the psychiatrically disabled. Vocational support can be either directly or indirectly related to the job. For example, a direct support could be modifying the job's hours to part-time initially to provide for a period of adjustment. Other direct supports include job modification, on-site support, weekly follow-up visits to check in with both employer and client, and vocational staff availability for job-site crisis intervention.

One important indirect support relates to handling of issues relating to entitlements. Although the newest Social Security regulations are more favorable in terms of allowing individuals with disabilities to return to work, it is not always easy for Social Security workers to understand the modifications made to assist individuals with psychiatric disabilities in returning to work; therefore, active case management is necessary. Another indirect support that has proven extremely beneficial is the job support group or "follow-along" group. Made up of clients who are working and facilitated by a staff person, the follow-along group is an excellent mechanism for solving work-related issues off-site. Other indirect supports include familiarizing clients with new travel routes, educating employers in mental health issues, and liaison meetings between caregivers to report changes and guarantee consistency of services. 5. Provide a continuum of supported employment services to meet client needs.

One of supported employment's assets is the variety of forms it can take. In determiining which form is best for an agency it is important to keep in mind both client need and the needs of the business community. For example, it may be far easier to create an enclave in an industrial versus a rural area. More important than providing various kinds of supported employment (e.g. enclave, individual placement, etc.) is providing a continuum of employment opportunities with various levels of support (e.g. full-time support, first week support, drop-in visits). Fortunately, for a community which can accommodate them, the types of supported employment available fall easily into greatest (enclave) and least (individual placement) levels of support.

This continuum of services would also allow individuals with psychiatric disabilities the flexibility of changing positions as their needs changed. For example, an individual may begin needing the support of an enclave with fun-time supervision. Within a year, this same individual may be ready to move on to an individual supported employment placement. The agency which provides a continuum of supported employment services facilitates client movement to the least restrictive employment environment. 6. Eliminate artificial time barriers.

Another asset of supported employment is its focus on providing long-term placement. Many TEP positions have "cut-off" points at which individuals are expected to move on to another TEP or competitive position. These cut-off points meet programmatic needs (i.e. the need to own and keep TEP positions available for other clients) more than they meet individual's needs for stable employment. An alternate solution is a time frame with built-in evaluation points to determine if the supported employment placement is meeting the client's needs, if the client is meeting the needs of the employer, and make necessary changes. 7. Structure placements to meet supported employment regulations.

The Federal Register (1987) clearly outlines the necessary ingredients for placements to meet the supported employment definition. Agencies need to be aware of these and make programmatic adjustments accordingly in order to take full advantage of supported employment grants and awards.

Conclusion

It is true that individuals with psychiatric disabilities have the least probability for vocational success. It is also true, however, that service providers are being given a unique opportunity to improve these dismal results. That opportunity is supported employment. It is essential that agencies providing vocational services to the psychiatrically disabled take this time to evaluate services provided, determine their effectiveness in meeting vocational needs, and make necessary programmatic changes to meet the supported employment regulations. Only after understanding supported employment and implementing it into vocational programs can service providers be assured that they are utilizing all available resources to meet the vocational needs of the psychiatrically disabled.