Models of vocational rehabilitation for youths and adults with severe mental illness: implications for AMERICA 2000 and ADA.

To achieve and maintain community employment among people with severe mental illness rehabilitation technology has undergone significant development in the past two decades. The first wave of activity was fostered by the federal mandate for supported employment, which combined existing transitional employment strategies pioneered by psychosocial rehabilitation agencies to create increased community job placements for clients with mental illness. As a result, there is now a second wave of vocational issues, imperatives, and challenges faced by professionals and the mental health consumers they serve. This second wave has been stimulated by recent federal initiatives, such as AMERICA 2000, combined with new legislation, such as the Americans with Disabilities Act (ADA) and the Individuals with Disabilities Education Act (IDEA). This article reviews the approaches that comprise both waves of research and program development in vocational rehabilitation for people with mental illness.

The field of vocational rehabilitation for people with psychiatric disabilities has a long, rich tradition. Models to provide people who have severe mental illness with community job placements have been used since the 1940's. However, while the first authorization to provide vocational rehabilitation services to people with mental illness did not occur until the Barden-LaFolette Amendments of 1943, it was another 10 years before P.L. 83-565 (1954) provided for services to larger numbers of people with this disability, offered incentives to states for serving this population, and authorized training funds to enable collaboration between vocational rehabilitation and mental health (Tashjian, Hayward, Stoddard, & Kraus, 1989). It is interesting that some professionals who began delivering supported employment services to this population in the 1980's were unaware of the technology that already existed. Agencies using the psychosocial approach (Dincin, 1975) have decades of experience in vocational skills training, job development, job coaching, and workplace advocacy and support for people with severe psychiatric disabilities. Typically, however, this vocational expertise could not be readily acquired except by working at these agencies.

A number of experimentally controlled studies of vocational rehabilitation have been conducted, including those focusing on hospital-based programs, sheltered workshops, and transitional employment in psychosocia1 programs. Several literature reviews exist to guide the interested reader (Anthony & Jansen, 1984; Bond & Boyer, 1988). A major conclusion of research in this area is that diaguoses and symptomatology alone are not reliable predictors of the ability to work. Similarly, intelligence tests and personality tests also are found to be poor predictors of employment among those with this disability.

Based on research to date, four factors predict vocational ability among people with mental illness:

* Situational Assessment. Research indicates that a job assessment made in an actual or simulated work setting with people performing real work tasks reliably predicts later community employment for adults (Bond & Fried-meyer, 1986) and youths (Cook, Solomon, Jonikas & Frazier, 1990).

* Quality of Social Skills. People with better social skills and better self-image are better equipped to handle community employment (Cook, Roussel, & Skiba, 1987). The ability to cooperate with co-workers, negotiate with supervisors, and participate in the workplace social milieu all contribute to an employee's longevity.

* Ongoing Vocational Support. People with severe mental illness need ongoing support that is not time limited (Rosenberg & Cook, 1990). To some extent, this is due to the nature of mental illness itself; the illness course is highly variable, creating changing needs over time. The ongoing need for support also is tied to the way mental illness is viewed in society. The intensity of public stigma regarding mental illness was recently confirmed by a national opinion survey conducted by Daniel Yankleovich and associates (1990). People with severe mental illness have needs for advocacy because co-workers and employers find their disability frightening.

* Community Support. In addition to ongoing support on a one-to-one basis, the notion of community support is crucial in all areas of services for people with mental illness, not just in the vocational area. Without a comprehensive case management and rehabilitation plan, many with this disability are unable to work in the community. There is recognition of this need for community support at the federal level as well. State mental health agencies receiving federal monies have been required to formulate and implement a Community Support Plan for comprehensive, coordinated care of people with mental illness (Stroul, 1986).

Early Models of Vocational Rehabilitation

Early vocational models used in inpatient settings were hospital work programs where clients were employed in segregated work sites for piece rate. Eventually, controlled studies showed that hospital-based programs were not effective in establishing community employment (Becker, 1967; Walker, Winick, Frost, & Lieberman, 1969). Sheltered employment also was offered to people with mental illness, but this model too had its limitations. People with psychiatric disabilities did poorer than workers with physical disabilities or mental retardation--they earned less money, had more behavioral difficulties at work, and had lower job satisfaction (Whitehead, 1977; Ciardiello, 1981; Olshansky & Beach, 1974; 1975).

The transitional employment (TE) model--part of psychosocial programming which began in 1948--uses time-limited community job placements at minimum wage or above. The idea is that workers progress through a series of jobs learning new job skills, acquiring a work history, and gaining confidence. A version of this transitional model used at Thresholds involves progressing from a group placement (where an individual works with a permanent job coach for minimum wage in a group setting) to an individual placement (working alone and supervised by the firm's own managers) to an unsupported job found with the help of a job club or job developer (through employer/client matching). This TE model is embedded in a program offering an extensive number of services, including social skills, housing and independent living training, leisure and recreation activities, medication management, and educational services.

While the transitional model is effective for many clients, it does not meet the needs of a wide range of people with psychiatric disabilities. One of these needs is for ongoing support. Evidence indicates that many people with this disability require ongoing assistance with issues related to job maintenance and career adjustment. For example, multivariate regression analysis of logged vocational support (Rosenberg & Cook, 1990) indicates higher usage of support as clients' jobs increase in independence. This calls into question the notion of the "fading job coach" model for people with mental illness. It is possible that some clients require more rather than less support over time and as they advance on their chosen career paths. To address these issues at Thresholds we created a new staff position called the mobile job support worker (MJSW) to provide ongoing, mobile support and intervention at the work site or nearby. Delivering services in nonstigmatizing contexts away from the rehabilitation agency, the MJSW is available to assist on an asneeded basis providing evaluation, training, advocacy with employers and co-workers, and job development.

Another concern raised by use of a TE model is that it does not allow for job placements to be held beyond a certain length of time. Some clients may wish to remain at the jobs in which they are initially placed or require longer periods before they are ready to move on to more challenging employment. To alter this, we removed the time limits for many of our placements so that clients could stay on permanently if they and their employers wished.

The suspension of time limits on job placements, along with MJSW support, became the basis of supported employment (SE) services delivered at Thresholds. Through this approach, clients receive ongoing assistance in finding employment and, once on the job, support in maintaining their jobs within integrated work settings. The Federal Government has encouraged the growth of programs based on this model, and today there are various supported employment initiatives throughout the country at federal and state levels (Anthony & Blanch, 1987). The supported employment model echoes the AMERICA 2000 principle that learning is a "lifelong challenge" (AMERICA 2000, p. 55) confronted by both people with and without disabilities throughout their employment careers.

Principles from the First Wave of Vocational Service Models

For people with mental illness, the emphasis is on providing services in the community as much as possible, rather than at rehabilitation or mental health centers. The need for nonstigmatizing normalized service sites is important, given the high level of stigma attached to mental illness and the low self-esteem many consumers experience. Providing job support that goes where the worker goes and intervening on an as-needed basis rather than on some artificially scheduled basis is seen as best. There is increasing awareness that people's work needs are highly variable a client may need us intensively when he or she loses a trusted supervisor and has to adjust to a new and unfamiliar one. But, once adjusted, the client may not need us for long stretches of time. There is growing recognition that we have to make a commitment to provide ongoing support to people throughout periods of employment and unemployment. Clients need service delivery systems that provide an array of vocational services (such as situational assessment, skills training, job coaching, ongoing support, advocacy, and job development) as needed, with individually tailored rehabilitation plans. From the perspective of program models, we need this "array of services" rather than any one particular model.

The Second Wave: New Commitments and Imperatives

As the availability of transitional and supported employment services has increased, new issues and challenges have emerged. A series of second wave imperatives is facing professionals and clients alike. To some extent, this stems from the successes in the field to date. As more and more people with mental illness are employed, their aspirations rise for higher paid, more creative, and more secure employment. Such a trend is echoed in the AMERICA 2000 plan's recognition that "85 percent of America's work force in the year 2000 is already in the work force today" (AMERICA 2000, p. 55). Thus, the goal of vocational rehabilitation is to help people with psychiatric disabilities who are already employed to secure positions at advanced levels of responsibility, salary, and independence. Another set of principles is emerging to guide the development of services in this next era of vocational rehabilitation.

Client Choice

There is a growing understanding of the importance of consumer choice in vocational rehabilitation. This involves recognition that what clients define as a "good job" is not always the same as the preferences of family members, professionals, and employers. Many times we design jobs for people with mental illness without giving much thought to what is therapeutic about the work and

what is not therapeutic. For example, we might develop a series of jobs that pay well but also are dull and repetitive and, thus, frustrating. Or, we sometimes develop a job because it is entry level, which means that we can move people in and out of the position to give them some work experience using a TE model but then discover that the entry level job is very stressful and not at all appropriate. If we fail to consult with consumers, we never learn that the job environment is more important to them than the salary, or that they need a position where they can work at their own pace rather then according to a tight production schedule.

When developing jobs, we were faced with the demands of Thresholds' own consumers for community employment opportunities that would involve creative work that incorporates their artistic abilities. In response, we developed the Theater Arts Program to create employment opportunities for people with mental illness in Chicago area theaters (Cook, 1989). In this program, participants hold jobs in theaters, learn new skills through apprentice-ships with theater professionals, and attend theater arts classes to develop acting and social skills as well as self-expression and creativity. Jobs in 12 local theaters include costume cataloging, house managing, clerical support, janitorial work, and scenery construction.

Cultural Diversity and Gender

In using the workplace as a site for normalization, one .must acknowledge research that shows that women and minorities, both disabled and nondisabled, are at a disadvantage in the employment market (Cook & Roussel, 1987). TE programs may be able to override unequal labor force treatment by giving clients an equal chance at a job placement, something that a program is unable to do for clients once they reach the stage of independent employment (Cook, 1991). Culturally sensitive services should offer clients assistance dealing with sexual harassment, discrimination in hiring and promotion, and other labor and personnel issues.

Adapting Services for Youth

Federal authorization of funds for transitional services to youths with handicaps, under the Education of the Handicapped Act Amendments of 1983 and the IDEA legislation of 1990, focused attention on the issue of transition to work. Our research and service delivery experiences indicate that youths with mental illness require specially tailored vocational services emphasizing the peer group as a supportive milieu (Cook, Solomon & Mock, 1989; Roussel & Cook, 1987). For example, youths with mental illness display job-ending patterns that differ from nondisabled younger as well as disabled older aged populations (Cook, forthcoming). Recognition of developmental needs of younger workers with disabilities involves designing services that acknowledge issues such as separation-individuation, development of future time perspective, and the importance of peer acceptance. Knowledge of these differences can be used to create services that address special issues faced by younger populations.

Family Involvement in Rehabilitation

Another new trend in vocational service delivery is the involvement of families in partnership roles in rehabilitation efforts. Family members of people with severe mental illness often report that they are ignored or neglected by rehabilitation professionals. The exclusion of families from rehabilitation planning is unfortunate, given their long-term, intimate knowledge of their relative's illness. Professionals come and go in the lives of clients, but families often remain a consistent force. Relatives have known the client over time and in a variety of situations; sometimes, families can identify areas of interest that predate the illness as well as talents and strengths that can be used in rehabilitation efforts (Cook, Jonikas & Solomon, 1989).

Rehabilitation counselors may create expectations for improvement and change that are not always viewed by families as being in their best interests or their relative's (Cook, 1988). Parents' increased needs for assistance as they and their children age (Cohler, Pickett, & Cook, 1991) may constrain parental support for their off-springs' vocational aspirations. Suggestions that the client risk losing benefits by aiming for full-time employment is another area of conflict between families and rehabilitation professionals.

There also is a need for better understanding of how families can enhance rehabilitation goals through the provision of social support and reinforcement of new skills. Given the importance of one's social environment to the generalization and durability of learned skills, collaboration with the family allows rehabilitation professionals to enlist the help of relatives in fostering maintenance of acquired skills. Studies of the use of family/professional collaboration, in the sense of shared responsibility or partnership, are needed to determine whether this is an effective way to involve relatives.

Supported Education as a Route to Career Development

One drawback of job placements in both SE and TE is that employment typically involves entry level positions that are low in creativity, responsibility, and growth potential. To move beyond entry-level employment, consumers often need postsecondary education and training. Because the average age of onset for mental illness is during the secondary and postsecondary period, schooling often is interrupted. Therefore, adults with psychiatric disabilities tend to test below their age-appropriate levels in mathematics and reading (Cook, Wessell, & Dincin, 1987). Supported education is needed to help consumers prepare for postsecondary education and vocational training (Unger, et al., 1987). Enhancement of postsecondary training, in turn, enables people with psychiatric disabilities to be part of the AMERICA 2000 goal of creating a "Nation of Students" (AMERICA 2000, p. 56) capable of competing in a global economy and exercising full rights as citizens.

The supported education services at Thresholds are delivered through the Community Scholar Program (Cook, 1987). The intent of the program is to help clients obtain advanced education or technical training and then secure employment commensurate with their new levels of education. The program works with 29 colleges and trade schools in the Chicago area, offering clients linkage and advocacy services, remedial education, a campus visitation program, a support group, college preparatory curricula, mobile educational support, and tutoring.

As part of this program we are studying faculty attitudes toward having students with psychiatric disabilities in their classrooms. This involves administering an anonymous questionnaire delivered via faculty mailboxes and returned via U.S. mail. Completed by 63 instructors from one university and one vocational school, results thus far indicate noteworthy proportions of post-secondary faculties who feel students with psychiatric disabilities have "higher than average difficulty" handling courses in the following fields: dental or medical technician (29 percent), hotel management (29 percent), computer programming (23 percent), mathematics, truck driving and "hard" sciences (all 21 percent). While the large - majority (over 90 percent) of faculty at both colleges and trade schools report experience with psychiatrically disabled students, just over half (54 percent) feel that such students do not deal as effectively as nondisabled students with academic pressure, such as deadlines, competition, and workload. Helping clients obtain the postsecondary training they desire and need will be part of more comprehensive employment efforts in the second wave of service models for people with severe mental illness. Helping faculty to better address the needs of students with psychiatric disabilities will assist in the development of well-prepared teachers capable of helping students realize their goals, the Nation' s education goals, and those of IDEA and ADA legislation.

Use of Natural Supports to Enhance Employment Opportunities

A relatively new concept in psychiatric vocational rehabilitation, the use of "natural supports," is based on the idea that making job support as natural and unobtrusive as possible maximizes its effects. Also, using already-existing parts of the work setting may be one way of ensuring the provision of long-term services. Finally, use of natural supports locates services in the settings where people with psychiatric disabilities live and work, cultivating "communities where learning can happen" (AMERICA 2000, p. 5). There are several ways in which this is being done.

Using Non-Handicapped Co-Workers (NHCW). The help of nondisabled people in the client's work setting can be enlisted to provide support and opportunities for integration with other workers. This may involve an arrangement where an NHCW regularly includes a client along with other workers in socializing during breaks or at lunch; using an NHCW to do job training is another example of this strategy. Job sharing is a third form of co-worker involvement. For example, a client may be able to do some but not all parts of a job (e.g., the person may be able to perform seven out of eight steps of a production process). By identifying an NHCW who can do the eighth step (and who perhaps even dislikes the seventh step), it is possible to arrange a "trade" where the client does step seven for the NHCW and the NHCW handles step eight for the client. This creative strategy involves changing the job environment through job task analysis rather than changing the disabled worker. It provides co-workers with a "stake" in the success of workers with disabilities and it uses a mentor-protege model that clients find less stigmatizing than services from a professional job coach. Moreover, co-worker involvement is one means of creating reasonable accommodations as mandated by ADA.

There are many questions that remain to be answered in designing this type of natural support. One obvious question is what kind of person makes a good NHCW to involve in vocational support of someone with mental illness? Our research has shown that the people who befriend our clients on community job sites tend to be co-workers with higher productivity on the job rather than the poorer performers; they are the team players who are well-integrated and well-liked rather than marginal co-workers. We surveyed one group of co-workers (N=36) at a large grocery chain 4 days after they began working with Thresholds clients. We wanted to ascertain their opinions and attitudes about working with people from our agency. The anonymous questionnaire responses revealed a high degree of acceptance of working alongside people who have psychiatric disabilities. For example, there was widespread agreement (over 95 percent) with statements such as "I feel fairly comfortable working with a person who has a psychiatric disability" and "Most people with a psychiatric disability are willing to work." When correlating background features of the nondisabled co-workers with their pro-disability, pro-integration attitudes, significant relationships were found by gender. Women co-workers were more accepting of disability and reported higher levels of comfort working with people with mental illness. Older co-workers were significantly more likely than younger workers to agree with the statement-- "When I know someone who works with me has had emotional problems, I wait and judge that person on his or her own individual merits"--and they were significantly less likely to feel that customers would be uncomfortable if they knew some co-workers had mental illness. Interestingly, no relationships were found with the ethnicity, education level, or the job tenure of the co-workers.

Using Employee Assistance Organizations. Employee Assistant Organizations (EAO's), which are located in departments or divisions of large to medium-size companies, are concerned with matters related to employee health and well-being. Examples of EAO services include programs designed to encourage health and fitness, such as smoking cessation classes and employee fitness programs. Staff in EAO's could be recruited to provide support to employees with psychiatric disabilities. This is a sound approach because the organizational structure and mission are already in place, and staff are already concerned about the health and well-being of the company's workers. In order to advance this technology, we need a better understanding of how to recruit, train, and motivate EAO staff to provide the kinds of support and advocacy required of mental health consumers.

Peer Job Coaching. Consumers of mental health services have important roles to play in defining their own needs, in developing policies, and in planning and operating services. In 1987, the National Institute of Mental Health, Community Support Program, funded six consumer-operated projects around the country to study the effectiveness of consumer involvement in program outcomes. Since that time, mental health consumer-operated businesses (described below), as well as consumer-run support groups, self-help networks (local, state, and national), and clearinghouses have been established.

Since consumers have an "insider view" of the mental health system, they often possess valuable informal knowledge and find it easier to empathize with clients. This is especially so in a work setting; often the consumer was the first one with a psychiatric disability to work at a particular location, and is well aware of what it is like to be new on the job and coping with stress and stigma. The use of consumers to provide job coaching may result in enhanced self-esteem, while those who receive this peer supervision may feel better understood and supported.

To examine these issues we conducted weekly telephone interviews with five consumer job coaches working in three different settings over a course of 5 to 6 months. Our interview data reveal the kinds of ups and downs faced by any supervisor who has to deal with deadlines, production quotas, and quality control responsibilities. Also, peer job coaches report a notable amount of "testing" behavior from their new subordinates. Open refusal to follow instructions, silently ignoring the peer job coach's requests, and walking off the job were some employee behaviors reported by the peer coaches. Over time, however, peer job coaches have been able to establish their authority and develop effective working relationships with their subordinates. Descriptions of a "good week" by peer coaches tend to emphasize morale-building experiences where everyone pulls together to meet a challenging deadline or production quota. All peer job coaches were able to report positive moments such as these.

Consumer Run Businesses. Another strategy using natural supports is to engage consumers in starting and operating a business that provides job opportunities. This uses the principle of being one's own boss as a natural way to ensure greater flexibility and tolerance from employers. Some examples of accommodations that can be made when consumers themselves run a business include shorter work days or weeks, increased tolerance for phobias or delusional thinking at work, and job configurations that are designed to meet consumers' specific needs. A wide variety of successful businesses have been started around the country, ranging from restaurants, sandwich and ice cream shops, yard cleaning services, horticultural services, and maid services. One model of rehabilitation developed specifically for people with psychiatric disabilities is the Fair-weather Lodge model in which a group of clients live together and operate a business together. Currently, these programs exist in 16 states around the country.

Employers: The Forgotten Partner. Much of the technology for job placement and maintenance focuses exclusively on the client and vocational rehabilitation personnel. Too little attention is paid to working with employers, especially to understanding and addressing employers' unique concerns, including those not related to people with disabilities.

Because we were interested in employers' perceptions of the accommodations they make for their workers, we conducted telephone interviews with 10 employers of young and older adults with psychiatric disabilities (Solomon, 1991). This is particularly important, given the ADA mandate for "reasonable accommodation" by employers for workers with disabilities. Under this new legislation, employers will be challenged to create flexible leave practices, reorganized job tasks, and adjusted work schedules that help people with mental illness succeed at work.

Many employers mentioned that they allow more time for Thresholds workers to learn their jobs and, in some cases, to perform job tasks. Other employers accommodated clients through flexible scheduling that allowed them to attend therapy sessions, support groups, and doctor's appointments. Still other employers described tailoring responsibilities to the strengths and limitations of employees' abilities; sometimes this meant providing clients with reduced responsibilities during periods of symptomatology. Employers also pointed out that the presence of agency clients sometimes boosted morale among nondisabled co-workers and served as an example of the employers' concern to other workers.

Conclusions: Implications for Public Policy

Several decades of vocational rehabilitation programming and research have revealed the necessity of ongoing, community-based support to help people with mental illness maintain competitive employment. As mental health and rehabilitation service providers have responded to these needs, the vocational achievements and aspirations of clients have grown, resuiting in a greater sense of empowerment for consumers. The psychiatric rehabilitation field is now ushering in a second wave of development in which consumers and natural supports play a much greater role in the design and delivery of vocational rehabilitation services. This trend has been reinforced by recent federal initiatives, such as AMERICA 2000, emphasizing education and training of America's existing work force in preparation for the 21st century.

Given the foregoing list of second wave principles and the growing consumer empowerment movement, there is an opportunity to influence public policy as the implementation of AMERICA 2000, ADA, and IDEA begins. The nature of reasonable accommodation for people with severe mental illness is a topic that will be addressed as this federal legislation is enforced. This will involve understanding the nature of accommodations needed by workers, especially as these needs are influenced by cross cultural ethnic, gender, and age considerations.

Throughout this article we have indicated the direction in which the field is headed and the issues which we feel demand the attention of those working in vocational rehabilitation. We encourage readers to continue advocacy efforts on behalf of people who have psychiatric disabilities to promote self-determination, enhanced quality of life, and equal employment opportunities for all mental health consumers.

The contents of this article were developed under a grant from the National Institute on Disability and Rehabilitation Research, Department of Education, cooperative agreement number H133B00011, and the National Institute of Mental Health, Systems Development and Community Support Branch. This article does not necessarily reflect the views of the institute and does not imply endorsement by the U.S. Government.

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Dr. Cook is Director, Ms. Jonikas is Managing Assistant Director, and Ms. Solomon is Principal Investigator at the Thresholds National Research and Training Center on Rehabilitation and Mental Illness, Chicago, Illinois.