Psychiatric disabilities: challenges and training issues for rehabilitation professionals.

More than 40 million people in the United States have psychiatric disabilities, and of this number, 4 to 5 million adults have been diagnosed with severe psychiatric disabilities (National Institute on Disability and Rehabilitation Services, 1993). Despite the desire to work, functional competencies and appropriate educational qualifications, many individuals with psychiatric disabilities do not have long-term success in the labor market (Garske, 1999). Clients who have poor social skills, limited peer relationships, and who have difficulty adjusting to community living need more than vocational counseling Many clients require comprehensive services dealing with a variety of psychosocial and emotional issues before they can focus effectively on vocational issues (Garske, 1999).

Psychiatric rehabilitation and case management services are very demanding and complex requiring advanced training (Chan, et al., 1998) as part of rehabilitation counselor education programs. Nemec, Spaniol, and Dell Orto (2001) have noted: "The gap is wide between current knowledge of best practices in psychiatric rehabilitation and current instruction on psychiatric rehabilitation in rehabilitation education programs" (p. 118). For rehabilitation professionals, working with individuals who have a psychiatric disability can seem daunting, especially if adequate training has not been provided (Garske, 1992).

Although there appears to be a consensus among rehabilitation professionals that employment is an important part of life for persons with mental illness (VandenBoom & Lustig, 1997), estimates of the unemployment rate for the working-age members of this population are around 85% (National Institute of Disability and Rehabilitation Services, 1993). Even when persons with serious psychiatric disabilities seek vocational services, they have success rates of only about half of those with physical disabilities (Marshak, Bostick, & Turton, 1990) For individuals with psychiatric disabilities, employment remains all important, but often elusive, goal.

Work is extremely important in a person's life, providing direct economic and social benefits and contributing to self-esteem and quality of life (Fabian & Coppola, 2001). Some researchers attribute low employment rates to the nature of the disability, lack of effective vocational support methods, and continuing negative attitudes and stigma that impede workplace entry and retention. Less frequently addressed however are the competencies and attitudes of rehabilitation professionals who work with this population (Fabian & Coppola, 2001). To this end, this article will address the following issues as they apply to working with individuals with psychiatric disabilities: (a) invisibility of people with psychiatric disabilities, (b) psychosocial barriers, (c) recovery philosophy, (d) intervention models, and (e) psychiatric rehabilitation training needs.

Invisibility of People with Psychiatric Disabilities

The nature of therapeutic disbelief toward an individual with chronic illness has been discussed at length in the literature (Bowman, 1991; Lovgren, Engstorm & Norberg, 1996; Thorne, 1993). Clients who are put in the position of needing to convince a disbelieving professional of the seriousness of symptoms creates a context in which clients are often viewed, and many times labeled, as complaining, over-anxious, or obsessed with their condition (Benner, Janson-Bjerklie, Ferketich, & Becket, 1994; Johansson, Hamberg, Lindgren, & Westman, 1996; Malterud, 1992, 1993). Negative altitudinal patterns of professionals toward individuals with psychiatric disabilities serve to undermine the therapeutic relationship (Thorne, Nyhlin, & Paterson, 2000) and such tendencies on the part of professionals' serves to further diminish the rehabilitation and recovery of the person with a psychiatric disability (Singer, 2001).

Many consumers with psychiatric disabilities report a sense of feeling invisible, or not important when interacting with service providers (Carling, 1995). In the wake of such negative interactions with professionals, the consumer is left with a diminished sense of self-worth that further intensifies feelings of isolation and invisibility (McReynolds, Ward, & Singer, 2002). Furthermore, Leete (1988) reported that when individuals with psychiatric disabilities describe their personal experiences of the illness to professionals they are not taken seriously because professionals often misinterpret client's descriptions as being merely delusions. The sense of not being taken seriously functions to diminish self esteem of the person with the psychiatric disability and adds to the person's sense of invisibility. The person with a psychiatric disability may feel increasingly alienated when his or her experiences are not met with understanding and empathy. The sense of alienation further undermines the person's potential for recovery while increasing the person's identification with the role of 'patient' (Carling, 1995; Torrey, 1995)--which is known to foster a sense of learned helplessness and hopelessness, both of which are strong barriers to recovery (Carling, 1995).

Psychosocial Barriers

Perhaps the greatest barrier for persons with a psychiatric disability to achieving psychosocial adaptation is not the disability, but rather the stigma attached to it by members of society. People with psychiatric disabilities have experienced negative stereotyping and discrimination for centuries with various myths perpetuating the misunderstanding of the nature of severe psychiatric disability (Garske & Stewart, 1999). Even though psychiatric illness is recognized as a primary brain disease today, misunderstanding of this illness still exists with members of society continuing to react with fear, embarrassment shame, and guilt toward individuals with psychiatric disabilities (Garske & Stewart, 1999). People with psychiatric illness continue to be viewed as dangerous and unpredictable. Entertainment and media further the stereotyped beliefs as images are portrayed of individuals with psychiatric disabilities being criminally violent people to be feared and mistrusted. In reality, and in stark contrast to such misperceptions, people with a psychiatric disability are no more likely to commit crimes than the general population and are usually passive and anxious (http://www.bcss.org/schizophrenia/index.html).

People with psychiatric disabilities are affected in many ways by stigma, not the least of which include rejection by relatives, friends, neighbors, and employers. Stigma can also cause feelings of rejection, loneliness, and depression in the individual with the psychiatric disability. When a family member has been diagnosed with a psychiatric disability, relatives often react with shock, sadness, anger, guilt and confusion. A sense of hopelessness felt by family members only serves, to reinforce the person's feelings of loneliness and contributes even more to the social isolation and withdrawal (http://www.bcss.org/schizophrenia/index.html).

No more clearly do we see the effects of bias, stigma, and discrimination among persons with a psychiatric disability than in the area of employment. Vocational professionals routinely direct individuals with a psychiatric disability to unskilled jobs with little potential for advancement. Vocational placements in such areas as food service, gardening, laundry, and janitorial services industries have been so popular they have been dubbed the "Four F's," standing for food, flowers, folding, and filth (Garske & Stewart, 1999). According to a recent study, more than 70% of the participants were employed full time in the health, mental health, or non-helping professions. Additionally, the results of a longitudinal study conducted by Harding, et al., (1987) found that people with a psychiatric disability do recover, maintain successful employment and have meaningful lives.

Individuals who have a psychiatric disability are clearly challenged at the personal, social, and vocational levels by the stigma attached to their illness. Rehabilitation professionals can assist in changing attitudes and beliefs by providing accurate information to family members, vocational workers, employers, and society at large. Improved attitudes can further the goal of community integration for individuals with psychiatric disabilities.

Russinova (1999) stated that the practitioner's ability to inspire hope is critical in the process of recovery for people with severe psychiatric disability. Promoting the use of external and internal resources (i.e., adequate housing, job training, supported education, coping skills, self-acceptance) is seen as an effective, hope-inspiring strategy leading to recovery. Implementing such an approach would seem to be a worthwhile strategy and an effective tool for rehabilitation professionals (McReynolds, et al., 2002).

Recovery Philosophy

Recovery is viewed as a "reformulation of one's life aspirations and an eventual adaptation to the disease" (Pratt, Gill, Barrett, & Roberts, 1999, p.91). The recovery model of psychiatric rehabilitation has been described as a fundamental shift regarding the perception of individuals with psychiatric disabilities (Anthony, 1993; Deegan, 1988; Pratt, et al., 1999). Within this concept of recovery lies the belief that individuals with psychiatric disabilities can and do adjust to psychiatric disabilities through a process of acceptance of the disability and the development of a positive self-image. Further bolstering the recovery model are developments in improved medications, the use of supported employment and the debunking of long-held myths perpetuating stigma and discrimination of individuals with psychiatric disabilities.

Psychiatric Rehabilitation Intervention Models

An often-held misconception about psychiatric rehabilitation services is that they are provided through highly structured procedures within mental health centers, sheltered workshops, group homes, hospitals, and other such settings. Although some services may fit this description, the range of locations where rehabilitation may take place is endless. Community settings may include clients' homes, places of employment grocery stores, laundromats, and parks (Bond, 1995).

Clubhouse Model. The Clubhouse Model is a comprehensive group approach that focuses on practical issues in informal settings (Bond, 1995). Clubhouses are community-based rehabilitation programs for people with psychiatric disabilities offering vocational opportunities, planning for housing, problem-solving groups, case management, recreational activities, and academic preparation. Individuals can learn, or regain skills necessary to live a productive and empowering life. The Clubhouse Model provides for the societal, occupational, and interpersonal needs of the person as well as medical and psychiatric needs (Fountain House, 1999).

Developed at the Fountain House in New York, transitional employment (TE) is an integral part of the Clubhouse approach. Clients, or members as they are called, are placed in part-time entry-level positions for three to nine months and are supervised by one another and/or rehabilitation professionals. Members work at a place of business in the community and are paid the prevailing wage rate by the employer. The placements are part-time and limited generally to 15 to 20 hours a week. The program is designed to develop a client's self-confidence, current job references, and improve work habits necessary to secure permanent employment (Anthony, Cohen, & Farkas, 1990). TE continues to be an effective rehabilitation strategy in many mental health systems (Bond, 1995).

Community Support System. The National Institute of Mental Health (NIMH) began the community support system (CSS) initiative in 1977. The intent was to assist states and communities in developing a broad array of services to assist people with psychiatric disabilities. This initiative eventually became known as the NIMH Community Support Program, with case management as one of the essential services (Anthony et al., 1990).

One of the leading models of CSS is the assertive community treatment (ACT) approach that works with clients on an individual basis providing services primarily in the client's home and neighborhood rather than in offices. ACT programs are staffed by a group of professionals who work as a treatment team in the community (Bond, 1995). In most ACT teams, staff provide a range of services to clients in their natural surroundings assisting with social service agencies, medication management, housing, employment, family issues, and teaching clients coping skills (Chinman et al., 1999). The ACT team maintains frequent contact with clients and assists with client's concerns around activities of daily living (i.e., budgeting money, shopping, housing, taking medication, employment, problem solving on the job).

Community-based treatment of persons with psychiatric disabilities, as provided in the ACT model, focuses primarily on the teaching of basic coping skills necessary to live and function as autonomously as possible in the community. These coping strategies consist of activities of daily living, vocational skills, leisure time skills, and social or interpersonal skills (Bond, 1995). Several characteristics of the ACT approach make it distinctive. The first of these is assertive outreach in which staff members initiate contacts rather than depending on clients to keep appointments. A second characteristic of ACT is its emphasis on continuity and consistency whereby care is ongoing and the services are integrated. Finally, ACT programs combine treatment and rehabilitation in a comprehensive and interdisciplinary approach (Bond, 1995). This case management approach has been widely adopted across the United States, especially for persons with psychiatric disabilities.

Supported Employment. Supported employment (SE) is one of the models of vocational rehabilitation that has been successful in helping individuals with psychiatric disabilities secure competitive employment (Ahrens, Frey, & Senn Burke, 1999). It emphasizes direct placement in a community job, assistance in locating the job with the consumer, and ongoing job-related problem solving and support after consumers obtain work. Individual placement is the key vocational strategy nationwide (Wehman & Revell, 1996). An evaluation of an SE program for persons with psychiatric disabilities found that clients were able to exercise more control over their career choices due to the client-centered approach used in SE programs (Block, 1992). By 1995, a national survey had identified 36,000 persons with psychiatric disabilities who were employed in SE jobs (Wehman, Revell & Kregal, 1997).

Supported Education. Like supported employment and supported housing, supported education (SEd) takes a rehabilitation approach in providing assistance, preparation, and advocacy to individuals with psychiatric disabilities who desire to pursue postsecondary education or training (Mowbray, Bybee, & Shriner, 1996). SEd as a program model has been nationally recognized as a promising method to improve employment rates (Anthony, 1994). A variety of SEd approaches have been identified, of which two of the most common are the structured classroom and on-site support (Moxley, Mowbray, & Brown, 1993). In the structured, or self-contained classroom, students attend classes with other students with psychiatric disabilities. In the onsite support model, students attend regular classes with support provided by the staff of the educational facility (Unger, 1990). SEd programs can and do work (Mowbray & Megivern, 1999); however, for optimal success, these programs require considerable support and coordination from a variety of community provider agencies.

Psychiatric Rehabilitation Training Needs

Psychiatric rehabilitation can be a complex and formidable task. Without proper training and exposure to effective psychiatric rehabilitation strategies, the unprepared rehabilitation professional can become overwhelmed and unable to contribute to successful intervention planning with individuals who have psychiatric disabilities (McReynolds & Garske, 2002). Moreover, rehabilitation professionals have difficulty effectively negotiating important adaptations for individuals with a psychiatric disability on the worksite, with coworkers and employers alike. With the current unemployment rate for individuals with psychiatric disabilities at more than 85% (Nobel Honberg, Hall, & Flynn, 2001) additional training may be needed in this specific topic area. Because individuals with psychiatric disabilities often struggle with a wide variety of challenges and needs, rehabilitation professionals need training in the provision of effective intervention strategies regarding positive vocational outcomes for individuals who have psychiatric disabilities.

Curricula of most professional counselor training programs have not typically included psychiatric disabilities (Anthony, et al., 1990). A 1999 survey of CORE-Recognized Masters Programs in Rehabilitation Counselor Education revealed that only 39% of programs offered a course related to psychiatric rehabilitation (McReynolds, Garske & Turpin, 1999). To this end, it would appear that many rehabilitation professionals may not have had adequate exposure to current trends and issues emerging in the area of psychiatric rehabilitation.

Persons with psychiatric disabilities want access to the same housing, work, recreational, and interpersonal experiences as any other member of society (Corrigan, Rao, & Lam, 1997; Deegan, 1992) and the service delivery setting needs well-trained professionals (Caldwell, Fishbein, & Woods, 1994). Like all responsible professions, the field of rehabilitation may need to re-evaluate the current level of training considered necessary to effectively work with individuals who have psychiatric disabilities.

To facilitate the achievement of such goals, rehabilitation professionals must be knowledgeable of the various types of interventions designed to assist individuals with severe psychiatric disability overcome disability-related challenges. Such interventions can include skills training (i.e., coping skills, interpersonal skills), medication and symptom management, social support, family education and support transfer training (i.e., generalization), cognitive rehabilitation (Corrigan, Rao, & Lam, 1999), and use of the strengths model as applied to individuals with psychiatric disabilities (Rapp, 1998).

Likewise, the goal of training rehabilitation professionals must flow from the goal of rehabilitation, which is for practitioners to acquire the knowledge, the skills, and the values necessary to effect positive client outcome with individuals with psychiatric disabilities (Farkas & Anthony, 1980). Nobel, Honberg, Hall, and Flynn (2001) offered the following commentary on the federal-state vocational rehabilitation systems track record with individuals with psychiatric disabilities:

   Studies show that the federal-state vocational
   rehabilitation system has achieved dismal
   outcomes in serving people with severe mental
   illnesses. It achieves a lower rate of closure
   into meaningful jobs as compared to others
   with physical disabilities or mental retardation.
   More than for any other type of disability
   people with severe mental illnesses are "closed-out"
   of state vocational rehabilitation systems
   as "failures." In many cases it is actually these
   state systems that have "failed" to provide the
   services individuals with these brain disorders
   require (p.3).

Pratt and Gill (2001) indicated that while there are good reasons to develop new coursework, certain practical problems persist (e.g., accreditation requirements leave little space for additional coursework, psychiatric rehabilitation curriculum may be seen as competition to the traditional program of study). To address the concern regarding limited space for additional coursework, the recent inclusion of multiculturalism into traditional programs of study as well as the increased focus on ethics in rehabilitation counseling serve as examples of what can be accomplished with emphasis being placed on a particular emerging issue. Both of these topic areas were considered neither important nor requiring specific focus prior to the last decade or so; however, space has been made for each of these topics within academic and agency continuing education settings.

Potential solutions for inclusion of psychiatric disability material into existing training programs could be as simple as adding a segment in a job development and placement course specific to individuals with psychiatric disabilities; likewise, in a course on occupational aspects of disability information specific to employment aspects of individuals with psychiatric disabilities could be included as a starting point for training programs.

By increasing the coverage of psychiatric rehabilitation programming within rehabilitation counselor education programs as well as within vocational rehabilitation agencies continuing education training programs, a shift could occur that would benefit all parties involved by ultimately generating greater rates of successful employment of individuals with psychiatric disabilities. For rehabilitation counselor education training programs, such efforts could take a variety of avenues ranging from (a) establishing a specialized track in psychiatric rehabilitation, (b) developing special topics courses offered on an annual or bi-annual basis, (c) incorporating segments on psychiatric disabilities within existing rehabilitation counselor education courses, (d) offering workshops and/or lecture series by local professionals who work in psychiatric rehabilitation, and (e) providing guest lecturers in various types of courses on psychotropic medications and diagnoses, functional limitations, and reasonable accommodations in related courses. In addition, the following suggestions could also be considered: (1) allow and encourage students to take elective courses in psychiatric disabilities from other departments; (2) encourage research papers and projects related to psychiatric rehabilitation in the basic rehabilitation counseling curriculum; (3) provide opportunities for specialized practicum experiences; (4) obtain grants to provide in-field learning and training opportunities, provide additional coursework, or offer special topics courses as potential electives in a program of study; and (5) encourage students to participate in internships with community psychiatric facilities (McReynolds, et al, 1999).

For vocational rehabilitation agencies, continuing education training programs could include: (a) offering workshops by rehabilitation professionals who embrace the recovery model of rehabilitation for psychiatric disabilities; (b) providing training on psychotropic medications, diagnoses in psychiatric rehabilitation, and the use of natural supports (including family members) during the rehabilitation process; (c) discussing functional limitations related to job placement and development, and (d) identifying methods and techniques for successful implementation of reasonable accommodations in various types of employment settings.

Conclusion

Today, in addition to serving people with physical disabilities, rehabilitation professionals' caseloads are comprised of a large percentage of individuals who have psychiatric disabilities. Vocational rehabilitation has demonstrated limited success for people with psychiatric disabilities, especially when one considers this population represents the next-to-the-largest category of disabilities served by the federal-state funded vocational rehabilitation system (McDonald-Wilson, Revell Jr., Nguyen, & Peterson, 1991). Although some gains have been made in service provision for individuals with psychiatric disabilities, the increasing number of persons with lifelong psychiatric disabilities continues to challenge rehabilitation professionals (Garske, 1999). Without proper training and exposure to effective psychiatric rehabilitation strategies, the unprepared rehabilitation professional can be overwhelmed and unable to contribute to successful intervention planning with individuals who have psychiatric disabilities (McReynolds & Garske, 2002).

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Connie J. McReynolds

Kent State University

Gregory G. Garske

Bowling Green State University

Connie J. McReynolds, Ph.D., CRC, Rehabilitation Counseling Program, Center for Disability Studies, Department of Educational Foundation and Special Services, Kent State University, Kent, Ohio 44242-0001.