Stigmatic and Mythical Thinking: Barriers to Vocational Rehabilitation Services for Persons with Severe Mental Illness.

More than 40 million people in the United States have psychiatric impairments; and of that number, 4 to 5 million adults are considered seriously mentally ill (SMI; National Institute on Disability and Rehabilitation Services, 1993). Due to the severity of impairment in many persons with serious mental illness, psychiatric rehabilitation programs face a challenging task. Similar to out-patient mental health workers, many rehabilitation counselors are overwhelmed because of the increased referrals and complexities of clients with a primary disability of a mental or emotional nature (Garske, 1999).

Competitive work is increasingly a goal for persons with severe mental illness. Like other Americans, people with psychiatric impairments wish to lead normal lives and view work as a signifier of normal adult life (Becker & Drake, 1994). Vocational rehabilitation for people with serious mental illness was not an issue prior to deinstitutionalization. People with mental illness spent much of their lives in back wards at state hospitals or in back rooms at home. Thus, the concept or possibility of rehabilitation was never considered. However, when antipsychotic medications became available to control some of the symptoms of these illnesses and patients were emptied out of the hospitals, it became apparent that many people with even very serious mental illnesses can learn work skills and seek and retain jobs (Torrey, Erdman, Wolfe, & Flynn, 1990). In spite of the wide range of educational backgrounds, intelligence levels, career aspirations, and previous work history, people with severe psychiatric disability typically have unemployment rates as high as 85 percent or higher. Vocational disability is frequently associated with psychiatric disorders and constitutes a significant element in the diagnostic criteria for many mental disorders (American Psychiatric Association, 1994: p. xxi). According to McDonald-Wilson, Revell, Jr., Nguyen, and Peterson (1991), vocational rehabilitation programs have demonstrated limited success for people with psychiatric disability, considering that this population consists of the second largest category of disability reported to be served by the state-federal vocational rehabilitation (VR) system. While there is a consensus among rehabilitation professionals that employment is an important part of life for persons with mental illness (VandenBoom & Lustig, 1997), the employment success rate of persons with serious psychiatric disabilities is only about half of the rate experienced by persons with physical disabilities (Marshak, Bostick, & Turton, 1990). Moreover, individuals with severe mental disorders are notorious for having the worst employment outcomes of the various disability groups served by the state-federal rehabilitation programs.

Issues of dysfunction, disability, and disadvantage are more often more difficult than the actual impairments. An inability to perform valued tasks and roles and the resultant loss of self-esteem are significant barriers to recovery. The barriers caused by being categorized as "mentally ill" can be overwhelming (Anthony, Cohen, & Farkas, 1990). The barriers to employment for people with severe mental disorders include societal stigmatic attitudes of professionals, family members, consumers, and employers; economic incentives of social insurance programs (e.g., Supplemental Security Income, Social Security Disability Insurance, Medicaid, and Medicare); lack of access to vocational services; and services that emphasize assessment and prevocational goals rather than competitive employment and following supports (Bond & McDonel, 1991).

Effects of Stigma

People with SMI have a long history of being stigmatized, reviled, shunned, shut away and, in previous eras, killed. Before the development of effective medications and psychosocial treatments, communities often found the behavior of such people too bizarre and unpredictable to tolerate in their midst. Even today stigmatization, fear, and mistrust regarding people with severe mental illnesses, especially those who are homeless, are commonplace in our nation. Such reactions influence both the direct responses of community members to these individuals and the development of local, state, and federal policies affecting them (Task Force on the Homeless and Severe Mental Illness, 1992). Yuker (1995) suggested that positive attitudes toward people with disabilities result in warm feelings and positive behavior and interactions. Negative attitudes usually result in bias and discrimination. Negative societal attitudes result in the erection of barriers that prevent people with disabilities from participating in society.

Stigmatization appears to play a major role in the success rates of vocational efforts of persons with severe mental illness. At the heart of the problem is the old belief that severe impacts of mental illness limit the employment prospects of people with psychiatric disabilities (National Institute on Disability and Rehabilitation Services, 1993). According to Mechanic (1996), stigmatization of people with mental illness has been a pervasive problem. In resource constrained programs, staff often prefer to work with those less ill and those who seem to offer greater promise of substantial improvement. There is a long legacy of neglect of those most in need, in part because they were devalued. In fact, mental health and vocational rehabilitation workers often unwittingly reinforce stigma through their interactions with clients by holding faulty ideas about the nature of the disability, by perpetuating negative stereotypes by expecting clients to conform to dictated treatment and dependency roles, and by using unskilled jobs inappropriately. For example, vocational workers often limit vocational placements to the so-called four F's: food, flowers, folding, and filth (referring to the stereotypical entry-level positions often offered to clients with long-term mental illness: food service, gardening, laundry or clerical work, and janitorial services). The handicapping effects of stigma may often be more powerful than the disability itself (National Institute on Disability and Rehabilitation Services, 1993). There is no reason for anyone to be ashamed of having a mental illness and yet many people feel that way and experience unwarranted discrimination due to the associated stigma (Carter, 1998).

Labeling Dilemma

The word stigma first originated from ancient Greece and was used to refer to marks on the body that represented something morally negative about an individual (Cockerham, 1996). Modern references still hold very similar meanings whereas stigma involves both extreme negative perceptions and social rejection of the marked individual. Goffman (1963) characterized stigma as an attribute that is socially defined as "deeply discrediting," spoiling one's identity and disqualifying one from full social acceptance (p. 3). In many cases, it is not the physical effects, but the stigma of severe mental illness that may keep an individual from fulfilling his or her potential. According to Link et al. (1997), stigma related to mental illness has numerous far-reaching effects. Stigma can affect people with mental illness in two ways: externally, through rejection by relatives, friends, neighbors, and employers, or internally, in aggravating feelings of rejection, loneliness, and depression. In essence, they are denied full participation in family life, normal social activities, and productive employment.

While the benefits of receiving mental health services may alleviate one's illness, the stigma of being "mentally ill" can further complicate the lives of persons with severe mental illness even as treatment improves symptoms and functioning (Link et al., 1997). Because such labels inevitably develop stigmatic connotations, both the label and labeling process eventually become damaging to the persons to whom they are applied (Chubon, 1994). According to Rosenfield (1997), a psychiatric label sets into action cultural stereotypes and negative images about mental illness that are applied to the person by others and by himself or herself. Hence, these perceived images devalue those with mental illness and tend to result in discrimination. In initial impressions and reactions to disability labels, some disabilities are evaluated more positively than others. People with disabilities such as asthma, diabetes, and heart disease are considered acceptable in most situations. Persons with mental illness are often avoided (Yuker, 1995). If rehabilitation professionals treat people as if they are schizophrenics, manics, and paranoids rather than people, how can we expect society to interact with persons rather than a stereotyped image of a disease (Anthony et al., 1990)?

Persons with mental illness are more likely to be unemployed, have less income, experience a diminished sense of self, and have fewer social supports. According to Link and Cullen (1990), labeling theory attributes these deficits partly to the stigma of mental illness. Echoing Goffman's view, Link, Cullen, Mirotznik, and Struening (1992), indicated that to be stigmatizing, "a mark must link the bearer to unwanted, usually undesirable attributes that discredit him or her in the eyes of others" (p. 88). Research has consistently indicated that people with mental disorders have problems in both finding and maintaining work (Cockerham, 1996; McCrohan, Mowbray, Bybee, & Harris, 1994; Xie, Dain, Becker, & Drake, 1997). Furthermore, jobs that are found often tend to be low in pay and status. Barriers to employment experienced by persons with mental illness include external barriers, such as lack of transportation or job availability; as well as attitudinal barriers expressed by others; and internal barriers, such as a lack of self-confidence. According to the National Institute of Mental Health (1991), the consequences of stigma are many and they can be devastating. They include exclusion from, or limited access to, adequate housing, meaningful work, routine social interactions, and essential services such as education, loans, health insurance, and even driver's licenses. Hence, stigma produces discrimination, loneliness, and loss of hope. Unlike persons with less stigmatizing physical disabilities, persons with psychiatric disabilities are often treated as less-than-human and incompetent. This maltreatment, combined with the effects of the illness itself, can lead to disconnectedness, spiritual crises, and disempowerment (Deegan, 1990).

Myths

Our society has great difficulty in talking about and dealing with mental illness. While there has been some improvement in the past decades, as we have learned about causes and treatments, the stigma-based myths and misinformation are still quite enormous (Carter, 1998). The belief that mental disorders are not as real as physical disorders has presented a major obstacle to societal understanding toward persons with mental illness (Judd, 1990). Fortunately, mental illnesses are now considered to be illnesses that affect the way a person thinks, acts, and feels. Like most illnesses, they have intertwined biological, psychological, and environmental roots (Carter, 1998). People have misunderstood the nature of mental illness for centuries. This misunderstanding has led them to react to it with fear, embarrassment, shame, and guilt. Some people even thought of mental illness as a punishment God gives to sinners, as a spiritual torment due to possession by the devil, or as a moral defect due to weakness of will. Several myths have directed blame toward the behaviors of the families of origin. One myth states that the family alone caused the person to have a psychiatric disorder. An early version of this myth includes simple acts by the parents as the cause of the curse placed upon their children. Still later versions of the family-related myths that psychoanalysts put forth attribute the SMI to early childhood traumas and poor parenting (Dolnick, 1998). Fortunately, people are now recognizing that mental illnesses are diseases affecting the brain and are not the result of weak will, laziness, bad character, or a bad upbringing (Andreason, 1984).

Understanding the causes, manifestations, and course of SMI can influence the conceptualization of the client's treatment planning and service provision. For example, it is considered a myth that all individuals with SMI, such as those with diagnoses of schizophrenia or manic depression, are alike in the manifestation of their particular disorders. The reality is that there is a great variability in the number and severity of symptoms in each of the SMI disorders (Harding & Zahniser, 1994). In addition, many clinicians believe that most severe mental disorders are life-long in intensity and debilitation (Weiner, 1992). The fact is that many forms of SMI are intermittent and will eventually remit, showing significant improvement over time (Harding, Zubin, & Strauss, 1992). Rehabilitation planning should at least consider the potential for the eventual remission of debilitating symptoms. Many recently introduced psychotropic medications have produced significant and unanticipated symptom improvement for the more supposedly intractable mental disorders (Meltzer, Lee, & Ranjan, 1994).

Other myths relate to treatment efforts. For instance, one myth states that the person with SMI must first be "cured" of the mental disorder before he or she can be rehabilitated. The fact is that vocational rehabilitation can be an integral part of the symptom cure for persons with SMI (Desisto, Harding, McCormick, Ashikaga, & Brooks, 1999). Another myth is that persons with SMI need to be on medication for the rest of their lives. The reality is that 25% to 29% of persons who experience the most debilitating mental illness, schizophrenia, are able to eventually stop their medications (Harding & Zahniser, 1994). Still another myth related to treatment insists that persons with SMI are so fragile that confronting them in counseling or requiring them to take chances in the community will lead to psychotic breakdowns (Gauron & Rawlings, 1973). The fact remains that consumers who take risks in treatment are more likely to improve and remain stable (Karon & Vanderbos, 1981).

Some myths refer to the characteristics of people with SMI. One myth is that people with severe mental disorders have no feelings. While it is true that they may not show feelings, their confused thinking prevents the articulation and communication of emotional states (Karon, 1992). Individuals with SMI are likely to feel anger, hopelessness, loneliness, and humiliation -- emotions that are likely to limit the rehabilitation process. Easy and quick exploration of these emotions is unlikely in the typical rehabilitation counseling setting. Another myth is that persons with SMI are violent and have an increased propensity toward dangerous behavior (Carter, 1998; Levey & Howells, 1995). It is true that a very small percentage of those with serious illnesses who do not receive proper treatment can be dangerous, yet the worries regarding neighborhood safety are unwarranted. Such concerns emanate from a perception that persons having mental disabilities are all violence prone. Fear of murder, rape, child molestation, and property damage are common themes that permeate objections. In general, the fears reflect ignorance or misconceptions about the nature of this population (Chubon, 1994).

The list of myths regarding people with SMI is lengthy. Anthony et al. (1990) supplied a list of 15 other myths which must be discarded in order for the field of psychiatric rehabilitation to develop further. For example, one myth concludes that the majority of people with psychiatric disabilities are being successfully rehabilitated and yet another myth suggests that a person's diagnostic label provides significant information relevant to a person's future rehabilitation outcome. Anthony et al. (1990) suggested that "Free from these myths, rehabilitation practitioners can locus on their mission -- helping persons who have experienced psychiatric disabilities to function successfully and be satisfied in the living, learning, working, and social environments of their choice; with the least amount of ongoing intervention by helping professions" (p. 36).

Future Needs and Considerations

In 1992, amendments to the Rehabilitation Act called for the state-federal vocational rehabilitation system to give emphasis to individuals with the most severe disabilities, that is, disabilities that significantly limit one or more life functions. Within this group are persons who have a psychiatric disability that impairs their functioning in obtaining employment (Finch & Wheaton, 1999). While this legislation is welcome, the mandate is not necessarily new. The Vocational Rehabilitation Amendments of 1943, referred to as the Barden-LaFollette Act, extended state vocational rehabilitation services from serving only persons with physical disabilities to serving persons with mental retardation and mental illness (Finch & Wheaton, 1999). Unfortunately, when compared to persons with other disabilities, persons with SMI have extremely low rehabilitation success rates (Marshak, Bostick, & Turton, 1990). While some gains have been made in psychiatric rehabilitation programming, it appears that major challenges still exist (Garske, 1999). Anthony, Cohen, and Farkas (1990) commented: "We wonder how many more clients could be employed, return to school, live more independently -- without the clients themselves ever changing -- if only the attitudes change in the world" (p. 227).

The consensus is that, above all, the issue of stigma must be addressed. Education and dissemination of accurate information about psychiatric disabilities are the keys to challenging stigma. Two goals should be of special concern: (a) to establish a systematic approach to increasing consumer empowerment and (b) to improve the attitudes of employers (both public and private) with regard to hiring people with mental illness (National Institute on Disability and Rehabilitation Services, 1993). In order to facilitate goals such as these, it is necessary for rehabilitation counselors to become more informed and assertive about psychiatric rehabilitation efforts.

According to Anthony, Cohen, and Farkas (1990), professionals are beginning to understand how the philosophy of rehabilitation can be relevant to persons with severe psychiatric disabilities. However, the trained personnel and effective programs needed to put this philosophy into practice are not typically available in communities across the country. While gains have been made in psychiatric rehabilitation programming, it appears that rehabilitation counseling could do much more. Based on current trends, it appears that qualified rehabilitation counselors will continue to be in demand to work with persons with severe psychiatric disabilities. In this case, it is recommended that graduate level counselor training programs assess the adequacy of their curricula regarding this specialized preparation (Garske, 1999). Directed toward this end, Chan et al. (1998) made specific recommendations for both preservice and inservice training programs with a focus of training rehabilitation counselors to work in mental health settings, managed care settings, or both. They recommended that these programs should consider strengthening their teaching efforts in medical aspects and treatment of psychiatric disabilities, medical diagnoses, case management, managed care concepts, functional assessment, brief therapy, cost containment, community resources utilization, and outcome research. Chan et al. (1998) further noted that due to the demands of the prescribed rehabilitation curriculum standards of the Council on Rehabilitation Education (CORE), there may not be room to add these psychiatric rehabilitation-related courses. Rehabilitation counselor education programs may consider offering these courses to students in a "mental health track" (p. 342). Emphasis on serving people with severe disabilities will continue to drive service delivery and the nature of these severe disabilities will become increasingly complex (Benshoff & Barrett, 1995). It would seem appropriate for rehabilitation educators to focus more on psychiatric rehabilitation training.

Concluding Remarks

The current challenges for a rehabilitation counselor working with a person with severe mental illness still involves dealing with the fear society holds for this illness. The stigma that accompanies mental illness can prevent many people from seeking treatment and countless others to keep their conditions secret for fear of losing their jobs, health insurance, or homes (Arons & Schauer, 1995). While the involvement of rehabilitation counselors in psychiatric rehabilitation may prove to be stressful, their involvement seems both appropriate and necessary (Garske, 1992). According to Torrey, Erdman, Wolfe, and Flynn (1990), "Individuals with serious mental illnesses do not have a `life adjustment problem' but rather a primary brain disease. They do not need `counseling' alone as much as they need medication, vocational rehabilitation, and decent housing. They do not need to `face the world' but rather to become part of the world" (p. 11).

In agreement with Anthony (1993), "Recovery from mental illness involves much more than recovery from the illness itself. People with mental illness may have to recover from the stigma they have incorporated into their very being; from the iatrogenic effects of treatment settings; from lack of recent opportunities for self-determination; from the negative side of effects of employment; and from crushed dreams. Recovery is often a complex, time-consuming process" (p. 19). As Anthony, Cohen, and Farkas (1990) indicated, "A prejudiced society is a great barrier to the vocational rehabilitation of persons with psychiatric disabilities. VR systems certainly need not erect additional ones" (p. 223).

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Gregory G. Garske, Ph.D., CRC, Division of Intervention Services, Bowling Green State University, Bowling Green, OH 43403. Email: [e-mail]

Jay R. Stewart

Bowling Green State University