Strategies to increase job tenure for people with psychiatric disabilities: an overview of the Back to Work Program.

This article presents an overview of one program's techniques for increasing job tenure for people with psychiatric disabilities. The Back To Work Program (BTW) of St. Luke's House, Inc., has used a combination of successful supported employment models to increase job tenure. Program design and philosophy, consumer choice and responsibility, coordination of services, and the relationship with the business community are presented as primary components of the program.

It is well documented that people psychiatric disabilities have the west rate of successful vocational rehabilitation of any consumer population. A National Alliance for the Mentally Ill (NAMI) study surveying relatives of people with psychiatric disabilities revealed that only 5 percent of their relatives with mental illness were competitively employed on a full-time basis (Spaniol & Zipple, 1988). This poor success rate occurred despite the fact that 92 percent of these people had high school degrees and 60 percent had either post high school or college training. Similarly, in a survey of 99 long-term psychiatrically disabled consumers, Spivak, Slaver, Deuschle, and Garrett (1982) found that only 13 percent were working on more than a half-time basis.

In recent years, considerable effort and funding have gone into creating supported employment programs to address these problems. This article is based on the practical experiences and techniques that have been used by one agency to support its consumers in maintaining employment. The Back To Work Program of St. Luke's House, Inc., supports adults with long-term mental illness in obtaining regular competitive jobs in the community. Located in Bethesda, Maryland, BTW has been providing supported employment services for the last 8 years. Originally a residential program, St. Luke's House began offering vocational services in 1982. From 1982 to 1987, job placement services were offered to residents with the highest level of interest and motivation. An accurate description of services during this period was "place and pray." At that time, consumers of these services were employed at a rate of 50 percent. With the arrival of supported employment funding in 1988, The Back To Work Program was developed. The program adopted a zero rejection model and began receiving funding from Maryland's Division of Vocational Rehabilitation. By 1990, the program had developed a specialized evaluation for supported employment, The Business Cluster Model (Barker 1994), an employment rate of 75 percent, and an average length of employment of over a year. Today, BTW offers a continuum of vocational services including vocational evaluation, transitional employment, job search and job keep groups, and supported employment. The program is also a part owner of a Mail Boxes Etc. franchise. As BTW has expanded the average length of stay on the job has increased to over 17 months.

BTW has combined portions of the Fountain House Model; The Boston University Choose, Get, Keep Approach; and The Assertive Community Treatment Model of Vocational Rehabilitation (Barker, 1994). These models, among others, were discussed in a 1992 conference sponsored by the National Institute for Disability and Rehabilitation Research. This conference, entitled "Strategies to Secure and Maintain Employment for People with Long-Term Mental Illness," attempted to define the most current data and empirically based knowledge concerning variables that positively influence the vocational rehabilitation and employability of people who have severe psychiatric disabilities (Danley, 1994). All three of these models have produced successful outcomes independently.

From the Boston University model we have adopted a standard psychiatric rehabilitation practice of functional assessments, measurable goals, and an emphasis on consumer choice. From the Fountain House model we have added transitional employment positions. From the ACT model we incorporated the practice of an integrated treatment approach and the commitment to long-term support. The BTW experience has shown that even higher outcomes are possible when a combination of the three models is used along with a customer service focus toward employers and consumers.

The purpose of this article is not to promote a specific model of vocational rehabilitation but to discuss qualities of The Back To Work Program that lead to increased job tenure. The four key characteristics of BTW are described below.

Program Design and Philosophy

BTW has chosen to task job coaches with a full range of supported employment services, including comprehensive vocational evaluations, goal planning, job development, job placement, job coaching, and follow along. Because of the nature of these responsibilities, the job title has been changed from job coach to supported employment specialist (SES). In many programs, there are vocational evaluators, transitional employment program (TEP) placement managers, job developers, and follow along staff. BTW has found that what is lost in specialized skills is regained in the relationship and trust between the consumer and the SES and that this relationship is a key ingredient in obtaining and keeping jobs. With a current staff-to-consumer ratio of 1 to 10, BTW staff work as a team both in the job search phase and in the job keep phase. They are empowered to schedule their activities independently but are clear that their first priority is to support consumers in keeping jobs. Mutual support of staff is a key component to reducing burnout and having consumers benefit from the sum of staff expertise.

BTW'S guiding principles start with the belief that any consumer who walks in the door is capable of being successfully employed. Work itself is considered treatment, and vocational services are integrated into the treatment team. Consumers benefit from having clear and measurable goals based on choosing, finding, and keeping a job and job match is based on the consumer's interest, preference, and skill level. Support services need to be flexible and available on a long-term basis. The consumer and the employer are treated as customers. Job coaching services are delivered in a fashion to minimize stigma and facilitate supervisor and coworker involvement. Any support that can be given naturally rather than by a paid professional is optimal.

Consumer Choice and Responsibility

An important element in assisting mental health consumers in developing job tenure is the consumer's investment in his/her own vocational rehabilitation processes. Consumers who are invested in their individual vocational pursuits naturally will do better in their jobs. To foster this investment The Back to Work Program encourages the personal choices of the consumer in career direction and job development efforts.

Much work is devoted to assisting consumers in making their vocational choices. Initially, this work begins in the evaluation process with work histories and interest inventories. This process helps the potential employee begin to make informed choices which with later develop ownership and the assumption of responsibility for keeping (or losing) the job. Informational interviews and work trials are excellent devices to help consumers gain firsthand knowledge of various employment areas. Investing time and effort in assisting the consumer in the development of appropriate job choices often extends the job development process but results in increased longevity on the job once it is obtained. This investment is a welcome trade-off for virtually all BTW consumers.

Choosing an appropriate type of work is essential in establishing job tenure. However, the consumer faces a myriad of choices during the rehabilitation process. Each decision made by the consumer is important in that decision making itsef contributes to a sense of ownership in the various phases of supported employment.

One of the first of these choices is the decision to disclose or not to disclose one's disability and the need for job coaching support. This is a very personal decision that should be considered with a counselor's assistance but can only be made by the consumer. This decision will determine the nature of support that is provided onsite and offsite as well as the type of relationship the counselor may have with the employer. Having such input encourages the consumer to welcome support rather than resist it and consequently has a very direct impact on job tenure. The consumer is invested in determining the type of support that is provided and develops a sense of ownership of the vocational support plans.

A consumer's recognition that this job is part of a chosen career plan greatly enhances the potential for tenure in a given job. The consumer is able to view the placement as a means, not merely an end, and is often able to make a more substantial commitment as a result. BTW supports consumers in resigning from jobs that they find to be inappropriate in some way, or that do not meet their career objectives. Consumers are assisted in making these choices and in leaving their jobs in a professional manner if they so decide.

The program values a high degree of consumer investment and participation in the job development process. This is often described as the "50-50 philosophy" and depicts the expectation that consumers will work as hard on their job search concerns as their SES. Supported employment specialists often remind potential employees that they will receive assistance in their job search, but that they will not be "given a job." This serves to illustrate to consumers that their own commitment to the job is essential if they are to experience success in finding and maintaining employment.

BTW consumers assisted in developing their own strategies of vocational support to address work-related difficulties. This again contributes to a sense of ownership throughout the rehabilitation process and enhances the capacity to develop long-term job tenure. When someone has difficulty developing strategies and solutions, they are assisted in identifying an array of choices to support their own sense of empowerment regarding work. Regardless of the final decision, the consumer experiences a feeling of control that enhances the development of self-confidence so essential to establishing job tenure.

Ultimately, consumer choice in vocational rehabilitation empowers the new employee with an awareness of responsibility that results in more dedication and commitment to the job. It is natural that people work harder to keep things that they have strived for and are not merely provided.

Coordination of Services

For the purposes of this article, coordination of services shall be deemed to include all the collaborative efforts made by members of the consumer's treatment team to support the consumer in his/her vocational success. Because many consumers of mental health services are involved with a variety of service providers, it is important that these providers keep in regular contact with one another throughout their work with that consumer. This group of service providers is commonly referred to as the "treatment team" and may include vocational rehabilitation counselors, employment specialists, case managers, employers, therapists, psychiatrists, and Alcohol Anonymous sponsors, among others.

Previous research has supported the importance that coordination of services can have in the vocational rehabilitation of people with mental illness (Jones, 1986). Dellario (1985) looked at interagency functioning between mental health agencies and the state division of vocational rehabilitation. His results suggested that improved mental health-vocational rehabilitation interagency linkages can increase the probability of successful rehabilitation outcomes for people with psychiatric disabilities. Further, Rao, Kaplan, Harvey, and Jellinek (1982) showed that a cooperative relationship between a psychiatrist and a trained rehabilitation counselor during the evaluation and planning phases resulted in better vocational rehabilitation outcomes.

It is the BTW philosophy that coordination of services should continue throughout the consumer's entire rehabilitation. Effective coordination among all service providers can help consumers to maintain long-term employment in many ways. Regular contact ensures that the consumer is not overloaded and that each individual program is a support to the other programs and the consumer. Frequent contact can also help to identify potential problems before they occur and therefore contribute to a culture of preventative rehabilitation.

Coordination is critical throughout the job choice, search, and keep phases of employment. Providers may have information on the consumer's vocational past or more general history on the consumer's interpersonal skills that may be critical to selecting a good job match. Psychiatrists and other medical doctors are consulted to determine how many hours and in what kind of environment a person can work. Beginning in the vocational evaluation phase, employment specialists should be required to contact all. service providers, including family members and at least three previous employers, if possible.

The importance of these practices is reinforced by Rogers, Anthony, and Danley's (1989) research, which demonstrated that increased mental health-vocational rehabilitation collaboration led to a decrease in consumer referrals and an increase in numbers of consumers rehabilitated. The increased communication between agencies apparently resulted in a reduction of inappropriate referrals. For these reasons, a treatment team meeting should be arranged to discuss the vocational evaluation and to establish uniform goals for choosing, finding, and keeping a job.

In addition to valuable insight, the treatment team will be needed to provide support to the consumer around work issues even when the consumer is not at work. Coordination is essential for someone maintaining employment because an integrated work environment is often less tolerant of certain behaviors than other environments. For example, one employee may be working with his SES who is helping him to arrive at work clean shaven, showered, and neatly dressed. Residential counselors or case managers who also work with this consumer might create goals around waking up on time, laundry skills, and personal hygiene.

If both programs address the issues independently, different approaches may confuse or overload the consumer and prevent success instead of encouraging it. Similar overlap can occur with interpersonal issues like communication and anger management. It is critical for employees to know how to manage anger on the job, and the SES can help to find options while at work, but it would make sense for this also to be a topic discussed in therapy. A coordinated treatment team also supports consumers in focusing on one thing at a time. If providers talk to each other regularly and see themselves as a team, natural priorities will occur and decisions can be made on what are the current support needs.

At BTW, employment specialists focus many of their efforts towards helping the treatment providers visualize the role of work in the consumer's overall welfare. Much of the emphasis in current community mental health is placed on maintenance outside the hospital, and, as research has shown, many programs rate their effectiveness in terms of hospital recidivism.

Hospitalizations often occur when a consumer's stress level is increased; therefore, therapists are concerned with helping consumers reduce stress. Starting and maintaining work can be very stressful, and vocational programs must work closely with therapists when advocating that consumers explore increasingly stressful environments. Research has shown that a consumer's need for support increases during the first 6 months on the job, indicating the need for preparatory work by the SES.

Supported employment specialists involve other team members in the vocational rehabilitation process by explaining how employment promotes community integration. They work to provide consistent and reliable assistance to both the consumer and the treatment team and enlist team members in specific tasks that will help the consumer acquire and maintain employment.

Relationship with the Business Community

The Back To Work Program also assists consumers in maintaining long-term employment by developing good relationships in the business community People trust others who know and understand .their needs and who have demonstrated a concern for these needs. The business community is no diffferent. For these reasons, BTW has found it important to become active participants in their local business communities.

The idea of creating strong relationships between employment specialists and the business community is not new. For years, researchers have talked about the need for job developers to adopt a marketing or service-orientated approach to the employment of people with disabilities (Ninth Institute on Rehabilitation Issues, 1982; Garvin, 1983). Following these approaches, employment specialists encourage employers tb hire people with disabilities not because of their "humanitarian good will," but because it makes good business sense. Others have spoken about the myth that employers are not interested or are afraid of hiring people with disabilities.

The Americans with Disabilities Act (ADA) brought many of these fears to light as people argued that the business community would feel undue pressure to hire people with disabilities if this law were passed. More recent studies have shown, however, that the business community is not against ADA and hiring people with disabilities. They just do not know how to do it (Satcher & Hendren, 1991). In a study of persons preparing to enter the business field, Satcher and Hendren (1991) found "acceptance of ADA," but warned, however, that this acceptance "may not result in improved employment opportunities for persons with disabilities unless employers are trained about the legislation's requirements." The business community is definitely in need of this training and support. A recent survey of Fortune 500 corporate policies revealed that among the companies responding, fewer than 25 percent actually had a policy concerning the hiring of people with psychiatric disabilities (Jones, Gallagher, Kelley, & Massari, 1991).

As this research has clearly shown, changing the community's perception of hiring people with psychiatric disabilities from an act of charity to a service for business can help to generate many opportunities for potential employees. For example, The Back to Work Program has created the Business Cluster Model of Supported Employment. In this model, supported employment specialists become members of several local chambers of commerce and regularly participate in the chambers' function. Supported employment specialists attend networking breakfasts and market their services as a support for the business community. As well, several supported employment specialists are involved in communittees to advocate for the needs of the chambers, including fundraisers and planning committees. One staff member is on the marketing committee for a chamber; another is on the board of directors. This contact creates long-term relationships between BTW and the business community. Therefore, when job placements are made for consumers within this business cluster, chances are higher for problems to be worked through without dismissal. As mutual involvement in projects increases, business cluster members learn to depend on BTW for technical assistance in helping their employees.

Advancing this philosophy further, BTW has joined hands with business by becoming a limited partner in a Mail-Boxes Etc. franchise. This relationship connects BTW's reputation with understanding and knowing business and also provides consumers with a realistic, yet supportive, training ground for retail work.

With all of this involvement in the business community the supported employment agency and its workers learn what is expected by managers and coworkers and are therefore better suited to relate this information to their consumers. By being involved in the business world, the supported employment SES gains an appreciation and understanding of the customer service mind set. The norms of the business community are internalized for the SES and then passed on to the consumers.

BTW's emphasis on developing business savvy does not start when an SES is hired. BTW recruits and hires individuals who have had connections with business in the past. Having staff who have been involved with business settings before helps keep the program focused on serving the business community and readying consumers to deal with employers. Potential supported employment specialists should have experience in counseling skills, prior experience with the same population, and some private sector business experience. Their training for the position will integrate all three of these aspects.

Conclusions

Implementing specific techniques to increase the job tenure of people with psychiatric disabilities should be as important as the job placement responsibilities of employment specialists. A commitment to increasing job tenure begins with program design and philosophy. Programs need to prioritize long-term job-keep skills instead of focusing solely on placement. Consumers and employment specialists need to work closely to develop a trusting relationship where each can challenge the other to work as independently as possible to achieve the consumer's goals. Employment specialists should support consumers to find their own jobs and then work with the employer to promote a successful work environment. Similarly, a strong trusting relationship must be developed with the business community by having employment specialist market their services to employers. Finally, vocational programs need to take the responsibility to insure that each consumer's treatment team is unified, informed, and working towards the same goal of vocational independence for people with psychiatric disabilities.

Preparation of this article was supported by St. Luke's House, Inc., Bethesda, Maryland.

The authors gratefully acknowledge the employees and consumers of the vocational program at St. Luke's House, Inc., for their effort and dedication.

Bibliography 

1. Barker, L. T. (1994). Community-based models of employment services for people with psychiatric disabilities. Psychosocial Rehabilitation Journal, 17(3).

2. Brown, M. A., & Basel, D. (1988). Understanding differences between mental health and vocational rehabilitation: A key to increased cooperation. Psychosocial Rehabilitation Journal, 12(2) 23-33.

3. Danley, K. (1994). Introduction. Psychosocial Rehabilitation Journal, 17(3) 1-4.

4. Delario, D. J. (1985). The relationship between mental health, vocational rehabilitation interagency functioning, and outcome of psychiatrically disabled persons. Rehabilitation Counseling Bulletin, 30(1) 177-200.

5. Garvin, R. E. (1983). Industrial relations: a service orientated approach to job development. Journal of Applied Rehabilitation Counseling, 14(2) 44-50.

6. Jones, B. J, Gallagher, B. J., Kelley, J. M., & Massari, L. O. (1991). A survey of Fortune 500 corporate policies concerning the psychiatrically handicapped. Journal of Rehabilitation, 57(4) 31-35.

7. Jones, C. 1. (1986). Social adjustment, vocational, and employment services for the chronically mentally ill SAVES): A system-integration model. Psychosocial Rehabilitation Journal, 10(2), 46-54. Ninth Institute on Rehabilitation Issues. (1982). Marketing: An approach to placement. Research and Training Center, University of Wisconsin-Stout, Menomonie, WI.

8. Rao, N., Kaplan, S., Harvey, R. E, & Jellinek, H. M. Vocational outcome: Impact of a cooperative physiatrist/rehabilitation counselor outpatient clinic program. Journal of Applied Rehabilitation Counseling, 13(4) 32-34.

9. Rogers, E. S., Anthony, W, & Danley, K. S. (1989). The impact of interagency collaboration on system and consumer outcomes. Rehabilitation Counseling Bulletin, 33(2) 100-109.

10. Satcher, J., & Hendren, G. R. (1991). Acceptance of the Americans with Disabilities Act of 1990 by persons preparing to enter the business field. Journal of Applied Rehabilitation Counseling, 22(2) 15-18.

11. Spaniol, L. J., & Zipple, A. M. (1988). Family and professional perception of family needs and coping strengths. Rehabilitation Psychology, 33(1), 37-45.

12. Spivak, G., Siegel, J., Sklaver, D., Deuschle, L., & Garrett, L. (1982). The long term patient in the community: Lifestyle patterns and treatment implications. Hospital and Community Psychiatry, 33(4) 291-295.

Mr. Abramson is the Vocational Director, Mr. Ripke is the Supervisor of the Career Transition Project, and Mr. Joseph and Ms. Schweitzer are Supported Employment Supervisors with the Back To Work Program at St. Luke's House, Inc.