Supported employment for people with mental illness: myths & facts.

Only after Supported Employment's initial research and development phase from 1978-1986, was this concept seen as being useful for individuals with mental illness (Anthony & Blanch, 1987; Minn. DHS/Dept. of Jobs & Training, 1989). Even then, it was seen as transferring a knowledge base from one realm of disability specific interventions to another, i.e., from the mental retardation to the psychiatric field (Bond, 1987; Hirsch, 1989). There has been an attendant controversy over whether the SE approach can be generalized to other populations without significant modifications.

This paper is based upon the premise that the clinical concepts inherent in this methodology of rehabilitation service delivery owe as much to past work in the field of psychiatric disabilities as to that of developmental disabilities. These core principles have been cornerstones of the psychiatric rehabilitation movement since the mid-1960s, though never articulated within this typology. These concepts include:

* "in vivo" learning, i.e., site-based training

* onsite support

* support as a healthy, not dysfunctional, need

* zero reject policy, i.e., a presumption of suitability for services

* integration into the work force

* new definition of success--i.e., extra support a person may need is an obligation for the service system to address. Working with intensive on or off-site support, now constitutes a desirable outcome, not a failure, as it had been viewed prior to the Rehabilitation Amendments of 1986 that define SE as an acceptable VR outcome (Minnesota DHS/Dept. of Jobs & Training, 1989).

Historically, examination of several seminal programs buttresses this contention. The Fairweather (Community) Lodge model (Fairweather, 1980; Fergus, Balzell, & Bryant, 1991; Tornatsky, et al., 1978) formed a supportive peer living and work group in the community and defined work success as that produced through a Lodge business entity. Psychosocial rehabilitation clubhouses such as Fountain House (Beard, Propst, & Malamud, 1982; Malamud & McCrory, 1988; Vorspan, 1988) created open, life-time membership with no rejection and created "in vivo" rehabilitation environments through individual TE in integrated work settings. The Community Support (CSP) movement has focused on establishing resources within the community of functioning to support people with major mental illness (Turner & Ten Hoor, 1978). Finally, another community psychiatric rehabilitation approach with a history dating from the 1970s, is the Program of Assertive Community Treatment (PACT), which provided support, not in clinics or treatment centers, but in the community and which defined withdrawing from support, not the need for it, as dysfunctional (Stein & Test, 1980).

The Supported Employment movement has advanced the concept of employment services from a strictly clinical issue to one of civil rights and societal inclusion, involving both social and work integration. Supported Employment was much more of a radical departure from the norm of developmental disability day programs. Day programs serving persons with developmental disabilities were an outgrowth of school and institution based services developed by special educators. Therefore, these programs often were designed on a Special Education model, i.e., one based on sequential skill acquisition, or what has been labeled a continuum of services. On the other hand, day programs for people with mental illness, were usually developed on a medical model, i.e., one focused on psychiatric pathology and treatment, and were usually created by adult service providers.

Historical Antecedents of Employment and Mental Health Programming

Before examining the current wave of rehabilitation programming labeled "Supported Employment," it is important to understand the broader historical context that formed the background for these important developments. In the field of mental retardation, the panoply of Supported Employment options has sprung from pioneers like Marc Gold, Lou Brown, Wolf Wolfsenberger and most recently, vocational leaders such as Tom Bellamy, Madeline Will, and Paul Wehman. Their respective contributions have been well chronicled in the literature over the last 10 years.

As well as the specific rehabilitation innovations, it is important to recognize the social and political context out of which SE grew. Public Law 94-142 (Education for All the Handicapped Act) and IDEA (Individuals with Disabilities Education Amendments), the Civil Rights Act of 1964 (for minorities), Title IX of the Education Amendments of 1972 (for women), Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act - ADA (for people with disabilities), are all elements of all increasingly overt commitment to ensure integration of all people throughout American society.

The 1960s and 70s also saw advances in what are now viewed as supported employment opportunities for people with psychiatric disabilities. Fountain House in New York City developed the concept of Transitional Employment(TE) -- a series of time limited experiences in entry level jobs which staff obtained for members as a core component of its services (Beard, Propst, & Malamud, 1982; Malamud & McCrory, 1988). The TE concept used some of the same principles that were later popularized in the Supported Employment movement of the 1980s in the developmental disabilities field (Bond, 1987). TE, in its Fountain House roots, grew out of the intuitive sense that "in vivo" learning was a good way for people to acquire good work habits, as well as out of the belief that members -- by virtue of their skill deficits, lack of a good work history, and status as ex-mental patients -- would almost always have great difficulty in securing employment (Beard, Propst, & Malamud, 1982.) Another concept from the psychiatric rehabilitation field of this era was the Fairweather Lodge, developed by George Fairweather in Northern California. This methodology combined group residential and working environments and placed a great value on client control. empowerment and self-help processes (Fairweather, 1980; Fergus, Balzell, & Bryant, 1991). The Lodge model incorporated key principles that have relevance to later SE development, especially the fact that people can learn skills needed to function in a group and reach effective group decisions by consensus and the establishment of a group small business enterprise as a way to maintain themselves within the community (Tornatzsky, et al., 1978). The CSP movement included the development of vocational options as one of its key principles (Turner& Ten Hoor, 1978). The Program of Assertive Community Treatment (PACT) model has always included employment assistance as one of the features forming its intensive case management ethos within which, "work is viewed as treatment and outcome" (Russert & Frey, 1991, p. 9). A more recent conceptual approach to SE and people with psychiatric disabilities is characterized by the "Choose, Get, Keep" model developed by the Center for Psychiatric Rehabilitation at Boston University (Anthony, Howell, & Danley, 1984 Danley & Anthony, 1987; MacDonald-Wilson, Mancuso, Danley, & Anthony, 1991).

Myths That Exist About Supported Employment For Persons With Mental Illness

Mental illness as a disability label has spawned much myth and social stigma around those who bear it. Similarly, labelling a program as SE causes many misconceptions about its application to people with mental illness. There are certain problems inherent in mental retardation (poor cognitive ability) different from those in severe psychiatric disability (often poor interpersonal skills) that require some different methods of support and job coaching interventions. However, the values that underlie this concept remain the same. The following information is presented to clarify some of the mythology in this area.

People with severe mental illness are on a lifetime downward spiral

This myth strikes at the very core of rehabilitation service programs. The image of severe psychiatric disability -- in particular, schizophrenia -- in the popular and even in the clinical literature, has been of steady, inexorable regression or at best, maintenance. However, more recent studies (since 1976) that follow the course of severe mental illness over an extended period of time report much more promising results (Wasylenki, 1992). The most dramatic and longest running follow-up study done with former long-term patients at the Vermont State Hospital suggest that half to two thirds of people with schizophrenia achieve considerable improvement or recovery over the course of 20-25 years (Harding, et al., 1987). It appears that with time, resources, on-going intervention, and enough support, significant employment outcomes can be achieved (Bond & Boyer 1988).

SE for persons with mental illness is a new untried concept derived from the work done with people with mental retardation

Supported employment as a concept that supports people to work within their communities, as opposed to a rigidly defined way to structure services, has a strong tradition within the community psychiatric rehabilitation philosophy. However, a great deal of the socio-political impetus created by the formal concept of Supported Employment has been created by advocates in the developmental disabilities field. This creation of a large-scale ground swell of public and legislative support cannot be minimized as a major step forward for all people with disabilities.

Other authors have cited the roots of SE in some of the earlier psychiatric rehabilitation models mentioned above (Anthony & Blanch, 1987; Bond, 1987). The importance of choice with active client involvement in job-seeking (MacDonald Wilson, et al., 1989; Danley & Anthony, 1987) and the emphasis on longer-term, direct job entry alternatives, as opposed to transitional services after a preparation period (Bond, 1987) have been cited as significant differences in programming. There is no reason why choice is less crucial for people with mental retardation (Beeman & Ducharme, 1988; Mount & Zwernik, 1989; O'Brien & Lyle, 1987). Nor why service providers to people with mental retardation shouldn't be just as concerned with avoiding prerequisites (a major premise of SE). Conversely, transitional experiences can be as useful a tool for people with mental illness as school-based work programs are for people with developmental disabilities (Brown, et al., 1981).

People with mental illness should always be served in different venues than people with mental retardation

Many persons with mental illness feel stigmatized by being helped in programs that also assist people with retardation. Often, people can feel as if their psychiatric problems are attributed to reliable indicator of vocational capacity for clients with mental illness than for other persons (Anthony & Jansen, 1984; Whitehead & Marrone, 1986). The stigma attached to mental retardation is a result of the way society communicates its views regarding the people with developmental disabilities (Rees, Spreen, & Harnadek, 1991; Roper, 1990; Schneider & Anderson, 1980). Often, individuals who ostensibly are primary advocates for full societal inclusion of all people with severe disabilities insist on segregating people by disability, either because of this aforementioned attitude or funding exigencies. If SE is based on individual needs and individual needs cannot be inferred by disability label, then programming by label should not be tolerated.

SE is always better than transitional employment (TE) because the workers do not have to leave their jobs after a short period

For some people with psychiatric disabilities, a permanent placement is a superior option if they cannot tolerate the stress of change involved in moving through a continual series of jobs. However, the prospect of a time-limited transitional experience has positive aspects for many people. It provides a sense of completion and graduation. During the difficult times it allows people to glimpse some light at the "end of the tunnel." If a person drops out, working one month out of six provides a measure of limited achievement that would not be there if the person only stayed one month at an on-going job (Malamud & McCrory, 1988). Also, there is a face validity to the premise, though no empirical data exists in the literature, that employers are more willing to take risks with a TE worker whom they will only be involved with for a short time, than with someone whom they feel will be there indefinitely. Finally, TE, as originally conceived in the Fountain House clubhouse model, only makes the particular job transitional, not the employment experience itself. Therefore, a person often works on multiple transitional jobs before moving on into competitive employment. The Federal SE regulations themselves recognize TE as a viable SE program model. (Federal Register, 1987)

People with psychiatric disabilities are too fragile to withstand the stress of change involved in trying out an SE job

Both positive and negative changes can cause a great deal of stress. Working successfully may entail risks of losing a considerable amount of a social support network that may have been very difficult to create in the first place (McCrory, et al., 1982), leading to a "rehabilitation crisis," which is often predictable and understandable. Some people cannot tolerate this transition well but several factors need to be considered before discouraging a person from continuing his/her vocational exploration. Remaining passive is no guarantee that changes will not occur in one's life. Planned changes with built-in supports can help minimize or at least ameliorate stress. Indeed, one of the major attractions of SE as a service option is that a person can work, without simultaneously losing major supports in his/her life.

Teaching coping skills that help individuals anticipate and rectify potential problems that occur at change points can help ease transitional stress. Also, part of the stress response can probably be attributed to the fact that since mental illness is cyclic, people often misread the problems that occur as the recurrence of pathology, rather than normal new worker adjustment issues. An example might be a person' s not remembering the names of co-workers s/he has been introduced to on the first day of work. While an obviously expected, and remediable problem for most, the worker with a psychiatric disability might be convinced that this represents the beginnings of decompensation ("I'm having trouble concentrating and remembering things. This must mean I'm getting sick again.") Other caregivers, family members, or the client may see these problems as manifestations of the person's inability to work, rather than natural adjustment barriers that must be overcome.

Many people with mental illness have some fairy clear patterns of reactions to certain situations or a particular development of symptomatology as they decompensate (prodromal symptoms). One element of the rehabilitation intervention process is to help educate clients and/or significant others on these warning signs to help them become better at self-monitoring. The process of acute psychiatric decompensation can be arrested in some instances by medication use and/or timely hospitalization. Employers can be encouraged to see this period in light of medical treatment for other physical ailments (such as heart disease, arthritis, seizure disorders, etc.) and perhaps as one form of "reasonable accommodation" under the ADA.

Group SE Models are always an "inferior" form of employment

Many people do not wish to be part of a program or readily identifiable as a "client." Nor do they wish to be segregated as part of a group with disabilities. However, there do exist various group approaches within the psychiatric rehabilitation field whose influence cannot be ignored. The Fairweather (Community) Lodge, the Psychosocial Clubhouse using the "work-ordered day" (perhaps best exemplified by Fountain House), and the Drop-In Center (both peer and professionally run) all rely on group process to one degree or another.

Each takes as a given that people with severe mental illness will generally be isolated and stigmatized by society at large. Some ways to combat this stigma and sense of isolation are to garner support from other members of the reference group, spare information about common experiences, and model both successes and coping strategies with others. None of these approaches is meant to permanently separate people with psychiatric disabilities from the world at large. Rather, they attempt to ensure that membership in the group confers the ability to seek a safe haven where the person will be accepted and supported. Practically, group SE models are often a useful way of taking risks with people with poor work skills or who need (or desire) an extra modicum of peer support. If a program adopts a group option, care should be taken that other, individual employment choices are created and that attempts are made to break down social stigma and community exclusion.

Really motivated people will give anything a try

Motivation is a function of the helper as well as the helpee (Deegan, 1988). It is influenced by values, i.e., a goal that the person feels is worth striving for, and expectancy of success, i.e., the probability of success the person perceives of his[her] efforts towards goal attainment. Furthermore, this personal assessment of likelihood derives from both the person's views of his[her] own capacities and the resources or supports available to him[her] in this effort (McClelland, 1961; Roessler, 1980). Some people are motivated to do anything productive or to do anything to get off welfare. However, people with serious mental illness often do not have the reservoir of successful experience to feel comfortable that everything will work out if they only just try.

Within the job development process, care must be taken not to misinterpret such varied concepts as fear, caution, need for high status employment or strong specific vocational interests as lack of motivation. Also, most major psychiatric symptomatology manifests itself in late adolescence or early adulthood (Bachrach, 1984; Goldman, et al., 1981; Talbott, 1983). While the client may be chronologically older, very often [s]he can be at an earlier stage of vocational development (Ciardello & Bingham, 1982), seeking to explore varied opportunities, rather than making what may be perceived by others as realistic or sensible choices. A person without a great deal of vocational experience might, very appropriately, try out multiple jobs based on preferences, as opposed to aptitude, knowledge or experience.

Finally, the value base that the person comes from, in terms of family and social status, has a great bearing on that individual's motivation for any specific goal. An example might be a son or daughter who comes from a professional, well-to-do family, who may be extremely reluctant to settle for a traditional type of SE job -- often an entry level service position. Or, a client who resides in the same small town where [s]he grew up and went to school, may be very embarrassed at the thought of interacting with more successful college and childhood friends, while doing what [s]he views as menial work.

What are Quality Services in SE for People with Psychiatric Disabilities?

Quality services designed for individuals are, by definition, high quality services for people, regardless of disability label. However, people with severe psychiatric disabilities do have some unique needs and face special barriers. What the following section does is to highlight the areas of SE programming that are particularly important in creating work opportunities for people with psychiatric disabilities. Some considerations are the same for anyone, but will be examined in light of their unique ramifications for people with mental illness. Another set of characteristics will then be reviewed which are particularly relevant to this population either because of the stereotypes society holds of people with mental illness or the nature of psychiatric disability itself. The intent here is not to label programs that do not meet these criteria as "bad" programs, but to help identify potential gaps and problem areas when these are not met.

I. General Program Characteristics

(With Unique Ramifications for People with Mental Illness)

Integration and Visibility

There needs to be a concentrated effort to ensure that supported employees are an integral pan of the regular work force and everyday society. One concern should be to avoid congregating large numbers of workers with disabilities at any one worksite. To be truly meaningful, integration, to the extent that the client wishes, must involve both social and physical proximity in areas such as lunch, after hours socializing, employee training, etc. (Nisbet & Hagner, 1988; Wolfensberger & Thomas, 1983). Because people with mental illness often have problems in developing meaningful interpersonal relationships (both because of their own behavior and societal stigma) the SE provider may need to provide advocacy with employers to insure this relationship building occurs -- and not merely accept a steady work opportunity. Also, there is a very real stigma attached to mental illness. A provider must be prepared to confront it -- even with employers who agree to provide SE jobs. One obvious way to combat stigma is the recognition that "front of the house" jobs (sales, waiters, etc.) do more to confront social stereotypes than "back of the house" functions, (e.g., stock room, dish washing, etc.). On a more subliminal level, jobs requiring interpersonal interaction with customers and other employees present a different message about individual capacity than jobs requiring more solitary functioning. The issue is one of doing work that is valued by employers. co-workers, and the general public.

Non-stigmatizing Support

In many cases, societal fear, stigma and guilt associated with mental illness, is neither dependent on, nor influenced strongly by, individual behavior (Link, et al. 1991). Therefore, the provider must provide opportunities for non-obtrusive interventions to avoid further compounding this problem of socially reinforced stereotypes in interactions with people labeled with mental illness. Also, a client may wish to include, or avoid, certain support strategies as part of the work support plan. This may involve breakfast, lunch or dinner meetings, or surreptitious (to employer) observations (e.g., job coach as customer or phone contact at night). Such "invisibility" is not always possible or even desirable. It is not a value in and of itself, but service providers should include the inconspicuous provision of support within the menu of options.

What distinguishes support for clients is less the type of support (clinical intervention for psychiatric problems, while sometimes necessary, is not the rule) but rather the fact that paid human service providers must do it. People with mental illness often have problems forming interpersonal relations, so their natural support network may be less extensive than is typical. There are not as many spouses, friends, lovers, neighbors, etc. to lean on during the stressful time associated with making a major change in a person's life, such as finding and maintaining employment.

Prevention, not remediation, is the key

The supports inherent in the concept of SE must be available to the worker quickly when crises do occur. But supports are best seen as preventive measures. In the authors' experience, barriers to a person's reaching out for support include: embarrassment, discouragement, lack of time for personal attention due to staffing constraints at many agencies, or service provider reluctance to make the person too "dependent" on the system. All people undergo stress in making life changes. A system of supports is needed that is not totally dependent upon a client' s identifying a need before an intervention is made. When problems occur, the support structure needs to be flexible enough to allow for increasing contact, even after the initial withdrawal has begun. Once again, these supports can be individual meetings, phone contacts, dinner meetings, work discussion groups, etc. They can range from ten minutes to a full day in length.

Comprehensive planning and cooperation among service providers

Programs with experience in offering work opportunities for people with severe disabilities have found that non-work areas of people's lives often cause more problems than work issues do (MacDonald-Wilson, Mancuso, Danley, & Anthony, 1991). This fact is especially relevant to SE participants with serious mental illness. When developing a plan for SE, it is essential that rehabilitation counselors, case managers, program providers, clients and significant others include strategies for dealing with all facets of the client' s life (treatment, housing, family problems, etc.).

Comprehensive planning cannot be achieved without paying special attention to cooperation among service providers and significant others involved in the client's rehabilitation. However, several dangers exist. One is that there is often much concern about client "splitting," or causing dissension among two or more helpers. Conversely, a circumstance occurs entitled the "Stanton-Schwartz phenomenon" (Stanton & Schwartz, 1949), wherein two helpers' covert disagreements "split" the client. It is not necessary to always agree nor even to avoid presenting competing alternatives for clients. It is necessary to be clear on the rationale for alternatives to assist the client to choose courses of action rather than among people.

Another potentially problematic area has to do with the mechanics of collaboration. There has been documentation of barriers to organizational collaboration with VR and other agencies for many years (RRI, 1976; RUL, 1977). Specifically, teamwork between VR and MH agencies is colored by the fact that: "differences in philosophy, goals, and mandates were perceived as significant problems" (Katz, Geckle, Goldstein, Eichenmuller, 1990, p. 297) in a recent study of 640 staff working within six states. Solutions to this dilemma can only be achieved by addressing these differences directly and focusing on meeting the needs of clients to be served, rather than on the needs of the service deliverers.

Active involvement and alliance building with the client and others

Another important element in the collaborative network for delivering high quality SE services for people with psychiatric disabilities is the active involvement of the clients themselves and their significant others (spouses, lovers, family members) in the planning and implementation of the SE program for an individual (Lamb, 1988; McCrory, 1991). The client' s needs are not the same as his (her) family' s needs, but they are certainly inextricably woven together. However, the primary responsibility is to the client. The rehabilitation process is an active collaborative model, not a passive service recipient one.

Establishing a personal relationship with the client who is getting the employment service, while seemingly an obvious element in the helping process, has not always been perceived as crucially important in mental health services. This relationship should serve as the basis for helping this person gain mastery and skills to proceed vocationally (Lamb, 1988). A plan for SE must include as a starting point the client's goals, fears, values and interests as well as the impact seeking and maintaining employment will have on those around him. Within the array of support services offered, the creation of peer support mechanisms (e.g., workers' dinners or discussion groups) must also be an important element of this natural support network.

Opportunity for career mobility

The provision of career mobility positions can easily be seen as contradictory to the nature of SE positions -- particularly transitional employment options. To some extent, this concern is factual. Employers are not usually given to identify high level, career positions as suitable for TE or SE. However, not all SE positions need to be identified as part of a "program" or a "service." What is more important, a well structured SE program will allow and encourage a client's moving on to a better job. Often, providers discourage such movement because it causes more "work" (i.e., new jobs have to be obtained and new transitions have to be made) and there can be a sense of "not rocking the boat" (i.e., it was hard enough helping someone get to this point, why change things?). Even seemingly unrealistic career aspirations are a legitimate, natural and healthy part of the rehabilitation process as they provide a vehicle for people to test out possibilities and opportunities for legitimizing personal needs and desires.

Program clients, not the employer, are the primary constituency of the program

Supported Employment is a rehabilitation program, not just a job placement program. No SE provider can stay in business if it does not maintain credibility with employers as well as clients. The relationship is analogous to a real estate agent who needs to please both buyer and seller. The agent's preliminary responsibility is to help sell the seller's house, not ensure that the buyers get the best possible house for their money. Very often, the employer's and the client's needs are complementary. In areas where they conflict, this focus on the client as primary customer must be maintained. For providers, this priority could be manifested by keeping potentially stigmatizing information from the employer, advocating in marginal situations for the client (not always defer to the employer) and being clear to staff that what is being offered is a rehabilitation employment program to assist clients in achieving their self-identified career goals, not merely a labor supply company.

Low reject -- easy in and out

With the exception of recent history of violence or active drug/alcohol abuse, there should be no reason to "screen out" a client from an SE program without offering some services. If a provider has a more comprehensive, community psychiatric rehabilitation program (e.g., a clubhouse, a social club, a community Fairweather Lodge), then engagement in the larger program is a way of giving someone a chance. A potential client can understand concretely how participation in the other components can be tied in to eventual job placement. For programs that only run SE components, there should be employers and work sites that are either solidly developed or tolerant enough that a program can place "high risk" clients, perhaps as part of a work group.

Another aspect of this approach is the need to allow for multiple entries and exits. At some stage, people may run out of chances if rehabilitation interventions have not resolved recurring problems. However, rehabilitation must be seen as a series of steps that do not necessarily move upward at a steady rate. Particularly with people with psychiatric disabilities, it is a long slow process. A variety of seeming regressions occur many times. However, this opportunity to "catch one's breath"-- what Strauss and associates call "woodshedding"--may be a sign of a healthy marshaling of resources towards continued progress (Strauss, et al, 1985). A program that makes it difficult for clients to re-enter after a failure or which does not have an option for people who could not handle the transition to work, may compromise its ability to deliver quality rehabilitation services.

Opportunity to opt out of the "fast track"

A quality SE program that responds to the needs of people with severe psychiatric disabilities will probably be required to create options and opportunities for people by encouragement, cajoling, nagging, pushing, etc. It is unrealistic to expect people who have probably not made many successful or fortuitous life decisions to be optimistic about taking on responsibility for decision making. People with disabilities, however, should not be the only group in society required to achieve vocational success at their highest level of independent functioning.

There are other factors that go into work choices such as family considerations, social values, geographical desires, legitimate fears about success or failure, etc. People who choose to live in rural areas presumably restrict their career options, but one is generally not considered pathological or weak for doing so. SE clients must be given the freedom of making career choices that go beyond just "what they can do," even with support. They must be encouraged to take on the level of work responsibility they wish to and they should be offered explanations on the consequences of such choices (e.g., low earnings, loss of Social Security benefits, etc.) They should not be made to feel guilty at choosing other values (e.g., security, friends, family, etc.) that are higher priorities for them and transcend the goal of operating at their highest level of functioning.

II. Special Program Characteristics For People With Severe Psychiatric Disabilities

Comprehensive involvement with provider for other than SE

This concept reflects an ideal that may not always be feasible because of the nature of a particular local service delivery system. The nature of support is personal and caring, not technical assistance. It is hard for people to provide the level of support people need during a difficult period in their lives (i.e., starting work) when there is no meaningful relationship behind the provision of support. When persons want solace, they turn to someone they know and trust (lover, spouse, family members, etc.), if that resource is available. In the authors' view, the service delivery models of SE for persons with severe mental illness, such as the psychosocial clubhouse and the Fairweather Lodge, where people can form caring relationships to exploit when needed, are the best equipped to utilize personal relationships to support individuals, precisely because relationship-building is a key element of both. Sometimes these services do not exist in a given area or clients do not choose this option. In that case, an independent SE provider must develop a mechanism, before a job site is obtained, for ensuring that relationships that transcend the work place contact are developed between job coach and SE workers.

The issues of discrimination and stigma

People with psychiatric disabilities are feared, stigmatized, rejected and discriminated against more overtly than people with other disabilities, particularly with regard to job hiring (Coombs & Omvig, 1986; Drehmer, 1985). There is more social acceptance of this discrimination as warranted towards people with mental illness than for others. Especially with the advent of the Americans with Disabilities Act (ADA), providers of SE to people with serious mental illness should examine the amount of possibly damaging biographical information they make available to potential employers. The concern of most people in our society, including employers, is more about safety and potential for violence -- what the senior author refers to as the "Lizzie Borden Syndrome" in his discussions of this phenomenon -- than about diminished functioning of the individual. One long used and effective strategy is "passing" -- not informing the prospective employer or other employees about the psychiatric history (Olshansky, 1966). This approach involves both practical and philosophical problems. The philosophical dilemma lies in the ethical implications of lying or withholding information for both the service provider and the potential worker, the lack of ability to affect attitudinal change in hiring practices if the problem is "covered up," and the potential for the added stress of having to carry around an "explosive" secret. The practical conundrum is how to provide effective pre-employment advocacy and post-employment support if the provider doesn't identify the support needs to the employer.

If, and when, a decision is made to disclose data about history of psychiatric illness, then an SE program must accept an advocacy role (occasionally adversarial) with employers. The pervasiveness of discrimination and fear of mental illness in Western society demands an aggressive response to this reaction on the part of community employment providers. Program providers must not participate in employment discrimination (i.e., screening out clients for reasons employers are not legally allowed) and must see community education as a part of their role.

There is often personal discomfort on the part of the provider staff

Provider agency staff is not immune to societal stereotypes and biases against people with psychiatric disabilities (Atwood, 1982). Many people with serious mental illness are difficult to relate to for a variety of reasons having to do with symptomatology, side effects of medication, deficits in appearance or hygiene, and poorly learned social skills acquired in medical treatment settings. Additionally, people with mental illness are commonly viewed as difficult to deal with in employment programs due to the cyclical nature of the illness. Staff will not have a sense of easy completion of their task; there is always the uncertainty of a psychiatric exacerbation; and clients with psychiatric disabilities are much harder to market as employees to business people. Just as much care must be taken to examine attitudes internal to an organization regarding the people it serves, as is directed towards the external environment.

People with mental illness probably have a greater sense of lost potential

This point is often overstated when comparing employment services for people with mental illness to those with mental retardation. People with cognitive disabilities can, and do, recognize their differences and often grieve them. However, as Anthony & Blanch (1987) state: "In contrast to persons who are developmentally disabled, persons with a psychiatric disability...become disabled relatively later in life,...and often retain the hopes of return to a normal or near normal lifestyle." SE service providers to people with psychiatric disabilities usually are dealing with people who have been exposed to culturally normative vocational maturation activities through adolescence, whose progress was then hindered by the development, or at least formal labeling, of the mental illness. By comparison, the overwhelming majority (81%) of people with developmental disabilities in services are served in day or sheltered employment settings, not supported employment (McGaughey, Kiernan, McNally, & Gilmore, 1993). For people with developmental disabilities, many SE jobs are probably more socially enhancing than the work offered in rehabilitation facilities or day or work activity centers because it is done in the community in integrated work settings. In the words of a service provider to people with developmental disabilities, Susan Brown: "Most people I work with, because of their limited experiences, their vocational choices focus on broad areas...individuals with psychiatric disabilities... are frequently less realistic and do not accept the limits imposed by their disability." (Rehab Brief, 1993) The later age of onset and labeling would allow people with psychiatric disabilities the opportunity to participate in more varied pre-SE, pre-morbid vocational experiences, which they could use to compare to current opportunities.

Greater worry about labeling

As with the concept of lost potential addressed previously, there is a tendency to exaggerate the concern about labeling or stigmatization in programs serving people with mental illness versus those with mental retardation. But, when providing SE for persons with severe mental illness, the need for overt manifestations of support on the job site may cause greater self-consciousness among the people who are supported. They may feel that they are labeled as "inferior," or, "weak," or part of a stigmatized group. Hence the concern about non-obvious support interventions, as opposed to the one -- to -- one, on-site job coach model so prevalent in many of the current SE programs developed out of the mental retardation field. One -- to -- one, on site support is needed or wanted by many people with psychiatric disabilities, but program providers cannot take for granted the idea that the job coach/support person will be seen as more of a help than a hindrance. A client's resistance to this intensive approach needs to be appreciated as a natural skepticism due to societal prejudice and discrimination. It should not necessarily be seen as an unrealistic concern, manifestation of recurring pathology, or lack of motivation.

Parent expectations caused by guilt and social stigma

Any parent of a disabled child or adult has totally warranted concerns about the nature and quality of services offered to his (her) son or daughter -- no matter what the disability label. In the case of clients with mental illness, parents, particularly mothers, have been scapegoated many times as causative factors in the development of the disease (Dincin, et al., 1978). Labels such as "schizophrenic family" (Lefley, 1988, p.339) have been coined by the mental health profession, which cause defensiveness and pain to people who already have had their lives disrupted and affected negatively. This natural skepticism is augmented by societal reinforced guilt and the stigma that mental illness holds. Parents of persons with mental illness are often characterized as "part of the problem" by helpers, while parents of people with mental retardation are more often seen as "part of the team" allied to solve the problems (Wasow & Winkler, 1983). The National Alliance for the Mentally III was formed to combat these attitudes, as well as to advocate for better services for people with mental illness (Hatfield, 1981). The exponential growth of this group's membership over the last 13 years, is indicative of the niche this organization filled in providing a voice to frustrated, disgruntled, and concerned parents.

Parent expectations for even non-disabled children are often unburdened, as they should be, by what more disinterested parties might call "realistic" limitations. In the case of SE for people with severe psychiatric problems, these expectations may run counter to the options that programs may have to offer. Also, as noted before, in the case of adults, client and parent needs are often complementary, but rarely identical. This tension is exacerbated by the need for confidentiality and client control of his (her) own rehabilitation process. Program providers need to give credence to parental concerns while not backing away from their primary responsibility to the client. Program staff should not minimize differences of opinion, nor try to imply parents should be "realistic" and accept what is there. They also should be clear when they are acting on the client's wishes, as opposed to deferring to the parents, when disagreements do occur.

Systematic training focused on people with psychiatric disabilities

Traditionally, SE and TE providers have assumed that since mental illness is not an intellectual deficit, there was very little need to concentrate on systematic training methodology. However, attention should be devoted to insuring that job training matches individual learning styles. Difficulty in skill acquisition can be a source of added stress on a client, particularly in one who lacks a history of success and self-confidence -- the great majority of the people with major mental illness who receive community rehabilitation services. Many times, a person who is having typical new job "problems" (e.g., anxiety over starting or worrying about being liked), internalizes this adjustment problem into something much worse (e.g., "I must be having an anxiety attack. Does this mean I'm getting sick again?"). Job instruction can quickly resolve many such problems and what is more important, readily alleviate the attendant anxiety. Other factors particularly relevant to a person with a serious mental illness, such as side effects of medication and lack of work site social skills, also might cause a person to require work-site instruction and support beyond that usually provided by the employer.

CONCLUSION

This paper has presented how Supported Employment for individuals with psychiatric disabilities fits into both the historical and cultural contexts of the entire SE movement and its antecedents. The emphasis has been placed on this service model's strong roots within the community psychiatric rehabilitation philosophy -- even though the terminology and legislative impetus came from advocates within the developmental disabilities field. There are areas where differences exist because of some of the unique characteristics of mental illness and its medical, social, emotional, and behavioral consequences. These differences cannot be adequately addressed by categorizing SE services by disability type. They are functions of issues like stigma, prior vocational development, family interactions, and learning styles. Additional research is needed to identify whether there are disability specific characteristics that can be used to develop better community employment options. Furthermore, there needs to be continued study of how to adequately assess individual needs in a manner that can lead to prescriptive supports to enhance the possibilities of vocational success.

The core tenets and philosophy of Supported Employment do not represent a radical departure from other psychiatric rehabilitation efforts over the last 30 years. Rather, they are clearly within the framework of community services that have been, and continue to be, developed to assist people with serious mental illness to improve their capacity to live, work, befriend, and love within the communities of which they choose to be a part.

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