The Challenge of Rehabilitation Counselors: Working with People with Psychiatric Disabilities.

An estimated 40 million people in the United States have psychiatric impairments; and of this number, 4 to 5 million adults are considered seriously mentally ill. Despite their strong desire to work, functional competencies, and educational qualifications, many of those who have severe and persistent emotional problems have no long-term attachment to the labor market. While there is a consensus among rehabilitation professionals that employment is an important part of life, for persons with mental illness (VandenBoom & Lustig, 1997), estimates of unemployment are at a rate of 85 percent for the working-age members of this population (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. Even when persons with serious psychiatric disability seek vocational services, they have success rates only about half of those persons with physical disabilities (Marshak, Bostick, & Turton, 1990).

Emphasis on community-based treatment, along with the development of effective antipsychotic medications, has resulted in a major shift in treatment patterns and has put significant stress on an as yet not fully developed outpatient system. Since the 1950s, state mental health institutions have been radically depopulated, resulting in a greater number of individuals with severe psychiatric disability in the community (Rogers, Anthony, & Jansen, 1991). There are more than twice as many people with schizophrenia and manic depressive psychoses in public shelters and on the streets than are in mental hospitals (Torrey, Erdman, Wolfe, & Flynn, 1990). Along with other human service workers, rehabilitation counselors are being challenged by the large number of people with severe and life-long mental disorders.

Mental Health Service Changes

In the early 1960s, the education of the public on mental illnesses and their treatment was more widespread. The public's awareness stimulated the community's involvement in raising the standards of treatment for mental disorders. The passage of the Mental Health Centers Act of 1963 (P.L. 88-164) mandated a major change in the care of people with severe psychiatric disabilities. This legislation was amended in 1975 (P.L. 94-63) to further define the mental health services that each center was required to provide (Peterson, et al., 1996). The intent of this legislation was to initiate the development of a decentralized community-based treatment system as opposed to state hospital care. The deinstitutionalization effort of the 1960s and 1970s resulted in the discharge of many thousands of people with severe psychiatric difficulties into communities that were neither prepared nor willing to accept them (Gerhart, 1990). More recently, many young adults with severe psychiatric difficulties are found with a similar dilemma. While not hospitalized for a long period of time, these young adults also struggle with life in the community due to their functional limitations and with a community mental health service system due to its often inadequate services.

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, 1992). 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 represents the next-to-the-largest category of disability served by the state-federal vocational rehabilitation (VR) system. 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. The reported average unemployment rates for persons with other disabilities is between 50 percent and 75 percent.

Case Management Problems

In contrast to physical disabilities, psychiatric disabilities can be more difficult to measure. For people experiencing physical disabilities, the methodology of the public rehabilitation agency is usually effective. The counselor collects information related to the client's disability and assesses the client's vocational goal. With the participation of the client, the services are smoothly coordinated, and the client often enters the labor force with a renewed sense of self-worth. However, this practice is too cursory to achieve rehabilitation with many clients who have severe psychiatric disabilities (Rogan, 1980).

As a practical matter, most psychiatric rehabilitation programs limit their services to people with the most disabling conditions. According to Bond (1995), program admissions ordinarily require that clients have serious mental illness (SMI). Serious mental illness, which is sometimes referred to as "chronic mental illness" or "serious and persistent mental illness," is defined by three general criteria: diagnosis, disability, and duration. Bond (1995) indicated that in order for the diagnostic criteria to be met, an individual must have a major mental disorder, as indicated by the Diagnostic and Statistical Manual of Mental Disorders of the American Psychological Association (1994). Disability is defined by impairment in such areas of functioning as self-care, self-direction, interpersonal relationships, learning and recreation, independent living, and economic self-sufficiency. Typically, the duration criterion is met when an individual requires at least one admission to a psychiatric in-patient service or some other restrictive setting (e.g., a group home) within a five-year period.

People with severe psychiatric disabilities experience limitations in everyday functioning. Some common limitations are: (a) difficulties with interpersonal situations, including the most basic ones (greeting a friend on the street, paying for a purchase in a store); (b) problems coping with stress (including minor hassles, such as finding an item in a store); and (c) difficulty concentrating, and lack of energy or initiative (Bond, 1995). To help people with severe mental illnesses become and remain contributing members of society, rehabilitation, vocational training, and assistance in work settings are essential. Major obstacles to employment of individuals with severe mental illnesses result from the individual's lack of currently marketable skills. Additional problems may stem from negative interactions with co-workers and supervisors who may lack information about the nature of mental illnesses and the person's strengths and limitations (Task Force on the Homeless and Severe Mental Illness, 1992). It may be that the VR agency is attempting to achieve results with clients with severe psychiatric disabilities by using methods that do not compensate for their clients' unique characteristics. For this reason, clients with severe psychiatric disabilities may create havoc within the structure of the agency and increase daily pressures on the rehabilitation counselor. Still, while the involvement of rehabilitation counselors in psychiatric rehabilitation may prove to be stressful, their involvement seems both appropriate and necessary (Garske, 1992).

Psychiatric Rehabilitation

Definitions of rehabilitation essentially converge around the idea that the client should achieve the best life adjustment in his or her environment. It appears that rehabilitation professionals have little difficulty in understanding this concept in relation to physical disability, yet many rehabilitationists do not understand what is involved in the principles and practices of psychiatric rehabilitation (Anthony, 1991). While there are obvious differences between the two treatment approaches, the psychiatric rehabilitation approach is based on a rehabilitation model, the same model of impairment-disability-handicap that underlies the field of physical rehabilitation (Rogers, Anthony, & Jansen, 1991). According to Bond (1995), psychiatric rehabilitation provides individuals with psychiatric disabilities the opportunity to work, live in the community, and enjoy a social life, at their own pace, through planned experiences in a respectful, supportive, and realistic atmosphere. Psychiatric rehabilitation typically involves helping individuals gain or improve the skills and obtain the resources and support they require to attain their goals. Philosophically, the psychiatric rehabilitation model coincides with the practice of rehabilitation counseling. The mission of psychiatric rehabilitation as defined by Anthony, Cohen, and Farkas (1990) is to assist persons with long-term psychiatric disabilities to increase their functioning so that they are successful and satisfied in the environments of their choice with the least amount of ongoing professional intervention. The process by which this mission can be achieved includes developing individual's skills and/or developing more supports in their environments; in other words, helping people to change and/or change their living, learning, or working environments (Anthony, 1991). Psychiatric rehabilitation practice is guided by the basic philosophy of rehabilitation in that people with disabilities require skills and environmental supports to fulfill the role demands of their living, learning, social, and working environments (Anthony, Cohen, & Farkas, 1990). According to Lamb (1988), no part of this work is more important than giving these clients a source of mastery over their internal drives, their symptoms, and the demands of their environment.

Traditionally, medication and psychotherapy were the two major treatment approaches, with little attention given to preventing or reducing functional limitations or handicaps to social performance. According to the Task Force on the Homeless and Severe Mental Illness (1992), community treatment of the person who is severely psychiatrically impaired should focus on the teaching of those coping skills necessary to live as independently as possible in his or her community. It is the presence or absence of such skills, rather than symptoms, that is the determining factor related to rehabilitation outcome. Psychosocial programs must encompass the development or relearning of skills and competencies required for successful interpersonal and social functioning as well as those needed for specific vocational pursuits. Psychosocial programs may provide training in activities of daily living, such as cooking, shopping, housekeeping, and budgeting. Whatever diagnostic category these individuals may fit into, or whatever specific mental symptom they manifest, they are all characterized by a relative inability to master age-appropriate tasks. Therefore, the individual's functional impairment may result in the inability to live independently and to sustain gainful employment and the neglect of personal hygiene and health needs. Consequently, the individuals may experience a breakdown in social support systems, and, in extreme cases, even an inability to provide for basic nutrition and emergent medical problems. According to Anthony, Cohen, and Farkas (1990), the preferred method of increasing a client's skills or abilities is a skills-training approach. In such an approach, the intent of the rehabilitation diagnosis, as opposed to the traditional psychiatric diagnosis, is to identify those specific client skill deficits that are preventing the person from functioning more effectively in his or her living, learning, and/or work community. For clients with skill deficits, despite a high degree of motivation for employment, a referral to traditional vocational rehabilitation programs may contribute to a negative experience and may reduce their motivation for future work. Therefore, a thorough assessment of individual client needs may be necessary in order to make a successful work referral (Braitman, et al., 1995).

Two primary strategies emphasized in state-of-the-art rehabilitation efforts with people who have mental illness include the strengthening of client skills and competencies and strengthening environmental supports. Psychiatric rehabilitation practice should be guided by the basic philosophy of rehabilitation; that is, persons with disabilities require skills and environmental supports to fulfill the role demands of various living, learning, and working environments (Rogers, Anthony, & Jansen, 1991). Highly endorsed client skill strengthening approaches involve social and independent living skills training, symptom management, and job-finding clubs. Environmental support strengthening approaches identified as critical include family behavior management and the use of peer groups in the transition to community living. Finally, supported employment was cited as a critical service component which places equal emphasis on both the strengthening of client skills and competencies and environmental supports.

From a rehabilitation counselor's point of view, it is understandable that a major focus of rehabilitation may be primarily on improving vocational outcomes for people with severe psychiatric disabilities. However, clients who have poor social skills and no peer relationships and who are unable to adjust to community living need more than vocational counseling services. Many clients require comprehensive services dealing with a variety of psychosocial and emotional issues before they can focus effectively on vocational issues.

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

Among the many psychiatric rehabilitation models in current practice, the clubhouse model and the community support system (CSS) model deserve special attention. According to Bond (1995), the clubhouse model is a comprehensive group approach that focuses on practical issues in informal settings. Clubhouses offer vocational opportunities, housing, problem solving groups, case management, recreational activities, and academic preparation. The centerpiece of the clubhouse model is transitional employment (TE). Developed at the Fountain House in New York, TE was originally developed as an integral part of the club-house approach. Clubhouse programs address basic needs of members for housing, recreation, and social support (Bond & McDonel, 1991). Clients, or members, as they are called, are placed in part-time entry-level positions, usually for three to nine months and are supervised by the psychosocial rehabilitation center. ATE program is designed to develop a client's self-confidence, job references, and work habits necessary to secure permanent employment (Anthony, Cohen, & Farkas, 1990). The club-house model is a well-defined model with a strong national network. According to Bond, only a few studies have evaluated the effectiveness of clubhouse approaches, especially for individuals who are motivated to pursue community employment and who enjoy group activities.

The community support system (CSS) initiative was begun in 1977 by the National Institute of Mental Health (NIMH). The intent was to assist states and communities in developing the broad array of services that comprise the CSS. This initiative eventually became known as the NIMH Community Support Program (CSP) with case management as one of the essential CSS services (Anthony, Cohen, & Farkas, 1990). One of the leading models of case management is the assertive community treatment (ACT) approach that works with clients on an individual basis, mostly in clients' homes and neighborhoods rather than in offices. According to Bond (1995), the ACT programs are staffed by a group of professionals who work as a treatment team in the community. ACT was first developed in Madison, Wisconsin, and has spread throughout the United States, especially in the Midwest (Bond & McDonel, 1991). The ACT team keeps in frequent contact with clients and helps with things such as budgeting money, shopping, finding housing, taking medication, finding jobs, and problem solving difficulties on the job. Community treatment of persons with severe mental disabilities focuses primarily on the teaching of basic coping skills necessary to live and function as autonomously as possible in the community. These coping skills consist of activities of daily living skills, vocational skills, leisure time skills, and social or interpersonal skills (Bond, 1995). The emphasis on social skills and social skills training has received considerable attention in the field of psychiatric rehabilitation in the past two decades. For example, Tsang and Pearson (1996) noted how psychiatric patients, especially those with schizophrenia, have significant deficits in social skills and social performance. They are often unable to find competitive work, or if they secure a job, may lose it because of poor interpersonal skills (Corrigan, Reedy, Thadani, & Ganet, 1995). Characteristics of the ACT approach make it distinctive. The first characteristic is assertive outreach in which staff initiate contacts rather than depending on clients to keep appointments. A second characteristic of ACT is its emphasis on continuity and consistency. Finally, ACT programs combine treatment and rehabilitation in a comprehensive and interdisciplinary approach (Bond, 1995).

Future Challenges

Today, rehabilitation counselors are not only working in state VR agencies, but many are working in community mental health centers, psychiatric hospitals, community residential programs, supported employment programs, and community support programs. It is encouraging that the paradigm is changing and rehabilitation counselors are becoming proactive and learning to work with people with severe and life-long psychiatric disabilities. Vocational rehabilitation interventions have now become an integral part of the history and evolution of the psychiatric rehabilitation field (Anthony, Cohen, & Farkas, 1990).

Regardless of the types of services provided to people with severe mental illness, a consensus exists among policy makers, providers, clients and their families, and researchers that one of the most serious contemporary problems in the mental health field is the widespread fragmentation of mental health services (National Institute of Mental Health, 1991). In response to this problem, vocational rehabilitation and mental health (MH) agencies are beginning to make progress. It was generally accepted in the late 1980s that the needs of persons with chronic and severe psychiatric disabilities extend well beyond the boundaries of any one system and require coordinated efforts with an array of health and human service agencies. Nationally, about one-third of all VR offices are reported to have formal inter-agency collaboration agreements with one or more local MH agencies (Katz, 1991).

While gains have been made in psychiatric rehabilitation programming, it appears that the major challenges still exist. 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 rehabilitation counselor training programs assess the adequacy of their curricula regarding this specialized preparation. According to Anthony, Cohen, and Farkas (1990), the literature attests to the historical omission of psychiatric disabilities in the curricula of most professional training programs. Furthermore, Kelley and Cooper (1992) indicated that university training programs focusing on the academic preparation of psychiatric rehabilitation professionals have lagged behind. Regarding psychiatric rehabilitation program assistance, limited assistance appears to be available. Bond (1995) indicated that as of 1995 there were three federally funded Research and Training Centers on Psychiatric Rehabilitation: at Boston University, at Thresholds (in Chicago), and at Matrix Research Institute (in Philadelphia). All three centers have been active in producing written materials, sponsoring conferences, and offering technical assistance.

Mechanic (1996) noted that 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 the services they require were not those professionals most enjoy providing, and in part because they were devalued. Stigmatization is a major factor that affects the success of vocational efforts. In fact, mental health and vocational rehabilitation workers often unwittingly reinforce stigma in 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 rehabilitation 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 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). 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).

In agreement with Farkas and Anthony (1980), the goal of training rehabilitation professionals must flow from the goal of rehabilitation. In other words, the goal of training would be to have the potential psychiatric rehabilitation practitioner learn the knowledge, skills, and values necessary to effect positive client outcomes. The mastery of various conceptual components (knowledge), performance components (skills), and affective components (attitudes and values) is critical to the professional's efforts to increase client functioning and to reduce the client's dependence on the mental health system.

References

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Gregory G. Garske, Ph.D., CRC, Associate Professor, Division of Intervention Services, Bowling Green State University, Bowling Green, OH 43403.