The Social Center for Psychiatric Rehabilitation: adapting to change.

Psychosocial rehabilitation, which encompasses both a philosophy and a set of interventions, is a rehabilitation choice that offers positive outcomes in addressing issues of serious mental illness. There are over 2,000 programs offering psychosocial rehabilitation in the United States and, while they may vary, they all, in general, offer or coordinate a variety of integrated services (i.e., vocational, social, recreational, residential) in a holistic and comprehensive manner to individuals with serious mental illness. They also share basic core values, including:

* helping individuals to develop normalizing roles and relationships,

* addressing practical and realistic aspects of adjustment and needs,

* facilitating learning through experiential activities, and

* minimizing differences in roles, authority, and status between staff and members (Rutman, 1994.)

Integrated services, implemented in an environment faithful to these values, help individuals with serious mental illness to move ahead in their recovery.

The Social Center for Psychiatric Rehabilitation (or Social Rehab Center), one of the nation's oldest psychosocial rehabilitation programs, annually provides a wide range of social, residential, vocational, and case management services to over 600 adults in the Northern Virginia communities of Merrifield, Engleside, and Reston. Founded in 1963 as a free-- standing, private, nonprofit corporation, its mission is to provide comprehensive, well--integrated services to adults with serious mental illness so they may attain the highest possible quality of life by acquiring the skills and resources needed to live, learn, and work in the community of their choice. The agency is governed by an active volunteer board of directors that is representative of this suburban community of Washington, D.C.

Since its inception, the agency has been dedicated to providing whatever supports and services are needed by people with severe mental illness to live successfully in the community. It is this commitment to a target population, rather than to any one rehabilitation approach, that is the center's strength. Services which help members meet their goals are continually developed and evaluated for their utility and effectiveness. Programs and services are driven by the needs identified by members, not by staff interests and/or skills, and are interwoven with a sense of hope. These values are highly congruent with the basic values of psychosocial rehabilitation and the emerging recovery vision.

Recovery refers to the process of restoring something lost. Mental health consumers can utilize the assistance offered in psychosocial programming to regain normalizing roles in their lives, such as that of a husband or wife, community resident, or worker. Anthony (1993) makes the distinction that individuals recover; service providers assist to facilitate the process; ownership of the process belongs to the consumer. Hence, empowerment is a critical component of the recovery process. Recovery means more than the removal of symptoms. Recovery refers to the change of attitudes, values, feelings, goals, skills, and/or roles such that an individual lives a satisfying and meaningful life, even with limitations caused by the illness itself.

Characteristics of Serious Mental Illness

Individuals with serious mental illness comprise a heterogeneous group with varying diagnostic labels. The most common diagnoses are schizophrenic disorders, major affective disorders, such as depression or bipolar (manic-depression), and/or serious anxiety or personality disorders. Individuals can be dually diagnosed with more than one disorder, such as having bipolar disorder and a personality disorder, or schizophrenia and a learning disability. There may be concomitant physical health conditions, such as epilepsy, diabetes, or deafness.

Serious mental illness causes severe disturbances in thinking, feeling, and relating. When discussing the effects of mental illness, it can be useful to group them under three categories. First, individuals must cope with acute or positive symptoms. In schizophrenia, for example, this may involve experiencing hallucinations or delusions. For individuals with bipolar disorder, these acute symptoms may include extreme "high" moods (mania) or extreme "lows" (depression).

Individuals with severe personality disorders may experience periods of intense, fearful and chaotic feelings that lead to maladaptive and/or self-destructive thoughts. While medication management has been effective in reducing or eliminating some of these acute symptoms, individuals also experience residual effects of their illness, called negative symptoms. These may include such things as anhedonia (diminished ability to experience pleasure), apathy (lack of feeling), social withdrawal, poverty of thought (slow and confused thinking), blunting of emotion (emotional insensitivity), slowness of movement, lack of drive, and vulnerability to stress (Hughes, 1994).

Finally, individuals may experience secondary symptoms that are attributed to both the individual's and the community's response to mental illness. These may include a sense of hopelessness and helplessness, low self-esteem, fear of taking risks, and the trauma of dealing with society's stigma and fear regarding mental illness (Hughes, 1994).

Program Components

The center's rehabilitation program helps members compensate for or eliminate functional deficits, interpersonal skills deficits, and environmental barriers created by the disability. Through skill and resource development in a supportive atmosphere, individuals can restore their ability to live independently and effectively manage their lives. The program components described below are designed to restore a sense of confidence and hope, increase self-esteem, build on strengths, and emphasize wellness vs. illness.

Clubhouse Units

Using an approach known as the clubhouse model, the center provides a supportive environment in which people with psychiatric disabilities participate as members, rather than as patients. Members with and without vocational goals participate in the work units, which serve as the foundation of the program and therefore contribute to the daily operation of the center. Based on their interests and skills, members of the center choose from among the business/clerical, consumer advocacy, support and education (C.A.S.E.), food, maintenance, and thrift shop units for their daily participation. In these units, members learn important work, socialization, and problem solving skills; make friends; and build self-confidence. For example, the business unit performs clerical tasks, teaches computer skills, and publishes the members' newsletter. The clubhouse units are also supplemented by a variety of educational and support groups. Because the center strives to be a "no-reject" agency, members come into the program with a variety of skills and goals; consequently, no one rehabilitation plan will meet all needs. It is, rather, the availability of a comprehensive array of easily accessed services that results in successful vocational outcomes for 40 percent of members served.

Vocational Program 

Utilizing material developed by Anthony and his associates at the Boston University Center for Psychiatric Rehabilitation, members work collaboratively with staff to develop individual goals and plans, many of which focus on choosing, getting, and keeping jobs.

Prior to 1992, the center operated two thriving business ventures: Merri-field Mailings provided bulk mailing services to area businesses and SRC Tees produced a line of silk screened tee shirts by special order. Both businesses met the Department of Labor definition of sheltered workshops, offering members an opportunity to gain work experience and to earn less than minimum wages within the center's supportive environment. However, in 1992, a series of satisfaction surveys indicated that these workshop experiences had not been helpful to members in moving on to community-based employment. Over the next several months, the two businesses were closed and the agency focused on improving its community-based job development and employment activities. Members now focus on preparing for and entering into two different types of employment, namely:

* Transitional Employment, in which members who are not sure about either their vocational capacities or their employment goals have the opportunity to be placed in one or several entry level, short-term (6-month) placements in the community at competitive (rather than sheltered) wages; and

* Supported Employment, in which members who have more definite career goals are assisted in gaining and maintaining permanent employment and are supported by agency staff on the job to assure both short-term and long-term success.

Members are active partners in the process of locating these job opportunities for themselves through the operation of the center's Job Resource Center, which is open to all members in the program. The Job Resource Center at each location offers members staff support, peer support, and practical services in their efforts to find work. In addition to being a physical location within the larger center, the Job Resource Center is also a set of supports for the member seeking work.

The Social Rehab Center's vocational program has four major phases or components--job preparation, job development, initial job stabilization, and long-term followup--and is an approved vendor of vocational services through the Virginia Department of Rehabilitative Services. All components have been developed in response to member needs and available technology. Members come into the vocational program from either the clubhouse or from direct referrals from the Department of Rehabilitative Services. It is important to note that, while the following description of interventions is presented sequentially, members are not required to utilize all components, nor to use them in sequence.

Job Preparation

Job preparation begins as soon as the member is accepted into the program and continues until the member begins seeking a job. The major objectives of this phase are to ensure that the members are job ready and to help them choose the type of employment they wish to pursue. Services provided in this phase include:

* Assessment. For individuals referred directly into the vocational program, assessment includes obtaining referral and background information, such as clinical history, work history, and educational background. Personal interviews are utilized to gather behavioral observations of interpersonal skills, grooming and dress, and the member's assessment of services needed and desired. Situational assessments, deemed a quality predictor of vocational ability (Cook, Jonikas, & Solomon, 1992), are utilized through participation in the Job Resource Center.

Members also develop written functional assessments as part of the overall service plan. Each member works with a vocational staff person to prioritize defined skill and/or resource deficits in terms of urgency, motivation, capability, and availability of support.

The Job Resource Center at each location makes available an array of vocational services that can be easily accessed by any member wishing to pursue a job goal. Services listed below are designed to meet members' needs at any stage of their vocational plan, whether it be choosing, getting, or keeping a job.

* Job Matching. Individual and group activities in career exploration and in job choosing (career counseling) are provided within the Job Resource Center by the vocational counselor. Members learn about the world of work through jobsite visits in the community and from speakers invited to the center to describe various employment settings. Additionally, the vocational counselor assists members in gathering previous work history information, administers vocational interest inventories, facilitates exploring job values and job skills, and then helps members match individual skills, abilities, and values to specific jobs and careers.

* Job Keeping. Through the functional and situational assessment process stated above, members identify their skill strengths and needs and begin to understand how their deficits interfere with their ability to keep a job. They then learn how to remediate these skill deficits through the development and implementation of a rehabilitation plan. Skills identified in a person's Individual Service Plan (ISP) are worked on initially within the Job Resource Center and are reinforced, as needed, during the placement and followup period.

Job Development

Once a member is job ready and has targeted a field, the job development phase begins. The objective of this phase is to help the member secure employment in his or her chosen field. Services provided in the job development phase include:

* Job Location. Job location assistance is provided through a combination of two vehicles, the job developer and the job club. The job club uses a modification of Azrin and Besalel's (1980) work and focuses on getting a job in the community through active participation in structured activities. These activities include locating job leads, practicing interviewing, evaluating grooming, writing resumes, and making daily contacts with prospective employers with the assistance and support of vocational staff and fellow job seekers. To help facilitate a successful job search, a wide variety of resources is readily provided, such as the use of telephones, computers, newspapers, and stationery supplies. Eighty percent of members use the full support of the job developer. Twenty percent request consultation to support their individual actions. After initial openings are identified, job developers engage in extensive outreach to the business community to secure jobs for members. If requested, job developers will go on interviews with members and then provide feedback and additional training and practice as indicated.

* Employer Education. The job developer assists employers in increasing their understanding of mental illness/etiology, symptomatology, and rehabilitation methodologies. Attention is given to separating the symptoms of the illness from the strengths of the individual. Member confidentiality is protected during this process. Additionally, employers are provided with information and feedback on their rights and responsibilities under the Americans with Disabilities Act.

* Pay and Benefits Negotiation. The job developer works with the member to negotiate wages. Members always earn wages and benefits equal to that being paid to nondisabled individuals in the same position. Members who are currently working and have been placed by the center earn between $4.25 and $11.00 per hour. Job coaches continue to review and advocate together with the member for increased pay and benefits commensurate with his/her performance and the employer's policies.

* Job Accommodation. Part of the job choosing process involves helping members to decide whether or not to disclose their disability. If they choose to do so, members learn to identify needed accommodations based on specific functional limitations. They may need to practice with the vocational counselor on how to present their needs to employers. In the job getting phase, the job developer negotiates any needed accommodation in the job before placement. After placement, the job coach may negotiate other accommodations. Some examples may include arranging part-time or reduced hours during periods of increased psychiatric symptomatology, allowing for short breaks during the workday, or restructuring part of the job to allow for maximum productivity.

Initial Stabilization

The objective of this phase is to help the member meet the demands of the new job. Once a job has been found, the job coach works closely with the client and the employer to help the client succeed in the job. During this phase, intensive on- and off-the-job supports are provided as needed; these services include:

* Orientation. Job coaches assist members onsite in learning the routine of the work environment, role modeling interactions with coworkers and supervisors, and providing support during the initial period of employment. Assistance is provided in filling out paperwork, such as tax forms, etc.

* Followup Visits. Members in individual placements are visited weekly by vocational staff, as warranted, usually for the first 6 months. During visits, the member, his/her supervisor, and the staff person meet to discuss job related issues. The frequency of followup visits decreases in accordance with member needs. Follow-along services continue as needed on an individualized basis.

* Medication/Symptom Management. Members often need assistance in making regular therapy and medication appointments and in notifying therapists and psychiatrists when there is a change in psychiatric symptomatology. Vocational staff assist with this process.

* Natural Supports. Job developers and job coaches identify and facilitate natural supports in the workplace. These supports include pairing members with other experienced workers within the employment site to orient the new worker--adopting a consultant's role with the worker's supervisor vs. taking on supervisory tasks directly--and to interpret the workplace culture. Job coaches assist new workers to identify their commonalities with nondisabled coworkers so they may further their social integration. Members of the Social Rehab Center Board and other community contacts sometimes serve as mentors.

* Financial Planning. Members receive intensive education regarding how returning to work may impact either their public supports or their disability income. Members are also assisted in reporting wages to the Social Security Administration and in advocating for help with Medicare and Medicaid. Additionally, members are given support and technical assistance during the benefit review process. Technical assistance with work incentives, such as the Plan for Achieving Self Support (PASS) and Impairment-Related Work Expenses (IRWE), is also provided.

* Transportation. Assistance with transportation planning, with hands-on training if necessary, is provided by vocational staff. Members are assisted in learning a new route by bus or Metro, or in learning the entire public transportation system.

* Family Involvement. The Social Rehab Center has worked with families since 1974 and regularly offers psychoeducational support groups. Topics discussed include medication, utilization of the mental health service delivery system, social isolation, and other familial concerns.

Family members are supported and encouraged to form a partnership with staff in providing services to members. This may take the form of families participating in team meetings, in update sessions, or simply talking periodically by phone about their family member's involvement and participation. The level of family involvement varies from individual to individual and, as adults, members have choices regarding the level of family involvement.

* Emergencies. Staff from the Social Rehab Center intervene on the jobsite during periods of crisis. Interventions may include responding onsite to crises, assisting members in obtaining emergency services, and negotiating with employers for time off during periods of stabilization.

Long-Term Followup

Once members are stabilized on a job they move into the long-term followup phase. The objectives here are to ensure that members remain employed and that they have the opportunity for career growth. Services offered include regular monitoring of the members' progress and the provision of support services described in the stabilization phase, as needed. The agency will have at least two face-to-face contacts with the member and one contact with the employer every month. Other services specific to the long-term followup phase are:

* Follow-Along Groups. The job follow-along group is a support unit for members who are working and is designed to increase job retention rates. The group has two main functions: to assist members in resolving work related issues and to provide peer support. Types of issues addressed may include communication skills, conflict resolution, accepting constructive criticism, dealing with anger appropriately, etc. Peer support is vital to help offset the isolation many clients feel and in offsetting views that their problems may be unique. Staff facilitate these groups and, together with peer group members, offer support, encouragement, and opportunities to problem solve and role play difficult situations. Groups are held at different times to accommodate varying work schedules.

* Assistance with Re-Employment or Job Changes. The comprehensive nature of the center provides a safety net for members who may lose their jobs. Support is available as needed and individuals may return and make use of the Job Resource Center.

Additionally, members are encouraged to think about career ladders. Job choosing skills are taught with the understanding that members will likely use them in making job changes. Members are assisted in making job changes for better pay, higher skill levels, and opportunities for advancement.

Adapting to Changing Populations

Historically, the center has primarily served individuals with schizophrenia. Over the years, the characteristics of this population have changed; client demographics and member satisfaction surveys have documented these changes. The following section will address two emerging populations and the specialized interventions developed at the center to facilitate their recovery.

Mental Illness and Chemical Dependency 

An emerging issue in service delivery for people with serious mental illness, and certainly a factor in the development of vocational services, is what is termed the "young adult chronically mentally ill individual" (Pepper, Kirshner & Ryglewicz, 1981). Pepper et al. (1981) found that approximately half of the people receiving mental health services were between the ages of 18 and 30. Substance abuse was a major issue with many; the incidence has been reported at 37 percent (Pepper et al., 1981). Many of these individuals turn to substance abuse because it allows them to be a peer member, alleviate stress, and behave more socially and it helps to medicate their symptoms (Ridgely, Goldman & Talbott, 1986.) A high risk of suicide (42 percent) is also reported among this group. Certainly, there are numerous issues to be considered in planning vocational programs.

At the center, we have developed an individualized, flexible substance abuse/vocational policy, with the goal of responsibly addressing the vocational and substance abuse issues and needs of all members who have a desire to work, but who also have a recent history or current indication of substance abuse.

Members interested in working will undergo a substance abuse evaluation/assessment or will have previous substance abuse assessments updated to determine the level of substance abuse counseling and support that the working member needs or requests.

Once a decision has been reached concerning the degree of support that the member requires, a substance abuse/vocational agreement, tailored to meet the individual needs and goals of the member, is drawn up and signed. It should be developed by both staff and member and be both realistic and attainable. Members are encouraged to request a meeting to revise/amend their agreements if their needs and goals are not being met.

A waiting period may be required before a member actively seeks work. This time period is set aside to give the member an opportunity to focus on sobriety and to transition to the social, interpersonal, physical, and intrapersonal changes that accompany a new, sober lifestyle. Types of support offered include inhouse groups such as substance abuse education, relapse prevention, work and recovery, or Adult Children of Alcoholics groups. Some individuals may benefit from drug screens. With agency transportation, some members attend community Alcoholics Anonymous meetings during program hours. The member works to remain drug and alcohol free.

Borderline Personality Disorder 

Another increasing population being served at the center consists of those with Borderline Personality Disorder (BPD). BPD is characterized by unstable and intense interpersonal relationships, chronic feelings of emptiness and boredom, and frantic attempts to avoid real or perceived abandonment (Holland, Zipple, & Batscha, 1993).

Two aspects of the more traditional clubhouse environment can be counterproductive for working with persons with BPD. People with this disorder have difficulty in establishing boundaries with others; they experience difficulty identifying appropriate roles and expectations of others. Since psychosocial rehabilitation minimizes the role, status, and authority differential between members and staff, this can lead to role confusion for individuals with BPD. The second difficulty is that, traditionally, many of the activities of the clubhouse occur in a group milieu with an emphasis on hands-on behavioral tasks. While this milieu can certainly be a good vehicle for assessment, it cannot be the sole environment for interventions. Persons with BPD need individual time and attention to process some of the cognitive and affective skill deficits they possess.

In a continuing effort to adapt our programs and services based on the needs of this group, several modifications have been made. Careful attention is given to address the affective and cognitive skill areas during the functional assessment process. Individuals with BPD are generally given additional individual time, perhaps daily time, to meet with staff and process feelings and reframe maladaptive ways of evaluating situations. This extra time also helps facilitate the member's trust and rapport with staff, which is crucial to their ability to tolerate the difficult feelings accompanying change. Three educational groups have been effective in working with members with BPD. One is "Understanding Your Illness." Many individuals with BPD have never been told of their diagnosis; helping them to understand how they may have increased vulnerability to interpersonal conflict is helpful. A second group, "Anger Management," involves helping members to identify the antecedents to their anger and helping to intervene before the feelings of anger escalate and contribute to a negative interaction. A third group, "Confidence," helps members to improve their interpersonal skills, especially their assertiveness and direct communication skills.

These groups and the individual service planning process take place concurrently with other phases of job preparation for members with vocational goals. Successful strategies and techniques utilized during the job preparation process can then be continued with the job coach after job placement and through the follow-along groups.

In the future, as new populations emerge, our interventions will again be modified. One of the keys to our members' success is the ability of our staff to help them deal with psychiatric symptomatology and vocational issues at the same time.

Program Evaluation 

A management information system tracks client information, program services, and vocational outcomes. The system gathers information on the types of services used (e.g., attendance at the Job Resource Center, on-the-job and off-the-job supports) as well as the outcomes (e.g., number of days employed, wages earned, job changes) to assess the program's effectiveness. In FY '91, 24 percent of the members served in the clubhouse were employed, 29 percent were employed in FY '93, and 40 percent in FY '94. Employed members also complete quarterly Member Satisfaction Surveys (Bond & Miller, 1991) that document whether they are pleased with their work, pay, hours, supervisors, etc. Evaluation is a management tool for improving services and providing accountability to our funding sources.

Summary

Treatment and rehabilitation for people with serious mental illness have made enormous strides in the past 20 years. Psychosocial rehabilitation programs have grown increasingly sophisticated in their ability to define best practices and to document client outcomes.

The International Association of Psychosocial Rehabilitation Services has recently provided a review of the literature citing the cost effectiveness of psychosocial rehabilitation. When contrasted with the high cost of repeated hospitalizations, high utilization of emergency rooms, unemployment, and homelessness, psychosocial rehabilitation offers substantially lower costs for better outcomes (Hughes, 1994).

National healthcare reform presents a special opportunity to educate the public on both the pragmatic cost--efficiency and the positive gain in human dignity found through these interventions. They help people to live more productive lives, and thereby to contribute more to society.

Bibliography

(1.)Anthony, W.A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990's. Psychosocial Rehabilitation Journal, 16(4), 11--23.

(2.)Azrin, N.H., & Besalel, V.A. (1980). Job Club Counselor's Manual: A behavioral approach to vocational counseling. Austin: Pro-ed.

(3.)Bond, G., & Miller, L.D. (1991). Indiana's supported work project. (Grant No. 12--D--70299--5). Washington, DC: Social Security Administration.

(4.)Cook, J.A., Jonikas, J.A., & Solomon, M.L. (1992). Models of vocational rehabilitation for youth and adults with severe mental illness. American Rehabilitation, 18(3), 6--11.

(5.)Holland, P.M., Zipple, A.M., & Batscha, C.L. (1993). Borderline personality disorder in psychosocial rehabilitation programs. Innovations & Research, 2(4), 35--40.

(6.)Hughes, R. (1994). Psychiatric rehabilitation: An essential health service for people with serious and persistent mental illness. In L. Spaniol, M.A. Brown, L. Blankertz, D.J. Burnham, J. Dincin, K. Furlong-Norman, N. Nesbitt, P. Ottenstein, K. Prieve, I. Rutman, & A. Zipple (Eds.), Psychiatric Rehabilitation (pp. 9--17). International Association of Psychosocial Rehabilitation Services.

(7.)Pepper, B., Kirshner, M.C., & Ryglewicz, H. (1981). The young adult chronic patient: Overview of a population. Hospital & Community Psychiatry, 32(7), 463--469.

(8.)Ridgely, M.S., Goldman, H.H., & Talbott, J.A. (1986). Chronic mentally ill young adults with substance abuse problems: A review of the literature and creation of a research agenda. Baltimore: University of Maryland Mental Health Policy Studies Center.

(9.)Rutman, I. (1994). What is psychiatric rehabilitation? In L. Spaniol, M.A. Brown, L. Blankertz, D.J. Burnham, J. Dincin, K. Furlong--Norman, N. Nesbitt, P. Ottenstein, K. Prieve, I. Rutman, & A. Zipple (Eds.), Psychiatric Rehabilitation (pp. 4--8.). International Association of Psychosocial Rehabilitation Services.

(10.)Prieve, K, Rutman, I., & Zipple, A. (Eds.), Psychiatric Rehabilitation (pp. 4--8.). International Association of Psychosocial Rehabilitation Services.