Work Opportunities for Rewarding Careers (WORC): insights from implementation of a best practice approach toward vocational services for Mental Health Consumers.

Integrated competitive employment has become the focus of vocational rehabilitation for mental health consumers. Forces promoting this focus include evidence that work is therapeutic (Black, 1988; Bond, 1998; Bond et al., 2001; Drake, McHugo, Becker, Anthony, & Clark, 1996; Peretti, 1974); medications that better control symptoms, allowing consumers to assume work roles; laws that protect consumers from discrimination and tie funding streams to work outcomes (ADA PL 101-336; TWWIIA PL 106-170); pressure from the consumer movement (Steele & Berman, 2001); and employers' willingness to diversify their workforce.

Although support for employment is strong, providers have not caught up with recommendations of treatment efficacy (Wolf-Branigin, Daischlein, Cardinal, & Twiss, 2000). In a study by the Schizophrenia Patient Outcomes Research Team (PORT) of conformance rates by professionals, of twelve current care recommendations, offering vocational rehabilitation had the next to lowest rate at 22.5% (Lehman et al., 1998).

This article uses the Work Opportunities for Rewarding Careers (WORC) Program, a program based on current evidence and best practices, to identify the obstacles and promoting forces to achieving employment outcomes. It describes the WORC Program, discusses factors that affect its implementation, its impact on the policies and practices of social service agencies in which it has been implemented, and implications for future program development.

Vocational Best Practices and the WORC Program

The WORC Program goal is to help consumers secure competitive jobs in the community, jobs that pay at least minimum wage and where co-workers are primarily people without disability. The WORC Program combines evidence based practices in a systems approach, helping mental health consumers make life long connections to the world of work that meet their career interests and promote their well-being and helping employers make connections to a source of workers that meets their labor force needs. The program uses an approach to providing employment services called Supported Employment (SE). Like most SE programs, the WORC Program helps consumers through a process common to anyone securing and sustaining work, regardless of disability status, including identifying a career path, selecting a job along that path, finding and securing such a job, maintaining that job, and then, if desired, transitioning to another job along the career path. Like most SE programs, the WORC Program also provides the unique vocational support needed by consumers because of the way their mental health conditions interact with the employment process.

Research helps to identify the types of services and supports that are most effective in helping consumers reach their vocational goals (Corrigan, Steiner, McCracken, Blaser, & Barr, 2001). These include:

Coordinated services: Often mental health services are provided independently of vocational services, with little communication between the clinician and employment specialist. As a consequence, consumers can find themselves caught between contradictory advice when clinicians counsel that the consumer is not ready for work while the employment specialists encourage the consumer to seek a job. Studies comparing outcomes provided through brokered services to teams where vocational and mental health services are integrated, such as through Assertive Community Treatment (ACT) teams, find job placement and retention more likely with an integrated approach (Bond, 1998; Phillips et al., 2001), suggesting that integrated clinical and vocational services lead to improved planning and remove the burden of coordination from the consumer.

Service coordination, however, is broader than integration of clinical and vocational services. Consumers typically experience a range of issues (for example, unstable housing, involvement in the criminal justice system, domestic violence, lack of transportation, and physical health problems, among others) that could pose barriers to work and, therefore, need attention as they move into employment. Additionally, the state vocational rehabilitation agency needs to coordinate with an SE program, assisting consumers with needs not covered by the SE program, including training, uniform costs, or transportation to work. Current findings confirm the experience of mental health service providers that work outcomes are enhanced when services that remediate such potential barriers to employment are coordinated with vocational services (Akabas & Gates, 2000; Gates et al., 2004).

Limited pre-vocational activities: Based on research that shows that the longer consumers remain in work readiness activities the less likely they will be to actually get a job (Bond, 1998; Gowdy, Carlson, & Rapp, 2003), best practice SE programs take a "place and train" approach. When a consumer indicates interest in work, the program actively begins a job search process and only focuses on skill training once the consumer is employed.

Individualized services: Not surprisingly, people with mental health conditions, like most people, do not stick with work that they do not like. Research shows that the most effective employment outcomes are achieved when jobs are matched to individual interests and accommodations are identified with respect to an individual's specific job (Bond et al., 2001; Gates et al., 2004). Psychosocial assessment focused on psychiatric history and symptom status is insufficient for informing a good match between the consumer and the job (Ridgeway & Rapp, 1999; see also Dorio, 2004, Gates, 2000). Rather, through individual comprehensive assessment, interests, skills, and abilities need to be identified and gaps in functional capacity determined with respect to a specific job.

On-going support: Evidence suggests that, once placed, consumers often need support to retain jobs (Akabas & Gates, 2000). House (1981) defines the dimensions of support important to successful employment outcomes: emotional, instrumental, informational and appraisal support. Emotional support can be provided in the context of counseling and peer groups that allow consumers the opportunity to share their feelings about the employment process. Once employed, emotional support can also be provided at the workplace, expressed as the trust and caring co-workers offer. Informational support is the information consumers need to be effective workers. For example, the information might range from understanding rights and responsibilities under the Americans with Disabilities Act or the impact of work on benefits to workplace information around good places to eat lunch. Instrumental support is the things people do, including counselors, friends, family, supervisors and co-workers, which help consumers sustain work. It often includes job skills training provided through job coaching. However, people with mental health conditions are often qualified for their jobs and do not need skills training. Rather, because of the way the symptoms of the conditions, or side effects of the medications taken as part of the treatment interact with work, they require accommodation at the workplace, i.e., some change to job tasks, job routines, relationships at work or the physical environment, to best be able to meet job expectations (Akabas & Gates, 2000; Gates, 2000; Gates et al., 2004; Neff, 1985). Effective accommodation activates workplace players--supervisors, co-workers, Employee Assistance counselors, or union representatives--to provide support (Akabas, 1994; Gates, 1993, 1996). Appraisal support provides feedback about how well one is doing. In the context of counseling or a peer support group, appraisal support may help consumers sort out whether or not a particular experience is a function of the mental health condition. For example, if a consumer fails to secure a job after ten interviews, discussion helps to determine if it is a problem with interviewing or reflects a very tight job market. At the workplace, supervisor feedback is essential for consumers to know how well they meet job expectations.

Consumer involvement: Empowerment literature indicates that recovery is positively affected by consumer involvement (Davidson et al., 1999; Holter, Mowbray, Bellamy, MacFarlane, & Dukarski, 2004; Torrey, Rapp, Van Tosh, McNabb, & Ralph, 2005; Weick & Chamberlain, 1997). SE programs that provide opportunities for consumers to make informed choices about what best meets their needs are more likely to help consumers reach their vocational goals.

Demand side job development: Often providers are unable to respond to individual interests because they do not develop a range of jobs in the community. Job developers traditionally rely on finding one job for one consumer (Baron, 1995; Garvin, 1983; Gilbride & Stensrud, 1992; Jenkins & Strauser, 1999; Martin & Vieceli, 1988; Mullins, Roessler, Schriner, Brown, & Bellini, 1997; Rumrill & Roessler, 1999). Recent research suggests that a more effective approach is to build a bridge between the agency and employment systems by establishing relationships with employers independent of individual need (Akabas, Gates, Koball, & Imperiali, 2003; Gates, Akabas, & Zwelling, 2001). This approach shifts the role of the job developer to that of labor market intermediary, with a role of matching consumers' skills and interests with employers' labor force requirements.

In sum, the evidence base suggests that coordinated services, limited pre-vocational activities, individualized services based on comprehensive assessment, on-going support, consumer involvement and demand side job development strategies are components of SE programs most often associated with successful employment outcomes for consumers. WORC integrates these best practices through both program structure and program operation (see Table 1).

The WORC Program has three components that integrate best practice: Assessment and Workplace Intervention, Career Club, and Labor Market Employment Strategy.

1) Assessment and Workplace Intervention. The WORC[c] Program starts with a comprehensive assessment process using structured forms to identify individual career interests, non-vocational barriers to employment, gaps in functional capacity that might interfere with job requirements, and workplace accommodations to respond to the identified gaps. The assessment process starts on the day consumers enter the Program. Steps toward vocational goals are embodied in the treatment plan to achieve rapid placement (Lougheed, 1999).

The Program offers an intervention strategy for building effective practice with employers and consumers by approaching the workplace to negotiate needed accommodations and provide necessary education and support around disclosing the condition at the workplace and setting up accommodations (Gates, Akabas, & Oran-Sabia, 1998). Consumers, actively involved throughout, decide which jobs to pursue, exercising their right not to take the first available job but to take the job that they feel best fits their career path. They manage disclosure at the workplace, deciding if to disclose, when, how, and with whom and what information to share. They also participate in ensuring that the negotiated accommodations best meet their needs.

2) Career Club. Career clubs support members through all stages of career development. Like job clubs (Azrin, Besalel, Wisottzek, McMorrow, & Bechtel, 1982; Azrin, Flores, & Kaplan, 1977) and work readiness training at many day treatment programs, career clubs are consumer groups that provide skills needed to secure employment. They, however, exceed the singular goal of placement, typical of job clubs, by offering additional information important to working with a mental health condition such as rights under the Americans with Disabilities Act (ADA), strategies of disclosure, and utilizing natural supports in the workplace like unions and Employee Assistance Programs (EAPs). Facilitated by a counselor, Clubs support consumers through all stages from just thinking about work, to securing and sustaining competitive employment. A formal curriculum helps consumers develop job search strategies, select career paths, and feel empowered to make decisions on the basis of informed choice. Thus, Clubs are an essential component for peer involvement and for support throughout the employment process.

3) Labor Market Strategy. The Labor Market Strategy is based on a demand-side approach that establishes continuing relationships with employers that are independent of individual need (Gates et al., 2001). Consumers ready for work under the WORC Program, with their counselors, can contact an employer from the already established responsive network. Creating a network frees individual professionals from the fear, often cited to explain their hesitancy to help consumers move toward work, that employers will not hire them. The Labor Market Strategy has four stages.

1) In Stage 1, the provider organization takes stock of its image in the community and develops marketing materials to communicate the agency's mission and services.

2) In Stage 2, an employer network is developed through internal and external efforts. Employers that individuals within the agency know are identified by formal data collection instruments. These contacts might be personal (e.g., the names of restaurants where employees frequently buy lunch) or professional (e.g., the companies/vendors, such as banks, with whom the agency does business). Local businesses are inventoried and interviewed for information about their labor needs and their responsiveness to hire consumers.

3) Stage 3 utilizes the network created by these contacts. Jointly, a consumer and counselor identify an employer likely to have a job that meets the consumer's expressed interest from a database that includes key employer information such as name, location, whom to contact, days and hours of operation, staff composition, types of jobs available and the time frame for job availability, process for follow-up and general impressions by the initial interviewers and those who try, subsequently, to connect to employment at the site.

4) Stage 4 involves contacting the identified employer to review whether and what kind of job opening exists, to note any gaps in the specific consumer's functional capacity that might interfere with the job requirements, and to negotiate placement and accommodation.

WORC Program Implementation

The Workplace Center of Columbia University (the Center) has implemented the WORC Program in 21 agencies, representing 121 programs, throughout New York City between 1999 and 2005. Training and consultation has been provided to approximately 375 staff. It is funded by the NYC Department of Health and Mental Hygiene. The diverse agencies participating include residential programs, inpatient and outpatient services at Departments of Psychiatry in hospital settings, fee-for-service clinics, mental health agencies with continuing day treatment programs, Intensive Psychosocial Rehabilitation Treatment programs, programs for those with co-occurring chemical dependency and mental health conditions, psychosocial clubs, adolescent skills centers, and social service agencies serving multiple target populations of which mental health consumers is one. They range in size from as small as four staff serving approximately 300 clients to several thousand staff serving tens of thousands of clients annually.

Participation in the WORC Program is voluntary and available without cost to interested agencies. In response to the Center's outreach, interested agencies serving people with mental health conditions respond by having leadership formalize their commitment in a signed letter of understanding. Center staff then conduct site interviews with management to learn agency operations and policies, and brief interviews with each of the trainees to gain an understanding of their agency role and their feelings about participation in the Program, enabling Center staff to anticipate trainees' reaction to the change required (Marrone, Hoff, & Gold, 1999; see also Carnochan & Austin, 2002).

Implementation unfolds over 13 months, based on the experience that training alone is often insufficient to ensure that new systems are secure. Agencies need assistance with integrating the program into existing policies and operations. After training, Center staff, in regular meetings with agency leadership and in consultation sessions with staff, support the organizational change necessary for implementing the 3 WORC Program components.

Training of 18 hours, conducted over nine consecutive weeks (or collapsed into four longer sessions), covers an overview of WORC, an understanding of disclosure planning, benefits, the Americans with Disabilities Act and other legislation affecting employment, and how to conduct the assessment, identify and negotiate appropriate accommodation, and implement career clubs and labor market strategies. A maximum of 25 staff comprise the training cohort. Composition is key to successful implementation. All agency units including clinicians should be represented to ensure service integration and help the vocational mission permeate agency culture. This approach is consistent with research that documents that successful employment outcomes are related to service integration (Ahrens, Frey, & Senn Burke, 1999). Following training, Center staff meet with trainees once a week for two months to review consumer cases, initiate career clubs, and implement labor market initiatives. Consultation sessions are semi-monthly for the next six months. The final two consultation sessions are once a month. To develop agency-wide support and understanding for the WORC Program, staff provide a one-shot training to supervisors of all trainees, give a "grand rounds" presentation and/or help vocational staff prepare in-service presentations.

Factors Affecting Implementation

The Center's seven year systematic and regular observation and debriefing on the Program process is the basis for analysis of WORC Program impact on agency operation. Three categories of Program factors have emerged as important to successful implementation, including staff readiness for change in the way they provide vocational services, leadership support and maintaining staff commitment and consistent participation.

Readiness for change: The WORC Program represents significant change in mindset and designated roles in providing vocational services for most participating agencies, especially a change in the mindset of who is "work ready." The WORC Program forces agency staff to confront the fact that many do not truly believe that consumers can be productive, competitive workers. Excuses about why staff hesitate to enroll consumers are frequent. For example, a typical response would be, "This [Program] doesn't apply to the consumers I work with because my consumers are too low functioning." The concepts of appropriate job fit and meeting consumers where they are receive lip service but are not put into action. Another frequent response to new approaches to service delivery was, "We do that already." Staff often used the language of a recovery perspective without implementing the changes to activate this perspective. Agency attitudes toward disclosure, for example, were often at odds with the agency mission to promote integration into the community. Staff tended to perpetuate stigma, giving consumers the contradictory messages that there is nothing shameful about having a mental health condition but it is better not to tell anyone. Although the WORC Program does not require disclosure of the mental health condition at the workplace, it does promote planned, controlled disclosure, particularly when accommodation is needed to meet performance expectations, or when the symptoms or side effects of medications are obvious and open to misinterpretation, or if the stress of a secret life outweighs the possible risks of revealing the mental health condition. Consumers who implement a planned disclosure tend to experience increased communication and understanding with supervisors and coworkers, more effective accommodation, and enhanced trust between the service provider and the employer.

The need for change in mindset was also evident in staff's initial response to the Labor Market Strategy. Agency staff would comment that they could not imagine that employers would want to hire their consumers. Their tendency was to cling to the traditional social service perspective that defines consumers in terms of their gaps in functional capacity, resisting a business/marketing perspective that promotes the advantages of the consumer labor pool.

Mindset shifted in response to success. Consumer Career Club participation often was the driving force behind changes in staff behavior. Many agencies found, to their surprise, that consumers that they had labeled "low functioning" consistently and productively participated in Career Club and took positive steps to move into work. For example, the initial staff expectation for consumer participation was low. However, dozens, sometimes in numbers exceeding 100, routinely showed up at informational meetings about Career Club. This response would solidify staff commitment. Employment specialists learned when they prepared a marketing pitch that responded to employer needs, employers reacted positively. They learned that if offered something of value to their bottom line, employers are willing to consider applicants with mental health conditions, and that trust increased when disclosure occurred.

The WORC Program often requires staff to adopt new roles within the vocational unit as well as among staff more widely. Many vocational units operated in isolation from other units and from employer systems prior to Program implementation. Presented with the changes required by WORC, staff typically responded, "That's not my job," particularly when vocational staff needed to coordinate with both other internal service and administrative units and employer systems. Clinicians, housing case managers, benefits counselors, literacy trainers and substance abuse counselors are among the internal service providers that are involved in preparing consumers for work. Vocational staff also needed to coordinate with purchasing and development departments to identify employers for their labor market outreach. Thus, vocational staff needed to coordinate widely throughout the agency and other agency staff needed to understand and be responsive to the vocational mission.

WORC also expanded the role of vocational staff at worksites. Prior to program implementation many vocational staff limited their contact with employers to job coaching, if at all. Through WORC, for the first time, they established relationships with employers independently of individual consumer need, marketed services based on employer need and helped consumers identify and arrange ADA accommodations. The potential support of supervisors, EAP staff, and other Human Resources or union personnel was new information for vocational staff as was redefining their roles to include marketing, education, negotiation and advocacy in the workplace. Successful agencies recognized these expanded roles, changed job descriptions to include these activities, and/or hired new staff specifically to carry out these functions.

Leadership support: Leadership commitment is essential to change the mindset and operations needed to achieve successful consumer employment (Anthony, 2000; Gates et al., 2004; Kets de Vries & Balazs, 1999). The support is expressed in communication throughout the agency that work is a priority, in allocation of resources to the vocational effort, and in sanctioning the collaboration and sharing of information across units. Outcomes in several agencies were undermined by the executive director whose only sanction to participate in the WORC Program was, "Great, just as long as it doesn't interfere with your 'other' work." These executives lacked the understanding that employment is treatment and is an outcome that can enhance the agency's overall operation. Leadership that acted on the belief that it is every one's responsibility to support consumers' vocational goals was reflected in better outcomes. Center staff helped vocational staff maintain leadership support by structuring regular opportunities for feedback to leadership, offering materials that can be disseminated throughout the agency, and providing training to mid-level managers and supervisors to help everyone be on the same page.

To ensure meeting the goals of the vocational mission, leadership also needed to commit physical space and other resources such as phones and computers, to ensure adequate levels of staffing, and sanction time for WORC activities such as job development. This required leadership to find creative ways to support vocational activity. For example, several agencies solicited small technology grants to equip a resource room for consumers who were working on resumes or other computer tasks related to their job search. In other agencies, depending on the way programs were licensed and funded, they were able to bill Medicaid for career club as a group service on a day when individual service was not being provided to the consumer.

Maintaining commitment and consistent participation: During the consultation period, every agency experienced staff turnover, funding crises or agency re-organization. Those agencies that took steps to ensure WORC continuity were able to weather their changing environment. Steps to maintain commitment included:

1. Recognizing and rewarding incremental steps toward the primary goal of competitive employment for consumers (e.g., setting up career clubs).

2. Making sure that trainees represent all service units to promote service integration and spread the vocational mission throughout the agency.

3. Including supervisors among trainees to guarantee participation of individuals with authority over the work. Additionally key to WORC continuity was developing in-house training to cover staff turnover and transition.

4. Updating staff and supervisors in meetings, through inservice training, public recognition events, and Board meetings.

5. Requiring that WORC protocols be completed. Staff sometimes rebelled against completing WORC assessments, saying "I don't do forms." They believed they would gather all the information they needed to support consumers in employment through conversations with clients. However, without comprehensive tracking of individuals, information essential to providing service was lost.

6. Utilizing WORC protocols agency-wide. Some agencies integrated the vocational assessment into intake procedures and treatment plans, ensuring that vocational goals were communicated to both staff and clients.

7. Developing formal lines of communication among service units about vocational activity through clinical rounds, team or other staff meetings.

8. Developing a management information system that includes employer and consumer information and can be linked with other relevant agency data sources such as the agency's vendor database.

Lessons Learned from WORC Program Implementation

For the WORC Program to fulfill its goals of helping consumers secure jobs in the community that are obtained through a competitive process, pay at least minimum wage, and work in a setting where co-workers are primarily people without disabilities, the agency environment must be ready for change and staff must be open to following a best practice approach to service delivery. Agencies successful in implementing a vocational focus demonstrate most, if not all, of the following conditions:

1. Leadership (those with authority to sanction staff work) demonstrate support and commitment to Program

2. Formal lines of communication among units are established and a system-wide approach is adopted

3. Resources are allocated to vocational unit

4. Assessment forms are utilized agency-wide

5. Coordinated roles are reflected in job descriptions

6. An agency-wide shared MIS includes employer data

7. An employer network is established and maintained

8. Incremental changes receive public recognition from leadership

9. Consumer participation is encouraged and built into activity at all levels

These conditions allow an agency providing services to mental health consumers to transform itself from treating consumers as patients to supporting consumers as workers who make a life long connection to the world of work in a way that best meets their career interests. In so doing, it promotes the well-being of all.

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Sheila H. Akabas

Columbia University School of Social Work

Lauren B. Gates

Columbia University School of Social Work

Virginia Oran-Sabia

Columbia University School of Social Work

Table 1
Integration of Vocational Best Practice and WORC Program Activities

Best Practice             WORC Program Activity

Coordinated Services      Program training includes staff across
(clinical and other)      service units.

                          Program goals are presented in agency-wide
                          forums including staff and Board meetings.

                          Assessment process identifies non-vocational
                          barriers to employment.

                          WORC Program assessment forms utilized
                          agency-wide.

                          Inter-unit information sharing encouraged
                          through the agency MIS.

Limited Pre-vocational    Participation in placement activities occurs
Activities                from the first day of Program enrollment.

Individualized Services   Comprehensive assessment that includes gaps
                          in functional capacity that might interfere
                          with work, career interests, need for
                          accommodation, non-vocational barriers to
                          employment.

                          Career Club follow-up time to obtain
                          individual support on Career Club topics.

                          Individual review of employer network to
                          match individual vocational interests and
                          abilities with potential employers.

On-going Support          Intervention at the workplace to negotiate,
                          set in place and monitor accommodation and
                          provide education to workplace as needed.

                          On-going participation in Career Club.

                          On-going clinical services.

Peer (Consumer)           Participation in career development
Involvement               activities.

                          Participation in disclosure planning and
                          implementation.

                          Participation in negotiation and setting in
                          place of accommodations.

                          Participation in Career Club.

                          Co-facilitation of groups and employer
                          development.

Demand Side Job           Development of internal agency partnerships
Development               to identify potential employers.
                          Development of external agency partnerships
                          with employers responsive to hire consumers,
                          independent of individual need.

                          Establishment of data base to access
                          employer information and make a match
                          between consumer interests and skills and
                          employer needs.