Working with people who have severe psychiatric disabilities.

Gregory G. Garske, Ph.D.,CRC 

Rehabilitation counselors are working with increasing numbers of people with severe and lifelong psychiatric disabilities. Generally, this population includes people experiencing major psychoses, such as chronic schizophrenia, chronic recurrent affective disorders, and severe personality disorders. To better understand and serve this population, it would seem that rehabilitation counselors need appropriate graduate and in-service training.

An estimated 1.7 to 2.4 million people in the United States have severe and lifelong psychiatric disability (Goldman, Gattozzi & Taube, 1981). 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 (Olson, 1980). There are more than twice as many people with schizophrenic and manic depressive psychoses in public shelters and on the streets than are in mental hospitals (Torrey, Erdman, Wolfe & Flynn, 1990).

The passage of the Community Mental Health Centers Act of 1963 mandated a major change in the care of people with severe psychiatric disabilities. 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 1960's and 1970's resulted in the discharge of many thousands of people with severe psychiatric difficulties into communities that were not prepared or 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 long periods of time, they too struggle with life in the community due to their functional limitations and a community mental health service system that often fails to provide adequate services.

Similar to outpatient mental health workers, the state vocational rehabilitation (VR) counselors are overwhelmed because of the increased referrals of clients with a primary disability of a mental or emotional nature. When considering national data from all VR agencies, the second largest broad disability category is mental illness, at 17.8 percent of all cases. This percentage is only surpassed by orthopedic cases, which consist of 21.7 percent of all cases (Rehab Brief, 1989, vol. 11, p. 1).

According to the Rehabilitation Services Administration (1988), fiscal year 1985 data indicated that of the 218,039 people successfully rehabilitated nationally through the state-federal VR system, some 10,778, or 4.9 percent, fell into the category of people with severe psychiatric disabilities (RSA Code 500, psychosis). When the entire series is considered, the number of people in VR agency caseloads across the country amounts to nearly 40 percent. Cato and Rice (1988) indicated that the "rehabilitation rate" between the number of 26 closures (successfully rehabilitated status) and the total number of active cases closed for people in the 500 category was 47 percent. This figure is quite low when compared with the 66 percent rehabilitation rate for all other primary disability categories and the 56 percent rate for the entire 500 series, which also includes alcoholism, drug abuse, mental retardation, and autism.

For people with physical disabilities the methodology of the state rehabilitation agency is usually effective. The counselor collects information related to the client's disability and assesses his or her vocational goal with the cooperation of the client, the services are smoothly coordinated, and the client often enters the labor force with a renewed sense of self-worth. This mode of operation is, however, either too structured or too sketchy to achieve rehabilitation with many clients who have severe psychiatric disabilities (Rogan, 1980).

Characteristics of people experiencing severe psychiatric disabilities include: 1) high vulnerability to stress; 2) deficiencies in coping skills; 3) extreme dependency; 4) difficulty working in the competitive job market, with some exceptions; and 5) difficulty with interpersonal relationships (Test & Stein, 1978). It may be that the VR agency is attempting to obtain 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 can create havoc within the structure of the agency and increase daily pressures on the rehabilitation counselor.

While the involvement of rehabilitation counselors in psychiatric rehabilitation may prove to be stressful, their involvement seems both appropriate and necessary. Philosophically the new psychiatric rehabilitation model coincides with the practice of rehabilitation counseling. The clinical nature of psychiatric rehabilitation, just like its counterpart in physical rehabilitation, is comprised of two intervention strategies-client skill development and strengthening of environmental supports (Rehab Brief, 1989, Vol. 12). 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 sense of mastery over their internal drives, their symptoms, and the demands of their environment.

According to Test and Stein (1976), community treatment of the person who is severely psychiatrically impaired should focus primarily on the teaching of those coping skills necessary to live as autonomously as possible in his/her community. These coping skills consist of activity of daily living skills, vocational skills, leisure time skills, and social or interpersonal skills. It is the presence or absence of skills, not symptoms, that is the determining factor in rehabilitation outcome. The preferred method of increasing a patient's skills or abilities is a skills-training approach. In such an approach, the rehabilitation diagnosis, as opposed to the traditional psychiatric diagnosis, attempts to identify those specific patient skill deficits that are preventing the patient from functioning more effectively in his or her living, learning, and/or working community (Anthony, 1977).

From a rehabilitation counselor's point of view, it is understandable that a major focus of rehabilitation could 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 effectively focus on vocational issues. Until recently, rehabilitation counselors have done little in assisting clients to develop the prevocational skills requisite to satisfactory vocational adjustment. Typically, this task has been left to traditional mental health professionals or, in many cases, simply left to chance (Quinn and Richman, 1980).

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 (CSP's). It is encouraging that many rehabilitation counselors are becoming proactive and learning how to work with people with severe and life-long psychiatric disabilities.

Vocational rehabilitation and mental health (MH) agencies are beginning to make progress as well. It was generally accepted in the late 1980's that the needs of people 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 onethird of all VR offices are reported to have formal interagency collaboration agreements with one or more local MH agencies (Katz, 1991).

Based on the current trend, it appears that qualified rehabilitation counselors will continue to be in demand to work with people 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 Weinberger and Greenwald (1982), only 7 of 59 surveyed graduate programs offered a specialty preparation in psychiatric rehabilitation. Based on a study by Anthony, Cohen and Farkas (1990), these results regarding rehabilitation training programs are not unusual. They indicated that the literature attests to the historical omission of psychiatric disabilities in the curricula of most professional training programs.

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 outcome. The mastery of various conceptual components (knowledge), performance components (skills), and affective components (attitudes and values) would all seem to be critical to the professional's efforts to increase client functioning and to reduce the client's dependence on the mental health system (p. 129).

Dr. Garske is an Assistant Professor and Coordinator of Fieldwork in the Division of Rehabilitation Education Services at the University of Illinois at Urbana-Champaign.

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