Career counseling with clients who have a severe mental illness.
People who have a severe mental illness continue to be stigmatized and neglected because of numerous myths about this population. For example, it is widely believed that people with a mental illness are a danger to society and that they are incapable of maintaining a job. These myths persist in spite of evidence suggesting that people who have a mental illness are no more likely than individuals in the general public to commit violent crimes and that people with mental illnesses can be productive members of society, especially when they receive supportive services (Tenety & Kiselica, 2000).
The stigma of mental illness is only one of many barriers encountered by people who have been diagnosed with a serious psychiatric condition. The purpose of this article is to discuss these barriers and to describe a developmental approach to career counseling that is designed to help people who have been diagnosed with a chronic mental illness make a successful transition back into the community. We begin this article with an overview of barriers that reduce the chances of people with serious mental illness from obtaining gainful employment and independent and semi-independent functioning. We then suggest practical strategies that counselors can use to enhance the career development of this population, including recommendations regarding career-oriented intake interviews, assessments, and counseling.
Barriers Impeding the Career Development of Clients Who Have a Severe Mental Illness
People who have a serious mental illness represent the second largest category of individuals with a disability served by state vocational rehabilitation systems, yet vocational rehabilitation programs have demonstrated limited success with this population (Garske & Stewart, 1999). Although most psychiatric personnel claim that fostering the career development of this population is an important therapeutic goal, the unemployment rate for people with a major psychiatric illness has been estimated to be as high as 85% (Garske & Stewart, 1999).
The dismal record in the United States of addressing the career needs of clients who have received a diagnosis of a serious psychiatric condition is tied to a number of barriers that impede the career development of this population. For example, Bond and McDonel (1991) noted that negative attitudes about individuals who have been diagnosed with a mental illness pervade all levels of society. Consequently, many professionals, consumers, employers, and even relatives of these individuals view them as inappropriate candidates for employment (Herr & Cramer, 1996). When clients do receive career assistance, pertinent services tend to be focused on assessment and prevocational skills rather than on competitive employment. To make matters worse, the policies of many social insurance programs (e.g., Supplemental Security Income [SSI], Social Security Disability Insurance [SSDI], Medicaid, Medicare) and other federal programs fail to cover the career needs of persons with serious psychiatric illnesses adequately, or they create confusing circumstances that discourage many people in this population from seeking work. For instance, criteria differ for persons receiving SSDI or SSI and often involve calculating and maintaining accurate records of earnings and knowledge of a multitude of inclusionary/exclusionary criteria to determine the amount of an individual's benefits. Some of the criteria that are considered include substantial gainful activity amount ($780 per month), impairment-related work expenses, continued payments under a vocational rehabilitation program, trial work period, and continued Medicare/Medicaid benefits. In addition, a new position called the employment support representative (ESR) was recently established by the Social Security Administration to help beneficiaries make transitions to work/careers, adding another layer to this already overwhelming system (Social Security Administration Office of Employment Support Programs, 2002). The disinclination to risk losing assured benefits, which individuals who have a mental illness regard as essential to their sustenance, is understandable (Rutman, 1994).
In a related discussion of pertinent federal programs, which appeared in a report for the National Association for the Mentally Ill, Noble, Honeberg, Hall, and Flynn (1997) identified, in current federal and state vocational rehabilitation programs, numerous disincentives to employment for individuals who have a mental illness. For example, vocational rehabilitation services provided under the Smith-Fess Act of 1920 are time limited and are predicated on the idea that once people obtain employment, they no longer require services and supports from the vocational system. Vocational rehabilitation agencies currently perpetuate a system that rewards counselors for putting their greatest efforts and resources into helping individuals who are easiest to place into employment and most likely to retain employment. Noble et al. (1997) charged that the majority of state vocational rehabilitation agencies have not done a good job of developing and implementing ideas that would establish true incentives for serving individuals, such as people with a severe mental illness, who have more complicated, long-term needs. State vocational rehabilitation agencies still earmark a large proportion of their resources for disability and eligibility determination and administrative functions; the resources allocated for clients with a mental illness are often spent on evaluation methodologies that are inappropriate for this population (Noble et al., 1997). Typically, traditional vocational rehabilitation services require a person with a mental illness to look for a job without the benefit of receiving adequate support from career counselors (Bond & Meyer, 1999). Finally, these agencies stubbornly adhere to counselor-generalist models despite clear evidence that specialization is necessary to adequately serve individuals who have mental illnesses (Noble et al., 1997).
In summary, it appears that state vocational rehabilitation agencies, mental health agencies, and other systems do not adequately address the career development needs of people with severe mental illness. This state of affairs is disconcerting when one considers that establishing a career can be therapeutic and can lead to independent living for the individual who has a mental illness, while simultaneously reducing taxpayer expenses (Loughead, 1989). Effective developmental career counseling with this population is long overdue and can yield many positive benefits for clients with a mental illness and for society.
Developmental Career Considerations
Anthony, Cohen, and Danley (1988) described persons with mental illnesses as being vocationally immature because their life experiences and roles have been restricted; such experiences are important in the development of a vocational identity. Consequently, these individuals often tend to have unrealistic goals or inappropriate vocational behavior. In addition, their knowledge of themselves--including their skills, interests, and work values--is sometimes minimal. Also, their ability to test the reality of self-knowledge against the demands of the working world, a critical career development skill, can be sparse (Anthony et al., 1988). It is not surprising that clients with a psychiatric illness tend to experience lower occupational status and repeated failures in the world of work after hospitalization for a psychiatric illness (Huffine & Clausen, 1979). These kinds of discouraging career experiences can have a detrimental impact on the individual's self-concept.
In all of the systems in which they are treated, clients who have a mental illness present multifaceted problems to counselors, so it is imperative not to separate a client's personal and career issues, but to see how these concerns interface and affect the client's career (Burlew, 1997). As Niles and Pate (1989) noted, a symbiotic relationship exists between work and mental health. Individuals' jobs partially define their identities, and the fact that a person works is both a source of self-worth and evidence that he or she is a contributing member of society. Work/career gives structure to an individual's days, gives him or her something to do, and provides money so that the person can pay his or her way (Kaley-Isley, 1997). The interaction of life roles establishes a link between work satisfaction and life satisfaction.
Because the varied life roles of an individual overlap, each of these roles must be considered simultaneously as part of a holistic counseling process. Clients who have a serious mental illness have been reported to be more likely to be unemployed, to have less income, to experience a diminished sense of self, and to have fewer social supports (Garske & Stewart, 1999); therefore, they tended to have limited experience and success in the various life roles. Therefore, when compared with other clients, they require additional assistance in understanding life roles and making decisions about the kind of lifestyle, friendships, and leisure activities they would like to pursue.
In the remainder of this article, we use a developmental approach to career counseling to explain how counselors can address the many needs of clients who have a serious psychiatric illness. To illustrate this approach, we have drawn clinical material from our work in several different psychiatric hospitals in which we have counseled a variety of clients whose illnesses have represented every major category of mental illness. In order to protect the anonymity of these clients, the example of "Don" presented in this article is a composite of many clients, rather than a particular individual, whom we have served.
Developmental Career Counseling With Clients Who Have a Severe Mental Illness: The Case of Don
Don is a 33-year-old man who has been hospitalized numerous times to receive treatment for schizophrenia. During his most recent hospitalization, Don was committed to an inpatient unit after he was found "not guilty by reason of insanity" of criminal charges related to violent acts he had committed while he was ill.
Most of the clients with a serious illness who are admitted to psychiatric facilities have generally had several admissions and have participated in numerous assessments and interviews; this information is documented in the client's chart. Thus, the intake process includes a comprehensive review of the client's chart before the counselor meets with the client. This review allows the counselor to understand the client's history and to gather clues about his or her career issues. With this information in hand, the counselor conducts a career counseling intake interview.
The purpose of the career counseling intake interview is to identify social networks, support systems, the client's work history, and his or her unique beliefs about work. A preliminary assessment is completed of the client's motivation, emotional problems, and the impact of medication on his or her cognitive and physical functioning. If the client identifies any dysfunctional beliefs regarding his or her abilities or the work environment, cognitive restructuring of these beliefs is integrated into a life-span, life-space approach (Super, 1990) during the assessment, diagnosis, and counseling stages.
Our chart review and intake assessment with Don revealed that he had a very sporadic work history that was caused by periods of paranoid thinking, which caused him to isolate himself from others. He had no reliable social support network, and his job experiences had been limited to minimum wage positions and a brief period of selling illegal drugs. His paranoid beliefs caused him to behave as if he were suspicious of others. He was being treated with psychotropic medication to manage these symptoms, which was an important consideration as we began the assessment phase.
Super (1983) delineated the commonalties and distinctions between the classical "matching" model of career counseling and the developmental approach. We preferred the developmental model of career assessment to the matching model of career assessment because the latter does not address some factors, such as the client's career maturity and readiness for career decision making (Osborne, Brown, Niles, & Miner, 1997), which are crucial constructs to consider when working with people with a serious mental illness. For example, many of our clients have so few successful experiences that their career maturity may be low. Also, some chronically mentally ill clients have symptoms (e.g., auditory hallucinations, depressive ruminations) that can interfere with their decision-making abilities. Therefore, assessing these constructs helps us to better understand our clients' readiness to engage in career-related therapeutic activities.
To measure these constructs, we recommend that counselors use the assessment procedures of the C-DAC (career development, assessment, and counseling) approach, which was introduced by Super (1983, 1990) and refined by Osborne et al. (1997). This approach, which is designed to facilitate the career development of people across the life span, consists of administering at least five instruments that measure different dimensions of one's career development. These instruments include the following:
1. The Adult Career Concerns Inventory (ACCI; Super, Thompson, Lindeman, Jordaan, & Myers, 1988a), which assesses the client's stage of career development, planfulness, and his or her corresponding coping skills.
2. The Career Development Inventory (CDI; Super, Thompson, Lindeman, Jordaan, & Myers, 1988b), which measures the client's readiness for career decision making.
3. The Strong Interest Inventory (SII; Strong, Campbell, & Hansen, 1985), which measures the client's interests based on attitudes and knowledge related to stages of career development.
4. The Values Scale (VS; Nevill & Super, 1989), which assesses whether the client's interests and values match various educational and occupational options.
5. The Salience Inventory (SI; Nevill & Super, 1986), which attempts to help the client understand his or her degree of commitment to work and other four major life roles.
Administering these instruments with Don was tricky and illustrated many of the challenges associated with inpatient, psychiatric work. During the first assessment session, Don's symptoms interfered with his ability to complete assessment instruments, so we rescheduled it for 1 week later. The battery of assessment instruments required several weeks to complete as Don adjusted to the effects of his medication. The process of completing these assessments was interrupted by inevitable crises on the hospital unit by clients who were acting out and who
required restraint. Because Don was also scheduled for neuropsychological testing, we were careful not to overtax him with assessments during any given week. In addition, because current health care trends emphasize focusing treatment primarily on the immediate presenting problem, one of our professional colleagues did not appreciate the importance of career assessments as a treatment priority. Thus, we spent some time educating our colleague on the value of completing a thorough career assessment.
Although the realities of working in an inpatient facility made the assessment process with Don difficult, we also found that the unique features of inpatient work provided us with invaluable opportunities to gather information about his abilities and limitations. For example, by attending treatment team meetings, observing Don's progress and participation in hospital programs, and meeting with or telephoning the community on-site job supervisor while Don was still hospitalized, we obtained rich data to supplement the findings of the C-DAC assessment. The data obtained from these various sources of information indicated that Don had an unrealistic understanding of the world of work. However, we also noted that his personal strengths included good hygiene, the ability to follow his medication routine, active participation in therapies, and an interest in biology and chemistry and related fields. We also learned that a former employer was willing to help Don find a position after he was discharged from the hospital.
We obtained other important information about Don through our assessments of his behavioral and personality characteristics and their relationship to work environments. In a pertinent discussion of this issue, Kjos (1997) pointed out that the personality traits of persons with mental illness could be an asset in some jobs and a liability in others. For example, part of the key to helping a paranoid individual make a good adjustment to the world of work is to find a work environment in which vigilance and confidentiality are important and avoiding environments in which the supervisor is critical and controlling. Kjos argued that effective career counseling with people coping with a mental illness includes relating the positive and negative characteristics of the client's personality to career choice. We concur with Kjos and found that Don might fare well in a laboratory setting where he could work independently on projects that required him to complete repetitive tasks.
Counseling Goals and Process
In this section, we identity some standard goals and counseling processes that are used with clients who have a serious psychiatric illness. We then explain how this information was used with Don.
Counseling goals. The counselor uses findings that were obtained during the assessment phase to help the client develop an accurate picture of his or her self and life roles and to implement that self-concept into the world of work in a realistic manner (Zunker, 2002). Related to these tasks is the formulation of the following goals, which we have tailored toward the needs of individuals who have a serious mental illness:
1. Identify interests, values, and abilities.
2. Identify personal and community resources to facilitate career development.
3. Identify learning/training opportunities to support career choice.
4. Remediate any cognitive distortions related to self-concept, abilities to work, and beliefs about career choice.
5. Investigate a possible vocation while considering whether there is a need for accommodation related to managing the client's psychiatric symptoms.
6. Make a job match and begin employment while the client is still hospitalized.
7. Provide on-the-job training or job coaching.
Counseling process. The counselor must bear in mind that placing a person with a severe mental illness in a job does not signify the end of the career counseling process. Typically, the counselor will have to assist the client to continue to explore careers even after the client has been placed in a work setting. Keeping the client engaged in the process of reconsidering his or her skills and the world of work will help the client avoid premature career foreclosure.
Nevertheless, a crucial intervention associated with preventing a sudden relapse is to identify and secure a job placement, even with clients who have demonstrated a positive adjustment during their hospitalization (Bellus, Kost, & Vergo, 2000). Research evidence has indicated that an individual's vocational performance cannot be predicted by simply knowing how the person performs in other settings (Anthony, 1994). Other data have suggested that there is little relationship between hospital-based measures of adjustment and community-based measures of adjustment (Forsythe & Fairweather, 1961). Therefore, identifying a job for the client while he or she is still hospitalized can be critical for ensuring the client's successful discharge and return to the community.
Associated with this process is the challenge of countering the many stereotypes that prospective employers have about people who have a mental illness. Zunker (2002) urged counselors to emphasize, during their talks with prospective employers, that each individual should be considered on his or her own merits, not on preconceived notions about people with disabilities. Zunker also reminded counselors that the Americans With Disabilities Act of 1990 (ADA; West, 1993) requires employers to provide reasonable accommodations to individuals with disabilities. At the same time, the ADA does not require employers to furnish people with a disability with accommodations that impose an undue hardship on the employer. In light of these features of the ADA, counselors should be careful to attempt to place clients struggling with a psychiatric illness in settings where they are likely to be successful without posing exceptional hardships on the employer.
What then are some reasonable accommodations counselors should ask employers to make? Herr and Cramer (1996) recommended that counselors assist managerial and supervisory personnel and coworkers of the client to understand the symptoms of the client and to offer the client various forms of support, such as clarifying for the client his or her role at work and reducing interpersonal conflicts in the work environment that might stress the client. It can also be beneficial to explain to all of the parties involved any medications the client is taking and their potential effects on the client's behavior and appearance. Other simple accommodations recommended by Mancuso (1990) included the following: changing interpersonal communication (e.g., providing directions in writing instead of verbally), modifying the physical environment (e.g., reducing noise and interruptions), and scheduling modifications (e.g., shift hours to accommodate therapy).
There are several important services the counselor can provide once the client is placed in a community-based job. The counselor can help the client remain aware of his or her strengths and limitations and how they might affect the client's job performance (Ellison & Russinova, 1999). The counselor also can help the client to manage symptoms, medication issues, and interpersonal conflicts that might arise at work or between the client and his or her family (Torrey et al., 1998). In addition, the counselor can serve as a liaison between the client and external organizations, such as the state division of vocational rehabilitation and the Social Security Administration, to ensure that the client's benefits and services are maintained until the client no longer needs them.
A key service that the counselor can provide is a support group for all clients who are hospitalized and working simultaneously. The support group could focus on developing assertiveness, problem solving, and time management skills; addressing interpersonal relationship issues; and using community resources and problem solving. In their description of such a support group, Blankertz and Robinson (1996) found that the encouragement provided by group members helped the participants develop the skills required for successful entry or reentry into the employment sector. In addition, the participants became more adept at using the vocational rehabilitation system.
Applications with Don. We applied these many considerations in our work with Don. After completing the assessments, we discussed the findings with Don, which became the basis for his decisions to participate in a General Education Development (GED) program and to work 1 day per week in a photo-processing lab in the community. Gradually, he increased his work schedule to 4 1/2 days a week while still hospitalized. Through his participation in a weekly, career-counseling support group, Don addressed a number of work-related issues and continued to learn about the world of work. Through role playing, group feedback, and modeling by fellow clients, Don learned and practiced skills that were necessary for his job success. The role of medication and its impact on his ability to remain discharged and employed were discussed. His caseworker educated Don's work supervisor about Don's medication and negotiated accommodations at the lab, which permitted Don to leave work to attend his support group meetings at the hospital.
Because Don had a history of violent behavior, he was required to take a short hiatus from his job in order to attend a day program after his discharge from the hospital. Once Don completed the day program, he returned to his job, where he has been steadily employed for the past 6 years. Recently, Don received a promotion at work. He presently has his own apartment and a girlfriend. To this day, he sporadically calls his counselor to provide updates on his successes and progress. Through his engagement in developmentally appropriate, successful tasks, his self-concept has diversified, and he is now participating in several life roles simultaneously.
We have attempted to demonstrate that people with a serious mental illness encounter a number of barriers that can thwart their career development. We hope that this article will inspire counselors to serve as advocates for this population and to use a developmental approach to career counseling that can help people with severe psychiatric illnesses to enjoy fulfilling careers. We recognize, however, that the counseling profession must do more to prepare students for the complex task of counseling people with a chronic mental illness. We are concerned that many of the career counseling books we examined for our research on this project made little or no mention of counseling clients with serious psychiatric conditions. To address this gap in the literature, we urge career counseling scholars to say more about the needs of, and counseling processes with, people who have a serious mental illness. Furthermore, as Niles and Pate (1989) recommended, counselor educators should encourage students to enroll in courses that will equip them with skills in the diagnosis, treatment, and prevention of mental and emotional disorders and that these skills should be integrated into their work as career counselors.
Another challenge counselors must confront pertains to the administration of career assessment instruments with people who are in the acute stages of a psychiatric illness. As we have tried to demonstrate in our case example of Don, counselors must be wary of the impact of several variables (e.g., disruptive behavior on an inpatient unit, the effects of symptoms and medication on the client's ability to perform on tests) on the client's test performance and must adjust their administration practices in a way that assures the reliability of test results.
Regarding the role of the counselor as an advocate for social justice, we remind counselors that much of the progress that has been made in removing barriers to persons with severe mental illness has been won through the consciousness-raising and lobbying efforts of pioneering advocates, such as Clifford Beers (1907/1981) and the many generations of his followers, including the members of the National Alliance for the Mentally Ill. In addition, it should be remembered that Frank Parsons (1909), considered by many to be the father of career counseling, devoted much of his energy advocating for the needs of immigrant families and youth. (For related discussions of this tradition, see Kiselica & Robinson, 2000, and Tenety & Kiselica, 2000.) Continuing in the tradition of Beers and Parsons, we enjoin counselors to fight for changes in public policy that will enhance the career development of individuals with a mental illness. For example, as Roessler (1987) proposed long ago, our country needs new policies that provide employers with special tax incentives to hire populations of disabled people (e.g., persons with mental illnesses). Our government also should examine the current Social Security wage levels that serve as cutoffs for employed people receiving medical coverage. By working to effect such systemic changes and by providing comprehensive, developmental services to persons with chronic mental illness, we will help many persons with mental illness to move from being a stymied client toward becoming a vital and recovering worker who manages his or her impairment (Torrey & Bebout, 1998).
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Robyn A. Caporoso, College of New Jersey and Trenton Psychiatric Hospital; Mark S. Kiselica, Department of Counselor Education, The College of New Jersey. Correspondence concerning this article should be addressed to Robyn A. Caporoso, Trenton Psychiatric Hospital, Rehabilitation Services Department, PO Box 7500, W. Trenton, NJ 086283 (e-mail: Robyn. Caporoso@dhs.state.nj.us).
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|Title Annotation:||Effective Techniques|
|Author:||Kiselica, Mark S.|
|Publication:||Career Development Quarterly|
|Date:||Mar 1, 2004|
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