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The use of cognitive functional assessment in a psychiatric vocational rehabilitation program.

People with psychiatric disabilities have more difficulty attaining and maintaining competitive employment than any other disability group (Dunn, 1981; Mars, 1990; Rehabilitation Services Administration, 1992). Our success, however, in the vocational rehabilitation of people with severe and persistent mental illness until recently has been disappointing. In their review of research on the effectiveness of psychiatric vocational rehabilitation, Bond and Boyer (1988) concluded that no existing psychosocial or vocational rehabilitation approach unequivocally demonstratedd effectiveness in helping psychiatrically disabled persons obtain and retain competitive employment.

By the early 1980's, a consensus had developed in the psychiatric rehabilitation community that the traditional spectrum of vocational rehabilitation services had not been effective (National Institute on Handicapped Research, 1979; Skelley, 1980). Taking advantage of 1986 federal legislation which substantially reduced work disincentives for disabled people, specifically targeted people with psychiatric disabilities for transitional and supported employment, and made other improvements in psychiatric vocational rehabilitation services, practitioners began to adapt the place-train model of supported employment which had already demonstrated success with developmentally disabled people (Yankowitz, 1990). During the past decade, transitional and supported employment with job coaching and related services have proliferated, attaining widespread acceptance by psychiatric rehabilitation consumers, practitioners, and administrators and replacing the assess-train-place model as the preferred sequence of service delivery

In addition to the sequence of psychiatric vocational rehabilitation service delivery, the nature of the services has also changed. Traditional forms of assessment such as intelligence, personality, or neuropsychological assessment are oriented primarily towards symptomatology and diagnosis, and were useful in the assess-train-place model of vocational rehabilitation. The contemporary place-train-support model, however, requires more functionally oriented assessments which focus on the individual's profile of functional competencies and deficits, particularly as these relate to work and the work environment. While the traditional diagnostic vocational evaluation and simulated work assessment used in the assess-train-place model are function rather than symptom oriented, they are conducted in evaluation laboratories or sheltered workshops, and their outputs are therefore not based on real work environments. This reduces both their predictive validity and usefulness in guiding service delivery. Functional assessments conducted in real work settings, however, focus on disabled persons' strengths and limitations relevant to actual or likely work environments and therefore provide information more useful in the rehabilitation process than traditional methods of assessment.

Cognitive Deficits in Severe and Persistent Mental Illnesses

Schizophrenia is among the most prevalent and disabling of the severe and persistent mental illnesses. Of the 1 million people in the United States with the disorder who require treatment, the large majority are unable to work (Karno & Norquist, 1989; Talbott, 1987). The rehabilitation of schizophrenia can thus serve as a generic model which illustrates the relation between cognitive deficits and effective psychiatric vocational rehabilitation.

Cognitive symptoms (delusions, thought disorders, and related speech disturbances) constitute a major portion of the clinical signs and symptoms of both the acute and chronic phases of schizophrenia (American Psychiatric Association, 1987) and historically have been recognized as a hallmark of the disorder (Bleuler, 1911; Kraepelin, 1919/1971). In addition to cognitive symptoms, persons with schizophrenia have characteristic and pervasive cognitive deficits. These include significant impairment of attention and concentration, learning and memory, and executive skills, such as reasoning, organization, problem solving, and initiation. Persons with other severe and persistent mental illnesses (e.g., affective, anxiety, personality disorders) are similarly disabled by cognitive symptoms and deficits, although usually to a lesser extent than in schizophrenia. These cognitive deficits in turn exacerbate the occupational and social dysfunctions of people with schizophrenia (Jaeger & Douglas, 1992; Stuve, Erickson, & Spaulding, 1991). To be maximally effective, comprehensive psychiatric rehabilitation must therefore include cognitive rehabilitation (Erickson, 1988).

Although the pioneering work in cognitive rehabilitation was done primarily by neuropsychologists working with brain injured populations (Ben-Yishay, Gerstman, Diller, & Haas, 1970; Diller, Buxbaum, & Chiotelis, 1972; Luria, 1966, 1973; Trexler, 1981), there were some early efforts to develop cognitive rehabilitation techniques for populations with psychopathological disorders (Michenbaum & Cameron, 1973; Wagner, 1968). Despite the success of these early efforts, 15 years elapsed until systematic activity resumed to develop cognitive rehabilitation for people with severe and persistent mental illnesses (Erickson & Binder, 1986; Erickson & Burton, 1986; Spaulding, Storms, Goodrich, & Sullivan, 1986; Yozawitz, 1986). Spring and Ravdin (1992) suggested that the failure to apply cognitive rehabilitation to psychopathological disorders was due to the beliefs that psychotropic medications alone were adequate treatment, that cognitive deficits were epiphenomena(1) of no functional importance, and that they were not remediable. During the past 10 years, however, increasing numbers of workers have joined the effort to apply cognitive rehabilitation to psychiatric populations, and recently there has been a spate of interest in integrating this modality into the psychiatric rehabilitation process (Bellack, Mueser, Morrison, Tierney, & Podell, 1990; Green, 1993; Stuve et al., 1991). The recent increasing interest in cognitive rehabilitation by the psychiatric rehabilitation community may only have become possible now that the efficacy of other modalities (psychopharmacology, family treatments, instrumental and social skill training) has been demonstrated, and they have been integrated into comprehensive treatment. Practitioners now recognize that cognitive deficits remain even after people with severe and persistent mental illness have received adequate biopsychosocial treatments, and that these deficits impose a ceiling on the rehabilitation outcome. Thus, cognitive rehabilitation has become the latest frontier in psychiatric rehabilitation.

Cognitive Functional Assessment in Psychiatric Vocational Rehabilitation

The goal of the Psychiatric Vocational Rehabilitation Program at the Mount Sinai Medical Center, New York City, is integrated competitive employment. The program consists of three sequential phases of vocational services integrated with biopsychosocial services typical in psychiatric rehabilitation. The initial assessment phase lasts 1-2 months and includes traditional diagnostic vocational assessment, situational assessment in a supervised workshop setting, and career exploration. The second phase of the program is transitional employment (TE), which includes job coaching, as necessary, and comprehensive job placement services. Participants remain in the TE phase (TEP) as long as necessary to attain readiness for competitive employment, provided they continue to improve their psychosocial or vocational performance. Assisted competitive employment is the third phase, which begins after job placement. Participants continue to receive job coaching if they choose. Some continue to attend a supportive psychotherapy group one evening a week; some attend a regular evening social club; and all continue to receive psychiatric aftercare services through the Adult Psychiatry Clinic.

The Psychiatric Vocational Rehabilitation Program uses an open screening policy, preferring to admit questionable applicants, provided that from a psychiatric viewpoint they pose no physical danger to themselves or others. By December 1992, after 5 1/2 years of operation, the program had provided services to 181 people with severe and persistent mental illness. Of these, 42 were still enrolled in the program and 141 had terminated. Of the 141 people who had terminated the program, 51 (36 percent) had attained competitive employment with a 6-month job retention rate of 85 percent; four (3 percent) had entered a formal training program or college; and 86 (61 percent) had dropped out. Thirty-three (38 percent) of the dropouts had terminated the program for family or social problems, or

Dr. Yankowitz is Director, Department of Psychiatric Rehabilitation Mount Sinai Hospital, and Clinical Assistant Professor of Psychiatry, Mount Sinai School of Medicine, New York City. Ms. Musante is Director, Vocational Rehabilitation Program, Department of Psychiatric Rehabilitation, Mount Sinai Hospital, New York City.

because they had decided they didn't want to work or didn't like the program. The remaining 53 (62 percent) dropouts had terminated for reasons directly related to their illness (e.g., symptom exacerbation, dysfunctionality). Many of these were referred to psychiatric day treatment or other vocational rehabilitation settings.

Of the 51 individuals who attained competitive employment and the 53 who dropped out for reasons related to illness (total N=104), 41 had schizophrenia or organic brain syndrome with associated severe cognitive deficits and 63 had other psychiatric disorders--schizoaffective {81}, depressive {81}, bipolar {14}, personality {6}, anxiety {5}, and other {2}--with generally less severe cognitive deficits. Diagnoses were not, however, distributed as expected by chance between individuals who attained competitive employment and those who dropped out. For example, while 26 individuals with schizophrenia or organic brain syndrome had dropped out, the chance expectation would have been 21. While 36 individuals with diagnoses other than schizophrenia or organic brain syndrome attained competitive employment, the chance expectation would have been 26 (See Table 1). This disproportionality was statistically significant (chi square=4.35, p=.037 with one degree of freedom). Thus, individuals with severe cognitive deficits due to schizophrenia or organic brain syndrome were under represented in the group attaining competitive employment and over represented in the group of dropouts.

The Cognitive Functional Assessment Instrument

Recognizing what appeared to be an inverse relation between participants' degree of cognitive impairment and their attainment of competitive employment, we explored further the extent to which cognitive deficits created obstacles to employment. Staff discussions confirmed that, in many cases, participants who had trouble or failed to attain competitive employment seemed to have cognitive deficits. Furthermore, these participants' greatest work performance difficulties could be conceptualized in terms of cognitive dysfunctions. It seemed likely that cognitive deficits constituted a major obstacle for our participants which previously we had been ignoring. We therefore decided to seek additional support to develop a cognitive rehabilitation component for the program. In early 1993 we applied to the Rehabilitation Services Administration for a special project and demonstration grant to provide vocational rehabilitation services to severely disabled individuals. Our grant request was funded, and in late 1993 we hired additional staff to start the development of a cognitive assessment instrument which will be integrated into our vocational rehabilitation program. We also plan to shift the focus of treatment planning and intervention to include cognitive deficits and to develop additional cognitive rehabilitation services.

Based on the cognitive rehabilitation literature and extensive discussions with program staff who work directly with consumers and their worksite supervisors, we decided to target the six cognitive functions which seemed most frequently related to our consumers' work dysfunctions. These are: shortterm attention, sustained attention (concentration), memory, flexibility, initiative, and organization. The cognitive functional assessment protocol we have developed consists of 15 items of identical format, each stating either positively or negatively a common work behavior tapping a cognitive function. Two examples appear below:

* Item 2: The TEP employee sustains attention when doing a simple task, requiring no redirection back to the task.

* Item 14: The TEP employee has difficulty starting tasks without prompting. The answer choices are identical for all items. The respondent chooses one of four responses, each corresponding to a level of frequency with which the

behavior described in the item is typically exhibited. The answer choices are:

* Always (more than 85 percent)

* Often (51-85 percent)

* Occasionally (15-50 percent)

* Never (less than 15 percent)

There are two additional items to determine the extent to which the consumer has awareness of his or her strengths and weaknesses. The format of these items is similar to the other 15 which measure cognitive deficits.

The instrument was designed to be simple, clear, and easy to administer. It will be completed by program staff who serve as TE worksite liaisons in conjunction with the worksite supervisor who is actually familiar with the program participant's work performance. The TE liaison will read each question to the worksite supervisor, who in turn will choose the response that best describes the TE worker's behavior. A test administration handbook has been developed which contains illustrative examples for the TE liaison to read if the worksite supervisor is unclear about a question's meaning. Five examples have been developed for each item, one for each of five common TE work areas in the Medical Center. The examples corresponding to items 2 and 14 are:

Item 2: When the TEP employee is directed to:

* insert copies of the Hospital Newsletter in pre-addressed envelopes,

* file a set of documents,

* log the UPS numbers on a large number of items before delivery,

* enter a long series of numbers in a database, or

* sort silverware

the TEP employee finishes the job without losing track of what he or she is doing.

Item 14: Although the TEP employee remembers, when asked, standing instructions like

* handing in timecards to the secretary at the end of the day,

* fetching and distributing departmental mail,

* logging in all the packages prior to delivery,

* booting up the computer in the morning, or

* washing hands and putting on gloves and hair net he or she requires prompting to start the task.

At the present time we are conducting a study of the cognitive functional assessment instrument's internal consistency, interrater, and testretest reliability Based on the results of this study, we will refine or replace items as necessary, adjust our administration procedures, and then begin actual clinical use of the protocol in our program.

We also have developed a consumer awareness version of the cognitive functional assessment for completion by the program participants. Discrepancies between the staff's and participants' views of the latter's cognitive deficits will be rediscussed by the participants and their rehabilitation counselors in an effort to improve participants' awareness and acceptance of their deficits. We believe that consumer awareness of the effects of their illness on their functional deficiencies is directly related to their ability to remediate their deficiencies. It is also consistent with our use of psychoeducation in rehabilitation with people with severe and persistent mental illness.

Using the Cognitive Functional Assessment Protocol Throughout the Psychiatric Vocational Rehabilitation Process

The new cognitive functional assessment will be added to the program's existing functional work assessment, which consists of 20 behavioral questions addressing attendance, punctuality, interpersonal relationships, and work behaviors, including attitudes, skills, and stamina.

The first administration is 1 month after a consumer starts the program, while he or she is still in the initial assessment phase. The combined assessment protocol is administered periodically by program staff as follows:

* The participant's rehabilitation counselor completes the protocol based on discussion with the workshop supervisor. After the participant completes the consumer version of the protocol, both the participant and his or her rehabilitation counselor meet for a "progress review" to discuss the results of the protocols as completed by both staff and participant. The discussion focuses on identifying principal strengths and weaknesses and incorporating recognition of these into a general plan for corrective action and skill enhancement in the work setting.

* The treatment plan is modified as necessary with the participant's involvement and approval, and appropriate staff are informed of the new plan.

The second combined cognitive functional and work assessment protocol is completed 6 weeks after the participant is placed on a TE worksite. This time, the procedure is as follows:

* The participant's rehabilitation counselor completes the protocol based on discussion with the TE worksite supervisor.

* The participant again completes the consumer version of the cognitive functional assessment.

* As before, the participant and his or her rehabilitation counselor then meet for a progress review, during which they revise the treatment plan to incorporate outputs from the assessment protocol.

* The counselor consults with the staff cognitive rehabilitation specialist to develop a service plan which includes the necessary compensatory strategies, environmental modifications, and employer awareness interventions specific to the TE worksite based on the assessment protocol outputs. The cognitive rehabilitation specialist initiates the implementation of this plan, and supervises the job coach to continue implementation of the plan by working intensively with the participant on the worksite.

The cycle of functional assessment, progress review, treatment plan revision, and cognitive rehabilitation service implementation is repeated every 3 months while the participant is on the TE worksite. Some of these services may continue as necessary after the participant attains competitive employment, provided he or she is wants them. They then become part of the follow-along support services provided during the assisted competitive employment phase of the program.

Further Enhancements of the Psychiatric Vocational Rehabilitation Program

We expect that as program participants and staff become more aware of the pervasiveness and influence of cognitive deficits on participants' behavior, the focus of program activities will increasingly shift to include more emphasis on cognitive deficits and activities and interventions intended to ameliorate them. Development and continuous use of the functional cognitive assessment protocol and its outputs constitute the first structured push in this direction. This will be followed by the delivery of individualized cognitive rehabilitation services at the worksite. In addition, we have begun to develop cognitive rehabilitation group activities to be delivered on a regularly scheduled basis on the program premises by the program psychologist and cognitive rehabilitation specialist. In addition to small group (four to eight participants) activities designed to remediate deficits in specific cognitive functions (attention, memory, flexibility), we plan to start a group to promote participant awareness of their cognitive deficits. We believe that this awareness is crucial to participants' ability to utilize the program to achieve their goals.

Summary

These are exciting times to be working in psychiatric vocational rehabilitation. The biopsychosocial innovations developed and refined during the past 30 years are now commonplace. The supported employment techniques more recently developed are also practiced widely, and their benefits to consumers are apparent. Cognitive rehabilitation is the latest innovation to be grafted into psychiatric rehabilitation programs. Although its potential is promising, it is not a panacea. There are years of hard work ahead before we can routinely and systematically use cognitive rehabilitation in assisting our consumers to reach their highest level of independent community functioning. We would all be well-advised to temper our expectations with healthy realism as we proceed with our work.

This work was supported in part by a grant (Award Number H235N30013) from the Rehabilitation Services Administration Office of Special Education and Rehabilitative Services, U.S. Department of Education.

Notes

1. Secondary phenomena overlapping and resulting from another.

Bibliography

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Dr. Yankowitz is Director, Department of Psychiatric Rehabilitation Mount Sinai Hospital, and Clinical Assistant Professor of Psychiatry, Mount Sinai School of Medicine, New York City. Ms. Musante is Director, Vocational Rehabilitation Program, Department of Psychiatric Rehabilitation, Mount Sinai Hospital, New York City.
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Author:Musante, Susan
Publication:American Rehabilitation
Date:Sep 22, 1994
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