Career Exploration, Development and Planning for Consumers w/ SMI – Part 2 Improving Employment Outcomes for Individuals with Mental Health Disabilities

Career Exploration, Development and Planning for

Consumers w/ SMI – Part 2Improving Employment Outcomes for

Individuals with Mental Health Disabilities Learning Community Series

Charles Bernacchio, Ed.D., CRCEileen J. Burker, Ph.D., CRC

University of North Carolina at Chapel Hill

Consultants: Bonnie Schell, Consumer Affairs Project Manager

Obie Johnson, BA/QMHPLaurie Coker, Director of NC CANSO

March 9, 2012

TACE Center: Region IV, a project of the Burton Blatt Institute.Funded by RSA Grant # H264A080021. © 2012

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Webinar Overview

• Skill training and development (job seeking and support) Preparing for interviews Job clubs Clubhouse model Drop-in centers Peer support Individual Placement Service- SE models

• Disclosure and confidentiality Issues: Are clients prepared to deal with these questions?

• Suggestions/recommendations for rehabilitation counselors


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Preparing for Interviews

• Individuals with mental illness face discrimination and stigma when applying for jobs.

• In a survey of 502 employers, the following concerns were noted in hiring someone with a mental illness: Absenteeism (29%) Impaired job performance (20%) Symptoms may be a threat to others (17%) Person might not be able to handle stress (14%) Strange or unpredictable behavior (11%) High level of monitoring needed (7%) Other employees would have negative attitudes toward the

person (2%) (Brohan, Henderson, Little & Thornicroft,2010)


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Preparing for Interviews: How can rehabilitation counselors help?

• Be aware of potential discriminatory employer attitudes and be ready with information and assistance to employers.

• Offer assistance to consumers within a caring, hopeful and supportive environment—hope and support are the cornerstones of effective job placement.

• Believe that people with mental illness are citizens and have the right to work.

• Rehabilitation counselors must be willing to consider advocacy as a key part of their job in order to help consumers with mental illness find jobs.

• Employment advocacy to fight against discrimination will involve marketing, education and job development (Marrone, Gandolfo, Gold & Hoff, 1998).


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Provide consumers with training in basic social skills and then advanced training in work-related social skills A pilot study revealed that a social skills training module

followed by professional support improved social competence and vocational outcomes in consumers with schizophrenia (Tsang, 2001).

A recent innovative program:

• Researchers worked with a company that develops simulated job interviews and created virtual reality software that provides a virtual reality experience of a job interview.

• The program was piloted with 10 individuals with a psychiatric disability referred by their vocational rehabilitation counselor.


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• Results revealed that: Participants had a strong positive response to the job

interview simulation experience They found it easy to use, thought it felt real as well as

helpful, and enjoyed it. They initially felt anxious, but said that their anxiety

decreased as they became more skilled. They liked that they received ongoing feedback as

they interviewed and the transcript they received (Bell & Weinstein, 2011).


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Job Finding Clubs

• The Job Finding Club began in the mid 1970s as a way to address psychiatric symptoms that interfere with employment.

• Manuals now exist that lead you through the 7 components: readiness for work developing job interests finding job leads contacting employers completing job applications completing a job interview and finalizing the job offer.


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Job Finding Clubs (cont.)

• Corrigan, Reedy, Thadani, and Ganet (1995) involved 44 adults with SMI in a 3-month Job Finding Club.

• They found that: 30% completed the 3-month program Individuals with lower QOL pre-intervention attended more

job club sessions, suggesting they were motivated to participate to improve their QOL.

Individuals who were withdrawn had poorer participation. Individuals with more disturbance in thinking were better

participants. The authors concluded that more active individuals, even

those who may be more psychotic, are more likely to participate appropriately in job club.

6 months after the club ended those who completed the program (didn’t drop out) were more likely to be employed.


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Clubhouse Models

• The Clubhouse Model began in 1948 at Fountain House in NYC.

• 2 vocational concepts: the work-ordered day and transitional employment (TE). Work-ordered day is when members work in units

doing chores side-by-side with staff to help the clubhouse function (cooking meals, answering the phone, cleaning).

TE are temporary, part-time jobs in the community within the members’ stress tolerance and stamina limits. These jobs are supposed to help members get used to working and improve self-confidence.


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Clubhouse Models Goal

• The GOAL of the Clubhouse Model = permanent competitive employment! (Bond, Drake, Becker, & Mueser, 1999).

• The Clubhouse Model is based on the belief that recovering from SMI has to include the person in a culturally sensitive community where people with SMI get the necessary supports to live productive and satisfying lives (McKay, 2005).


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Clubhouse Models Services

What services do clubhouses offer?• Vocational supports• Community-based employment

Transitional employment Supported employment Independent employment

• Education• Housing• Outreach• Advocacy• Assistance accessing health care• Treatment of substance abuse• Recreational activities


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Clubhouse Models: Cost?

An international survey of clubhouses in 12 countries found that:

• Average cost per person per day was $27.12

• Annual cost per person was $3,203(McKay, Yates, & Johnsen, 2007).


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Clubhouse Models: How effective are they for employment?

• Study of employment outcomes of individuals with SMI at 17 clubhouses between 1998 and 2001.

• 1,702 people with SMI worked in 2,714 jobs in either transitional, supported or independent employment.

• The researchers found: People who had been members of the clubhouse

longer had longer length of employment and higher earnings than people with shorter memberships.


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Clubhouse Models: How effective are they for wellness?

• 17 members of a clubhouse completed a 16-week exercise program.

• The researchers found: Members’ aerobic capacity and perceived mental

health improved Members perceived improvements in physical and

social functioning Members said they were satisfied with the program

and said the support they felt from the group helped them stick with the exercise (Pelletier, Ngyuen, Bradley, Johnsen, & McKay, 2005).


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Clubhouse Models: Recent Innovations

• The Thinking Skills for Work program is a cognitive remediation program.

• 23 adults with a history of trouble getting or keeping a job, who were participating in a supported employment program at a clubhouse, were recruited into the Thinking Skills for Work program.


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Clubhouse Models: Recent Innovations - Findings

Findings:• 91% completed 6 or more cognitive training sessions on

the computer.• Significant improvements were found on measures of

processing speed, verbal learning and memory, and executive functions.

• 60% obtained a competitive job during the 2-year follow-up

• 74% were involved in some type of work. • Participants worked significantly more competitive hours

in the 2 years after joining the Thinking Skills for Work program than they had worked before the program (McGurk, Schiano, Mueser, Wolfe, 2010).


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Consumer-Run Drop In Centers• Less structured than clubhouses; often used by males w/

SMI (fewer hospitalizations) and more at-risk for SUDs/less quality of life reported

• Provides social activities in community setting 40+ hrs/week, night and weekends (transitional)

• Funding, goods and services often donated; in rural settings, fewer activities/transportation ↓

• Depends on volunteers and partnering w/ other agencies, e.g., housing


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Consumer-Run Drop In Centers (cont.)• Greatest need in rural areas; low status and poor

neighborhoods; lack funding resources

• Key to providing PSR services to MH clients in rural areas; can facilitate linkages to specialty MH care that’s important for rural regions

• Linkages w/ other MH and social services that CRDIs provide is beneficial to consumers and providers alike.


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Peer Specialists (Salzer et al. 2010)

Trained peers serve in many roles/settings:

• Residential/partial, day, crisis, inpatient

• Case management/PSR/therapeutic rec.

• Independent peer support/drop-in

• Education and advocacy

• VR* and clubhouses*Employment services not typically internal to DVR


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Peer Specialists (Salzer et al. 2010)

• Pressure to develop national standards for CPS• Most time is spent in agency settings and giving support to

individual peers; not w/ families• Focus on offering mutual aid, foster illness management,

self-determination & personal responsibility; promote health & wellness, advocate w/ providers and combat stigma

• More effective supervision and continuing educ. where CPS have insight on other areas related to recovery- e.g., employment, citizenship, spirituality


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Work & People with SMI

• 4 to 5 million adults have severe and persistent mental illness

• Only 10 to 30% of these adults are employed• When compared to other individuals with disabilities,

those with SMI are less likely to achieve successful rehabilitation closure rates in the state VR system.

• Research also shows that persons with SMI want to work.


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Definition of SE

Competitive work in integrated settings or other employment in integrated setting leading towards competitive work; consistent with strengths, resources, priorities, concerns, abilities, capabilities, interests and informed choice of the individuals for people with the most significant disabilities who are not traditional served effectively with VR services and who are likely to need ongoing long-term supports to maintain employment.


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Supported Employment in PSRShifted to Individual SE Models; enclave or mobile work

crew are problematic (work adjustment only)• Choose/Get/Keep• Program of Assertive Community Treatment (PACT)• Individualized Placement & Support (IPS)*• Enhanced SE Approach- ( Employer Consortium)NOT-

TEP (clubhouses); or Extended Employment Programs (sheltered workshops) have poor VR outcomes

* Evidence-based model of supported employment


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VR Principles for Persons w/ Psychiatric Disabilities

Based on IEDP longitudinal study on integrated employment for persons w/ severe and persistent mental illness (SPMI) from current research, several principles emerged on the effectiveness of VR with this population.

(Cook, 1999; J. Cook et al. 2005)


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SE as an Evidence-Based Practice SAMHSA, 2005

Key elements of fidelity- (Cook, 2005; Bond, 2004)• Competitive employment is the goal• Rapid job search (establish work hx.)• Integration of Rehabilitation & MH services• Attention to consumer preferences• Continuous comprehensive assessment • Time unlimited support• Economic disincentives (benefit risk)*


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IEDP Service Integration(Cook et al. 2005)

• Integrated VR (SE) and Psych services (i.e., individual therapy & med. management)

• Best results if co-located services, using single-case record system regular/frequent staffings (2-3 x/week) enhancing communication and coordination of Tx. & VR planning and services

• National, multi-site randomized study of 1,273 patients with SMI using several individual SE approaches


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IEDP Service Integration -Part 2(Cook et al. 2005)

• Consumer outcomes compared according to models of high (HI) v. low (LI) service integration

• HI participants were 2x more likely to get comp. work than LI participants; and 1.25x more likely to work 40+ hrs./month than the LI group

• After controlling for the amount of Psych services, those receiving VR services achieve significantly better outcomes


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IEDP Service Integration -Part 3(Cook et al. 2005)

• Critically important for programs to monitor level of VR services to ensure consumers can access needed services without time limits

• Consumers may benefit from more VR services to complement or exceed the Psych services being integrated with them

• Provider communication and coordination between the programs is paramount in working towards identified employment goals


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Disclosure of PD to Employers(MacDonald-Wilson, 2005)

Benefits include:• Eligible protection under ADA; reasonable

accommodations can be accessed• Can qualify for certain jobs, e.g, peers or for positions

where experience is valued• Provides role model and reduces stress-induced by

secrecy; explains gaps or adjustments in work• Reduces isolation; fosters self-acceptance; facilitates

relationships/support with co-workers and supervisor• If job coach involved, fewer workplace difficulties

(Rollins, Mueser, Bond & Becker, 2002; Granger, 2000)


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Disclosure of PD to Employers(MacDonald-Wilson, 2005)

Risks:• Decrease in job options (not interviewed, not offered job,

offer withdrawn, not promoted, laid off, or not getting accommodated) or passed over as a result

• Being treated differently; iatrogenic effects and viewed as incomplete; patronized by others

• Performance issues emerge when accommodation is sought; barrier to getting constructive feedback

• Social disapproval and avoidance at work; fear of isolation or being harassed; potential for gossip and negative reactions; and treated as less competent


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Factors to Consider w/ Disclosure

• Need for reasonable accommodation in job• Co-worker & supervisor support at work• Self-identity and self-acceptance• Symptom visibility; risk of masking• Process of disclosure- who, what, what, to

whom and why ; (where are the supports?)• Preparing for disclosure; managing

disclosure process in the workplace(MacDonald-Wilson, 2005 ; Ralph, 2003)


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Judicial in Communicating(Howton-Ford, 1995)

• Do not divulge confidential information; disclosure is always consumer’s choice

• Stress positive aspects of person’s functioning

• Do not volunteer negative information• Avoid using medical/clinical terms re: SMI• Keep emphasis on work skills and person’s

competencies; account for gaps due to past health that is now stable


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References (1)

Bell , M. & Weinstein, A. (2011). Simulated job interview skill training for people with psychiatric disability: Feasibility and tolerability of virtual reality training. Schizophrenia Bulletin, 37 suppl 2, 91-97.

Bond, G. (2004). Supported employment: evidence for an evidence-based practice. Psychiatric Rehabilitation Journal, 27(4), 345-359.

Bond, G., Drake, R., Becker,D. & Mueser, K. (1999). Effectiveness of psychiatric rehabilitation approaches for employment of people with severe mental illness. Journal of Disability Policy Studies, 10 (1), 18-52.

Brohan, E. Henderson, C., Little, K., & Thornicroft, G. (2010). Employees with mental health problems: Survey of UK employers’ knowledge, atittudes, and workplace practices. Epidemiologic Psychiatry Society, 19 (4),326- 32.


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References (2)

Cook, J. (1999) Understanding the failure of vocational rehabilitation: What do we need to know and how can we learn it? Journal of Disability Policy Studies, 10, 127–132

Cook, J. et al. (2005). Integration of psychiatric and vocational services: A multi-site randomized, controlled trial of supported employment, American Journal of Psychiatry, 162, (10), 1948-1956.

Corrigan, Reedy, Thadani, & Ganet (1995). Correlates of participation and completion in a job club for clients with psychiatric disability. Rehabilitation Counseling Bulletin, 39 (1), 42-53.

Granger, B. (2000). The role of psychiatric rehabilitation practitioners in assisting people in understanding how to best assert their ADA rights and arrange job accommodations. Psychiatric Rehabilitation Journal, 23 (3) 215-223

Holter, M. & Mowbray, C. (2005). Consumer-run drop-in centers: Program operations and costs. Psychiatric Rehabilitation Journal, 28 (4), 323-331.


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References (3)

Marrone, J.,Gandolfo, C., Gold, M., & Hoff, D. (1998). Just Doing It: Helping people with mental illness get good jobs. Journal of Applied Rehabilitation Counseling, 29(1), 37-48.

MacDonald-Wilson, K, (2005). Managing disclosure of psychiatric disabilities to employers, Journal of Applied Rehabilitation Counseling, 36 (4), 11-21.

McKay, C. (2005). Recent research findings from the program for clubhouse research. Center for Mental Health Services Research Issue Brief, 2(8), 1-2.


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References (4)

McKay C., Yates B., Johnsen M. (2007). Costs of clubhouses: An international [perspective. Administration Policy in Mental Health, 34(1):62-72.McGurk, S., Schiano, D., Meuser, K. & Wolfe, R. (2010). Implementation of the Thinking Skills for Work program in a psychosocial clubhouse. Psychiatric Rehabilitation Journal , 33 (3), 190-9.Mowbray, C., Woodward, A., Holter, M. & Bybee, D. (2009). Characteristics of users of consumer-run drop-in centers versus clubhouses. The Journal of Behavioral Health Services & Research, 36 (6), 361-371.Pelletier, J., Nguyen, M., Bradley, K., Johnson, M. & McKay, C. (2005). A study of a structured exercise program with members of an ICCD Certified Clubhouse: program design, benefits, and implications for feasibility. Psychiatric Rehabilitation Journal, 29 (2), 89-96.


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References (4)

Ralph, R. (2002). The dynamics of disclosure: Its impact on recovery and rehabilitation. Psychiatric Rehabilitation Journal, 26 (2), 165-172.Rollins, A., Mueser, K., Bond, G. & Becker, D. (2002). Social relationships at work: Does the employment model make a difference? Psychiatric Rehabilitation Journal, 26 (1), 51-61.Salzer, M., Schwenk, E. & Brusilovskiy, E. (2010). Certified peer specialists roles and activities: Results from a national survey. Psychiatric Servi ces, 61 (5), 520-523.SAMHSA (2008). Self-disclosure and it’s impact on individuals who receive mental health services. Department of Health & Human Services, Community Mental Health Services/SAMHSA.Tsang, H. Wing-Hong. (2001) Applying social skills training in the context of vocational rehabilitation for people with schizophrenia. The Journal of Nervous and Mental Disease, 189 (2), 90-98.


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Resources Links

• http://www.dol.gov/odep/ietoolkit/

• http://www.psych.uic.edu/eidp/default.htm

• http://www.dartmouth.edu/~ips/

• http://www.quintcareers.com/job_club.html


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Comments & Questions


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Contact InformationCharlie Bernacchio

Assistant Professor, Coordinator Rehabilitation Counseling - University of Southern MaineEmail: [email protected]

Eileen BurkerAssociate Professor/Director, Rehabilitation Counseling & Psychology- University of North Carolina at Chapel HillEmail: [email protected]


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Upcoming Webinars

Improving Employment Outcomes for

Individuals with Mental Health Disabilities • March 30 – Job Development, Placement & Support

Strategies for Consumers w/ SMI

• April 17 – Job Development, Placement & Support Strategies for Consumers w/ SMI – Part 2


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Education Credits

CRCC Credit - (1.0)Approved by Commission on Rehabilitation Counselor

Certification (CRCC) • By March 19, 2012, participants must score 80% or

better on a online Post Test and submit an online CRCC Request Form via the MyTACE Portal.

My TACE Portal: TACEsoutheast.org/myportal


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THANK YOU!


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Southeast TACE (Region IV)

Toll-free: (866) 518-7750 [voice/tty]

Fax: (404) 541-9002

Web: TACEsoutheast.org

My TACE Portal: TACEsoutheast.org/myportal

Email: [email protected]


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DisclaimerThis presentation was developed by the

TACE Center: Region IV ©2011 with funds from the U.S. Department of Education, Rehabilitation Services Administration (RSA) under the priority of Technical Assistance and Continuing Education Projects (TACE) – Grant #H264A080021. However, the contents of this presentation do not necessarily represent the policy of the RSA and you should not assume endorsement by the Federal Government [34 CFR 75.620 (b)].

Documents

Career Exploration, Development and Planning for Consumers w/ SMI – Part 2 Improving Employment Outcomes for Individuals with Mental Health Disabilities