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Work as a Priority: A Resource for Employing People who have Serious Mental Illnesses and are Homeless

A Recovery-based Foundation for Employment Services^[1]

Recovery from mental illness is a personal process. The struggle to live with and beyond the limits of a disability is well described in consumer literature as "the urge, the wrestle, and the resurrection."^[2] Recovery means different things to different people; it is not a linear process. For some, recovery means no longer experiencing symptoms of a mental illness or needing to take medication. Others experience recovery as a life-long process of learning to live fully with the ongoing presence of symptoms. Daniel Fisher, MD., Ph.D., has suggested that a person has recovered from a mental illness when he or she regains primary control of major life decisions and functions in a significant and valued social role,^[3] such as being an employee. By combining supports that help consumers establish or re-establish social roles and self-management skills, and make their own decisions, recovery can become an achievable goal.^[4]

Though recovery is an individual process, some people in recovery have articulated what they deem important: the ability to have hope, trust their own thoughts, enjoy their environment, feel alert and alive, experience increased self-esteem and spirituality, know there is a tomorrow to look forward to, and have a job.^[5] They also have suggested how mental health professionals can assist them in the recovery process by encouraging independent thinking, treating them as equals in planning services, giving them freedom to make their own mistakes, listening to and believing what they say, recognizing their abilities, and working with them to find the resources and services they need.

Having a job often can facilitate recovery, but having a job is not essential to the recovery process. Many people gain the same satisfaction and self-esteem a wage-paying job provides from other life activities, including parenthood, caring for ill or disabled family members, or volunteerism. However, many people view employment as important to them in their recovery. Recovery-oriented employment programs should be person-centered, culturally and linguistically appropriate, responsive to individual need, and should recognize individuals’ strengths and potential that could help them get and keep a job. Many individuals have significant, though perhaps intermittent, educational and work histories; others have worked little, or not at all. Beyond employment or educational credentials, thousands possess inherent skills and strengths derived from surviving day-to-day with serious mental illness and homelessness.

Recognizing and endorsing the strength, resilience, and survival skills gained from these experiences expands the definition of work readiness beyond job-related skills to include personal and experiential factors that can contribute to job success. In Figure 2.1, insight and humor illustrate the view shared by many consumers who regard their experiences in the mental health system as potential sources of strength that can be transferred to the employment sector.

This chapter presents and discusses both program elements that facilitate worker role recovery and a conceptual framework for providing recovery-based employment. Cultural and environmental factors in the development of employment programs are also considered.

Worker Role Recovery

Over 80% of persons with severe mental illnesses are unemployed, despite heightened awareness of the value of work promoting recovery, the presence of effective program models to help consumers to obtain employment, and the fact that most persons with mental illnesses want to work.^[7] A number of factors contribute to this chilling fact:

• The stigma associated with mental illness can result in many employers’ reluctance to hire;

• Fear of failure and of loss of entitlement benefits influences consumers’ reluctance to try employment;

• The impact of co-occurring mental illness and substance use disorders carries severe functional implications for a person’s ability to obtain and sustain a job; and

• Lack of job training and access to jobs that are flexible enough to support an individual’s recovery.

Rehabilitation services that restore work-related skills and that help individuals develop a new self-image as workers, not just as mental health consumers, also are necessary.^[8] Such rehabilitation support and assistance must continue as needed, even after a job is obtained, to help individuals function effectively "so they may learn to adapt to their world."^[9] In the field of psychiatric rehabilitation, "skill performance" includes job interviewing, money management, and interpersonal skills, among other measures. However, improved skill performance alone cannot be a replacement for "role performance" or worker role recovery, the fundamental outcome that individuals and programs seek.

Helping people obtain jobs quickly and building skills appropriate for success in a given work setting is more effective than programs that emphasize skills development as a prerequisite for seeking and finding work.^[10] First, the types of occupational skills taught in employment programs may not be relevant to either local employer hiring needs or consumer job preferences. Second, some "soft" employment skills, such as organization, setting priorities, time management, anger management and accepting criticism, are among the most difficult and important skills that all individuals, regardless of disability, must master. These are learned best in actual work situations, with natural, peer, and professional support services to assist in the learning process.

Vocational growth, including perception of oneself in a worker role, is built over time and with experience. This growth process occurs not only through the ability to perform a job, but also through success at assimilating and/or acculturating to the employment environment. Vocational services should be dynamic and reflective of an individual’s particular needs, expectations, and goals at a particular time of life. Services also should be adaptable to meet the changing needs of the individual, and should define success in more flexible ways, including modifying standardized measures of achievement, a threshold of hours worked per week, and job retention milestones. For example, the ability to work for one hour a day for two days per week may be a valid measure of success when an individual has been unable to work for more than 30 minutes in any given week. Endorsing successes, no matter how small, is an essential element to help consumers rebuild the confidence, self-esteem, and trust necessary to achieve advanced employment.

At the same time, consumers with mental illnesses who want to pursue a career should be encouraged to do so under the right conditions. Many individuals, even those without disabilities, leave entry-level jobs that provide few benefits, little opportunity for advancement, and a lack of stimulation. An individual who changes jobs frequently threatens his or her residential stability and recovery process. Providers help individuals who want to pursue more demanding work set realistic goals to prepare fully for the challenges of career opportunities.

The following program elements can help facilitate worker role recovery:

• Consumer/practitioner partnerships –  participation in decisions regarding an individual’s own career future;

• Focused skill development –  developing the skills and resources required to be successful in a particular job;

• Support consistent with individual choice –  active consumer participation in finding, retaining, or changing a job;

• Ongoing assistance as needed –  ensuring that the person receives ongoing support services to maintain employment and facilitate job and career growth;

• Provision of holistic, comprehensive support services – assisting the individual in achieving a sustainable, satisfying life in his/her community as a productive, contributing member. This includes services that address needs beyond employment, such as housing, treatment, opportunities to develop meaningful friendships, socialization opportunities, etc.;

• A hopeful, supportive environment –  encouraging the consumer to consider the future; respecting his/her needs and aspirations; providing tangible assistance that enables the individual to meet job and career goals; and

• A culturally, linguistically appropriate environment –  providing services that are accessible to and appropriate for individuals of diverse racial, ethnic, and cultural backgrounds and sexual preferences; respecting different cultural views about help-seeking behavior, mental illness, and employment.

Conceptual Framework for Providing Employment Services

Offering options for work throughout all stages of contact between consumer and mental health provider can facilitate worker role recovery. The four-phase model below describes the stages and objectives of consumer-practitioner contact, incorporating work-related services that respect consumer needs, interests, and growth potential. This menu of services does not constitute a step-wise continuum; any or all stages may be revisited over the course of an individual’s working life.

Engagement

The purpose of engagement is to connect with individuals and establish trust, rapport, and information-sharing that could lead to involvement in employment services. Successful engagement requires development of a relationship built on empathy and respect; it should not be perceived as coercive or considered a prerequisite to gaining privileges or services. People diagnosed with mental illnesses, especially those with co-occurring substance use disorders, have significant barriers to overcome in order to recover a worker role. However, the goal of getting and keeping a job can help motivate change. Providers can help individuals move through the stages of change (from pre-contemplation to contemplation, determination, action, maintenance, and relapse)^[11] that will help stabilize symptoms and recover a valued social role.

Elements that support engagement in work-related activities during this early stage of contact can include:

• Conversations recognizing and supporting the possibility of work as a current option, including discussions with individuals who have made the transition to work;

• Building partnerships with individuals by validating their perspective, exploring their vision of the future, and establishing a sense of hope that employment is achievable;

• Recognizing and reinforcing that past work experiences, no matter how brief, have value;

• Building desire to consider employment as a rehabilitation goal; and

• Identifying and accepting individuals’ strengths, abilities, and perceived barriers as they relate to employment.

Exploration

Practitioners can help individuals choose to participate in employment services, though such efforts should not be used as a prerequisite for obtaining other services or privileges. Techniques of motivational interviewing^[12] can be especially useful here. To help individuals move through the stages of change, counselors who employ motivational interviewing avoid argumentation, express empathy, support self-efficacy, "roll with resistance," and help consumers develop a discrepancy between where they are now and where they want to be. Tools that can be used in this phase include:

• Meeting and discussing with peers how participation in employment services has made a positive difference in their lives;

• Visiting employment sites to view work environments and to talk with workers and supervisors;

• Reading and discussing written program materials, such as training schedules, job descriptions, etc.;

• Testing an employment service by sitting in on a skills-building group session, or briefly partnering with a peer or staff mentor; and

• "Job shadowing" that pairs a consumer with a staff person for a short period of time, enabling the consumer to observe, and possibly assist, in a real work setting.

Exposure

Exposure to employment at the earliest opportunity helps test job choices. It combines involvement in the real-life demands of work with insight and evaluation, examination of barriers, and assessment of possible alternative job choices. Practitioners must help create opportunities for people to succeed and help them see the strides they have already made. Activities that build exposure to the world of work may include:

• Experiencing work for short periods in a supportive setting to build confidence and motivation. Settings can include residential programs, drop-in centers, and mental health programs;

• Discussing elements that contributed to past job success and reinforcing them, while participating in the current work experience;

• Discussing elements that impeded past job success, and developing plans to address them in current or future jobs;

• Enhancing knowledge of alternative job options sharing information, visiting other work sites, and planning to acquire a more preferred job; and

• Reinforcing the hope and belief that employment success is possible by emphasizing current successes (e.g. increased work hours, productivity, attendance).

Experience

Supported work experiences are jobs in integrated work environments that help participants gain skills and experience, and allow them to test job goals. Supported work experiences should include assistance in retaining a job, and also should address non-work critical services (e.g., housing, mental health treatment, and family/friend relationships). Among the objectives of supported work experiences are:

• Building increased tolerance for work demands;

• Increasing proficiency in general work skills (e.g. attendance, co-worker interactions, concentration, task completion);

• Establishing proficiency in specific, needed work skills;

• Developing a record of work accomplishment and a resume of recent work experience;

• Continuing the goal development, including awareness of alternative, more fulfilling, and/or higher paying jobs with career opportunities or increased hours;

• Acquiring additional training, education, or experience to obtain a better job and advance in a career;

• Employing job retention services that include working with employee and employer to sustain employment;

• Identifying and utilizing natural workplace supports, including co-workers and supervisors; and

• Evaluating skills and abilities, identifying those that need to be strengthened to meet a particular job or career goal.

Worker role recovery, like the process of recovery from mental illness, is a complex, often circuitous path. Understanding the relationship between these two dimensions and adapting services that accommodate both the progress and setbacks on the journey towards recovery, can help facilitate employment success.

Cultural and Environmental Considerations

This discussion would not be complete without considering cultural and environmental factors that affect the design and delivery of employment services. To facilitate successful worker role recovery, employment programs must incorporate sensitivity to these critical personal dimensions.

Cultural Considerations

Practitioners need to recognize that each individual they approach may be culturally different from themselves in ways not always obvious. Becoming culturally competent provides the knowledge, skills, and attitudes to enable administrators and practitioners within systems of care to provide effective services to diverse populations, i.e., to work within the person’s values and reality conditions.^[13] A number of essential ingredients are needed to develop employment services sensitive to consumers’ ethnic and cultural needs and issues:

• Hire staff who reflect the language, ethnicity, and culture of the persons served. The value of a common culture and language cannot be underestimated in engaging and supporting consumers in the worker role recovery process. Work has different priorities in different cultures; barriers to work may be unique as well. Practitioners need to be sensitive to these issues and understand that what may appear to be a lack of motivation or unwillingness to work may have a cultural basis, and may mean something else altogether.

• Recognize that peer support is fundamental. Staff who also are mental health consumers share the language of their peers—they can better understand the neighborhoods in which consumers live, are sensitive to their cultural needs, and serve as powerful and positive role models. Moreover, peers as staff are living proof that success is possible. It is important to acknowledge, however, that not all consumers are prepared to serve in this role.

• Meet with consumers who have varied ethnic/cultural backgrounds and listen to how they perceive their employment goals, barriers, and issues. Employment program strategies cannot take place in a vacuum. Conversations with small groups of consumer stakeholders may generate valuable information regarding family support for work and what types of jobs are acceptable and non-acceptable in a particular culture. For example, in some cultures, particular jobs are viewed as appropriate for one gender and not the other. Other important considerations in facilitating employment success are: how mental illness is viewed and accepted; factors related to pride, honor, and self-worth; and how biomedical and alternative treatment approaches are used.^[14]

Every organization has its own mission-driven "internal cultures" that often can lead to cultural dissonance between consumers and employment programs. For example, the culture of state vocational rehabilitation (VR) emphasizes independence, individual uniqueness, and person-centered planning. However, some cultures view the individual as an interdependent part of family and community. Consumers from a background reflecting this view may find themselves caught in a clash between vocational rehabilitation cultures and their collectivist culture. Strategies should be developed to address this issue, such as training VR counselors in more effective counseling approaches that facilitate the provision of services to persons with disabilities from diverse cultural backgrounds; developing new assessments of independence and interdependence; and exploring how VR could consider interdependence as an equally viable philosophy and practice.^[15]

In addition, the culture within an organization may not place an emphasis on "work first." Front line providers who are expected to advance this concept with their clients may need additional training in the value of this approach, as opposed to more traditional pre-vocational training.

A recent report describes programs that provide culturally competent mental health services throughout the country.^[16] While not limited to employment programs or emphasizing people who also are homeless, the report offers many valuable lessons and examples of ways to improve the ethnic and cultural relevance of mental health services. For example, the Muscogee Creek Nation Behavioral Health Services of Oklahoma, serving Native Americans, utilizes a variety of culturally appropriate strategies when providing treatment, including a focus on traditional values and coping skills training exercises. These are augmented by employment services that include career counseling, vocational assessment and vocational rehabilitation counseling, delivered by a predominately Native American staff who are sensitive to cultural norms.

Casa Primavera, a subsidiary of Bay Cove Human Services in Massachusetts, operates a Fountain House model clubhouse. It is language- and culture-friendly, and is staffed and managed by Latinos. Casa Primavera is focused on a work-ordered day. Members and staff work together in teams at in-house food service, office support, and maintenance employment programs ("La Cocina", "El Kiosko," "Oficina," and "Mantenimiento"). Members are helped to move into regular jobs through a transitional employment program. The African-American Counseling Center in Minnesota recognizes that the anxiety associated with racial discrimination and prejudice can be a barrier to getting and holding a job. By acquainting people with others who have faced and overcome the same challenges, they help clients achieve their employment goals.

Chapter Summary

Persons with mental illnesses face the challenge of recovery on multiple levels. The first is the internal struggle to come to terms with, accept, and move beyond the devastating consequences of severe mental illness. Second is the task of recovering the skills needed to meet the demands of everyday life. Third is the challenge of transferring survival skills to new life roles, including the role of worker. These challenges can be met through a partnership between consumer and practitioner. By recognizing and supporting consumers’ inherent strengths and aspirations, practitioners can facilitate the training, advocacy, and resources necessary to attain employment goals. With assurance that work-related services are a constant option throughout all stages of the recovery process, worker role recovery can become both a possibility and a priority.

Chapter 2 Notes

^[1] This chapter contains original material authored by Gary E. Shaheen, M.P.A., Advocates for Human Potential, Delmar, NY.

^[2] Deegan, P. Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal 11(4): 11-19, 1988.

^[3] National Technical Assistance Center for State Mental Health Planning. Embracing recovery: A simple but powerful vision. Networks, Winter 1999.

^[4] Fisher, D. A new vision of recovery: The empowerment vision. National Empowerment Center Newsletter: 12-13, Spring/Summer 1998.

^[5] Ralph, R., et al. Recovery Issues in a Consumer Developed Evaluation of the Mental Health System. Proceedings of the Fifth Annual Conference on Mental Health Services Research and Evaluation, Arlington, VA, February 1996.

^[6] Anthony, W.A., and Blanch, A. Supported employment for people who are psychiatrically disabled: An historical and conceptual perspective. Psychosocial Rehabilitation Journal 11(2): 5-19, 1987.

^[7] Kravitz, M. Address delivered at the Coalition of Mainstream Employment Programs, New York, NY, November 14, 1996.

^[8] Anthony, W. Integrating psychiatric rehabilitation into managed care. Health Affairs 11(3): 170, 1995.

^[9] Deegan, op.cit. p. 3.

^[10] Ridgeway, P., and Rapp, C. The Active Ingredients in Achieving Competitive Employment for People with Serious Mental Illness: A Research Synthesis. Lawrence, KS: University of Kansas School of Social Welfare, 1998.

^[11] Prochaska, J.O. and DiClemente, C.C. Trans theoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice 19:276-288, 1982.

^[12] Miller, W.R. and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York/London: The Guilford Press, 1991.

^[13] Center for Mental Health Services. Cultural Competence Standards in Managed Mental Health Care Services: Four Underserved/Underrepresented Racial/Ethnic Groups. Rockville, MD: Center for Mental Health Services, 2000.

^[14] Alverson, H., and Vicente, E. An ethnographic study of vocational rehabilitation for Puerto Rican Americans with severe mental illness. Psychiatric Rehabilitation Journal 22(1): 69-72, 1998.

^[15] Thompson, V.C. Independent and interdependent views of self: Implications for culturally sensitive vocational rehabilitation services. Journal of Rehabilitation 63(4): 16-20, 1997.

^[16] National Technical Assistance Center for State Mental Health Planning. Examples from the Field: Programmatic Efforts to Improve Cultural Competence in Mental Health Services. Alexandria, VA: National Technical Assistance Center for State Mental Health Planning, 2000.

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