A Supported Entployntent Enclave Model for the Psychiatrically Challenged A Program Critique Donna GaHi, MPH, OTRIL Clinical Supervisor Clinical Vocational Assessment Program Rehabilitation Services Department McLean Hospital Belmont, Massachusetts
Supported employment programs are an increasingly popular option in vocational rehabilitation, involving the competitive employment and ongoing support of disabled individuals in work settings that integrate disabled and nondisabled workers. This article describes one such supported employment program for a group of psychiatrically challenged clients and includes some of the practical issues encountered in the development of this program. The program will be critiqued from Roann Barris's theoretical concepts related to system-environment interactions. In addition, a demographic profile of 20 client participants, both inpatients and outpatients, will be presented, together with survey results of client perceptions comparing and contrasting their supported employment experience with their earlier participation in hospital-based clinical vocational assessment programs. With over two-thirds chronic unemployment among the moderately to severely mentally ill, supported employment programs hold considerable promise for the chronically dysfunctional psychiatric client as well as for those suffering from more temporary functional impairments. Combining a theoretical understanding of the advantages and disadvantages of supported employment together with client assessments of their participation is hoped to enhance program planning and development for those
professionals engaged in vocational rehabilitation with the psychiatric population.
A PROGRAM PREMISE Work consumes at least a third of our adult lives, not only providing economic benefits but often meeting our psychological needs for affiliation and self-esteem. Anthony and Blanch state that "work is a place to spend one's time, a way to stay involved and active, to participate in society and feel included. For persons with psychiatric disabilities work can be all these things, and perhaps even more. Some believe that work can have an ameliorating effect on psychiatric symptoms."! They go on to suggest that although work can provide such benefits to psychiatrically challenged individuals, somehow "the mental health and rehabilitation systems seem to have done a better job of teaching persons with psychiatric disabilities how to be clients than in teaching them how to be workers."! The employment statistics for psychiatric clients are grim. There is a full-time competitive employment figure of 20%-25% for all persons discharged from psychiatric hospitals; for the more severely psychiatrically disabled persons in this population, the figure drops to 15% and below.! Psychiatric clients comprise the largest number of cases eligible for vocational rehabilitation services, but have the least probability of successful vocational placement. ! While employment rates of other disability groups have actually increased, a slight decrease was observed in the vocational rehabilitation of clients with a primary disability of mental illness. !
20
W 0 R K / WINTER 1991
Supported employment is a vocational initiative of the 1980s that attempts to increase the percentage of disabled persons who are able to get and keep jobs.' It originated with service providers for the developmentally disabled and reflected the providers' frustration with a system that endlessly prepared people for jobs that never materialized.' The supported employment approach departs from the unsuccessful "train and place" orientation and instead proposes that clinicians find jobs for prospective clients and then provide whatever training and supports are necessary for those clients to maintain their employment.' Gary Bond 2 likens supportive employment to the process of work hardening, an occupational therapy concept usually applied in the physical disabilities area of rehabilitation to describe the development of tolerance, endurance, and flexibility needed to succeed on a job. Using this analogy, the experience for psychiatric clients of repeated exposure to successful paid work experiences contributes to vocational success.
A PROGRAM DESCRIPTION Anthony and Blanch' define the supported employment model as having three basic characteristics: (1) a goal of paid full-time or part-time employment in the natural employment community, (2) integration of the disabled worker with the nondisabled, (3) ongoing support services, including supervision, training, or transportation. The group supported employment program under consideration here was developed by McLean Hospital's Rehabilitation Services Department in 1987 in response to a perceived need for vocational placements for certain clients with prolonged psychiatric disorders, ranging from chronic schizophrenia to severe manicdepressive illness, severe obsessive-compulsive disorders, and borderline personality. The first 20 clients participating in this program were surveyed for their perceptions ofthe supported employment experienced versus their previous in-hospital work therapy program participation (Appendix). The average age of this group was
approximately 27 years; the group was fairly evenly divided between males and females. About half of the group had some previous competitive employment, albeit generally limited to short-lived and/or unskilled positions. All members surveyed had experienced inpatient hospitalization within the previous year, with two individuals still in the hospital at the time of the survey. All of the clients had participated in one or more of the hospital-based Clinical Vocational Assessment Programs (CVAPs)-coffee shop, greenhouse, officellibrary, thrift shop-prior to their particpation in the Supported Employment Program. The different CVAP environments provide the opportunity to make situational assessments of each client's vocational functioning, to teach basic work skills, and to coach clients regarding appropriate work behaviors. CVAP clients average 1 to 3 hours of participation per day. In general the CVAPs offer significant task structure and emotional support to individuals, with minimal to moderate demands for production. Most of the 20 clients surveyed had participated in the hospital CVAP for 6 months or more, and on the basis of their participation were judged to have sufficient functional skills and the behavioral capacity to appropriately manage a competitive work setting. These clients were also regarded as unable to make the leap to competitive employment on their own, based on either their recent attempts and subsequent failures to do so, and/or a perception that they would be unable to manage the job-finding and job-holding functions without massive support. The majority of these clients probably best fit the level of occupational dysfunction Kielhofner 3 describes as incompetence: They experience "a major loss or limitation of skills, a failure or disruption of self-confidence and satisfaction, and inability to routinely and adequately perform the tasks of everyday living associated with occupational roles." In considering potential employers for the Supported Employment Program, two criteria were believed paramount: (1) the capacity to accommodate a group of workers simultaneously-the enclave model-and (2) some
Enclave Model for the Psychiatrically Challenged
breadth and variety in available tasks to be performed. The decision to place a group versus individuals stemmed from a number. of factors, both practical and clinical. Clearly, group placements can be cost-effective and possess logistical advantages. The one staff member who coordinates the McLean Hospital Supported Employment Program (SEP) transports and supervises up to 14 clients at a time in the work setting, a feat that would be much more labor-intensive if staff were traveling to multiple individual placements to provide supervision and support. In addition, the relationship with the company developed more quickly given the size of the McLean SEP-its 14 employees constitute approximately 15% of the work force. Clinically, despite moderate turnover in the client group, a sense of cohesion and peer support develops for most participants. For some clients, the very function of being transported from the hospital grounds by a staff member provides a kind of object constancy that is critical to their stability in community-based employment. The actual employment site is a large stationery supply warehouse and offices located in an industrial park about 40 minutes from the hospital. The 40-minute travel time is a definite drawback-obviously the hour plus spent commuting each day is time that might have been added to the work shift, and also represents a complicated public transportation commute for those clients who eventually attempt to manage traveling to and from work themselves. Closer geographic proximity will definitely be a prerequisite for any future SEP sites with which the McLean Hospital Rehabilitation Staff becomes involved. Clients in the SEP start at $4.25 an hour, a wage that, while competitive, may not sufficiently offset the value of disability compensation. It is often a catch-22 for people on disability to resume working. While they may regain selfesteem and self-respect through a return to work, they ultimately stand to lose the very real economic and emotional security provided by such disability insurance, especially when they are subject to the chronicity or unpredictable
21
relapses intrinsic to many forms of mental illness. Estimates of the value of Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) and their concomitant benefits range from $4.50 to $4.85 per hour. 4 Certainly, placing clients for less than this amount may not provide sufficient incentive for them to accept or maintain employment. The tasks available at the supported employment site met the criteria stated earlier for variety and different levels of cognitive challenge. Some are very simple one-or-two step tasks: peeling and applying self-sticking labels to rolls of tape, sorting and boxing binders by color, ticketing item lots with designated prices. Others require more judgment and/or sequencing of multiple steps and attention to detail: for example, filling computer orders, which entails locating the appropriate quantity and type of merchandise from among many long warehouse aisles of stationery supplies. Shipping and receiving tasks are also common: boxing orders, loading and unloading boxes, including forklift operation. In addition, the McLean Hospital SEP currently fills one part-time position for a computer programmer in the office. This degree of task variety is essential in accommodating the different functional levels and task preferences of participating clients. The individuals in the SEP generally work three 4-hour shifts per week on a Monday, Wednesday, Friday morning schedule, allowing them time to meet other treatment commitments. Those individuals who have graduated to outpatient status have the freedom to work additional hours and/or days at their discretion. The fact that most of the clients are not able or willing to take on more than the 12 hours per week has created some ongoing tension with the company, which frequently requests more hours.
A PROG RAM CRITIQUE Client response to the SEP has been interesting and evokes a number of theoretical comments. A 3!f2-page questionnaire was administered to the 20 participants requiring them to evaluate
22
W 0 R K / WINTER 1991
and compare their SEP experience with their earlier in-hospital participation in the Clinical Vocational Assessment Program. Of the 20 respondents, 11 remain active in the SEp, while 9 have terminated. Three of the 9 who left pursued competitive employment, 4 returned to CVAP participation; and 2 have not continued their vocational rehabilitation to date. In general, clients viewed the two programs as more similar than different. The two programs provided almost identical degrees ofjob satisfaction and were seen as equally difficult in terms of task demands (Table 1). The most strikingly dissonant feature between programs, however, was the clients' perception of social isolation at the SEp, whereas the need for affiliation was generally regarded as well served in the hospital work programs. Viewing clients' perceptions from Barris's environmental themes helps to elucidate some of the SEP's strengths and weaknesses. For one thing, the press, or environmental demands for performance made at the SEP site too closely approximate the press of the in-hospital Clinical Vocational Assessment Program and thereby may not provide an appropriate level of challenge or opportunities for growth for all clients. 5 Tasks are varied, but the majority fall along a lateral level of cognitive demands rather than a vertical spectrum from simple to complex. Clients doing more skilled work have been shown to remain employed for longer periods of time. As one client respondent commented on the
survey: "I would like to see more SEP job opportunities in the future, with more different possibilities for learning skills. . .. I think more challenging jobs would be very beneficial. I know that even ill patients can be productive since I held on to a job at a computer graphics firm for several months following my breakdown." One caveat is relevant here. Since more skilled positions can produce added stress, practitioners do need to identifY what factors constitute stress for a given client. 6 In addition to the issues around performance press, social press is clearly inadequate at the SEP company; in fact, this is probably the most outstanding program deficit. Clients work primarily independently, frequently in physical isolation from one another, with only a 15minute break in which to congregate. For the four patients who left the company to return to the hospital work programs, social isolation was clearly a large motivating factor. One study has shown that persons with mental illness are more likely to remain employed in situations characterized by work that requires a working relationship with others; apparently "the need to make self-evaluations in relation to other workers is why non-isolated work fared better, in contrast to some earlier thinking which stressed the need for isolated work opportunities."6 The Supported Employment Program site also falls short on Barris's concepts of arousal potential, those environmental variables that determine how likely a person is to attempt a
Table 1. A Client Comparison of CVAP Versus SEP Experiences Ratings by Number of Respondents, n = 20 High
Similarity to previous nonhospital work Amount of pressure from job Amount of pressure from supervisor Amount of responsibility Amount of criticism Amount of praise Degree ofjob difficulty General job satisfaction
Medium
Low
CVAffSEP
CVAffSEP
CVAffSEP
2/7 3/5 4 / 6 5/8 o/ 4 lO / 7 1/ 2 5/4
8/5 lO/1I II / 12 II / 7 9/7 lO / 7 lO/1I lO/lO
lO / 8 7/4 5/2 4/5 II / 9 o/ 6 9/7 5 / 6
Enclave Model for the Psychiatrically Challenged
performance, the match between volition and environment. These variables include the quality or intensity of physical stimuli or so-called psychophysical properties, ecological variables or the meaning an event has to a person, and finally, collative variables: properties of the setting such as novelty, complexity, incongruity, and ambiguity. S The arousal potential in general is somewhat limited in the stationery warehouse atmosphere. Ecological variables, in particular, are a concern in this setting, with its significant population of other disabled workers and its concentration of repetitive, isolated, and somewhat personally meaningless tasks. Roann Barris proposes that when a setting's innate value and interest resonate with those of its client, there is a greater chance of a person's satisfaction and sense of efficacy in his or her environment. S The ecological limitations of the SEP site contrast rather sharply with some of the real ecological strengths found in the hospital work programs: the potential value and meaningfulness to people of a thrift shop that recycles merchandise; a greenhouse, which provides the opportunity to grow and nurture plants; or even the coffee shop, which offers the chance to feed people. It should be noted that clients differentiated the SEP experience from the hospital Clinical Vocational Assessment Programs in ways that are also positive and/or appropriate. The SEP was regarded as slightly more similar to previous, nonhospital competitive work experiences in which clients had participated. The SEP environment was also perceived as more pressured in terms of supervisory demands, as slightly more critical, and as offering less positive reinforcement or praise. These are largely appropriate differences from the perspective of Roann Barris's environmental concept of the trajectory of increasing occupancy.5 This is the notion that as people master the performance expectations in one setting, they will usually seek new settings in which to both practice their acquired skills and increase their skill repertoire. Obviously, some similarity between settings is necessary to facilitate the transfer of behavior, but if they are too alike, the oppor-
23
tunity for new learning and behavior will be stunted. s More than two-thirds ofthe client respondents regarded the CVAP experience as helpful in preparing them for the Supported Employment Program in the community, as illustrated in some of the following comments: "CVAP made me stronger." "Built up my confidence and perseverance." "Helped me recognize more areas that I really needed to work on. I saw the inconsistencies of my attendance and not calling in .... It was a good start." 'lust enough for me at the time." "I did a lot of crucial growing up III the CVAP." "Showed I could handle the SEP." Despite many of the perceived similarities between the CVAP and SEP experiences, clearly the Supported Employment Program was viewed as a manageable step beyond the more sheltered hospital work programs. Seventy percent ofthe clients rated SEP as the more helpful ofthe two vocational experiences. "Having support in a real job setting has been extremely beneficial," one client commented. Other client comments on the SEP included "higher paying," "more responsibility," "helped prepare me and provided references," and "helped me find a job and realize what I could do." One client remarked of her SEP experience, "I've had to be more independent." Another client noted that she was "not so appreciative of the CVAP because I had not been far enough in my recovery to see the benefits that I could have gained. It was much more difficult for me to take it seriously because I could not see the thrift shop as a real job. CVAP is a good way to help people right when they get out of the hospital. The TEP was more of a challenge to me becuase I looked at it as being a real job with distinct responsibilities." In summary, some recent research suggests that the more traditional, gradual approaches in vocational rehabilitation may be allowing at least some clients to remain away from work too long, thereby enhancing their fears of failure
24
W 0 R K / WINTER 1991
and allowing them to become too dependent on the support system. 6 There is little data to support the assumption that vocational rehabilitation programs can be used only after the clients' symptoms have stabilized, but (as noted earlier) there are clinical experiences to suggest that for some people a work setting can actually have the effect of stabilizing symptom status. 6
Supported employment is not a vocational panacea, of course, but it is an important option, another strata of vocational programming that can serve as an appropriate sequel to hospitalbased vocational rehabilitation and maximize paid employment outcomes for a challenging population.
REFERENCES 1. Anthony WA, Blanch A: Supported employment for persons who are psychiatrically disabled: An historical and conceptual perspective. Psyclwsocial Rehab J 1987; 11: 5-23. 2. Bond G: Supported work as a modification of the transitional employment model for clients with psychiatric disabilities. Psychosocial Rehab 1987; 11:55-73. 3. Kielhofuer, G: Occupational function and dysfunction. In G Kielhofuer (ed): A Model of Human Occupation: Theory and Application. Bal-
timore: Williams & Wilkins, (1985), pp 63-75. 4. Black BJ: Work and Mental Illness: Transitions to Employment. Baltimore: Johns Hopkins University Press, 1988. 5. Barris R: Environmental interactions: An extension of the model of occupation. Am J Occup Ther 1982; 36: 637-656. 6. Ciardiello JA, Bell MD: Vocational Rehabilitation of Persons with Prolonged Psychiatric Disorders. Baltimore: Johns Hopkins University Press, 1988, p. 40.
Enclave Model for the Psychiatrically Challenged
25
Appendix A CVi\ffSEP SURVEY This survey asks participants to compare and contrast their CVAP (greenhouse, thrift shop, coffee shop, office!library) experiences with the Supported Employment Program (SEP). 1. Which CVAP did you attend? (Check as many as apply.)
_ _ Greenhouse
_ _ Thrift shop
_ _ Coffee shop
_ _ Office/library
2. How long did you participate in CVAP? _ _ Less than 3 months
_ _ 3 to 6 months
_ _ 6 months or more
3. What were your goals for participating in CVAP?
4. Overall, would you say that you met your goals? _ _ Yes _ _ No Whydoyouthinkso? _________________________________________________________
5. Please rate CVAP according to the following items. (If you attended several, please rate the one in which you spent the most time.)
High
Medium
Low
Similarity to previous nonhospital work experiences Amount of pressure on workers from job demands Amount of pressure on the workers frOIJl the supervisor Amount of responsibility given to the workers Amount of criticism from the supervisor Amount of praise or support from the supervisor Degree of job difficulty General job satisfaction 6. My contact with coworkers was: _ _ Satisfactory _ _ Unsatisfactory. Please explain: _____
26
W 0 R K / WINTER 1991
7. What did you find the most frustrating? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~ostfun?
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
~ostch~len~ng?---------------------------------
8. Please rate the SEP experience according to the following items: High Similarity to previous nonhospital work experiences
Medium
Low
Amount of pressure on workers from job demands Amount of pressure on the workers from the supervisor Amount of responsibility given to the workers Amount of criticism from the supervisor Amount of praise or support from the supervisor Degree of job difficulty General job satisfaction 9.
~y
contact with coworkers was ______ Satisfactory ______ Unsatisfactory.
Please explain. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 10. What did you find the most frustrating? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~ostfun?
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
Enclave Model for the Psychiatrically Challenged
27
Most challenging? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
11. In what ways have the two programs (SEP and CVAP) been different? _ _ _ _ _ _ _ _ _ __
12. In what ways have the two programs been alike? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
13. If you had to pick one, which experience has been more helpful to you and why? _ _ _ _ __
14. Did the CVAP experience help to prepare you in any way for the SEP? Yes _ _ No _ _ Please explain. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
15. If you have terminated with the SEp, please note the reason(s). _ _ _ _ _ _ _ _ _ _ _ _ __
16. Any additional comments about the two experiences would be appreciated. _ _ _ _ _ _ _ __
Supported employment programs are an increasingly popular option in vocational rehabilitation, involving the competitive employment and ongoing support of disabled individuals in work settings that integrate disabled and nondisabled workers. This article describes one such supported employment program for a group of psychiatrically challenged clients and includes some of the practical issues encountered in the development of this program. The program will be critiqued from Roann Barris's theoretical concepts related to system-environment interactions. In addition, a demographic profile of 20 client participants, both inpatients and outpatients, will be presented, together with survey results of client perceptions comparing and contrasting their supported employment experience with their earlier participation in hospital-based clinical vocational assessment programs. With over two-thirds chronic unemployment among the moderately to severely mentally ill, supported employment programs hold considerable promise for the chronically dysfunctional psychiatric client as well as for those suffering from more temporary functional impairments. Combining a theoretical understanding of the advantages and disadvantages of supported employment together with client assessments of their participation is hoped to enhance program planning and development for those
professionals engaged in vocational rehabilitation with the psychiatric population.
A PROGRAM PREMISE Work consumes at least a third of our adult lives, not only providing economic benefits but often meeting our psychological needs for affiliation and self-esteem. Anthony and Blanch state that "work is a place to spend one's time, a way to stay involved and active, to participate in society and feel included. For persons with psychiatric disabilities work can be all these things, and perhaps even more. Some believe that work can have an ameliorating effect on psychiatric symptoms."! They go on to suggest that although work can provide such benefits to psychiatrically challenged individuals, somehow "the mental health and rehabilitation systems seem to have done a better job of teaching persons with psychiatric disabilities how to be clients than in teaching them how to be workers."! The employment statistics for psychiatric clients are grim. There is a full-time competitive employment figure of 20%-25% for all persons discharged from psychiatric hospitals; for the more severely psychiatrically disabled persons in this population, the figure drops to 15% and below.! Psychiatric clients comprise the largest number of cases eligible for vocational rehabilitation services, but have the least probability of successful vocational placement. ! While employment rates of other disability groups have actually increased, a slight decrease was observed in the vocational rehabilitation of clients with a primary disability of mental illness. !
20
W 0 R K / WINTER 1991
Supported employment is a vocational initiative of the 1980s that attempts to increase the percentage of disabled persons who are able to get and keep jobs.' It originated with service providers for the developmentally disabled and reflected the providers' frustration with a system that endlessly prepared people for jobs that never materialized.' The supported employment approach departs from the unsuccessful "train and place" orientation and instead proposes that clinicians find jobs for prospective clients and then provide whatever training and supports are necessary for those clients to maintain their employment.' Gary Bond 2 likens supportive employment to the process of work hardening, an occupational therapy concept usually applied in the physical disabilities area of rehabilitation to describe the development of tolerance, endurance, and flexibility needed to succeed on a job. Using this analogy, the experience for psychiatric clients of repeated exposure to successful paid work experiences contributes to vocational success.
A PROGRAM DESCRIPTION Anthony and Blanch' define the supported employment model as having three basic characteristics: (1) a goal of paid full-time or part-time employment in the natural employment community, (2) integration of the disabled worker with the nondisabled, (3) ongoing support services, including supervision, training, or transportation. The group supported employment program under consideration here was developed by McLean Hospital's Rehabilitation Services Department in 1987 in response to a perceived need for vocational placements for certain clients with prolonged psychiatric disorders, ranging from chronic schizophrenia to severe manicdepressive illness, severe obsessive-compulsive disorders, and borderline personality. The first 20 clients participating in this program were surveyed for their perceptions ofthe supported employment experienced versus their previous in-hospital work therapy program participation (Appendix). The average age of this group was
approximately 27 years; the group was fairly evenly divided between males and females. About half of the group had some previous competitive employment, albeit generally limited to short-lived and/or unskilled positions. All members surveyed had experienced inpatient hospitalization within the previous year, with two individuals still in the hospital at the time of the survey. All of the clients had participated in one or more of the hospital-based Clinical Vocational Assessment Programs (CVAPs)-coffee shop, greenhouse, officellibrary, thrift shop-prior to their particpation in the Supported Employment Program. The different CVAP environments provide the opportunity to make situational assessments of each client's vocational functioning, to teach basic work skills, and to coach clients regarding appropriate work behaviors. CVAP clients average 1 to 3 hours of participation per day. In general the CVAPs offer significant task structure and emotional support to individuals, with minimal to moderate demands for production. Most of the 20 clients surveyed had participated in the hospital CVAP for 6 months or more, and on the basis of their participation were judged to have sufficient functional skills and the behavioral capacity to appropriately manage a competitive work setting. These clients were also regarded as unable to make the leap to competitive employment on their own, based on either their recent attempts and subsequent failures to do so, and/or a perception that they would be unable to manage the job-finding and job-holding functions without massive support. The majority of these clients probably best fit the level of occupational dysfunction Kielhofner 3 describes as incompetence: They experience "a major loss or limitation of skills, a failure or disruption of self-confidence and satisfaction, and inability to routinely and adequately perform the tasks of everyday living associated with occupational roles." In considering potential employers for the Supported Employment Program, two criteria were believed paramount: (1) the capacity to accommodate a group of workers simultaneously-the enclave model-and (2) some
Enclave Model for the Psychiatrically Challenged
breadth and variety in available tasks to be performed. The decision to place a group versus individuals stemmed from a number. of factors, both practical and clinical. Clearly, group placements can be cost-effective and possess logistical advantages. The one staff member who coordinates the McLean Hospital Supported Employment Program (SEP) transports and supervises up to 14 clients at a time in the work setting, a feat that would be much more labor-intensive if staff were traveling to multiple individual placements to provide supervision and support. In addition, the relationship with the company developed more quickly given the size of the McLean SEP-its 14 employees constitute approximately 15% of the work force. Clinically, despite moderate turnover in the client group, a sense of cohesion and peer support develops for most participants. For some clients, the very function of being transported from the hospital grounds by a staff member provides a kind of object constancy that is critical to their stability in community-based employment. The actual employment site is a large stationery supply warehouse and offices located in an industrial park about 40 minutes from the hospital. The 40-minute travel time is a definite drawback-obviously the hour plus spent commuting each day is time that might have been added to the work shift, and also represents a complicated public transportation commute for those clients who eventually attempt to manage traveling to and from work themselves. Closer geographic proximity will definitely be a prerequisite for any future SEP sites with which the McLean Hospital Rehabilitation Staff becomes involved. Clients in the SEP start at $4.25 an hour, a wage that, while competitive, may not sufficiently offset the value of disability compensation. It is often a catch-22 for people on disability to resume working. While they may regain selfesteem and self-respect through a return to work, they ultimately stand to lose the very real economic and emotional security provided by such disability insurance, especially when they are subject to the chronicity or unpredictable
21
relapses intrinsic to many forms of mental illness. Estimates of the value of Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) and their concomitant benefits range from $4.50 to $4.85 per hour. 4 Certainly, placing clients for less than this amount may not provide sufficient incentive for them to accept or maintain employment. The tasks available at the supported employment site met the criteria stated earlier for variety and different levels of cognitive challenge. Some are very simple one-or-two step tasks: peeling and applying self-sticking labels to rolls of tape, sorting and boxing binders by color, ticketing item lots with designated prices. Others require more judgment and/or sequencing of multiple steps and attention to detail: for example, filling computer orders, which entails locating the appropriate quantity and type of merchandise from among many long warehouse aisles of stationery supplies. Shipping and receiving tasks are also common: boxing orders, loading and unloading boxes, including forklift operation. In addition, the McLean Hospital SEP currently fills one part-time position for a computer programmer in the office. This degree of task variety is essential in accommodating the different functional levels and task preferences of participating clients. The individuals in the SEP generally work three 4-hour shifts per week on a Monday, Wednesday, Friday morning schedule, allowing them time to meet other treatment commitments. Those individuals who have graduated to outpatient status have the freedom to work additional hours and/or days at their discretion. The fact that most of the clients are not able or willing to take on more than the 12 hours per week has created some ongoing tension with the company, which frequently requests more hours.
A PROG RAM CRITIQUE Client response to the SEP has been interesting and evokes a number of theoretical comments. A 3!f2-page questionnaire was administered to the 20 participants requiring them to evaluate
22
W 0 R K / WINTER 1991
and compare their SEP experience with their earlier in-hospital participation in the Clinical Vocational Assessment Program. Of the 20 respondents, 11 remain active in the SEp, while 9 have terminated. Three of the 9 who left pursued competitive employment, 4 returned to CVAP participation; and 2 have not continued their vocational rehabilitation to date. In general, clients viewed the two programs as more similar than different. The two programs provided almost identical degrees ofjob satisfaction and were seen as equally difficult in terms of task demands (Table 1). The most strikingly dissonant feature between programs, however, was the clients' perception of social isolation at the SEp, whereas the need for affiliation was generally regarded as well served in the hospital work programs. Viewing clients' perceptions from Barris's environmental themes helps to elucidate some of the SEP's strengths and weaknesses. For one thing, the press, or environmental demands for performance made at the SEP site too closely approximate the press of the in-hospital Clinical Vocational Assessment Program and thereby may not provide an appropriate level of challenge or opportunities for growth for all clients. 5 Tasks are varied, but the majority fall along a lateral level of cognitive demands rather than a vertical spectrum from simple to complex. Clients doing more skilled work have been shown to remain employed for longer periods of time. As one client respondent commented on the
survey: "I would like to see more SEP job opportunities in the future, with more different possibilities for learning skills. . .. I think more challenging jobs would be very beneficial. I know that even ill patients can be productive since I held on to a job at a computer graphics firm for several months following my breakdown." One caveat is relevant here. Since more skilled positions can produce added stress, practitioners do need to identifY what factors constitute stress for a given client. 6 In addition to the issues around performance press, social press is clearly inadequate at the SEP company; in fact, this is probably the most outstanding program deficit. Clients work primarily independently, frequently in physical isolation from one another, with only a 15minute break in which to congregate. For the four patients who left the company to return to the hospital work programs, social isolation was clearly a large motivating factor. One study has shown that persons with mental illness are more likely to remain employed in situations characterized by work that requires a working relationship with others; apparently "the need to make self-evaluations in relation to other workers is why non-isolated work fared better, in contrast to some earlier thinking which stressed the need for isolated work opportunities."6 The Supported Employment Program site also falls short on Barris's concepts of arousal potential, those environmental variables that determine how likely a person is to attempt a
Table 1. A Client Comparison of CVAP Versus SEP Experiences Ratings by Number of Respondents, n = 20 High
Similarity to previous nonhospital work Amount of pressure from job Amount of pressure from supervisor Amount of responsibility Amount of criticism Amount of praise Degree ofjob difficulty General job satisfaction
Medium
Low
CVAffSEP
CVAffSEP
CVAffSEP
2/7 3/5 4 / 6 5/8 o/ 4 lO / 7 1/ 2 5/4
8/5 lO/1I II / 12 II / 7 9/7 lO / 7 lO/1I lO/lO
lO / 8 7/4 5/2 4/5 II / 9 o/ 6 9/7 5 / 6
Enclave Model for the Psychiatrically Challenged
performance, the match between volition and environment. These variables include the quality or intensity of physical stimuli or so-called psychophysical properties, ecological variables or the meaning an event has to a person, and finally, collative variables: properties of the setting such as novelty, complexity, incongruity, and ambiguity. S The arousal potential in general is somewhat limited in the stationery warehouse atmosphere. Ecological variables, in particular, are a concern in this setting, with its significant population of other disabled workers and its concentration of repetitive, isolated, and somewhat personally meaningless tasks. Roann Barris proposes that when a setting's innate value and interest resonate with those of its client, there is a greater chance of a person's satisfaction and sense of efficacy in his or her environment. S The ecological limitations of the SEP site contrast rather sharply with some of the real ecological strengths found in the hospital work programs: the potential value and meaningfulness to people of a thrift shop that recycles merchandise; a greenhouse, which provides the opportunity to grow and nurture plants; or even the coffee shop, which offers the chance to feed people. It should be noted that clients differentiated the SEP experience from the hospital Clinical Vocational Assessment Programs in ways that are also positive and/or appropriate. The SEP was regarded as slightly more similar to previous, nonhospital competitive work experiences in which clients had participated. The SEP environment was also perceived as more pressured in terms of supervisory demands, as slightly more critical, and as offering less positive reinforcement or praise. These are largely appropriate differences from the perspective of Roann Barris's environmental concept of the trajectory of increasing occupancy.5 This is the notion that as people master the performance expectations in one setting, they will usually seek new settings in which to both practice their acquired skills and increase their skill repertoire. Obviously, some similarity between settings is necessary to facilitate the transfer of behavior, but if they are too alike, the oppor-
23
tunity for new learning and behavior will be stunted. s More than two-thirds ofthe client respondents regarded the CVAP experience as helpful in preparing them for the Supported Employment Program in the community, as illustrated in some of the following comments: "CVAP made me stronger." "Built up my confidence and perseverance." "Helped me recognize more areas that I really needed to work on. I saw the inconsistencies of my attendance and not calling in .... It was a good start." 'lust enough for me at the time." "I did a lot of crucial growing up III the CVAP." "Showed I could handle the SEP." Despite many of the perceived similarities between the CVAP and SEP experiences, clearly the Supported Employment Program was viewed as a manageable step beyond the more sheltered hospital work programs. Seventy percent ofthe clients rated SEP as the more helpful ofthe two vocational experiences. "Having support in a real job setting has been extremely beneficial," one client commented. Other client comments on the SEP included "higher paying," "more responsibility," "helped prepare me and provided references," and "helped me find a job and realize what I could do." One client remarked of her SEP experience, "I've had to be more independent." Another client noted that she was "not so appreciative of the CVAP because I had not been far enough in my recovery to see the benefits that I could have gained. It was much more difficult for me to take it seriously because I could not see the thrift shop as a real job. CVAP is a good way to help people right when they get out of the hospital. The TEP was more of a challenge to me becuase I looked at it as being a real job with distinct responsibilities." In summary, some recent research suggests that the more traditional, gradual approaches in vocational rehabilitation may be allowing at least some clients to remain away from work too long, thereby enhancing their fears of failure
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W 0 R K / WINTER 1991
and allowing them to become too dependent on the support system. 6 There is little data to support the assumption that vocational rehabilitation programs can be used only after the clients' symptoms have stabilized, but (as noted earlier) there are clinical experiences to suggest that for some people a work setting can actually have the effect of stabilizing symptom status. 6
Supported employment is not a vocational panacea, of course, but it is an important option, another strata of vocational programming that can serve as an appropriate sequel to hospitalbased vocational rehabilitation and maximize paid employment outcomes for a challenging population.
REFERENCES 1. Anthony WA, Blanch A: Supported employment for persons who are psychiatrically disabled: An historical and conceptual perspective. Psyclwsocial Rehab J 1987; 11: 5-23. 2. Bond G: Supported work as a modification of the transitional employment model for clients with psychiatric disabilities. Psychosocial Rehab 1987; 11:55-73. 3. Kielhofuer, G: Occupational function and dysfunction. In G Kielhofuer (ed): A Model of Human Occupation: Theory and Application. Bal-
timore: Williams & Wilkins, (1985), pp 63-75. 4. Black BJ: Work and Mental Illness: Transitions to Employment. Baltimore: Johns Hopkins University Press, 1988. 5. Barris R: Environmental interactions: An extension of the model of occupation. Am J Occup Ther 1982; 36: 637-656. 6. Ciardiello JA, Bell MD: Vocational Rehabilitation of Persons with Prolonged Psychiatric Disorders. Baltimore: Johns Hopkins University Press, 1988, p. 40.
Enclave Model for the Psychiatrically Challenged
25
Appendix A CVi\ffSEP SURVEY This survey asks participants to compare and contrast their CVAP (greenhouse, thrift shop, coffee shop, office!library) experiences with the Supported Employment Program (SEP). 1. Which CVAP did you attend? (Check as many as apply.)
_ _ Greenhouse
_ _ Thrift shop
_ _ Coffee shop
_ _ Office/library
2. How long did you participate in CVAP? _ _ Less than 3 months
_ _ 3 to 6 months
_ _ 6 months or more
3. What were your goals for participating in CVAP?
4. Overall, would you say that you met your goals? _ _ Yes _ _ No Whydoyouthinkso? _________________________________________________________
5. Please rate CVAP according to the following items. (If you attended several, please rate the one in which you spent the most time.)
High
Medium
Low
Similarity to previous nonhospital work experiences Amount of pressure on workers from job demands Amount of pressure on the workers frOIJl the supervisor Amount of responsibility given to the workers Amount of criticism from the supervisor Amount of praise or support from the supervisor Degree of job difficulty General job satisfaction 6. My contact with coworkers was: _ _ Satisfactory _ _ Unsatisfactory. Please explain: _____
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W 0 R K / WINTER 1991
7. What did you find the most frustrating? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~ostfun?
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
~ostch~len~ng?---------------------------------
8. Please rate the SEP experience according to the following items: High Similarity to previous nonhospital work experiences
Medium
Low
Amount of pressure on workers from job demands Amount of pressure on the workers from the supervisor Amount of responsibility given to the workers Amount of criticism from the supervisor Amount of praise or support from the supervisor Degree of job difficulty General job satisfaction 9.
~y
contact with coworkers was ______ Satisfactory ______ Unsatisfactory.
Please explain. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 10. What did you find the most frustrating? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~ostfun?
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
Enclave Model for the Psychiatrically Challenged
27
Most challenging? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
11. In what ways have the two programs (SEP and CVAP) been different? _ _ _ _ _ _ _ _ _ __
12. In what ways have the two programs been alike? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
13. If you had to pick one, which experience has been more helpful to you and why? _ _ _ _ __
14. Did the CVAP experience help to prepare you in any way for the SEP? Yes _ _ No _ _ Please explain. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
15. If you have terminated with the SEp, please note the reason(s). _ _ _ _ _ _ _ _ _ _ _ _ __
16. Any additional comments about the two experiences would be appreciated. _ _ _ _ _ _ _ __
