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Vocational Rehabilitation in Psychiatry and Mental Health
Lyndsey Swart1 and Tania Buys2
1 Occupational Therapy private practitioner, Krugersdorp, South Africa
2 Occupational Therapy Department, School of Health Care Sciences, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
Work is an essential part of life. Not only do we spend a large proportion of waking hours engaged in work activities, but work is a means to earn a livelihood. It also gives a sense of personal identity and social contribution. Access to meaningful, paid employment is recognised as a basic human right in most countries. Health care professionals generally agree that work has therapeutic value and is fundamental to a person’s sense of well-being. Despite these widely accepted benefits of work, employment rates for people with serious or long-term mental disabilities remain low all over the world. Compared to other disability groups, people with mental illness have high rates of unemployment (Crowther et al. 2001; Zwerling et al. 2003; Jensen et al. 2005; Cook 2006; Duncan & Peterson 2007), and the World Health Organisation (WHO) and International Labour Organization (ILO) estimate a worldwide unemployment rate of 90% for people with serious mental disability (Ruesch et al. 2004).
Compelling evidence however indicates that people with mental disabilities can and should work. A growing body of research reveals that with proper interventions and supports, the majority of people with mental disabilities are ableto function in various levels of competitive employment (Grove 2001; Secker & Membrey 2003). Successful employment is associated with reduced symptoms, reduced hospital admissions, improved social skills, improved self-esteem, improved family atmosphere and greater personal independence. In fact, Hill (1995) proposed that for people with mental disabilities, one does not get better in order to work, but one works in order to get better.
The underlying principles and practices of occupational therapy lend themselves well to vocational rehabilitation. The philosophical base of occupational therapy requires a holistic approach to the client and the use of meaningful and purposeful activity as the fundamental treatment tools. In vocational rehabilitation, the same principles apply: comprehensive, holistic assessment of the client; analysis of the job and work environment; and the use of work tasks, work activities and reasonable accommodations to assist the client in fulfilling the essential job demands. ‘Work is at the heart of the philosophy and practice of occupational therapy. In its broadest sense, work, as productive activity is the concern in almost all therapy’ (Jacobs 1991, p. xi).
The effect of mental illness on a person’s ability to work
There are several intrapersonal characteristics of mental illness that interfere with work functioning including the impact of the psychiatric diagnosis itself, the episodic and fluctuating nature of mental impairment, poor social interaction patterns, cognitive dysfunction, reduced motivation and emotional impairments. These may vary significantly from individual to individual and are further influenced by social and environmental barriers (extra-personal effects).
Intrapersonal effects of mental illness onemployability
The impact of diagnosis and symptoms
Studies on the effect of diagnosis and psychiatric symptoms (abnormalities in mood, thoughts and behaviours resulting from the mental illness) on a person’s ability to work have produced mixed findings. While some researchers have found diagnosis and psychiatric symptoms to be a poor predictor of vocational outcome (Anthony & Jansen cited in MacDonald-Wilson et al. 2001), others have found diagnosis and symptoms to have a significant bearing on the ability to secure and retain employment (Arns & Linney 1993; Goldberg et al. cited in Schneider et al. 2002). These latter studies generally predict better vocational outcomes for people with mood disorders and personality disorders and poorer vocational outcomes for people with schizophrenia or psychoses. This is because people with psychotic disorders are more likely to harbour inappropriate and even false perceptions about their work aspirations, the work environment, colleagues and work in general.
There are often vast functional and prognostic differences in individuals with similar diagnoses, and cautioning against any form of stereotyping based on diagnosis or clinical presentation alone is recommended. Adequate medical management of the client and his/her medication is also an important determinant of functional outcome, as are the environmental and social barriers. It is recommended that vocational rehabilitation planning should bebased on comprehensive, multidisciplinary assessment of the client that considers both intrapersonal and extra-personal factors.
The episodic nature of mental illness
Most mental illnesses tend to be episodic in nature causing sufferers to go through periods of relative wellness followed by periods of increased symptoms and functional deterioration. While these periodic ‘ups’ and ‘downs’ are frequently predictable and preventable, they may also occur without warning and for no apparent reason, which can severely disrupt a person’s work attendance and performance. When symptoms occur unpredictably, this can also seriously undermine the worker’s self-confidence and motivation. When dealing with unpredictable fluctuations in a client’s condition, the occupational therapist should consider the following:
- Does the client have access to adequate medical treatment and management of his/her psychiatric condition?
- Is the client compliant with medication and other treatment regimes?
- Does the client have insight into his/her illness and how to deal with episodic deterioration?
- If employed, is his/her employer aware of the episodic nature of the client’s condition? Have efforts been made to recognise and control stressors that may trigger psychiatric symptoms? Have efforts been made to accommodate periodic deterioration if it can’t be prevented?
It is very important that a client’s symptoms be properly managed as excessive absenteeism can lead to disciplinary steps and eventual dismissal. In clinical experience, excessive absenteeism is one of the leading reasons why workers with mental disability lose their jobs. It is often a good idea for clients affected by episodic mental illness to disclose their condition to their employer to enable a process of reasonable accommodation to be established.
Impaired social interactions and communications
Social incompetence is another major problem affecting workers with mental illness. These people frequently experience difficulties in relating to others and may struggle to read social cues or fit in with workplace culture. Co-workers may perceive them as difficult, strange or inappropriate. They are often oversensitive to negative feedback, which they may perceive as personal criticism. Rehabilitation should include social skills training, assertiveness training and stress management. Sensitising supervisors and fellow workers to the challenges faced by the client is often beneficial, but should only be done with the client’s consent. Depending on the size of the workforce and the nature and types of disabilities represented, disability sensitisation may take the form of a multimedia general information session, such as a film or a talk presented by a guest speaker. In smaller businesses or more intimate work teams, general team-building exercises are useful, whereby the entire work team, including the worker with mental illness, embarks on an interactive but fun activity that allows the team members to get to know one another better on a social level. If facilitated well, such personalised sensitisation sessions can go a long way to building team cohesiveness, understanding and empathy on both sides. In some instances, it may be necessary for the occupational therapist to provide information to selected colleagues and supervisors about the challenges faced by an individual. This should only be done with the express consent of the person/employee and should be factual, focused on work-related (as opposed to personal) issues and highlight positive attributes of the person with the disability.
Poor work performance
Cognitive, emotional and motivational difficulties are at the core of most mental illnesses and may affect worker’s ability to perform their essential work tasks efficiently and accurately. These workers typically have difficulty managing assignments, setting priorities or meeting deadlines. Underlying problems may include:
- Inability to sustain concentration. This often manifests in restlessness, jumping from one activity to the next, inability to complete tasks and difficulty in remembering work-related instructions and information.
- Difficulty in screening out environmental stimuli such as sounds, sights or smells, which may interfere with the worker’s ability to focus on work tasks. This problem is often aggravated by the modern trend to large, open-plan offices and work areas.
- Poor flexibility in decision-making and problem-solving abilities. The worker fails to see more than one, if any, solution to even small problems and will respond with rigidity, negativity, anxiety or avoidance. This impairs his/her ability to function independently, and they require a well-structured work environment with clearly defined roles and responsibilities.
- Poor memory, which interferes with work performance and efficiency. The worker often hasto review information he/she has already completed. This upsets the workflow. Poor memory also leads to increased errors and difficulties in processing and linking related information.
- Difficulty in organising thought processes. The worker may struggle to identify what is important in a work task leading to poor planning of work tasks, errors and inadequate control of work.
- Difficulty in controlling preoccupations or delusional thinking. Paranoia about being victimised by supervisors or colleagues is a common example.
- Problems with motivation and drive. The worker may struggle to set goals or implement action plans.
- High levels of anxiety, which may impair the worker’s ability to interact effectively with others or work independently and productively. This worker generally requires a lot of support and reassurance.
- Difficulty in responding to changes at work, for example, new rules, new job duties or a new co-worker.
- Lack of stamina. Common problems include difficulty in working a full day and drowsiness caused by medication.
The aforementioned problems often require behavioural changes, which are best offered in a comprehensive vocational rehabilitation programme.
Extra-personal effects of mental illness onemployability
Social and environmental barriers facing people with mental illness
While social and environmental barriers affect many job seekers at some point in their working career, people with disabilities, particularly people with mental disabilities, are at a particular disadvantage. This is well documented in the literature (Duncan & Peterson 2007; Loveland et al. 2007). The occupational therapist working in the field of vocational rehabilitation must beable to recognise and address these extra-personal barriers in the vocational rehabilitation process.
Job availability
Several factors can affect job availability in a society, including economic recession or downturn in a particular industry. When there are fewer available jobs, competition for employment increases, and those traditionally at the back of the employment queue are most harshly affected. For those lucky enough to be employed, there is increased risk of retrenchment when companies resort to downsizing or restructuring, particularly for low-skilled workers and those in supported employment.
Prejudicial attitudes and misconceptions about people with mental illness
Despite advances in the understanding of mental illness over the past few decades, our society still has difficulty in accepting and dealing with people living with these conditions. Misunderstanding about the nature and the cause of mental illness results in people reacting with fear, shame, guilt and embarrassment. For people living with mental illness, these reactions tend to aggravate feelings of inadequacy, poor self-esteem, rejection and loneliness, stifling their confidence and motivation to work. Prejudicial attitudes can be harboured by families, employers, work colleagues, rehabilitation professionals and people with mental disabilities themselves.
Inadequate or limited vocational rehabilitation services and facilities
Common problems with vocational rehabilitation facilities include:
- Programmes tend to be time limited and provide no follow-up support for the client. This way of functioning is entirely contrary to the reality of mental disability, which tends to be episodic and fluctuates over time in terms of severity and impact (Noble et al. 1997). Vocational rehabilitation services should therefore be restructured to offer ongoing support and follow-up.
- Poor integration of medical and vocational rehabilitation services. When there is poor or no communication between acute psychiatric rehabilitation professionals and vocational rehabilitation professionals, the gains made in acute psychiatric rehabilitation are often reduced or lost. Services are also often unnecessarily replicated. This is costly and time-consuming for all involved.
- Many insurance schemes tend to put their energies and resources into determining eligibility for compensation as opposed to rehabilitating people for return to work. This is evident in the strong focus on functional capacity evaluation (FCE) offered by most vocational rehabilitation professionals and facilities in South Africa today. While many insurers have started offering return-to-work benefits in their insurance products, these have not been sufficient to motivate the vocational rehabilitation industry to include job placement and follow-up in its portfolio of services.
- Occupational therapists in the field of vocational rehabilitation frequently come from a physical rehabilitation background and may lack skill in the special needs of people with mental illness. These professionals often unwittingly reinforce stigma by holding faulty ideas about the nature of mental illness and by fostering low vocational expectations for their clients (Garske & Stewart 1999; Lloyd & Waghorn 2007).
Disability benefits often provide a disincentive to work
Sick leave is usually recommended for clients with mental illness whilst they undergo assessment and intervention. Should this sick leave exceed the legal recommendations, extended leave may be implemented, and it is during this time that the client may receive disability benefits from an insurer or from the state in order to replace their salaried income. Through experience, many of these income replacement benefits contain a clause stipulating that if the recipient earns even a nominal income, the benefit will be discontinued. Such benefits serve to discourage a person with a disability from returning to work in either a full- or part-time capacity during the recovery process.
Predictors of employment success
Considerable research has been conducted on factors that promote successful employment in persons with mental illness. In a review of the literature, Tsang et al. (2000) found premorbid functioning and particularly previous work history to bethe most consistent and reliable predictors of employment success. Clients who had worked before were more likely to secure and retain employment. The better their previous work history, the greater their chances were of employment success. The same study also found social competence to be a strong and consistent indicator of vocational outcome. This is because most jobs require productive social interactions with customers, co-workers, supervisors and managers. Becker et al. (2006) found interpersonal difficulty to be the most frequently reported workplace problem leading to job terminations among people with severe mental illness.
Other noteworthy predictors of employment success are level of cognitive functioning (McGurk et al. 2003) and good family relationships. Tsang etal. (2000) found clients with supportive families more likely to adjust to the demands of work and experience employment success than clients without family support.
A vocational rehabilitation professional should consider these predictors of employment success when planning a client’s intervention (Tsang et al. 2000).
The vocational rehabilitation process
Vocational rehabilitation is a systematic process which enables the occupational therapist to facilitate employment in various work settings. Vocational rehabilitation is a process which is multidisciplinary and has many stakeholders (Finger et al. 2011).Based on the International Classification of Functioning, Disability and Health (ICF) (WHO 2001), vocational rehabilitation is described by Escorpizo et al. (2011, p. 130) as ‘a multi-professional evidence-based approach that is provided in different settings, services, and activities to working age individuals with health-related impairments, limitations, or restrictions with work functioning, and whose primary aim is to optimize work participation’. The International Labor Office (ILO) description of vocational rehabilitation (ILO 1985) identifies five steps: (1) vocational assessment, (2) vocational guidance, (3) vocational preparation and training, (4) selective placement and (5) follow-up.
Various models and theoretical frameworks canbe used during the vocational rehabilitation process as applied to clients with mental illness. These may be the Model of Human Occupation (Kielhofner 2008), bio-psycho-social model (Ross 2007), the International Classification of Functioning (ICF) (WHO 2001), the Disability Management Model (Ross 2007), Person–Environment–Occupation Model (Strong et al. 1999) and the Model of Creative Ability (Casteleijn & de Vos 2007). Occupational therapists use these models individually or in combinations, but the theoretical models indicate that the person, the working environment (context) and the specific work are important throughout the entire process.
Vocational assessment, which initiates the vocational rehabilitation process, is generally known as the Functional Capacity Evaluation (FCE) in the physical field of practice. However, the processes followed in the psychiatric field of practice are similar as the emphasis is on functional evaluation. Outcomes of the FCE vary, however, as well as the processes followed (Buys & van Biljon 2007). Vocational assessment is a continuous and ongoing process that takes place throughout the vocational rehabilitation process. Following the initial evaluation, the client’s progress is constantly evaluated and monitored to determine work readiness, placement suitability and the need for reasonable accommodations. Ongoing evaluation is particularly important in the case of people with psychosocial disabilities. Their work performance can change significantly from one day to the next due to the effects of their medication, environmental stresses and fluctuations in their condition. An effective vocational rehabilitation programme should closely monitor these changes and attempt to identify any work-related factors that could be triggering mental illness symptoms.
Using the aforementioned as a framework and following a client-centred approach which considers the complexities of the mental illness, the following steps are proposed:
Referral for vocational rehabilitation
Referral for vocational rehabilitation services for clients with mental health disorders can come from a number of sources including the treating physician, psychiatrist, employer, employee wellness practitioner, occupational health practitioner, insurer or case manager. The referral should clearly indicate the parameters for service delivery and payment. Vague or ambiguous referrals should be immediately clarified before contact is made with the client. Letters of referral should also be accompanied by comprehensive information in order to give direction to the vocational rehabilitation process. Medical reports, reports from treating practitioners, job descriptions and reports regarding workplace performance are useful and facilitate the process. This information should be disclosed to the occupational therapist with the consent of the client and the referring agent.
Preparation for the vocational assessment/functional capacity evaluation
The referral instruction will clearly indicate the purpose of the evaluation and/or further intervention. All accompanying documentation must carefully be reviewed, and its relevance to the process noted. As part of preparation, it is essential that the occupational therapist understands the mental health condition, its progress, prognostic indicators for employment and potential interventions. This will determine the evaluation process. For example, if a client presents with fatigue, it would be important to schedule an early morning appointment to assess the client’s strengths as well as a later appointment to determine what the effect of the fatigue has on work performance. Should a client’s documentation reveal anxiety, it may be appropriate to first build a therapeutic relationship with the client before assessment commences in order to manage anxiety. In this regard, an informal interviewprior to the FCE may be appropriate. Althoughthese accommodations are useful, the occupational therapist must note these, as they may not be possible in an open labour placement. In confirming the appointment, the client should be informed of what is expected of them and also requested to bring his/her medication to the evaluation. This is important to confirm medication use and compliance. It is also useful to request the client to bring curriculum vitae detailing work history as well as current job description and any available medical documentation. In preparation for the initial evaluation, the occupational therapist must also be prepared to conduct a physical assessment as there may be physical co-morbid conditions.
Preparation is concluded by drawing up the evaluation plan which documents the sequence of tests, the required observations to note and evaluation methods to be used. The occupational therapist must have a comprehensive understanding ofvarious methods of evaluation, sources of information, statistical interpretation of standardised tests as well as the value each method will contribute towards understanding the client’s strengths and limitations in terms of work functioning. Both qualitative and quantitative data are of value. The evaluation plan must allow for flexibility but should remain consistent with the requested purpose/outcome.
Selecting an appropriate venue for vocational assessment
This could be a clinic, hospital, rehabilitation setting, the client’s home or client’s place of employment. An important aspect to consider is the availability of appropriate testing tools and other requirements. Although the client’s home may be an important source of collateral information, it may not be an appropriate venue to conduct vocational assessment as the occupational therapist may not have access to appropriate assessment tools. Evaluation conducted at the place of work may draw unnecessary attention tothe client. Irrespective of the location, the occupational therapist must ensure that the evaluation can take place without distractions and that client confidentiality is ensured. Family members and employer representatives should not be permitted to sit in on the evaluation unless formally requested to do so.
Obtaining informed consent
Forensic Psychiatry and Occupational Therapy
Sensory Integration in Mental Health
