Abstract
As a result of mental health reform, there have been widespread changes to service delivery. However, concerns have been raised that current services fall far short of the strategy vision for Australia [1]. As one of the future directions that should be prioritized, the Evaluation of the National Mental Health Strategy recommended strengthening rehabilitation and personal recovery [1]. This report stated that, for many people with psychiatric disability, effective treatment of symptoms needs to be accompanied by approaches that emphasize personal recovery, social integration, and rehabilitation. It was noted that the skills required to assist people with psychiatric disability to adapt to living with a chronic illness are under-emphasized in favour of models promoting the treatment of acute symptoms. It is necessary to adopt a better balance of approaches to improve long-term outcomes for individuals suffering from chronic mental illness.
A study by Jablensky et al. [2] provides information on the mental health status and the needs of the Australian population. The study highlighted the fact that psychotic disorders represent a major public health challenge in Australia. They found that there was a serious lack of community-based rehabilitation services that could provide occupational therapy, social skills training and psycho-education. It was a matter of concern that less than 20% of their study sample of individuals suffering from psychotic illness had participated in any rehabilitation activities in the past year. This report suggested that there was a need to strengthen partnerships to better provide accessible and flexible accommodation, employment, legal aid services, vocational training, andcommunitybased rehabilitation services. Without investment in effective treatments in the coming decade, direct mental health costs will top $1 billion, and many people with chronic psychotic disorders will still be living on the edge of Australian society, with only limited opportunities to be healthy and participating members of the community [3].
Work and employment are of primary importance for people with psychiatric disability. There are many benefits associated with working and having a job. These include increased satisfaction and self-esteem and an opportunity to socialize and communicate. Importantly, employment breaks the cycle of poverty and economic dependence [4]. The literature on psychiatric rehabilitation argues in favour of interventions that lead to the re-entry of the individual into competitive employment, and a service management system that incorporates well-defined pathways to recovery involving psychiatric rehabilitation and disability support services [4].
The aim of this article is to: (i) highlight the gap between psychiatric services and employment/vocational services; (ii) outline the conceptual framework of psychiatric vocational rehabilitation; and (iii) review the evidence for supported employment as a recent development for effective vocational intervention.
Psychiatric rehabilitation: definitions and goals
Rehabilitation is the process of helping people with psychiatric disability to make the best use of their residual abilities to function at an optimal level in as normal a context as possible. The goal of psychiatric rehabilitation is to ensure that the person with the psychiatric disability can perform those physical, emotional, social and intellectual skills needed to live, learn and work in the community with the least amount of support necessary from helping professionals and carers [5]. Methods employed in psychiatric rehabilitation include teaching people specific skills and developing community and environmental resources needed to support levels of functioning. A fundamental tenet of the psychiatric rehabilitation approach is that rehabilitation is designed to improve the person's competencies [5].
The goals of rehabilitation centre on adjustment to everyday life. Comprehensive rehabilitation involves assessment, training and modification of living environments in those areas of function relevant to personal and community life. These areas include self-care (including medication and symptom management), family relations, peer and friendship relations, vocational and employment pursuits, money management and consumerism, residential living, recreational activities, transportation, food preparation and choice and use of public agencies [5].
Conceptual framework for rehabilitation
Psychiatric impairment is a loss or abnormality of psychological function. These impairments can limit a person's social and vocational roles. Such impairments lead to significant disability and handicap. Disability is a restriction or lack of ability of the individual to perform a function. Handicap is a disadvantage from a disability that limits a role that can be performed by the individual. Unemployment is a prime index of handicap. For example, employment rates of only 8–15% for people with severe mental illness are generally cited and unemployment is thus the norm [6]. Stigma and discrimination can worsen handicap and are barriers to employment [3]. It can be seen therefore that the impairments, disabilities and handicaps of people with psychiatric disability are related to their psychiatric symptoms and to their vocational and social deficits.
The stress-vulnerability-protective factors model of mental illness is a helpful method of understanding influences that give rise to and perpetuate psychiatric illness as well as the ways that the individual can be assisted in recovering from psychiatric illness [5]. Stress can be psychosocial, but may also be biological (e.g. infections). Stress can precipitate psychiatric illness in a dramatic way (e.g. following psychological trauma), but chronic stress can also lead to psychiatric illness (e.g. chronic work stress, marital problems or interpersonal difficulties). Vulnerability to psychiatric disorder is usually understood as a genetic (or biological) predisposition. However, vulnerability can also be produced by chronic difficulties in childhood (e.g. childhood physical, emotional or sexual abuse) leading to disturbed attachments and personality problems. Heightened vulnerability can make an individual more susceptible to acute or chronic stress so that in very vulnerable individuals low levels of stress may induce psychiatric illness.
Protective factors are important in protecting the individual against illness and/or assisting the individual recover from illness and preventing relapse. Protective factors include personal resilience, effective coping strategies and social supports. Use of effective medication and compliance (adherence) to treatment can prevent relapse and maintain remission. Rehabilitation and vocational programmes can also be seen as protective factors assisting recovery and preventing relapse [7]. Vocational activities contribute to the recovery process in two major ways. Work is perceived as a means of self-empowerment and a sense of selfactualization [7].
Rehabilitation interventions
Assessment forms the foundation on which all psychiatric rehabilitation is built. Assessment involves a full medical and psychiatric diagnosis, a functional assessment of the individual looking for strengths, weaknesses and deficits and a resource assessment of the individual's social field and environment. A functional assessment identifies impairments, disabilities and handicaps that affect the individual's ability to engage in the repertoire of roles, relationships and occupations required in the course of daily life.
Multi-dimensional treatment involves a number of treatment domains (biological, psychological and social), which are determined by the type and stage of the disorder that is present. Treatments are designed to reduce impairments and disabilities and to enhance community support and environmental resources, in order to reduce handicap and to diminish stigma and discrimination.
A substantial improvement in impairments for many psychiatric disorders can be obtained through drug therapy. Specific psychotherapies can also reduce impairments. Cognitive behaviour therapy and interpersonal therapy are two of many psychotherapies designed to reverse deficits brought about by psychiatric illness [8]. Psychological treatments for psychotic disorders can yield indirect benefits by enhancing the use of other treatments or by improving compliance with drug treatment. Although reduction of impairment is important, it is salient to note that there is only a weak correlation between impairment and disability in psychiatric disorders.
Research on psychosocial skills training models shows that targeted skills can be trained and maintained over time [9]. Skills training can improve disability through the basic observation that people with psychiatric disability are able to learn new behaviours. It is worth noting that premorbid and postmorbid social competence is a major predictor of response to psychiatric rehabilitation and vocational success [5]. Two types of skills are targeted in skills training programmes: goal directed coaching and problem solving skills [9], [10]. Efforts are directed to provide the individual with supporting persons, supportive settings (or environment) and ideally, both.
Skills training is the core of psychiatric rehabilitation. People with psychiatric disabilities can learn skills and skills acquisition is related to general rehabilitation outcome. Skill development improves rehabilitation results, diminishes the demand for clinical services and increases the likelihood of gaining employment [3]. The preliminary outcomes from the Blankertz and Robinson study [6] of people with severe mental illness, suggested that individuals with psychiatric disabilities can improve their vocational status within a relatively short period of time by either attaining competitive employment or becoming involved in training or work experience to prepare for competitive employment. These authors suggested that vocational rehabilitation should be an integral part of the psychiatric rehabilitation process.
Principles of psychiatric rehabilitation: vocational aspects
During the period of the community mental health movement there was the realization that a proportion of institutionalized individuals would never return to full psychosocial function. These individuals would need continued support and accommodation and their vocational capacity would be substantially limited. In response to these needs, self-help clubs developed in the US (e.g. Fountain House and Horizon House), often run by ex-patients [11], [12]. These centres provided social and vocational support for ex-patients of mental hospitals.
Transitional employment (TE) programmes in psychiatric rehabilitation emerged from the clubhouse model developed by Fountain House in 1948 [11]. The majority of these TE programmes have begun since 1980 [12]. Transitional employment is a time-limited, supported work experience that provides a sequence of transitional experiences in work for people with psychiatric disabilities. Transitional employment programmes typically operate out of clubhouses. However, clubhouses do have a number of other functions, for example providing their members with a meaningful day, educational opportunities, in-house vocational training and social/recreational options. In a TE programme, the clubhouse owns the positions rather than an individual owning the position. These positions are filled consecutively by individuals who are clubhouse members, usually over a 6-month period and frequently in a part-time capacity [5]. If the experience in a TE placement is successful, the person may graduate to competitive employment in a part-time or full-time capacity. The Australian approach to TE approximates the standard clubhouse model and reflects the close links between Australian clubhouses and Fountain House [13]. There are 10 clubhouses in Australia that have been certified by the International Centre for Clubhouse Development (ICCD), in addition to a number of other clubhouses that operate without certification [14].
Many people with psychiatric disabilities have deficits in the skills that are needed for social interaction and vocational success. The skills training era of psychiatric rehabilitation developed in the 1980s and 1990s. A large body of research supports the efficacy of psychosocial skills training for people with psychotic disorders [10]. Skills training methods are based on social learning principles and human resource development training methods and have a vocational rehabilitation focus. Skills training uses active-directive learning principles, which focus on work skills, work preparation and enhancing interpersonal skills [10]. Deficits are assessed, but the sources (aetiology) of deficits are less important than the remedial training required to help develop coping strategies. The application of skills training for vocational rehabilitation has been limited by the lack of well-trained clinicians who can impart these skills.
Supported employment (SE) programmes became a prominent part of vocational rehabilitation in the 1990s. Similarly to TE, SE is another model of service delivery that was imported from the US to Australia. The individual with a psychiatric disability is placed in a full or part-time job and is then supported by an employment consultant in order to help the person succeed in the position and retain the position indefinitely. There is usually a minimum of prevocational training. The major aim is to get the individual into a job and then support the individual as they perform their duties. A number of techniques have been developed and used to facilitate this process, including ‘choose-get-keep’, ‘job coach’, assertive community treatment and individual placement and support [15]. Unlike in the US, SE has become the most prevalent form of vocational rehabilitation for people with mental illness in Australia by gaining a major advantage over TE in funding arrangements [13]. In practice, TE has a minor role compared with SE in providing vocational rehabilitation.
In Australia, there has been a separation of clinical treatment (provided by hospital and community-based services funded by Commonwealth and state health departments) and disability support (provided by a mix of government and non-government services funded by several Commonwealth and state departments) [13]. Role delineation limits mental health services to providing clinical treatment and mainstream services to providing vocational rehabilitation. As a result, there is a low level of integration between mental health services and vocational services, which limits successful vocational rehabilitation. This separation of clinical and rehabilitation services appears to disadvantage people with a mental illness. It could be argued that people with psychiatric disabilities require more specialist services that address their need to enter the paid workforce.
These rehabilitation interventions need to be integrated so that gains made through psychiatric rehabilitation are carried over into vocational rehabilitation outcomes. This can only be achieved where mental health services have a rehabilitation focus and are closely integrated with vocational rehabilitation services. Unfortunately, this is a situation that occurs only rarely in Australia. SANE Australia's Gap Project found a ‘rehabilitation gap’ in services for people suffering from mental illness, with over 80% of those who might benefit from rehabilitation not attending programmes [16]. This study identified that in the great majority of cases (92%), psychiatrists did not refer people with psychiatric disabilities for rehabilitation. The findings suggest that lack of referral by clinicians is a key factor in the under-utilization of rehabilitation programmes, thereby withholding from people with psychiatric disabilities important choices about the levels of support available to them. We suggest that it is time to integrate vocational rehabilitation services within mental health services by either co-location of services or by having dedicated staff within mental health services, whose brief it is to provide supported employment.
Supported employment: evidence-based practice
Over the past 10 years a substantial amount of evidence has been accumulated demonstrating the effectiveness of SE for vocational rehabilitation in chronically mentally ill populations. Results from SE programmes are better than standard or traditional vocational rehabilitation approaches. There now have been eight randomised controlled trials and three quasiexperimental studies demonstrating the effectiveness of SE [15]. A number of common features link SE in all these studies. The following are characteristics of SE programmes that provide successful vocational outcomes: commitment to a competitive employment goal (not day treatment or a workshop placement); rapid job search and placement; jobs selected on the basis of individual preference and the skills and experience of the person; follow-up employment consultant support and case management is maintained indefinitely; and there is close integration of SE programmes with mental health teams [15].
Among SE programmes, prior work history is the most important predictor of ultimate success. However, characteristics that have been shown to be important in other vocational rehabilitation settings (such as age, sex, diagnosis, hospital admission history) have not shown to be predictors in the SE setting [15]. It is recognized that not all people with psychiatric disabilities benefit from SE programmes. In particular, those who do not have an employment goal are not likely to succeed. Finally, most SE jobs are part-time. Full-time employment is not the most common outcome of SE or, indeed, other forms of psychiatric vocational rehabilitation. The most salient therapist characteristic for successful vocational rehabilitation is that the therapist has a positive view of work and does not see this as an additional stress or burden for the person with psychiatric disability.
The implementation of SE across a whole system of care has shown that the rate of competitive employment placement and retention can be increased substantially. In the US state of New Hampshire, SE programmes were introduced state-wide in 1990 and over the following 10-year period the rate of competitive employment for people with chronic psychiatric disabilities undergoing rehabilitation went from 7% to 37% state-wide [15].
Conclusions
In Australia, psychiatric rehabilitation has been underutilized in favour of acute care service delivery models. Many people living with psychiatric disabilities are not gaining access to treatments and supports necessary to enable them to achieve stability and progress with the illness and lead a satisfying and fulfilling life in the community. There is a need for a re-orientation of mental health services to include psychiatric rehabilitation and to increase the rate of referral to these services. The vocational aspect of psychiatric rehabilitation is an important but neglected area of psychiatric practice. Clinicians often underestimate the need for vocational services or fear that work will be too stressful for patients. Attitudes need to change. The separation of mental health services from vocational services means that many people who might benefit from vocational assistance are denied this opportunity. Mental health services (both public and private) and vocational rehabilitation services need to be better integrated to provide optimal rehabilitation results. New methods of vocational rehabilitation such as supported employment hold promise for improving the placement of people with psychiatric disabilities in competitive employment positions.