Transcript Improving Employment Outcomes for Individuals with

Improving Employment
Outcomes for Individuals
with
Psychiatric Disabilities
Charles Bernacchio, Ed.D., CRC
Eileen J. Burker, Ph.D., CRC
University of North Carolina at Chapel Hill
Consultants: Martha Brock, Freelance Writer
Laurie Coker, Director of NC Consumer
Advocacy Network and Support Organization
October 6, 2011
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Psychiatric Disabilities
• Schizophrenia, Major Depressive Disorder, and Bipolar
Disorder are 3 types of mental health or psychiatric
disabilities.
• In order to empower individuals with psychiatric
disabilities, rehabilitation professionals need to
understand the symptoms associated with these
disabilities.
• The Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR) is a guide that provides basic
information about the symptoms of these disabilities.
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DSM Criteria: Schizophrenia
• Two (or more) of the following, each present during a 1-
month period:
 delusions
 hallucinations
 disorganized speech (e.g., frequent derailment or
incoherence)
 grossly disorganized or catatonic behavior
 negative symptoms, i.e., affective flattening, alogia, or
avolition
• Social/occupational dysfunction: One or more areas of
functioning are markedly below the level achieved prior
to the onset.
• Duration: Continuous signs of the disturbance last for at
least 6 months.
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DSM Criteria: Major Depressive
Disorder
• Presence of a single Major Depressive Episode
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How does the DSM define a
Major Depressive Episode?
5+ of the symptoms and 1 of the symptoms is
either depressed mood or loss of interest or
pleasure.
• depressed mood most of the day, nearly every day
• markedly diminished interest or pleasure in all, or almost
•
•
all, activities most of the day, nearly every day
significant weight loss when not dieting or weight gain or
decrease or increase in appetite nearly every day.
insomnia or hypersomnia nearly every day
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How does the DSM define a
Major Depressive Episode?
•
•
•
•
psychomotor agitation or retardation
fatigue or loss of energy nearly every day
feelings of worthlessness or excessive guilt
diminished ability to think or concentrate, or
indecisiveness, nearly every day
• recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing suicide
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DSM Criteria: Bipolar Disorder
• Presence of only one Manic Episode and no
past Major Depressive Episodes.
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How does the DSM define a
Manic Episode?
• A distinct period of abnormally and persistently elevated,
expansive, or irritable mood, lasting at least 1 week.
• During the mood disturbance, 3+ of the symptoms are
noted:
 inflated self-esteem or grandiosity
 decreased need for sleep
 more talkative than usual or pressure to keep talking
 flight of ideas or racing thoughts
 increase in goal-directed activity or psychomotor
agitation
 excessive involvement in pleasurable activities that
have a high potential for painful consequences
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Employment is important to
individuals with psychiatric
disabilities…
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Impact on Vocational
Functioning
Schizophrenia:
• Work is a goal for most people with SMI
•
•
(Bush et al., 2009)
Unemployment rates range from 60 to 90%
(Bond & Drake, 2008; Salkever, et al., 2007).
Factors associated with better vocational outcomes:
greater insight (Lysaker et al, 2002), awareness of
mental illness, better verbal memory and lower general
psychopathology, fewer positive and negative symptoms
(Giugiario, et al., 2011)
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Impact on Vocational
Functioning
Major Depressive Disorder:
• depression has an negative effect on employment; it is
•
•
associated with job loss, absenteeism, & decreased atwork job performance & productivity
treatment can reduce the impact of depression on work
performance
the impact on job performance may persist even after
depression symptoms have improved (Adler, et al.,
2006)
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Impact on Vocational
Functioning
Bipolar Disorder:
• Unemployment rates are high, despite high levels of
•
education (Wingo, 2010)
More education, fewer years of illness, and being
married were associated independently with functional
recovery (Wingo, et al., 2010)
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People with psychiatric
disabilities want to work
“Courage doesn't always roar. Sometimes
courage is the quiet voice at the end of
the day saying, "I will try again
tomorrow.”
Mary Anne Radmacher
http://thinkexist.com/quotes/mary_anne_radmacher/
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Gaps in VRC Preparation
• Persons with PD present unique challenges to VR
•
•
counselors (VRCs); various conditions include severe
persistent mental illness (SPMI) with other co-morbid
diagnoses (substance abuse)
Studies reveal VRCs are poorly prepared to serve this
group. (Lee et al. 2005; Chan et al. 2003)
Infusing psychiatric rehabilitation practices into pre- and
in-service VRC training has long been advocated in the
field. (Nemec et al. 2001; McReynolds & Garske, 2003;
and Lee et al. 2005)
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The Critical Role of VRCs
• PD population’s weak participation rate in VR due to
•
•
false beliefs of high costs needed to maintain them in
jobs. (Baron, 2000; Casper & Carloni, 2007)
Ave. per capita costs are less for all PD conditions in
VR (except eating dx.) than overall VR clients
associated w/ successful employment.
Despite fear over VR costs for persons w/ PD, evidence
reveals people w/ PD are less costly to serve than all
other VR populations (Cimera 2008 & 2009)
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Persons with SPMI
• Among all other groups of persons w/ PD, people w/
•
Schizophrenia had higher rates of successful
employment. (2002-2006)
Comparing wages earned/hours worked, one PD group
(*Persons w/ Schizophrenia) had higher per capita
costs than overall VR population when factoring their
lower wage-jobs and greater PT work for costbenefit. (Cimera 2008 & 2009)
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What Are Evidence-Based
Practices?
• Services that have consistently demonstrated their
effectiveness in helping people with mental illnesses
achieve their desired goals
• Effectiveness was established by different people who
conducted rigorous studies and obtained similar
outcomes
SAMHSA, 2011
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Examples of Evidence-Based
Practices
•
•
•
•
•
Illness Management and Recovery (IMR)
Integrated Treatment for Co-Occurring Disorders
Supported Employment (IPS)
Assertive Community Treatment (ACT)
Family Psychoeducation (FPE)
• SAMHSA toolkits
http://store.samhsa.gov/facet/Professional-ResearchTopics/term/Evidence-Based-Practices?headerForList
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What Is Illness Management and
Recovery (IMR)?
By providing information about mental
illnesses and coping skills, IMR empowers
consumers to:
• Manage their illnesses;
• Develop their own goals for recovery; and
• Make informed decisions about their treatment.
*IMR strategies handout
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Funded by RSA Grant # H264A080021. © 2011
Conceptual Framework for Illness
Management Recovery Program
Program
Proximal Outcomes
Alcohol & Drug Use
Distal Outcomes
Objective Recovery:
Role functioning
Social functioning
Medications
IMR Program:
Biological Vulnerability:
Goal Setting
Symptom control
Education about illness
Relapse
Using medications effectively
Coping skills training
Social skills training
Stress
Relapse prevention training
Coping
Skills
Social
Support
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Subjective Recovery:
Perceived recovery
Sense of Purpose
Personal agency
Meaningful
Activities
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How is IMR provided?
 Consumers meet weekly w/ IMR staff either individually
or as a group for 3 to 10 months
 Staff distribute/review HOs w/ consumers during
sessions
 Various interventions1) Psychoeducation: basic info about SPMI & treatment
2) Behavioral tailoring (for consumers who choose to
take medication): strategies to help to better manage
daily meds
3) Relapse prevention: triggers, early warning signs
and prevention plan
4) Coping skills training: learn effective strategies to
manage symptoms
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Funded by RSA Grant # H264A080021. © 2011
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What is Family Psychoeducation?
• Family Psychoeducation (FPE) is a structured approach
for partnering with consumers and families to support
recovery.
• Consumers and families receive information about
mental illnesses and learn problem-solving,
communication, and coping skills.
*Family SMI Burden Issues handout
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How Is FPE Provided?
1. Joining Sessions is to learn about experiences with
2.
3.
SPMI, their strengths and resources, and their recovery
goals
1-day educational workshop based on a standardized
curriculum to address needs
Ongoing sessions that use a structured problemsolving approach to address current issues consumers
and families face (9+ mos. for single or multi-family)
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Funded by RSA Grant # H264A080021. © 2011
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Who gets Assertive Community
Tx?
ACT is intended for people with:
• Severe and persistent mental illness/SPMI
• Significant difficulty doing the everyday things needed
to live independently in the community, or
• Continuously high-service need
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Assertive Community Treatment
(ACT) ACT practice principles• A team approach
• A shared caseload
• In vivo services (in real
world settings)
• Flexible service
delivery
• A small caseload
• Fixed point of
responsibility
• Time-unlimited services
• Crisis management
available 24 hours a
day,
7 days a week
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Funded by RSA Grant # H264A080021. © 2011
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What Is Supported Employment?
• Supported Employment (SE) helps people with mental
illnesses find and keep meaningful jobs in the community
• The jobs exist in the open labor market, pay at least
minimum wage, and are in work settings that include
people who are not disabled
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Practice Principles of SE (IPS)
• Eligibility is based on
consumer choice
• Personalized benefits
counseling is important
• Supported
Employment services
are integrated with
comprehensive mental
health treatment
• Job search starts soon
after consumers express
interest in working
• Competitive
employment is the goal
• Follow-along supports are
continuous
• Consumer preferences are
important
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Recovery-Oriented ApproachesAssumptions
Assumptions About Recovery
• Recovery can occur without professional intervention.
• Recovery can occur even though symptoms reoccur.
• Common to recovery are people who believe in and
stand by the person who needs to recover.
• Recovery demands that a person w/ SPMI has choices.
• Recovery from consequences of the illness is sometimes
more difficult than recovering from the illness itself.
• Recovery is a unique process
Anthony (2000). A recovery-oriented service system: Setting some
system level standards. Psychiatric Rehabilitation Journal, 24 (2),
159-168.
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Recovery-Oriented Approaches
Recovery & Independent Living Requires
Symptom Management
• Learn to make own decisions in collaboration w/ other
•
•
•
supportive people including VR counselor or family
(external to mental health).
Develop meaningful, fulfilling network of friends/supports
outside of paid professional staff.
Achieve major social role/identity i.e., employee,
spouse/parent, student, friend.
Meds are tools freely chosen to assist in one’s daily life
(similar to an adaptive aid).
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Recovery-Oriented Approaches
(cont.)
Recovery & Independent Living Requires
Symptom Management
• Express and understand emotions to degree that one
•
•
can cope w/ severe emotional distress without
interrupting a social role and without the distress being
labeled symptomatic.
Global Assessment of Functioning (GAF) scale of
greater than 60 (i.e., 61+).
Sense of self is defined by the person through life
experiences and interactions w/ peers.
Dr. Dan Fisher, MD, National Empowerment Center (2011)
www.power2u.org
*IMR strategies handout
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Medication Adherence
A Complex Process
• Partnership (professionals & consumers) to help
psychiatric clinicians get prescribed meds right in treating
SMI symptoms effectively.
• Incumbent on professionals to be cognizant of reported
experiences w/ meds, e.g., changes in affect or behavior.
• Side effects are difficult to tolerate- difficulties
remembering, and concentrating, being fatigued, sleeping
too much, feeling restless and putting on weight.
• Consumers stop following prescribed meds to selfmedicate can be in response to different issues, e.g.,
effectiveness, cost, more tolerable and perceived to have
benefit (relieving stress) that are all factors in decisions of
whether to stop taking meds.
*Reclaiming your power . . . By Pat Deegan (2002) 5 Strategies to Prepare for Psychiatrist
www.power2u.org
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Stigma: Public & Self-Perception
Stigma is a major barrier to rehabilitation
goals.
Public Stigma: when people with power don’t extend
opportunities and this blocks a person’s life opportunities
Self-stigma: when someone with a mental health disability
internalizes the stigma of mental illness
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Figure1: Two Factors That May Influence
Whether a Person Who Might Benefit From
Mental Health Treatment Seeks It
Public Stigma
Stereotype
All people with mental illness are
dangerous
Prejudice
I agree, people with mental illness are
dangerous and I am afraid of them
Discrimination
I do not want to be near them: don’t hire
them at my job
Avoid the label, escape
public stigma
Self-Stigma
Stereotype
All people with mental Illness are
incompetent
Prejudice
I have a mental illness, so I must be
incompetent
Discrimination
Why should I even try to get a job: I’m
incompetent mental patient
Don’t go to treatment, don’t
suffer self stigma
Treatment seeking
Ongoing participation in treatment
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Suggestions & Recommendations
for Rehabilitation Counselors
• Consider power of supports (including peers) and the
•
•
importance of engaging consumers to be actively
involved in their rehab. plan.
Recovery involves learning effective self-advocacy and
self-determination.
Wellness & Recovery Action Plan (new addition to EBP)
provides skill development and illness management
facilitated through peers.
Cook, J. A., Copeland, M. E., Hamilton, M. M., Razzano, L. A., Hudson,
W. B., Grey, D. D., Macfarlane, R. T., Floyd, C. B., & Jonikas, J. A.
(2009). Initial outcomes of a mental illness self-management
program based on wellness recovery action planning. Psychiatric
Services, 60 (2), 246-249.
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Suggestions & Recommendations
for Rehabilitation Counselors (cont.)
• Focus of IMR involves: psycho-education, behavioral
•
•
tailoring, relapse prevention and coping skills to help
consumers manage SPMI.
VRCs play key part in helping people w/ SPMI to achieve
recovery and live meaningful lives.
Employment is fundamental to facilitating recovery for
most people with SPMI; work has a therapeutic benefit
improving clinical outcomes as well as vocational
outcomes.
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Funded by RSA Grant # H264A080021. © 2011
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References
• Bond, G. (1998). Principles of individual placement and support model:
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Empirical support. Psychiatric Rehabilitation Journal, 22, (1), 11-23.
Bond, G. & Drake, R. (2008) Predictors of competitive employment among
patients with schizophrenia. Current Opinion Psychiatry 21:362–369
Bush P, Drake R, Xie H, McHugo G, Haslett W (2009) The longterm impact
of employment on mental health service use and costs for persons with
severe mental illness. Psychiatric Services 60:1024–1031
Chan, F. et al. (2003) Training needs for rehabilitation counselors for
contemporary practices. Rehabilitation Counseling Bulletin, 46, 82-91.
Cimera, R. (2009). Outcomes and costs for vocational rehabilitation
consumers with mental illness, Journal of Applied Rehabilitation
Counseling, 40 (2), 28-33.
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Funded by RSA Grant # H264A080021. © 2011
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References
• Cimers r. (2008). The costs of providing supported employment
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•
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services to individuals with psychiatric disabilities. Psychiatric
Rehabilitation Journal, 32 (2), 110-116.
Corrigan, P. (2004). How stigma interferes with mental health care,
American Psychologist, 59 (7), 614-625.
Deegan, P. (2002). Reclaiming your power during medication
meetings with your psychiatrist, The Rights Tenet, spring/summer
2000, pp 14-15, 18. [publication of the National Association of Rights
and protection, Box 4664, Lawrence KS 66046-1661.
Drake, R.E., Merrens, M.R., & Lynde, D.W. (2005) Evidence-based
mental health practice, New York, NY: W.W. Norton and Company.
Fisher, D. (2011). What are the characteristics of a person who has
recovered from mental illness? retrieved from
http://www.power2u.org/articles/recovery/characteristics.html on
Sept. 28, 2011, National Empowerment Center, Inc.
TACE Center: Region IV, a project of the Burton Blatt Institute.
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More References
• Furlong, M., Leddy, J. & Ferguson, J. (2009). Assertive community
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treatment and recovery at Thresholds, American Journal of
Psychiatric Rehabilitation, 12, 108-123.
Giugiario, M., et al. (2011) Cognitive function and competitive
employment in schizophrenia: relative contribution of insight and
psychopathology, Soc Psychiatry Psychiatr Epidemiol DOI
10.1007/s00127-011-0367-7.
Lee, G. Ingraham, K., Chronister, J. Oulvey, E. & Tsang, H. (2005).
Psychiatric rehabilitation training need of state vocational
rehabilitation counselors: A preliminary study, Journal of
Rehabilitation, 71 (3), 11-19.
McFarlane,W.R., Multifamily groups in the treatment of severe
psychiatric disorders, New York, NY, Guilford, 2002.
McReynolds, C. & Garske, G. (2003). Psychiatric disabilities:
Challenges and training issues for rehabilitation professionals,
Journal of Rehabilitation, 69 (4), 13-18.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2011
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More References
• Miller, A. (2005). Medication adherence, In Drake, R.E., Merrens, M.R., &
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Lynde, D.W., Evidence-based mental health practice, New York, NY: W.W.
Norton and Company.
Mueser, K., Drake, R.,& Noordsky, D. (1998). Integrated mental health and
substance abuse treatment for severe psychiatric disorders. Journal for the
Practice of Psychiatry and Behavioral Health, May, 129-139.
Mueser, K.T. & Glynn, S.M., Behavioral family therapy for psychiatric
disorders, Oakland, CA, New Harbinger Publications, 1999.
Meuser, K., Myer, P., Penn, D., Clancy, R., Clancy, D. & Salyers, M. (2006).
The illness management and recovery program: Rationale, development and
preliminary findings, Schizophrenia Bulletin, 32(1), 32-43.
Salkever, D., Karakus, M., Slade, E., Harding, C., Hough, R., Rosenheck, R.,
Swartz, .M, Barrio, C., & Yamada, A. (2007). Measures and predictors of
community-based employment and earnings of persons with schizophrenia in
a multisite study. Psychiatric Services 58:315–324
Nemec, P. Spaniol, L. & Dell Orto, A. (2001). Psychiatric rehabilitation
education, Rehabilitation Education, 15 (2), 115-118.
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Funded by RSA Grant # H264A080021. © 2011
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Comments & Questions
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Contact Information
Charlie Bernacchio
Assistant Professor, Coordinator Rehabilitation
Counseling - University of Southern Maine
Email: [email protected]
Eileen Burker
Associate Professor/Director, Rehabilitation
Counseling & Psychology- University of North
Carolina at Chapel Hill
Email: [email protected]
41
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Upcoming Webinars
Improving Employment Outcomes for
Individuals with Mental Health Disabilities
• December 1 – Adults with SMI, Substance Use/Abuse
•
•
and Corrections
February 2 – Career Exploration, Development and
Planning for Consumers w/ SMI
March 9 – Job Development, Placement & Support
Strategies for Consumers w/ SMI
42
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Education Credits
CRCC Credit - (1.0)
Approved by Commission on Rehabilitation Counselor
Certification (CRCC)
• By Friday, October 14, 2011, participants must score
80% or better on a online Post Test and submit an
online CRCC Request Form via the MyTACE Portal.
My TACE Portal: TACEsoutheast.org/myportal
**For CRCC credit, you must reside in the 8 U.S. Southeast states served by
the TACE Region IV [AL, FL, GA, KY, MS, NC, SC, TN]. If beyond TACE Region
IV, you may apply for CEU credit.
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be the change you want to see in the world
THANK YOU!
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Southeast TACE (Region IV)
Toll-free: (866) 518-7750 [voice/tty]
Fax: (404) 541-9002
Web: TACEsoutheast.org
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Disclaimer
This presentation was developed by the
TACE Center: Region IV ©2011 with funds from
the U.S. Department of Education, Rehabilitation
Services Administration (RSA) under the priority of
Technical Assistance and Continuing Education
Projects (TACE) – Grant #H264A080021. However,
the contents of this presentation do not necessarily
represent the policy of the RSA and you should not
assume endorsement by the Federal Government
[34 CFR 75.620 (b)].
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A080021. © 2011