Improving Employment Outcomes for Individuals with Psychiatric Disabilities

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1 1 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 Psychiatric Disabilities 2 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. DSM Criteria: Schizophrenia 3 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.

2 2 DSM Criteria: Major Depressive Disorder Presence of a single Major Depressive Episode 4 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 5 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 6

3 3 DSM Criteria: Bipolar Disorder 7 Presence of only one Manic Episode and no past Major Depressive Episodes. 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 8 9 Employment is important to individuals with psychiatric disabilities

4 4 Impact on Vocational Functioning 10 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) 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) 11 Impact on Vocational Functioning 12 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)

5 5 People with psychiatric disabilities want to work 13 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 Gaps in VRC Preparation 14 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) The Critical Role of VRCs 15 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)

6 6 Persons with SPMI 16 Among all other groups of persons w/ PD, people w/ Schizophrenia had higher rates of successful employment. ( ) 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) What Are Evidence-Based Practices? 17 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 Examples of Evidence-Based Practices 18 Illness Management and Recovery (IMR) Integrated Treatment for Co-Occurring Disorders Supported Employment (IPS) Assertive Community Treatment (ACT) Family Psychoeducation (FPE) SAMHSA toolkits Topics/term/Evidence-Based-Practices?headerForList

7 7 What Is Illness Management and Recovery (IMR)? 19 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 Conceptual Framework for Illness Management Recovery Program 20 Program Proximal Outcomes Distal Outcomes IMR Program: Goal Setting Education about illness Using medications effectively Coping skills training Social skills training Relapse prevention training Alcohol & Drug Use Medications Biological Vulnerability: Symptom control Relapse Stress Objective Recovery: Role functioning Social functioning Subjective Recovery: Perceived recovery Sense of Purpose Personal agency Coping Skills Social Support Meaningful Activities How is IMR provided? 21 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 interventions- 1) 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

8 8 What is Family Psychoeducation? 22 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 How Is FPE Provided? Joining Sessions is to learn about experiences with SPMI, their strengths and resources, and their recovery goals 2. 1-day educational workshop based on a standardized curriculum to address needs 3. Ongoing sessions that use a structured problemsolving approach to address current issues consumers and families face (9+ mos. for single or multi-family) Who gets Assertive Community Tx? 24 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

9 9 Assertive Community Treatment (ACT) ACT practice principles- 25 A team approach In vivo services (in real world settings) A small caseload Time-unlimited services A shared caseload Flexible service delivery Fixed point of responsibility Crisis management available 24 hours a day, 7 days a week What Is Supported Employment? 26 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 Practice Principles of SE (IPS) 27 Eligibility is based on consumer choice Supported Employment services are integrated with comprehensive mental health treatment Competitive employment is the goal Personalized benefits counseling is important Job search starts soon after consumers express interest in working Follow-along supports are continuous Consumer preferences are important

10 10 Recovery-Oriented Approaches- Assumptions 28 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), Recovery-Oriented Approaches 29 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). 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. 30 *IMR strategies handout Dr. Dan Fisher, MD, National Empowerment Center (2011)

11 11 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 31 Stigma: Public & Self-Perception 32 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 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 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 33 Avoid the label, escape public stigma Don t go to treatment, don t suffer self stigma Treatment seeking Ongoing participation in treatment

12 12 Suggestions & Recommendations for Rehabilitation Counselors 34 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), Suggestions & Recommendations for Rehabilitation Counselors (cont.) 35 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. References 36 Bond, G. (1998). Principles of individual placement and support model: Empirical support. Psychiatric Rehabilitation Journal, 22, (1), Bond, G. & Drake, R. (2008) Predictors of competitive employment among patients with schizophrenia. Current Opinion Psychiatry 21: 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: Chan, F. et al. (2003) Training needs for rehabilitation counselors for contemporary practices. Rehabilitation Counseling Bulletin, 46, Cimera, R. (2009). Outcomes and costs for vocational rehabilitation consumers with mental illness, Journal of Applied Rehabilitation Counseling, 40 (2),

13 13 References 37 Cimers r. (2008). The costs of providing supported employment services to individuals with psychiatric disabilities. Psychiatric Rehabilitation Journal, 32 (2), Corrigan, P. (2004). How stigma interferes with mental health care, American Psychologist, 59 (7), 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 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 on Sept. 28, 2011, National Empowerment Center, Inc. More References 38 Furlong, M., Leddy, J. & Ferguson, J. (2009). Assertive community treatment and recovery at Thresholds, American Journal of Psychiatric Rehabilitation, 12, Giugiario, M., et al. (2011) Cognitive function and competitive employment in schizophrenia: relative contribution of insight and psychopathology, Soc Psychiatry Psychiatr Epidemiol DOI /s 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), McFarlane,W.R., Multifamily groups in the treatment of severe psychiatric disorders, New York, NY, Guilford, McReynolds, C. & Garske, G. (2003). Psychiatric disabilities: Challenges and training issues for rehabilitation professionals, Journal of Rehabilitation, 69 (4), More References 39 Miller, A. (2005). Medication adherence, In Drake, R.E., Merrens, M.R., & 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, Mueser, K.T. & Glynn, S.M., Behavioral family therapy for psychiatric disorders, Oakland, CA, New Harbinger Publications, 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), 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: Nemec, P. Spaniol, L. & Dell Orto, A. (2001). Psychiatric rehabilitation education, Rehabilitation Education, 15 (2),

14 14 40 Comments & Questions Contact Information Charlie Bernacchio Assistant Professor, Coordinator Rehabilitation Counseling - University of Southern Maine charlieb@usm.maine.edu Eileen Burker Associate Professor/Director, Rehabilitation Counseling & Psychology- University of North Carolina at Chapel Hill eileen_burker@med.unc.edu 41 All Rights Reserved 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 All Rights Reserved

15 15 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. 43 All Rights Reserved 44 be the change you want to see in the world THANK YOU! 45 Southeast TACE (Region IV) Toll-free: (866) [voice/tty] Fax: (404) Web: TACEsoutheast.org My TACE Portal: TACEsoutheast.org/myportal tacesoutheast@law.syr.edu

16 16 46 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 #H264A 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 (b)].