Making Work Possible for the Reluctant Person NYAPRS Conference 2010 Neil Harbus LCSW,CPRP Pathways To Housing
Agenda Defining The Population Why the Reluctance to Seek Employment? Overcoming the Reluctance
Who are We Speaking About? This could be as much as 30-40 % of the people on ACT Teams, and in Day Treatment Programs. These are people who rarely make it to VR or SE programs
Other Characteristics These are people that may be very socially isolated and marginalized in the Community These are people who may be very symptomatic and may not believe medications are necessary They may also be the Dually Diagnosed who are actively using substances (Give me a reason to stop!) Many of these clients avoid any programs with too many rules, regulations, restrictions, and pre-requisites They do not fit into the Linear Continuum of Care Model!
Why The Reluctance? Self Stigma is a major factor: The Trauma of Mental Illness Feelings of Hopelessness Numerous Losses and Traumas over the Years Perceived Failures Pervasive Negative Thoughts Positive Change does not seem to be an Option Disempowerment * Yanos 2009
Additional Factors Fear: Employment might bring a loss of benefits Fear of any change, and the fragility of their situation Last Employment was many years ago Ongoing Obstacles in Many Life Areas Cognitive Deficits
The Flip Side- Staff Attitudes Negative Reinforcing Attitudes of the Staff: You are too fragile to work You are not ready to Work * Staff belief that providing employment services is a low priority, and is not treatment * *Waynor UMDNJ 2007
If Work Makes People with Mental Illness Sick what do Unemployment, Poverty, and Social Isolation Cause Marrone and Golowka 97
The Model Fidelity to Individual Placement and Support (IPS) Principles Use of Motivational Techniques Use of Motivational Activities Interventions based on the Trans- Theoretical Model (Stages of Change) Use of Cognitive Behavioral Techniques especially in the area of reversing Negative Thoughts
Use of the Model Jonathan Larson Illinois Institute of Technology -2006-2x as many job offers as people move through each Stage., Use of MI leads to stage change more quickly for clients. Carlo Di Clemente Ohio SE Coordinating Center of Excellence -Case Western Reserve Univ. advocates and puts forth this model NJ Study 2007 2.5x better outcomes using this model
Individual Placement and Support Principles Zero Exclusion Benefits Counseling is Provided Consumer choice in job selection Rapid Job Search Competitive Employment is the Goal Supports are Time Unlimited Integration of Employment with other Treatment Services
Why Use Stages of Change? Especially Effective when a Team is Providing Services-Provides a Common Descriptive Language that Translates into common Practice Ensures that the Team is on the same page in providing services, and in their interventions Aids in Service Planning and Documentation Provides a method for measuring progress for both the Individual and Team.
Why Motivational Interventions? Helps the person start to believe in themselves again, and that a better quality of life is possible Reestablishes hopes and dreams in the individual Puts the Client in the drivers seat on considering change, deciding the pace of the work and the direction in which it goes
Stages of Change The clients in question fall primarily in the Pre-Contemplation Stage In the Pre-Contemplation Stage: The client is not open to nor thinking about the possibility of work at all Some may fall in the Contemplation Stage are starting to think about work,but are very ambivalent about making an active change. Sometimes they are just telling us what they think we want to hear.
Pre-Contemplation: Supported Employment Interventions Assertive Outreach Patience Engagement,Engagement, Engagement-Build Trust and a Working Alliance Having Open-Ended Conversations on less threatening but related topics (Education/Financial Empowerment) Let Consumer tell His or Her Life Story- Focus on Unique Qualities, Interests, Skills, Talents, and Work History Explore long-term and short term goals Consciousness Raising-Employment is Possible Reconnect to the Community
Practical Activities Assist people with solving their most pressing and immediate issues: food, clothing, finances, shelter People don t usually think about work until basic living issues are under control Provide Benefits Counseling that is easily understandable, practical, and satisfies the client s questions Coordinated Team approach
Motivational Interventions Helping people to feel hopeful again about their situation, and the possibility of change: guided conversations Possibilities Challenge is to bring the issue into awareness again Setting and achieving small goals to increase self esteem and feelings of competence Involvement in Wellness Programs: IMR,WSM,WRAP etc. Incredibly powerful tools in increasing feelings of self esteem, self competence, and that change is possible Use of Specialized Curricula to address trauma and loss especially those with co-occurring disorders
Motivational Interventions Increasing empowerment: Taking Charge of ones life Increased decision making, greater independence in activities Develop discrepancies Non-Confrontational approach Affirm past successes and applicable work place skills such as resilience and survival skills Encourage Reevaluation of situation Plant The seeds of change Uninformed or Under informed of the consequences of lack of change or negatives of being stuck Non Threatening, Non Judgmental approach, Unconditional Acceptance
Motivational Activities Exposure to others that are working- Invitations to Alumni Dinners, or plan an Engagement Get Together Use of collaterals to reinforce that work is possible, work as a positive value, a part of citizenship, a way to give back, a way to realize hopes and dreams, a way toward independence Reconnect to the Community: Exposure to resources in the community especially places where work is going on Meet in the Community
Employing CBT to Reverse Negative Beliefs These negative beliefs (NBs) about the self significantly predict poor rehabilitation outcomes(lecomte,et al.,1999) NB s have been linked to other behaviors that may compromise vocational functioning, including more avoidant coping, poorer participation in treatment, and generally poorer social functioning (Davis,Lysaker, et al.,2005)
CBT Interventions Regarding NB s Identify and Gradually reinterpret Dysfunctional (Negative) Thoughts. These are thoughts that are not based in reality and not a true appraisal of our ability, commitment, our worth These become Automatic Thoughts over time, and hold us back from attempting changes * Beck,J.S. 95
Core Beliefs Our world view, fundamental understandings. So fundamental we often don t articulate them even to ourselves. CBT helps individuals identify and change or modify their core beliefs. Beck,J.S. 1995 These core beliefs can also be impacted by our life experiences, for example living with psychiatric disabilities and the messages received from society, family, providers, internalized stigma Beck,J.S. 1995
Use of CBT Target Negative Thoughts and Beliefs about ourselves as a worker I cannot Work, I can t succeed Target negative thoughts and beliefs about our work experiences e.g., My boss criticized me, she must not like me). Davis, Lysaker et al. 2005
Identifying Core Beliefs about Employment In the past what messages have you received about your ability to go to work Have those messages been positive or negative? From Whom Did you receive these messages What do you believe about your ability to be successful at work? What do you tell yourself about your ability to be successful at work? How might you go about changing the negative beliefs that you have about going to work to more positive ones. SAMHSA Self Esteem Booklet
Identifying and Challenging Our Negative Thoughts: The Four A Method Step 1: Be Aware of inaccurate, unhelpful thoughts and resultant feelings Step 2: Answer inaccurate, unhelpful thoughts with more accurate,helpful thoughts Step 3: Act based on more accurate, helpful thoughts which will increase the likelihood for success Step 4: Accept that you will make mistakes, and don t have to be perfect. Accept that you are of value rather than being at odds with yourself. Davis and Lysaker 2006
Changing Negative Thoughts to Positive Ones Identify Negative Thoughts Check the Validity of the Negative thought Is it really true? Would a person who cares about me be thinking this about me? Ask other people you trust if this negative thought is true? What do you get out of thinking the negative thought? Develop Positive thoughts to contradict the negative ones. Reinforce the positive thoughts Many Thanks to Bill Burns-Lynch MA,CPRP IEI,UMDNJ for CBT Material
Actual Use of the Model 2 PACT Teams in NJ- went from 5% to 30% competitive employment over 18mos.with a significant number starting in the pre and contemplation stage of change 2 ACT Teams in NYC,went from 7% to 30% overall employment over 2 yrs with almost half of the participants starting in pre and contemplation stage of change
The Mental Health Treatment Study A National Study Involving 1,027 people randomly chosen off the SSDI roles at 22 sites both rural and urban around the United States. The goal was to attempt to get this group back to work given the right mix of services, and resources* Participants in the experimental arm of the study expressed an interest in working. 30% of the 80 participants at the NY site were in the pre or contemplation Stage at the outset 11% are now in pre and contemplation stage of change, and into the 3 rd year have achieved a 40% competitive employment rate * Bob Drake, Deb Becker, Gary Bond, Westat Corp,SSA
Final Words No Substitute for Assertive Engagement and Spending Quality Time with Individuals Removing Daily Life Obstacles is also a key Bringing Back Hope, and the Belief that Change is possible Patience: This may take several years to assist people in moving toward the Action Stage
Thank You Neil Harbus LCSW,CPRP nharbus@pathways to housing.org