In contrast with prevailing models of supported employment (4), our approach to vocational rehabilitation combines placement of clients who have schizophrenia into real community-based jobs with, if necessary, a flexible, transitional period during which the clients receive their salary from the state vocational rehabilitation agency. Although some of our clients move directly into competitive employment, the aim of the transitional trial work phase is to help clients who have had little or no work experience move incrementally toward competitive work.
During the trial work period, clients who face significant barriers to employment can demonstrate their ability to work in a competitive work environment. The community employer is expected to eventually hire the client. However, if the client does not meet competitive standards for productivity and social interaction, the employer can terminate the employee's position at the end of the transitional period. Because this arrangement is relatively risk free, it appeals to both employers and clients.
Our vocational program is available to clients with schizophrenia, who are recruited from a large, urban community mental health center. Prospective participants must express an interest in competitive employment, must be clinically and residentially stable, and must have had no psychiatric hospitalizations or medication changes in the 30 days before intake. In addition, clients with active substance abuse, a history of traumatic brain injury, or a known neurologic disease are excluded. The participants in the program are persons with chronic mental illness and have an average of 11 lifetime psychiatric hospitalizations. Forty-five percent of the participants are women, and there are equal proportions of African Americans and Caucasians. The program began in September 2000 and is funded for five years.
The specific goal of the program is for people to work in the community and to earn the minimum wage or better. As in supported employment, each participant is assigned a job coach who provides assistance with all phases of the job search and employment. Before placement, participants meet with their job coach and discuss their work history and work-related goals. In subsequent sessions, participants and job coaches explore job availability, accessibility to public transportation, and scheduling conflicts between mental health and medical appointments. Every effort is made to match participants with their job preferences while taking into account clients' strengths and liabilities. Participants are encouraged to "try out" a job to find out whether they like it.
After the client is placed in a work situation, the job coach provides as much support as necessary to ensure the client's success at the job. Support may involve transporting the client to and from work, providing full-time job coaching, or making brief weekly visits to the client at the work site. Typical functions of the job coach include teaching the client the technical components of the job, such as how to most efficiently set the tables in a banquet room, and coaching the client in work habits, such as learning the best bus schedule in order to be on time for work. Job coaches also attend treatment planning meetings and communicate with case managers.
Case management and clinical decisions related to the psychiatric needs of the clients—especially medication and crisis intervention—remain the responsibility of the referring treatment team at the community mental health center. The team typically includes a psychiatrist, a primary clinician or therapist, a housing coordinator, and a caseworker. During the period that the client is enrolled in the transitional and supported employment phases of our program, problems related to the person's adjustment and performance at the work site are handled by the research psychologists from the project, which is funded by the National Institute of Mental Health. For example, research psychologists conduct weekly work skills sessions and support groups and also collect assessment data for the study. Whenever a participating client experiences some clinically relevant stress or exacerbation of symptoms, the project staff communicate directly with the client's mental health team so that early intervention can be made.
Mr. M, a 36-year-old African-American man with schizophrenia, has been disabled by his illness since adolescence. He was first hospitalized and diagnosed when he was 19 years old and has been psychiatrically hospitalized more than 25 times since then, most often as a result of symptom exacerbation related to noncompliance with medication. His most recent hospitalization was a year before intake into the program, when he experienced increased paranoia and auditory hallucinations, which he attributed to the stress of being arrested and fined for urinating in public. He lives in a supported housing apartment that provides 24-hour supervision.
Mr. M dropped out of high school in the ninth grade, has never held a full-time job, and for most of his life has not worked at all. However, during the year before Mr. M entered our program, a local pastor hired him to work in the church warehouse unloading crates and performing light cleaning duties. Mr. M worked about 12 hours a week, earning the minimum wage, but he left the job after three months because he found it overwhelming. He stated, "There were too many boxes."
Mr. M had adapted to his relatively constant persecutory auditory hallucinations and delusions. He demonstrated insight into his illness in that he could identify the experiences defined by his physicians as symptoms of an illness and was able to engage in reality testing. His thought process was tangential, easily derailed, and punctuated with neologisms. Mr. M's awareness of his own difficulty with communication led to frustration, which, in turn, caused him to perseverate in trying to make his point.
Although Mr. M endorsed paranoid ideas, he was not suspicious in his day-to-day life. In fact, he related well to others and was friendly with his peers and treatment staff. However, his impulsive outbursts of affection were combined with poor social judgment, so that he had to be reminded daily that spontaneous touching and hugging were inappropriate and could be perceived by others as threatening.
Mr. M took medication twice a day under supervision at his supported housing complex. His medication regimen was 850 milligrams of clozapine, 3,000 milligrams of divalproex sodium, and 6 milligrams of risperidone. He had followed this regimen for six months before intake and had experienced some improvement in symptoms. The medications produced moderate improvements in Mr. M's thought processes and paranoia and made the voices more tolerable and easier to ignore. However, he experienced several stigmatizing side effects: specifically, he experienced significant weight gain and drooled continually, often to the point where his shirt was soaked through. Medications to decrease the drooling were considered but were ruled out because of their side effects.
Mr. M. presented with several major barriers to employment. Neuropsychological testing at intake revealed severe deficits across a broad spectrum of cognitive domains and a full-scale IQ in the extremely low average range of intellectual functioning. He demonstrated severe impairments in cognitive flexibility and problem solving, verbal and visual memory, and affect recognition. Other significant barriers to work included the stigmatizing side effects of his medication, his poor work history, and some minor legal problems.
On the other hand, Mr. M had several vocational strengths. He was motivated to work, because he believed that work would keep him busy and thereby distract him from his annoying symptoms. Moreover, he said that he wanted to "contribute to society." He also had realistic expectations about the type of work he could do, stating that the type of job was less important than having a "real job" in the community.
In response to queries about his job preferences, Mr. M listed housekeeping, maintenance, or janitorial work. His job coach learned that a local hotel laundry needed help. Mr. M. agreed to take the job at the laundry, where he would primarily sort and fold laundry. When he started the job he was paid the minimum wage with transitional funds. The job coach and the laundry supervisor agreed that Mr. M. could try out the job and that the supervisor could evaluate his performance.
Mr. M was scheduled to work 20 hours a week in the hotel laundry and initially required 100 percent job coaching—for example, he needed constant reminders about how to perform his job, such as prompting so that he would not to put dirty towels on top of clean, sterilized sheets. In addition to these memory problems, he repeatedly asked his coworkers as well as pedestrians on the sidewalk outside the hotel for money and cigarettes. In addition, hotel staff members were concerned about Mr. M's drooling, for hygiene reasons.
The job coach continued to assist Mr. M, making it clear that asking coworkers for money and cigarettes was not an appropriate behavior in the workplace and suggesting that he carry a tissue for wiping the drool from his mouth. Because Mr. M seemed unaware of his drooling, the job coach prompted him nonverbally every few minutes to wipe his mouth. Mr. M. also had some difficulty interacting with the laundry staff. He reported that coworkers picked on him, whereas the job coach observed that coworkers were just joking with him. The job coach helped Mr. M. learn to gauge the difference between workplace humor and insults. Mr. M also discussed these difficulties in his weekly support group, which was led by a research psychologist. He attended this group regularly and accepted feedback and advice from other members of the group, who were also working. After 24 weeks of Mr. M's being paid with transitional funds, his worrisome behaviors had declined and his work performance had improved enough that the hotel decided to hire him.
After 78 weeks in the program, Mr. M continued to work in the laundry approximately 23 hours a week without job coaching. In addition to his vocational success, Mr. M showed clinical improvement. He reported less paranoia, anxiety, and depression as well as a greater sense of purpose. However, he still experienced auditory hallucinations and thought disorder.
Although our study of this program will not be completed for another two years, some preliminary data are available for the purpose of evaluating the program's effectiveness. Of the 57 participants enrolled in our program, 56 (98 percent) have worked for at least one week. A total of 35 participants (61 percent) have completed one year of work in the program. The average number of hours worked by clients who worked for at least two weeks was 6.2 hours per week. Seventy percent of their salaries came from transitional funds, and 30 percent came from employers' funds. A total of 23 participants (41 percent) graduated into supported employment and had their salaries paid solely by their employers. Most of the participants experienced job turnover—for example, worked at one job for several months, left that job, and, with assistance from their job coach, began another job. Of the participants who completed a year in the program, only ten (17 percent) subsequently dropped out. The remaining 47 clients (83 percent) continued to work at least intermittently.
It appears that transitional funds made it possible for a large proportion of our clients with chronic mental illness to work in competitive settings alongside coworkers who did not have a mental illness. This observation is particularly noteworthy, because none of the participants had held competitive jobs in the six months before they started our program. The case of Mr. M suggests that competitive employment can be achieved even in the presence of severe symptoms, stigmatizing side effects, and a poor work history if effective supports are in place.
We are collecting data that will permit us to answer several questions. Can predictions about the degree of vocational success be made on the basis of clients' cognitive impairments, symptom severity, medication compliance, side effects, and work history at the time of intake? What personal, on-the-job, and supervisory factors and stressors differentiate clients who successfully graduate into supported employment from those who remain in transitional employment? Can the hybrid program be modified to improve vocational outcomes, including turnover, hours worked per week, and shifts from transitional to supported employment?
Afterword by the column editors: As illustrated by the case of Mr. M, transitional funds may facilitate the vocational development of persons with severe mental illness. The provision of transitional funds and support from a job coach and the treatment team allowed Mr. M to move from transitional employment into competitive employment in a job that he "owns." Transitional funds made it possible for the hotel to take a chance on someone who had several strikes against him when he entered the competitive job market. Both Mr. M and the hotel came out as winners: Mr. M is reaping the benefits of working, and the hotel has hired a competent employee.
Although evaluation of the program so far has revealed that a preponderance of the clients' salaries are coming from the state vocational agency, further follow-up data will determine whether these publicly supported funds can be winnowed down to levels that can be affordable to states that face severe budget restrictions. The extent to which clients can shift to salary support from their employers without receiving state-funded subsidies will be decisive in determining the long-term viability of the hybrid program and its disseminability to other states and cities.
The authors are affiliated with the department of psychiatry of Yale University School of Medicine, CMHC, Fifth Floor, 34 Park Street, New Haven, Connecticut 06519 (e-mail, email@example.com). Robert Paul Liberman, M.D., and Alex Kopelowicz, M.D., are editors of this column.