Work Progratnllling for Psychiatric Clients An Interdisciplinary Approach Jack Rabin, MS, LCSW Assistant Clinical Director Division of Mental Health Substance Abuse and Forensic Services San Francisco, California
Community Mental Health (CMH) staff can do much to encourage or discourage psychiatric clients from working. Clients meet with myriad staff in the course of their treatment day, especially in day treatment, residential, and inpatient settings. Social workers, psychiatrists, occupational therapists, and other counselors each play a part in a client's treatment planning. However, staff do not necessarily present a unified picture when it comes to the importance of vocational planning. Each discipline has its own perspective, and vocational planning is often omitted or left up to a vocational specialist to handle. However, contact with a vocational specialist is not enough for many CMH clients; the thought of working for any length of time is just too frightening for them to pursue. A unified, supportive, interdisciplinary approach is required if more clients are to become involved with work. There are many hard-to-reach clients who value work above other treatment approaches. Often they return to the most restrictive levels of care-emergency and long-term care facilities-because work opportunities and job support are not made available to them when they are living in the community. Meaningful, purposeful, paid work activities can become a viable way for these clients to make a commitment to more comprehensive treatment planning. In a time of continuing cutbacks in mental health
services, the introduction of work activities into program planning can be a way of reducing recidivism and maintaining more clients in the community. For the purposes of this discussion, work will be defined as paid, purposeful activity for any length of time. For some clients this means ten minutes a day stuffing envelopes. For other clients, half-time or full-time employment cleaning, delivering mail, or teaching is appropriate. A client's interest is as important as previous job experience, work preference, and endurance. It is important for staff to tailor work opportunities to fit the interests and needs of individual clients. It is possible for all staff to playa part in this process. The psychiatrist who evaluates a client for medication could evaluate how medication affects a client's work performance. At intake social workers, psychologists, and other counselors could provide vocational information as an integral part of standard assessment procedures. Discussion of work-related experiences should become a regular part ofindividual contact with clients, and this information should be brought into weekly treatment planning meetings. Activity therapists can assist occupational therapists in doing work evaluations and vice versa. There are many ways for staff to become involved even without previous vocational training. It starts with a mental health worker's understanding and interest in the value of work for all clients. Clients take immense pride in completing a task and in knowing that their work is important enough for someone to pay for it. I What may appear Il)enial to staff may be, for the client, the first time he or she has the opportunity
64
W 0 R K / WINTER 1991
to take pride in a completed assignment. Taking responsibility and completing a task are new experiences for many clients, especially longterm clients, and staff playa vital role in encouraging involvement. The following paper describes how different disciplines are involved in coordinating work projects with clients. These examples are taken from CMH day treatment and residential programs in San Francisco.
VOCATIONAL PROGRAMMING Geriatric Day Treatment The creative arts therapist (CAT) for the Geriatric Day Treatment program is responsible for coordinating the arts program and work activities. One of the activities she supervises is a bulk mailing project. Each project is usually 10,000-20,000 pieces. The clients involved are seniors between the ages of 58 and 75, many of whom have been diagnosed as psychotic. The program subcontracts for this work with another San Francisco Community Mental Health (SF/CMH) program, Community Vocational Enterprises (CVE). CVE procures contracts for many different kinds of work including bulk mailing which can then be subcontracted to other SF/CMH programs. CVE calls Geriatric Day Treatment to let them know when this work is available, and the CAT uses a van to pick up and return the mailers. Whil~ this work is unpredictable, the program always has a crew of clients prepared whenever the work is available. For all of these clients, this is their favorite activity. The work, for which they are paid at a piece rate, makes them feel useful, a feeling that many have not had for a long time, if ever. The repetitive tasks remind some of similar work they did in the past, and they are proud to be able to work again and be paid for their labour. The CAT notices a significant rise in each client's self-esteem and ability to concentrate, and the group provides a safe place for them to recapture long lost skills. The opportunity to complete a repetitive task with a beginning and an end that is of use to someone else helps
clients to tap into a feeling of hope and personal integrity.2 Each group lasts 45 minutes and requires minimal supervision and support from the CAT. Clients are shown how to prepare each mailer, and then their work is monitored by the CAT. The work crew also provides for a higher level of social interaction as compared to other groups. Clients are able to sublimate their anxiety and interact with each other in ways that are less threatening and more social. For example, clients are able to make eye contact with each other while working and talking about their work. Their focus is on getting the job done; distracting behavior is made subordinate to this. Clients are able to bond with each other because of the labor they have in common. It feels good to be tired from concentration and physical exertion by the end of each group. Even though the CAT is not trained as a vocational counselor or job coach, he or she finds that there is a natural link between running a creative arts group and running a work group. Both require attention to sequencing tasks and building on the natural rhythm of the group process. In this case, each mailing project is set up in an assembly line fashion, tasks are kept simple, and clients learn to work collectively and to be paid for what they do. In weekly staff meetings the CAT lets other staff know about the progress of each client, and then this information is considered in relationship to a client's overall treatment planning. Clients who show a higher rate of skill development are considered for referral to other paid work projects available outside of the program including preparation for supported employment.
Adult Day Treatment The preceding discussion gives an example of a work project that is well received by the program as a whole. The following discussion will desc;ribe work projects in two adult day treatment programs, one where these activities are well integrated into the overall program structure and one where the activities aren't well integrated. Example 1 describes a day treatment program where the work project is
Work Programming for Psychiatric Clients
isolated from the rest ofthe program. Example 2 describes a day treatment program where work is very well received. The extent of integration or isolation of work activity affects what staff can do to promote a client's skill development. Example 1. In this example, work is not well integrated into the whole program. Here the creative arts therapist is responsible for coordinating the arts program and work activities. The work activities include a janitorial crew made up of six clients. For three hours a day, Monday-Friday, these clients clean a children's program located across town in the Chinatown area of San Francisco. Their duties include vacuuming a wall-to-wall carpet, dusting, and cleaning the bathrooms. Clients are paid the minimum wage. Clients are invited to apply for this work. The CAT meets with interested clients and discusses the level of personal hygiene and communication skills required for the job. Clients who meet the requirements are invited to visit the work site and talk with clients who are already working. If a client remains interested, placement into the crew is made when vacancies arise. There is generally turnover once every six months. Once placed, the CAT maintains regular contact with each client and completes an evaluation on a quarterly basis. For many of the clients who work on this crew, this may be the only time they spend away from the community in which they live. It is something of an adventure for them to get on the bus and travel across town to Chinatown and work. There are other clients who want to work but who are not ready to leave the day treatment program to do so. They are encouraged to participate in other activities on site including the recycling project. Working outside the program is not for everyone. Problems with the interface between the CAT who coordinates the janitorial crew and the rest of the program first arise in the referral process. There is no formal referral process between the CAT and staff who have clients interested in the janitorial crew. It is up to each client to express an interest in this work. Staff do not refer interested clients to the CAT. Once
65
a client is placed, there are no regular communication channels for updating staff on a client's participation and progress nor are there ways to build this information into an ongoing treatment plan. Some staff refuse to release clients from other scheduled groups to allow clients to participate on the janitorial crew. Also, staff sometimes refer clients to jobs outside of the program, including full-time employment. However, without adequate preparation and support, many of these clients fail and return to day treatment within a short period of time. Some staff think this indicates that a client is not ready to work when the real issue is giving the CAT more of an opportunity to transition clients to higher levels of work activity. This is an example of a program that values work for clients but whose clients are discouraged from working because coordination and referral between the CAT and other staff are handled in a disorganized way. There are other ways for staff to encourage clients to work. A vocational group could have weekly meetings that are co-led by the CAT and other staff. This group could provide support to clients who are already working and information to clients interested in working. Clients could also discuss work-related issues in the weekly client-run community meeting. New ideas could be generated for work projects that are either program-based or outside the program, and staff could join with clients in discussing ways to tap into these opportunities. What's missing is a sanction by the administration for the CAT to lead the planning for vocational activities in a way more central to the program as a whole. It is counterproductive for vocational involvement to be left up to the initiative of individual staff or clients without a way to monitor what happens vocationally with each client. Example 2. The second example involves a day treatment program where vocational planning is well integrated with the program as a whole and starts at intake and with the development of the initial treatment plan. In this program all staff including social worker, counselor, psychiatric technician, psychologist, nursing, and
66
W 0 R K / WINTER 1991
physician are expected to record a client's work experience and potential for work in every treatment plan. If a client has no work skills, this is listed as a problem, and over the next two weeks the client is evaluated in several prevocational work groups, including furniture stripping or cooking. Information about each client's performance is reported back to their primary therapist in the weekly staff meeting. In this program, it is the recreation therapist who coordinates recreational and vocational activities including job development. Another counselor with a college degree is in charge of the prevocational activities. The hierarchy of work responsibilities includes clients who are assigned to train and supervise each other, and there is a formal organizational chart that shows the relationship between the supervising staff and the clients. The recreation therapist gets involved if a problem arises; or, if a client is particularly hard on another client, this client can ask for assistance from the recreation therapist. Otherwise, the crews are self-maintained. The work projects include a janitorial crew that cleans a community center across town Monday-Friday, plus snack bar, cooking, and janitorial crews for the program site. Clients who participate on the work crews are also involved with the recreational program. Clients are encouraged to train for and participate in Special Olympic events held throughout the year. Here psychiatric clients compete with other disabled clients in track and field, bowling, swimming, weight lifting, basketball, and volleyball. Clients' participation in the olympics often helps them to work. Clients train hard for individual and group events and many of the skills they acquire are directly transferable to their participation on work crews. Clients engage in goal-setting, become increasingly motivated, see tangible results of their labor (including gold and silver medals), take leadership responsibility, and learn to work and play together in a team fashion. In this example, work activities are fully integrated into the program structure as a whole, because each component of the program complements every other part of the program. Cli-
ents who want to compete in Special Olympics are self-directed and motivated to follow their treatment plan, and clients who are both can participate in paid work projects. In this way, each activity reinforces every other activity, which in turn makes it easier to do vocational planning as an integral part of all treatment planning.
Residential Day Treatment Residential treatment programs including halfway houses can be excellent settings to develop paid work projects. Many of the staff in these programs already have experience in running work groups because of the strong social rehabilitation orientation of these programs. The following example describes a vocational unit for three psychiatric halfway houses in San Francisco. The unit is operated by four staff including two psychiatric nurses, one clinical psychologist, and the director, who has a master's degree in counseling. The unit provides assessment, supervision, and support services to 80% of the clients who reside in the three houses, about 200 clients annually. The unit also makes referrals to other vocational programs including the Department of Rehabilitation and Keystone Vocational Services (a SF/CMH program) when clients are ready for supported work. The work projects within the three houses include clerical,janitorial, food distribution, bookkeeping, telephone reception, moving, and painting. The unit also supervises clients who operate an interoffice messenger crew for SF/CMH programs. Clients are hired as volunteers or are paid minimum wage or better, depending on the level of skill required for each job. Each week, unit staff meet with clients individually or in groups to discuss work-related problems. The three houses contract with the vocational unit to refer clients for various work activities, and requests to the unit are made with a work order. Clients are initially placed in work situations where there is a lot of flexibility and room for error and gradually move on to more difficuit work settings. Clients are given specific feedback about what they need to do in order
Work Programming for Psychiatric Clients
to progress. Staff also meet regularly with individual counselors from each of the houses and report biweekly on the vocational status of clients at an all-staff meeting. Open, on-going communication between the vocational unit and counselors is encouraged, especially when changes in the treatment plan are anticipated. Clients remain in the halfWay houses for up to two months at a time. Clients who complete the halfWay house program can then choose to live in independent co-op apartments which are case managed by residential staff. When clients leave the halfWay house, the unit refers them to other appropriate vocational services including supported work. Unit staff will talk with employers or make site visits at the request ofa client. Occasionally, the vocational unit and the halfway house counselors differ in their analysis of a client's behavior. A client who appears to be hearing voices may appear to be a poor candidate for referral for work when, in fact, this client may be able to work even while experiencing hallucinatory events. When a client gets in trouble at the house, a counselor may decide the client cannot go to his or her job when, in fact, the two areas should be kept separate. The unit is usually able to reach a compromise with counselors when these situations arise without having to escalate the matter to a higher administrative level.
CONCLUSION This article has described how interdisciplinary mental health staff coordinate work activities in day treatment and residential programs. There are several characteristics that have made it possible for them to get involved in these ways, whatever their professional backgrounds. First and foremost has been the value they place on work as treatment for psychiatric clients. Work is viewed as an integral part and not separate from treatment. Second has been their ease in taking what is useful from their own academic or work experience amd applying this to their role in coordinating work activities. They have shown a tremendous desire to incorporate from past
67
experience and then learn from new experience. Third has been their willingness to remain open and flexible in their expanding role as work coordinators. There has been no hint of the territorial prerogative of rigid professionalism. What have been described are examples of paid work opportunities at the program level. However, these examples also point out the need for opportunities throughout and beyond CMH. Evaluation for and an opportunity to participate in paid work activities must be made available in outpatient and inpatient facilities along with day treatment and residential programs. Psychiatric clients move through all levels of CMH care, and their potential for work must be considered as their needs change. Vocational goal setting must consider work opportunities that lie within and beyond CMH programs. A continuum of work activities must be developed for clients from the highest to the lowest functioning. 3 A broad range of CMH staff can playa vital role in this process. Clients who are ready for supported employment need ongoing followup from mental health providers, and CMH programs are excellent places for individual or group contact. SF/CMH has developed two programs, CVE and Keystone Vocational Services, which assist mental health staff at both ends of the continuum. CVE procures contracts for work that can be done onsite as well as organizes off-site work crews; these include janitorial, food service, and messenger jobs. Keystone evaluates clients for supported work and then contracts with CMH staff to provide follow-up contact once their client is placed. Keystone also offers vocational support groups and workshops and provides consultation to CMH staff who wish to offer similar groups in their program. Not all staff can be expected to become involved in the same way. The goal is a unified, balanced treatment plan to which each staff member can contribute. Some staff can serve as role models for the rest. Day treatment and inpatient programs often hire occupational therapists (ills) to coordinate work activities. Keystone Vocational Services of SF/CMH is run by an ill who administers the program and
68
W 0 R K / WINTER 1991
also does work evaluations. All clients referred for supported work are evaluated for their cognitive, motor, and perceptual skills to assess their strengths and their ability to adjust on the job. While most staff are not expected to provide vocational services at this level, staff can gather general information that is work-related and provide ongoing support for clients who are working. ills can also provide consultation to staff interested in starting various support services. Finally, the use of interdisciplinary staff in these ways is more than cost-effective or good practice. For many clients, paid work may be the only activity acceptable to them as a form of treatment. Many hard-to-reach clients cycle through emergency and inpatient facilities over and over again because they feel there is noth-
ing for them to connect with in the community. Paid work is very attractive to these clients and can serve as a gateway to other forms of treatment. A broad range of CMH staff are in a good position to understand the need of these clients and offer them a bridge back to the community.
REFERENCES 1. Husted JR: The day treatment center experience. J Calif Alliance for the Mentally III 1(3):7-8.
2. Erikson EH: Identity, Youth and Crisis. New York: Norton, 1968, pp 138-141. 3. Lang, SK, Cara E. Vocational integration for the psychiatrically diabled. Hosp and Commun Psychiatry 1989, 40:9.
Community Mental Health (CMH) staff can do much to encourage or discourage psychiatric clients from working. Clients meet with myriad staff in the course of their treatment day, especially in day treatment, residential, and inpatient settings. Social workers, psychiatrists, occupational therapists, and other counselors each play a part in a client's treatment planning. However, staff do not necessarily present a unified picture when it comes to the importance of vocational planning. Each discipline has its own perspective, and vocational planning is often omitted or left up to a vocational specialist to handle. However, contact with a vocational specialist is not enough for many CMH clients; the thought of working for any length of time is just too frightening for them to pursue. A unified, supportive, interdisciplinary approach is required if more clients are to become involved with work. There are many hard-to-reach clients who value work above other treatment approaches. Often they return to the most restrictive levels of care-emergency and long-term care facilities-because work opportunities and job support are not made available to them when they are living in the community. Meaningful, purposeful, paid work activities can become a viable way for these clients to make a commitment to more comprehensive treatment planning. In a time of continuing cutbacks in mental health
services, the introduction of work activities into program planning can be a way of reducing recidivism and maintaining more clients in the community. For the purposes of this discussion, work will be defined as paid, purposeful activity for any length of time. For some clients this means ten minutes a day stuffing envelopes. For other clients, half-time or full-time employment cleaning, delivering mail, or teaching is appropriate. A client's interest is as important as previous job experience, work preference, and endurance. It is important for staff to tailor work opportunities to fit the interests and needs of individual clients. It is possible for all staff to playa part in this process. The psychiatrist who evaluates a client for medication could evaluate how medication affects a client's work performance. At intake social workers, psychologists, and other counselors could provide vocational information as an integral part of standard assessment procedures. Discussion of work-related experiences should become a regular part ofindividual contact with clients, and this information should be brought into weekly treatment planning meetings. Activity therapists can assist occupational therapists in doing work evaluations and vice versa. There are many ways for staff to become involved even without previous vocational training. It starts with a mental health worker's understanding and interest in the value of work for all clients. Clients take immense pride in completing a task and in knowing that their work is important enough for someone to pay for it. I What may appear Il)enial to staff may be, for the client, the first time he or she has the opportunity
64
W 0 R K / WINTER 1991
to take pride in a completed assignment. Taking responsibility and completing a task are new experiences for many clients, especially longterm clients, and staff playa vital role in encouraging involvement. The following paper describes how different disciplines are involved in coordinating work projects with clients. These examples are taken from CMH day treatment and residential programs in San Francisco.
VOCATIONAL PROGRAMMING Geriatric Day Treatment The creative arts therapist (CAT) for the Geriatric Day Treatment program is responsible for coordinating the arts program and work activities. One of the activities she supervises is a bulk mailing project. Each project is usually 10,000-20,000 pieces. The clients involved are seniors between the ages of 58 and 75, many of whom have been diagnosed as psychotic. The program subcontracts for this work with another San Francisco Community Mental Health (SF/CMH) program, Community Vocational Enterprises (CVE). CVE procures contracts for many different kinds of work including bulk mailing which can then be subcontracted to other SF/CMH programs. CVE calls Geriatric Day Treatment to let them know when this work is available, and the CAT uses a van to pick up and return the mailers. Whil~ this work is unpredictable, the program always has a crew of clients prepared whenever the work is available. For all of these clients, this is their favorite activity. The work, for which they are paid at a piece rate, makes them feel useful, a feeling that many have not had for a long time, if ever. The repetitive tasks remind some of similar work they did in the past, and they are proud to be able to work again and be paid for their labour. The CAT notices a significant rise in each client's self-esteem and ability to concentrate, and the group provides a safe place for them to recapture long lost skills. The opportunity to complete a repetitive task with a beginning and an end that is of use to someone else helps
clients to tap into a feeling of hope and personal integrity.2 Each group lasts 45 minutes and requires minimal supervision and support from the CAT. Clients are shown how to prepare each mailer, and then their work is monitored by the CAT. The work crew also provides for a higher level of social interaction as compared to other groups. Clients are able to sublimate their anxiety and interact with each other in ways that are less threatening and more social. For example, clients are able to make eye contact with each other while working and talking about their work. Their focus is on getting the job done; distracting behavior is made subordinate to this. Clients are able to bond with each other because of the labor they have in common. It feels good to be tired from concentration and physical exertion by the end of each group. Even though the CAT is not trained as a vocational counselor or job coach, he or she finds that there is a natural link between running a creative arts group and running a work group. Both require attention to sequencing tasks and building on the natural rhythm of the group process. In this case, each mailing project is set up in an assembly line fashion, tasks are kept simple, and clients learn to work collectively and to be paid for what they do. In weekly staff meetings the CAT lets other staff know about the progress of each client, and then this information is considered in relationship to a client's overall treatment planning. Clients who show a higher rate of skill development are considered for referral to other paid work projects available outside of the program including preparation for supported employment.
Adult Day Treatment The preceding discussion gives an example of a work project that is well received by the program as a whole. The following discussion will desc;ribe work projects in two adult day treatment programs, one where these activities are well integrated into the overall program structure and one where the activities aren't well integrated. Example 1 describes a day treatment program where the work project is
Work Programming for Psychiatric Clients
isolated from the rest ofthe program. Example 2 describes a day treatment program where work is very well received. The extent of integration or isolation of work activity affects what staff can do to promote a client's skill development. Example 1. In this example, work is not well integrated into the whole program. Here the creative arts therapist is responsible for coordinating the arts program and work activities. The work activities include a janitorial crew made up of six clients. For three hours a day, Monday-Friday, these clients clean a children's program located across town in the Chinatown area of San Francisco. Their duties include vacuuming a wall-to-wall carpet, dusting, and cleaning the bathrooms. Clients are paid the minimum wage. Clients are invited to apply for this work. The CAT meets with interested clients and discusses the level of personal hygiene and communication skills required for the job. Clients who meet the requirements are invited to visit the work site and talk with clients who are already working. If a client remains interested, placement into the crew is made when vacancies arise. There is generally turnover once every six months. Once placed, the CAT maintains regular contact with each client and completes an evaluation on a quarterly basis. For many of the clients who work on this crew, this may be the only time they spend away from the community in which they live. It is something of an adventure for them to get on the bus and travel across town to Chinatown and work. There are other clients who want to work but who are not ready to leave the day treatment program to do so. They are encouraged to participate in other activities on site including the recycling project. Working outside the program is not for everyone. Problems with the interface between the CAT who coordinates the janitorial crew and the rest of the program first arise in the referral process. There is no formal referral process between the CAT and staff who have clients interested in the janitorial crew. It is up to each client to express an interest in this work. Staff do not refer interested clients to the CAT. Once
65
a client is placed, there are no regular communication channels for updating staff on a client's participation and progress nor are there ways to build this information into an ongoing treatment plan. Some staff refuse to release clients from other scheduled groups to allow clients to participate on the janitorial crew. Also, staff sometimes refer clients to jobs outside of the program, including full-time employment. However, without adequate preparation and support, many of these clients fail and return to day treatment within a short period of time. Some staff think this indicates that a client is not ready to work when the real issue is giving the CAT more of an opportunity to transition clients to higher levels of work activity. This is an example of a program that values work for clients but whose clients are discouraged from working because coordination and referral between the CAT and other staff are handled in a disorganized way. There are other ways for staff to encourage clients to work. A vocational group could have weekly meetings that are co-led by the CAT and other staff. This group could provide support to clients who are already working and information to clients interested in working. Clients could also discuss work-related issues in the weekly client-run community meeting. New ideas could be generated for work projects that are either program-based or outside the program, and staff could join with clients in discussing ways to tap into these opportunities. What's missing is a sanction by the administration for the CAT to lead the planning for vocational activities in a way more central to the program as a whole. It is counterproductive for vocational involvement to be left up to the initiative of individual staff or clients without a way to monitor what happens vocationally with each client. Example 2. The second example involves a day treatment program where vocational planning is well integrated with the program as a whole and starts at intake and with the development of the initial treatment plan. In this program all staff including social worker, counselor, psychiatric technician, psychologist, nursing, and
66
W 0 R K / WINTER 1991
physician are expected to record a client's work experience and potential for work in every treatment plan. If a client has no work skills, this is listed as a problem, and over the next two weeks the client is evaluated in several prevocational work groups, including furniture stripping or cooking. Information about each client's performance is reported back to their primary therapist in the weekly staff meeting. In this program, it is the recreation therapist who coordinates recreational and vocational activities including job development. Another counselor with a college degree is in charge of the prevocational activities. The hierarchy of work responsibilities includes clients who are assigned to train and supervise each other, and there is a formal organizational chart that shows the relationship between the supervising staff and the clients. The recreation therapist gets involved if a problem arises; or, if a client is particularly hard on another client, this client can ask for assistance from the recreation therapist. Otherwise, the crews are self-maintained. The work projects include a janitorial crew that cleans a community center across town Monday-Friday, plus snack bar, cooking, and janitorial crews for the program site. Clients who participate on the work crews are also involved with the recreational program. Clients are encouraged to train for and participate in Special Olympic events held throughout the year. Here psychiatric clients compete with other disabled clients in track and field, bowling, swimming, weight lifting, basketball, and volleyball. Clients' participation in the olympics often helps them to work. Clients train hard for individual and group events and many of the skills they acquire are directly transferable to their participation on work crews. Clients engage in goal-setting, become increasingly motivated, see tangible results of their labor (including gold and silver medals), take leadership responsibility, and learn to work and play together in a team fashion. In this example, work activities are fully integrated into the program structure as a whole, because each component of the program complements every other part of the program. Cli-
ents who want to compete in Special Olympics are self-directed and motivated to follow their treatment plan, and clients who are both can participate in paid work projects. In this way, each activity reinforces every other activity, which in turn makes it easier to do vocational planning as an integral part of all treatment planning.
Residential Day Treatment Residential treatment programs including halfway houses can be excellent settings to develop paid work projects. Many of the staff in these programs already have experience in running work groups because of the strong social rehabilitation orientation of these programs. The following example describes a vocational unit for three psychiatric halfway houses in San Francisco. The unit is operated by four staff including two psychiatric nurses, one clinical psychologist, and the director, who has a master's degree in counseling. The unit provides assessment, supervision, and support services to 80% of the clients who reside in the three houses, about 200 clients annually. The unit also makes referrals to other vocational programs including the Department of Rehabilitation and Keystone Vocational Services (a SF/CMH program) when clients are ready for supported work. The work projects within the three houses include clerical,janitorial, food distribution, bookkeeping, telephone reception, moving, and painting. The unit also supervises clients who operate an interoffice messenger crew for SF/CMH programs. Clients are hired as volunteers or are paid minimum wage or better, depending on the level of skill required for each job. Each week, unit staff meet with clients individually or in groups to discuss work-related problems. The three houses contract with the vocational unit to refer clients for various work activities, and requests to the unit are made with a work order. Clients are initially placed in work situations where there is a lot of flexibility and room for error and gradually move on to more difficuit work settings. Clients are given specific feedback about what they need to do in order
Work Programming for Psychiatric Clients
to progress. Staff also meet regularly with individual counselors from each of the houses and report biweekly on the vocational status of clients at an all-staff meeting. Open, on-going communication between the vocational unit and counselors is encouraged, especially when changes in the treatment plan are anticipated. Clients remain in the halfWay houses for up to two months at a time. Clients who complete the halfWay house program can then choose to live in independent co-op apartments which are case managed by residential staff. When clients leave the halfWay house, the unit refers them to other appropriate vocational services including supported work. Unit staff will talk with employers or make site visits at the request ofa client. Occasionally, the vocational unit and the halfway house counselors differ in their analysis of a client's behavior. A client who appears to be hearing voices may appear to be a poor candidate for referral for work when, in fact, this client may be able to work even while experiencing hallucinatory events. When a client gets in trouble at the house, a counselor may decide the client cannot go to his or her job when, in fact, the two areas should be kept separate. The unit is usually able to reach a compromise with counselors when these situations arise without having to escalate the matter to a higher administrative level.
CONCLUSION This article has described how interdisciplinary mental health staff coordinate work activities in day treatment and residential programs. There are several characteristics that have made it possible for them to get involved in these ways, whatever their professional backgrounds. First and foremost has been the value they place on work as treatment for psychiatric clients. Work is viewed as an integral part and not separate from treatment. Second has been their ease in taking what is useful from their own academic or work experience amd applying this to their role in coordinating work activities. They have shown a tremendous desire to incorporate from past
67
experience and then learn from new experience. Third has been their willingness to remain open and flexible in their expanding role as work coordinators. There has been no hint of the territorial prerogative of rigid professionalism. What have been described are examples of paid work opportunities at the program level. However, these examples also point out the need for opportunities throughout and beyond CMH. Evaluation for and an opportunity to participate in paid work activities must be made available in outpatient and inpatient facilities along with day treatment and residential programs. Psychiatric clients move through all levels of CMH care, and their potential for work must be considered as their needs change. Vocational goal setting must consider work opportunities that lie within and beyond CMH programs. A continuum of work activities must be developed for clients from the highest to the lowest functioning. 3 A broad range of CMH staff can playa vital role in this process. Clients who are ready for supported employment need ongoing followup from mental health providers, and CMH programs are excellent places for individual or group contact. SF/CMH has developed two programs, CVE and Keystone Vocational Services, which assist mental health staff at both ends of the continuum. CVE procures contracts for work that can be done onsite as well as organizes off-site work crews; these include janitorial, food service, and messenger jobs. Keystone evaluates clients for supported work and then contracts with CMH staff to provide follow-up contact once their client is placed. Keystone also offers vocational support groups and workshops and provides consultation to CMH staff who wish to offer similar groups in their program. Not all staff can be expected to become involved in the same way. The goal is a unified, balanced treatment plan to which each staff member can contribute. Some staff can serve as role models for the rest. Day treatment and inpatient programs often hire occupational therapists (ills) to coordinate work activities. Keystone Vocational Services of SF/CMH is run by an ill who administers the program and
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also does work evaluations. All clients referred for supported work are evaluated for their cognitive, motor, and perceptual skills to assess their strengths and their ability to adjust on the job. While most staff are not expected to provide vocational services at this level, staff can gather general information that is work-related and provide ongoing support for clients who are working. ills can also provide consultation to staff interested in starting various support services. Finally, the use of interdisciplinary staff in these ways is more than cost-effective or good practice. For many clients, paid work may be the only activity acceptable to them as a form of treatment. Many hard-to-reach clients cycle through emergency and inpatient facilities over and over again because they feel there is noth-
ing for them to connect with in the community. Paid work is very attractive to these clients and can serve as a gateway to other forms of treatment. A broad range of CMH staff are in a good position to understand the need of these clients and offer them a bridge back to the community.
REFERENCES 1. Husted JR: The day treatment center experience. J Calif Alliance for the Mentally III 1(3):7-8.
2. Erikson EH: Identity, Youth and Crisis. New York: Norton, 1968, pp 138-141. 3. Lang, SK, Cara E. Vocational integration for the psychiatrically diabled. Hosp and Commun Psychiatry 1989, 40:9.
