Authors: Chris J. Croner [croner@siu.edu]
Institution: DePaul University
In its influence over each aspect of a patient's life, clinical depression creates psychological and social barriers between the individual and his or her desire to enter or sustain gainful employment. By applying principles of physical rehabilitation to the needs of the mentally ill, psychosocial rehabilitation allows psychiatrists, psychologists, and case workers to collaborate in removing each of these barriers (Wallace, 1993). Psychosocial rehabilitation is defined in the literature as "a therapeutic approach to the care of mentally ill individuals that encourages each patient to develop his or her fullest capacities through learning procedures and environmental supports" (Bachrach, 1992). As it implements such a program, the Institute for Positive Mental Health, my internship site, prepares individuals with long-term mental illnesses to reenter a competitive work environment. This effort toward deinstitutionalization supports, contradicts, and expands on rehabilitation literature in its service to individuals diagnosed with clinical depression.
The institute's objectives include the training and placement of graduates in competitive clerical positions with growth potential, presenting unique challenges in serving clinical depressives. Through selective screening, skill assessment, training, and career planning and placement, the institute creates an individualized rehabilitation program for each participant. The Illinois Department of Rehabilitation Services (DORS) refers these individuals, whom it believes will benefit most from the institute's rehabilitation program; the screening process examines the patient's basic skills, attitudes, and work behavior through a psychological history profile and an intake interview. A clerical test involving typing, filing, and language skills allows for the creation of an individualized training plan, including goals, anticipated outcomes, a time frame, and specific training methods. These objectives are tailored to the participant's career preference, ranging from receptionist to file clerk; because of the institute's capabilities and the severity of most participants' disabilities, training focuses on clerical positions. As the participant progresses, he or she attends staffing meetings with a program supervisor every eight weeks to assess goal completion and to establish new objectives. The institute supplements this training with other services designed to foster psychosocial rehabilitation, including the development of interpersonal and daily living skills, identification of community and financial resources, and an understanding of behavioral and psychological symptoms. Through one-on-one and group sessions, the participants learn to recognize and monitor their symptoms, allowing them to seek early intervention when they reappear. My group session responsibility includes a weekly presentation called "Managing Your Disability," at which participants learn these identification and monitoring skills for their disorders; each session covers a separate disorder's symptoms, causes, and coping techniques, and allows participants to discuss their experiences and feelings with each other. Interns also receive responsibility for managing the cases of four participants, ensuring that their rehabilitation addresses the personal and social demands of each disorder. The one-on-one sessions allow us to formulate rehabilitation goals based on these psychosocial needs, ranging from low self-esteem and inappropriate behavior to grooming, timeliness, and nutritional deficits.
However, the societal relationship between employment and self-esteem threatens unemployed clinical depressives with perpetuation of their symptoms, heightening the need for effective workforce reintegration (Schwartz & Schwartz, 1993). Hence, the institute's method for dealing with such issues involves a self-esteem building course, in which the participant studies and completes exercizes in a workbook and reviews them with an intern in a private session. Although self-esteem presents recurring difficulties throughout the client's life, this course provides methods of interpreting past and present experiences to minimize their threatening implications. Through each of these assessment, training, and educational efforts, the Institute for Positive Mental Health implements psychosocial rehabilitation, fostering personal growth and opportunity development.
During this program, the institute also collaborates with each participant's psychiatric service providers to monitor their progress and ensure a thorough rehabilitation. In an analysis of the relationship between psychiatry and psychosocial rehabilitation, Leona L. Bachrach, Ph.D. (1992) presents recommendations that are both congruent with and contradictory to the institute's practices. Like the institute, Bachrach recognizes the importance of developing each participant's fullest abilities through learning and environmental support. She also identifies several underlying themes of psychosocial rehabilitation that match the institute's philosophies, including the aim of restoring hope to individuals who have lost self-esteem and functional capacity and maintaining an optimistic view of each participant's vocational potential. Thus, Bachrach indicates that workforce reintegration should inform all of the activities involved in rehabilitation. She also highlights the importance of case management efforts in addressing personal and social needs beyond employment, paralleling the institute's methods. However, as she discusses her concerns regarding overburdening the mentally ill with several complex tasks, Bachrach addresses a potential difficulty for the institute's participants: "I refer specifically to the regimentation that creeps into some programs and virtually forces mentally ill people always to do something, to complete something, to go somewhere, or to be somewhere" (Bachrach, 1992, p.1458). Because of its strong focus on work-related goal-setting and timelines, the institute often places such productivity and travel demands on participants; failure to meet these demands may result in a reprimand or program termination for repeat offenders. Individuals with clinical depression may find such policies particularly problematic, as anhedonia and slowness of thought may impair their efforts. However, this inconsistency with Bachrach's concern may also be addressed by the institute's recruiting policies, ensuring that each participant has the skills and ability to succeed in the program. Finally, Bachrach discusses the disagreements between psychiatrists and helpers in psychosocial rehabilitation, involving both parties refuting each other's necessity. However, the institute maintains congenial and productive relationships with each of the participants' doctors, allowing for continuity in treatment.
The desirability of continuity becomes central to an analysis by Got (1991), in which he describes psychosocial rehabilitation as a lifeline which each of the client's helpers must recognize and accept. According to Got, this lifeline has two components: the understanding and timely use of all resources for the client and a quest for coordination and collaboration among all of the client's helpers. It is important for the participant to feel that each person whom he or she has been close to, from caregivers to family members, has participated together in developing opportunities (Got, 1991). Sartorius (1995) echoes this point, emphasizing the frequent need for advocacy, tolerance, and understanding by all helpers involved in a client's rehabilitation. This resulting continuity allows the clinically depressed participant to feel a sense of security and direction in that each of his or her helpers has acted as a guide for a portion of an agreed-upon journey. Therefore, the institute's efforts toward therapeutic continuity among psychiatrists, program directors, and interns serve this purpose, facilitating rehabilitative continuity. However, as a therapeutic program seeks to maintain this consistency, the model of approach which it uses also becomes important. As he discusses models of vocational rehabilitation, Charles Wallace, Ph.D. (1993) identifies two styles which, in combination, reflect the Institute for Positive Mental Health's reintegration program. First, the Boston University Model involves development of individualized Vocational Rehabilitation Plans (VRPs), which include identifying the desired work site and duties that are the final goals of rehabilitation; the specific education and skills necessary to successfully perform these duties; an assessment of the participant's current education and skills; the techniques for teaching the participant the skills necessary to reach his or her goals; and the techniques for progress evaluation. The institute's program satisfies each of these requirements, through its assessment, educational, and staffing policies. Second, the Job Club model maintains an exclusive focus on teaching the skills needed to find employment. This program uses brief, highly focused methods to teach skills in job seeking, resume construction, application completion, and interviewing. Job clubs also include supportive activities to allow individuals to practice their skills until they find employment. Again, the institute uses each of these elements in preparing participants for workforce reentry. However, the institute also places participants in a non-paid internship for a minimum of four weeks to facilitate the transition to employment and continue skills training. Thus, as a combined Boston University and Job Club model, the Institute for Positive Mental Health gives participants the benefits of two vocational rehabilitation methods and adds an internship experience to strengthen its psychosocial rehabilitation program.
In developing the participants' skills and opportunities and negotiating with the Illinois Department of Rehabilitation Services for their financial needs, the institute's staff engages in case management, using techniques that closely match literature recommendations. Anthony, Forbess, and Cohen (1993) discuss two major results of rehabilitation-oriented case management: helping individuals to access the services they need and want and assisting them in functioning in their chosen roles. The institute's staff satisfies both of these requirements through individualized client plans and assessment staffings. Further, Anthony et al. stress the importance of client involvement in rehabilitation, allowing them to communicate their experiences, values, ideas, feelings, and goals during each stage of the process. Sartorius (1995) reiterates this necessity, as it reflects on the client's quality of life: "If quality of life is to become a central criterion of success of health services and rehabilitation, the views of those whose life is being changed must become the decisive factor rather than remain just an interesting observation in the process of rehabilitation and in the assessment of its effects" (p.11). Again, one-on-one sessions allow for this communication, tailoring the rehabilitation process to the participants' needs. Finally, Farkas and Anthony (1993) discuss the importance of case management evaluation by assessing client satisfaction and service utilization. Through a job retention and follow-up program, the Institute for Positive Mental Health examines the progress of graduates for one full year, focusing on employee retention and satisfaction, employer satisfaction, and comparison of participants who succeed or fail in graduating. Therefore, effective case management becomes a priority of the institute's staff, reflecting its concern for continuity and following the literature's recommendations.
As it provides psychosocial rehabilitation directed toward workforce reentry, the Institute for Positive Mental Health allows clinically depressed participants to progress from service recipients to social contributors. Through continuity in each aspect of personal and environmental support, the institute's staff helps in removing the psychological and educational barriers between institutionalization and gainful employment.
References Anthony, W. A., Forbess, R., & Cohen, M. R. (1993). Rehabilitation-oriented case management. In M. Harris & H. C. Bergman (Eds.), Case Management for Mentally Ill Patients (pp. 99-118). Langhorne, PA: Harwood.
Bachrach, L. L. (1992). Psychosocial rehabilitation and psychiatry in the care of long-term patients. The American Journal of Psychiatry, 149(11), 1455-1463.
Farkas, M. D. & Anthony, W. A. (1993). Rehabilitation case management research. In M. Harris & H. C. Bergman (Eds.), Case Management for Mentally Ill Patients (pp.119-141). Langhorne, PA: Harwood.
Got, R. (1991). Continuity and rehabilitation. International Journal of Mental Health, 20(3), 31-40.
Sartorius, N. (1995). Rehabilitation and quality of life. International Journal of Mental Health, 24(1), 7-13.
Schwartz, A. & Schwartz, R. M. (1993). Depression: Theories and Treatments: Psychological, biological, and social perspectives. New York: Columbia University Press.
Wallace, C. J. (1993). Psychiatric rehabilitation. Psychopharmacology Bulletin, 29(4), 537-548.
Postal Address:
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c/o Chad Briggs
Department of Psychology
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Last Modified: April 19, 2005 | csb
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