|
Materials from Office
of Vocational and Educational Services for
Individuals with Disabilities (VESID)
Website.
Introduction
Key Point Summaries
Section I: Definition and
Description of Mental Illness
Definition of Mental Illness
Description of Mental Illness
DSM IV - R
Stigma and Discrimination
Medication
Section II: Recovery, Research and Rehabilitation
A Vision for Recovery
Research on Recovery
Connecting MH with VESID
Practical Rehabilitation Strategies for Facilitating
Employment Services
Addressing Additional Personal Challenges to
Employment
Peer Support/Self Help Groups
Section III: Related Resources for VESID Staff
MH Advocates
ADA and NYS Human Rights Law
Benefits Counseling
Supported Education
Transition of School Age Youth
Mental Illness and Chemical Abuse (MICA)/Dual
Diagnosis
Mental Illness and Deafness
Cultural Diversity
IPRT Tool Kit
Existing Program Service Models in NYS for
Employment of Individual
with Psychiatric Disabilities
Appendices:
Practical Solutions and Possible Practical Job
Accommodations to Common Side Effects
Additional Readings and Research Based Principles
Local VESID/MH Program Liaisons
OMH Territories with Points of Contact (map)
Common MH Abbreviations and Acronyms
Statewide Resources
Questions that may be Asked by Community
Stakeholders
Introduction
The
Technical Assistance Brief on Mental Health (MHTAB)
is intended to:
-
Enhance access to VESID services for individuals
with mental illness;
-
Improve employment outcomes for individuals with
mental illness; and
-
Assist
in training VESID Counselors, mental health
providers and other stakeholders to promote
effective employment services through increased
collaboration and mutual understanding.
The
format is designed to present information with links
to additional resources. The “Key Points” are
abbreviated summaries that highlight the main points
of each section. You may also link to a more
detailed discussion of each main point. For issues
related to VESID Policy, the Vocational
Rehabilitation (VR) Manual should be consulted. The
Technical Assistance Brief is not vocational
rehabilitation policy or meant to be a single
prescription for services.
Section I Key Points:
|
Definition & Description of Mental Illness |
|
-
Definition:
- Mental
disorders are health conditions that are
“characterized by alterations in thinking,
mood, or behavior (or some combination
thereof) associated with distress and/or
impaired functioning.” (American Psychological
Association).
Section I provides additional information on
the definition of mental illness.
-
Description:
- Consumers with
mental illness have demonstrated the ability
to benefit from VR services, even in the
presence of symptoms. Vocational involvement
is essential to successful recovery, while the
recovery process in turn aids the consumer in
maintaining employment.
Section I provides additional information on
the description of mental illness.
-
DSM IV-R:
- The Diagnostic
and Statistical Manual of Mental Disorders,
Fourth Edition-Revised is the reference used
by mental health professionals to
differentially diagnose mental disorders. A
person’s DSM IV-R diagnosis is not a predictor
of recovery or employment success. Vocational
planning should be based on all employment
factors (strengths, resources, priorities,
concerns, abilities, capabilities, as well as
interests and informed choice), rather than a
diagnostic category.
Section I provides additional information on
the DSM IV-R.
-
Stigma and Discrimination:
- Stigma and
discrimination are major factors that affect
individuals with mental illness and their
vocational rehabilitation efforts. Stigma and
discrimination may influence employment
outcomes more than the disability itself.
Stigma and discrimination is not just the use
of the wrong word or action. Stigma and
discrimination are primarily about disrespect
and fear. This must be consciously addressed
in the vocational rehabilitation process,
especially for individuals with psychiatric
disabilities.
Section I
provides additional information on stigma and
discrimination.
-
Medication:
- To understand
mental illness and rehabilitation, it is also
important to understand the potential benefits
and precautions regarding medication
treatment. Medication, often combined with
various recovery-oriented services and other
personal supports, assists individuals in
their rehabilitation and recovery efforts.
Clear and continuous communication between
vocational staff and the individual treatment
team regarding medication issues is critical
to the success of the vocational
rehabilitation process. New medications are
being discovered every day and it’s essential
to access the most up-to-date information
regarding medications and their side effects.
Vocational Rehabilitation Counselors should be
familiar with possible practical solutions to
common medication side effects.
Section I provides
additional information on medication and side
effects.
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Section II Key
Points:
Section III Key
Points:
Section I: Definition & Description of Mental
Illness
Definition of
Mental Illness
Mental
Illness is a term that refers collectively to all
diagnosable mental disorders. There are many terms
used to define mental illness. Mental disorders are
health conditions that are “characterized by
alterations in thinking, mood, or behavior (or some
combination thereof) associated with distress and/or
impaired functioning.” (American Psychological
Association) The terms mental illness, mental
disorders, psychiatric disability and psychiatric
disorders are used interchangeably.
Description
of Mental Illness
Researchers
and mental health professionals have identified many
psychiatric disorders. Some are extremely rare such
as schizophrenia with a prevalence of less than 1%
of the population, and others occur relatively
frequently such as depression with a prevalence of
greater than 10% of the population. Some of these
disorders reflect acute episodes that occur once or
infrequently for the individual, and others present
as more long-term in nature.
Symptoms of mental illness are often cyclical in
nature. Even when individuals may experience long
periods of symptom remission, there may be times
when they experience an exacerbation of symptoms
that require additional supports, a medication
adjustment, time off from work, and/or
hospitalization. The ability to provide vocational
rehabilitation services despite symptoms is key to
successful recovery. (An individual does not have to
be free of symptoms to participate in VESID
sponsored services)
Additional information on specific mental disorders
can be found at:
The DSM IV-R
Mental health
professionals use a reference developed by the
American Psychiatric Association (APA) called the
Diagnostic and Statistical Manual of Mental
Disorders
(Fourth Edition), in order to select a specific
diagnosis based on a pattern of symptoms.
However, a person’s diagnosis does not determine
their prognosis. The DSM IV-R diagnosis is not
predictive of rehabilitation success. People with
severe mental illness often work successfully while
experiencing symptoms.
The DSM IV-R
diagnosis does not describe or predict the extent of
the disability. Individuals diagnosed with the same
disorder can be very different from one another.
Furthermore, the same individual may function
differently at different points in time. It is
important to look beyond the diagnosis to evaluate
the specific individual’s strengths and limitations.
An individual’s employment plan should not be based
on a diagnosis.
As stated in the
VESID/OMH MOU, a DSM IV-R diagnosis, if available,
should be provided to VESID as part of the referral,
but it is not mandated. VESID utilizes a four-digit
code for tracking impairments, not a DSM diagnosis.
A current diagnosis or referral information can
indicate the presence of mental illness (VESID/OMH
MOU). It is more important, however, for VESID to
have information to document functional abilities
and limitations, than it is to have a diagnosis. A
good rehabilitation plan, vocational or otherwise,
focuses on assets, while eligibility requirements
include an objective listing of functional
limitations.
See
Appendix A
for the DSM IV–R, Axes and Disability Categories.
Stigma and
Discrimination
Research has indicated that psychiatric disabilities
are the most negatively perceived of all
disabilities. Recovery often begins with finding
someone who believes in you. The VESID Vocational
Rehabilitation Counselor is often that person who
can provide the hope the individual needs in order
to regain their role in society and validate their
identity through work.
The stigma and
discrimination connected with mental illness promote
inaccurate beliefs about the abilities of
individuals with psychiatric disabilities to benefit
from vocational rehabilitation services to be
successfully employed. Stigma-related discrimination
can even result in the exclusion from the very
services that will enable an individual with a
psychiatric disability to be successful. Stigma and
discrimination, which include the use of
inappropriate labeling of individuals, is a major
factor that affects the success of employment
efforts. It can occur in any setting.
Bias, distrust,
stereotyping, embarrassment, fear and anger toward
individuals with mental illness are manifestations
of stigmatization of people with mental disorders.
These attitudes and behaviors perpetuate low
self-esteem, isolation, and hopelessness.
Addressing barriers
resulting from stigma and discrimination involves a
commitment to the belief that all people can
participate in recovery. This includes recognition
that individuals with mental illness enjoy equal
rights and opportunities to achieve their potential
with equal access and civil liberties.
The negative
effects of stigma and discrimination may impact
outcomes (including employment) more than the
disability itself. Fear, resulting from myths
regarding mental illness, is a paramount factor that
perpetuates stigma and discrimination. Education and
the dissemination of accurate information about
psychiatric disabilities are key to challenging
stigma and discrimination. Mental health and VESID
staff can be instrumental in reducing stigma and
discrimination by maintaining the assumption that
people who are diagnosed with mental illness can
recover and can work.
For more information
on how to eliminate discrimination against people
with psychiatric disabilities, click on:
Medication
Medication
can be essential in rehabilitation and recovery.
Medication is used to treat symptoms, but by itself
is usually not sufficient to effect recovery. New
medications are continuously being discovered and
recommended drug treatments are changing regularly.
Rehabilitation efforts to enhance all areas of a
person’s life can have a dramatic influence on the
effectiveness of prescribed medications. It is
important for VESID staff to communicate with the
consumer regarding medications and their potential
effect on employment. A brief summary of
medications, their classifications and side effects,
can be found in Appendix B.
Three recommended
Web Sites for the most up-to-date information on
medications include:
Medication Side Effects:
The
consumer should be encouraged to discuss possible
side effects with the treatment provider and/or
physician and their treatment team. VESID staff
should work with the consumer and the treatment
team regarding any issues or concerns related to
medication that may be impacting the employment
plan.
VESID staff can
enhance treatment efforts by assuring that
observation of side effects are accurately
documented and reported. Not all side effects
require immediate medical attention. Many of them
can be alleviated through techniques that can be
taught and that individuals can use on the job.
Some
Common Medication Side Effects:
-
Tardive Dyskinesia: This is a pronounced
involuntary movement, often of the mouth and
tongue. Tardive Dyskinesia can become permanent.
-
Anticholinergic effects: These include dry
mouth, tachycardia (rapid heartbeat), blurry
vision, and constipation.
-
Extrapyramidal effects: Refers to disorders
related to motor control, including:
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Pseudoparkinsonism: stiffness, shuffling,
tremors, motor rigidity
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Dystonias: twisting and contractions of muscle
groups
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Akathisia: motor restlessness
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Rabbit Syndrome: fine tremor of lower lip
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Pisa Syndrome: leaning to one side
Questions VESID
Counselors Should Ask Consumers Regarding
Medications:
-
If you are taking
medication, how does it affect you?
-
Do you require
any reasonable accommodation as a result of
taking medication?
-
Do you require
flexibility in your employment to attend
appointments with your physician or others?
-
Do you require
assistance taking medication? If so, what is it?
For "Practical
Solutions to Common Side Effects and Other Job
Accommodation Ideas," click here for
Appendix C.
Section II: Recovery, Research & Rehabilitation
A Vision for
Recovery
In the last century it
was believed that people with severe mental
illnesses could not recover. Recent research
underscores the reality that people, even those on
the back wards of state hospitals three decades ago,
can and do recover when offered the opportunity to
focus on self-determined goals, choice, growth in
skills, and have, above all, hope. Current research
helps correct the perception that some people are
too "sick" to recover. Core values inherent in
recovery should include self-determination, consumer
choice, personal growth, and hope. A Vision for
Recovery, Rehabilitation and Rights involves a
dedication to the belief that all people can grow,
change and gain desired opportunities and roles
in contrast to perspectives that view some
people as "too sick" to reach a vision of recovery.
(Adapted from NYAPRS’ Vision for a Recovery-Centered
Mental Health System, September 2000)
It is
never too early or late to begin the recovery
process. Understanding the recovery process
emphasizing consumer empowerment and applying it to
the vocational rehabilitation process are essential
to confronting the devastating effects of stigma.
(adapted from Center for Psychiatric Rehabilitation
Areas of Expertise. For more information:
http://www.bu.edu/cpr/expertise/recovery.html)
Research on Recovery
There
has been a shift in the mental health system from
traditional beliefs that focused on maintenance and
stabilization to rehabilitation and recovery. This
shift has been accompanied by an emphasis on
improved medications and treatment, the self-help
and empowerment movement, and advocacy efforts
championed by consumers and families. Pivotal to
this move towards self-sufficiency and independence
is the recognition that employment for persons with
psychiatric disabilities is an achievable role,
which fosters financial security, personal identity
and an opportunity to make a meaningful contribution
to community life.
Recently, a NY
statewide survey of consumers of mental health
services was conducted to identify their most
important priorities. In all regions of the state,
the first ranked response was "Increasing the
opportunities and skills training programs necessary
to getting and keeping a job."
Currently, more
than 85% of individuals with psychiatric
disabilities are unemployed and less than 25% are
currently receiving vocational services. The success
of various employment program approaches, such as
transitional and supported employment, have
developed into evidence-based practices which
demonstrate that effective employment interventions
can promote recovery.
Click
below for the latest information for research on
recovery.
For
further recommended readings and "Research Based
Principles" published by Judith Cook Ph.D. and other
publications, see Appendix D.
Connecting MH
with VESID
Guidance for increasing
access to services can be found in the Memorandum of
Understanding between NYSED/VESID and OMH (October
1999).
A key recommendation in the MOU is for VESID and OMH
to encourage their field offices and programs to
establish a liaison or point of contact to
facilitate service delivery, foster interagency
cooperation and address local systems issues.
It is strongly believed that providing appropriate
services for individuals with psychiatric
disabilities can be facilitated by having a local
agency and program listing of "liaisons and POCs"
(Points of Contact). It is highly recommended that
each region inserts this important local reference
or guide and that it is made readily available to
all stakeholders and be widely disseminated. See
Appendix E for additional
information.
Also,
Appendix F provides a map
of the OMH 5 Field Offices and counties covered with
names, addresses and telephone numbers of OMH Field
Office Directors and Rehabilitation Liaisons.
Some Practical Rehabilitation Counseling Strategies
for Facilitating Employment Services
The table below provides a
framework with some practical activities that
promote positive employment outcomes. The framework,
while outlining phases of a process, is not meant to
be a step by step, sequential process, but a list of
strategies that can be used to assist the individual
as needed, throughout the vocational rehabilitation
process.
|
Engagement
(focus is to establish trust, rapport, and
information sharing) |
- Have conversations that
support work as an option, including
conversations with people who have already
made the transition to work.
- Reinforce the value of
previous work or training experiences, no
matter how brief or limited.
- Help the person to identify
and accept strengths, resources, priorities,
concerns, abilities, capabilities, interests
and informed choice to set an employment goal.
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Exploration
(utilize motivation counseling techniques to
help consumers move through stages of change) |
- Meet and talk with peers
about how employment services have made a
positive difference.
- Read and discuss written
materials on training and placement programs
and job information.
- Visit employment and
training programs or work sites and talk with
workers and supervisors.
- "Job shadowing" that pairs
a consumer with a staff person for a short
period of time, enabling the consumer to
observe, and possibly assist, in a real work
setting.
|
|
Exposure
(to employment at the earliest opportunity to
test job options) |
- Participate in short or
part-time work try-outs or situational
assessments.
- Discuss factors that
contributed to past job or other successes and
reinforce those factors in current efforts.
- Identify factors that have
interfered with job success and develop plans
to address.
- Enhance awareness of
alternative job options through information
sharing, visits to other work sites, and
developing plans to acquire a more preferred
job.
|
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Experience
(assist consumers in gaining skills & experience
& test job goals) |
- Facilitate supported work
experiences, defined as jobs in integrated
work environments that assist participants in
gaining skills and experience, and test job
goals.
- Provide supports for
retaining the work experience gains.
- Use the experiences to
reinforce employment goal planning and
direction of vocational efforts.
|
Addressing Additional Personal Challenges to
Employment
Although "empowerment" is
used often in discussing the needs of
disenfranchised groups of people, few programs and
services enable people with psychiatric disabilities
to make fundamental decisions regarding one’s own
career future. VESID is committed to applying the
principle of informed choice and providing tangible
assistance to meet job and career goals.
|
Challenge |
Impact on
Work |
Strategy |
|
Undeveloped
vocational goals |
Lack of awareness
of personal skills related to available jobs. |
Use involvement
in work experiences, transitional or volunteer
work to learn about skills and job demands and
to develop goals. |
|
Functional
disabilities caused by psychiatric symptoms or
other physical health conditions |
Difficulty
meeting the physical and cognitive demands of
work or managing work-related interpersonal
relationships, e.g. supervisor. |
Ensure access to
integrated treatment and rehabilitation that
includes medications, mental health counseling
and support services, and case management.
Cognitive remediation and physical therapy may
also be needed. |
|
Alcohol and
drug dependency |
Increases
absences from work, impairs physical and
cognitive functioning and increases errors or
injury on the job. Provides just cause for
termination. |
Ensure access to
alcohol/drug treatment, recovery/motivation
support groups and peer and family support
networks. Include joint case management (VR, MH,
SA) as part of an integrated planning strategy
that addresses the individual’s needs at various
stages of recovery. |
|
Criminal
justice system involvement |
Criminal record
can exclude eligibility from some jobs and
questions regarding past criminal involvement in
the hiring process are not precluded under ADA. |
Vocational case
management that builds motivation for change,
addresses recovery, and focuses on acquiring and
retaining work to rebuild an acceptable work
history. Enrollment in job training or
educational programs that provide credentials
which employers need and indicate the person’s
motivation to succeed. |
|
Fear of losing
entitlements |
Decision not to
work, or to limit hours worked per week, or
reluctance to accept wage increases. |
Make benefits
counseling available on an ongoing basis.
Utilize options that retain health care
benefits. |
Peer Support/Self Help
Peer self-help employment
groups can dramatically contribute to recovery and
can support VESID efforts to assist the consumer to
regain and maintain a desired employment role. Peer
support provides people with an opportunity for
meeting on a regular basis to discuss on-going needs
related to employment issues with others who have
similar struggles. Peer support also offers a safe
and confidential place to share concerns outside of
the work place. People can communicate more openly,
view problems more objectively, and find more
effective coping strategies based on the experience
of others. Peers can serve as role models to each
other. Utilizing peer advocacy can effectively
reduce the need for conflict resolution and
mediation. For more information on peer support for
people with psychiatric disabilities:
http://www.mhselfhelp.org/
Why Self-Help
Works
Self-help for individuals with psychiatric
disabilities aids in the process of symptom
reduction in several ways:
-
Self-help
provides a social network based on common
experience. Recipients of mental health services
are often isolated due to stigma and
discrimination within and outside of the mental
health system. In this situation, lack of
socialization becomes an acute problem. When
recipients come together in a self-help setting,
they share common experiences, which lead
readily to the formation of social
relationships.
-
Self-help
facilitates people moving from the role of
always being helped to helping. Always being
helped makes one feel helpless. It is a
demeaning role in our society, which leads to
low self-esteem and a poor self-concept, which
in turn may lead to increased anxiety. The role
of helper is valued in our society, and leads to
higher self-esteem and self-concept, thus
providing a buffer from anxiety and repeated
crises.
-
In self-help
groups people share specific ways of coping,
based on experience.
-
Those who
successfully cope serve as role models for
people who less successfully cope.
-
Self-help
provides some structure for people which is not
imposed from the outside but self-generated from
the members themselves.
The Mental
Health Empowerment Project, as part of its
self-directed rehabilitation series, teaches
many of these things to recipients and
ex-recipients. Many recipients and ex-recipients
find them helpful. A recommended reference:
OMH Bureau of
Evaluation & Services Research, "The Meaning to
Self-Help" Investigators: Sharon Carpinello,
Ed.D., Edward L. Knight, Ph.D., 1993.
Section III: Related Resources for VESID Staff
MH Advocates
Mental
Health Advocates can play an important and at times
necessary role in assisting a consumer with a
psychiatric disability in making certain decisions.
This can be especially important in the VESID
application/group orientation process for
individuals with a significant psychiatric
disability. Best practice has confirmed the value of
having an advocate accompany an applicant with a
significant psychiatric disability, if they desire.
Some additional
recommended resources:
Americans with Disabilities Act (ADA) and Human
Rights Law
It is important for
employment specialists to remember that psychiatric
disabilities are examples of hidden disabilities
that may be covered under ADA and the NYS Human
Rights Law. Rights are essential to a good
rehabilitation process. However, many employers have
grievance procedures to resolve disputes and this
option should always be explored with the consumer
first.
There are various
risks to disclosing or not disclosing to an employer
that a person has a psychiatric disability.
Disclosure can allow the worker to involve the
employer, an employment services provider, a job
coach or other third party in the development of
accommodations. Disclosure can also set clear
expectations in otherwise difficult situations.
However, there are also some valid reasons why it
would not be advantageous to disclose. This is
especially true if the person may not require a
specific accommodation. Disclosure should not occur
without a full discussion of resulting issues with
the psychiatric consumer.
-
ADA for People with
Mental Health Disabilities, Cornell University
Participant Handbook, 2000. (607/255-2906)
-
"Mental Health
Issues in the Workplace. How the Americans with
Disabilities Act Protects You Against Employment
Discrimination" written by the MATRIX Research
Institute (2nd edition, June 2000) (www.matrixresearch.org)
-
Equal Employment
Opportunity Commission Web Site, for specific
psychiatric assistance: (
www.eeoc.gov )
-
Bazelon Center for
Mental Health Law Web Site:
http://www.bazelon.org
-
NYS Human Rights
Law:
http://www.nysdhr.com/
Click below for an
interactive and informative web site for people with
a psychiatric condition that address issues and
reasonable accommodations related to work and
school. Remember that there are some good reasons
why someone should disclose one's disability to an
employer and some good reasons why someone should
not disclose. This is the only site designed
exclusively to provide information about ADA and
other employment and education issues for people
with psychiatric disabilities.
http://www.bu.edu/cpr/jobschool/
Benefits Counseling
Many consumers who receive
SSDI or SSI fear that going to work will result in a
loss of benefits. Fortunately, many recent changes
in Social Security regulations encourage people with
disabilities to go to work and to retain health care
and other benefits. This is crucial since mental
illness tends to be cyclical.
Benefits counseling
is a resource for an individual to obtain benefits
and/or to understand and use work incentives
available through the Social Security Administration
and other public or private programs. Benefits
counseling provide reliable information on the
impact of earned income on cash benefits and
entitlement programs that the person may depend on
for overall income.
Benefits
counseling can also help the individual to make
informed choices regarding working and earnings,
applying work incentives to manage benefits and the
costs associated with going to work, and developing
a plan that leads to greater economic
self-sufficiency. It reduces the risk of losing
essential entitlements and helps the person
establish a secure financial situation. This service
is often available through independent living
centers, legal services offices, SSA-funded Benefits
Planning, Assistance and Outreach providers
(1-888-224-3272); and other qualified community
providers.
One
excellent resource for SSA work incentives is the
Social Security Redbook SSA Pub. No. 64-030. (www.ssa.gov/work
click on "Resources Tool Kit" )
Supported Education
Supported Education is a
service that can assist the consumer with a
psychiatric disability to access when pursuing
postsecondary education. It is available on many
college campuses and provides individualized
instruction and support to assist people with
psychiatric disabilities to obtain educational goals
that will enable them to achieve an employment
outcome. The purpose is to help current or potential
students with disabilities to select, enroll in, and
graduate from an educational or training site of
their choice. While there are several different
program models (on-site support, self contained
classroom and mobile support model), most Supported
Education Programs include the following program
services:
-
Coordination of
services on campus
-
Direct on-campus
assistance
-
Referrals to
resources on and off campus
-
Financial
assistance advisement and advocacy
-
Coordination of
services with mental health providers
-
On-going support
-
Public relations
-
Crisis resolution
on campus
-
In New York State,
Supported Education is a relatively new concept in
mental health services and is funded through a
variety of possible sources (VESID may or may not
be directly involved in funding this service). New
programs, however, are being developed on a
regular basis. The best way to find out about
Supported Education Services in local communities
is to contact the County Mental Health Director’s
Office (Directory and Index: MHANY (518) 427-8676)
and/or the Disabled Student Services Office
located on college campuses.
Transition
of School Age Youth
VESID staff need to assure
that they are getting referrals on students with an
emotional disability in a timely and appropriate
manner. Because there may be some reluctance to
label kids with a psychiatric disabling condition,
legitimate eligible applicants may not be referred
to VESID. There are often special education supports
available for those youth that choose to
self-disclose and plan to attend some type of
postsecondary education. Sometimes there is
reluctance to authorize additional testing and
evaluations to confirm psychiatric diagnoses. If the
CSE (Committee on Special Education) determines that
further assessment is not necessary to fulfill the
requirements of the IEP (Individualized Education
Program), then it is VESID’s responsibility to
arrange and pay for any additional testing needed to
establish VESID eligibility or to adequately develop
an IPE. (Individualized Plan for Employment)
Accessing additional information on "Student
Transition" can be found at the VESID Web Site:
http://web.nysed.gov/VESID.
Mental Illness and Chemical Abuse (MICA)/Dual
Diagnosis
"Mental Illness and Chemical
Abuse" (MICA) is an example of a dual diagnosis.
Research indicates that over 50% of the mentally ill
population also have a substance abuse problem. Two
disorders require an integrated treatment approach.
It is not mandated that MICA consumers complete
substance abuse treatment or have a certain length
of abstinence in order to apply or be eligible for
VESID services. VESID staff should be sensitive to
other types of dual diagnoses. One good resource:
National Alliance for the Mentally Ill Web Site:
www.nami.org/helpline/dualdiagnosis.htm
Mental Illness
and Deafness
There are few special deaf
resources for intensive psychiatric intervention
across the state. The VESID Counselor/s in each
local VESID district office that specialize in
serving consumers who are hearing impaired or a
local ILC (Independent Living Center) advocate are
the best resources for recommending local
"specialty" psychiatric counseling services related
to deafness. The normal mental health referral route
with the assistance of a qualified interpreter may
be the best course of action for immediate
counseling intervention.
A good statewide
resource is the Coalition of Organizations Serving
the Deaf and Hard of Hearing (COSDHH). To access the
best local resource person to help address issues
related to effective treatment of mental illness in
people who are Deaf, can be obtained through the NY
Society for the Deaf:
nysd@aol.com
Cultural Diversity
There are significant differences
among cultures as to what is considered "normal"
behaviors and the perception of mental illness. For
example, American Indian, Asian, and Hispanic
cultures have both a wider tolerance for
communication with voices, dead spirits, etc. At the
same time, the broader culture can be intolerant of
members of the culture who appear to be different.
Vocational Rehabilitation Counselors should explore
the cultural implications of the individual’s
disability. Working with the consumer, family
members and significant others are necessary to
gather accurate insights related to cultural
dynamics. In addition, by acquainting people with
others of the same culture and who have faced and
overcome the same challenges, aids success in
achieving employment goals.
More information on
cultural diversity can be found in the Surgeon
General’s Report (www.surgeongeneral.gov/library/mentalhealth/home.html)
OMH IPRT Tool Kit (Rehabilitation Readiness
Determination)
This instrument is widely used in
MH to help determine rehabilitation readiness. OMH
requires its completion to determine readiness for
Intensive Psychiatric Rehabilitation Treatment (IPRT)
Programs and vocational rehabilitation services.
Psychiatric rehabilitation readiness determination
is a process developed at Boston University that
assesses to what extent a consumer is ready to make
a change in their life in one of four environments:
living, working, educational, social. This readiness
to set an "Overall Rehabilitation Goal" is based on
the consumer’s perceived need and commitment level
to making a change in their life. Other
considerations include awareness of themselves,
awareness of possible goal environments and the
consumer’s ability and willingness to work with a
service provider. This assessment does not indicate
whether a person has the skills necessary to make a
change in their life, but does assess whether or not
a person has the need, motivation, awareness and
perceived support to undertake the steps necessary
to set and achieve an "Overall Rehabilitation Goal".
Copies of the Readiness Assessment Forms can be
obtained at the OMH website:
www.omh.state.ny.us under "Resources;" then
"Print Shop Catalog;" enter Form # 346 to view form.
Existing MH Program Models in NYS for Employment of
Individuals with Psychiatric Disabilities
-
Psychosocial Club:
The objective is to
assist individuals disabled by mental illness to
develop or establish a sense of self-esteem and
group affiliation; to promote their recovery
from mental illness and their reintegration
into a meaningful role in community life through
the provision of two or more of the following: 1.
Recipient and self-help empowerment interventions;
2. Community Living; 3. Academic; 4. Vocational
and/or 5. Social, leisure, time rehabilitation,
training and support services.
-
Assisted
Competitive Employment (ACE):
The objective is to assist
individuals in choosing, finding, and maintaining
satisfying jobs in the competitive employment
market at minimum wage or higher. When
appropriate, ACE provides these individuals with
job related skills training as well as long-term
supervision and support services, both at the work
site and off-site.
-
Intensive
Psychiatric Rehabilitation Treatment (IPRT):
The IPRT program is time-limited, with active
psychiatric rehabilitation designed to assist a
recipient in forming and achieving mutually agreed
upon goals in living, learning, working and social
environments; to intervene with psychiatric
rehabilitation technologies, to overcome
functional disabilities and to improve
environmental supports. The IPRT program shall
provide the following services:
-
Readiness
Determination. (IPRT tool kit)
-
Goal Setting
-
Functional
Assessment
-
Service Planning
-
Skills and
Resource Development
-
Discharge
Planning
-
Affirmative
Business/Industry: The
objective is to provide vocational assessment,
training, transition or long-term paid employment,
and support services for persons disabled by
mental illness in a less restrictive/more
integrated employment setting than sheltered
workshops. Affirmative programs may include mobile
contract services, small retail or wholesale
outlets, and manufacturing and service oriented
business.
-
Peer Advocacy:
Peer Advocacy Services
are, by definition, provided by current or former
service recipients who have been trained in such
areas as negotiation and mediation skills,
recipient’s rights, mental hygiene law, and access
to entitlements and local resources. Peer advocacy
programs may provide individual advocacy, systems
advocacy, or a combination of both types.
-
Self-Help Program:
The objective is to
provide rehabilitative and support activities
based on the principle that people who share a
common condition or experience can be of
substantial assistance to each other. These
programs may take the form of mutual support
groups and networks, or they may be more formal
self-help organizations, which offer specific
educational, recreational, social, or other
program opportunities.
-
Continuing Day
Treatment: A continuing
day treatment program (usually a MH prevocational
service) shall provide active treatment and
rehabilitation designed to maintain or enhance
current levels of functioning and skills, to
maintain community living and to develop
self-awareness and self-esteem through exploration
and development of recipient strengths and
interests. A continuing day treatment program
shall provide the following services:
-
Assessment and
Treatment Planning
-
Discharge
Planning
-
Medication
Therapy
-
Medication
Education
-
Case Management
-
Health Screening
and Referral
-
Psychiatric
Rehabilitation Readiness Development
-
Psychiatric
Rehabilitation Readiness Determination
-
Referral
-
Symptom
Management
-
The following
additional services may also be provided:
-
Supportive
Skills Training
-
Active Therapy
-
Verbal Therapy
-
Crisis
Intervention Services
-
Clinical
Support Services
Appendices
Appendix
A: DSM IV-R Axes and Disability Categories
-
Diagnosis Axes:
Five axes are used to
diagnose a person, each reflecting an important
aspect of that person’s current condition. The
five axes are:
Axis I Clinical Disorders, and Other
Conditions That May Be a Focus of Clinical
Attention.
Axis II Personality Disorders, and Mental
Retardation.
Axis III General Medical Conditions.
Axis IV Psychosocial and Environmental
Problems.
Axis V Global Assessment of Functioning.
Mental
disorders are characterized by specific symptoms,
which generally result in difficulties for the
individual. These symptoms can be seen in the
individual’s behavior, emotions, perceptions and/or
thinking. Different disorders are characterized by
different symptoms, which are identified very
clearly in the DSM IV-R. Remember that diagnoses are
not a valid predictor of vocational success.
-
Categories of
Disorders: Each section
of the DSM IV-R reviews a different category of
disorders. The following outline provides a sense
of the variety and complexity of the mental
disorders:
-
Disorders usually first diagnosed in infancy,
childhood or adolescence (e.g., mental
retardation, learning disorders, pervasive
developmental disorders)
-
Delirium, dementia, and amnesic and other
cognitive disorders
-
Mental disorders due to a general medical
condition not elsewhere classified
-
Substance related disorders (e.g., alcohol
abuse, cocaine dependence)
-
Schizophrenia and other psychotic disorders
-
Mood
disorders (e.g., depressive disorders, bipolar
disorders)
-
Anxiety disorders (e.g., panic disorder,
agoraphobia, post traumatic stress disorder)
-
Somatoform disorders (e.g., pain disorder,
hypochondriasis)
-
Factitious disorders
-
Dissociative disorders (e.g., dissociative
identity disorder)
-
Sexual and gender identity disorders
-
Eating disorders (e.g., anorexia nervosa,
bulimia nervosa)
-
Sleep disorders
-
Impulse-control disorders not elsewhere
classified
-
Adjustment disorders
-
Personality disorders (e.g., borderline
personality disorder, antisocial personality
disorder)
-
Other conditions that may be a focus of clinical
attention
Easy to
understand information on specific disorders can be
found at the NIMH web site:
http://www.nimh.nih.gov/publicat/index.cfm
Appendix B: Medications and
their Classifications
Medications are often less effective than they could
be because many clients do not regularly take them
or have access to them. Vocational counselors need
to have a basic knowledge of medications to
effectively communicate with the treatment team
regarding medication treatment effects relative to
successful employment.
-
Antipsychotic Medications:
These medications are used to treat
individuals who have psychotic illness primarily
schizophrenia. They help to
lessen the symptoms but are not cures. Many on
these medications will sometimes experience side
effects. These may affect someone’s ability to
work and it is important to discuss with the
consumer their particular situation. There are two
classifications: typical and atypical.
The
typical are the older drugs and include: thorazine
(chlorpromazine), taractan (chlorprothixene),
permitil and prolixin (fluphenazine), haldol,
haloperidol, daxolin, loxitane (loxapine),
serentil (mesooridazine), lidone and moban (molindone),
trilafon (perphenazine), orap (pimozide (for
tourette’s syndrome), mellaril (thiordazine),
navane (thiothixene, stelazine (triflupromazine),
and vesprin (triflupromazine)
Atypical neuroleptics were developed starting in
1990. These drugs have proven helpful for
individuals who have not responded well to the
typical anti-psychotic drugs. They have fewer side
effects (particularly tardive dyskinesia),
although there is a greater likelihood of weight
gain. One drug Clozaril (clozapine) requires close
monitoring because of the possibility of a blood
disorder. Weekly or bi-weekly blood testing is
required. Other atypical neuroleptics are
risperdal (risperidone ), zyprexa (olanzapine),
seroquel (quetiapine) and geodon (ziprasidone).
-
Anti-Manic Medications:
These
medications are used to treat bipolar disorder
(manic depression). The medications are used to
even out the mood from the extreme highs or lows.
Medication often takes time to build up in the
system. The most common medication used is
lithium. Possible side effects include drowsiness,
weakness, nausea, vomiting, fatigue, hand tremor,
or increased thirst and urination. There is a very
small therapeutic window, so close blood level
monitoring needs to be done.
Lower levels of
sodium in the body can also increase the toxicity
of lithium. Lithium can also effect the thyroid
and kidneys. People being treated with lithium
also tend to have weight gain as one of the side
effects of this medication.
Anti-seizure
medication has been found to be useful for some
people who do not benefit from lithium. Two
medications that fit this class are tegretol (carbamazepine)
and depakote (divaplpoex). Other anti-manic
medications include Neurotin (garapentin),
Lamitical (lamotrigine), Cibalith-S (lithium
citrate), and Topomax (topiramate).
-
Anti-Depressant
Medications:
These medications are used to treat people with
depression. Generally someone will need to
experience symptoms for at least 2 weeks and they
interfere with their functioning before medication
is prescribed. Someone who is depressed may also
have psychotic symptoms. These medications can
also be used to treat anxiety disorders. There are
3 main classifications of antidepressant
medications: tricyclic; newer antidepressants (SSRI’s)
and the monoamine oxidase inhibitors (MAOIs).
Each of the classes of these drugs
can have various side effects. Other side effects
with tricyclics may include blurred vision, dry
mouth, constipation, weight gain, dizziness when
changing position, increased
sweating, difficulty urinating, changes in sexual
desire, decrease in sexual ability, muscle
twitches, fatigue, and weakness. Examples of
tricylic drugs include elavil (amitriotyline),
asendin (amoxapine), norpoamin (desipramine),
Pamelor (nortriptyline) adapin (doxepin), tofranil
(imipramine), ludiomil (maprotiline), surmontil
(trimipramine), and vivcatil (protriptyline).
Drugs that are similar to the tricylic but have
different side effects are deseryl (trazodone),
wellbutrin (bupropion), and Serzone (nefazodone).
The
newer antidepressants have side effects that are
gastrointestinal and headache. Insomnia, anxiety
and agitation also occur. There are also potential
drug interactions with other medications. Examples
of the SSRI’s include Prozac (fluoxetine), Luvox (fluvoxamine),
Paxil (paroxetine), Celexa (citalopram), and
Zoloft (sertraline).
The
MAOI’s have similar side effects to other
antidepressants but also interact with certain
foods so that anyone using these drugs needs to be
on a restricted diet, Examples of theses drugs
include: Marplan (isocarboxazid), and parnate (tranylycpromine),
nardil (phenelzine).
-
Anti-Anxiety Drugs:
These drugs are used to treat symptoms of anxiety
that include "butterflies in the stomach," sweaty
palms, irritability, uneasiness, jumpiness,
feelings of apprehension, rapid or irregular
heartbeat, stomach ache, nausea, faintness, and
breathing problems. Besides generalized anxiety,
other anxiety disorders are panic, phobia,
obsessive-compulsive disorder (OCD), and
posttraumatic stress disorder.
Anti-anxiety medications help to calm and relax
the anxious person and remove the troubling
symptoms. There are a number of anti-anxiety
medications currently available. Benzodiazepines
are usually used although there is also a
non-benzodiazepine, buspirone (BuSpar), is
used for generalized anxiety disorders.
Antidepressants are also effective for panic
attacks and some phobias and are also used. for
more generalized forms of anxiety, especially when
it is accompanied by depression. The medications
approved by the FDA for use in OCD are all
antidepressants clomipramine, fluoxetine, and
fluvoxamine.
The
most commonly used benzodiazepines are xanax (alprazolam)
and valium (diazepam) followed by Librium,
Librax, Libritabs. (chlordiazepoxide).
Other benzodiazepines are azene (clorazepate),
paxipam (halazepam), ativan (lorazepam), serax (oxazepam)
and centrax (prazepam). Benzodiazepines are
relatively fast-acting medications; in contrast,
buspirone must be taken daily for 2 or 3 weeks
prior to exerting its antianxiety effect.
Benzodiazepines have few side effects. Drowsiness
and loss of coordination are most common; fatigue
and mental slowing or confusion can also occur.
These effects make it dangerous to drive or
operate some machinery.
With benzodiazepines, tolerance, dependence and
abuse can occur. This is why they are usually
prescribed only for brief periods of time or
intermittently. There are occasional situations
where one of the following medications may be
prescribed: antipsychotic medications;
antihistamines (such as Atarax, Vistaril,
and others); barbiturates such as phenobarbital;
and beta-blockers such as Inderal or Inderide (propranolol).
Propanediols such as equanil (meprobamate)
were commonly prescribed prior to the introduction
of the benzodiazepines, but today rarely are used.
For
additional information on medications link to:
http://www.nimh.nih.gov/publicat/medicate.cfm#index
Appendix
C: Practical Solutions to Common Side Effects
|
SYMPTOMS |
SOLUTION |
|
Eyes sensitive to strong sun or light |
- Use sunglasses, a hat or
visor
- Avoid prolonged exposure
|
|
Dryness of lips and / or mouth |
- Increase fluid intake
- Rinse mouth with water
- Keep hard candies or
sugarless gum handy
|
|
Occasional indigestion / upset stomach |
- Drink small amounts of
clear soda water
- Eat dry saltine crackers or
toast
- Do not provide or encourage
antacids without a physician’s permission
|
|
Occasional constipation |
- Increase water consumption
- Increase physical exercise
- Increase consumption of
leafy green vegetables or bran cereals
- Drink lemon juice in warm
water
|
|
Fatigue / Sleepiness |
- Take a brief rest period
during the day
- Speak to physician about
switching entire daily dose to bedtime
|
|
Dizziness when upright |
- Practice getting up slowly
from a sitting or reclining position
|
|
Mild
extra-pyramidal symptoms (restlessness, muscle
stiffness, slowed movements) |
- Increase regular exercise
- Take short walks
- Learn stretching exercises
for muscles
- Use music to relax
|
|
Dry
Skin |
- Use mild shampoos and soaps
- Use lotion after each bath
- Wear seasonal protective
clothing
|
|
Weight gain |
- Increase regular exercise
- Watch diet and reduce
overeating
|
|
Skin
Discoloration |
- Wear clothing that covers
skin
|
|
Sunburn |
- Use sunscreen
- Use sunglasses, a hat or
visor
- Avoid prolonged exposure
|
Other
Ideas for Job Accommodations that may be Related to
Medication Side Effects or the Disability
|
Potential Barriers |
How to Cope/Possible Solutions |
|
Inability to screen out environmental stimuli,
such as sounds, sights, or smells, which
distract. For example, an individual may have a
hard time working next to a noisy printer or in
a high-traffic area. |
- Move the noise
source away from the work area or vice versa
whenever possible.
- Wear
headphones playing soft music while working.
- Install high
partitions around the work area.
- Change spatial
arrangements, noise and lighting levels as
needed.
|
|
Inability to concentrate.
Feelings of
restlessness, having a short attention span,
being easily distracted, or having a hard time
remembering verbal directions. Difficulty
focusing on one task for an extended period of
time. |
- Break large
projects into smaller tasks;
- Assign tasks
in writing or tape record instructions.
- Take short,
frequent breaks to stretch or walk around
whenever attention is slipping.
- Provide access
to private space.
|
|
Lack
of stamina.
Not having enough
energy to work a full day or drowsiness from
medication. |
- Request
part-time schedule.
- Request
flexible schedule or job sharing to be sure
the individual is working only during
high-energy hours.
- Take a mid-day
rest break.
- Change
medication times, if allowed by M.D.
- Access to
water in workspace.
- Review diet
and exercise lifestyle with physician.
|
|
Difficulty handling time pressures and multiple
tasks.
Having trouble managing assignments, setting
priorities, or meeting deadlines. For example,
not knowing how to decide which tasks to do
first in order to complete a project by its due
date. |
- Break larger
projects down into manageable tasks.
- Meet regularly
with the supervisor or job coach for help
prioritizing or estimating how long it will
take to meet a deadline.
- Use written
instructions (or tape recorder) and a daily
"To Do" list.
- Provide a
co-worker "buddy" or mentor.
|
|
Difficulty interacting with others.
For example, being
too shy to talk with co-workers at breaks, or
having trouble figuring out "how things go
around here". |
- Pair the
individual with a co-worker who can introduce
him/her around and show him/her the ropes.
|
|
Difficulty handling negative feedback.
Having a hard
time understanding and interpreting criticism.
For example, getting defensive when someone
says, "work isn’t up to standards." Having
difficulty figuring out what to do to improve,
or believing that trying to change is worthless. |
- Ask that a job
coach be present when there is a meeting with
the employer for feedback.
- Permit calls
to job coach as needed.
- Encourage the
worker to offer their own perspective on
individual strengths and weaknesses.
- Request
specific ways to improve.
- Ask to receive
feedback in writing with an opportunity to
discuss later.
|
|
Difficulty responding to change.
Unexpected changes
at work, such as new rules, job duties, or
supervisors and co-workers, may be unusually
stressful. For example, it may take a long time
to learn new tasks, or the person may feel
especially anxious around new co-workers. |
- Ask for
advance notice of job changes. Introduce tasks
gradually. Minimize changes to job description
over time.
- Make a special
effort to introduce the worker to new
co-workers. Ask the employer to notify new
supervisors of the individual’s needs.
- Exchange tasks
with others.
- Limit
supervisory or staff changes, if possible.
|
|
Difficulty with Scheduling Demands |
- Allow time off
for medical appointments and time off without
pay when needed.
- Allow use of
vacation and personal leave for medical needs.
- Allow for more
frequent breaks.
|
|
| |
