Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Supported Employment
Workbook
Chapter 8 :Job Supports
Job supports facilitate successful competitive employment
Chapter overview
This chapter describes and demonstrates ways in which employment specialists can support consumers on the job.
Job supports help facilitate the vocational lives of people with severe mental illnesses. The task of an employment specialist is to provide appropriate supports for the specific job challenge facing a consumer. These challenges tend to differ depending on whether the employment specialist is supporting someone who is 1) starting a new job, 2) doing a job, 3) having a crisis on a job, or 4) ending a job.
Rehabilitation theory
Job support is psychiatric rehabilitation. The goal of all rehabilitation is to help people do their best in regular adult roles. Rehabilitation interventions can focus on the individual or on the individual’s social network, or physical environment. In a general medical example, the rehabilitation of a person who is paralyzed from the waist down can include interventions aimed at the individual, such as building arm strength and teaching the person how to transfer from a wheelchair to a chair, or interventions aimed at the environment, such as building a ramp into a building or teaching a spouse how to assist the person in dressing. Likewise, psychiatric rehabilitation interventions can be focused on the individual, such as using role-playing to teach a person the skill required to relate effectively to a boss and co-workers, or they can focus on the person’s support system, such as enlisting family members to help wake a person up on time for work in the morning, or advocating for a work environment that is not too noisy or chaotic.
Using this chapter
In the sections that follow, case examples illustrate consumers who can benefit from job supports:
- Starting a new job
- Doing a job over time
- Having a crisis on the job
- Ending a job
After reading each case example, please challenge yourself by listing possible strategies for solving the consumers’ dilemmas before reading on.
Remember:
- Job support interventions can be aimed at
- The consumer
- The consumer’s support network, including friends, family, and practitioners
- The workplace social and physical environment
Supervisor’s note
This chapter lends itself to group teaching and discussion.
Use these vignettes, or others from your experience, to stimulate creative problem-solving discussions.
Make an effort to help employment specialists to develop a broad repertoire of interventions that can be used to facilitate work. Ask them to list out supports to the environment as well as supports to the consumer.
Starting a Job
This section describes Mary’s issues when starting a new job.
Case history: Mary’s Story
Mary worked as a secretary before becoming ill with recurrent depression five years ago. She misses working and, with the help of her employment specialist, had recently arranged to work part-time again as a secretary. Knowing Mary was anxious, the employment specialist made an appointment to check in with her after her first day of work.
Mary arrives late, with teary eyes and a disheveled appearance, saying, “I can’t work. It is all too much for me. I got lost on my way, so I was late for my first day! And my boss made comments about how I look. She doesn’t like me.” Mary reports that her mother, her case manager, and her psychiatrist have all cautioned her about working, saying it would be too stressful for her.
Tackling the Issues
If you were the employment specialist, what would you do?
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Reasonable responses
Some Possible Responses: There is no single correct answer as to how to handle this situation. Here are several approaches the employment specialist might take.
Strengthening the Individual’s skills and abilities
Rehabilitation supports aimed at the individual
The first few days on a new job are often stressful. As the employment specialist, you want to gather information about the difficulties the consumer is experiencing, since an assessment of the problem will guide the intervention.
First, you can help Mary to become calm by getting her a Kleenex and a glass of water. Help to normalize the situation by saying that lots of people find the first day at a new job difficult but that initial problems are often solved. Then ask Mary to describe what happened. You may learn that Mary’s boss had asked if Mary could begin working an hour earlier than had been originally arranged. Wanting to please her new boss, Mary had said she could begin at the earlier time; however, on the first morning, Mary found it difficult to get her children off to school in time to run for the bus. She then got on the wrong bus and arrived late to work. During the bus ride, she became more and more worried about what her boss would think and began to seriously doubt her ability to do the job.
After understanding the situation you want to respond in a way that is consistent with Mary’s coping strategies. For example, you may know from previous sessions and from team meetings, which include her case manager and psychiatrist, that Mary can become overwhelmed with worry, but responds well to direct, practical support. If Mary still wants to work, she may realize it will not be possible for her to start work at the earlier hour. You and Mary need to work out a plan that provides her with the confidence to continue in the job.
The plan could include how Mary could talk to her new boss about her work hours. You and Mary could role-play how the phone call could go. To provide support, you offer to stay nearby while Mary makes the call.
When starting a new job, consumers can benefit from employment specialists reviewing with them the transportation plan for getting to work. You and Mary may want to ride Mary’s bus route to work together, timing how long the trip takes and writing out the bus changes on a card that Mary can carry in her purse as a reference.
And finally, you could congratulate Mary for staying at work through a hard first day. She reached out to you for support and assistance in problem solving in just the right way.
Strengthening network and team supports
Rehabilitation supports aimed at the consumer’s support network
The consumer’s support network plays an important role in providing effective job supports. Are team members giving Mary consistent messages about work? As the employment specialist, you want to update team members on what is happening and ask their views on the situation. Is everyone on the team supporting the current work effort? If the psychiatrist, for example, expresses concern about work causing stress, you might describe how others have achieved greater levels of independence by learning ways to deal with stress in work situations.
Addressing family members’ concerns and enlisting their support helps consumers in their work efforts.
With Mary’s permission, you could call Mary’s mother. What are her worries? You may learn that she believes you are pushing work on Mary when she believes Mary is not ready. Setting up a meeting between you, Mary, and her mother can provide a way for Mary to clearly communicate to her mother that she wants to work. Families can be very supportive particularly if someone on the team addresses their concerns and provides them with information about the advantages of supported employment.
Arranging Workplace accommodation and providing support
Rehabilitation supports aimed at the consumer’s work environment
The third area of support is the social and physical environment at the workplace. With the consumer’s permission, the employment specialist can speak directly with the work supervisor to problem solve. Mary may want you to tell the boss about her struggles with anxiety and depression, but also to communicate her desire to succeed at the job.
What is the employer’s assessment of the consumer/employee’s work performance? You may learn that Mary’s boss had noticed that Mary had been late the first day but had thought that, generally, the day had gone very well and found she caught onto the routine quickly. Through direct contact with an employer you can learn what concerns the employer has. You may learn that the boss’s only real concern is that Mary had not brushed her hair and did not look quite tidy enough for her position, which involves greeting the public.
Employment specialists provide guidance and support to employers and suggest ways to help consumers/workers improve their work performance. When you meet with the employer you might explain that Mary is anxious about returning to work, after being away from work for five years. You could encourage the employer to give Mary positive feedback about her ability to learn quickly and to regularly tell her when work is going well to try to overcome Mary’s initial anxiety. Let the employer know that you believe Mary’s confidence will build in time. Employers oftentimes find it helpful to talk with employment specialists to better understand how to supervise and support employees.
Discussion of Job Starts
Starting a new job can be stressful for anyone. The process can be even more challenging for someone who is managing a mental illness and may not have worked for a while. As an employment specialist, your job is to anticipate and try to head off job start problems. You can make sure a consumer has practical plans to address common concerns, such as waking up on time, wearing the right clothes, and traveling to work. You can coach the consumer to practice the workday routine ahead of time. You can also work with a consumer’s family, friends, and treatment team to be sure she has the support she needs to get to and through the critical early days on the job.
Common concerns
Starting a Job checklist
In the appendix, you will find a checklist that you can use with a consumer to help him plan for a job start. You will also find an expanded list of questions that you can use to anticipate the possible challenges of starting a job.
Doing a Job
Doing a job over time can bring other challenges, from reactions to a change in routine to a gradual outgrowing of the job. Patrick’s story focuses on this phase of competitive employment.
Doing a Job over time
Case history : Patrick’s Story
Patrick is a 32-year-old single male with schizoaffective disorder who has been receiving mental health services for 8 years. Today, Patrick shows up at the office saying he is hearing more voices and is having trouble sleeping. He says that he has recently been changed to the evening shift at the convenience store where he works.
Patrick’s employment specialist asks a few more questions about Patrick’s situation and finds out that the evening shift is busy. Often, there are long lines of customers, who at times, become irritated.
On breaks, Patrick has been drinking lots of coffee, and after work, he has been going out with coworkers to drink beer. He says that he does not want to go to the state hospital again.
Tackling the Issues
If you were the employment specialist, what would you do? How would you address supports related to Patrick, his network, and his workplace?
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Reasonable responses
Some Possible Responses: There is no single correct answer as to how to handle this situation. Here are several approaches you might take.
Strengthening the Individual’s skills and abilities
Rehabilitation supports aimed at the individual
Changes in work schedule and work responsibilities can be stressful. Employment specialists need to understand how people respond differently to these changes. What is stressful for Patrick? What would Patrick find most helpful? Patrick may ask for help in figuring out what to say when his coworkers ask him to go out for beer. He is glad for the friendships but remembers that he has had problems from drinking in the past.
Many consumers, like Patrick, are motivated to change because they want to work. Reviewing with Patrick ways to say no to invitations to drink provides him with a response in these stressful situations. Trading off role-playing coworkers who want Patrick to join them allows Patrick to practice the skill.
Employment specialists need to consult with the psychiatrist or nurse about increased symptoms and troubles sleeping. They may recommend an adjustment in Patrick’s medications to effectively manage his sleep and voices.
Strengthening network and team supports
Rehabilitation supports aimed at the consumer’s support network
Employment specialists are in constant communication with case managers and other team members about how consumers are functioning in their jobs. In this example, you would communicate with Patrick’s case manager who may provide more information that is helpful for problem solving. For example, the case manager would know that Patrick’s last hospitalization began with a similar period of drinking and sleeping problems. He also would know that Patrick had actively participated in a dual-diagnosis group at the center in the past and had had a year without drinking. When the case manager sees Patrick, he needs to remind him of this achievement and ask him if he would like to rejoin the group. Group members are often glad to see each other and provide useful suggestions.
Arranging Workplace accommodation and providing support
Rehabilitation supports aimed at the consumer’s work environment
Evaluating how a consumer functions in the workplace can provide clues to what supports and accommodations would be helpful. You and Patrick might discuss what could be done differently at his work site. Is he able to manage the pace and tension of the evening shift? Helping Patrick identify the pros and cons of staying on the evening shift or requesting a return to the day shift is a way to bring clarity to the problem. At this point consumers who have not disclosed their disability status to their employer may reconsider. Under the Americans with Disabilities Act (ADA) people with disabilities who are otherwise qualified for the job can request an accommodation.
Discussion of Doing a Job
After a job gets underway, a consumer will be confronted by different challenges. Work may have an impact on many areas of a consumer’s life including his daily schedule, relationships with friends and family, financial benefits, substance use, and medication needs. Work will also bring him into new, and sometimes complex, social situations. Coping with these may require your support and assistance. Establishing and keeping contact with him and, when appropriate, his employer, will keep you informed and available to both of them as he continues to do the job.
Common concerns
Doing a job over time checklist
In the appendix, you will find a checklist that you can use with a consumer to help her address some common work-related concerns. You will also find an expanded list of questions that you can use to anticipate some of the possible challenges of work.
Crisis on the Job
In the next section, you will read about Bonita’s Crisis on the Job.
Case history: Bonita’s Story
Bonita has been working as a mail distributor at a large company. She has a diagnosis of schizophrenia, but has not had a relapse since starting this job several years ago. Yesterday she did not show up at work. Today, she is slapping the mail down on people’s desks and muttering under her breath. The employer calls her employment specialist saying he is getting calls from all over the building. He sounds frightened on the phone and wants to fire Bonita. Tackling the Issues
If you were the employment specialist, what would you do? How would you address supports related to the consumer, her network, and workplace?
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Reasonable responses
Some Possible Responses: There is no single correct answer as to how to handle this situation. Here are several reasonable approaches that you could take.
Strengthening the Individual’s skills and abilities
Rehabilitation supports aimed at the individual
With a release of information, employment specialists can talk with employers when problems occur on the job. In this example, you could thank the boss for calling and provide some reassuring information. You could tell the employer that Bonita has lived with her illness for many years and has no history of aggression. You could then offer to go over to the workplace to try to figure out what is going on, saying, “It would be a shame if she lost her job after years of service, without looking into it first.” The offer of an onsite, immediate visit often helps calm the boss in a crisis situation.
Visiting the work site allows you to assess Bonita and the work situation. Is Bonita having increased symptoms such as talking to herself and pacing in the cafeteria. How are other employees responding to her? You need to assess whether Bonita needs to be seen by another team member for evaluation. If Bonita is unable to return to work right away, you would need to arrange a sick leave with her employer.
Strengthening network and team supports
Rehabilitation supports aimed at the consumer’s support network
People in a consumer’s network may function positively or negatively in providing support. How are people in Bonita’s support network affecting the crisis situation? As the employment specialist, you want to find out what stressors are causing the escalation in Bonita’s symptoms. When Bonita feels ready to talk about the situation, you ask her about stressors. She may reveal that over the last month, her ex-husband has been encouraging her to have more contact with her children, who live with him. He has also been asking her to contribute money to help meet the children’s needs. Although she has welcomed the additional contact and even, to some degree, the responsibility, the increased demands have disrupted her routine. Knowing that Bonita’s case manger has had contact with Bonita’s ex-husband periodically, you ask her case manager about setting up a meeting with Bonita and her ex-husband. With the support of you and her case manager, Bonita can work out an arrangement with her ex-husband that is less stressful to her.
Arranging Workplace accommodation and providing support
Rehabilitation supports aimed at the consumer’s work environment
Employment specialists need to find out what causes stress for people at the workplace. What does Bonita find stressful at her job? She might say that delivering mail on a new floor is a stressor. Since changing her route she has to walk in front of a man who looks just like her uncle, who sexually abused her as a child. She was able to manage for a few days, but then began to think that the man actually was her uncle and started to hear his voice in her head at work. Even though she is no longer hearing voices, she is afraid to go back to work. She is also embarrassed that she got so sick at the workplace. She worries that now her boss will treat her differently.
One way employment specialists provide support is facilitating communication between the consumer/worker and the boss. You suggest arranging a meeting with Bonita and her boss to talk over what happened and to see if he is willing to put her back on her old mail route. At the meeting, which you attend, Bonita says that she is ashamed about what happened and asks if she can go back to her old route, saying that she found the new route “too stressful.” The boss sees that she is back to her old self and welcomes her back to her old job.
Discussion of Crisis on a Job
Symptom recurrence or substance abuse relapse may interfere with how well a consumer is able to perform at work. Changes at work or in a consumer’s personal life can also create problems at work. While avoiding all crises may be impossible, you can reduce the risk by learning what has triggered difficulty in the past, helping a consumer avoid situations that are high-risk, and monitoring for early signs of a problem. If difficulties do occur, you can often keep a small problem from becoming a large crisis by responding quickly with problem solving and support.
Common concerns
Crisis on a Job checklist
In the appendix, you will find a checklist that you can use with a consumer to help him avoid a crisis at work. You will also find an expanded list of questions that you can use to help a consumer through the difficult time at work.
Ending a Job
In the next section, you will read about Jack’s Ending a Job.
Case history: Jack’s Story
Jack is a 44-year-old divorced man with bipolar disorder who has been working at the same janitorial job for five years. He is a good worker and has become a team leader, orienting and supervising others. He has been grumbling about being sick of cleaning toilets but has taken no action to look for other employment. Suddenly, he disappeared for three days, missing work and clinical appointments. When his employment specialist finally gets him on the phone, Jack tells her angrily that he does not want to work and hangs up on her.
Tackling the Issue
If you were the employment specialist, what would you do? How would you address supports related to Jack, his support network, and workplace?
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Reasonable responses
Some Possible Responses: There is no single correct answer as to how to handle this situation. Here are several approaches that you might take.
Strengthening networking and team support
Rehabilitation supports aimed at the consumer’s support network
Employment specialists are sometimes puzzled by someone’s behavior. You might know Jack as a very quiet person but you have always seemed to get along well. You might want to talk with someone else on the team who knows him well and could offer some answers. Case managers, who work closely with consumers over time, can offer a different perspective. Jack’s case manager might suggest that the difficulty is not with the global issue of work, but rather, with the specific job he has now.
Consumers may not always want to tell their employment specialist what they are thinking in terms of a job. Does Jack have a strong relationship with the case manager with whom he may feel more comfortable to discuss the situation? Jack may open up to his case manager that the boring nature of his job makes him feel that he is going nowhere in life. He is angry with you for encouraging him to stick with this job, not seeing how bad it now makes him feel. In the conversation, Jack says, for the first time, that he wants to go back to school to study Human Services. The case manager tells Jack he is confident that you will support Jack’s goals. He then brings you into the room so the three of you can work out a plan that is consistent with Jack’s preferences and goals.
Strengthening the individual’s skills and abilities
Rehabilitation supports aimed at the individual
Gathering information from the consumer’s support network, which includes other practitioners and family and friends, helps employment specialists understand more clearly a consumer’s goals. Now that you know more about what Jack wants, you can assure Jack that you support his vocational development and that you will be honored to be able to help in the process. You might tell Jack about various programs you are aware of and show him how to research jobs on the Internet.
Arranging Workplace accommodation and providing support
Rehabilitation supports aimed at the consumer’s work environment
Employment specialists assist consumers in ending jobs in a good way. If at all possible, you want to help the consumer end a job on good terms with the employer in order to obtain a good job reference. Jack might feel he just cannot face his employer after three days of unexcused absence. You could then offer to explain the situation to Jack’s employer. You might find out that Jack’s employer has been worried about Jack and is relieved to hear he is safe. He indicates that if Jack really has to leave, he would like Jack to work for two more weeks, which will give him a chance to try to hire a replacement.
Discussion of Ending a Job
Leaving a job may be a healthy decision for a consumer. Exploring her reasons for wanting to leave, and investigating if there are any other options is useful before any final decision is reached. Of course, the ultimate decision to leave is up to the individual. If she decides to leave, the role of the employment specialist is to be a resource for her so that she may leave the job in an informed and successful manner.
Common concerns
Ending a Job checklist
In the appendix, you will find a checklist that you can use with a consumer to help her address the challenge of ending a job. You will also find an expanded list of questions that you can use to think through how to help a consumer end a job effectively.
Supervisor’s note
We suggest that you use these four vignettes as starting points for discussing the issues that come up at the different phases of the work experience. You may want to ask the employment specialists to write up their own responses before discussing them with the group. Feel free to change these vignettes to illustrate different points. Please add situations from your own experience that are relevant to your town or city.
This discussion may be done in a unit meeting or during group supervision.
Chapter summary
Supporting the work effort of people with severe mental illness is a creative process. Some problems can be anticipated. Others must be addressed as they arise. Often, there are numerous possible solutions to each challenge. As an employment specialist, you assess each situation, then support the consumer and her environment so that the job works out.
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