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Widening the definition of work

November 1, 2007
by Morris L. Roth, MSW, Paul D. Sexton, MBA, Jonathan A. Liebert, MA, and Jennifer Howard Smith, PhD
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A recovery-based model encourages consumers to adopt work strategies that work best for them

There is a dramatic and disturbing disconnect within the mental health community when it comes to vocational programming. According to the President's New Freedom Commission on Mental Health's final report, an incredible 90% of mentally disabled individuals do not work, making this group the most unemployed of any group with disabilities.1 However, survey research suggests that a great majority (almost three-fourths) of these individuals possesses both the desire and the potential ability to work.2

This set of incongruent statistics is troubling, since further research on mental health points to vocational activity as one of the most critical components of the recovery process.3 Mental healthcare consumers regularly identify work as both a goal and a motivating force in recovery.4 Recovery from mental illness requires many elements including "developing hope, moving beyond preoccupation with one's illness, forging a new identity, and pursuing meaningful life activities."5 These critical ingredients are found in vocational activities and achievements. Vocational activities allow consumers to take inventory of, and stock in, their set of competencies and apply them in meaningful, efficacious ways. This helps to establish an active, enduring, functional sense of self, which provides the necessary foundation upon which the "work" of recovery can be manifested.6

The IPS Model

What mental health professionals mean by "work" seems to vary in both definition and scope. For many years, work for individuals with severe mental illness was synonymous with participation in sheltered workshops; segregated groups of disabled individuals worked together on tasks chosen and supervised by mental health staff, usually for less than minimum wage. A very different, but equally narrow, concept of work was introduced in the mid-1990s with the Individual Placement and Support (IPS) model of vocational rehabilitation.

IPS programs solely emphasize client-driven "competitive employment," defined as regular, supervised work for at least minimum wage pay in integrated (i.e., including nondisabled coworkers) settings.7,8 Prevocational training and education are deemphasized and discouraged, and any vocational activities other than competitive employment are considered suboptimal. Proponents of the IPS model state:

Some clients will inevitably need to transition through volunteer jobs or other prevocational activities. Nevertheless, since expectations tend to provide a self-fulfilling prophecy, and low expectations (e.g., sheltered employment) may result in clients failing to fulfill their wishes and potentials, IPS focuses consistently on competitive work as the ultimate goal.7

Although the IPS model has been linked to a variety of positive vocational outcomes (e.g., hours worked, wages earned, satisfaction with finances), it consistently has shown little, if any, effect on clinical outcomes (e.g., self-esteem, quality of life, global functioning, reduced psychiatric symptoms, and rehospitalization rates).8-11 Yet according to the Center for Reintegration, any meaningful employment experience provides five critical factors that promote mental well-being:

  • time structure;

  • social contact and affiliation;

  • collective effort and purpose;

  • social and personal identity; and

  • regular activity.12

While these factors are present in a "competitive" work setting, they also are likely to be present in other vocational settings. The IPS model's narrow definition of work may unnecessarily exclude some consumers who might clinically benefit from alternative forms of vocational activities.

The ACCESS Model

A model with a much broader definition of work is making significant vocational and clinical strides for a group of mental healthcare consumers in Colorado Springs. Incorporated in 1991, Aspen Diversified Industries (ADI) is an affirmative business affiliated with Pikes Peak Behavioral Health Group. ADI is dedicated to assisting disadvantaged, disabled, and nondisabled people by creating a diverse set of meaningful vocational opportunities for those who may lack such opportunities in the existing job market. Unlike many vocational programs, in which placement is both the focus and the benchmark for "success," ADI uses the recovery model to steer its evidence-based practices. Hence, ADI's ACCESS model provides Alternative Avenues of Community Placement Chosen by Clients, to promote: Empowerment, Skills Improvement, and Self-Sufficiency (figure 1).


Figure 1. ADI's ACCESS Model of Vocational Rehabilitation

The hallmark of ADI's ACCESS model lies in its broad array of opportunities for mental healthcare consumers interested in some type (or types) of community integration and involvement. Because ADI offers such a wide variety of avenues to its consumers, it is able to reach a larger, more diverse set of mental healthcare consumers than more restricted vocational programs.

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