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Change is not inevitable

March 1, 2010
by Elizabeth M. Van Houtte, MS, MSW, LSW, CPRP
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SERV Behavioral Health System implements in-depth intervention steps to change its recovery goals

Employment is central to recovery, yet it can be neglected when not accepted as such within an organization's culture.1 For a large housing services provider, reestablishment of vocational and educational goals for program participants arrived with a new administration: a CEO and COO with a deep-rooted philosophy in psychiatric rehabilitation.

SERV (Social, Educational, Residential, and Vocational) Behavioral Health System is a private, not-for-profit provider. Its adult supported housing services operates in five counties of the central and northern portions of New Jersey and serves over 500 people diagnosed with severe and persistent mental illness (SPMI).

Shifting an organizational culture focused on finding, getting, and keeping housing to one incorporating employment and education as integral parts of recovery was overwhelming. Attaining ownership by the different segments of the organization and eliminating old assumptions were daunting, but essential tasks.2

Administrators sought assistance from the Integrated Employment Institute (IEI) in the Department of Psychiatric Rehabilitation at the University of Medicine and Dentistry of New Jersey. The IEI consultant shared the new administration's view of employment as an individual outcome critical to achieving successful recovery for people with SPMI.

Roll up your sleeves

SERV's management team recognized that lingering paternalism was the largest organizational barrier to overcome. Yet, trained staff had to buy in to the change. In the world of behavioral healthcare, acquiring and retaining staff is not easy, and turnover is high. Management had to provide the tools for them to see positive outcomes from the new expectations.

Management committed to supporting each employee in accepting the shift in corporate focus. Goals of employment and education had to be endorsed by consumers and other stakeholders as well. There needed to be a joint commitment to the change.

To foster this commitment, steering committees were established at each of the five organizational locations and were comprised of professional and support staff, family members, and consumers so that site-specific concerns could be identified and addressed. It was quickly accepted that not all components of change could be under control at all times. Flexibility was critical to success.

We tend to build dams, not bridges

Persons with SPMI face very real barriers to employment, including: (1) lack of effective, long-term employment support; (2) concerns about losing benefits; (3) professionals who retain beliefs that consumers are unmotivated, fragile, and who underestimate the need for vocational services; and (4) consumers and families discouraged by past vocational failures.3 As Bill O'Brien, COO of SERV, noted, “It became apparent that even though we had learned a lot about and endorsed wellness and recovery values as an organization, many staff did not embrace competitive employment as a valid goal for all of our consumers. Consumers and staff together have had to unlearn what they had previously been taught, let go of their beliefs, and realize that competitive employment is a real possibility for all.”

The evidence-based research is clear. If consumers do not have employment as an active, written goal, they typically will not receive support to achieve that goal. Providing assistance to consumers in determining whether (and which) employment is right for them is critical to bringing employment goals into the individual plan.4

Informal (and some formal) attitudes undervalued staff roles in encouraging employment. Many staff had long accepted their sole purpose as providing compassionate services in a protective environment. There were the usual gripes: “We've always done it this way,” “Safety will be compromised,” “Everyone will go off of meds,” and “We are already doing recovery and work.” Addressing these effectively meant openly acknowledging that protective behavior was part of the culture of SERV and was counterproductive; old assumptions needed to go.

Intervention steps for change

Commitment. Sustaining any change effort requires resources, supervisory support, and administrative commitment.5 For many staff and consumers, a belief that obtaining and maintaining employment for consumers is achievable was the most difficult commitment to obtain. To counter persistent comments about “betraying consumers” who “only wanted protection and support,” each of the five county site directors developed measurable outcomes that could be readily achieved. Demonstrating frequent and visible successes under the new outcome goals allowed both players to ease away from complacency. They paved the way for further inroads into staff and consumer buy-in and commitment.

Contributions. Implementing change always requires sound leadership. Therefore, personnel who demonstrated or acquired skills, knowledge, and competencies related to vocational rehabilitation were acknowledged as leaders by management. At the same time, staff positions specializing in employment-related service delivery were put into place in the formal organizational structure. Consumers were included in the site steering committees, and their contributions played a key role in attaining desired organizational outcomes.

External employment and educational resources-such as Workforce Investment Act (WIA) One-Stop Centers and supported employment providers-tend to be underutilized by mental health professionals.