VOCATIONAL

REHABILITATION
IN PSYCHIATRY & MENTAL HEALTH
 WORK

⊡ Includes activities needed for engaging in

remunerative employment or volunteer activities
(Mosey, 1996, p. 341)

⊡ Employment interests and pursuits

⊡ Employment seeking and acquisition
⊡ Job performance
⊡ Retirement preparation and adjustment—
⊡ Volunteer exploration
⊡ Volunteer participation
 WORK IN THE MENTAL HEALTH
SETTING

People with mental illness have high unemployment

rates compared to other disability groups

People with mental disabilities are able to function in

various levels of competitive employment (Grove, 2001;
Secker & Membrey 2003)

People with mental disabilities does not get better in

order to work; they work in order to get better. (Hill,
1995)
 OT IN VOCATIONAL
REHABILITATION

OT requires holistic approach to the client and the use

of meaningful and purposeful activities.

Vocational rehabilitation applies a comprehensive,

holistic assessment of the client, analysis of the job and
the work environment, and the use of work tasks,
activities and accommodations to assist the client in
fulfilling essential job demands.
 EFFECT OF MENTAL ILLNESS IN
A PERSON’S ABILITY TO WORK

⊡Impact of the diagnosis

⊡Episodic and fluctuating nature of the
impairment
⊡Poor social interaction skills
⊡Cognitive dysfunction
⊡Reduced motivation
⊡Emotional impairments
 IMPACT OF DIAGNOSIS AND
SYMPTOMS

Better vocational outcomes for persons with

mood and personality disorders

Poorer vocational outcomes for people with

schizophrenia and psychosis
 EPISODIC NATURE OF MENTAL
ILLNESS

People suffer mental illnesses through

periods of relative wellness followed by
increased symptoms and functional
deterioration.

Unpredictable symptoms may have a

negative impact on a person’s motivation and
self-confidence.
 HOW TO DEAL WITH
UNPREDICTABLE SYMPTOMS?

⊡Adequate medical treatment and management of

his/her condition

⊡Compliance with medication and other treatment

regimes

⊡Insight about illness and how to deal with episodic

deterioration

⊡If employed, consider the awareness of the employer

regarding the client’s condition
 IMPAIRED SOCIAL
INTERACTIONS AND
COMMUNICATION

Social incompetence
⊡ Difficulty relating to others
⊡ Struggles in recognizing and interpreting social cues
⊡ Struggles to fit in with workplace culture

Perceived as difficult, strange, weird, inappropriate

Oversensitive to feedback
 IMPAIRED SOCIAL
INTERACTIONS AND
COMMUNICATION

Management should focus on:

⊡ Social skills training
⊡ Assertiveness training
⊡ Stress management
⊡ Sensitizing supervisors and fellow
employees
 POOR WORK PERFORMANCE

Cognitive, emotional and motivational

difficulties may affect a worker’s ability to
perform their essential work tasks efficiently
and accurately.
 POOR WORK PERFORMANCE

Inability to sustain concentration

Difficulty screening out environmental stimuli

Poor flexibility in decision making and problem solving

skills

Poor memory

Difficulty in organizing though process

 POOR WORK PERFORMANCE

Difficulty in controlling preoccupations or delusional

thinking

Problems with drive and motivation

High levels of anxiety

Difficulty responding to changes at work

Lack of stamina
Extra-personal effects of mental
illness on employability
 JOB AVAILABILITY

Fewer jobs = increase in competition for

employment

Risk for retrenchment when companies

downsize or restructure for those with jobs
⊡ Target low-skilled workers and those in
supported employment
 PREJUDICIAL ATTITUDES AND
MISCONCEPTIONS ABOUT
PEOPLE WITH MENTAL ILLNESS

Misunderstanding about the nature and cause

of mental illness

Various reactions towards mental illness: fear,

shame, guilt, embarrassment

Reaction of patients: poor self-esteem,

rejection, loneliness, feelings of inadequacy
 LIMITED OR INADEQUATE
VOCATIONAL REHABILITATION
SERVICES AND FACILITIES

Programs tend to be time limited and provide no

follow-up support for the client

Vocational rehabilitation services should be

restructured to offer ongoing support and follow-up.
 LIMITED OR INADEQUATE
VOCATIONAL REHABILITATION
SERVICES AND FACILITIES

Poor integration of medical and vocational

rehabilitation services.

Services are often unnecessarily replicated.

 LIMITED OR INADEQUATE
VOCATIONAL REHABILITATION
SERVICES AND FACILITIES

Many insurance schemes tend to put their energies

and resources into determining eligibility for
compensation as opposed to rehabilitating people for
return to work.
 LIMITED OR INADEQUATE
VOCATIONAL REHABILITATION
SERVICES AND FACILITIES

Occupational therapists in the field of vocational

rehabilitation frequently come from a physical
rehabilitation background and may lack skill in the
special needs of people with mental illness.

These professionals often unwittingly reinforce stigma

by holding faulty ideas about the nature of mental
illness and by fostering low vocational expectations for
their clients (Garske & Stewart 1999; Lloyd & Waghorn
2007).
 DISABILITY BENEFITS OFTEN
PROVIDE A DISINCENTIVE TO
WORK

Sick leave is usually recommended for clients with

mental illness whilst they undergo assessment and
intervention.

Extended leave may be implemented if the client goes

beyond the sick leave minimum
⊡ Client may receive disability benefits from an
insurer or from the state in order to replace their
salaried income.
Predictors of employment
success
 PREDICTORS OF EMPLOYMENT
SUCCESS

Premorbid functioning and particularly previous work

history to be the most consistent and reliable
predictors of employment success. (Tsang et al., 2000)

1. Clients who had worked before were more likely to

secure and retain employment.
2. Social competence to be a strong and consistent
indicator of vocational outcome.
 PREDICTORS OF EMPLOYMENT
SUCCESS

Interpersonal difficulty to be the most frequently

reported workplace problem leading to job
terminations among people with severe mental illness.
(Becker, et.al., 2006)
 PREDICTORS OF EMPLOYMENT
SUCCESS

Level of cognitive functioning (McGurk et al. 2003) and

good family relationships.

Clients with supportive families more likely to adjust to

the demands of work and experience employment
success than clients without family support. (Tsang et
al., 2000)
The Vocational Rehabilitation
 THE VOCATIONAL
REHABILITATION

Vocational rehabilitation is a systematic process which

enables the occupational therapist to facilitate
employment in various work settings.

Vocational rehabilitation is a process which is

multidisciplinary and has many stakeholders (Finger et
al. 2011).
 THE VOCATIONAL
REHABILITATION

A multi-professional evidence-based approach that is

provided in different settings, services, and activities to
working age individuals with health-related
impairments, limitations, or restrictions with work
functioning, and whose primary aim is to optimize
work participation. (Escorpizo et al., 2011, p. 130)
 INTERNATIONAL LABOR
OFFICE
5 STEPS

1. Vocational assessment
2. Vocational guidance
3. Vocational preparation and training
4. Selective placement
5. Follow-up
 MODELS AND THEORETICAL
FRAMEWORKS

MOHO (KIELHOFNER, 2008)

BIO-PSYCHOSOCIAL MODEL (ROSS, 2007)
ICF MODEL (WHO, 2001)
DISABILITY MANAGEMENT MODEL (ROSS,
2007)
PEO MODEL (STRONG, ET. AL., 1999)
MODEL OF CREATIVE ABILITY (CASTELEJIN &
DE VOS 2007)
The Vocational Assessment
 REFERRAL FOR VOCATIONAL
REHABILITATION

Referral for vocational rehabilitation services

for clients with mental health disorders can
come from a number of sources including the
treating physician, psychiatrist, employer,
employee wellness practitioner, occupational
health practitioner, insurer or case manager.
 REFERRAL FOR VOCATIONAL
REHABILITATION

Letters of referral should also be

accompanied by comprehensive information
in order to give direction to the vocational
rehabilitation process.

Medical reports, reports from treating

practitioners, job descriptions and reports
regarding workplace performance are useful
and facilitate the process.
 PREPARATION FOR THE
VOCATIONALASSESSMENT
FUNCTIONAL CAPACITY
EVALUATION

Understand the mental health condition, its progress,

prognostic indicators for employment and potential
interventions – will determine appropriate evaluation
process

Request the client to bring curriculum vitae

⊡ Detailing work history
⊡ Current job description
⊡ Any available medical documentation
 PREPARATION FOR THE
VOCATIONALASSESSMENT
FUNCTIONAL CAPACITY
EVALUATION

Preparation is concluded by drawing up the

evaluation plan
⊡ Must include: sequence of tests, required
observations to note and evaluation
methods to be used
 SELECTING AN APPROPRIATE
VENUE FOR VOCATIONAL
ASSESSMENT

Clinic, hospital, client’s home or place of

employment

Consider the availability of appropriate

testing tools and other requirements
 OBTAINING INFORMED
CONSENT

Informed consent:
⊡ explaining the purpose of the referral to the client
⊡ Discussing what the assessment entails
⊡ Informing to whom feedback and reports will be
directed
⊡ Informing what the client’s rights are during the
process.
 INITIAL INTERVIEW

Collect all relevant information related to the purpose

of the vocational assessment whilst maintaining the
therapeutic relationship

Use of an interview guide and a semi-structured

interview format is recommended
 INITIAL INTERVIEW

The interview guide is developed before interviewing

commences

Client’s education/training backgrounds

Psychiatric history
Other relevant medical history
Current treatment
Current functional status (including that of activities of
daily living and leisure participation)
 INITIAL INTERVIEW

Qualitative observations
⊡ Verbal and non-verbal behaviour
⊡ Communication
⊡ Insight
⊡ Concentration
⊡ Anxiety
 INITIAL INTERVIEW

Self-report measures/questionnaires to
evaluate the client’s:
⊡ Levels of anxiety
⊡ Depressive feelings
⊡ Self-esteem
⊡ Levels of stress
 PHYSICAL SCREENING
EVALUATION

Purpose:
To determine any physical side effects of the
medication as well as the presence of any physical
and/or neurological disease.
 PSYCHOSOCIAL/MENTAL
HEALTH EVALUATION

Ongoing process which is conducted throughout the

vocational rehabilitation process and is integrated in all
aspects of testing.
 PRE-VOCATIONAL SKILL
EVALUATION

‘Antecedents to job skill development such as

cooperative behaviour, task focus and
motivation’. (Jacobs & Jacobs, 2001, p. 148)
 PRE-VOCATIONAL SKILL
EVALUATION

Motivation to work

Work habits

Work endurance
 PRE-VOCATIONAL SKILL
EVALUATION

Work habits

• Self-presentation skills
• Social skills as applied in social
situations
• Regular attendance and punctuality
• Work competency skills
 PRE-VOCATIONAL SKILL
EVALUATION

Work endurance

• Ability to sustain an
appropriate level of
performance over a full eight
working hours per day on a
continual basis
 PRE-VOCATIONAL SKILL
EVALUATION

Ability to read and write

Perform basic mathematical calculations
Use a calculator
Operate a computer (and related technology)
Manage finances
Drive a car or use public transport
 VOCATIONAL SKILL
EVALUATION

Role of OT: assess specific work demands and

uses various techniques and methods to do
this.

Focus of the vocational skill evaluation:

provide an assessment of work-related
knowledge and work skills as well as speed of
performance or productivity.
 VOCATIONAL SKILL
EVALUATION

Work sample: ‘a well-defined work activity

involving tasks, materials and tools which are
identical or similar to those in an actual job or
cluster of jobs’. (Jacobs, 1991, p. 39)

Valpar
Component Work Samples (2013)
 VOCATIONAL SKILL
EVALUATION

Work simulation: placing the person into a

realistic work situation where environmental,
interpersonal, task, tool and other such
demands are simulated in order to represent
the work situation as closely as possible.
 VOCATIONAL SKILL
EVALUATION

On-the-job evaluation: assesses the client at

the place of his/her potential or current
employment.
 OBTAINING COLLATERAL
INFORMATION

Contributes towards understanding the client’s

strengths, limitations and motivations.
 JOB ANALYSIS AND WORK
VISIT

Conducting a workplace visit

Meeting with people in the workplace
Conducting a job analysis of the client’s current or
potential work
 JOB ANALYSIS AND WORK
VISIT

Understanding work-related factors such as the

environmental factors, interpersonal relationships,
work stressors and the pace of work

Visiting the workplace facilitates an

understanding of potential reasonable
accommodation and realignment positions.

Obtaining job descriptions and performance

management agreements are useful during this
step.
 ANALYSIS
INTERPRETATION
PLANNING

CLINICAL
REASONING
 ANALYSIS
INTERPRETATION
PLANNING

Understanding the client’s vocational interests, needs and

goals and determining how realistic his/her job goals are.

Providing the client with honest and practical feedback on

his/her performance in the vocational assessment.

Providing information on suitable and realistic

opportunities for training, education and work.

Assisting the client to develop a career plan, consisting of

short- and long-term goals.
The Vocational Intervention
 VOCATIONAL INTERVENTION

Impact of the mental illness

Client’s educational and work history
Context
Available resources (including intervention
facilities and finances)
Whether client is employed, unemployed or
on sick leave
 VOCATIONAL INTERVENTION

Transitional
Pre-vocational Work
work programs
skills training hardening
(TWPs)

Case Supported
management employment
 PREVOCATIONAL TRAINING

Treatment of cognitive and psychosocial performance

components such as attention span, planning skills,
interpersonal skills, time management skills and coping
skills.
 WORK HARDENING

Conditioning tasks that are graded to progressively

improve the biomechanical, neuromuscular,
cardiovascular/metabolic and psychosocial functions
of the person in conjunction with real or simulated
work activities (Jacobs 1991)
 TRANSITIONAL WORK
PROGRAMS

Return to work in a restricted or modified capacity for

a specific length of time.

Advantages:
⊡ Early return to work
⊡ Reduced duration of illness and disability
⊡ Reduced illness and disability costs
⊡ Increased employer involvement and accountability
⊡ Reduced work disruptions
⊡ Enhanced morale
⊡ Protection of the employability of the worker
⊡ Realistic work environment and culture
 CASE MANAGEMENT

Vocational case management activities (Ross, 2007)

Counselling and encouragement

Referral to services

Coordination of service provision

Support to and facilitation into work

 SUPPORTED EMPLOYMENT

Method to improve their

work readiness and
employability (Crowther et al.
2001).
Vocational Training
 VOCATIONAL TRAINING

Formal vocational training programs at universities,

colleges, schools, training centers and special training
institutions as part of vocational rehabilitation
program.

Role of OT:
⊡ Help the client select an appropriate course of
training
⊡ Assist with the application and enrolment process
⊡ Assist the client to identify the need for, and request
reasonable accommodations where appropriate
Placement
 PLACEMENT

Competitive employment/open labor market

Supported employment
Sheltered and protective workshops
 PLACEMENT

Legislation that protects the rights of people

with disabilities and ensures equality within
the workplace.
 4 PHASES OF PLACEMENT

Effecting
the
Matching placement
Workplace
assessment
Vocational
(re)
assessment
 FOLLOW-UP AND CLOSURE

Final stage of the vocational rehabilitation

process

It measures how effectively the program

objectives have been achieved.

Provides ongoing support to the client and

endeavors to correct any problems that may
have arisen.
 OT IN THE WORKPLACE

Consultants to employers on issues of disability equity

and disability management.

1. Conducting sensitization and awareness training

sessions on disability and disability- related issues
and advising employers on strategies for disclosure
2.
3. Advising employers on the practical
implementation of applicable disability legislation,
regulations and good practices
 OT IN THE WORKPLACE

3. Advising employers on the management of

employees with disabilities in the various phases of
employment, including recruitment and selection,
placement and training, retention, development
and career advancement, disciplinary procedures
and termination of employment

3. Advising employers on reasonable

accommodation-related issues

4. Case managing employees