Career counseling with clients who have a severe mental illness.

Individuals who are diagnosed with a serious mental illness encounter a variety of barriers that can impede their career development. In this article, the career barriers of clients who have a severe mental illness are reviewed, and a developmental approach to career counseling with this population is described. A case example is provided to illustrate the complex process of developmental career counseling with people who are seriously impaired by a psychiatric illness.

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People who have a severe mental illness continue to be stigmatized and neglected because of numerous myths about this population. For example, it is widely believed that people with a mental illness are a danger to society and that they are incapable of maintaining a job. These myths persist in spite of evidence suggesting that people who have a mental illness are no more likely than individuals in the general public to commit violent crimes and that people with mental illnesses can be productive members of society, especially when they receive supportive services (Tenety & Kiselica, 2000).

The stigma of mental illness is only one of many barriers encountered by people who have been diagnosed with a serious psychiatric condition. The purpose of this article is to discuss these barriers and to describe a developmental approach to career counseling that is designed to help people who have been diagnosed with a chronic mental illness make a successful transition back into the community. We begin this article with an overview of barriers that reduce the chances of people with serious mental illness from obtaining gainful employment and independent and semi-independent functioning. We then suggest practical strategies that counselors can use to enhance the career development of this population, including recommendations regarding career-oriented intake interviews, assessments, and counseling.

Barriers Impeding the Career Development of Clients Who Have a Severe Mental Illness

People who have a serious mental illness represent the second largest category of individuals with a disability served by state vocational rehabilitation systems, yet vocational rehabilitation programs have demonstrated limited success with this population (Garske & Stewart, 1999). Although most psychiatric personnel claim that fostering the career development of this population is an important therapeutic goal, the unemployment rate for people with a major psychiatric illness has been estimated to be as high as 85% (Garske & Stewart, 1999).

The dismal record in the United States of addressing the career needs of clients who have received a diagnosis of a serious psychiatric condition is tied to a number of barriers that impede the career development of this population. For example, Bond and McDonel (1991) noted that negative attitudes about individuals who have been diagnosed with a mental illness pervade all levels of society. Consequently, many professionals, consumers, employers, and even relatives of these individuals view them as inappropriate candidates for employment (Herr & Cramer, 1996). When clients do receive career assistance, pertinent services tend to be focused on assessment and prevocational skills rather than on competitive employment. To make matters worse, the policies of many social insurance programs (e.g., Supplemental Security Income [SSI], Social Security Disability Insurance [SSDI], Medicaid, Medicare) and other federal programs fail to cover the career needs of persons with serious psychiatric illnesses adequately, or they create confusing circumstances that discourage many people in this population from seeking work. For instance, criteria differ for persons receiving SSDI or SSI and often involve calculating and maintaining accurate records of earnings and knowledge of a multitude of inclusionary/exclusionary criteria to determine the amount of an individual's benefits. Some of the criteria that are considered include substantial gainful activity amount ($780 per month), impairment-related work expenses, continued payments under a vocational rehabilitation program, trial work period, and continued Medicare/Medicaid benefits. In addition, a new position called the employment support representative (ESR) was recently established by the Social Security Administration to help beneficiaries make transitions to work/careers, adding another layer to this already overwhelming system (Social Security Administration Office of Employment Support Programs, 2002). The disinclination to risk losing assured benefits, which individuals who have a mental illness regard as essential to their sustenance, is understandable (Rutman, 1994).

In a related discussion of pertinent federal programs, which appeared in a report for the National Association for the Mentally Ill, Noble, Honeberg, Hall, and Flynn (1997) identified, in current federal and state vocational rehabilitation programs, numerous disincentives to employment for individuals who have a mental illness. For example, vocational rehabilitation services provided under the Smith-Fess Act of 1920 are time limited and are predicated on the idea that once people obtain employment, they no longer require services and supports from the vocational system. Vocational rehabilitation agencies currently perpetuate a system that rewards counselors for putting their greatest efforts and resources into helping individuals who are easiest to place into employment and most likely to retain employment. Noble et al. (1997) charged that the majority of state vocational rehabilitation agencies have not done a good job of developing and implementing ideas that would establish true incentives for serving individuals, such as people with a severe mental illness, who have more complicated, long-term needs. State vocational rehabilitation agencies still earmark a large proportion of their resources for disability and eligibility determination and administrative functions; the resources allocated for clients with a mental illness are often spent on evaluation methodologies that are inappropriate for this population (Noble et al., 1997). Typically, traditional vocational rehabilitation services require a person with a mental illness to look for a job without the benefit of receiving adequate support from career counselors (Bond & Meyer, 1999). Finally, these agencies stubbornly adhere to counselor-generalist models despite clear evidence that specialization is necessary to adequately serve individuals who have mental illnesses (Noble et al., 1997).

In summary, it appears that state vocational rehabilitation agencies, mental health agencies, and other systems do not adequately address the career development needs of people with severe mental illness. This state of affairs is disconcerting when one considers that establishing a career can be therapeutic and can lead to independent living for the individual who has a mental illness, while simultaneously reducing taxpayer expenses (Loughead, 1989). Effective developmental career counseling with this population is long overdue and can yield many positive benefits for clients with a mental illness and for society.

Developmental Career Considerations

Anthony, Cohen, and Danley (1988) described persons with mental illnesses as being vocationally immature because their life experiences and roles have been restricted; such experiences are important in the development of a vocational identity. Consequently, these individuals often tend to have unrealistic goals or inappropriate vocational behavior. In addition, their knowledge of themselves--including their skills, interests, and work values--is sometimes minimal. Also, their ability to test the reality of self-knowledge against the demands of the working world, a critical career development skill, can be sparse (Anthony et al., 1988). It is not surprising that clients with a psychiatric illness tend to experience lower occupational status and repeated failures in the world of work after hospitalization for a psychiatric illness (Huffine & Clausen, 1979). These kinds of discouraging career experiences can have a detrimental impact on the individual's self-concept.

In all of the systems in which they are treated, clients who have a mental illness present multifaceted problems to counselors, so it is imperative not to separate a client's personal and career issues, but to see how these concerns interface and affect the client's career (Burlew, 1997). As Niles and Pate (1989) noted, a symbiotic relationship exists between work and mental health. Individuals' jobs partially define their identities, and the fact that a person works is both a source of self-worth and evidence that he or she is a contributing member of society. Work/career gives structure to an individual's days, gives him or her something to do, and provides money so that the person can pay his or her way (Kaley-Isley, 1997). The interaction of life roles establishes a link between work satisfaction and life satisfaction.

Because the varied life roles of an individual overlap, each of these roles must be considered simultaneously as part of a holistic counseling process. Clients who have a serious mental illness have been reported to be more likely to be unemployed, to have less income, to experience a diminished sense of self, and to have fewer social supports (Garske & Stewart, 1999); therefore, they tended to have limited experience and success in the various life roles. Therefore, when compared with other clients, they require additional assistance in understanding life roles and making decisions about the kind of lifestyle, friendships, and leisure activities they would like to pursue.