Widening the definition of work: 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.

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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:

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* 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).

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.

Like the IPS model, ADI's ACCESS model encourages competitive employment but only for the subset of consumers interested in independent, supervised work for pay in the community. ADI also offers and encourages other prevocational, vocational, and community opportunities such as:

* traditional job-seeking skills training;

* on-the-job training;

* support for continued education;

* volunteer opportunities; and

* more supported employment opportunities within ADI's own line of services (e.g., custodial, food services, maintenance, etc.).

These five vocational areas are equally encouraged, for it is presumed that each can lay the foundation for ADI's ultimate objective--recovery.

To test this assumption, Applied Research Solutions, Inc., a research and consulting firm, was contracted to empirically evaluate the clinical impact of consumer participation across ADI's five vocational programs. Preprogram consumer data were compared to post-program data for 49 ADI consumers who also were consumers at Pikes Peak Mental Health (PPMH) Center. These numbers then were compared to a demographically and clinically comparable set of 47 PPMH consumers who did not participate in ADI's programs.

Changes in the dependency on PPMH services were tracked and analyzed for both groups, as were changes in psychological health, using Colorado Client Assessment Records (CCARs). The CCAR is completed by primary therapists for all persons who present for behavioral health services at the time of initial enrollment, annually thereafter for the duration of treatment, and at disenrollment. Because consumers typically have multiple CCAR scores, this instrument is ideal for tracking demographic information, diagnosis, and mental health changes.

For each consumer, preprogram and post-program averages were calculated to test for significant changes across time. For the inpatient data, preprogram scores were computed by dividing the number of days hospitalized before program participation by the number of months transpiring between initial (mental health center) intake and program start date. Post-program scores were computed by dividing the number of days hospitalized after program start dates by the number of months transpiring between program start and the date of each client's last hospitalization. A similar procedure was followed for the CCAR data. CCAR scores collected prior to program participation were averaged to compute a preprogram score for each consumer; CCAR scores collected after program start dates were averaged to compute post-program scores.

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Findings revealed that ADI consumers showed meaningful and significant improvements with respect to psychological functioning (overall problem severity decreased; overall level of functioning increased), as well as a reduced dependency on mental health services, particularly inpatient (hospitalization) services. This resulted in an annual average cost savings of more than $7,500 per consumer! Figures 2 and 3 display how these patterns of psychological improvement and reduced treatment needs surfaced across all groups of ADI consumers, not just those in the external (i.e., competitive) work program. These changes did not surface for the comparison group.

The fact that all ADI groups showed meaningful clinical improvements lends strong preliminary support to ADI's ACCESS model over more restricted models of vocational rehabilitation. The ACCESS model casts a wide net and demonstrates that a number of diverse vocational avenues lead to improved functioning and wellness. The ACCESS model might have applicability outside of the mental health community as well (e.g., for people with physical disabilities, disadvantaged youths, etc.).

ADI's goal is not solely competitive employment and placement. Rather, it is for consumers to achieve their highest potential while working toward self-sufficiency in any one of a variety of ways. Consumers are "working toward recovery" when they see themselves as self-directed agents contributing purposefully to objectives that focus on bettering both themselves and their surrounding communities. These findings suggest that it may be wise for mental health and vocational rehabilitation experts to think broadly when it comes to encouraging their consumers to work.

Morris L. Roth, MSW, is President and CEO of Pikes Peak Behavioral Health Group in Colorado Springs, which includes Pikes Peak Mental Health Center, Pikes Peak Integrated Solutions, Pikes Peak Foundation for Mental Health, Connect Care, and Aspen Diversified Industries (ADI). He can be reached at morrisr@ppbhg.org.