Special Topic Report:

Vocational Rehabilitation in
Psychiatry and Mental Health
Prepared by: Jeri-Anne Liwanag, PRI OT Intern 2018

Introduction
Work is an essential part of life. Not only do we spend a large proportion of waking hours engaged in work
activities, but work is a means to earn a livelihood. It also gives a sense of personal identity and social
contribution. Health care professionals generally agree that work has therapeutic value and is
fundamental to a person’s sense of well-being. Compared to other disability groups, people with mental
illness have high rates of unemployment (Crowther et al. 2001; Zwerling et al. 2003; Jensen et al. 2005;
Cook 2006; Duncan &Peterson 2007), and the World Health Organization (WHO) and International Labour
Organization (ILO) estimate a worldwide unemployment rate of 90% for people with serious mental
disability (Ruesch et al. 2004).

The effect of mental illness on a person’s ability to work

There are several intrapersonal characteristics of mental illness that interfere with work
functioning including the impact of the psychiatric diagnosis itself, the episodic and fluctuating nature of
mental impairment, poor social interaction patterns, cognitive dysfunction, reduced motivation and
emotional impairments. These may vary significantly from individual to individual and are further
influenced by social and environmental barriers (extra-personal effects).

Intrapersonal effects of mental illness on employability

The impact of diagnosis and symptoms
Studies on the effect of diagnosis and psychiatric symptoms on a person’s ability to work
have produced mixed findings. While some researchers have found diagnosis and
psychiatric symptoms to be a poor predictor of vocational outcome (Anthony & Jansen
cited in MacDonald-Wilson et al. 2001), others have found diagnosis and symptoms to
have a significant bearing on the ability to secure and retain employment (Arns & Linney
1993; Goldberg et al. cited in Schneider et al. 2002).

The episodic nature of mental illness

Most mental illnesses tend to be episodic in nature causing sufferers to go through
periods of relative wellness followed by periods of increased symptoms and functional
deterioration, they may also occur without warning and for no apparent reason, which
can severely disrupt a person’s work attendance and performance. When symptoms
occur unpredictably, this can also seriously undermine the worker’s self-confidence and
motivation. When dealing with unpredictable fluctuations in a client’s condition, the
occupational therapist should consider the following: client’s access to adequate medical
treatment and management of his/her psychiatric condition, compliance with medication
and other treatment regimes, insight into his/her illness and how to deal with episodic
deterioration, If employed, is his/her employer aware of the episodic nature of the client’s
condition, recognition and control of stressors that may trigger psychiatric symptoms, and
efforts made to accommodate periodic deterioration.

Impaired social interactions and communications

 Social incompetence is another major problem affecting workers with mental illness.
These people frequently experience difficulties in relating to others and may struggle to
read social cues or fit in with workplace culture. Co-workers may perceive them as
difficult, strange or inappropriate. They are often oversensitive to negative feedback,
which they may perceive as personal criticism. Rehabilitation should include social skills
training, assertiveness training and stress management. Sensitizing supervisors and fellow
workers to the challenges faced by the client is often beneficial but should only be done
with the client’s consent. If facilitated well, such personalized sensitization sessions can
go a long way to building team cohesiveness, understanding and empathy on both sides.

Poor work performance

Cognitive, emotional and motivational difficulties are at the core of most mental illnesses and may affect
worker’s ability to perform their essential work tasks efficiently and accurately. These workers typically have difficulty
managing assignments, setting priorities or meeting deadlines. Underlying problems may include: inability to sustain
concentration, difficulty in screening out environmental stimuli, poor flexibility in decision-making and problem-solving
abilities, poor memory, difficulty in organizing thought processes, difficulty in controlling preoccupations or delusional
thinking, problems with motivation and drive, high levels of anxiety, difficulty in responding to changes at work, and lack
of stamina.

Extra-personal effects of mental illness on employability

Social and environmental barriers facing people with mental illness
While social and environmental barriers affect many job seekers at some point in their
working career, people with disabilities, particularly people with mental disabilities, are
at a disadvantage. This is well documented in the literature (Duncan & Peterson 2007;
Loveland et al. 2007). The occupational therapist working in the field of vocational
rehabilitation must be able to recognize and address these extra-personal barriers in the
vocational rehabilitation process
Job availability
Several factors can affect job availability in a society, including economic recession or
downturn in an industry. When there are fewer available jobs, competition for
employment increases, and those traditionally at the back of the employment queue are
most harshly affected.
Prejudicial attitudes and misconceptions about people with mental illness
Despite advances in the understanding of mental Illness over the past few decades, our
society still has difficulty in accepting and dealing with people living with these conditions.
Misunderstanding about the nature and the cause of mental illness results in people
reacting with fear, shame, guilt and embarrassment. For people living with mental illness,
these reactions tend to aggravate feelings of inadequacy, poor self-esteem, rejection and
loneliness, stifling their confidence and motivation to work. Prejudicial attitudes can be
harbored by families, employers, work colleagues, rehabilitation professionals and people
with mental disabilities themselves.
Inadequate or limited vocational rehabilitation services and facilities
Common problems with vocational rehabilitation facilities include: programs tend to be
time limited and provide no follow-up support for the client, poor integration of medical
and vocational rehabilitation services, many insurance schemes tend to put their energies
and resources into determining eligibility for compensation as opposed to rehabilitating
people for return to work, and 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.
 Disability benefits often provide a disincentive to work
Sick leave is usually recommended for clients with mental illness whilst they undergo
assessment and intervention. Should this sick leave exceed the legal recommendations,
extended leave may be implemented, and it is during this time that the client may receive
disability benefits from an insurer or from the state in order to replace their salaried
income. Through experience, many of these income replacement benefits contain a
clause stipulating that if the recipient earns even a nominal income, the benefit will be
discontinued. Such benefits serve to discourage a person with a disability from returning
to work in either a full- or part-time capacity during the recovery process.
Predictors of employment success
Considerable research has been conducted on factors that promote successful employment in
persons with mental illness. Clients who had worked before were more likely to secure and retain
employment. The better their previous work history, the greater their chances were of employment
success. The same study also found social competence to be a strong and consistent indicator of
vocational outcome. Other noteworthy predictors of employment success are level of cognitive
functioning (McGurk et al. 2003) and good family relationships. Tsang et al. (2000) found clients with
supportive families more likely to adjust to the demands of work and experience employment success
than clients without family support. A vocational rehabilitation professional should consider these
predictors of employment success when planning a client’s intervention (Tsang et al. 2000).

The vocational rehabilitation process

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). Based on the International Classification
of Functioning, Disability and Health (ICF) (WHO 2001), vocational rehabilitation is described by Escorpizo
et al. (2011, p. 130) as ‘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’. The
International Labor Office (ILO) description of vocational rehabilitation (ILO 1985) identifies five steps: (1)
vocational assessment, (2) vocational guidance, (3) vocational preparation and training, (4) selective
placement and (5) follow-up.

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. The referral should clearly indicate the parameters for service delivery and
payment. Vague or ambiguous referrals should be immediately clarified before contact is made with the client. 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. This information should be disclosed to the occupational
therapist with the consent of the client and the referring agent.

Preparation for the vocational assessment/ functional capacity evaluation

The referral instruction will clearly indicate the purpose of the evaluation and/or further
intervention. All accompanying documentation must carefully be reviewed, and its
relevance to the process noted. As part of preparation, it is essential that the occupational
therapist understands
the mental health condition, its progress, prognostic indicators for employment and
potential interventions. This will determine the evaluation process. Preparation is
 concluded by drawing up the evaluation plan which documents the sequence of tests,
the required observations to note and evaluation methods to be used. The occupational
therapist must have a comprehensive understanding of various methods of evaluation,
sources of information, statistical interpretation of standardized tests as well as the
value each method will contribute towards understanding the client’s strengths and
limitations in terms of work functioning. Both qualitative and quantitative data are of
value. The evaluation plan must allow for flexibility but should remain consistent with
the requested purpose/outcome.

Selecting an appropriate venue for vocational assessment

This could be a clinic, hospital, rehabilitation setting, the client’s home or client’s place of
employment. An important aspect to consider is the availability of appropriate testing
tools and other requirements. Although the client’s home may be an important source of
collateral information, it may not be an appropriate venue to conduct vocational
assessment as the occupational therapist may not have access to appropriate assessment
tools. Evaluation conducted at the place of work may draw unnecessary attention to the
client. Irrespective of the location, the occupational therapist must ensure that the
evaluation can take place without distractions and that client confidentiality is ensured.
Family members and employer representatives should not be permitted to sit in on the
evaluation unless formally requested to do so.

Obtaining informed consent

Ethical considerations in terms of obtaining consent must be adhered to before the
vocational rehabilitation process commences. During this process, the occupational
therapist begins to build a therapeutic relationship with the client. Informed consent
involves explaining the purpose of the referral to the client, what the assessment entails,
to whom feedback, and reports will be directed and what the client’s rights are during the
process. Information sharing and opportunity to ask questions should be encouraged.
Consideration must be given to the client’s level of understanding and function.
Interpreters should be used where language is a problem.

Initial interview
The therapeutic relationship initiated during the informed consent phase is usually
strengthened during the initial interview. The occupational therapist needs to collect all
relevant information related to the purpose of the vocational assessment whilst
maintaining the therapeutic relationship but should be mindful that the initial interview
is not primarily therapeutic in nature. For this reason, the use of an interview guide and a
semi structured interview format is recommended.

Physical screening evaluation

Although the focus of the evaluation is on the functional effects of the mental illness, it is
important to conduct a physical screening evaluation to determine any physical side
effects of the medication as well as the presence of any physical and/or neurological
disease. A mobility evaluation (stooping, squatting, crouching, working overhead,
handling weights, walking, climbing stairs, etc.) as well as coordination, balance and hand
function screening may be of value.
Psychosocial/mental health evaluation
 This is an ongoing process which is conducted throughout the vocational rehabilitation
process and is integrated in all aspects of testing. The mental functions described by the
ICF (WHO 2001), namely, orientation, attention, memory, thought processes, energy and
drive, emotion and psychomotor functions, should be used.

Pre-vocational skill evaluation

Pre-vocational skills are described in the Quick Reference Dictionary for Occupational
Therapy (Jacobs & Jacobs 2001, p. 148) as the ‘antecedents to job skill development such
as cooperative behaviour, task focus and motivation’. Prevocational skills form the
foundation for work and are generic to many types of work in various work settings. The
client’s level of pre-vocational skills will give the occupational therapist an indication of
placement options.

Vocational skill evaluation

Evaluation of skills related to a specific occupation, occupational level, alternate
occupation and the specific work setting or context. The occupational therapist assesses
specific work demands and uses various techniques and methods to do this. The focus of
the vocational skill evaluation is the assessment of work-related knowledge and work
skills as well as speed of performance or productivity. Vocational skills are those skills
necessary to perform the job competently and efficiently within accepted time frames
whilst meeting safety standards and other workplace rules and regulations. The use of
work samples, work simulation and on-the-job evaluations can be used to obtain an
indication of work-specific abilities.

Obtaining collateral information

Obtaining collateral information from relevant people in the client’s life is an essential
aspect of the vocational assessment process as this will contribute towards understanding
the client’s strengths, limitations and motivations. Understanding the client’s functioning
prior to and after the development of the mental illness can give an indication of possible
prognosis. Information from a spouse or partner can indicate the client’s functioning in
the home environment as well as his/her daily activity profile.

Evaluation of the workplace: Job analysis and work visit

Conducting a workplace visit, meeting with people in the workplace and conducting a job
analysis of the client’s current or potential work are important both during the vocational
assessment and as part of placement. Understanding work-related factors such as the
environmental factors, interpersonal relationships, work stressors and the pace of work
is important in formulating an intervention plan with the focus on work participation.
Visiting the workplace further facilitates an understanding of potential reasonable
accommodation and realignment positions. Obtaining job descriptions and performance
management agreements are useful during this step.

Analysis, interpretation and planning

This step involves applying clinical reasoning in order to obtain an understanding of the
client’s strengths and limitations and plan a way forward in terms of facilitating
optimum work performance. The ILO (1985) refers to this step as vocational counselling,
which involves the following elements: Understanding the client’s vocational interests,
needs and goals, Providing the client with honest and practical feedback on his/her
 performance, providing information on suitable and realistic opportunities for training,
education and work, and assisting the client to develop a career plan, consisting of
short- and long-term goals.

Vocational intervention
Intervention for work-related problems will vary depending on the impact of the mental
illness, the client’s educational and work history, the context, available resources
(including intervention facilities and finances) and whether he/she is employed,
unemployed or on sick leave.

Pre-vocational skills training

Deals with the treatment of cognitive and psychosocial performance components such as
attention span, planning skills, interpersonal skills, time management skills and coping skills. Occupational
group therapy can be used very effectively in treating these performance components.

Work hardening
Defined by the Commission on Accreditation of Rehabilitation Facilities as programs which are
interdisciplinary in nature and which make use of 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). Work hardening provides a
stepping stone to the workplace while addressing issues of productivity, safety, physical tolerance and
worker behaviour. Work hardening programs are invaluable in building up self-esteem, confidence and
consolidating work habits in clients with psychosocial disabilities. These programs are however very
labour intensive and therefore costly.

Transitional work programs (TWPs)

Workers with mental illness, who are employed at the time of the initial vocational assessment,
could return to employment using TWPs where they return to work in a restricted or modified capacity
for a specific length of time. These programs are graded in terms of time and work requirements and
depending on the contribution (work output) for the employer, the worker may be remunerated. TWPs
have advantages for those clients who are already employed, including 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 (the employee feels valued by the employer)
and protection of the employability of the worker.

Case management
Case management is gradually being used more frequently to facilitate return to work for clients
with mental illness. Ross (2007, p. 201) states that vocational case management activities may
include ‘counselling and encouragement, referral to services, co-ordination of service provision, and
support to and facilitation into work’. Various models of case management exist including the broker
model, therapist–case manager model and the strengths model which appears to have good application
possibilities in vocational rehabilitation (Selander & Marnetoft 2005).

Supported employment
Although supported employment may become a placement option for a client with mental illness,
it is also a method to improve their work readiness and employability (Crowther et al. 2001).

Vocational training
 Clients may enroll in formal vocational training programs at universities, colleges, schools,
training centers and special training institutions as part of their vocational rehabilitation
program. The role of the occupational therapist in this instance would be to 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. Once the clients have commenced with their
training, the occupational therapist should provide supportive follow-up on a regular
basis. Following formal training or retraining, most clients re-enter the vocational
rehabilitation facility for placement services.

Placement
Facilitating placement or return to work is an important outcome for clients with mental
illness. Placement may be facilitated into any of the work classification groups including
competitive employment/open labour market, supported employment or sheltered and
protective workshops. It is not a distinct step occurring at the end of the vocational
rehabilitation process but is integrated into all evaluations and planning starting at the
initial interview. Many countries have developed legislation which protects the
rights of people with disabilities and ensures equality within the workplace. The
implementation of reasonable accommodations and the management of disability
disclosure are usually facilitated through the implementation of these laws. Placement of
clients living with mental illness must take place within the provisions of the law and any
other relevant guidelines such as the Codes of Good Practice. Placement usually involves
four distinct phases: (1)Vocational (re)assessment, (2)Workplace assessment,
(3)Matching, (4)Effecting the placement. Clients should acquire a sound understanding
of any legislation that protects their rights as a job seeker with a disability. They should
also receive guidance in dealing with ‘difficult’ issues.

Follow-up and closure

Follow-up and closure is the 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.

The occupational therapist in the workplace

Occupational therapists with expertise in vocational rehabilitation are increasingly moving into
corporate and industrial work settings as consultants to employers on issues of disability equity and
disability management. Occupational therapists are also performing the following functions: Conducting
sensitization and awareness training sessions, advising employers on the practical implementation of
applicable disability legislation, regulations and good practices, advising employers on the management
of employees with disabilities in the various phases of employment, advising employers on reasonable
accommodation- related issues, Case managing employees to perform specialized roles.

Conclusion
The aim of vocational rehabilitation is to optimally (re)integrate the individual with a disability
into society and, wherever possible, into remunerative employment. Vocational rehabilitation spans the
corporate/industrial sector as well as the medical/rehabilitative sector, the occupational therapist has the
opportunity to work with a wide variety of people and professions. The challenge for many schools of
occupational therapy is to develop appropriate undergraduate and postgraduate training programs that
will empower their graduates to move out of the clinics and into the workplace. For it is in the workplace
and in society that true integration of people with mental disabilities can really occur.