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Vivyn Mathew Junior Consultant (PSW) DPNR

Impairment is any loss or abnormality of psychological, physiological or anatomical structure or function. Disability is any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. Handicap is a disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal (depending on age, sex and social and cultural factors) for that individual

Rehabilitation is the process of helping a person to reach the fullest physical, psychological, social, vocational, avocational and educational potential consistent with his or her physiologic or anatomic impairment, environmental limitations and desires and life plans.

According to ILO (1955), vocational rehabilitation is defined as a stage in the continuous and coordinated process of social rehabilitation whose aim is to prevent or minimize the functional , physical, psychological, socio- cultural or economic consequences of disability of different types and origin.

Vocational Rehabilitation is a process that assists individuals with impairments to overcome their handicaps to employment and to return to work at their maximum physical and intellectual capacities at or near their previous earning level. (Allen, 1996)

Vocational Rehabilitation
A range of intervention that aim to improve the quality of life and functional capacity of people who are subject to social exclusion by virtue of their disabilities, by providing them with the skills and attributes necessary for them to return to open paid environment

Stemmed from hospital-based programs which suggested that work activities in the hospital could increase self-esteem and functioning and could ultimately accelerate discharge (Bond & Boyer, 1988).

The era of deinstitutionalization began in the 1950s at a time when vocational programs first began to implement hospital-based, sheltered workshops and outpatient halfway houses geared toward vocational training and rehabilitation (Black, 1988)

Vocational rehabilitation represents but one of the many services. Need for medical care and social support must be acknowledged Need for an adequate array of vocational options for mentally ill Illness of these individuals may at times interfere with work, hence they need support/ back up.

Principles of vocational rehabilitation

Principles of vocational rehabilitation

Need for realistic expectations. Strive to do no harm to patients by expecting either too much or to little of them Ensuring sufficient compensations lie pay and other benefits Attention should also be paid to economic conditions in the larger society outside mental health agency

Why Vocational Rehabilitation?

Work plays a number of important roles in human behavior. Consonant with the stress vulnerability coping competence model of chronic mental disorders, the ability to work is an important indicator of psychiatric rehabilitation

Types of VR
1. Prevocational

training ( Train n place) Assumes that people require a period of preparation before entering into competitive employment Can include sheltered workshops, transitional employment, work crew, skills training.

2. Supported

employment (Place n train) Places people directly into competitive employment without extended period of preparation, provides time unlimited, on the job training from job coaches A variant of this is IPS Individual Placement and Model

There are 6 principles for this programme Developed by Becker in 1994

Competitive employment in work settings Clients are expected to take job directly instead of waiting period Rehab is an integral part of mental health treatment Services are based on client choices and preferences Assessment is continuous and based on real life experiences Follow up support is continued indefinitely

Cook and Razzario ( 2000)

Use of Situational Assessment Competitive or supported employment Rapid placement Ongoing vocational support Tailoring job developmentts and support to the clients individual preferences Addresses economic disincentives

Stein and Test, 1980, have shown that holding a job, even a voluntary / sheltered job is a significant predictor of sustained remission for chronic mental patients Decrease in psychiatric symptoms, when they are actively engaged in productive work activities

In 1968 an agreement was signed between the Government of India and the Government of USA for setting up of two Vocational Rehabilitation Centres, one at Mumbai and other at Hyderabad for assessing vocational and psychological needs of the handicapped persons and to render rehabilitation assistance to them.


Current Trends

earlier programs emphasised training in sheltered and transitional work settings before placement in unsupported work settings. the more recent approach, namely supported employment, is based on placing people directly into employment and providing training and support to help these individuals sustain employment (Bond et al., 1997).

Knowledge : Principles of counseling Theories of vocational counseling Career development Psychometric testing Vocational assessment Medical and psychosocial aspects of disability Community resources Legislation Supervised fieldwork

Vocational Rehabilitation Process

INTAKE Receipt and review of referral information Description of impairment, functional limitations, work capacities Vocational interview Determination of labour market data

Vocational Rehabilitation Process

EVALUATION Vocational assessment Establishment of tentative goals PLANNING Vocational exploration Selection of targeted job goals Labour market survey

Vocational Rehabilitation Process

TRAINING (if necessary) Evaluation of training resources Educational, vocational or on thejob training

Vocational Rehabilitation Process

JOB PLACEMENT: Job seeking skills training Job placement Employer consultation Job modification Job coaching Follow up

Vocational Rehabilitation Process

RELATED SERVICES Assistance with benefit entitlement Identification and co ordination of support services Architectural and vehicular modifications Tools and equipments Referral for family and social services

Continuum of Rehabilitation Services

Work skills assessment Work adjustment Job skill training Sheltered employment Transitional employment Job finding Job maintenance

Adjustment to the Work Experience

Attendance and punctuality Personal hygiene and grooming Use of leisure time on the job Accepting job related compliments and criticism Following specific instructions Helping co workers Prioritizing tasks Requesting help from co workers

Adjustment to the Work Experience

Requesting help from co workers Following rules Initiating and responding to conversation Initiating request for special needs Interacting with supervisors, customers and other authority figures

When to Refer For Vocational Rehabilitation???

Whenever it becomes clear that the person will not be capable of resuming regular, modified , or alternate duties with their employers

What to Expect From a Vocational Rehabilitation Program???

An individualized job plan based on initial assessment and clients needs

REALITY FACTORS: Timing of referral Medical condition Educational and vocational background Personal and family background Systems (litigations, economic loss etc)

Factors Affecting Vocational Rehabilitation

Factors Affecting Vocational Rehabilitation

BEHAVIOURAL FACTORS: Denial Fixation on reliving past events Blaming others Avoidance of responsibility for own recovery Dependency Anger or depression Overprotection by caregivers Identification of self by job roles Symptom magnification/ malingering

Research shows that between 41% and 77% of people with mental illness terminate their supported jobs within 6 months (Gervey et al., 1995; Becker & Drake, 1996). Thus, despite the increase in the number of programs to prepare people with mental illness for work, employment outcomes continue to be poor for this target group.

Griffith (1974) : Low success rate of vocational rehabilitation in persons with schizophrenia McCathy and Latz ( 1980) : more success in paid jobs in the community

Botton and Roessler (1986) poor functioning with prominent negative symptoms Santer and Nevid (1991) Significant functional improvement following work skill training in Schizophrenia

Silverstein et al(1991) association between work dysfunction and improved pre-marital cognitive perceptual functioning Fabian (1992) Association between employment and quality of life.

Harrow et al (1997) Less than 20% employment of Schizophrenia patients with a mean of 7.5 years period. Becker and Associates (1996) better outcome with preferred employment fields

Schizophrenia vs Other psychiatric Illness

Most of the studies point towards patients with schizophrenia having poorer work functioning than patients with other psychotic and non psychotic illness The reason for this could be non availability of modern neuroleptics Lack of social skills and cognitive impairment

Studies when comparing PWS receiving clozapine, case management and transitional employment placements, 57% were still in paid employment at the end of 12 months (Littrell,1995) Work functioning also improved PWS who received work skills training in comparison with PWS who did not receive training (Sauter n Nevid, 1991)

Neurological Disorder

Study was done with People with MS They identified two key needs; managing performance and managing expectations Performance difficulties could be managed either by treating symptoms, by changing the environment, or by altering the demands of the job PwMS highlighted the need for counselling to help them, and advocacy to help their employers have appropriate expectations Sweetland et al ( 2007)

Traumatic Brain Injury

To study the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI).

Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility.

A successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult

Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW

Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work. Shams et al, 2007

The only handicap is a closed mind