Change is not inevitable

Employment is central to recovery, yet it can be neglected when not accepted as such within an organization's culture.1 For a large housing services provider, reestablishment of vocational and educational goals for program participants arrived with a new administration: a CEO and COO with a deep-rooted philosophy in psychiatric rehabilitation.

SERV (Social, Educational, Residential, and Vocational) Behavioral Health System is a private, not-for-profit provider. Its adult supported housing services operates in five counties of the central and northern portions of New Jersey and serves over 500 people diagnosed with severe and persistent mental illness (SPMI).

Shifting an organizational culture focused on finding, getting, and keeping housing to one incorporating employment and education as integral parts of recovery was overwhelming. Attaining ownership by the different segments of the organization and eliminating old assumptions were daunting, but essential tasks.2

Administrators sought assistance from the Integrated Employment Institute (IEI) in the Department of Psychiatric Rehabilitation at the University of Medicine and Dentistry of New Jersey. The IEI consultant shared the new administration's view of employment as an individual outcome critical to achieving successful recovery for people with SPMI.

Roll up your sleeves

SERV's management team recognized that lingering paternalism was the largest organizational barrier to overcome. Yet, trained staff had to buy in to the change. In the world of behavioral healthcare, acquiring and retaining staff is not easy, and turnover is high. Management had to provide the tools for them to see positive outcomes from the new expectations.

Management committed to supporting each employee in accepting the shift in corporate focus. Goals of employment and education had to be endorsed by consumers and other stakeholders as well. There needed to be a joint commitment to the change.

To foster this commitment, steering committees were established at each of the five organizational locations and were comprised of professional and support staff, family members, and consumers so that site-specific concerns could be identified and addressed. It was quickly accepted that not all components of change could be under control at all times. Flexibility was critical to success.

We tend to build dams, not bridges

Persons with SPMI face very real barriers to employment, including: (1) lack of effective, long-term employment support; (2) concerns about losing benefits; (3) professionals who retain beliefs that consumers are unmotivated, fragile, and who underestimate the need for vocational services; and (4) consumers and families discouraged by past vocational failures.3 As Bill O'Brien, COO of SERV, noted, “It became apparent that even though we had learned a lot about and endorsed wellness and recovery values as an organization, many staff did not embrace competitive employment as a valid goal for all of our consumers. Consumers and staff together have had to unlearn what they had previously been taught, let go of their beliefs, and realize that competitive employment is a real possibility for all.”

The evidence-based research is clear. If consumers do not have employment as an active, written goal, they typically will not receive support to achieve that goal. Providing assistance to consumers in determining whether (and which) employment is right for them is critical to bringing employment goals into the individual plan.4

Informal (and some formal) attitudes undervalued staff roles in encouraging employment. Many staff had long accepted their sole purpose as providing compassionate services in a protective environment. There were the usual gripes: “We've always done it this way,” “Safety will be compromised,” “Everyone will go off of meds,” and “We are already doing recovery and work.” Addressing these effectively meant openly acknowledging that protective behavior was part of the culture of SERV and was counterproductive; old assumptions needed to go.

Intervention steps for change

Commitment. Sustaining any change effort requires resources, supervisory support, and administrative commitment.5 For many staff and consumers, a belief that obtaining and maintaining employment for consumers is achievable was the most difficult commitment to obtain. To counter persistent comments about “betraying consumers” who “only wanted protection and support,” each of the five county site directors developed measurable outcomes that could be readily achieved. Demonstrating frequent and visible successes under the new outcome goals allowed both players to ease away from complacency. They paved the way for further inroads into staff and consumer buy-in and commitment.

Contributions. Implementing change always requires sound leadership. Therefore, personnel who demonstrated or acquired skills, knowledge, and competencies related to vocational rehabilitation were acknowledged as leaders by management. At the same time, staff positions specializing in employment-related service delivery were put into place in the formal organizational structure. Consumers were included in the site steering committees, and their contributions played a key role in attaining desired organizational outcomes.

External employment and educational resources-such as Workforce Investment Act (WIA) One-Stop Centers and supported employment providers-tend to be underutilized by mental health professionals.

The management/consultant team organized program-specific workshops, arranging formal links with representatives from local One-Stop Career Access Centers, vocational rehabilitation offices, and local supported employment specialists. Establishing these links promoted use of available employment services, development of protocols, and helped to formalize working relationships between organizations.

Communication. To ensure everyone was on the same playing field, the management/consultant team included all board members, staff, family members, and consumers in the change and evaluation process. Regular meetings took place at each of the five sites, with the steering committees reporting back suggestions and concerns. Progress toward attaining goals and objectives was communicated in newsletters, meetings, and through the SERV Web site. Identifying emerging leaders and encouraging them to accept roles in the change process brought allies to the administration. Over a period of 12 months, the organization's informal leadership took ownership of the new model, allowing for full implementation through formal policy and practice.

Competency building. Many of the existing SERV staff did not possess the requisite skills, capacity, or interests in providing recovery-focused services, especially employment services. The management/consultant team designed and organized training sessions for each of the five organization locations. During a six-month period, more than 270 staff and consumers explored the significance of work to the recovery process. These workshops became the venue for exposing staff to community resources specializing in employment and educational services and for discussing our consumers who successfully obtained employment.

Providing access to information does not mean the information is put to use. SERV implemented data collection to measure the shift of individual goals and outcomes to the new vocational focus. This was done to measure the amount of time employees spent working with consumers on vocational issues before and after training.

Following staff training, there is a need to ensure management follow-up at all levels. Some sites demonstrated significant increases in vocational counseling directly after the training while other locations recorded no increase. These data allowed the management/consultant team to focus management-level interventions on those sites that were experiencing difficulty while praising those that were attaining objectives.

Collection and feedback of data. Following our change in goals, all SERV procedures, including intake, echoed the important role of employment in the recovery process. Consumer demographics, diagnosis, symptomology, and need for services are commonly collected to meet requests and requirements from external funding or regulatory sources. The SERV changes required data supporting or contesting the achievement of internal corporate goals. The shift required a new way to collect intervention and personal goal activity.

To capture new employment-related data, the management team added new categories for employment and educational counseling to the existing data base. It also conducted a case review with each consumer to obtain his/her educational levels and measure his/her desire to work. From these reviews, the data base could then report on the number of consumers: (1) in competitive employment; (2) who attempted employment; (3) in sheltered employment; (4) involved with state vocational services; (5) involved in volunteer work; (6) who list employment as a goal in the service plan; and (7) who wish to pursue their high school diploma.

Staff at all of the site locations began utilizing the new reporting categories. These data became an effective method to monitor progress toward the organizational goals to increase employment and education outcomes, as well as an effective tool for providing regular feedback to staff about how they applied the employment-specific skills they learned in training.

Continuation. Continuation takes place as: (1) the new methods and practices show desired results not attained by the old methods; (2) key leaders in the organization (administration and supervisory staff) accept roles in support of the new methods and practices; and (3) end-users (staff or consumer) recognize personal benefit from adoption of the new methods or practices.6 Adoption of the employment and education goals by administration without consumer and staff commitment would have resulted in a significant struggle to achieve the required changes. Employing a mutually supportive approach to identifying, learning about, and testing the changes allowed all players to participate, contribute, and succeed.

Outcomes

The management team adopted the view early on that they needed to stop talking about change in meetings and “go out and just do it.” They were aware of resistance by staff members who claimed, “We are already doing it,” but they were determined not to cave to the inertia of the organization's existing culture.

With a new administration, this particular organization was ripe to make significant shifts in policy and practice. A major first step in achieving change was acknowledging and addressing the culture of the organization with particular focus on staff and consumer pre-conceived ideas. Providing immediate feedback through a management information system brought about a process of self-monitoring.

Change and growth took place over a three-year period. As jobs and career development became a central social theme, working consumers relayed their increased sense of satisfaction and self-worth to other consumers and to staff. At the third quarter report in 2009, 72 consumers were competitively working, 46 were enrolled in school, 183 consumers had a vocational goal, and 176 had a résumé. Such organization-wide acceptance lines up well with literature on the critical role of employment in achieving self-confidence and a sense of belonging to a community for people with serious mental illness.7

Through carefully orchestrated interventions, management was able to affect a major philosophical change. Whether the impetus is from funding mandates or a change in corporate philosophy, following a clear, well-planned path can enable any organization to support individual recovery through employment services.

Intervention steps for change

At the time of this technical assistance project, Ms. Van Houtte was an employment consultant in the Integrated Employment Institute, Department of Psychiatric Rehabilitation and Counseling Professions, School of Health Related Professions, University of Medicine and Dentistry in New Jersey. She currently is a PhD candidate in the School of Social Work Education at Widener University in Chester, PA.

For more information, e-mail her at houtte2@aol.com.

References

1. Gao N., Waynor W., & O'Donnell S. (2009). Creating organizational commitment to change: Key to consumer employment success in a supportive housing agency. Journal of Vocational Rehabilitation, 31, 45-50.
2. Day J. (2009). Leading from the inside out, Behavioral Healthcare, 29 ,(10), 18.
3. Bond G. R., Becker D. R., Drake R. E., Rapp C. A., Meisler N., Lehman A. F. et al.(2001). Implementing supported employment as an evidence-based practice. Psychiatric Services. 52 (3), 313-322.
4. Bond G. R., Resnick S. G., Drake R. E., Xie H., McHugo G. J., & Bebout R. R. (2001). Does competitive employment improve non-vocational outcomes for people with severe mental illness. Journal of Consulting and Clinical Psychology, 69 (3), 489-501.
5. Milne D., Gorenski O., Westerman C., Leck C., Keegan D. (2000). What does it take to transfer training? Psychiatric Rehabilitation Skills. 4 (2), 259-281.
6. Pascaris A., Sheilds L.R., & Wolf J. (2008). The work and recovery project: Changing organizational culture and practice in New York city outpatient services. Psychiatric Rehabilitation Journal. 32 (1), 47-53.
7. Dunn E. C., Wewiorski N.J., & Rogers E.S. (2008). The meaning and importance of employment to people in recovery from serious mental illness: results of a qualitative study. Psychiatric Rehabilitation Journal. 32 (1), 59-62.
8. Van Houtte E. M., Gao N., Backs A. (2006). Making room for work. Workshop presented at New Jersey Psychiatric Rehabilitation Association Conference.

Behavioral Healthcare 2010 March;30(3):20-22