Susan M. Franer RN, MSN CNS
Jennifer Linnabary, MA, LPC
The Project SEARCH adult employment model at Cincinnati Childrens Hospital Medical Center is unique in the field of supported employment for individuals with developmental disabilities, particularly those with intellectual disabilities. Unlike other rehabilitation modes that officer intermittent and variable support, Project SEARCH offers daily on-site support and accommodations which allow individuals served by the program to obtain and maintain competitive employment in a variety of non-traditional, competitive positions at the medical center.
Because individuals with intellectual disabilities are more likely to lose jobs due to behavioral issues rather than inability to perform job tasks (McDermott, 2007; Salzberg, Lignugaris-Kraft & McCuller, 1988), Project SEARCH has taken the step of proactively weaving mental health treatment into the very fabric of support offered by the program. We believe the availability of on-site mental health intervention is critical for maintenance of successful employment for the population served.
The mental health strategies used in the program fall into four basic categories: (a) individual interventions, (b) group interventions, (c) manager training and support and (d) co-worker education and support. Individual strategies include the availability of on-site individual therapy and medication management provided by a psychiatric advanced practice nurse employed by Project SEARCH. Group intervention with the supported adult employees is provided on a weekly basis through an hour long open gathering known as Job Club (Sterrett, 1998). Topics covered in job club are wide ranging and can be as global as how to cope with and manage change to how to deal with a specific conflict happening in a group members work setting. Job Club topics are consistently timely and relevant because they reflect the issues and concerns that arise, in real time, on the job for the supported employees.
Additionally, the mental health professionals on the staff of Project SEARCH provide support to department managers through modeling, educational forums and expert consultation on behavioral or disciplinary issues. Coworker education and support can range from individual consultation on how to understand the cognitive and problem-solving abilities of coworkers with intellectual disabilities, to large education forums such as hospital wide lunch and learns about specific syndromes or disabilities.
To illustrate what these various mental health strategies look like in action consider the following supporting scenarios. PJ is a 30 year old with Down syndrome who has been supported by Project SEARCH for the past eleven years in her position as a sterilization technician for a busy clinic at Cincinnati Childrens. Up to approximately two years ago, PJ required minimum support/intervention from the Project SEARCH staff. Unfortunately, two and half years ago PJs parent fell ill with a fatal neuromuscular disease. Progression of the disease was rapid and this parent soon lost ability for self care. PJ and her family managed all care for this parent up to the time of death. PJ, as the only child still living at home, was often called on during the night and early morning hours to help manage her parents medical needs. PJ often found herself on the receiving end of her ill parents depressed and angry feelings. In spite of family support, PJ became overwhelmed and began to experience problems with focus and personal boundaries at work and her overall job performance began to significantly suffer. Ordinarily at this point, PJ would have been referred to the hospitals employee assistance program by her manager or to a community based therapist for support. Unfortunately, the hospital employee assistance program did not have staff familiar with treatment individuals with an intellectual disability and community resources with this type of expertise were also lacking. Because of its unique support structure, Project SEARCH was able to provide PJ with individual and group interventions that ultimately allowed her to maintain employment while assisting her to deal with her overwhelming feelings of confusion, loss, and sadness. PJ received individual therapy on a weekly basis and more frequently during times of particularly high stress. She also attended Job Club weekly where she received the support and encouragement of group leaders and peers. PJ would use Job Club to talk about her worries and how difficult life had become at home. Although PJs focus continued to be impacted, it was at a tolerable level for her manager and co-workers who could empathize with PJs very difficult situations. During this period, PJs manager and co-workers were offered opportunities for expert consultation and discussion about how best to support PJ through this major time of transition and loss, as well as the opportunity to talk about their own worries and concerns, about how this would ultimately impact PJs life.
In another case, RC, a thirty four year old with Down syndrome who functioned as an exemplary employee in food services for a number of years began to have difficulty following directions about how many cups and napkins needed to place in the cafeteria serving spaces. A number of approaches were tried including visual strategies to cue him on how high to stack the specific supplies, all without much success. At the same time RCs parent reported that he had begun to collect and hoard soda pop at his apartment. RCs parent had not initially been alarmed by this behavior because RCs roommate was known to borrow pop without permission and would not replace it. However, when RCs mother discovered that every square inch of cabinet and closet space were filled with soda pop, she realized this was more than a passing coping strategy and notified Project SEARCH staff to ask for assistance.
At this point, RC was assessed by the Project SEARCH psychiatric advanced practice nurse and was started on medication to help curb his compulsive behaviors. In addition to the medication RC received individual therapy and group intervention through regular attendance at Job Club. RC responded well to this combination of treatment and he has shown definite behavioral improvement both on the job and at home.
Another example from Job Club involved a discussion focused how a fellow co-worker with a disability has been treated during lunch. Apparently, this individual was asked to eat at another table because of the way she chewed her food. This discussion lead to a teachable moment not only about the mechanics of the oral-motor impact of Down syndrome, but also about the meaning of empathy for others. In the end the group members decided that it was the disability that caused their co-worker to eat differently and therefore was not a reason to ostracize her. Furthermore, other Job Club members began to share stories about their own disabilities and the struggles they face. A number of Job Club members decided that they would make an effort include this coworker at to their lunch table. During the next week, the previously excluded co-worker was noted to be eating with her peers and she even rejoined Job Club at their next meeting.
Job Club has provided the opportunity to discuss specific work related issues. In another recent meeting the group topic of discussion centered on the difference between following hospital policy and following the crowd. The particular focus was Croc shoes which are very similar to slip on shoes that many hospital staff wear and how cute and comfortable they are. However, the Croc model discussed has ventilation holes that accommodate various theme based charms and although quite the fashion statement, they were not approved by the hospital as acceptable footwear. Project SEARCH job club attendees are encouraged to follow the dress code and not the fashion tends. In the process, a lively discussion ensued about the importance of having rules and why following them keeps everyone safe. Similar policy topics are raised at various times throughout the year as fashions and behavior standards evolved and get challenged by hospital staff, including those supported by Project SEARCH.
These examples and many others like them, support our belief that on-site mental health services for employees with intellectual disabilities fits with the whole concept of universal design. Universal design, refers to adaptations made for individuals with disabilities which are ultimately adopted by an entire workforce because they work for everyone. We believe this because the model reflects the understanding that mental illness and mental wellness are not compartmentalized states and are as present on the job as anywhere else in a persons life. Project SEARCH is committed to providing the resources and attention necessary for management of mental health issues in the workplace for the employees with disabilities we serve. We would contend that this model had much to offer the general workforce population and is worthy of emulation because the design is truly universal.
McDermott, S. (2007) Why Do People with MR in SC Lose Their Jobs? What Predicts Rehire? (2007) Presentation at the Annual Reinventing Quality Conference. Retrieved from http://reinventingquality.org/docs/McDermott07-2.pdf, October, 2007.
Salzberg, C., Lignugaris-Kraft, B., & McCuller, G. (1988). Reasons for job loss: A review of employment termination studies of mentally retarded workers. Research in Developmental Disabilities, 9(2), pp.153-70 1988.
Sterrett, E. (1998). Use of a Job Club to Increase Self-Efficacy: A Case Study of Return to Work, Journal of Employment Counseling, 35(2), pp. 69-78.