Assertive Community Treatment (ACT)

The Role of ACT Programs in Helping Consumers Find and Keep Employment

Elizabeth Edgar, director of NAMI’s ACT Technical Assistance Center, recently had a chance to meet with Howard Swanson, employee of the State of Wisconsin Disability Determination Bureau, and John Fuller, vocational specialist at the PACT Program of Mendota Mental Health Institute, to discuss how ACT programs can support consumers in their return to work.

Elizabeth Edgar (EE): Howie, what do you do for work?

Howard Swanson (HS): I work for the Wisconsin Disability Determination Bureau, where the state determines whether or not a person is eligible for (SSI) Supplemental Security Income. I work four hours every day Monday through Friday, doing a lot of different tasks.

In the mailroom I work with four other people, and we divide up the work of copying, collating, filling envelopes, stamping mail, and getting and delivering SSI applicants’ case files to various offices. I use a computer to log and track cases. I've worked here for two and a half years and only missed three days of work.

EE: How has working affected you?

HS: I get paid, have holidays and vacations. I get a Christmas bonus. I've been able to save some money and get nice things for my apartment that without working I wouldn't be able to have.

I've become more adaptable. The responsibilities of the job itself are rewarding. My quality of life is better now. I feel more accomplished; I'm not worrying as much. I like the structure of getting up and going to work in the morning. I'm more productive in other areas too, like reading books and writing poems. I'm doing better all around since I've had a job. If I won the lottery tomorrow, I would still want to go to my job every day.

I used to have problems with hearing voices. Now I'm taking a different medication and can concentrate better and don't hear voices. That was an about-face for me.

EE: What do you look forward to?

HS: I'm looking forward to staying at this job. I like doing it. Over the years, it has taken me a long time to come to this situation. This is the best job I've had since I became ill. Aside from work, I'd like to write a whole book of poems and get more of my poems published. I've already had three published in an anthology.

EE: How did PACT help you with work?

HS: They helped the job to become more and more routine. They encouraged my expectations of working five days a week.

John Fuller (JF): Howie and I have work-review meetings with his supervisor every six months. Howie won an award for the quality of his work. The PACT team is not as involved now as at first. Before Howie began the job, we toured the workplace, and he said, "This is too much; I can't work here." It seemed overwhelming, but with encouragement, he decided to go back and give it a try.

HS: At first I was scared, and the easiest thing was to say no, I can't do it. I didn't like not feeling competent with the job. I feel better doing things that I'm good at. But, I learned the job and how to use the computer.

JF: Howie is capable of doing any task that comes along, and that is a boost to his self-esteem.

EE: Howie, what advice about work would you give others?

HS: Have expectations for yourself. Don't get discouraged if things don't look rosy. Each step along the way is essential and takes time. Try different jobs. Keep moving forward and things will get better. Time helps. You have to try certain things even if you don't know what to expect. I had to go through many steps to get where I am today.

EE: What is the role of work in an assertive community treatment (ACT) program?

JF: Employment is therapeutic. It helps people integrate into the community and provides meaningful structure to the day. Work provides a consistent routine. It provides an opportunity for the person to put the psychotic world on the back burner and not let psychiatric symptoms such as hearing voices or delusional thoughts run their life. Working can help people self-manage their symptoms. It is something else to focus on.

EE: Are there other benefits to working?

JF: At PACT, we've learned that when a person is working, other areas of life tend to improve. Work provides a reason to take better care of oneself, to be consistent with medication regimes, to control alcohol or drug use. Work is "normalizing"; it provides a chance to socialize with others besides mental health workers and family. It helps to have people in your life that you see every day. Working is a way of getting back into the mainstream of life. A person develops pride in themselves, knowing that they are contributing to society.

Plus, extra income helps. It is hard to get by on Social Security's SSI (Supplementary Security Income) amount (less than $600 a month). Earning money really helps with a person's quality of life. You can save and buy things you want, not just the bare necessities.

EE: There are many benefits to working, but in assertive community treatment, how do you overcome the many obstacles?

JF: Some of the obstacles we work around are lack of work histories, interrupted education, financial disincentives that reward unemployment, misconceptions both from clients themselves and from others that they are not able to work.

At PACT, we want people to enjoy the therapeutic benefits of work. We have the expectation and communicate the expectation that people with mental illness can and do work. We assist people to work to the best of their ability. That may be four hours a week, or 40 hours a week. When a person enters PACT, we do an assessment of all areas of life, including education and employment. As we build a supportive clinical relationship, we learn likes and dislikes, what they've done in the past, and get a good clinical understanding of their illness. Personal preferences and psychiatric symptoms will determine the kind of job we pursue. If a person is highly anxious, they may prefer to work alone or in a small group, rather than meeting the general public. If symptoms interfere with concentration, we may look for a job that is only an hour or two at a time.

EE: How does the ACT model provide vocational services?

JF: In the ACT model, the team itself provides vocational services rather than referring clients to other agencies for help getting a job. This makes sense because the ACT team has a long-term, clinical, trusting relationship with its clients. We see them often and have insight into what the vocational obstacles are, and what direction the vocational plan should go in. Clients are more willing to take risks when they know they have the support of people they know and trust.

While each team has one or more vocational specialists who take the lead in developing contacts within the business and vocational services communities, the whole team supports employment efforts. Vocational specialists should be competent clinicians because it is the client's mental illness that causes employment difficulties. An urban ACT team usually has 100 clients. If only the vocational specialists helped people get and keep work, few people could be assisted. Work is an expectation for nearly all clients on an ACT team. Employment is a priority for the entire team because of its powerful therapeutic value.

EE: How do you find jobs?

JF: We do job development by communicating with the business community. We approach businesses who might have work, stop and introduce ourselves, letting them know what kind of jobs we are looking for and describe the support we provide our clients. We ask if we could work together. We try our best to match opportunities with people's interests and skills. An ACT team should always be looking for job opportunities. The jobs don't just pop out, we have to find them, to dig for them. We problem-solve with our clients and with employers to create needed accommodations, such as splitting one job into two part-time jobs. We tell employers about people's skills and special needs (such as a shorter shift, or afternoon or evening work if medication makes it hard to get up in the morning). We help our clients with their job search. Like everyone else, we look in the want ads in the newspaper, at on-line databases, on community bulletin boards, and at government job centers. But, we also need to go out into the community to actually try to create jobs that are a good match.

EE: Once a person has a job, how do you help them keep it?

JF: Because the benefits of working are so great, we are willing to go to great lengths to support employment. Initially, we can go to the job and help a person learn the job by working side by side. We may have weekly meetings with the supervisor to proactively solve any potential problems. This is important. We offer productive workers and provide support to both clients and employers. We expect our relationships with employers to be business relationships, not a charity. Both benefit: it is a win-win situation.

EE: How do you provide support?

JF: ACT provides ongoing, intensive support. Because we see our clients often, we know how the job is going. We monitor psychiatric symptoms. We try to be proactive. If a person is having a very hard time with symptoms, we may arrange a leave of absence so they will still have the job when the symptoms are back under control.

Most of the support we provide is not at the job site. For example, we may call in the morning to help people get started, give rides to work to offer support and monitor the job, we may call after work to talk about how the day went. If we deliver medications in the evening, we can talk about work then. We try to follow their situation closely and hopefully address any problems early on.

EE: How do you work with families?

JF: This is an important area. Families don't want their children hurt, and they worry about the obstacles to working. We share information about the therapeutic value of work. We explain the clinical benefits. We provide information and counseling on how work earnings may impact benefits, including Medicaid, SSI, and SSDI (Social Security Disability Income). We assure families that we will always work within the guidelines of these benefit programs so that access to health insurance and income from Social Security will continue while their family member is employed. We ask families to encourage work; we want both PACT and the family to encourage and support work. We assure families that the ACT team will support their family member and that work can be a very positive experience.

We assure the family that if a job is not working out, we will help to facilitate an end. We want positive experiences. When a job does end prematurely, however, we want all involved to view it as a positive. Every attempt at work represents progress and accomplishment. The client has done a job search and been hired and worked for a time. That is experience to build on.

EE: Is there anything else you'd like to share?

JF: Lots of people equate treatment of mental illness with medication. Medication can help make symptoms less intense and less frequent, but it doesn't eradicate the mental illness. We need to combine medication treatment with additional kinds of treatment such as work for the best available treatment. People with severe mental illnesses deserve the best available treatment techniques.

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