Cathaleene Macias

Work Interest as a Predictor of Competitive Employment: Policy Implications for Psychiatric Rehabilitation

Consumers with serious mental illness (N=166) enrolling in two community-based mental health programs, a vocational Program of Assertive Community Treatment and a clubhouse certified by the International Center for Clubhouse Development (ICCD), were asked about their interest in work. About one third of the new enrollees expressed no interest in working. Equivalent supported employment services were then offered to all participants in each program. Stated interest in work and receipt of vocational services were statistically significant predictors of whether a person would work and how long it would take to get a job. Two thirds of those interested in work and half of those with no initial interest obtained a competitive job if they received at least one hour of vocational service. Once employed, these two groups held comparable jobs for the same length of time. These findings demonstrate the importance of making vocational services continuously available to all people with serious mental illness, and the viability of integrating these services into routine mental health care.

Transitional Employment: an evaluative description of Fountain House practice

The present study is a record-based evaluative description of Transitional Employment (TE) in Fountain House, New York. The study sample (n = 295) consisted of members entering Fountain House between 1988 and 1993 who participated in TE. Of the 720 TEPs worked during this period, 420 (58%) were held by a single member for over 3 months and 253 (35%) were held by a single member for over 6 months. Seventy-four percent of the sample had 3-month tenure on at least one TEP, and 54% of the sample had 6-month tenure on at least one TEP during the study period. Length of tenure in TE was significantly related to time spent in Fountain House programs, primarily the Work-Ordered Day, prior to employment: an analysis of member attendance records at Fountain House programs revealed that those members who spent more time in Fountain House before beginning a TEP worked more days on their first TEP. This finding conflicts with research suggesting that unpaid prevocational work is a poor predictor of paid work performance.

Strategic Planning for ICCD Clubhouse Implementation: Development of the Clubhouse Research and Evaluation Screening Survey (CRESS)

The Clubhouse Research and Evaluation Screening Survey (CRESS) is a brief instrument designed to predict clubhouse readiness for certification assessment and, hence, performance in regard to expected model outcomes. The development of CRESS provides a practical example of the methodological challenges involved in creating a brief and valid screening instrument. Developed over a period of 5 years, CRESS is grounded in a series of workgroups, surveys, and pilot studies conducted by Fountain House and the International Center for Clubhouse Development (ICCD) in New York City. CRESS is shown to have criterion-oriented validity for the measurement of ICCD clubhouse model-related performance, as well as demonstrated ease in administration to a national sample of mental health programs.

Coping with recurrent loss in mental illness: Unique aspects of clubhouse communities

Abstract Fountain House, in New York City, is a psychosocial program for adults with serious mental illnesses that has operated continuously for nearly 50 years. The majority of members of this “Clubhouse” program have diagnoses of schizophrenia, bipolar disorder, or major depression, but membership is open to any individual whose life and functioning have been continuously or repeatedly disrupted by brain dysfunction or psychiatric symptomatology. This article presents one Clubhouse members personal account of loss, failure, and the recovery of individual dignity and purpose. Key experiences within this very individualized account are identified as exemplars of Clubhouse rehabilitation and interpreted in the context of current psychological theory.

When Programs Benefit Some People More than Others: Tests of Differential Service Effectiveness

Practitioners need to know for whom evidence-based services are most or least effective, but few services research studies provide this information. Using data from a randomized controlled comparison of supported employment findings for two multi-service psychiatric rehabilitation programs, we illustrate and compare procedures for measuring program-by-client characteristic interactions depicting differential program effectiveness, and then illustrate how a significant program-by-client interaction can explain overall program differences in service effectiveness. Interaction analyses based on cluster analysis-identified sample subgroups appear to provide statistically powerful and meaningful hypothesis tests that can aid in the interpretation of main effect findings and help to refine program theory.

PARENTAL DEATH IN THE LIVES OF PEOPLE WITH SERIOUS MENTAL ILLNESS

Nearly a fourth (22%) of the participants within a research sample of 148 individuals with serious mental illness reported the death of a loved one as a significant loss, and two thirds of these deaths involved the loss of one or both parents. The key determinant of the severity and duration of grief in response to the death of a parent was whether or not there were extenuating circumstances that complicated the death event, such as co-residence with the deceased at the time of death or a lack of regular social contact with anyone other than the deceased. In all instances of severe or prolonged grief, there was no preparation for the parental death, either through preparatory counseling or practical plans for funeral arrangements, financial repercussions, life-style changes, or residential relocation. Mental health agencies serving people with serious mental illness should being to incorporate financial and emotional preparation for parental deaths and bereavement counseling as essential services.

Preference in random assignment: implications for the interpretation of randomized trials

Random assignment to a preferred experimental condition can increase service engagement and enhance outcomes, while assignment to a less-preferred condition can discourage service receipt and limit outcome attainment. We examined randomized trials for one prominent psychiatric rehabilitation intervention, supported employment, to gauge how often assignment preference might have complicated the interpretation of findings. Condition descriptions, and greater early attrition from services-as-usual comparison conditions, suggest that many study enrollees favored assignment to new rapid-job-placement supported employment, but no study took this possibility into account. Reviews of trials in other service fields are needed to determine whether this design problem is widespread.

The Value of Program Certification for Performance Contracting

A survey of clubhouses listed in the 1996 ICCD Clubhouse Directory provided a research sample of 80 ICCD-certified clubhouses and 88 non-certified clubhouses with which to test the discriminant validity of ICCD certification. A statistically significant logistic regression model revealed that ICCD certification status could be clearly predicted for 78% of the clubhouses in the survey sample on the basis of director-reported compliance with representative measures of the Standards for Clubhouse Programs. The predictive power of compliance with the Standards was obtained even while controlling for other organizational variables, including clubhouse age, total staff salaries, and receipt of Medicaid funding. These findings provide support for the practical utility of adopting program certification as a performance indicator in an era of managed care, as well as the specific value of relying on ICCD certification as a quality assurance indicator.

Choice of service provider: how consumer self-determination shaped a psychiatric rehabilitation program.

OBJECTIVE To document the impact of consumer self-selection of service providers on their service receipt and attendance in a psychiatric rehabilitation program. METHODS Staff (8 FTE) in a new drop-in resource center tracked their service activities and contacts with consumers using daily service logs. Consumers (N = 46) checked their service needs at enrollment, and recorded their attendance on daily sign-in sheets. Regression analyses were conducted to examine correlations between these service measures and each consumers count of key providers, with key provider defined as any staff worker with whom the consumer logged the equivalent of more than a full workday of contact (9+ hours) during a 6-month study period. RESULTS Service log findings suggest that key service providers were chosen by consumers through informal social interactions with staff. Members who had more key providers were more active in the program and more likely to have checked a need for psychiatric care at enrollment. In spite of member choice of provider, caseloads remained small and staff were able to dedicate their time to services related to their specialty training. CONCLUSIONS Facility-based programs can encourage consumer self-selection of service providers without overloading staff or restricting specialty services if they provide ample time for staff and consumers to get to know one another in informal social interactions.

Does Competitive Work Improve Quality of Life for Adults with Severe Mental Illness? Evidence from a Randomized Trial of Supported Employment

A randomized trial comparing a facility-based Clubhouse (N = 83) to a mobile Program of Assertive Community Treatment (PACT; N = 84) tested the widely held belief that competitive employment improves global quality of life for adults with severe mental illness. Random regression analyses showed that, over 24 months of study participation, competitively employed Clubhouse participants reported greater global quality of life improvement, particularly with the social and financial aspects of their lives, as well as greater self-esteem and service satisfaction, compared to competitively employed PACT participants. However, there was no overall association between global quality of life and competitive work, or work duration. Future research will determine whether these findings generalize to other certified Clubhouses or to other types of supported employment. Multi-site studies are needed to identify key mechanisms for quality of life improvement in certified Clubhouses, including the possibly essential role of Clubhouse employer consortiums for providing high-wage, socially integrated jobs.