June/July 2002

The Power of Work

By Renee Leavitt, OTR/L, and Susan Spear, OTR/L

Work is highly valued in our society and it defines who we are and how we think about ourselves. Individuals with mental illness want to lead a normal life and see work as a principal component of that life. As many as 90% of individuals with mental health disabilities in America are unemployed, which is due in part to the functional impairments caused by mental illness.¹

Here at Maine Medical Center in Portland, individuals with mental health disabilities are being helped to obtain and retain employment, and become working members of the community through the joint efforts of the Vocational Services Department and the Department of Psychiatry. These two departments began working together during the Employment Intervention Demonstration Project, a 5-year national multisite research project, funded by the Center for Mental Health Services.²

STANDARDIZED ASSESSMENTS

Our model of practice developed from the increasing research findings on cognitive deficits in individuals with mental illness. Cognitive disabilities impact the ability to function, more than the positive symptoms of the illnesses, ie, hallucinations, delusions, looseness of associations. The most significant areas affected are memory, problem solving, and attention.³ Since new skills are difficult to learn when an individual's cognitive function is impaired, it is important to identify the specific challenges an individual faces prior to employment. Therefore, our initial contact begins by administering a series of cognitive assessments, used to identify the client's information processing skills, executive functioning, and memory and learning style. These standardized assessments include:

Allen cognitive level screening. This is a standardized instrument used to establish a baseline and to outline potential cognitive function. It provides information about the client's ability to process information, problem solve, learn, and attend. Scores on this screening range from 2.0 to 6.0.

Rivermead behavioral memory test. This test detects impairment of everyday memory function and monitors changes following treatment. Test items involve remembering to carry out daily living tasks and retaining the type of information needed for everyday function.

Motor-free visual perception test-revised. Designed to assess visual perception with individuals who may have learning, cognitive, motor, or physical limitations, the motor-free visual perception test-revised evaluates five types of visual perception: spatial relationships, visual discrimination, figure-ground discrimination, visual closure, and visual memory.

Contextual memory test. This is a standardized assessment tool designed to assess awareness of memory capacity, strategy use, and recall in adults.

Test of everyday attention. The test of everyday attention uses common functional tasks to examine four areas of attention that affect information processing ability: visual selective attention, attentional switching, sustained attention, and auditory verbal working memory.

BUILDING A FOUNDATION

Findings from the cognitive assessments are used to identify an individual's strengths and skills, and to provide a foundation for the vocational rehabilitation process. Vocational providers typically refer clients for an occupational therapy evaluation when questions arise about the person's abilities, or because they sense a discrepancy between the person's verbal and task-related skills. In discussing the assessment results with individuals, emphasis is placed on assisting them in understanding their learning style and its functional implications for activities of daily living and work. Strategies that maximize their strengths and minimize disability are shared.

After the assessment findings are interpreted, potential job matches are analyzed to identify what parts of the job do or do not fit with an individual's strengths. Environmental, cognitive, and supervisory strategies are developed to improve the job match and support the individual's highest level of function. Key to this process is to base job placement not only on clients' interests, but also on whether they can do the job according to the job analysis, cognitive assessments, environmental factors, and level of supervision provided. This process calls for close collaboration between the individual, the occupational therapist, and the vocational providers.⁴

KIM'S CASE

Kim (not her real name) is a 42-year-old woman with a history of schizophrenia. She had been working in an office and had succeeded in her job when her essential functions were clear and concrete. With changes in office procedures and a new expectation to multitask, Kim became highly stressed and her productivity was reduced. Her employment specialist made a referral for occupational therapy evaluation to gather more information about her overall cognitive function.

Kim participated in the Allen cognitive level screening, test of everyday attention, contextual memory test, and motor-free visual perception test-revised. These assessments were chosen because of their particular emphasis on information processing, memory, and attention capabilities. Assessment findings indicated that Kim had difficulty processing auditory and visual information simultaneously, as well as decreased visual processing speed and auditory-working memory. On a scale from 2.0 to 6.0, she achieved an Allen cognitive level score of 5.0. At this cognitive level, people typically have very good verbal skills, which can mask their areas of difficulty. Also at this level, learning is most effective when they are provided with a demonstration and allowed to practice the task several times. Being closely supervised and taught in a hands-on manner greatly enhances new learning. Because of the tendency to use ineffective trial and error problem-solving methods, the person will benefit from assistance to generate viable solutions to errors or problems.⁵

Kim also identified several factors of importance to her in her next job, specifically job tasks that are clear, concrete, and hands-on, yet still intellectually stimulating and visually oriented. Kim was aware of being "not so good with verbal directions," and also of being easily distracted by auditory input, so that the structure of the environment in which she was working is very important. Recommendations were made for Kim in three areas:

1. Work Tasks
   Kim is motivated by tasks that are predictable and clear to her, as well as intellectually stimulating. She enjoyed the data entry job she had done in the past because of its orderliness and predictability, yet tired of its "sameness." Work activities that are organized and follow a pattern will be most meaningful to Kim, such as distributing items, recording information/typing, or sorting objects. Highly visual tasks will be appealing to Kim, such as work activities involving words, numbers, pictures, or colors. In order for her work to be accurate and complete, Kim's work should be structured so that she can finish one task before starting the next, without the requirement of multitasking. Separating working from talking will allow Kim to focus fully on the task at hand. Incorporating tasks both routine and challenging into a consistent schedule is an ideal match for her.
2. Supervision
   Kim benefits the most from demonstrated instructions, especially with new, unfamiliar tasks. Allowing ample opportunities to practice these, and accompanying demonstrated steps with written instructions, will allow Kim to be more independent in sequencing the steps of tasks. Having a supervisor or trainer readily available for assistance with problem solving will help Kim to more quickly generate solutions to new or unanticipated problems. A supervisor should also check in periodically throughout the day, to answer questions Kim might have and assist her with planning and prioritizing the day's work as needed.
3. Work Environment
   Kim will benefit from a work environment that is as distraction-free as possible. Competing auditory demands are the most distracting to her, so avoiding excess background noise (ie, radios, overhead intercoms, multiple conversations) will support Kim in paying attention to directions being given to her, or to other information being shared. Working in a private office or cubicle area will assist Kim to stay focused on her work, but it is important for her to also have access to common areas for break and meal times to increase her social connections. Opportunities throughout the day to take brief breaks can help Kim to maintain/regain her focus on work tasks. Movement-based activities done during these breaks, such as stretching and walking, will not only support Kim's ability to sustain attention to her work, but will also help her to manage her symptoms of anxiety while at work.

1. The Center for Reintegration, Employment, Mental Illness and the Workplace. Available at: www.reintegration.com/CONSUMERS/Employment/employment_workplace_Remployr. Accessed May 2,
2002.
2. Employment Intervention Demon–stration Program Coordinating Center. Project information. Available at: www.psych.uic.edu/eidp/. Accessed May 2, 2002.
3. Green MF. What are the functional consequences of neurocognitive deficits in schizophrenia? Am J Psychiatry. 1996;153:321-330.
4. Leavitt R, Spear SN. Cognitive assessments and work. OT Practice. 1998;3(3):35-38.
5. Allen CK, Earhart CA, Blue T. Understanding the Modes of Performance. Ormand Beach, Fla: Allen Conferences Inc; 1996.

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