Schizophrenic patients run into a number of obstacles in their efforts to become productive, functioning, contributing members of society. Sadly, the very professionals who are "helping" them frequently erect the barriers. Mental health professionals often see these patients as useless and incapable of doing productive work. To a large extent, lower-level, entry jobs, or sheltered workshop activities are looked down upon and not considered worthwhile. There is much preoccupation with the "monotony" of routine work and the nonintellectual nature of nonprofessional work. The result is that the benefits derived simply from working - the feeling of being productive, the sense of being needed, the social outlet in terms of relationships with coworkers - are all largely neglected.
If work therapy is to be used to its fullest advantage, more middle-class professionals need to guard against the tendency to view nonprofessional work in terms of their own subjective reaction to it. Concentrating on the aspects of work they themselves find dull, monotonous, and even degrading, these professionals often fail to see that others achieve as great a sense of mastery and self-worth by success in whatever job is within their capabilities as they, as professionals, do in their own jobs. Upward-striving, high-achieving professionals must recognize that their patients' values may be different from theirs and that their patients do not necessarily consider tasks requiring less cognitive skills demeaning.
A situation comes to mind of a young man recently discharged from a state hospital who was able to leave a sheltered workshop after only 3 months and get a job as a dishwasher in a large, busy cafeteria. Understandably proud, he came to report this to his aftercare group. The response of the group leader was, "Isn't that great! That will help you to get a better job later." Insensitive to the satisfaction his patient was feeling, the professional in one sentence destroyed his patient's joy by downgrading his achievement.
CONCEPTIONS AND MISCONCEPTIONS
We believe that whenever possible the day treatment center should not be used as an ongoing, lifelong resource for the schizophrenic patient. The alternative, which is much more appropriate and does not foster regression and undue dependency, is one that combines work therapy and social therapy in a mix tailored to fit the needs of each patient. However, before work can be used therapeutically, a number of misconceptions must be discarded.
There is no clear relationship between work capacity and degree of emotional recovery; that is, the ability to obtain a job and perform it does not require a certain degree of well-ness. Some of the sickest and most disturbed people are able to work - some marginally, some with a high degree of competence. Also, it is often assumed that people have to be socialized before they are able to work, that they have to achieve a high enough level of social skills to get along with other people on some basis of reciprocity. Experienced clinicians know, however, that this is not necessarily true. Some expatients can act appropriately within a structured work situation when cues are available to guide them but may be immobilized and confused by the lack of structure in a social situation. Others may achieve a high level of social skills but be unable or unwilling to work.
Work is seen by many patients as an activity in which they are not required to exercise social skills. This makes it more comfortable than other activities. For instance, one patient said, "On my job I don't have to be me." What she meant was that while she was working, the nature of her job defined her; she was a "cashier," and all her social anxieties could be put aside while she concentrated on the tasks of a cashier. She understood clearly what she had to do and felt competent to carry out the specific activities connected with the job. By contrast, she was lost in a social situation where she saw herself as having to chart her own course and meet standards that seemed frighteningly amorphous to her.
A related point is that sometimes, for the person who is schizophrenic, stressing socialization is contratndicated. For example, a withdrawn young man had always had difficulty relating to others in social situations. He could, however, work effectively as an electronics assembler because his interaction with other wor kers was minimal and could be limited to job matters. In the course of therapy, the patient was encouraged to develop social skills and to try them out on the job. Within a short period, he had quit his job and required hospitalization; he could not determine what degree of socializing was appropriate to the various situations in which he found himself. He felt that he had completely lost control and became so upset that he had to flee from the situation. The expectation that schizophrenic patients will learn to socialize is not always realistic, and many can function much more adequately when not called upon to develop and use social skills.
Frequently, having gained a degree of self-confidence from being successful at a job, schizophrenics can very gradually begin to devote their energies to performing better in social situations. For this reason, some should be considered for very early placement in a work situation rather than in a day center or any other treatment requiring free social interaction with others. Such placement allows them to work on their interpersonal interactions gradually, while engaged in a structured work task.
Many disabled persons cannot be rehabilitated into regular competitive employment. They lack either the capacity or the will to meet the rigorous demands of most employers. For this group, permanent sheltered workshops or other sheltered work arrangements are needed. It is often the professionals rather than the clients who believe that permanent sheltered work is not good. Having a reason to get up in the morning, a place to go where one can be useful and productive and earn money, and where one has friends and feels accepted can be a tremendously important factor in the life of a person for whom the alternative is sitting at home watching television.
We cannot, however, automatically assume that all schizophrenics will remain in need of a sheltered workshop. Some for whom we would predict little improvement will surprise us and ultimately go on to competitive employment. There should be no limit on how long schizophrenics can remain in the workshop and no pressure on them to leave. When they are ready to move on, they find ways to let us know.
Professionals need to understand that work therapy must have a well thought-out rationale. Using work only to provide a daytime activity accomplishes little in the way of therapy. How serious and important the professional feels the work task is and how he or she communicates this attitude, consciously or unconsciously, to the patient has a profound impact on how effective the work therapy is. To begin with, the professional must maintain the same attitude whether or not the work involves competitive employment. If the task the patient is doing is made to seem of little consequence, the patient cannot see it or him- or herself as being valuable. The mental health professional can communicate - both verbally and nonverbally - his or her reaction to lowlevel, low-pay jobs; such disclosures need to be guarded against when reacting to patients' work activities. For most patients, work has been an important, integral part of their lives, and in our culture, our work still remains a major means by which we take our place in the mainstream of life.
Whether we are talking about a sheltered workshop or some other work setting, we are using sophisticated techniques even though at first glance they may appear simple. Work therapy often is seen as nonintellectual by mental health professionals because it does not involve an intellectual discussion of psychodynamics. However, a number of important concepts underlie work therapy.
Mastery is one of these concepts. Both a feeling of accomplishment and the knowledge of being able to perform a task of proven value (because the patient has been paid money for it or because the work has resulted in a useful product) give the patient a sense of mastery, a feeling that he or she is not powerless and helpless in the world. The patient can begin to discard the dependent patient role and assume the identity of a worker.
Also involved is the concept of high but realistic expectations. This does not mean that every schizophrenic achieves competitive employment. Rather, for each person, the expectation is to perform at the highest level he or she is capable of. For example, in a workshop, if the highest possible level for a particular client is 50% of what workers in industry would be able to achieve, then 50% is a high expectation for this particular person. However, if the patient is able to achieve 50%, we should not be satisfied or let him be satisfied with 25%. Schizophrenics respond to these expectations in a positive way in terms of both their achievement and their self-esteem, and the professionals working with them need to communicate clearly what the expectations are. An attitude of high but realistic expectations tells patients in a meaningful way that others see them as more competent then they themselves supposed and that they are capable of achieving at a higher level.
The same principle of high but realistic expectations should be applied to the schizophrenic's behavior in any type of training or work activity. If the patient is given a clear, consistent message that a certain kind of performance is expected and that craziness, apathy, or a rationalization such as, "I can't do that, I'm handicapped," are not acceptable, then the patient is likely to perform better.
Work therapy is directed to the healthy part of the person. The aim is to maximize the individual's strengths rather than to focus on psychopathology. Work therapy focuses on reality factors rather than on intrapsychic phenomena and on changing behavior rather than on changing character structure. Work therapy may seem mundane, but it can make the difference between a life of regression, dependency, and depression or a life with considerable gratification and a sense of mastery.
The following example illustrates some of these points. A workshop client is sitting at his work station hallucinating and not working. The foreman says to the client, "Stop talking back to the voices and get back to work." The foreman is talking to the well part of the ego by conveying to the schizophrenic that he is capable of being productive and is expected to strive to realize his potential. The foreman is emphasizing the client's identity as a worker rather than as a patient and is using a direct approach to reach the client. The foreman is helping the client achieve control. Further, he is indicating to the client that he cares about him instead of simply allowing him to sit there preoccupied with his psychotic symptoms.
VOCATIONAL REHABILITATION COUNSELING
The attitude that vocational rehabilitation counselors should play a relatively unimportant part or no part in the treatment of the schizophrenic patient is common. The basis for this point of view is the fact that a substantial percentage of these patients will not enter the competitive labor market. However, the intrinsic value of work therapy makes quality rehabilitation counseling a necessity whether or not the goal is regular employment. Certainly, how much counseling, what kind, and when it is used will depend on the needs of the individual patient. However, work therapy attempted without the particular skills of a rehabilitation counselor has greatly diminished potential.
In what ways can the counselor work more effectively in this area than other helping professionals? It is true that what the counselor does often seems indistinguishable from what the psychotherapist does. The important difference, however, lies in the counselor's orientation to the occupational aspects of life, his or her special knowledge in the field, and his or her focus on accomplishing behavior change with regard to work. Purposely setting aside other areas of the person's life, the counselor focuses on vocational planning and vocational activities. The counselor's conviction is, however, that successes in these areas enhance other therapy and help change other facets of the patient's life.
What kind of patient should be referred for vocational rehabilitation services? Counselors are apt to reply that anyone who expresses any interest at all and who can get to a facility should at least have the opportunity to be considered. Assessment by a professional vocational rehabilitation counselor may bring different results than the referring therapist might have expected. Sometimes, the patient who appeared to the ther> apist to be a questionable referral seems highly appropriate in the judgment of the counselor and vice versa. Counselor and therapist see the patient from different perspectives.
Moreover, the patient may present him- or herself very differently to the counselor than to the therapist. The patient who sees a therapist in a psychiatric setting usually will conform to the role expectations of the environment and behave like a patient, so his or her employment potential may not be evident. On the other hand, the patient may be expressing a desire to work because he or she wants to be perceived by the therapist as a person who wants to work. In actuality, the patient may be extremely fearful of work and not ready to consider it. During a discussion about work with a vocational counselor, the patient may see these realities, or they may become plain to the counselor.
Although referral of the schizophrenic patient should be made as early as possible, it should not be made at an unpropitious time. The patient can derive little benefit from vocational rehabilitation if his or her energies are totally involved with a divorce, a separation, the loss of a loved one, or a major change in lifestyle. The therapist, however, should be sensitive to the start of recovery from crisis and help the patient to become involved in work activity before he or she settles into a life pattern of apathy and inactivity.
Following referral, counselor and patient will work together to determine immediate plans. Frequently for the schizophrenic patient, the sheltered workshop is a good beginning. At this point, the counselor's concern will be that the patient be clear about what he or she hopes to accomplish in the workshop. The counselor will have reviewed the patient's employment history and made some judgments about employment potential, as well as which behaviors would need to be adjusted before successful and satisfying employment could be obtained. With these judgments in mind, the counselor can help the patient identify problems to be dealt with in the workshop. However, the counselor must be cautious in this determination and plan for simple goals that the patient will have no trouble reaching.
During the time the patient is in the workshop, regular meetings with the counselor need to be scheduled so that progress or lack of progress can be assessed and new goals can be set. The counselor should be open with the schizophrenic as the patient is then likely to respond with a similar openness and deal with real issues. To illustrate, a workshop client on anti-parkinsonian medication consistently came to the workshop without taking the medication. He would say he had forgotten and would have to go home to take it, thus losing several hours of time. The counselor felt free to say, "Several times in the past two weeks you have missed hours of work because you had to return home for your medication. I think you are trying to tell us you don't want to be here." With the situation clearly spelled out, the patient could then talk about his real concerns - not really wanting to work, feeling resentment because he felt his wife and therapist were forcing him to come, and the fear that eventually he would have to face a job that was beyond his capabilities.
Schizophrenics sometimes can tolerate closeness in only very small amounts, and contacts may be very short and limited to the workshop floor. For instance, one patient, who now has been employed for 4 years, was at first unable to tolerate 10 minutes in the counselor's office. She would sit on the very edge of the chair and protest continually that she wasn't worth the counselor's time. Because of her evident discomfort, the patient was seen only during work for a short conversation or greeting. Regular interviews were not set up until the patient came to the counselor's office and requested an appointment. Even then, the sessions were never longer than 1 5 or 20 minutes. Eventually, the patient was able to stay in the counselor's office without discomfort.
A rather common outcome of the client-counselor relationship in work with schizophrenic patients is the discovery that a patient who has the intellectual capacity or aptitude for certain careers has neither the emotional strength nor the personality characteristics to succeed in those fields. An in-depth knowledge of occupational requirements is necessary to reach and act on this conclusion. Counselors are aware of the ingrethents that make up work environments of various occupations and the essential personality traits required. Knowledge of the patient will suggest to the counselor which occupational fields will be compatible with his or her personality.
Sometimes this knowledge is used to reinforce the appropriateness of the patient's current job, and psychiatric therapy can then focus on the real problems. An excellent example of such reinforcement is a 42-yearold engineer, a schizophrenic who had been in therapy since the age of 15. He had been able to achieve a very good employment history despite his illness. He was employed on an experimental electronics project, working largely alone in a situation that was low key and relatively unpressured. He was referred for vocational counseling and testing to find another kind of work he could do because he believed a recent exacerbation of his illness was caused by his job. Following counseling and a battery of vocational interest and aptitude tests, it was clear that the job in which he was engaged was uniquely suited to him. He and his therapist then were able to explore other areas in his life and pinpoint why he was particularly troubled at that time.
With many schizophrenic patients who express a desire to work, it will become clear that there is only a very remote possibility or no possibility that work outside a sheltered setting can be considered. Here, the counselor's role will be to alleviate anxiety about "not progressing" and give support to the patient in what he or she is doing in the workshop. In this type of situation, the counselor's attention to the details of a continuing evaluation reassures the patient of the value of his or her work activity. Furthermore, in this way, the door is left open for future spontaneous change and improvement that occurs even in very regressed patients.
USE OF VOCATIONAL REHABILITATION SERVICES
The wise therapist is aware that he or she cannot be knowledgeable about everything and can comfortably refer patients to specialists in areas outside of his or her own training. Attempting psychotherapy leading to personality reconstruction is outside the vocational therapist's role, and the vocational therapist does a disservice to a client by attempting it. This is also true of the therapist who attempts vocational counseling and career selection - the therapist would better serve his or her patient by a judicious referral to a person with vocational rehabilitation skills.
In referring a patient for vocational rehabilitation services, some therapists specify a particular activity: "Needs sheltered workshop," for example, or, "Place in training to be a landscape gardener's assistant." However, better results can be obtained if the therapist simply refers for a vocational evaluation. In this way, the counselor and the patient are allowed to work out vocational plans unhindered. The patient who arrives unannounced at the vocational services center, lunch in hand, prepared to enter the workshop "because the doctor sent me" is rarely able to consider other plans without a great deal of difficulty. As already mentioned, from the perspective of a vocational rehabilitation counselor, the patient may look almost totally different than he or she appeared to the therapist, and the workshop may not be the best plan for him or her.
Along the same line is the encouragement by the therapist of a particular vocational aspiration for the sake of supporting any positive activity on the patient's part. Frequently, and understandably, the therapist sees an interest in a vocation as a healthy sign, takes that interest at face value, and fosters it without any real discrimination. For instance, the patient may say he or she wants to be an electronics technician, and the therapist agrees that the idea is a good one. This endorsement from the therapist without any determination of the patient's fine finger dexterity, mathematical ability, patience with minute detail, or even whether the patient is colorblind usually results in the patient's adamantly pursuing that career selection no matter how inappropriate. Rather, the therapist could have responded, "I'm glad to see that you are considering employment. Why don't you discuss this with your vocational counselor, who might have some other ideas you would want to consider."
It is easy to take a simplistic approach to the choosing of a career and the preparation for it. Questions constantly heard by counselors - "Why can't my patient be a machinist. ..a lab technician. ..an electrician?" - indicate just how little the average psychiatrist really looks at what is involved. Not only must there be the more obvious match between the occupation and ability, aptitude, and interest of the patient, but the patient also must go through the whole painful process of facing up to weaknesses and limitations. The difficulty experienced by most schizophrenic patients in making decisions must be overcome, then a commitment to a course of action must be made. Most often, altering maladaptive behavior and attitudes must be the first step. With the schizophrenic patient, this whole process is very slow, and if hurried, unlikely to succeed. Thus, in using vocational rehabilitation services, the referring therapist should caution him- or herself as well as the patient that careers are not pulled out of a hat and patience must be exercised by all concerned.
This caution is particularly necessary when patient and therapist have unrealistic ideas of the capabilities and readiness of the patient. A good example of this is a referral of a 47year-old housewife with the notation "Needs a job right away to get her out of the house." This woman had a 20-year history of multiple hospitalizations for schizophrenia and had not worked since she was 2 1 . She had no work skills, appeared withdrawn and fearful, and had no idea of the kind of work she would like to do. She came prepared to have the counselor produce some magic results, and when these were not forthcoming she gave up and did not keep further appointments.
Work therapy with schizophrenic patients can be an extremely effective activity that not only helps these patients remain in the community, but also makes their lives more meaningful. Work therapy contributes to patients' mental health by increasing their feelings of selfesteem and mastery over their lives and often leads to their achieving a greater degree of independence through employment. Mental health professionals need to extend their use of vocational rehabilitation services in order to make available to their patients all the options open to them to improve the quality of their lives. In so doing, referring therapists need to be aware that they can have a profound impact on the effectiveness of work therapy by the ways in which they use these services and by their attitudes and the importance, or lack or it, that they attach to the work activities of their patients.