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Development of vocational potential assessment tool and counseling module for persons with severe mental disorders
Journal Pre-proof Development of vocational potential assessment tool and counseling module for persons with severe mental disorders Nikitha Harish, Aarti Jagannathan, Chennaveeraachari Naveen Kumar, Jagadisha Thirthalli, Santosh Kumar Chaturvedi, Devvarta Kumar, Poornima Bhola, Krishna Prasad Muliyala, Sivakumar Thanpal, G. Radhakrishnan, Hareesh Angothu, Deepak Jayarajan
PII:
S1876-2018(19)30902-5
DOI:
https://doi.org/10.1016/j.ajp.2019.101866
Reference:
AJP 101866
To appear in:
Asian Journal of Psychiatry
Received Date:
13 September 2019
Revised Date:
2 November 2019
Accepted Date:
3 November 2019
Please cite this article as: Harish N, Jagannathan A, Kumar CN, Thirthalli J, Chaturvedi SK, Kumar D, Bhola P, Prasad Muliyala K, Thanpal S, Radhakrishnan G, Angothu H, Jayarajan D, Development of vocational potential assessment tool and counseling module for persons with severe mental disorders, Asian Journal of Psychiatry (2019), doi: https://doi.org/10.1016/j.ajp.2019.101866
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Om sri sai ram
DEVELOPMENT OF VOCATIONAL POTENTIAL ASSESSMENT TOOL AND COUNSELING MODULE FOR PERSONS WITH SEVERE MENTAL DISORDERS Nikitha Harish1, Aarti Jagannathan2, Chennaveeraachari Naveen Kumar1, Jagadisha Thirthalli1, Santosh Kumar Chaturvedi1, Devvarta Kumar3, Poornima Bhola3, Krishna Prasad Muliyala1, Sivakumar Thanpal1, Radhakrishnan G4, Hareesh Angothu1, Deepak Jayarajan1.
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1- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru.
2- Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru.
Neurosciences (NIMHANS), Bengaluru.
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3- Department of Clinical Psychology, National Institute of Mental Health and
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4- Department of Nursing, National Institute of Mental Health and Neurosciences
Highlights:
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(NIMHANS), Bengaluru.
Development of a detailed vocational potential assessment tool and a semi-
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structured counseling module to facilitate individual employment goals of persons with SMD.
Comprehensive assessment tool yields specific targets/goals to counselling, that can be tailor made to suit individual needs and includes all the stakeholders involved in the vocational process; the person with SMD, the
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caregivers and the employer
ABSTRACT: Objective: To develop and validate the vocational potential assessment tool and counselling module for persons with severe mental disorders (SMD). Method: The tool and the module were developed through review of existing assessment tools, individual interviews and focused group discussions with key stake
Om sri sai ram holders- persons with SMD, caregivers, expert mental health professionals and employers. The developed tool and module were validated by experts. Result: The process of tool and module development was conducted simultaneously and included 11 persons with SMD, 9 caregivers, 9 experts and 9 employers. A total of 38 themes were obtained through individual interviews and focused group discussions. The developed tool and module along with a scoring key were validated by 6 mental health experts. Conclusion: The tool is easy to use and comprehensive, takes approximately 45 minutes to 1 hour for assessment. The module provides a framework for vocational
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counselling. The scoring key provides a guideline for professionals during assessment.
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Key words: Vocational Potential; Severe Mental Disorder; Assessment.
INTRODUCTION:
Employment status among persons with severe mental disorders (SMD) is a crucial
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aspect in the recovery and rehabilitation process (Ramasubramanian et al, 2016). Clinicians often perceive employability of a person with SMD to their symptom
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control and reintegration back into the community. Work is seen to improve selfsatisfaction and self-esteem, being a source of income, facilitating socialization and
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improving social value (Durgoji et al, 2019).
Employment often ensures financial independence, boosts self-esteem, social acceptance, integration, and a sense of well-being, thereby improving mental wellbeing as well as having a therapeutic benefit characterised by clinical improvement, betterment in social functioning and reduction of symptoms (Ramasubramanian
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2008, Salzer et al, 2011, Jaleel et al, 2015).
Vocational rehabilitation services help persons with disabilities (including those with SMD) prepare for, find and sustain employment. This helps them integrate back into society by being gainfully employed and contributing to their family and community. A gainful employment is a status, where the person with SMD works full time or part time and is remunerated from the employer on par with the current market standards
Om sri sai ram for the job profile; this does not include mere engagement at a day-care or vocational training service on a stipendiary basis.
However a number of persons with SMD, due to various factors are unable to prepare for, find or keep a job. Thomas et al, 2019 in their study to understand the challenges faced by persons with severe mental illness with professional degrees in obtaining and maintaining employment identified factors to be either facilitators for work or hindering. Facilitators for obtaining and maintaining employment included personal strengths, social support, accommodative work environment, disclosure, support from
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mental health professionals and services. Factors that were identified as hindering for obtaining and maintaining employment included symptoms of the illness, side effects of medications, stigma, poor social support, academic under- achievement, disjointed work history, poor workplace environment and specific cultural, gender issues.
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(Thomas et al, 2019).
Though persons with disabilities constitute a significant percentage of Indian
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population, their needs for meaningful employment largely remain unmet despite legislative measures (Shenoy 2011). These factors include those directly linked to the
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illness as well as psychosocial. Barriers for employment include those linked to illness (like treatment resistant symptoms, certain specific symptom dimensions including negative and cognitive symptoms, adverse effects of medications) and
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psychosocial factors (including inability to find a job that suits their profile and interest, uncompromising attitude of the employers, inability to continue working due to various factors at workplace and stigma).
With persons having such specific rehabilitation needs alongside other psychosocial
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needs, a vocational rehabilitation service would facilitate gainful employment of eligible recovered persons with SMD. This can be achieved primiarily through assessment of their vocational potential, by providing vocational counselling and guidance and there by securing suitable employment options and providing continued support through their vocational tenure. There is dearth of objective assessment tools and structured counseling programs to assist persons with SMD achieve their employment goals. To facilitate achievement of such goals a detailed vocational potential assessment tool to assess their vocational functional capacities and a
Om sri sai ram predesigned vocational counseling module that directs towards individual goals would fulfill such a gap. The present study aimed at developing a detailed vocational potential assessment tool and a semi-structured counseling module to facilitate individual employment goals of persons with SMD.
METHODOLOGY: The study was reviewed and approved by the Institute’s Ethics Committee. Written informed consent of the key stakeholders- persons with SMD, caregivers of persons with SMD, expert mental health professionals and employers, involved in the study
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were taken.
The development and validation of the vocational potential assessment tool and the counselling module were done simultaneously. The process of development and
validation of the Vocational Potential Assessment Tool (Phase 1) and the Vocational
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Counselling Module (Phase II) is elucidated under the below headings
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Phase I (a) and II (a) Development of the Vocational Potential Assessment Tool and Counselling Module:
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Review of available assessment tools- A detailed list of organizations working in the field of vocational rehabilitation of persons with mental disability (disability due to mental illness, developmental disabilities) was prepared. The organizations with
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scales for pre-placement assessment or job skills assessment were enlisted. Organizations registered as per World Association of Psycho-social Rehabilitation, India or Rehabilitation Council of India or Mental Health Act 1987 were enlisted to be 15, that were focusing on vocational rehabilitation of persons with mental disabilities, inclusive of mental illness, intellectual and developmental disabilities.
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Based on this review and experience of team members of the Psychiatric Rehabilitation Services, the Vocational Potential Assessment tool was drafted. The drafted assessment tool was modified further based on the suggestions given by various stakeholders in Focus Group Discussions and Individual interviews. The stakeholders considered were (Table 2) Persons with SMD availing treatment at NIMHANS meeting the criteria as per ICD-10 for F.20.0-29; Schizophrenia, schizotypal and delusional disorders,
Om sri sai ram F.31.0-31.9; Bipolar Affective Disorder, for the purpose of this study, F.33.0– 33.9; Recurrent Depressive Disorder and F.42; Obsessive Compulsive Disorder were also considered for recruitment. Those who were symptomatically stable as assessed by the clinician, being able to understand the aims of the study and consenting to participate. Primary care-givers- a person providing care to as person with SMD for at least 6 months- Parents, siblings, spouses, spouses of siblings. Experts- Mental Health Professionals and staff from NGO’s working in the area of vocational rehabilitation of persons with SMD (psychiatrists, psychiatric social workers, clinical psychologists, special educators).
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Employers- Human Resource personnel, recruiters, Managing directors, CEO’s (who had both previous experience of employing a person with SMD and also
those who did not have any prior experience of employing a person with SMD,
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but had employed other persons with disability).
Focused group discussions and individual interviews were conducted with the
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stakeholder groups:
An interviewer’s guide to facilitate individual interviews and FGD’s was formulated
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and used (available from authors on request). A written informed consent was obtained from the participants to take part in the interview/FGD process. Interviews were conducted through face-to-face interactions, or through telephonic/Skype
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conversations. The time taken per interview was between 30 minutes to 45 minutes. The interviews were conducted in English, Kannada or Hindi by a single researcher (NH). The process was audio recorded and transcribed with each response being coded into themes and subsequently sub-themes. In case the interviewees did not consent for audio recording but agreed for
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responding, the interview process was immediately transcribed in verbatim. Circular questioning technique was used to generate maximum elaborate responses from the participants. FGD’s and individual interviews were conducted till no new theme codes were emerging out of consecutive interviews and qualitative data saturation was reached (Gary, 1998).
The qualitative data thus collected was put through content analysis and the results were used to draft the Vocational Potential Assessment Tool using a deductive
Om sri sai ram approach (Burney, 2008). The counseling module was developed on the basis of specific areas identified by the participants as barriers/concerns in achieving their vocational potential, largely obtained from the assessment tool; areas such as assessment of strengths, weaknesses, opportunities, threats to vocational rehabilitation, areas of training and skill building, interview skills, etc. The counseling module was designed to be semi-structured, with fixed concepts but having flexible technique/ delivery to suit the needs of individual participants. It becomes essential to note that broad themes of Vocational Counselling may be generated that would address the key areas affecting vocational rehabilitation of the particular target group
be applied as per the needs of the individual participants.
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and not any specific themes unique to only one individual. These general themes can
The module incorporates specific target areas such as personal hygiene, social skills, handling medication side effects, travel skills, money management skills, perceived
cognitive deficits, adherence to treatment and need for social support as these factors
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play a crucial role in the placement and retention of employment.
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Phase I (b) and II (b): Validation of the Vocational Potential Assessment Tool and Counselling Module:
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Vocational Potential Assessment Tool (VPA):
Once drafted, the assessment tool was validated for Face and Content Validation
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among Mental Health Professions/ NGO staff working in the area of vocational rehabilitation (Table 3). The sampling of the professionals for validation was done using snowball sampling and data was collected using the iterative process. The validation process format included indicating a response of Appropriate (A) or Not Appropriate (NA) against each theme along with its sub-themes. The following
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were captured in the validation process: Possible response biases, which were, indicated to be- No bias, always agree, socially desirable response, carelessness, tendency to be uncertain, speedy response and not answering when in doubt. Cultural suitability of the items. 4 point Likert scale for recording the data.
Vocational Counseling Module:
Om sri sai ram The validation process format included indicating a response of Appropriate (A) or Not Appropriate (NA) against each theme along with its sub-themes and approaches/techniques of counselling to be applied. The responses also included at recording the cultural suitability of the items enlisted. Pilot testing: To assess whether the Vocational Potential Assessment Tool and the Vocational Counseling Module that was developed in earlier phases was easy to administer on the target population, it was tested for its feasibility by 3 professional staff (Table 3). It involved assessing if persons with SMD were able to understand the content of the
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VPA tool and Vocational counseling module, if it’s simple to understand, do they find it useful for the goal of vocational placement, is it easy to administer in an Out-Patient Setting, logistics and time in administering, ability of the person/researcher who is
administering the tool and Vocational Counselling Module etc. Subsequent changes were made in the Vocational Potential Assessment Tool and the Vocational
RESULTS: Themes and sub-themes generation:
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Counselling Module.
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After transcription of data collected in phase I (a) and II (a), themes and sub-themes were generated using the process of data saturation. The interviews were stopped if the theme codes did not emerge for consecutive interviews among the stakeholder
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groups. A total of 38 themes were generated after review of assessment tools, interviews and FGDs (Table 1). A draft tool and module were outlined to include main domains with sub-domains that incorporated all the themes and sub-themes elicited through Phase I (a) and II (a).
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Validation Process:
The drafted tool and module were given to 6 expert validators for assessing face and content validity. In the paragraphs below we elucidate the responses obtained during the validation process of the tool and the module by the experts.
Vocational potential assessment tool
Om sri sai ram All the 6 (100.0%) validators agreed that the items on the tool (both qualitative and quantitative aspects) were culturally relevant. All the validators agreed that there were expectations of no biases in responses expected out of the theme daily functioning under sub-themes- personal hygiene, grooming, eating, moving around, travelling and driving/riding vehicles. 1 (16.67%) validator reported that the tendency to be uncertain and not answering when in doubt could be expected in sub themes of basic money management, bank transactions and day-to-day decision-making. All the validators agreed that the items could be assessed on a 4-point likert scale.
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Under the theme of job related social skills training, while most validators agreed with the items as not being expected to have biased responses, 2 (33.33%)
validators foresaw biases in responses, precisely in the subthemes of initiating
conversations, keeping up with conversations, differentiating formal and informal social situations, interaction with superiors and colleagues and being a team
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player. 1 (16.67%) validator also reported of re-considering a 4-point likert scale for the particular theme.
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Under the theme of job related cognitive skills all the validators agreed upon the 4-point likert scale for assessment. One (16.67%) validator reported of the
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possibility of response bias in terms of giving socially desirable responses to the sub-theme of memory related difficulties. One validator (16.67%) was of the opinion that possible response bias of always agreeing with the assessor could
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occur with all the sub-themes.
Most of the validators (5, 83.33%) agreed up on all the sub-themes being assessed on a 4-point likert scale, whereas one (16.67%) validator responded that a 4-point likert scale might not be able to capture all the deficits in the theme. One validator reported that there could be a possible response bias in terms of always agreeing
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with the assessor, while all other validators did not expect any bias.
For the theme of job readiness, all the validators agreed upon 4-point likert scale of assessment for the sub themes. Only one (16.67%) validator reported that the sub-theme of insight might not be adequately assessed on the tool with a 4-point likert scale. All the 6 (100.0%) validators agreed that there might not be any possible response bias on sub-themes except for one sub-theme, willingness/motivation to work, where one validator responded the possibility of providing socially desirable responses on this item.
Om sri sai ram For the items of the theme job related details, all the validators opined that the 4point likert scale of assessment was adequate. 5 (83.33%), of the validators opined that the items of the sub themes may not have possible bias, however 1 (16.67%) validator reported of possibility of response bias in terms of place of work, duration of employment and gap in employment that could elicit socially desirable responses from the respondents. The validator also reported the possibility of response bias in sub-themes- nature of work (socially desirable responses, speedy responses), and reason to leave job (socially desirable response, carelessness, speedy responses).
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For the theme of family and client perspective, the validators responded that the items would adequately assess the level of potential on a 4-point likert scale. 5
(83.33%) validators reported that there could be no bias on responses for the sub-
theme of family efforts, while 1 (16.67%) validator was of the opinion that the sub
any response bias for any other sub-theme.
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theme could elicit socially desirable responses. All the 6 validators did not foresee For the theme of type of job, none of the 6 (100.0%) validators foresaw any
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response biases. However 3 (50%) of the validators reported that a 4-pont likert
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assessment may not be able to capture the sub-themes adequately.
Vocational counselling module
5 (83.33%) validators responded that the themes and sub-themes for the
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counseling module were relevant (appropriate) while 1 (16.77%) opined that they may not be appropriate as themes but can be renamed as targets to be covered in the counseling process.
5 (83.33%) validators responded that the approaches or skills enlisted in the module were culturally appropriate, however 1 (16.77%) validator felt they would
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have to be reframed for cultural appropriateness.
Development of tool, module and scoring guide: Based on the feedback provided by experts during validation, the final tool and the module were developed along with a scoring guide explaining the scoring of the quantitative items and explanation of the anchor points specific to each domain of assessment was developed. The possible exploratory questions to elucidate qualitative responses were also included to help assessors. During the pilot testing, the testers
Om sri sai ram remarked the tool to be easy to use, to be detailed and requiring simplification or rewording of questions to help all assessors (The tool and the module have been attached in the appendix as supplementary data).
DISCUSSION: The present study aimed at developing a detailed vocational potential assessment tool and a semi-structured counseling module to facilitate individual employment goals of persons with SMD. The primary goals of vocational assessment among people with mental health needs are development of skills and obtaining the supports needed for
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independent, interdependent, productive living, improved participation in every day life and better quality of living (Sethuraman L et al, 2016). The study looked at a
detailed process of developing not only a tool for assessment but also develop a semistructured counselling module to address areas of concerns identified by the scale
with the ultimate goal to faciltiate viable employment options for persons with SMD.
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Validated tools specifically assessing work functioning, needs and vocational goals of inidivuals with SMD are rather limited if not nil (Nieuwenhuijsen K et al, 2010,
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Sethuraman L et al, 2016).
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The available pool of data suggested the need to develop an assessment tool based on a rational scientific approach to achieve goals in vocational rehabilitation among persons with SMD who often pose different challenges due to their mental
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disabilities. The ultimate goal of any assessment is to provide tangible targets to be addressed through therapeutic interventions to facilitate recovery and well-being. Thus, a semi-structured counselling module developed alongside an assessment tool was conceived as a complete program to focus primarily on achieving optimum
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employability among persons with SMD’s.
With no specific employment models or programs available in India for persons with SMD, with a prevalence rate of mental illness being 14.9 people per 1000 general population (Lakhan R et al, 2015) the tool and the module were unique in providing a structured, guided approach to professionals in facilitating employability. The standardized tool developed by the National Institute of Mentally Handicapped, Secunderabad (currently known as the National Institute for the Empowerment of
Om sri sai ram persons with intellectual disabilities) assess vocational skills among persons with intellectual disabilities, that is less likely to fully assess the skills among persons with SMD. Sethuraman L et al, have developed a self report based 45 item tool to assess work related problems among persons with substance use disorders, which may not be able to address all the areas of assessment needed among persons with SMD’s (Sethuraman L et al, 2016). Thus, the tool developed in the present study covers areas of assessment specific to persons with SMD.
The tool is detailed and requires approximately 45 minutes to 60 minutes to be
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administered. The likert method of scoring makes it an easy tool for assessment that can be done by any mental health professional trained in the area of severe mental disorders. The comprehensive assessment tool yields specific targets/goals to
counselling, that can be tailor made to suit individual needs and includes all the
stakeholders involved in the vocational process, the person with SMD, the caregivers
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and the employer. The major strength of the tool and the module lie in the rational
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scientific method of their development through an iterative process.
However it is important to note that though the domains of assessment are
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comprehensive, the tool may not be easily applicable to persons with common mental disorders as they may not have similar vocational needs, or persons with intellectual development disorders or other neurological disorders. The domains of the tool also
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may not be completely capable of assessing vocational skills needed for selfemployment or agriculture-based job options. Further External" barriers such as age of onset of SMD which has a bearing on level of disability, socio-occupation functioning and self-stigma (Grover S et al, 2019); family, academic and social barriers faced during academic reintegration (Annapally SA et al 2019) and
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anticholinergic burden which affects cognitive and daily living functioning in patients with schizophrenia (Kim-S-Jin et al, 2019), may act as confounders to outcomes derived from the vocational potential assessment tool as these could potentially impact the performance of the client in any assessment.
The tool and the module indeed have clinical relevance as the assessment tool guides clinicians and practitioners towards goal achievement in therapy and also provide an objective understanding of the skills to the clients and their families. The module
Om sri sai ram provides a framework for collaborative therapeutic approach to achieve end results. It is imperative to note that the tool and module developed in the present study may in future be used for identification of jobs for persons with mental health disabilities at the government and private sectors and thereby advocating the need for inclusive communities. Further research is required to test out the effectiveness of the tool and the module in larger clinical environments.
CONCLUSION: The Vocational Potential Assessment Tool and the Counselling Module is developed
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and validated through a scientific iterative process. The feasibility of the tool and counselling module needs to be tested in larger research studies across various clinical settings.
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ETHICAL CONSIDERATIONS:
An informed written consent was obtained from the study Participants
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(Person’s with SMD, their Care-givers, Mental Health Professionals, NGO’s working in the area of rehabilitation) to participate in the study after explaining the objectives
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Participants were assured of the confidentiality of their identity and the shared
information.
The participants involved in the study could withdraw consent at any point of
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3.
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of the study in a manner understandable to them.
time during the course of the study. 4. 5.
The participants were entitled to know the results of the study if asked for. The participants of the study were not denied any form treatment at
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NIMHANS if they refused to further participate.
ACKNOWLEDGEMENT: The authors also thank The Ministry of Social Justice and Empowerment, Government of India for funding the research and all the participants and experts involved in the process of research.
CONFLICT OF INTEREST: NONE
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FINANCIAL DISCLOSURE: Financial support by The Ministry of Social Justice and Empowerment, Government
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of India.
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REFERENCES:
Annapally SA, Jagannathan A, Kishore T, Thirthalli J, Daliboina M, Chennaveerachari NK, Barriers to academic reintegration in students with severe mental disorders: Thematic analysis, Asian Journal of Psychiatry 45 (2019) 107– 112. https://doi.org/10.1016/j.ajp.2019.09.010
Burney SMA, Inductive & Deductive Research Approach. http://www.drburney.net. Retrieved April 15, 2012, Available at URL: http://www.drburney.net/INDUCTIVE%20&%20DEDUCTIVE%20RESE ARCH%20APPROACH%2006032008.pdf Durgoji S, Muliyala KP, Jayarajan D, Chaturvedi SK. Quality of life in
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Schizophrenia: What is important for persons with Schizophrenia in India?. Indian J Psychol Med 2019.
European Agency on Safety and Health at Work. Expert Forecast on Emerging
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Psychosocial Risks Related to Occupational Safety and Health. Brussels, Belgium: European Agency on Safety and Health at Work; 2007. Grady MP. Qualitative and Action Research: A Practitioner
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Handbook. Bloomington: Phi Delta Kappa Educational Foundation; 1998, p. 26.
Grover S, Sahoo S, Nehra R, A comparative study of childhood/adolescent and
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adult onset schizophrenia: does the neurocognitive and psychosocial outcome differ?. Asian Journal of Psychiatry 43 (2019) 160–169.
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https://doi.org/10.1016/j.ajp.2019.05.031
Jagannathan A, Harish N, Venkatalakshmi C, Naveen Kumar C, Jagadisha T, Chaturvedi SK., Devvarta K, Bhola P, Krishna Prasad M, Sivakumar T,
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Radhakrishnan G,Angothu H, Jayarajan D. Vocational Potential Assessment tool and Counselling module – For Persons with Severe Mental Disorder. National Institute of Mental Health and Neurosciences (NIMHANS), Publication No: 162, 2019.
Jaleel, F., Nirmala, B.P. & Thirthalli, J. Journal of Psychosocial Rehabilitation and Mental Health (2015) 2: 19. https://doi.org/10.1007/s40737-014-0020-3
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Kim S-Jin, Jung D, The effect of anticholinergic burden on cognitive and daily living functions in patients with schizophrenia, Asian Journal of Psychiatry (2019), doi: https://doi.org/10.1016/j.ajp.2019.10.013
Lakhan R, Ekúndayò OT. National sample survey organization survey report: An estimation of prevalence of mental illness and its association with age in India. Journal of Neuroscience in Rural Practice. 2015 Jan; 6(1):51-4.
Nieuwenhuijsen, K., Franche, R.-L., & van Dijk, F. J. H. 2010. Work Functioning Measurement: Tools for Occupational Mental Health Research. Journal of Occupational and Environmental Medicine, 52(8), 778–
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790.doi:10.1097/jom.0b013e3181ec7cd3. Ramasubramaniam C. Special employment exchange for persons with psychiatric disability. Indian Journal of Psychological Medicine. 2008;30:75–9.
Ramasubramanian C, Mohandoss AA, Namasivayam RK. Employability of
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mentally ill persons in India: A self-report-based population study. Industrial Psychiatry Journal 2016 Jul-Dec; 25(2): 171–178.
Salzer MS, Baron RC, Brusilovskiy E, Lawer LJ, Mandell DS. Access and
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outcomes for persons with psychotic and affective disorders receiving vocational rehabilitation services. Psychiatric Services. 2011;62(7):796–9.
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http://www.ncbi.nlmnih.gov/pubmed/ 21724795
Sethuraman L, Subodh B N, Murthy P. Validation of vocational assessment tool for persons with substance use disorders, Industrial Psychiatry Journal. 2016 Jan-
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Jun; 25(1): 59–64.
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challenges in severe mental illness: A qualitative study in persons with professional degrees, Asian Journal of Psychiatry 42 (2019) 48–54.
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TABLES
Table 1: Table showing the themes, sub-themes and verbatim of respondents. No. THEME
SUB-THEME
VERBATIM
1
Family
Type of job
“Sometimes, the person may like carpentry, but
Expectations
Knowledge of
the parents may not like it, then we need to
client skills
counsel the parents, explain them the need for interest of the person and need for acceptance”-
2
Type of job
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Expert, 50 year old female.
Preferred job
“..in an organization like us, we are a software
Type of job
developing company, opportunities are in day to day cleaning, that is housekeeping kind of a
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thing. That sort of a work then someone with poor skills also can do”- Employer, 42 year old
Hygiene
living
Grooming
Habits
Mobility
Money
Independent
Social skills
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brush properly”- Caregiver, 22 year old female.
“Important madam, I can but others I have seen
management
need help, they should be able t travel to work,
Travelling
then manage some money if not all, give salary
activities of daily living
“..he will not shave, wears old clothes, does not
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4
Activities of daily
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male.
to home, spend it properly, that is important no”- Person with SMD, 46 year old male.
Verbal and non-
“I think lack of assertiveness is one big lacuna
verbal skills
that they have. So whether it is to do with their
Initiating and
needs at the work place or their promotions, I
keeping up with
think they are not able to ask for what they need
conversations
for themselves. And they might also get pushed
Differentiating
around because they are not able to assert
situations
themselves” Expert, 65 year old female.
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Work Behaviour
Insight
Employer
Interaction skills
Assertive skills
Team skills
Punctuality
“It has taken him so many years to come
Regularity
regularly even here. They can’t work
Taking leaves
punctually”- Caregiver, 64 year old male.
Illness
“May be the fact that he does not even accept he
Skills
has an illness”-Caregiver, 22 year old female.
Organizational
“..is this person useful for the organization, see
goals.
every person I recruit irrespective of mental
Perspective
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issue, it is important that the company gets something out of this person, something useful.
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So that is important for me”- Employer, 27 year old male.
Reasonable
accommodation
“..I think the employer or company should be
infrastructure
proactive about employing them. Also giving
Behavioural/
them time to learn, as they may be slow to do
attitudinal work
task or also to mingle”- Employer, 33 year old
place
male.
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Accessible
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modifications.
Self stigma
“Again it depends on the employer but still,
Stigma by
other colleagues may stigmatize this person and
employer/collea
isolate him”- Expert, 56 year old female.
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10
Stigma
gues
Job related skills
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11
Motivation
“..first thing about any recruitment is will this
Flexibility
person X fit into the job role Y, do they have the
Reliability
skills, would they contribute to the team, will the
Productivity
company benefit from it, it’s a simple formula..” Employer, 27 year old male.
12
Client expectations
Realistic
“Then again there are concerns they don’t want
orientation of
low level jobs, they want jobs that suit their
job market
socio economic status not their skills, they may
Om sri sai ram
Cognitive skills
eventually fail that job also”- Expert, 66 year
of skills
old female.
Memory
“….the ability to follow an instructions when
Task completion given, including being able to recall the
Attention
instructions, problems solve the steps if the
Planning
instructions and they may require help to do
Decision
these. For some of them it could be about using
making
cognitive aids, to be aware of the problems that
Problem solving
they have is another area and to be aware of
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13
Understanding
how they can compensate for those”- Expert, 34 year old male. Symptoms
Current clinical
“My main concern will be, is this person
condition
violent, can he actually do this job role, have
Effect of
they worked before, how was their performance
symptoms on
then”- Employer, 27 year old male.
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job retention/
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14
securement. Coping
Recognizing
“…it helps to have cool and composed
stressors
approach to your job, everything doesn’t go as
Managing
planned, so you need to be able to be in control
stressors
of the situation without getting too hassled. So
Managing
you might have a customer coming and
conflicts with
screaming at eh wrong order placed, so you
colleagues
need to be calm, not retaliating, apologize. So
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15
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16
everything is not a part of our training, its also a part of you as a person- Employer, 38 year old female.
Psychosocial
Primary support
“then the family support, the support of the co-
support
Secondary
workers, the employer” Expert, 75 year old
support
male.
Om sri sai ram 17
Interest and
Hobbies
Interests that can “Doctor I also like to sing and learn to play be gainful
guitar. I have bought it and kept. I will join for classes”- Person with SMD, 22 year old male.
19
Interview skills
Disclosure
Meaningful
“…has a large gap in their CV, may have
responses in an
difficulty in explaining why there is a gap in
interview
their CV”- Expert, 34 year old male.
Role play
Selective
“Because, I think many of them feel that they
disclosure
are not doing well and since the client wouldn’t
Disclosure
have opened and said that I have a mental
before/ after
illness they are unable to understand why they
recruitment
are functioning ok on some days and not ok,
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18
why is there so much of inconsistency”- Expert,
22
Location
Distance
Timings
“Suppose only half a dozen jobs are available where we have to fit into the job which would
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Job readiness
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21
Job matching
require more efforts rather than the client’s suitability to the XYZ job; in this context the outcome may not be as it is expected”- Expert, 75 year old male.
Motivation
“Also their own self confidence to work may be
Willingness
a problem, they feel they cannot do any work..”
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20
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65 year old female.
“..in Mr.V he says he wants to work but does not attempt anything or even if we get a job he will not stick to it...”- Caregiver, 32 year old male.
Periodic
Follow-up
“..Periodically, for example in the incentive
Assessment
Re-assessment
scheme, every month we assess the progress on the Griffith Scale. Primarily to give incentive in the process of motivating, preserving”- Expert, 75 year old male.
Om sri sai ram 23
Attempt made by
client and family
Seeking
“In the family it self it may be essential to see
employment by
where family could be a barrier to vocational
client/ family.
aspirations; if the family thinks that the person is ready to work, what kind of support is the family willing to give, can they find jobs, come for sessions. It is important to look in the tool the support the family would provide; finding jobs, going with them, ready to support, reservations about this person working and how those person’s would change their behaviour,
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reasonable accommodation they family gives..”Expert. 34 year old male. Type of incentive
Remuneration
“so at he end of the day its all business and
Job
providing remuneration is a big part. So there is
development
a hierarchy for salary also. So if they can do it
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24
well, may be after 3-4 months, so initially we
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might not give the same remuneration for a
25
Educational
26
Vocational
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Side Effects
old male. “They may not be well educated, they may not
academic
have skills required at all”-Caregiver, 52 year
qualification
old female.
Prior experience
“He is an engineer, qualified but has never held
experience
27
also can see what they do”- Employer, 34 year
Highest
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Qualification
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person with disability and others, because we
one single job, he will never adjust, always says some silly reason and leave the job”- Caregiver, 22 year old female.
Tremors
“We take medicines, we feel sleepy, then there
Drowsiness
are shaking of hands and then once I do some
Dullness
mistake because of all this I will become tensed and do more mistake or become slow”- Person with SMD, 29 year old male.
Om sri sai ram 28
Difficulty of task
Complexity of
“..he is weak. He cannot do a lot of things that
task
involve physical strength”- Caregiver, 64 year old male.
29
Compliance
Regularity of
“ Oh yes, that is important also taking
follow-up
medicines so that mental health is ok to do the
Adherence
job is important”- Person with SMD, 46 year old male.
Employer
expectations
Employer
“..as an employer I think it will be unfair to
understanding
expect me to teach them that. If he already has
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30
got a skill then because of his own issues, we need to nurture him then its ok”- Employer, 42 year old male. 31
Job allocation
Role allocation
“..what kind of employment you give to them. A
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person cannot read or write then house-keeping job would be okay, say it is office administration
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then someone has to read and write in a
32
Employer
something, we cannot teach them”- Employer, 42 year old male.
Knowledge of
“May be explain to the employer what are the
illness
types of mental illnesses, what this person has,
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Psychoeducation
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register, those things people should have learnt
very clearly, what to expect what not to expect , so if they understand then they can be able to help. So if its only for the employer confidentially or with an open company the whole team, it depends. Like everybody knows what blindness is but not what schizophrenia or bipolar or depression is”- Employer, 34 year old male.
33
Job vacancy
Availability of
“..like there may not be vacancies when they
jobs
ask”- Employer, 42 year old male.
Om sri sai ram 34
Age
Age criteria
“..they may be older than others, not very young”- Employer, 42 year old male.
35
Qualities of an
employee
Personal
“I give examples to my own other friends or
qualities
business network, see I have seen that these guys have better productivity, they don’t gossip, they don’t get into unhealthy discussions, they don’t tell lies, they don’t try to hide things, they are very candid, which I think is very essential. This person is very transparent”- Employer, 42
36
Vocational
training received
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year old male. Duration of
“…the ability to follow an instructions when
training
given, including being able to recall the
Certification
instructions, problems solve the steps if the instructions and they may require help to do
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these. For some of them it could be about using cognitive aids, to be aware of the problems that
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they have is another area and to be aware of
Other disability
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38
IDEAS
year old male.
Standardized
The standardized assessment tool was used by
assessment
an organization as found in the review of
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37
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how they can compensate for those”- Expert, 34
literature.
Disability
“One is that people may not know about the
certification
schemes that are available to people who suffer from a disability”- Expert, 34 ear old male.
Om sri sai ram Table- 2- Table showing socio-demographic variables of stakeholders included in the Phase I (a) and II (a); Tool and module development: VARIABLE
CATEGORY Persons
Caregiver
Experts
Employers
with
s of
(N=9)
(N=9)
SMD’s
persons
(N=11)
with
7 (77.8%)
SMD’s (N=9) Male
7 (63.6%)
4 (44.4%)
3 (33.3%)
Female
4 (36.4%)
5 (55.6%)
6 (66.7%)
2 (22.2%)
Age in
Mean
36.18
49.67
54.56
34.22
years
Standard
±9.09
±15.98
±12.59
±7.06
Education Mean
14.25
14.25
17.66
16.5
in years
±4.34
±4.34
±2.51
±2.12
ro of
Gender
deviation
Unemploye
Home-
Teaching
Managing
d
makers
faculty
Director
(3,
(Department
(3, 33.3%)
33.33%)
of
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Occupation
re
Standard
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deviation
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(7, 63.6%)
Psychiatry and Clinical Psychology) (2, 22.2%)
Employed
Private
Retired
HR/Recruiter
(4, 36.4%)
employees
faculty from
s
(3,
Department
(5, 55.6%)
33.33%)
of Psychiatric Social Work (1, 11.1%)
Retired
Psychologist
Supervisors
Om sri sai ram
--
(3,
s
(1, 11.1%)
33.33%)
(2, 22.2%)
--
Government
--
employee (1, 11.1%) --
--
Special
--
Educators (3, 33.33%) Diagnosis
Bipolar
1 (9.1%)
NA
NA
NA
1 (9.1%)
NA
NA
NA
Schizophrenia
6 (54.5%)
NA
NA
NA
Schizophrenia
3 (27.3)
NA
NA
NA
NA
NA
7 (77.8%)
NA
2 (22.2%)
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Affective Disorder Schizoaffectiv
Yes
NA
experienc
No
NA
e of employin
with
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SMD
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g a person
NA
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Prior
re
with OCD
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e disorder
Om sri sai ram Table 3- Table showing socio-demographic data of experts who validated the tool and the module and professionals involved in pilot testing. VARIABLE
Age in years
VALIDATORS (N=
PILOT TESTERS
6)
(N=3)
Male
6 (100.0%)
1 (33.33%)
Female
0
2 (66.67%)
Mean
43.0
30.33
Standard
±2.36
±2.33
deviation Education in years
Mean
19 years
Standard
±1.41
2 (33.3%)
Practitioner
(Department of
1 (16.7%)
2 (66.67%)
2 (33.3%)
Research Staff
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Additional
Psychiatry)
re
(Psychiatrist) NGO employee
Resident Doctor
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Private
18 years --
deviation Occupation
ro of
Gender
NUMBER
(Department of
(Department of
Psychiatric Social
Psychiatry and
Work)
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Professors
Psychiatric
Social Work) Professor
(Department of
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Clinical
Psychology)
1 (16.7%)
1 (33.33%)
PII:
S1876-2018(19)30902-5
DOI:
https://doi.org/10.1016/j.ajp.2019.101866
Reference:
AJP 101866
To appear in:
Asian Journal of Psychiatry
Received Date:
13 September 2019
Revised Date:
2 November 2019
Accepted Date:
3 November 2019
Please cite this article as: Harish N, Jagannathan A, Kumar CN, Thirthalli J, Chaturvedi SK, Kumar D, Bhola P, Prasad Muliyala K, Thanpal S, Radhakrishnan G, Angothu H, Jayarajan D, Development of vocational potential assessment tool and counseling module for persons with severe mental disorders, Asian Journal of Psychiatry (2019), doi: https://doi.org/10.1016/j.ajp.2019.101866
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Om sri sai ram
DEVELOPMENT OF VOCATIONAL POTENTIAL ASSESSMENT TOOL AND COUNSELING MODULE FOR PERSONS WITH SEVERE MENTAL DISORDERS Nikitha Harish1, Aarti Jagannathan2, Chennaveeraachari Naveen Kumar1, Jagadisha Thirthalli1, Santosh Kumar Chaturvedi1, Devvarta Kumar3, Poornima Bhola3, Krishna Prasad Muliyala1, Sivakumar Thanpal1, Radhakrishnan G4, Hareesh Angothu1, Deepak Jayarajan1.
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1- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru.
2- Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru.
Neurosciences (NIMHANS), Bengaluru.
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3- Department of Clinical Psychology, National Institute of Mental Health and
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4- Department of Nursing, National Institute of Mental Health and Neurosciences
Highlights:
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(NIMHANS), Bengaluru.
Development of a detailed vocational potential assessment tool and a semi-
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structured counseling module to facilitate individual employment goals of persons with SMD.
Comprehensive assessment tool yields specific targets/goals to counselling, that can be tailor made to suit individual needs and includes all the stakeholders involved in the vocational process; the person with SMD, the
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caregivers and the employer
ABSTRACT: Objective: To develop and validate the vocational potential assessment tool and counselling module for persons with severe mental disorders (SMD). Method: The tool and the module were developed through review of existing assessment tools, individual interviews and focused group discussions with key stake
Om sri sai ram holders- persons with SMD, caregivers, expert mental health professionals and employers. The developed tool and module were validated by experts. Result: The process of tool and module development was conducted simultaneously and included 11 persons with SMD, 9 caregivers, 9 experts and 9 employers. A total of 38 themes were obtained through individual interviews and focused group discussions. The developed tool and module along with a scoring key were validated by 6 mental health experts. Conclusion: The tool is easy to use and comprehensive, takes approximately 45 minutes to 1 hour for assessment. The module provides a framework for vocational
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counselling. The scoring key provides a guideline for professionals during assessment.
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Key words: Vocational Potential; Severe Mental Disorder; Assessment.
INTRODUCTION:
Employment status among persons with severe mental disorders (SMD) is a crucial
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aspect in the recovery and rehabilitation process (Ramasubramanian et al, 2016). Clinicians often perceive employability of a person with SMD to their symptom
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control and reintegration back into the community. Work is seen to improve selfsatisfaction and self-esteem, being a source of income, facilitating socialization and
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improving social value (Durgoji et al, 2019).
Employment often ensures financial independence, boosts self-esteem, social acceptance, integration, and a sense of well-being, thereby improving mental wellbeing as well as having a therapeutic benefit characterised by clinical improvement, betterment in social functioning and reduction of symptoms (Ramasubramanian
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2008, Salzer et al, 2011, Jaleel et al, 2015).
Vocational rehabilitation services help persons with disabilities (including those with SMD) prepare for, find and sustain employment. This helps them integrate back into society by being gainfully employed and contributing to their family and community. A gainful employment is a status, where the person with SMD works full time or part time and is remunerated from the employer on par with the current market standards
Om sri sai ram for the job profile; this does not include mere engagement at a day-care or vocational training service on a stipendiary basis.
However a number of persons with SMD, due to various factors are unable to prepare for, find or keep a job. Thomas et al, 2019 in their study to understand the challenges faced by persons with severe mental illness with professional degrees in obtaining and maintaining employment identified factors to be either facilitators for work or hindering. Facilitators for obtaining and maintaining employment included personal strengths, social support, accommodative work environment, disclosure, support from
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mental health professionals and services. Factors that were identified as hindering for obtaining and maintaining employment included symptoms of the illness, side effects of medications, stigma, poor social support, academic under- achievement, disjointed work history, poor workplace environment and specific cultural, gender issues.
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(Thomas et al, 2019).
Though persons with disabilities constitute a significant percentage of Indian
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population, their needs for meaningful employment largely remain unmet despite legislative measures (Shenoy 2011). These factors include those directly linked to the
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illness as well as psychosocial. Barriers for employment include those linked to illness (like treatment resistant symptoms, certain specific symptom dimensions including negative and cognitive symptoms, adverse effects of medications) and
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psychosocial factors (including inability to find a job that suits their profile and interest, uncompromising attitude of the employers, inability to continue working due to various factors at workplace and stigma).
With persons having such specific rehabilitation needs alongside other psychosocial
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needs, a vocational rehabilitation service would facilitate gainful employment of eligible recovered persons with SMD. This can be achieved primiarily through assessment of their vocational potential, by providing vocational counselling and guidance and there by securing suitable employment options and providing continued support through their vocational tenure. There is dearth of objective assessment tools and structured counseling programs to assist persons with SMD achieve their employment goals. To facilitate achievement of such goals a detailed vocational potential assessment tool to assess their vocational functional capacities and a
Om sri sai ram predesigned vocational counseling module that directs towards individual goals would fulfill such a gap. The present study aimed at developing a detailed vocational potential assessment tool and a semi-structured counseling module to facilitate individual employment goals of persons with SMD.
METHODOLOGY: The study was reviewed and approved by the Institute’s Ethics Committee. Written informed consent of the key stakeholders- persons with SMD, caregivers of persons with SMD, expert mental health professionals and employers, involved in the study
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were taken.
The development and validation of the vocational potential assessment tool and the counselling module were done simultaneously. The process of development and
validation of the Vocational Potential Assessment Tool (Phase 1) and the Vocational
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Counselling Module (Phase II) is elucidated under the below headings
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Phase I (a) and II (a) Development of the Vocational Potential Assessment Tool and Counselling Module:
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Review of available assessment tools- A detailed list of organizations working in the field of vocational rehabilitation of persons with mental disability (disability due to mental illness, developmental disabilities) was prepared. The organizations with
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scales for pre-placement assessment or job skills assessment were enlisted. Organizations registered as per World Association of Psycho-social Rehabilitation, India or Rehabilitation Council of India or Mental Health Act 1987 were enlisted to be 15, that were focusing on vocational rehabilitation of persons with mental disabilities, inclusive of mental illness, intellectual and developmental disabilities.
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Based on this review and experience of team members of the Psychiatric Rehabilitation Services, the Vocational Potential Assessment tool was drafted. The drafted assessment tool was modified further based on the suggestions given by various stakeholders in Focus Group Discussions and Individual interviews. The stakeholders considered were (Table 2) Persons with SMD availing treatment at NIMHANS meeting the criteria as per ICD-10 for F.20.0-29; Schizophrenia, schizotypal and delusional disorders,
Om sri sai ram F.31.0-31.9; Bipolar Affective Disorder, for the purpose of this study, F.33.0– 33.9; Recurrent Depressive Disorder and F.42; Obsessive Compulsive Disorder were also considered for recruitment. Those who were symptomatically stable as assessed by the clinician, being able to understand the aims of the study and consenting to participate. Primary care-givers- a person providing care to as person with SMD for at least 6 months- Parents, siblings, spouses, spouses of siblings. Experts- Mental Health Professionals and staff from NGO’s working in the area of vocational rehabilitation of persons with SMD (psychiatrists, psychiatric social workers, clinical psychologists, special educators).
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Employers- Human Resource personnel, recruiters, Managing directors, CEO’s (who had both previous experience of employing a person with SMD and also
those who did not have any prior experience of employing a person with SMD,
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but had employed other persons with disability).
Focused group discussions and individual interviews were conducted with the
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stakeholder groups:
An interviewer’s guide to facilitate individual interviews and FGD’s was formulated
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and used (available from authors on request). A written informed consent was obtained from the participants to take part in the interview/FGD process. Interviews were conducted through face-to-face interactions, or through telephonic/Skype
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conversations. The time taken per interview was between 30 minutes to 45 minutes. The interviews were conducted in English, Kannada or Hindi by a single researcher (NH). The process was audio recorded and transcribed with each response being coded into themes and subsequently sub-themes. In case the interviewees did not consent for audio recording but agreed for
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responding, the interview process was immediately transcribed in verbatim. Circular questioning technique was used to generate maximum elaborate responses from the participants. FGD’s and individual interviews were conducted till no new theme codes were emerging out of consecutive interviews and qualitative data saturation was reached (Gary, 1998).
The qualitative data thus collected was put through content analysis and the results were used to draft the Vocational Potential Assessment Tool using a deductive
Om sri sai ram approach (Burney, 2008). The counseling module was developed on the basis of specific areas identified by the participants as barriers/concerns in achieving their vocational potential, largely obtained from the assessment tool; areas such as assessment of strengths, weaknesses, opportunities, threats to vocational rehabilitation, areas of training and skill building, interview skills, etc. The counseling module was designed to be semi-structured, with fixed concepts but having flexible technique/ delivery to suit the needs of individual participants. It becomes essential to note that broad themes of Vocational Counselling may be generated that would address the key areas affecting vocational rehabilitation of the particular target group
be applied as per the needs of the individual participants.
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and not any specific themes unique to only one individual. These general themes can
The module incorporates specific target areas such as personal hygiene, social skills, handling medication side effects, travel skills, money management skills, perceived
cognitive deficits, adherence to treatment and need for social support as these factors
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play a crucial role in the placement and retention of employment.
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Phase I (b) and II (b): Validation of the Vocational Potential Assessment Tool and Counselling Module:
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Vocational Potential Assessment Tool (VPA):
Once drafted, the assessment tool was validated for Face and Content Validation
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among Mental Health Professions/ NGO staff working in the area of vocational rehabilitation (Table 3). The sampling of the professionals for validation was done using snowball sampling and data was collected using the iterative process. The validation process format included indicating a response of Appropriate (A) or Not Appropriate (NA) against each theme along with its sub-themes. The following
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were captured in the validation process: Possible response biases, which were, indicated to be- No bias, always agree, socially desirable response, carelessness, tendency to be uncertain, speedy response and not answering when in doubt. Cultural suitability of the items. 4 point Likert scale for recording the data.
Vocational Counseling Module:
Om sri sai ram The validation process format included indicating a response of Appropriate (A) or Not Appropriate (NA) against each theme along with its sub-themes and approaches/techniques of counselling to be applied. The responses also included at recording the cultural suitability of the items enlisted. Pilot testing: To assess whether the Vocational Potential Assessment Tool and the Vocational Counseling Module that was developed in earlier phases was easy to administer on the target population, it was tested for its feasibility by 3 professional staff (Table 3). It involved assessing if persons with SMD were able to understand the content of the
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VPA tool and Vocational counseling module, if it’s simple to understand, do they find it useful for the goal of vocational placement, is it easy to administer in an Out-Patient Setting, logistics and time in administering, ability of the person/researcher who is
administering the tool and Vocational Counselling Module etc. Subsequent changes were made in the Vocational Potential Assessment Tool and the Vocational
RESULTS: Themes and sub-themes generation:
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Counselling Module.
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After transcription of data collected in phase I (a) and II (a), themes and sub-themes were generated using the process of data saturation. The interviews were stopped if the theme codes did not emerge for consecutive interviews among the stakeholder
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groups. A total of 38 themes were generated after review of assessment tools, interviews and FGDs (Table 1). A draft tool and module were outlined to include main domains with sub-domains that incorporated all the themes and sub-themes elicited through Phase I (a) and II (a).
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Validation Process:
The drafted tool and module were given to 6 expert validators for assessing face and content validity. In the paragraphs below we elucidate the responses obtained during the validation process of the tool and the module by the experts.
Vocational potential assessment tool
Om sri sai ram All the 6 (100.0%) validators agreed that the items on the tool (both qualitative and quantitative aspects) were culturally relevant. All the validators agreed that there were expectations of no biases in responses expected out of the theme daily functioning under sub-themes- personal hygiene, grooming, eating, moving around, travelling and driving/riding vehicles. 1 (16.67%) validator reported that the tendency to be uncertain and not answering when in doubt could be expected in sub themes of basic money management, bank transactions and day-to-day decision-making. All the validators agreed that the items could be assessed on a 4-point likert scale.
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Under the theme of job related social skills training, while most validators agreed with the items as not being expected to have biased responses, 2 (33.33%)
validators foresaw biases in responses, precisely in the subthemes of initiating
conversations, keeping up with conversations, differentiating formal and informal social situations, interaction with superiors and colleagues and being a team
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player. 1 (16.67%) validator also reported of re-considering a 4-point likert scale for the particular theme.
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Under the theme of job related cognitive skills all the validators agreed upon the 4-point likert scale for assessment. One (16.67%) validator reported of the
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possibility of response bias in terms of giving socially desirable responses to the sub-theme of memory related difficulties. One validator (16.67%) was of the opinion that possible response bias of always agreeing with the assessor could
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occur with all the sub-themes.
Most of the validators (5, 83.33%) agreed up on all the sub-themes being assessed on a 4-point likert scale, whereas one (16.67%) validator responded that a 4-point likert scale might not be able to capture all the deficits in the theme. One validator reported that there could be a possible response bias in terms of always agreeing
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with the assessor, while all other validators did not expect any bias.
For the theme of job readiness, all the validators agreed upon 4-point likert scale of assessment for the sub themes. Only one (16.67%) validator reported that the sub-theme of insight might not be adequately assessed on the tool with a 4-point likert scale. All the 6 (100.0%) validators agreed that there might not be any possible response bias on sub-themes except for one sub-theme, willingness/motivation to work, where one validator responded the possibility of providing socially desirable responses on this item.
Om sri sai ram For the items of the theme job related details, all the validators opined that the 4point likert scale of assessment was adequate. 5 (83.33%), of the validators opined that the items of the sub themes may not have possible bias, however 1 (16.67%) validator reported of possibility of response bias in terms of place of work, duration of employment and gap in employment that could elicit socially desirable responses from the respondents. The validator also reported the possibility of response bias in sub-themes- nature of work (socially desirable responses, speedy responses), and reason to leave job (socially desirable response, carelessness, speedy responses).
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For the theme of family and client perspective, the validators responded that the items would adequately assess the level of potential on a 4-point likert scale. 5
(83.33%) validators reported that there could be no bias on responses for the sub-
theme of family efforts, while 1 (16.67%) validator was of the opinion that the sub
any response bias for any other sub-theme.
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theme could elicit socially desirable responses. All the 6 validators did not foresee For the theme of type of job, none of the 6 (100.0%) validators foresaw any
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response biases. However 3 (50%) of the validators reported that a 4-pont likert
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assessment may not be able to capture the sub-themes adequately.
Vocational counselling module
5 (83.33%) validators responded that the themes and sub-themes for the
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counseling module were relevant (appropriate) while 1 (16.77%) opined that they may not be appropriate as themes but can be renamed as targets to be covered in the counseling process.
5 (83.33%) validators responded that the approaches or skills enlisted in the module were culturally appropriate, however 1 (16.77%) validator felt they would
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have to be reframed for cultural appropriateness.
Development of tool, module and scoring guide: Based on the feedback provided by experts during validation, the final tool and the module were developed along with a scoring guide explaining the scoring of the quantitative items and explanation of the anchor points specific to each domain of assessment was developed. The possible exploratory questions to elucidate qualitative responses were also included to help assessors. During the pilot testing, the testers
Om sri sai ram remarked the tool to be easy to use, to be detailed and requiring simplification or rewording of questions to help all assessors (The tool and the module have been attached in the appendix as supplementary data).
DISCUSSION: The present study aimed at developing a detailed vocational potential assessment tool and a semi-structured counseling module to facilitate individual employment goals of persons with SMD. The primary goals of vocational assessment among people with mental health needs are development of skills and obtaining the supports needed for
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independent, interdependent, productive living, improved participation in every day life and better quality of living (Sethuraman L et al, 2016). The study looked at a
detailed process of developing not only a tool for assessment but also develop a semistructured counselling module to address areas of concerns identified by the scale
with the ultimate goal to faciltiate viable employment options for persons with SMD.
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Validated tools specifically assessing work functioning, needs and vocational goals of inidivuals with SMD are rather limited if not nil (Nieuwenhuijsen K et al, 2010,
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Sethuraman L et al, 2016).
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The available pool of data suggested the need to develop an assessment tool based on a rational scientific approach to achieve goals in vocational rehabilitation among persons with SMD who often pose different challenges due to their mental
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disabilities. The ultimate goal of any assessment is to provide tangible targets to be addressed through therapeutic interventions to facilitate recovery and well-being. Thus, a semi-structured counselling module developed alongside an assessment tool was conceived as a complete program to focus primarily on achieving optimum
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employability among persons with SMD’s.
With no specific employment models or programs available in India for persons with SMD, with a prevalence rate of mental illness being 14.9 people per 1000 general population (Lakhan R et al, 2015) the tool and the module were unique in providing a structured, guided approach to professionals in facilitating employability. The standardized tool developed by the National Institute of Mentally Handicapped, Secunderabad (currently known as the National Institute for the Empowerment of
Om sri sai ram persons with intellectual disabilities) assess vocational skills among persons with intellectual disabilities, that is less likely to fully assess the skills among persons with SMD. Sethuraman L et al, have developed a self report based 45 item tool to assess work related problems among persons with substance use disorders, which may not be able to address all the areas of assessment needed among persons with SMD’s (Sethuraman L et al, 2016). Thus, the tool developed in the present study covers areas of assessment specific to persons with SMD.
The tool is detailed and requires approximately 45 minutes to 60 minutes to be
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administered. The likert method of scoring makes it an easy tool for assessment that can be done by any mental health professional trained in the area of severe mental disorders. The comprehensive assessment tool yields specific targets/goals to
counselling, that can be tailor made to suit individual needs and includes all the
stakeholders involved in the vocational process, the person with SMD, the caregivers
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and the employer. The major strength of the tool and the module lie in the rational
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scientific method of their development through an iterative process.
However it is important to note that though the domains of assessment are
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comprehensive, the tool may not be easily applicable to persons with common mental disorders as they may not have similar vocational needs, or persons with intellectual development disorders or other neurological disorders. The domains of the tool also
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may not be completely capable of assessing vocational skills needed for selfemployment or agriculture-based job options. Further External" barriers such as age of onset of SMD which has a bearing on level of disability, socio-occupation functioning and self-stigma (Grover S et al, 2019); family, academic and social barriers faced during academic reintegration (Annapally SA et al 2019) and
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anticholinergic burden which affects cognitive and daily living functioning in patients with schizophrenia (Kim-S-Jin et al, 2019), may act as confounders to outcomes derived from the vocational potential assessment tool as these could potentially impact the performance of the client in any assessment.
The tool and the module indeed have clinical relevance as the assessment tool guides clinicians and practitioners towards goal achievement in therapy and also provide an objective understanding of the skills to the clients and their families. The module
Om sri sai ram provides a framework for collaborative therapeutic approach to achieve end results. It is imperative to note that the tool and module developed in the present study may in future be used for identification of jobs for persons with mental health disabilities at the government and private sectors and thereby advocating the need for inclusive communities. Further research is required to test out the effectiveness of the tool and the module in larger clinical environments.
CONCLUSION: The Vocational Potential Assessment Tool and the Counselling Module is developed
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and validated through a scientific iterative process. The feasibility of the tool and counselling module needs to be tested in larger research studies across various clinical settings.
1.
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ETHICAL CONSIDERATIONS:
An informed written consent was obtained from the study Participants
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(Person’s with SMD, their Care-givers, Mental Health Professionals, NGO’s working in the area of rehabilitation) to participate in the study after explaining the objectives
2.
Participants were assured of the confidentiality of their identity and the shared
information.
The participants involved in the study could withdraw consent at any point of
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3.
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of the study in a manner understandable to them.
time during the course of the study. 4. 5.
The participants were entitled to know the results of the study if asked for. The participants of the study were not denied any form treatment at
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NIMHANS if they refused to further participate.
ACKNOWLEDGEMENT: The authors also thank The Ministry of Social Justice and Empowerment, Government of India for funding the research and all the participants and experts involved in the process of research.
CONFLICT OF INTEREST: NONE
Om sri sai ram
FINANCIAL DISCLOSURE: Financial support by The Ministry of Social Justice and Empowerment, Government
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ro of
of India.
Om sri sai ram
REFERENCES:
Annapally SA, Jagannathan A, Kishore T, Thirthalli J, Daliboina M, Chennaveerachari NK, Barriers to academic reintegration in students with severe mental disorders: Thematic analysis, Asian Journal of Psychiatry 45 (2019) 107– 112. https://doi.org/10.1016/j.ajp.2019.09.010
Burney SMA, Inductive & Deductive Research Approach. http://www.drburney.net. Retrieved April 15, 2012, Available at URL: http://www.drburney.net/INDUCTIVE%20&%20DEDUCTIVE%20RESE ARCH%20APPROACH%2006032008.pdf Durgoji S, Muliyala KP, Jayarajan D, Chaturvedi SK. Quality of life in
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Schizophrenia: What is important for persons with Schizophrenia in India?. Indian J Psychol Med 2019.
European Agency on Safety and Health at Work. Expert Forecast on Emerging
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Psychosocial Risks Related to Occupational Safety and Health. Brussels, Belgium: European Agency on Safety and Health at Work; 2007. Grady MP. Qualitative and Action Research: A Practitioner
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Handbook. Bloomington: Phi Delta Kappa Educational Foundation; 1998, p. 26.
Grover S, Sahoo S, Nehra R, A comparative study of childhood/adolescent and
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adult onset schizophrenia: does the neurocognitive and psychosocial outcome differ?. Asian Journal of Psychiatry 43 (2019) 160–169.
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https://doi.org/10.1016/j.ajp.2019.05.031
Jagannathan A, Harish N, Venkatalakshmi C, Naveen Kumar C, Jagadisha T, Chaturvedi SK., Devvarta K, Bhola P, Krishna Prasad M, Sivakumar T,
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Radhakrishnan G,Angothu H, Jayarajan D. Vocational Potential Assessment tool and Counselling module – For Persons with Severe Mental Disorder. National Institute of Mental Health and Neurosciences (NIMHANS), Publication No: 162, 2019.
Jaleel, F., Nirmala, B.P. & Thirthalli, J. Journal of Psychosocial Rehabilitation and Mental Health (2015) 2: 19. https://doi.org/10.1007/s40737-014-0020-3
Om sri sai ram
Kim S-Jin, Jung D, The effect of anticholinergic burden on cognitive and daily living functions in patients with schizophrenia, Asian Journal of Psychiatry (2019), doi: https://doi.org/10.1016/j.ajp.2019.10.013
Lakhan R, Ekúndayò OT. National sample survey organization survey report: An estimation of prevalence of mental illness and its association with age in India. Journal of Neuroscience in Rural Practice. 2015 Jan; 6(1):51-4.
Nieuwenhuijsen, K., Franche, R.-L., & van Dijk, F. J. H. 2010. Work Functioning Measurement: Tools for Occupational Mental Health Research. Journal of Occupational and Environmental Medicine, 52(8), 778–
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790.doi:10.1097/jom.0b013e3181ec7cd3. Ramasubramaniam C. Special employment exchange for persons with psychiatric disability. Indian Journal of Psychological Medicine. 2008;30:75–9.
Ramasubramanian C, Mohandoss AA, Namasivayam RK. Employability of
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mentally ill persons in India: A self-report-based population study. Industrial Psychiatry Journal 2016 Jul-Dec; 25(2): 171–178.
Salzer MS, Baron RC, Brusilovskiy E, Lawer LJ, Mandell DS. Access and
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outcomes for persons with psychotic and affective disorders receiving vocational rehabilitation services. Psychiatric Services. 2011;62(7):796–9.
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http://www.ncbi.nlmnih.gov/pubmed/ 21724795
Sethuraman L, Subodh B N, Murthy P. Validation of vocational assessment tool for persons with substance use disorders, Industrial Psychiatry Journal. 2016 Jan-
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Jun; 25(1): 59–64.
Shenoy M. Persons with disability and the India labour market: challenges and opportunities. Geneva: International Labour Organization; 2011. p. 46.
Thomas TL, Muliyala KP, Jayarajan D, Angothu H, Thirthalli J, Vocational
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challenges in severe mental illness: A qualitative study in persons with professional degrees, Asian Journal of Psychiatry 42 (2019) 48–54.
Om sri sai ram
TABLES
Table 1: Table showing the themes, sub-themes and verbatim of respondents. No. THEME
SUB-THEME
VERBATIM
1
Family
Type of job
“Sometimes, the person may like carpentry, but
Expectations
Knowledge of
the parents may not like it, then we need to
client skills
counsel the parents, explain them the need for interest of the person and need for acceptance”-
2
Type of job
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Expert, 50 year old female.
Preferred job
“..in an organization like us, we are a software
Type of job
developing company, opportunities are in day to day cleaning, that is housekeeping kind of a
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thing. That sort of a work then someone with poor skills also can do”- Employer, 42 year old
Hygiene
living
Grooming
Habits
Mobility
Money
Independent
Social skills
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5
brush properly”- Caregiver, 22 year old female.
“Important madam, I can but others I have seen
management
need help, they should be able t travel to work,
Travelling
then manage some money if not all, give salary
activities of daily living
“..he will not shave, wears old clothes, does not
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4
Activities of daily
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3
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male.
to home, spend it properly, that is important no”- Person with SMD, 46 year old male.
Verbal and non-
“I think lack of assertiveness is one big lacuna
verbal skills
that they have. So whether it is to do with their
Initiating and
needs at the work place or their promotions, I
keeping up with
think they are not able to ask for what they need
conversations
for themselves. And they might also get pushed
Differentiating
around because they are not able to assert
situations
themselves” Expert, 65 year old female.
Om sri sai ram
7
8
Work Behaviour
Insight
Employer
Interaction skills
Assertive skills
Team skills
Punctuality
“It has taken him so many years to come
Regularity
regularly even here. They can’t work
Taking leaves
punctually”- Caregiver, 64 year old male.
Illness
“May be the fact that he does not even accept he
Skills
has an illness”-Caregiver, 22 year old female.
Organizational
“..is this person useful for the organization, see
goals.
every person I recruit irrespective of mental
Perspective
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6
issue, it is important that the company gets something out of this person, something useful.
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So that is important for me”- Employer, 27 year old male.
Reasonable
accommodation
“..I think the employer or company should be
infrastructure
proactive about employing them. Also giving
Behavioural/
them time to learn, as they may be slow to do
attitudinal work
task or also to mingle”- Employer, 33 year old
place
male.
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Accessible
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9
modifications.
Self stigma
“Again it depends on the employer but still,
Stigma by
other colleagues may stigmatize this person and
employer/collea
isolate him”- Expert, 56 year old female.
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10
Stigma
gues
Job related skills
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11
Motivation
“..first thing about any recruitment is will this
Flexibility
person X fit into the job role Y, do they have the
Reliability
skills, would they contribute to the team, will the
Productivity
company benefit from it, it’s a simple formula..” Employer, 27 year old male.
12
Client expectations
Realistic
“Then again there are concerns they don’t want
orientation of
low level jobs, they want jobs that suit their
job market
socio economic status not their skills, they may
Om sri sai ram
Cognitive skills
eventually fail that job also”- Expert, 66 year
of skills
old female.
Memory
“….the ability to follow an instructions when
Task completion given, including being able to recall the
Attention
instructions, problems solve the steps if the
Planning
instructions and they may require help to do
Decision
these. For some of them it could be about using
making
cognitive aids, to be aware of the problems that
Problem solving
they have is another area and to be aware of
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13
Understanding
how they can compensate for those”- Expert, 34 year old male. Symptoms
Current clinical
“My main concern will be, is this person
condition
violent, can he actually do this job role, have
Effect of
they worked before, how was their performance
symptoms on
then”- Employer, 27 year old male.
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job retention/
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14
securement. Coping
Recognizing
“…it helps to have cool and composed
stressors
approach to your job, everything doesn’t go as
Managing
planned, so you need to be able to be in control
stressors
of the situation without getting too hassled. So
Managing
you might have a customer coming and
conflicts with
screaming at eh wrong order placed, so you
colleagues
need to be calm, not retaliating, apologize. So
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15
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16
everything is not a part of our training, its also a part of you as a person- Employer, 38 year old female.
Psychosocial
Primary support
“then the family support, the support of the co-
support
Secondary
workers, the employer” Expert, 75 year old
support
male.
Om sri sai ram 17
Interest and
Hobbies
Interests that can “Doctor I also like to sing and learn to play be gainful
guitar. I have bought it and kept. I will join for classes”- Person with SMD, 22 year old male.
19
Interview skills
Disclosure
Meaningful
“…has a large gap in their CV, may have
responses in an
difficulty in explaining why there is a gap in
interview
their CV”- Expert, 34 year old male.
Role play
Selective
“Because, I think many of them feel that they
disclosure
are not doing well and since the client wouldn’t
Disclosure
have opened and said that I have a mental
before/ after
illness they are unable to understand why they
recruitment
are functioning ok on some days and not ok,
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18
why is there so much of inconsistency”- Expert,
22
Location
Distance
Timings
“Suppose only half a dozen jobs are available where we have to fit into the job which would
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Job readiness
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21
Job matching
require more efforts rather than the client’s suitability to the XYZ job; in this context the outcome may not be as it is expected”- Expert, 75 year old male.
Motivation
“Also their own self confidence to work may be
Willingness
a problem, they feel they cannot do any work..”
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20
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65 year old female.
“..in Mr.V he says he wants to work but does not attempt anything or even if we get a job he will not stick to it...”- Caregiver, 32 year old male.
Periodic
Follow-up
“..Periodically, for example in the incentive
Assessment
Re-assessment
scheme, every month we assess the progress on the Griffith Scale. Primarily to give incentive in the process of motivating, preserving”- Expert, 75 year old male.
Om sri sai ram 23
Attempt made by
client and family
Seeking
“In the family it self it may be essential to see
employment by
where family could be a barrier to vocational
client/ family.
aspirations; if the family thinks that the person is ready to work, what kind of support is the family willing to give, can they find jobs, come for sessions. It is important to look in the tool the support the family would provide; finding jobs, going with them, ready to support, reservations about this person working and how those person’s would change their behaviour,
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reasonable accommodation they family gives..”Expert. 34 year old male. Type of incentive
Remuneration
“so at he end of the day its all business and
Job
providing remuneration is a big part. So there is
development
a hierarchy for salary also. So if they can do it
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24
well, may be after 3-4 months, so initially we
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might not give the same remuneration for a
25
Educational
26
Vocational
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Side Effects
old male. “They may not be well educated, they may not
academic
have skills required at all”-Caregiver, 52 year
qualification
old female.
Prior experience
“He is an engineer, qualified but has never held
experience
27
also can see what they do”- Employer, 34 year
Highest
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Qualification
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person with disability and others, because we
one single job, he will never adjust, always says some silly reason and leave the job”- Caregiver, 22 year old female.
Tremors
“We take medicines, we feel sleepy, then there
Drowsiness
are shaking of hands and then once I do some
Dullness
mistake because of all this I will become tensed and do more mistake or become slow”- Person with SMD, 29 year old male.
Om sri sai ram 28
Difficulty of task
Complexity of
“..he is weak. He cannot do a lot of things that
task
involve physical strength”- Caregiver, 64 year old male.
29
Compliance
Regularity of
“ Oh yes, that is important also taking
follow-up
medicines so that mental health is ok to do the
Adherence
job is important”- Person with SMD, 46 year old male.
Employer
expectations
Employer
“..as an employer I think it will be unfair to
understanding
expect me to teach them that. If he already has
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30
got a skill then because of his own issues, we need to nurture him then its ok”- Employer, 42 year old male. 31
Job allocation
Role allocation
“..what kind of employment you give to them. A
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person cannot read or write then house-keeping job would be okay, say it is office administration
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then someone has to read and write in a
32
Employer
something, we cannot teach them”- Employer, 42 year old male.
Knowledge of
“May be explain to the employer what are the
illness
types of mental illnesses, what this person has,
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Psychoeducation
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register, those things people should have learnt
very clearly, what to expect what not to expect , so if they understand then they can be able to help. So if its only for the employer confidentially or with an open company the whole team, it depends. Like everybody knows what blindness is but not what schizophrenia or bipolar or depression is”- Employer, 34 year old male.
33
Job vacancy
Availability of
“..like there may not be vacancies when they
jobs
ask”- Employer, 42 year old male.
Om sri sai ram 34
Age
Age criteria
“..they may be older than others, not very young”- Employer, 42 year old male.
35
Qualities of an
employee
Personal
“I give examples to my own other friends or
qualities
business network, see I have seen that these guys have better productivity, they don’t gossip, they don’t get into unhealthy discussions, they don’t tell lies, they don’t try to hide things, they are very candid, which I think is very essential. This person is very transparent”- Employer, 42
36
Vocational
training received
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year old male. Duration of
“…the ability to follow an instructions when
training
given, including being able to recall the
Certification
instructions, problems solve the steps if the instructions and they may require help to do
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these. For some of them it could be about using cognitive aids, to be aware of the problems that
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they have is another area and to be aware of
Other disability
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38
IDEAS
year old male.
Standardized
The standardized assessment tool was used by
assessment
an organization as found in the review of
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37
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how they can compensate for those”- Expert, 34
literature.
Disability
“One is that people may not know about the
certification
schemes that are available to people who suffer from a disability”- Expert, 34 ear old male.
Om sri sai ram Table- 2- Table showing socio-demographic variables of stakeholders included in the Phase I (a) and II (a); Tool and module development: VARIABLE
CATEGORY Persons
Caregiver
Experts
Employers
with
s of
(N=9)
(N=9)
SMD’s
persons
(N=11)
with
7 (77.8%)
SMD’s (N=9) Male
7 (63.6%)
4 (44.4%)
3 (33.3%)
Female
4 (36.4%)
5 (55.6%)
6 (66.7%)
2 (22.2%)
Age in
Mean
36.18
49.67
54.56
34.22
years
Standard
±9.09
±15.98
±12.59
±7.06
Education Mean
14.25
14.25
17.66
16.5
in years
±4.34
±4.34
±2.51
±2.12
ro of
Gender
deviation
Unemploye
Home-
Teaching
Managing
d
makers
faculty
Director
(3,
(Department
(3, 33.3%)
33.33%)
of
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Occupation
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Standard
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deviation
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(7, 63.6%)
Psychiatry and Clinical Psychology) (2, 22.2%)
Employed
Private
Retired
HR/Recruiter
(4, 36.4%)
employees
faculty from
s
(3,
Department
(5, 55.6%)
33.33%)
of Psychiatric Social Work (1, 11.1%)
Retired
Psychologist
Supervisors
Om sri sai ram
--
(3,
s
(1, 11.1%)
33.33%)
(2, 22.2%)
--
Government
--
employee (1, 11.1%) --
--
Special
--
Educators (3, 33.33%) Diagnosis
Bipolar
1 (9.1%)
NA
NA
NA
1 (9.1%)
NA
NA
NA
Schizophrenia
6 (54.5%)
NA
NA
NA
Schizophrenia
3 (27.3)
NA
NA
NA
NA
NA
7 (77.8%)
NA
2 (22.2%)
ro of
Affective Disorder Schizoaffectiv
Yes
NA
experienc
No
NA
e of employin
with
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SMD
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g a person
NA
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Prior
re
with OCD
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e disorder
Om sri sai ram Table 3- Table showing socio-demographic data of experts who validated the tool and the module and professionals involved in pilot testing. VARIABLE
Age in years
VALIDATORS (N=
PILOT TESTERS
6)
(N=3)
Male
6 (100.0%)
1 (33.33%)
Female
0
2 (66.67%)
Mean
43.0
30.33
Standard
±2.36
±2.33
deviation Education in years
Mean
19 years
Standard
±1.41
2 (33.3%)
Practitioner
(Department of
1 (16.7%)
2 (66.67%)
2 (33.3%)
Research Staff
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Additional
Psychiatry)
re
(Psychiatrist) NGO employee
Resident Doctor
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Private
18 years --
deviation Occupation
ro of
Gender
NUMBER
(Department of
(Department of
Psychiatric Social
Psychiatry and
Work)
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Professors
Psychiatric
Social Work) Professor
(Department of
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Clinical
Psychology)
1 (16.7%)
1 (33.33%)