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Client-centeredness in supported employment: Specialistand supervisor perspectives
KRISTIN M. KOSTICK1, ROB WHITLEY2, & PHILIP W. BUSH2
1Department of Community Medicine and Health Care, University of Connecticut School of Medicine,
Farmington, CT 06034, USA, and 2Department of Psychiatry, Dartmouth Medical School, Dartmouth
Psychiatric Research Center, Lebanon NH 03766, USA
AbstractAims. This article examines the notion of client-centeredness from the perspective of supportedemployment specialists and supervisors, identifying barriers and facilitators to implementation in thefield. Though by definition client-centered practices give precedence to clients’ wishes, in a realisticsetting client-centeredness is adapted to account for negotiations among clients, specialists, employers,and mental health service agencies.Method. Qualitative interviews (n¼ 22) were conducted with employment specialists and supervisorsto elicit facilitators and barriers to successful supported employment outcomes. Data were analyzedinductively using ATLAS.ti 5.0 software.Results. Principal factors influencing implementation of client-centeredness include (1) clients’anxieties about their interests and abilities, (2) difficulties interpreting and negotiating clients’preferences in realistic contexts, (3) quality of supervision and guidance in implementing client-centered practices and upholding morale when facing challenges in the field, and (4) managingdiscrepancies across resource-sharing agencies in what it means to be ‘‘client-centered’’.Conclusions. These factors suggest the need for (1) focused training among employment specialists tobetter understand and negotiate clients’ wishes, (2) more integration and communication betweenmembers of the treatment team, (3) hiring supervisors with first-hand supported employmentexperience, and (4) spreading awareness of the IPS model across resource-sharing agencies.
Keywords: Rehabilitation, severe mental illness, supported employment, client-centeredness,implementation
Introduction
In 2001, the Institute of Medicine’s (IOM) Committee on Quality of Healthcare in America
reported that the lack of individually tailored supports remains a central barrier to delivering
rehabilitative services for people with severe mental illness. The Committee’s suggestion for
improvement was to provide more effective, timely, equitable, and client-centered
treatment, customizing services to ensure more sustainable, need-based care. Client-
centered practices are defined as those in which the content and pace of service delivery are
governed by clients’ expressed wishes rather than by assumptions of service providers.
Programs are individualized to meet clients’ needs, including preparation for life in the real
world, mutual decision-making and goal planning (Cott, 2004). Client-centered practices
Correspondence: Rob Whitley, Department of Psychiatry, Dartmouth Medical School, Dartmouth Psychiatric Research Center, 2
Whipple Place, Suite 202, Lebanon NH 03766, USA. E-mail: [email protected]
Journal of Mental Health,
December 2010; 19(6): 523–531
ISSN 0963-8237 print/ISSN 1360-0567 online � 2010 Informa UK, Ltd.
DOI: 10.3109/09638237.2010.520364
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shift away from paternalistic or provider-centered approaches that can inhibit rather than
promote rehabilitation by encouraging dependency (Anthony, 1993; Curtis & Hodge,
1995). The individual placement and support (IPS) model of supported employment
incorporates this principle of client-centeredness, and is regarded as one of the most
effective approaches in psychiatric rehabilitation (Becker & Drake, 2003; Bond, 2004). This
model operates on the principle that many individuals in recovery want to work, but need
professional support to attain work goals. The strength of supported employment services
using the IPS model comes from their ability to harness clients’ own social and practical
skills to achieve goals (Drake & Bond, 2008). Such an approach appears to result in
greater satisfaction and longer job tenure (Becker et al., 1996; Mueser et al., 2001). The
rate of employment acquired and sustained for programs operating under this client-
centered model was recently reported to be 61% versus 23% for other models (Bond et al.,
2008).
While this rate attests to the benefits of rehabilitation programs that include client-
centeredness, practical challenges remain for the implementation of the IPS model,
including lack of consumer awareness about services (Mueser et al., 2001; Pandiani et al.,
2004), and negative effects of clients’ psychiatric symptoms and ambivalence about change
(Carey et al., 1999; Kemp et al., 1998). Other challenges include a lack of research on
effective implementation and integration of mental health services, which require
specialists to ‘‘innovate on the fly’’ and adapt services to a changing system and
environment (Gold et al., 2006). The underlying concepts guiding implementation of
services like the IPS model may themselves be interpreted differently across specialists,
supervisors, and agencies, with varying degrees of attention to clients’ wishes in schemes
of rehabilitation. To our knowledge, no studies to date have drawn from employment
specialists’ own experiences and narratives to examine how client-centeredness is
understood and implemented in the field. The present study employs qualitative methods
to elicit the views and experiences of employment specialists and their supervisors
regarding how ‘‘client-centeredness’’ is implemented in a realistic context. The open-
ended nature of the study enabled interviews to be guided not only by the researchers but
also by participants’ own concepts. The aim of this article is to describe approaches to
client-centeredness from the perspective of employment specialists and supervisors,
including facilitators and barriers to effective implementation. This article also addresses
how client-centered practices are adapted through negotiation among clients, specialists,
employers, and mental health service agencies in response to practical issues arising in the
field.
Method
The authors conducted 22 guided semi-structured open-ended interviews with employment
specialists and supervisors during the summer of 2007. Participants were recruited from one
community mental health hospitals and two outpatient centers delivering supported
employment services, located in three counties in Connecticut. Agencies were selected
because of their large supported employment programs following the IPS model. Staff size
ranged from 6 to 14 specialists, including 1–4 supervisors. Seven out of the 22 specialists
interviewed were employed by non-profit organizations, with the remainder employed
through the state. Number of clients served varied by location, with an average of 15–20
clients served per specialist. All three agencies received high fidelity ratings (mean¼ 69.25,
SD¼ 3.3, maximum¼ 75) using the IPS Fidelity Scale (Bond et al., 1997). The authors
collaborated with the State Mental Health Authority (SMHA) to design the research project
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and obtain permission to conduct the study. After review of the study by the Dartmouth
Medical School IRB, and upon obtaining permission from the SMHA, 27 employment
specialists and supervisors were contacted by email/phone to seek their participation for in-
depth interviews about challenges and facilitators to successful supported employment
practices. Of these 27 individuals, 22 (81%) agreed to participate.
Interviews lasting approximately 1 h were recorded and transcribed. The aims of the
study were described to participants, and written informed consent was obtained. As a part
of her training, the first author shadowed the second author for five interviews. The first
author then conducted the rest of the interviews alone. Individual interviews were
conducted in employment specialists’ offices within each agency following a topic guide
designed to elicit personal narratives of employment specialists and supervisors. Participants
were asked about their experiences as specialists/supervisors, using probes such as ‘‘tell me
about any difficulties you have encountered as an employment specialist,’’ and ‘‘what
strategies have you employed to overcome these difficulties?’’
Data were explored using ATLAS.ti 5.0 qualitative data analysis software. This inductive
approach followed guidelines of qualitative content analysis outlined by Strauss and Corbin
(1994), involving the progressive abstraction of patterns from raw data. All three authors
coded data independently and cross-checked to agree on prominent themes. The primary
issues discussed in their narratives serve as the basis for the arguments presented in this
article.
Results
Client-centeredness emerged as a key factor influencing the experience of employment
specialists. Participants helped pinpoint some of the major factors influencing their
attempts to practice client-centeredness in accordance with the IPS model. The
informant sample included 11 (50%) Caucasians, 8 (36%) African-Americans, and 3
(14%) Hispanics/Latinos. Ten (45%) were males, and the mean age was 39.9(+8.9). Of
the 22 participants, 6 (27%) were supervisors. Main themes discussed by participants are
addressed below.
Flexibility in addressing clients’ anxieties about work
Participants noted that clients’ psychiatric symptoms, along with self-doubts and
insecurities, often make them anxious about their abilities to work. This phenomenon was
also noted by Razzano et al. (2005) and Cook (2006). Individuals who worry that their
symptoms will interfere with work activities were reported as having problems engaging with
supported employment services. One specialist stated:
‘‘Sometimes clients just disengage. They set appointments with you and don’t show up,
then they just don’t call back or whatever, and it’s because they’re in the hospital or in jail
or they’re just not ready, not in that frame of mind to be working. So I’ll just say to them
‘whenever you feel like you need to commit, I’m here for you. Whenever you want to
come in.’’’
Specialists feel it is important to communicate their commitment and flexibility, two key
components of the IPS model. Clients are viewed as primary decision-makers regarding
work readiness. However, in cases where clients appear to be at a stage where employment
would be appropriate and beneficial to recovery, specialists and others on the treatment
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team may attempt to embolden clients to overcome fears about work. Another employment
specialist describes:
‘‘Here, you gotta prompt them, you gotta be like ‘Come on, you can do it, you can do it,’
but then after, they’re like ‘okay, I can do it,’ and you can change their mind. And they’ll
try, and then they’ll get sad if they messed up, or if they quit or whatever, but then we try
again, and they wanna keep on going.’’
Allowing clients’ preferences to direct the pace of rehabilitation is often cited as a
definitive feature of client-centeredness. However, many specialists actively try to positively
shape these preferences by encouraging clients to work through reservations about
employment. Specialists described a fragile balance between ‘‘meeting the client where
he/she is at’’ and encouraging clients to transcend self-doubt.
Interpreting and negotiating clients’ preferences
While Becker and Drake (2003) point out that most clients have realistic work
preferences, this is not always the case. They may have preferences for work that surpass
their experience or credentials. In these cases, employment specialists must engage in a
negotiation of clients’ preferences. The ability to identify and negotiate clients’ choices is
an integral skill involved in maintaining client-centeredness in supported employment.
One specialist stated:
‘‘Nobody wants the McDonald’s [job] and I don’t blame them. It can be kind of difficult
sometimes because everyone wants that particular job, the office, and . . . we don’t say
‘you can’t do that,’ so we try and get them as close to that job that they want . . . so if
someone said they want to be a pilot first, I’m not going to say ‘you can’t be a pilot,’ you
know, but I will try and get them as close to the airport or the plane as [I] can.’’
The need to negotiate unrealistic job expectations was raised frequently by specialists.
Others described how some clients insist they will ‘‘do anything’’ for work, and that the
type of work does not matter. While their indiscriminate willingness to work may be a
positive step, it could also potentially land clients in jobs that do not match their
preferences and may result in job failure. Participants reported that clients with this view
may switch jobs more frequently and are more dissatisfied with their work experiences. As
one specialist stated:
‘‘When you say ‘I’ll do anything,’ that means you’re gonna burn through a lot of jobs
before you’re gonna find the right one. And that’s, that’s the most frustrating part of it.’’
Understanding clients’ needs, then, goes beyond merely listening to what they say.
Specialists must be able to envision how clients will respond to particular work
environments and strategize employment-seeking efforts accordingly. As the IPS model
stipulates, the active engagement of employment specialists with other members of the
client’s treatment team may help to interpret clients’ expressed preferences and choose an
effective client-centered strategy. Specialists who are able to communicate commitment and
flexibility, who can encourage and embolden clients to exceed their own expectations, and
who can identify and effectively negotiate clients’ wishes are likely to have greater success in
engaging clients.
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Maintaining motivation to be client-centered: supervision, benchmarks, and evaluation
Certain aspects of supervision, including supervisor training and evaluation of specialists,
can also influence client-centered practice. Specialists report a preference for supervisors
with first-hand experience as a specialist, as suggested by the IPS model. Supervisors who
accompany specialists in the field and/or have their own client caseloads are highly regarded
and considered better able to impart client-centered values to specialists in situ rather than in
the abstract. One specialist said of her supervisor who had no personal experience as a
specialist:
‘‘Somebody’s critiquing you, telling you what to do, you know, what to try, instead of
saying ‘well, what I tried,’ and ‘what I did,’ and ‘I got this. . .’ you know what I mean?. . . It
sets up the dynamic ‘what do you know?’ We’re like ‘don’t tell me, show me.’’’
Supervisors with no prior experience as a specialist may inadequately impart client-
centered strategies that have been tried and tested in the field. Specialists also reported
that specific feedback from supervisors and other members of the treatment team (e.g.
case managers, clinicians, counselors) helps to maintain specialists’ morale in facing
difficulties with clients and to tailor specialists’ efforts to clients’ needs. One specialist
stated:
‘‘If I am struggling with any of my clients, I just bring it up to the table with the treatment
team and they . . . help me. Hey! You work with this person like this, or if you have any
situation, let’s have a meeting with you and me and the client. And it does work. I . . . I
have the support, at least from my mini-team. I have the support from every single one of
them. And it works.’’
Many participants remarked that client-centeredness can be undermined by the pressure
specialists feel to ‘‘meet numbers’’ or other expectations for employment outcomes set by
the agency. The main outcomes to measure and monitor the success of the IPS program are
the percentage of clients competitively employed and their average number of weeks
worked. The employment coordinator or supervisor tracks performance and meets
individually with each specialist regularly. A number of specialists mentioned such tracking
as a negative aspect of their job. One specialist shared, ‘‘I don’t like that numbers have to
deal with the success of your job . . . that you have to place certain people . . . for the job to
look successful. . .’’ Other specialists said that tracking performance in this way makes them
uncomfortable, unnecessarily competitive, and disregards the challenges in finding jobs for
clients. Some participants admitted that pressure to meet supervisor’s expectations could
increase the likelihood that a specialist will place clients into ‘‘any old job’’ rather than
seeking more sustainable positions. One specialist commented:
‘‘We have these clinical meetings in the mornings, and I feel like they try to push people
out so they can put more people in, and forgetting that those people aren’t ready to push
out. ‘Cause what happens is you have a big circle, and in maybe 2, 3 years, they’ll be right
back where they are. But because of the numbers, and the lack of extra facilities, people
feel like they gotta push them out.’’
In some cases client preferences may be overlooked to increase the number of employed
clients in the caseload. Rather than representing an effective means of tracking outcomes,
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‘‘numbers’’ appear to represent to many specialists an unnecessary and bureaucratic means
of evaluation, and tend to detract from their morale.
Inter-agency collaboration can compromise client-centeredness
Practicing effective client-centeredness is also influenced by institutional factors that
facilitate or compromise the ability of employment specialists to match client preferences.
Among these is the need to collaborate with other institutions with disparate philosophies.
When agencies following the IPS model share resources or obtain funding from other
institutions following a different model, the two paradigms may clash. The result is that
clients and practitioners may receive mixed messages and feel uncertain about how to
proceed.
For example, agencies participating in this study collaborate with other state-funded
institutions that also provide resources to their clients. Close collaboration between agencies
is designed to expand the scope of resources available to clients and thereby promote
positive employment outcomes. Additionally, if clients present specific needs (e.g. funding
for a monthly bus pass), employment specialists can call a separate agency to make specific
requests on their clients’ behalf. Often, however, the fulfillment of these requests depends on
whether specialists agree to institute certain practices mandated by the other agency, such as
a ‘‘working interview,’’ ‘‘job coaching,’’ or ‘‘situational assessment.’’ Depending on how
these practices are implemented, they may or may not be consistent with the IPS client-
centered approach. In a ‘‘working interview,’’ clients engage in unpaid employment so that
an employer can become familiar with their skills before officially hiring them on a paid
basis. Similarly, ‘‘job coaching’’ and ‘‘situational assessments’’ are means for monitoring
employee adjustment. These practices contradict a central tenet of the IPS model that pre-
employment preparation and coaching should be minimal. In the words of one supervisor:
‘‘I still cringe every single time I hear someone say ‘Well, you know, they need to try out
work.’’ And I’m like, ‘‘We didn’t try out work. We got work. If we screwed up, we got
fired.’ Like, that’s what life is about.’’
Pressure from outside organizations to implement procedures like those described above
can directly compromise client-centered practices, which aim to boost confidence and
independence in the workplace. Specialists report feeling ‘‘required’’ to use approaches
conflicting with client-centered practices in order to accommodate outside agencies.
Training of supervisors and specialists can help them understand when an approach is
inconsistent with client-centeredness and negotiate with collaborating agencies to develop
an individualized approach that best meets clients’ needs.
Clients and employment specialists struggle to adapt to the realities of the resources
available to them. Clients often rely on the advice of employment specialists and other
members of their treatment team to make major life decisions affecting their income and
lifestyle. Their willingness to work depends largely on the consistency of the information and
guidance they receive from their treatment team within and across agencies. A client-
centered employment specialist, then, is one who is keenly aware of how these institutional
dynamics affect clients’ strategies for optimizing income, and who can effectively negotiate
with clients to pursue strategies that promote their long-term goals.
These interviews revealed four primary factors influencing the implementation of client-
centered services, including (1) clients’ anxieties about their interests and abilities,
(2) specialists’ ability to interpret and negotiate client and employer preferences realistically,
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(3) the quality of supervision and guidance in implementing client-centered practices and
maintaining employment specialists’ morale when facing challenges in the field, and
(4) managing discrepancies across resource-sharing agencies in what it means to be ‘‘client-
centered.’’
Discussion
Evidence suggests that rehabilitation in relation to psychiatric impairments is advanced by
client/patient-centered services (Anthony et al. 1990; Becker & Drake 2003; Bond 2004;
IOM 2001). Studies of client-centered programs highlight the centrality of clients’ wishes
in making service delivery decisions. However, in a realistic setting, decisions are the
product of negotiations not only between client and specialist but also among employers,
agencies, and other para-professionals. While client-centeredness dispenses with a
counterproductive paternalistic approach, there remains a need for guidance from experts
trained in making well-informed decisions with regard to employment and rehabilitation.
Thus, client-centeredness may be defined as a negotiation among all parties in order to
encourage independence and rehabilitation. Consistent with contemporary ethical
standards in mental and other health care, effective client-led negotiation requires that
specialists elicit and understand client perspectives well enough to know when to set
standards and boundaries in their clients’ best interests (particularly in cases where clients
are confirmed to be incapable of making relevant decisions or the client’s decisions may
likely result in significant harm to others) and when to encourage these standards to be set
by clients themselves.
A primary tenet of client-centeredness suggested by Rogers (1946) is that service
providers have a ‘‘deep understanding’’ of patients’ emotions and attitudes. While therapists
are trained to recognize and respond to patients’ emotional needs, employment specialists
rarely receive such formal training. Specialists must often engage in guesswork about what
clients might be experiencing, or else ‘‘redirect’’ them to other members of the treatment
team. While treatment teams normally include clinicians who help clients work through
emotional or social issues, a number of specialists from this study indicated that a lack of
dialogue between specialists and clinicians is common. Poor communication among
treatment teams is also reported in other supported employment programs (e.g. Shannon
et al. 2001). Participants in the present study frequently suggested the need to enhance
specialists’ integration into the treatment team so that client needs may be better understood
from many perspectives and disciplines.
Participants in this study also conveyed that fidelity to client-centered practice is affected
by quality and content of supervision. Specialists revealed that their motivation to meet
clients’ needs is significantly enhanced by working with knowledgeable supervisors who
relate to challenges faced by employment specialists in the field. The IPS model thus
recommends that supervisors have (or have had) their own client caseload (Becker & Drake
2003). Participants also cited institutional factors like the distribution of salaries, benefits,
and other resources (especially inter-agency collaboration) as key factors affecting
motivation and performance. Furthermore, many specialists described how their con-
scientiousness in matching clients’ preferences is directly affected by pressure to meet
performance standards set by supervisors, agencies, and by the IPS model as a whole.
Supervisors and administrators may benefit from training about the significance of tracking
outcomes to improve evidence-based practices in order to protect against the view that
‘‘numbers’’ are superfluous measures of specialists’ productivity. An understanding of the
meaning and utility of these evaluation techniques may lead specialists to reevaluate their
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significance and protect against the potential of placing clients in inappropriate or
unsustainable jobs.
Participants in this study described how allocation of resources within and across agencies
affects client-centeredness by delivering inconsistent messages about employment and
rehabilitation. Many employment specialists and supervisors interviewed here expressed
frustration about collaborating with agencies working outside of the IPS paradigm. In
exchange for certain services, agencies may pressure specialists to arrange work trials and
pre-employment assessments for clients. These conditions can lead to diminished
enthusiasm for work and do not appear to help clients find more suitable jobs (Alverson
et al., 1995; Quimby et al., 2001). Though these practices often contradict central tenets of
the IPS model, they are regularly encountered because of the need to share limited resources
(Bond et al., 2008). Spreading awareness of the importance of IPS standards across agencies
via workshops or shared training sessions may help to resolve this problem.
A limitation to this study is a lack of reciprocal qualitative data from employment
specialists’ clients and other members of the treatment team regarding client-centered
interactions. Future studies may benefit from a more multi-dimensional approach in order
to better understand challenges to client-centeredness from multiple angles.
Employment specialists in our study identified four primary factors facilitating or
inhibiting client-centered supported employment practices. These factors described above
suggest the need for (1) greater familiarity of employment specialists with how clients’
psychiatric symptoms and emotional reactions to life changes may affect negotiation of
clients’ wishes, (2) more integration and better communication among members of the
treatment team, (3) the need to hire supervisors with first-hand supported employment
experience and the ability to convey to specialists the importance of tracking employment
outcomes, and (4) to spread awareness of the IPS model across resource-sharing
agencies. More efforts are needed to integrate service providers and to stress the importance
of client-staff negotiated practices across agencies to improve employment outcomes and
rehabilitation.
Declaration of interest: The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
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on 1
1/05
/14
For
pers
onal
use
onl
y.
