The Journal of Behavioral Health Services & Research

, Volume 42, Issue 4, pp 452–465

Appealing Features of Vocational Support Services for Hispanic and non-Hispanic Transition Age Youth and Young Adults with Serious Mental Health Conditions

Authors

    • Research and Training Center, Center for Mental Health Services Research, Department of PsychiatryUniversity of Massachusetts Medical School
    • Department of SociologyClark University
  • Jonathan Delman
    • Research and Training Center, Center for Mental Health Services Research, Department of PsychiatryUniversity of Massachusetts Medical School
  • Colleen E. McKay
    • Research and Training Center, Center for Mental Health Services Research, Department of PsychiatryUniversity of Massachusetts Medical School
    • Program for Clubhouse Research, Department of PsychiatryUniversity of Massachusetts Medical School
  • Lisa M. Smith
    • Research and Training Center, Center for Mental Health Services Research, Department of PsychiatryUniversity of Massachusetts Medical School
Article

DOI: 10.1007/s11414-014-9402-2

Cite this article as:
Stone, R.A.T., Delman, J., McKay, C.E. et al. J Behav Health Serv Res (2015) 42: 452. doi:10.1007/s11414-014-9402-2

Abstract

Transition age youth and young adults (TAYYAs) diagnosed with serious mental health conditions (SMHCs) are at greater risk of being unemployed compared to their peers without SMHCs. Job counseling and job placement services are the greatest predictor of competitive employment, yet we have limited knowledge about what TAYYAs believe they need to obtain gainful employment. In person, qualitative interviews were conducted with 57 non-Hispanic and Hispanic TAYYAs with SMHCs enrolled in three vocational support programs in MA (Vocational Rehabilitation, Individual Placement and Support; the Clubhouse Model as described by the International Center for Clubhouse Development). Six themes emerged from the data: three themes were identified as social capital (supportive relationships, readily available workplace supports, and vocational preparation), two themes related to human capital (effective educational supports and work experience), and one theme related to cultural capital (social skills training). Unique features (Spanish-speaking staff and/or familiar in Latino culture, familial-like staff support) were frequently noted by Hispanic TAYYAs.

Introduction

In the USA, serious mental illness is associated with an estimated economic cost of US$300 billion annually, which includes approximately US$193 billion from lost earnings and wages, US$24 billion in disability benefits in 2002,1 and US$100 billion in health care expenditures in 2003.2 Although a majority of unemployed adults with a serious mental health condition (SMHC) want to work, roughly, 75% are unemployed.3 These issues are compounded for transition-age youth who are only just beginning to engage in major adult life activities such as obtaining employment and becoming financially independent.4 The transition to adulthood typically begins at ages 15 or 16 and most commonly ends between the ages of 25 and 30. We will use the term “transition age youth and young adults” (TAYYAs) to mean individuals who are ages 18–30 who have a SMHC.5,6

The unemployment rate for people ages 16–24 years was over 16% in July 2013. Jobless rates are also high for young blacks (28.2%), Asians (15.0%), and Hispanics (18.1%).7 The employment rate for TAYYAs is even more alarming. Analyses show that although 91.2% of TAYYAs are employed at some time since high school, only 49.6% were employed 8 years post high school, a rate significantly lower than the general population.8 Accordingly, adults (age 18 through 40) who have experienced a first episode of psychosis have a 65% unemployment rate,9,10 a higher rate compared to their same age peers in the general population (20.6%).9 These higher unemployment rates are largely attributed to underdeveloped social and educational skills, social supports, fear of disclosing mental health conditions, and gaps in their employment history.11,12 The receipt of monthly Social Security Administration cash benefits provided to those who are unable to work because of a disability including a psychiatric disability may serve as a work disincentive.13 The more Social Security beneficiaries work the less benefits (e.g., housing and food stipends) they receive. For some people, the loss of benefits does not make up for the increase in work wages. Thus, participating in competitive employment in the face of uncertain job security may be a disincentive to work. In addition, TAYYAs are at high risk for other undesirable outcomes including dropping out of school or college or involvement with the criminal justice system.8,14,15

Nevertheless, the research indicates that the receipt of job counseling and job placement supports are the best predictors of achieving competitive employment for adults with SMHCs.13,1620 While many adults with SMHCs utilize a variety of employment services, providers have struggled to engage TAYYAs in such services.21 TAYYA’s disregard of available mental health services is not relegated to employment supports; studies consistently show that traditional adult mental health services are not appealing to transition age youth.4 Most adult service providers lack training in developmental processes and are unprepared for the service and treatment implications of the developmental issues of TAYYAs in obtaining work, which results in low retention rates of young adults for such services.5,6

The objective of this study is to identify unique and common perspectives of the general vocational needs of Hispanic and non-Hispanic TAYYAs to (1) inform the future direction of vocational support services for this population and (2) build prevention programs that could help stem the high unemployment rates for TAYYAs. Hispanics are the fastest growing ethnic group in the USA. In 2010, the US Census data showed that over the last decade, the Hispanic population grew from 35.3 million to 50.5 million, accounting for more than half of the nation’s population growth. Hispanics comprise 16.7% of the total US population and 23% of the population under age 18. In this study, we pay particular attention to Hispanic young adults because they are disproportionately associated with factors that place them at greater risk for poorer employment experiences compared to non-Hispanic whites.22 Prevalent issues for Hispanic young adults include lower educational attainment, higher unemployment rates, and higher representation in the juvenile justice compared to their white peers. In 2000, 63% of 25–29-year-old Hispanics were high school graduates, compared to 87% of African Americans and 94% of non-Hispanic whites. One tenth (10%) of young Latino adults (ages 25–29) had a college degree, compared to 18% of African Americans and 34% of non-Hispanics whites. Hispanic youth are 3.85 times more likely than white youth to be referred to juvenile court, and the rate at which Hispanic youth are securely detained for probation violations is 1.42 times greater than the rate of detentions of white youth.22 Moreover, Hispanics are less likely to utilize specialty mental health services.4 Cultural perceptions of the health care system, self-reliant attitudes, socioeconomic status, place of residence, lack of health insurance, lack of Hispanic staff in health care professions, linguistic barriers, and race/ethnic prejudice and discrimination have been linked to underutilization of mental health services.2325

We expect that for Hispanic TAYYAs, their race/ethnicity and economic position in US society and their cultural perceptions of the mental health system will uniquely shape their general vocational needs and participation in employment support services compared to non-Hispanic white TAYYAs. The basic premise is that race and socioeconomic status are interlocking systems of economic stratification that create different experiences and labor market opportunities for all groups.2630

Study Design and Setting

The Young Adult Mental Health and Employment Study (YAES) was a 2-year study funded by the National Institute of Disability and Rehabilitation Research (NIDRR) as part of the Learning and Working During the Transition to Adulthood Rehabilitation Research & Training Center (Transitions RTC). The relative lack of information on this topic influenced the decision to use qualitative methods to engage TAYYAs in participatory action research (PAR) to collaborate on efforts to improve vocational outcomes for TAYYAs.31,32 PAR is a process in which researchers and TAYYA research assistants collaborated on efforts to improve mental health services. To develop and complete the project, the TAYYAs we hired received intensive training and were active in all phases of the research in particular defining the problem, conducting the interviews, screening participants, and disseminating the results. The NIDRR grant provided funding to two full-time employment (FTE) TAYYA project assistant positions (broken out into several part time positions).

Researchers conducted semi-structured interviews with TAYYA consumers participating in vocational services to gather as much information as possible. The open and informal nature of semi-structured interviews allowed for a dynamic exchange of ideas with probes designed to elicit details and explanations.3335 Study participants were encouraged to respond in the form of narratives about their personal experiences with their vocational support service.35 The initial interviews consisted of 26 open-ended questions and narrative accounts. The interviewer encouraged elaboration of the individual’s experiences and feelings about different aspects of his/her vocational program, ideas about what he/she thought would work or not work in a vocational program, thoughts about various features in vocational programs, and the individual’s experience finding and keeping a job. Interviews were conducted in English or Spanish based on the participant’s primary language and translated as needed. To ensure that the translation was sensitive to regional differences in the Spanish language, the survey instrument was translated from English to Spanish, and then back translated from Spanish to English by two Spanish-speaking individuals of Puerto Rican and Central American and South American descent, independently. A bilingual Spanish-speaking interviewer was available for participants who requested to conduct the interview in Spanish. Once the participant completed the narrative portion of the interview, she/he was asked to provide socio-demographic background information.

Sampling and Participant Recruitment

A team of researchers and TAYYAs employed in the University of Massachusetts Medical School (UMMS) Transitions RTC held informational meetings for TAYYA mental health consumers, program directors, and staff members at three widely disseminated vocational supports for adults with SMHC. These include Vocational Rehabilitation (VR) programs, Individual Placement and Support (IPS) model of supported employment, and the Clubhouse models (ICCD CH). We used these three programs because of their long established empirical support of supporting employment of adults with mental illness and to inform adaptations to these programs to better serve TAYYAs.

One study reported that 55% of IPS clients obtained competitive employment over 12 to 18 months, compared to 34% of clients in traditional vocational services.36 Clubhouse members receive assistance in obtaining mainstream employment through transitional, supported, and independent employment (TE, SE, and IE) opportunities in the greater community. While employment outcomes for individuals participating in clubhouse employment have not been as widely scrutinized compared to the IPS Model, one study found that after 30 months, 74% of Program of Assertive Community Treatment (PACT) participants and 60% of clubhouse participants had been placed in at least one job. The average clubhouse participant worked 21.8 weeks per job and earned US$7.38 per hour, whereas the average PACT participant worked 13.1 weeks per job and earned US$6.30 per hour. Moreover, during that time, clubhouse participants earned significantly higher wages and remained competitively employed for significantly more weeks per job than PACT participants37 (see Tables 1 and 2 for program description details).
Table 1

Description of vocational support programs

 

Individualized Placement and Support

Massachusetts Rehabilitation Commission

Clubhouse

Service providers

Employment specialistsprovide employment related services including program intake, engagement, and assessment. Maximum caseload per specialist is 20 or fewer clients.

Vocational rehabilitation counselors assist individuals with physical, psychiatric, and/or learning disabilities and individuals with disabilities to obtain and maintain employment. MRC provides employment services including identifying job goals and aptitudes, vocational training, and work site accommodations.

Clubhouse staff members function as a generalists, maintain a caseload, manage employment placements, and provide employment supports and other supports offered by the clubhouse (e.g. housing, outreach, education, etc.).

Eligible participants and service acquisition

In order to be eligible, participants must be 16 years of age or older and demonstrate a motivation to work. The intake process includes an application and an interview.

To be eligible for MRC services, a person must have a physical or mental impairment that is a substantial impediment to employment. The MRC counselor conducts a diagnostic evaluation to determine eligibility.

Adults or young adults living with a major mental illness are typically eligible for clubhouse membership. There are no fees to join the clubhouse and members can participate as little or as much as they choose. Employment is a basic right of clubhouse membership. The only requirement for a clubhouse member to participate in clubhouse employment supports is the expressed desire to work.

Supports provided

A multidisciplinary team of professionals that coordinate services with clinical staff and rehabilitation services and provides individualized services. Employment specialists attached to mental health teams provide. Intake, assessment, help with resumes and interviews, job development/job placement, job coaching, and follow-up supports that include benefit counseling. Clients decide how much they want to work and may try multiple jobs.

MRC clients receive guidance and counseling to identify vocational services and a suitable job goal. MRC clients receive assistance with developing a resume, interviewing skills, job applications, and job placement as well as follow-up.

Clubhouses offer a range of employment supports including TE, SE,, and IE through which members can secure jobs at prevailing wages in the wider community. Assistance with career development, rapid job search, job choice, and ongoing job support is available to all members. Members have access to all clubhouse services including educational resources, outreach, assistance with housing, and evening, weekend, and holiday social programs.

Length of service

Indefinite, no time constraints

Closure after 90 days of employment

Indefinite, no time constraints

Unique features of model

Employment services are integrated with mental health treatment. Employment specialists attend treatment team meetings. The employment specialist and the treatment team develop client-related contacts for job opportunities.

An MRC counselor makes decisions about job placement based on the evaluation.

Clubhouses offer three types of job supports (IE, SE, TE). TE placements are part-time, time-limited job placements at prevailing wages. The clubhouse determines who will fill the TE. The clubhouse provides on-site training, support, and absence coverage for members in TE. Members employed in IE receive off-site supports at the clubhouse.

IPS Individualized Placement and Support, MRC Massachusetts Rehabilitation Commission, ICCD CH clubhouse, TE transitional employment, SE supported employment, IE independent employment

Table 2

Features of vocational support programs

 

IPS

MRC

ICCD CH

1. Ongoing job supports on job site

x

x

x (except for IE)

2. Consumer preferences are important in determining job placement

x

x

x

3. Continuous and comprehensive assessment

x

x

 

4. Applicant has to show a desire to work to be eligible for employment services

x

x

 

5. Help with identifying suitable job goals

x

x

x

6. Time-limited supports

 

xa

 

7. Job specialists provide employment supports

x

x

 

8. Offers assistance with obtaining educational supports (e.g. GED, college)

  

x

aCase closed after employed 90 days

x indicates features offered by vocational support program

Researchers and TAYYA project research assistants, in collaboration with program directors and staff members from each of the vocational programs, identified and recruited a purposive sample of eligible participants. The research team posted flyers and brochures describing the study (in English and Spanish) in the waiting area of each program. Eligibility criteria included, being between the ages of 18 and 30, currently or previously enrolled in a vocational support program VR, IPS, and the ICCD CH, had a minimum of one job consultation meeting with a vocational support, counselor, staff, or coordinator from any of the vocational programs, and self-identified as having a SMHC. A SMHC requires the person to have at least one DSM-V disorder of 12-month duration other than substance use disorder. Participants were ineligible for the study if they were incapable of participating or giving consent based on cognitive or emotional deficits. The study research coordinator and research-trained TAYYA employed at the Transitions RTC screened the study participants for eligibility criteria and obtained consent to participate in the study.

Data Collection

Over a year and half, we conducted one-time 1-h, open-ended audio-taped semi-structured interviews with 57 TAYYAs currently or previously enrolled in any of three well-established vocational support programs VR, IPS, and the ICCD CH. Because the number of TAYYAs served at each of the vocational programs varied, we over sampled TAYYAs from some of the programs to ensure participant representation across the three programs. At the end of each interview, participants received a US$20 gift card for their participation. The subject’s privacy was maintained by attaching a specific code to each interview. Participant data was then entered into analytic software by the participant’s code only. Any identifying data was kept in a locked file cabinet in a secured office or in a password-protected computer file. Transcribed audio-taped interviews had no identifying information recorded and were kept in a locked cabinet. Access to tapes and data was limited to the PI and study personnel.

The study research coordinator and research-trained TAYYA employed in the Transitions RTC screened the study participants for eligibility, obtained consent to participate in the study from the eligible TAYYA, and conducted the interviews. Participant interviews were conducted until a level of saturation in themes was reached. This is a qualitative exploratory study, and it is a core principle of grounded theory, indeed of all qualitative research, that one collects data only as long as one is finding new phenomena. Leading qualitative methodologist, Creswell,38 noted that researchers typically recruit 20–35 subjects to reach saturation. This study was approved by the University of Massachusetts Medical School’s Institutional Review Board and the Massachusetts Department of Mental Health’s Central Office Research Review Committee.

Analysis

The research team audio-taped and transcribed interviews verbatim and used a thematic analysis approach. Although existing literature generated the general topic for the interview guide, the initial coding of the data was not theory- or hypothesis-driven. We developed the codes after data collection was complete. Initially, the PI, a research coordinator, and the PAR team reviewed the transcripts and “open coded” to identify prominent coding schemes and themes which included social, human, and cultural capital. Social capital refers to the ways in which non-financial resources (e.g., trust, social control, support from friends, colleagues, and more general contacts) that are derived from membership in social network(s) can be used to acquire human and cultural capital.39 Human capital refers to individual investments in schooling, on the job training, and medical care.40 Cultural capital refers to the habitus of cultural practices, knowledge, and demeanors learned through exposure to role models in the family and other environment.41 Examples of cultural capital include, demonstrating appropriate attire, language, and knowledge. These three types of capital influence an individual’s employment experience differently depending on one’s social status in society (e.g., race and socioeconomic).2529 The basic premise is that race and socioeconomic status are interlocking systems of economic stratification that create different experiences and labor market opportunities for all groups.30

The PI and two coders manually reviewed the transcripts independently and coded text for instances where each theme occurred.34 To increase inter-rater reliability, the two coders developed a consensus regarding the major themes that needed further scrutiny. The research team and research-trained TAYYA mental health consumers discussed disagreements and agreements and mutually agreed on themes at weekly research meetings over a 4-month period. The primary investigators and the research coordinator developed a codebook to define the codes and themes and used the NVivo 8 software42 to sort and systematically organize the interview data to increase reliability. The thematic findings evolved from 57 codes in the codebook. To establish credibility of the findings, the interview script was iteratively pilot-tested with young adult mental health consumers for clarity and meaning in the interview questions. The primary investigator was only involved in the analytic portion of the study not in the interviews. A third coder, who had no previous knowledge of the coders’ responses, resolved any coding discrepancies.38

Findings

Characteristics of study sample

The participants in this study (N = 57) included 31 males and 26 females between the ages of 18 and 30, with a mean age of 23. The majority of the participants self-identified as non-Hispanic white. All participants either spoke English or English and Spanish. The majority were never married. The majority of participants reported a diagnosis of bipolar disorder or major depression followed by anxiety disorders and schizophrenia. Other disorders included (but were not limited to) schizoaffective disorder and post-traumatic stress disorder. Over 90% of the participants had prescriptions for psychiatric medications at the time of the study, and over 80% had reported a hospitalization for their disorder at some point in their life. Of the 57 participant interviews completed, 27 (47%) were recruited from ICCD CH, 16 (28%) from VR services, and 14 (25%) from IPS services. Of the15 (26%) Hispanic interviews completed for the study, 6 (40%) were from ICCD CH, 7 (47%) from VR services, and 2 (13%) from IPS services.

Narrative of findings

Respondents described their experiences with their current or past vocational support program and discussed their perceptions of what they viewed as general vocational needs. Six themes emerged from the data: three themes were identified as social capital (supportive relationships, readily available workplace supports, and vocational preparation), two themes related to human capital (effective educational supports and work experience), and one theme related to cultural capital (social skills training).

Social capital

Supportive Relationships

The majority of non-Hispanic white young adults expressed an appreciation for clients/members who understood their mental illness and friends who shared in recreational activities.

One member explained, “I have friends here… other members around my age that we go to the movies and we hang out downtown and… That’s been great for me to have people in my life to care about” (White non-Hispanic female, age 20).

Other participants described the supportive nature of the program and understanding way that staff and peers perceived their mental health difficulties. “We work together and people understand that you have an illness but that it doesn’t have to hold you back or dominate your life. Almost like the illness isn’t important in a sense because we are all in the same boat, we are all people together. Some of us just have different challenges than others” (White non-Hispanic male, age 22).

Compared to non-Hispanic white young adults, Hispanics were more likely to refer to program staff members as “family” and expressed an appreciation for the opportunity to “prove” themselves to other people. “…I learned a lot for myself, I learned a lot how to be in the real world, I learned how to respect myself and others. I learned about love you know. That was one big thing about me, why I was …depressed, and [Program X] is a family that just grows; it grows on you.” (Hispanic female, age 23)

Hispanics also expressed a need to feel included in vocational support programs by the greater availability of Spanish-speaking staff/Spanish translators and other specific supports. “Yeah I think there should be something set especially aside for Hispanics, I’ve seen other people that don’t speak English very well and I don’t think they do as well because they don’t think they fit in. Most of the people that I see here speak English” (Hispanic female, age 25).

Over two thirds of the Hispanic young adults reported that their families criticized them and did not trust they could get a job. Hispanic young adults also noted that their families were not equipped to deal with their mental illness given their own lack of understanding of their diagnosis and other family and financial responsibilities. As one Hispanic young adult age 30 explained, “like they think you’re out doing something different…you’re not out working as much as you say you are, you know because the money is not coming in as much as they think it is…then you have the issue of why don’t you pay rent.” Another Hispanic male age 18 stated, “The first time I went to the hospital, I was diagnosed with Bipolar Disorder, My mom said she wasn’t prepared to handle my symptoms. My mother’s home was not equipped to handle me. My mom had other family members living there and some of them were homeless.”

Readily Available Workplace Supports

A majority of respondents believed that the supervisor’s awareness of them having a mental health condition would benefit the course of their employment. Equipped with that knowledge, the supervisors would be more understanding of the employee’s behavior or performance and be in a better position to offer workplace supports and reasonable workplace accommodations. Additional advantages could include, providing the supervisor with emergency contact information (e.g., family or staff) that might help remove a distressed employee from engaging in a disciplinary action.

From a practical perspective, both Hispanic and non-Hispanic participants had mixed feelings about the idea of involving program staff members in the workplace and having them stay in touch with the supervisor/boss. They were concerned that contact with a program staff member in the workplace would result in increased negative judgment or discrimination (e.g., loss of hours, being fired, or not trusted) because of their mental health condition. One participant expressed her concern, “I feel like the boss never really trusts you…’because a lot of people don’t understand mental illness and have misconceptions and thoughts about mental illness that aren’t always accurate” (Hispanic female, age 20).

The young adults were comfortable with program staff members having contact with their supervisor/boss as long as they kept their mental condition confidential from other co-workers. As one young adult female stated, “I think that’s a good idea as long as the managers keep it confidential from other people that work there because having a co-worker find out that you have a mental illness or that you are in a mental health program doesn’t help anything” (White female, age 23).

Despite these concerns, both groups liked the idea of having someone to consult with outside of work about their workplace issues and/or work progress.

Vocational Guidance and Preparation

Many respondents expressed a strong desire for vocational assistance, such as guidance with resume writing, interviewing, and career exploration. Numerous participants reported experiencing various levels of anxiety in relation to the job search itself. Respondents desired time with employment specialists prior to conducting a job search in order to best prepare themselves. In terms of job preparation, the majority of young adults (both Hispanic and non-Hispanic) highly valued gaining interview skills primarily through mock interviews and general tips. One participant explained, “They help us call and get us ready for interview questions and stuff. It’s not like they’re there by my side…but they show me. They let me know what kinds of questions I’m going to answer…how to dress…how to speak appropriately with respect…to get us ready for the real world” (Hispanic female, age 23). For non-Hispanic whites, resume writing and preparing job applications were skills most often mentioned as desirable after job interview skills. The vocational programs generally provided guidance, peer editing, and advice for completing resumes and job applications. Hispanics and non-Hispanics frequently emphasized needing assistance with transportation, job interviewing skills, preparing resumes, and job applications. The programs often provided reliable transportation to and from interviews/meetings/work shifts or aided the young adult in obtaining funding for his/her own transportation. Other skills mentioned frequently as being useful to obtaining and maintaining work were goal setting and discovering one’s own strengths, educational supports, and computer skills.

Human Capital Characteristics

Effective Educational Supports

Both Hispanics and non-Hispanic respondents emphasized the importance of help in applying for, managing, and completing pre- and post-secondary education programs. Educational supports included completing college applications, identifying funding for post-secondary educational opportunities, and transportation assistance (rides to and from interviews and classes, funding for transportation). Both groups also noted receiving help in obtaining their general education degrees (GEDs). One participant stated, “I’ve been given endless opportunities here…these guys helped me get my GED. They got me to my appointment…to take the placement test for the GED exam, and they’re going to help me figure out the best way to go about going to college because I definitely want to go back”(White female, age 20). Non-Hispanic whites, slightly more so than Hispanics, valued having general support and guidance during the job search and application process.

Work Experience

Although not a prominent theme, both Hispanics and non-Hispanic whites liked the idea of gaining work experience from a time-limited transitional employment (TE) job offered by one of the vocational programs. They liked the idea of having someone ready to fill in for them in case he/she was unable to work. However, non-Hispanics were especially concerned that a TE job would only result in more anxiety about what will happen after the job was over. Non-Hispanic whites frequently reported wanting longer-lasting jobs and to know ahead of time that another job was available if they were unable to stay at a time-limited job. One participant explained, “I think it’s a good idea…to learn job skills…But maybe when they’re done with that TE…they could like help them find a permanent job. So I think it’s good to have temporary jobs, but in the long run somebody needs something permanent” (White female, age 23). Hispanics also expressed this same concern, but to a lesser extent.

Cultural Capital

Social Skills Training

For Hispanics, guidance in appropriate presentation of oneself and communication skills were the next two most desirable aspects of vocational supports. These young adults reported gaining a better understanding of appropriate dress, language (e.g., decreasing use of slang), physical appearance (posture), and social interactions (e.g., eye contact, mannerisms). Hispanics emphasized the importance of increasing communication skills, interview skills, improving one’s self-confidence, and ability to cope with various stressful workplace situations. White participants emphasized the importance of overcoming nerves in interviewing situations.

A Hispanic young adult commented on the vocational program, “It’s a neat place. It’s a good place for young adults. They are willing to help you, to give them a chance, help them, involve themselves in the work here so they can prove themselves worthy of working outside the house. What I like about it is, they teach you the basics like good communication skills, how to manage your illness while at work, and how to take care of that so it doesn’t affect your work” (Hispanic male, age 22).

Another Hispanic young adult stated, “because I’m from, I’m from the streets. they show me a different way to speak when you’re in a job interview. you can’t use terms like ‘yo what’s good’ and you got to say ‘hello, how are you doing’ you have to use proper english (hispanic female, age 18). a white young adult male expressed being nervous about the job interview process, “I learned about interviewing skills maybe a month after she helped me get a resume together. I wasn’t good at interviews because I get really nervous. I stutter and mutter and I kind of stare off into space. I can never focus on the actual person, talk to them and answer the questions, so that’s one a little barrier that I’ve had” (white non-hispanic male, age 20).

Discussion

The general vocational needs of TAYYAs are consistent with factors associated with gainful employment in the general population. Ample evidence from the sociology and economic literature supports that individual investment in social, human, and cultural capital is associated with positive employment outcomes in the USA.43 To date, employment services for individuals with SMHCs have focused primarily on the development of human and cultural capital, with less capacity devoted to the structural supports that increase social capital.44 Findings indicate that social, cultural, and human capital play crucial roles in determining the success of TAYYAs, especially the attainment of stable and rewarding employment.43 Thus, a large social network increases the likelihood of an individual accessing supportive advice, beneficial opportunities, trusting and cooperative relationships, and increased social and emotional support.43 Moreover, supportive relationships improve outcomes for individuals with SMHCs including measures of confidence, functioning, motivation, and empowerment.4547

These findings are noteworthy because young adults want competitive jobs but unlike older adults, they have little knowledge about the world and the culture of “competitive work.”48 Most young adults with mental health conditions do not have significant job experience and have poor or incomplete academic records.49 There is preliminary evidence that supported education (SEd) produces positive outcomes regarding goal identification, improved use of academic resources, and coping skills.50 Consumer preferences drive SEd and work to enhance the students’ academic strengths and build academic skills. However, there is a need for additional assistance such as workplace supports and work experience.

Because TAYYA were concerned about negative judgment or discrimination (e.g., loss of hours, being fired, not being trusted) as a result of their mental health condition, TAYYAs in our study struggled with the decision to disclose the nature of their mental health condition or request reasonable job accommodations from potential or current employers. Because programs that serve TAYYAs do not always directly address these psychological and systemic barriers, many respondents reported various levels of anxiety around, and not feeling ready for, a job search. Previous studies have demonstrated that one reason for this anxiety is the acute concern that potential employers would discriminate against them based on their psychiatric condition.51 Our study also showed that TAYYAs preferred supportive staff/provider relationships that were not only respectful, but also responsive to their specific workplace needs.

Although non-Hispanic and Hispanic TAYYAs identified several common appealing features of vocational supports, some unique features emerged in this study. For example, compared to their white counterparts, Hispanics elevated the staff to family status and appreciated the opportunity to show their family and peers that they could succeed. They also expressed a need for bilingual staff and Spanish translators to support and facilitate integration of TAYYAs of different cultural backgrounds. The reliance of Hispanics on family networks for material and emotional support is well documented in the literature.52,53 For Hispanic families, familismo symbolizes the importance of family cohesion, respect, honesty, and decision making for the benefit of all family members. This is important because the literature indicates that for Hispanic youth and parents, high levels of familismo operate to protect against negative mental health. However, the disproportionate burden of persistent life stressors and fewer resources in avoiding the impact of personal problems hinders Hispanic families’ ability to maintain strong family support systems. In our study, we found that the parents were not fully equipped to handle their child’s mental health diagnosis because of their lack of understanding of mental illness and other family and financial responsibilities. This often led to parent-child conflict over their work situation. Our work warrants future research in understanding the role of Hispanic family members in assisting TAYYAs to find work. Perhaps, family members can work in conjunction with vocational staff members to facilitate the job process. Nonetheless, our findings support that hiring staff that is competent in Spanish language and understands Hispanic culture and family dynamics may facilitate successful employment experiences.

Traditional employment services for individuals with SMHCs have focused primarily on the development of human capital (educational support) and cultural capital (vocational guidance/job preparation and social skills training), with less capacity devoted to the structural supports to increase social capital (trust, workplace supports, supportive provider relationships, and racial and ethnic diversity).43,44 In spite of the successes that these services have achieved, we may need a different approach to employment services that includes social capital supports. This study provides a better understanding of what young adults with SMHCs need in vocational support programs and offers information for culturally informed vocational support programs that would more effectively engage and retain youth and young adults with a SMHC. Some study limitations, however, are worth noting.

Limitations

Our study contained several methodological limitations. First, this study was conducted with a purposive sample of TAYYAs between ages 18 and 30 that were currently or previously enrolled in one of the three widely disseminated vocational support programs in one state; thus, the findings from this study cannot be generalized to all US young adults ages 18–30 with a SMHC. This is important because geographic variations in work restructuring (e.g., decline in the demand for unskilled and low-skilled workers and the increased demand for high technological skilled workers) may influence what young adults perceive as important factors to gainful employment. Occupations in high technological industries require continuing investments in productivity-related skills such as education and English-language proficiency.54 Another limitation worth noting is that our study population self-identified as having SMHC. We did not ascertain mental health diagnosis via patient clinical records. However, it seems unlikely that this would undermine our findings since we recruited study participants from programs that provide services to individuals with SMHCs. In addition, we examined unique and common perspectives of the general vocational needs and experiences with vocational support programs of TAYYAs and not the opinions and experiences of employers and vocational service providers for this population. Finally, because study participants are from programs with different models of fidelity and implementation, the findings are not generalizable to any one specific program. Despite these limitations, this study has important implications for behavioral health research and practice.

Implications for Behavioral health and practice?

Vocational programs are only as effective as the willingness of consumers to engage in those programs. To engage TAYYAs in vocational programs, service providers must be responsive to their development and cultural needs. Our work highlights the importance of including consumer voice in identifying features that facilitate participation in three well-established vocational services (Vocational Rehabilitation (VR), Individual Placement Support (IPS), and the Clubhouse Model (ICCD CH) (Table 2). Our study is the first to investigate the vocational perspectives and preferences of a culturally diverse sample of young adults with SMHCs. TAYYAs from ethnically diverse backgrounds in this sample emphasize unique needs. We offer several suggestions for promising practices and principles in order to help TAYYAs successfully obtain and maintain employment.

Programs serving TAYYAs should consider individualized assessment planning to identify job interests of young adults. The young adults in this study were at different phases of the job process. For example, Hispanic young adults seeking employment wanted guidance in appropriate dress, language (decreasing slang), and physical appearance. Some young adults expressed a need for resume building and work experience, while others needed support in completing their GED or college degrees. Supported education (SEd), an emerging evidence-based practice that has successfully addressed these kinds of challenges for people with SMHCs should be a readily available support in programs that serve TAYYAs. A recent study reported that young adult veterans with psychiatric disabilities desired age-relevant services that assisted with education planning and access integrated in the delivery of mental health services.55 However, there is limited evidence that SEd incorporated in vocational support programs translates into better employment outcomes overall.56

Implementing informal and formal job mentoring programs (e.g., social-networking opportunities, career fairs, social gatherings, and community activities) where TAYYA can engage with employers in a casual setting may alleviate feelings of anxiety over the job process. Our findings identified concerns regarding mental health stigma, discrimination, and disclosure in the workplace. Future intervention studies examining vocational support programs may want to consider the potential effectiveness of a peer mentoring, a promising practice, in managing the client’s personal and psychological issues that may be creating job anxiety. One study demonstrated the feasibility and potential effectiveness of a peer instructor/coaching role mentors within technical or vocational training programs.57 Moreover, the research indicates that the receipt of monthly Social Security Administration (SSA) cash benefits provided to those who are unable to work because of disability including psychiatric disability may serve as a work disincentive.13,1618,20 To our surprise, concern for loss of benefits did not emerge as a common vocational need of Hispanic and non-Hispanic TAYYAs. Future research may want to explore the impact of SSA cash benefits on long-term employment.

Clearly, stakeholders should place greater attention to how service providers can tailor their services to engage this population and assist TAYYAs with obtaining and maintaining employment. The knowledge gained through this study improves our understanding of what young adults with SMHCs want in a vocational support program. It also provides formative information for the design of the next generation of developmental and culturally informed vocational support programs that will more effectively target at-risk youth and young adults with a SMHC while successfully retaining them in vocational support services. However, to further validate our findings and inform future program development, future studies should consider theoretically and systematically informed triangulation methods (in person interviews, focus groups, and community-based surveys) in collaboration with TAYYA community advisory councils and service providers. Findings from these preference-oriented studies are most likely to influence program approaches when TAYYAs are active participants in developing research projects and quality improvement activities. Active transition age youth and young adult participation will also improve their likelihood of program engagement and individual ability to utilize the opportunities offered by the vocational programs. As noted by Woolsey and Katz-Leavy, “programs should consider how the youth are utilized through at least three filters: (1) youth involvement in daily program activities; (2) youth guidance and input on program policies and services; and (3) youth direction on decisions that directly affects services and policies” (p. 26).21

Acknowledgment

We would like to thank the Transitions Research and Training Center young adult project assistants, Amanda Costa and Jennifer Whitney, for their valuable help in collecting and reviewing the data, their enthusiastic encouragement, and their technical support in the development and planning of this research. We would also like to express our deep gratitude to Dr. Charles Lidz for his useful and constructive recommendations for this manuscript. His willingness to give his time so generously has been very much appreciated.

Funding Support

The content of this manuscript was developed with funding from the US Department of Education, National Institute on Disability and Rehabilitation Research, and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (NIDRR Grant H133B090018). Additional funding was provided by UMass Medical School’s Commonwealth Medicine Division. The content of this manuscript does not necessarily reflect the views of the funding agencies and you should not assume endorsement by the Federal Government.

Conflict of Interest Statement

I declare no conflict of interests. The content of this manuscript were developed with funding from the US Department of Education, National Institute on Disability and Rehabilitation Research, and the Center for Mental Health Services Research, Substance Abuse and Mental Health Services Administration (NIDRR Grant H122B090018). Additional funding was provided by UMass Medical School’s Commonwealth Medicine Division. The content of this manuscript does not necessarily reflect the views of the funding agencies.

Copyright information

© National Council for Behavioral Health 2014