Recovery From Schizophrenia: Psychiatry And Political Economy

TREATMENT 251vocational programming and the obstacles created by disincentives in the disabilitypension system. Let us look first at the provision of vocational services.In Britain and America the usual spectrum of employment opportunities forpeople with mental illness, from the most sheltered to the least, includes thefollowing:• Sheltered workshops. A widely diffused postwar model developed in northernEurope, regarded by many these days as too institutional and segregated.• Supported employment. Transitional and continuous supported employmentare American models in which jobs slots are developed for patients incompetitive work settings. Training and support for patients in these jobs areprovided by vocational staff known as job coaches.• Independent employment. People with mental illness find jobs in thecompetitive workforce, with or without the assistance of vocational staff.The last of these options requires no explanation; the others require somediscussion.Sheltered workshopsSheltered workshops are no longer popular. Critics argue that people placed inthese low-demand settings may fail to advance to more challenging work, eventhough they are capable of doing so. 27 Supporters point out that for some peoplewith limited functioning capacity, sheltered settings may be the only feasibleworkplace. At the Mental Health Center of Boulder County in Colorado, forexample, where both supported employment and a modernized shelteredworkshop are available, a high rate of employment has been achieved. More thanhalf of the working-age adults with psychotic illness are in paid employment, 12per cent of the group in the sheltered workshop. It is very easy for a client tomove from the sheltered workshop to supported employment, and such a move isstrongly encouraged, but very few of the people employed at the shelteredworkshop could hold down a job in the competitive labor market. Many of theseemployees work slowly and inefficiently at the most routine tasks in theworkshop and require a lot of day-to-day supervision. Without the workshop mostof these people would be unemployed.To address some of the critics’ concerns, it is possible to reconfigure thesheltered workshop to be more like the social firms described below, as has beendone with the workshop in Boulder. In this way, employees become involved inthe management of the workshop through a management council. The settingbecomes more integrated by hiring mentally healthy workers—for example, asheltered workshop can be made attractive to social service departments that aretrying to find work training and evaluation options for “welfare-to-work” clientswho have been unemployed for an extended period.