Ethics in Vocational Rehabilitation: The Need for EvidenceBased Practice

1
Ethics in Vocational Rehabilitation The Need
for Evidence-Based Practice

• Eileen J. Burker, Ph.D., CRC
• Kally Kazukauskas, Ph.D., CRC, CVE
• Charlie Bernacchio, Ed.D., CRC
• University of North Carolina at Chapel Hill
• NCRE/CSAVR/RSA Conference
• Washington, DC November 5, 2008

2
Overview

• What is evidence-based practice (EBP)?
• EBP in rehabilitation counseling What are the
  findings?
• Barriers to successfully using EBP
• Ethical responsibilities in implementing EBP
• Conclusions

3
What is Evidence-Based Practice?

• A total process that involves knowing
• which questions to ask
• how to find the best practice
• how to critically appraise the evidence and the
  degree to which it applies to a situation
• how to evaluate the effectiveness of the care and
  continually trying to improve the process.
• (Chronister, Cardoso, Lee, Chan Leahy, 2005)

4
What is Evidence-Based Practice?

• The best evidence for EBP comes from
• A series of results from research studies that
  help to form a consensus about the effectiveness
  of a treatment approach.
• (Ottenbacher Maas, 1998)

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Levels of Evidence of EBP

• Level 1 Evidence from at least 1 review of
  multiple well-designed randomized and controlled
  studies.
• Level 2 Evidence from at least 1 well-designed
  randomized and controlled study.
• Level 3 Evidence from well-designed research,
  but without randomization, single group pre to
  post, cohort, time series or controlled study.
• Level 4 Evidence from well-designed
  non-experimental studies.
• Level 5 Evidence based on opinions of respected
  authorities, clinical evidence, experts.
• (Gray, 1997 Holm, 2000)

6
Examples of EBP in Rehabilitation Counseling

• Vocational Rehabilitation Services
• Supported Employment
• Family Psychoeducation
• Integrated Substance Abuse Treatment

7
EBP in Vocational Rehabilitation Findings

• VR is effective in improving the employment
  outcomes of individuals with disabilities.
• Job placement and support services have
  consistently been positively associated with
  competitive employment.
• In one study, 60 of VR clients were employed
  compared with 33 of people with disabilities in
  the general population.
• (Pruett, Swett, Chan, Rosenthal, Lee, 2008)

8
EBP in Supported Employment Findings

• There was a 20-40 increase in competitive
  employment rates when using supported employment
  (Pruett, et al., 2008).
• The cumulative costs for employees in supported
  employment were significantly reduced in agencies
  that participated in a Natural Supports
  Initiative (NSI) (Cimera, 2007).
• For individuals with schizophrenia, supported
  employment consistently results in superior rates
  of competitive employment as well as more work
  hours and higher wages
• (Drake, et al., 2000).

9
EBP in Family Psychoeducation Findings

• Family psychoeducation provides education,
  support and skills to family members of people
  with schizophrenia. The goal is for family
  members to feel less burdened, and be more
  effective in helping their relative manage
  his/her disability and decrease the need for
  rehospitalization.
• Short-term, these programs increase knowledge and
  decrease burden.
• Long-term, these programs decrease the risk of
  relapse or rehospitalization by 25 to 50 over 2
  years.
• (Drake, Muser, Torrey, Miller, Lehman, Bond,
  Goldman, Leff, 2000)

10
EBP in Integrated Substance Abuse Treatment
Findings

• Current models integrate counseling for both
  disorders as well as case management,
  medications, housing, vocational rehabilitation,
  and family intervention.
• Individuals involved in integrated programs have
  higher rates of recovery than those in
  non-integrated programs.
• (Drake, Muser, Torrey, Miller, Lehman, Bond,
  Goldman, Leff, 2000)

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Other EBPs in Rehabilitation

• Individual Placement and Support Model
• Illness Management and Recovery
• Assertive Community Treatment
• Medication Management According to Protocol
• Supported Housing
• Consumer-directed Recovery Activities
• Social Skills Training
• Cognitive Behavior Therapy
• Positive Behavior Support Plans

12
Barriers to Implementing EBP

• What barriers you have encountered?

13
Barriers to Implementing EBP

• Lack of finances
• Lack of accessible information
• Lack of trained clinicians
• Lack of adminstrative supports
• Lack of consumer demand
• General resistance to change

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Barriers to Implementation of EBP Specific to
Vocational Rehabilitation

• Using experimental research to evaluate the
  effectiveness of VR is rare, perhaps because of
  the complex and holistic nature of the
  rehabilitation process.
• The VR process involves a wide variety of
  personal and environmental influences (and the
  interactions between them). This complex process
  makes it a challenge to figure out which aspects
  of the services contribute to which outcomes.
• (Johnston, Sineman, Velozo, 1997)

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Barriers to Implementation of EBP Specific to
Supported Employment

• Government Barriers
• Federal funding for VR has never been sufficient.
  
• Community health centers often allocate a very
  small portion of their budget for voc services
• Program Administrators
• It is difficult to find money to start and
  continue programs, manage organizational change,
  and cope with changes in the community.
• Clinicians and Supervisors
• Clinicians may underestimate the clients need
  for vocational services, resistance to change,
  and inadequate resources.
• Clients and Families
• Clients and families often do not have accurate
  information about supported employment. They may
  be discouraged from seeking employment from
  clinicians and family who believe work would be
  too stressful, and fear of losing Medicaid
  benefits.
• (Bond et al., 2001)

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Barriers to Implementation of EBP Specific to
Family Psychoeducation

• Consumer Barriers consumer concern about
  privacy, burdening the family, and belief that
  family participation might not help recovery,
  cultural concerns
• System-Level Barriers lack of reimbursement or
  lack of administrative support
• Provider Barriers limited clinician knowledge
  about the benefits of family psychoeducation,
  limited clinician skill, and clinician attitude
• Family Member Barriers transportation
  difficulties, child care, cultural concerns

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Its Our Responsibility

• Despite the considerable barriers to implementing
  Evidence-Based Practices, we have a
  responsibility to do so.

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Reasons to Embrace EBP

• EBP enables rehab counselors to provide services
  and programs proven to work.
• EBP enables rehab counselors to justify
  interventions to funding agencies by presenting
  evidence about effectiveness.
• EBP enables rehab counselors to offer choices,
  and info about advantages disadvantages of each
  choice. (Nemec, 2004)
• EBP is our ethical responsibility

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Ethical Responsibilities in Implementing EBP

• What are the ethical responsibilities in
  implementing EBP?
• Is one study enough to change the way you do
  something?
• Which codes are relevant?

20
Ethical Responsibilities in Implementing EBP
Relevant Codes

• Rehabilitation counselors will neither place nor
  participate in placing clients in positions that
  will result in damaging the interest and the
  welfare of clients, employers, or the public.
  (SECTION A.1.c.)
• Rehabilitation counselors will develop and adapt
  interventions and services to incorporate
  consideration of clients cultural perspectives
  and recognition of barriers external to clients
  that may interfere with achieving effective
  rehabilitation outcomes. (SECTION A.2.b.)

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Ethical Responsibilities in Implementing EBP
Relevant Codes

• Rehabilitation counselors will inform clients of
  their credentials, the purposes, goals,
  techniques, procedures, limitations, potential
  risks, and benefits of services to be performed,
  and other pertinent information. (SECTION
  A.3.a.)
• Rehabilitation counselors will be knowledgeable
  about referral resources and suggest appropriate
  alternatives. (SECTION A.9.d.)
• Rehabilitation counselors will provide the client
  with appropriate information and will support
  their efforts at self-advocacy both on an
  individual and an organizational level. (SECTION
  C.1.c.)

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Ethical Responsibilities in Implementing EBP
Relevant Proposed Codes

• Rehabilitation counselors use techniques/procedure
  s/modalities that are grounded in theory and/or
  have an empirical or scientific foundation.
  (SECTION D.6.a.)
• Rehabilitation counselors ensure that the
  resources used or accessed in counseling are
  credible and valid (e.g., Internet link, books
  used in bibliotherapy). (SECTION D.6.b.)

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Case Study 1

• Tom is a new consumer to your facility. The
  process at your facility is that everyone starts
  in the sheltered workshop and works their way to
  higher levels of independence and supported
  employment. Tom has worked in the community
  before, and based on his intake information, he
  appears appropriate for going directly into
  supported employment. In addition, you have read
  that research indicates that this is his best
  option for success. The treatment team is
  adamant that he starts in the workshop next week,
  because Thats the way we do things here.

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Case Study 2

• You are employed as a rehabilitation counselor.
  Your supervisor proudly tells everyone that he
  has not read a journal article since grad school
  30 years ago. You have seen him with clients and
  you believe this. You strongly believe his
  clients are suffering because they are missing
  out on the most effective EBP treatments.

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Case Study 3

• You are a brand new supervisor to a facility. You
  quickly realize your employees cannot embrace EBP
  because they dont even know what it is or where
  to start to look for it.

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Recommendations

• Change should involve 3 approaches
• Educational events and/or written materials
• Enabling techniques such as supervision
• Reinforcing strategies such as practice feedback
  or reimbursement

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Recommendations

• Package EBP so interventions are accessible and
  user-friendly to service providers
• Educate service providers about relevant
  knowledge and skills
• Evaluate the dynamics of the team to facilitate
  implementing the innovations
• (Corrigan, Steiner, McCracken, Blaser, Barr,
  2001)

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Relevant Portions of the Draft and Current Ethics
Codes

• Sections of relevant proposed and current ethics
  codes follow.

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Ethical Issues Draft Ethics Code

• D.6. SCIENTIFIC BASES FOR INTERVENTIONS
• a. TECHNIQUES/PROCEDURES/MODALITIES.
  Rehabilitation counselors use techniques/procedure
  s/ modalities that are grounded in theory and/or
  have an empirical or scientific foundation. When
  using techniques/procedures/modalities that are
  not grounded in theory and/or do not have an
  empirical or scientific foundation,
  rehabilitation counselors define the
  techniques/procedures as unproven or developing.
  They explain the potential risks and ethical
  considerations of using such techniques/procedures
  and take steps to protect the client from
  possible harm.

30
Ethical Issues Draft Ethics Code

• b. CREDIBLE RESOURCES. Rehabilitation counselors
  ensure that the resources used or accessed in
  counseling are credible and valid (e.g., Internet
  link, books used in bibliotherapy).

31
Ethical Issues Current Code

• SECTION A THE COUNSELING RELATIONSHIP
• A.1. CLIENT WELFARE
• c. CAREER AND EMPLOYMENT NEEDS. Rehabilitation
  counselors will work with their clients in
  considering employment that is consistent with
  the overall abilities, vocational limitations,
  physical restrictions, psychological limitations,
  general temperament, interest and aptitude
  patterns, social skills, education, general
  qualifications, and cultural and other relevant
  characteristics and needs of clients.
  Rehabilitation counselors will neither place nor
  participate in placing clients in positions that
  will result in damaging the interest and the
  welfare of clients, employers, or the public.

32
Ethical Issues Current Code

• A.2. RESPECTING DIVERSITY
• b. INTERVENTIONS. Rehabilitation counselors will
  develop and adapt interventions and services to
  incorporate consideration of clients cultural
  perspectives and recognition of barriers external
  to clients that may interfere with achieving
  effective rehabilitation outcomes.

33
Ethical Issues Current Code

• A.1. CLIENT WELFARE
• c. CAREER AND EMPLOYMENT NEEDS.
• Rehabilitation counselors will work with their
  clients in considering psychological limitations,
  general temperament, interest, and aptitude
  patterns, social skills, education, general
  qualifications, and cultural and other relevant
  characteristics and needs of the clients.
  Rehabilitation counselors will neither place nor
  participate in placing clients in positions that
  will result in damaging the interest and welfare
  of clients, employers, or the public.

34
Ethical Issues Current Code

• A.2. RESPECTING DIVERSITY
• b. INTERVENTIONS. Rehabilitation counselors will
  develop and adapt interventions and services to
  incorporate consideration of clients cultural
  perspectives and recognition of barriers external
  to clients that may interfere with achieving
  effective rehabilitation outcomes.

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Ethical Issues Current Code

• A.3. CLIENT RIGHTS
• a. DISCLOSURE TO CLIENTS. When counseling is
  initiated, and throughout the counseling process
  as necessary, rehabilitation counselors will
  inform clients, preferably through both written
  and oral means, of their credentials, the
  purposes, goals, techniques, procedures,
  limitations, potential risks, and benefits of
  services to be performed, and other pertinent
  information. Rehabilitation counselors will take
  steps to ensure that clients understand the
  implications of diagnosis, the intended use of
  tests and reports, fees, and billing arrangements.

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Ethical Issues Current Code

• A.9. TERMINATION AND REFERRAL
• d. REFERRAL UPON TERMINATION. Rehabilitation
  counselors will be knowledgeable about referral
  resources and suggest appropriate alternatives.

37
Ethical Issues Current Code

• A.10. COMPUTER TECHNOLOGY
• a. USE OF COMPUTERS. When computer applications
  are used in counseling services, rehabilitation
  counselors will ensure that
• The client is intellectually, emotionally, and
  physically capable of using the computer
  application
• The computer application is appropriate for the
  needs of the client
• The client understands the purpose and operation
  fo the computer applications
• A follow-up of client use of computer application
  is provided to correct possible misconceptions,
  discover inappropriate use, and assess subsequent
  needs

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Ethical Issues Current Code

• C.1. ADVOCACY
• c. EMPOWERMENT. Rehabilitation counselors will
  provide the client with appropriate information
  and will support their efforts at self-advocacy
  both on an individual and an organizational level.

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Ethical Issues Current Code

• D.1. PROFESSIONAL COMPETENCE
• a. BOUNDARIES OF COMPETENCE. Rehabilitation
  counselors will practice only within the
  boundaries of their competence, based on their
  education, training, supervised experience, state
  and national professional credentials, and
  appropriate professional experience.
  Rehabilitation counselors will demonstrate a
  commitment to gain knowledge, personal awareness,
  sensitivity, and skills pertinent to working with
  a diverse client population. Rehabilitation
  counselors will not misrepresent their role or
  competence to clients.

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Ethical Issues Current Code

• D.1. PROFESSIONAL COMPETENCE
• c. NEW SPECIALTY AREAS OF PRACTICE.
  Rehabilitation counselors will practice in
  specialty areas new to them only after
  appropriate education, training, and supervised
  experience. While developing skills in new
  specialty areas, rehabilitation counselors will
  take steps to ensure the competence of their work
  and to protect clients from possible harm.

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Ethical Issues Current Code

• D.1. PROFESSIONAL COMPETENCE
• d. RESOURCES. Rehabilitation counselors will
  ensure that the resources used or accessed in
  counseling are credible and valid (e.g., web
  link, books used in bibliotherapy, etc.).

42
Ethical Issues Current Code

• D.1. PROFESSIONAL COMPETENCE
• f. MONITOR EFFECTIVENESS. Rehabilitation
  counselors will take reasonable steps to seek
  peer supervision to evaluate their efficacy as
  rehabilitation counselors.

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Ethical Issues Current Code

• D.1. PROFESSIONAL COMPETENCE
• h. CONTINUING EDUCATION. Rehabilitation
  counselors will engage in continuing education to
  maintain a reasonable level of awareness of
  current scientific and professional information
  in their fields of activity. They will take
  steps to maintain competence in the skills they
  use, will be open to new techniques, and will
  develop and maintain competence for practice with
  the diverse and/or special populations with whom
  they work.

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References

• Bond, G., Becker, D., Drake, R., Rapp, C.,
  Meisler, N., Lehman, A et al. (2001).
  Implementing supported employment as an
  evidence-based practice. Psychiatric Services,
  52(3), 313-322.
• Cimera, R.E. (2007). Utilizing natural supports
  to lower the cost of supported employment.
  Research Practice for Persons with Severe
  Disabilities, 32(3), 184-189.
• Chronister, J.A., Cardoso, E., Lee, G.K., Chan,
  F., Leahy, M. (2005). Evidence-based practice
  in case management. In Chan, F., Leahy, M.,
  Saunders, J. (Eds). Case Management for
  Rehabilitation Health Professionals (2nd edition,
  Vol 1, pp. 369-387). Osage Beach, MO Aspen
  Professional Services.
• Corrigan, P., Steiner, L., McCracken, S.,
  Blaser, B., Barr, M. (2001). Strategies for
  Disseminating Evidence-Based practices for staff
  who treat people with serious mental illness.
  Psychiatric Services, 52(12), 1598-1606.
• Drake, R., Mueser, K., Torrey,W., Miller, A.,
  Lehman, A., Bond, G., Goldman, H., Leff, S.
  (2000). Evidence-based treatment of
  schizophrenia. Current Psychiatry Reports, 2,
  392-397.

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References

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