Research Based Principles of Vocational Rehabilitation for Psychiatric Disability

by Judith A. Cook, University at Chicago National Research & Training Center on Psychiatric Disability   

A series of principles has emerged from the research literature on vocational rehabilitation for people with severe mental illness and there is some consensus among experts about what works well for notable proportions of people. In what follows, these principles are reviewed and research supporting them is described.

The first principle is use of situational assessment in the evaluation of vocational skills and potential. Situational assessment is the longitudinal observation and rating of job behaviors and attitudes in actual or simulated work environments by a trained evaluator. Typical scales rate clients on aspects such as work quality (e.g., error rate), and quantity (e.g., % of industrial production rate), the ability to perform specific work tasks (e.g., alphabetizing), work attitudes (e.g., work motivation), and interpersonal relations (e.g., interaction with supervisor and coworkers). Situation-specific assessment is superior to both traditional psychiatric assessments, which generally are poor predictors of work outcomes (Anthony & Jansen, 1984), and to assessments designed for people with physical disabilities or mental retardation (Cook & Razzano, 1994). In one study, Anthony and his associates (Anthony, Rogers, Cohen & Davies, 1995) found that ratings from a situational assessment of 275 psychosocial rehabilitation clients significantly predicted employment status after receiving vocational services, even when controlling for symptoms, diagnosis, race, living arrangement, and lifetime hospitalizations. 

The second principle involves offering clients competitive or supported employment rather than sheltered or unpaid work. Enactment of this principle means that clients are rehabilitated by being placed and trained in community jobs in integrated settings, earning minimum wage or above. Wehman and Associates (Wehman & Moon, 1988) demonstrated convincingly that employment outcomes were significantly better for severely disabled individuals, including those with mental illness, when clients were rehabilitated through community placements into jobs at minimum wage or above in socially integrated settings. In a discriminant function analysis of 602 severely mentally ill clients following vocational rehabilitation (Cook & Razzano, 1995), those who had worked in sheltered workshops were significantly less likely to achieve later competitive employment, even controlling for demographic factors (ethnicity, gender, education), functional impairment, illness severity, length of time receiving services, and the nature of employment services received. 

The third principle involves rapid placement into paid community employment versus undergoing a lengthy prevocational training period. This principle acknowledges the importance of swiftly placing clients into community jobs in order to avoid demoralization that can accompany lengthy periods of job training and evaluation. Bond and Dincin (1986) showed that clients randomly assigned to an "accelerated" (versus gradual) job placement model were more likely to be employed at 9-month follow-up and to be working full-time at 15-month follow-up than those undergoing several months in unpaid, segregated work adjustment training. Another randomized study found that those supported employment clients who were placed in jobs immediately (Bond, Dietzen, Miller & McGrew, 1995) achieved superior outcomes (higher employment rate, higher job satisfaction) than those receiving prevocational services prior to their first jobs. 

A fourth principle involves the availability of ongoing vocational support that is appropriate to the individual's needs and situation. The continuous availability of vocational support following job placement is a hallmark of the supported employment model (Wehman, 1988). The idea is that the relapsing and remitting nature of severe mental illness means that clients should not be completely terminated from vocational supports upon attainment of a job, with the challenge being to avoid over-or under- serving successfully employed clients. In one study of 550 outpatients who received vocational rehabilitation (Cook & Rosenberg, 1994), a logistic regression analysis predicting employment status at 6-month follow-up after program exit found that ongoing support was a significant factor even controlling for client demographic features (age, education, ethnicity), prior work history, degree of functional impairment, hospitalization history, length of time in treatment, and types of job supports received. In another study of a model program at the same agency (Cook & Razzano, 1992), the addition of ongoing, as needed employment support services was followed by an increase in the agency-wide employment rate from 50% to above 80% throughout the 36 month program period. 

Yet another principle is tailoring job development and support to the client's individual preferences. To some extent this principle grows out of a reaction against one-size-fits-all approaches in some service delivery models of vocational rehabilitation in which clients have little say over the nature of the jobs they are offered and the level of intrusiveness of the job support they receive. Instead, research shows that clients have better outcomes when their services are designed to coincide with their preferences. For example, Becker and associates (Becker, Drake, Farabaugh & Bond, 1996) studied 143 clients with severe mental illness and found that people who obtained job in their preferred fields had twice the job tenure of those not employed in their preferred area. The former group also reported significantly greater job satisfaction than those with jobs in non-preferred fields. 

One final principle involves explicit acknowledgment and planning regarding how changes in clients' work status can alter their disability income and associated health care coverage. This principle addresses potential economic disincentives to achieve certain levels of paid employment that are inherent in the way disability entitlements are structured (Noble, 1998). A multivariate study of 1,634 male Vietnam-era veterans (Rosenheck, Frisman & Sindelar, 1995) found differences in likelihood and nature of employment according to the monthly amount the men were receiving. Veterans with psychiatric disabilities who received Veterans Administration work compensation of less than $500 a month were no less likely to work or earn less money than those who received no disability income. However, even controlling for illness status, functional impairment, and traditional labor force predictors such as ethnicity and education, veterans whose compensation was greater than $500 per month were significantly less likely to work and earned significantly less than all groups of eligibles. Interestingly, however, veterans with psychiatric disabilities were no less likely to be employed than their disabled counterparts with physical and other nonpsychiatric disabilities. 

To summarize, at the end of the 20th century there is a body of research evidence to guide psychosocial practice in the vocational rehabilitation of people with severe mental illness. The foregoing set of service delivery principles is echoed in published reviews on this topic, with slight variations, (Bond, Drake, Meuser & Becker, 1997; Cook & Pickett, 1995; Lehman, 1995; Mowbray et al., 1994). The interested reader should find these reviews useful in obtaining further information about state-of-the-art vocational rehabilitation services. References 

Anthony, W.A. & Jansen, M.A. (1984). Predicting the vocational capacity of the chronically mentally ill. American Psychologist, 39(5), 537-544. 

Anthony, W.A., Rogers, E.S., Cohen, M., & Davies, R. (1995), Relationships between psychiatric symptomatology, work skills, and future vocational performance. Psychiatric Services, 46(4), 353-358. 

Becker, D., Drake, R., Farabaugh, A., & Bond, G.R. (1996). Job preferences of clients with severe psychiatric disorders participating in supported employment programs. Psychiatric Services, 47(11), 1223-1226. 

Bond, G.R. & Dincin, J. (1986). Accelerating entry into transitional employment in a psychiatric rehabilitation agency. Rehabilitation Psychology: 32, 143-155. 

Bond, G.R. Dietzen, L., McGrew, J. & Miller, L. (1995). Accelerating entry into supported employment for persons with severe psychiatric disabilities. Rehabilitation Psychology, 40, 75-94, 1995. Bond, G.R., Drake, R., Mueser, K. & Becker, D. (1997). An update on supported employment for persons with severe mental illness. Psychiatric Services, 48(3), 335-346. Cook, J.A. & Pickett, S.A. (1995). Recent trends in vocational rehabilitation for people with psychiatric disability. American Rehabilitation, 20(4), 2-12. 

Cook, J. & Razzano, L.A. (1992). Natural vocational supports for persons with severe mental illness: Thresholds supported competitive employment program. In L. Stein (Ed.), Innovations in Mental Health Services, (pp. 23-42). (New Directions in Mental Health Services, 56), San Francisco, CA: Jossey-Bass. 

Cook, J.A. & Razzano, L.A. (1994). Predictive validity of the McCarron-Dial testing battery for employment outcomes among psychiatric rehabilitation clientele. Vocational Evaluation and Work Adjustment Bulletin, 27(2), 39-47. 

Cook, J.A. & Razzano, L.A. (1995). Discriminant function analysis of competitive employment outcomes in a transitional employment program. Journal of Vocational Rehabilitation, 5(2), 27-139. 

Cook, J.A. & Rosenberg, H. (1994). Predicting community employment among persons with psychiatric disability: A logistic regression analysis. Journal of Rehabilitation Administration, 18(1), 6-22. 

Lehman, A. (1995). Vocational rehabilitation in schizophrenia. Schizophrenia Bulletin, 21, 645-656. 

Mowbray, C., Rusilowski-Clover, G., Arnold, J, Allen, C., Harris, S., McCrohan, N & Greenfield, A. (1994). Project WINS: Integrating vocational services on mental health case management teams. Community Mental Health Journal, 30(4), 347-362. 

Noble, J. H. (1998). Policy reform dilemma in promoting employment of persons with severe mental illness. Psychiatric Services, 49(6), 775-781. 

Rosenheck, R., Frisman, L. & Sindelar, J. (1995). Disability compensation and work among veterans with psychiatric and nonpsychiatric impairments. Psychiatric Services, 46(4), 359-365. 

Wehman, P. (1988). Supported employment: Toward zero exclusion of persons with severe disabilities. In P. Wehman & M. Moon (Eds.),. Vocational rehabilitation and supported employment. (pp 3-14). Baltimore, MD: Faul H. Brookes. Wehman, P. & Moon, M. (1988),. Vocational rehabilitation and supported employment. Baltimore, MC: Paul H. Brookes. 

1 Reprinted from   IAPSRS Connection, Issue 4, September 1999 with permission of author.