Recent Research on Vocational Rehabilitation for Persons With Severe Mental Illness

Robert E Drake, Deborah R Becker, Gary R Bond


Curr Opin Psychiatry. 2003;16(4) 

In This Article

Factors that Influence Employment Outcomes

A major area of research interest in schizophrenia has been cognitive deficits. A study by Gold et al.[24] added some clarity to the inconsistent literature on cognition and employment by showing that cognitive measures (intelligence quotient, attention, working memory, and problem solving) did not predict competitive employment but did predict the total number of hours worked among clients who were employed. Another study by Lysaker et al.[25] showed that poor insight regarding illness was related to poorer ratings of work quality, work habits, cooperation, and personal presentation among clients with schizophrenia in a rehabilitation program.

Clients with co-occurring disorders, or dual diagnosis, also continue to be a focus of attention. These clients, who represent approximately 50% of the population of persons with severe mental illness, have traditionally been excluded from vocational services because of their substance abuse, despite some previous evidence that they do as well as single diagnosis clients in supported employment programs. Three new studies by Bell et al.,[26] Drebing et al.,[27] and Pickett-Schenk et al.[28] supported the finding that clients with dual diagnosis do as well or better than those with severe mental illness alone in vocational programs or in achieving competitive employment. In contrast, Lehman et al.[9] found that clients with severe mental illness and current substance abuse had worse vocational outcomes than those who did not have co-occurring substance abuse.

Client attitudes have also been identified as an important factor in employment. Dorio et al.[29] interviewed long-term (greater than 1 year) and short-term (less than 1 year) workers retrospectively and found that long-term workers were less disabled by illness, more positive in general, and more realistic about vocational goals.

Several studies addressed the impact of the Americans with Disabilities Act. MacDonald-Wilson et al.[30] described accommodations provided for a large number of clients with psychiatric disabilities in supported employment programs. The majority of accommodations related to changes in personnel to provide assistance or to change interactions, or to alter company procedures such as activities or operations. Accommodations rarely involved direct expenditures; rather they affected indirect costs related to, for example, reallocations of time and extra supervision. Using ethnographic methods, Francis et al.[31] found that legislation requiring accommodations and giving employees the right to sue also encouraged employers to emphasize performance obligations. Studying employment within the mental health system, they noted that the field is shifting away from a beneficent model to one with an equally strong emphasis on accountability. In a study of employment discrimination complaints filed with the Equal Employment Opportunity Commission under the Americans with Disabilities Act, Moss et al.[32] found that individuals with such complaints based on psychiatric disabilities were slightly less likely to be referred for mediation and that employers were significantly less willing to mediate with claimants than with those who had non-psychiatric disabilities. When employers agreed to mediation, however, cases were usually settled.


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