Place first, then train: an alternative to the medical model of psychiatric rehabilitation.
Corrigan, Patrick W. ; McCracken, Stanley G.
There are two overarching goals to psychiatric rehabilitation: Help
people with disabilities achieve (1) work and (2) independent living
goals in the real world. Over the past 30 years, two paradigms emerged
to guide rehabilitation professionals in helping people achieve these
goals. The traditional paradigm is a medical or clinical model called
"train-place," in which people are thoroughly trained to
manage the symptoms and dysfunctions of their mental illness and then
placed in a real-world job or home. A recently developed paradigm,
called "place-train," instead promotes rapid placement of
people with disabilities in real-world work and housing, followed by in
vivo support, resources, and training that help the person successfully
remain in those settings.
The train-place approach to rehabilitation is dominated by concerns
about relapse if a person with mental illness is too quickly placed in a
real-world setting with its commensurate demands and stresses.
Proponents of this model propose a continuum of care through which a
person with a disability cautiously progresses before being placed in a
job or an independent living situation. Place-train is consistent with a
core value of social work--client self-determination--by recognizing the
individual's desire for independence and providing in vivo
assistance (NASW, 1996; Reamer, 2001). In this article, we examine
research on the two models. Place-train makes sense in relation to
social work's perspective on psychiatric services; hence, we
juxtapose some of the basic assumptions of place-train to fundamental
assumptions of social work practice for people with psychiatric
disabilities.
TRAIN-PLACE MODELS FOR PSYCHIATRIC REHABILITATION
Medical or clinical models have evolved to address psychiatric
disabilities that block life goals related to work and independent
living. Clinical models, as outlined in practice guidelines developed by
the American Psychological Association (Sanderson & Woody, 1995) and
the American Psychiatric Association (1997, 2000), largely focus on
medication and psychosocial approaches that help people cope with the
symptoms and disabilities that cause psychological distress and that
interfere with life goals. Note, however, that these interventions are
not train-place per se. Common to traditional train-place approaches is
the assumption that people have a biological disorder that causes
"deficits" that prevent them from fitting into the kind of
work and independent living situations where life goals may be achieved.
Hence, individuals need preparatory services to learn the skills and
obtain the supports and resources--both psychopharmacological and
interpersonal--to deal with the demands of working and living
independently.
Failure to receive the preparatory services in safe and protected
environments (for example, hospitals and clinics) may result in two
problems. First, individuals may be unable to cope with the demands of
work or independent living because they have not learned the full set of
skills needed to offset their symptoms and dysfunctions. This kind of
failure may reinforce their sense of limited self-efficacy and lead to a
reluctance to pursue similar goals in the future. Second, this kind of
stress may exacerbate the symptoms and disabilities. Individuals who
have a biologically determined stress vulnerability are likely to
relapse in stressful situations like those associated with real-world
work and independent living (Bebbington, Bowen, Hirsch, & Kuipers,
1995; Goldstein, 1987). A train-place philosophy supports a conservative
approach to treatment, moving the person to more demanding situations
only when they have demonstrated the ability to handle preceding steps.
How might the train-place paradigm manifest itself in work and
independent living programs? Concerns about the ability to handle job
stress led to the development of sheltered workshops (Sauter &
Nevid, 1991). In theory, individuals receiving services in these
protected settings are trained on a variety of work adjustment skills,
such as working under time pressures, with a demanding supervisor, in
sometimes loud and busy environments. Consumers of these services need
to master these skills before they are ready to handle the stresses of
the next level, transitional work stations in regular business. Similar
concern has governed train-place approaches to independent living. Many
individuals discharged from hospitals are believed to be unable to
handle the demands of living alone, such as managing money, cooking,
shopping, and personal hygiene. Hence, they are placed in skilled
nursing facilities where 24-hour custodial services are available and
where independent living skills can be learned (Oliver & Mohamad,
1992).
Train-Place Continuum of Care
Typically, several training steps are provided in a train-place
program, going from the safest and most restrictive environment to the
real-world work or independent living setting. Called continuums of
care, these service ladders are a way to make sense of the relationship
between treatment possibilities and life-demanding situations (Bachrach,
1982, 1993; Schreter, Sharfstein, & Schreter, 1997). Continuums of
care serve several purposes, including psychological access (a graduated
set of services to mitigate fear of failure), affordable services,
reasonable geographic proximity, and long-term availability (Bachrach,
1982, 1988). Perhaps the purpose most relevant to this article's
thesis is definition of a ladder of treatment situations through which a
person can safely progress. Movement along this ladder is defined by
completion of training goals spelled out in the preceding stage. The
idea of care continuums is popular; such continuums have been proposed
for adults with serious mental illness (Bachrach, 1982) and dual
disorders (Minkoff, 2001), children with psychiatric disabilities
(Bickman et al., 1995), seniors struggling with mental illness (Mintzer
et al., 1997), and adults challenged by substance abuse disorders
(Miller, 1995) or borderline personality disorder (Quaytman &
Sharfstein, 1997).
Problems with Continuums of Care
Despite its theoretical promise, there are several limitations to
continuums of care (Carling, 1995).Transitional programs in a continuum
of care typically do not focus on independent work and living in the
real world. Instead, they teach skills that are most relevant to living,
working, and socializing in supervised settings. Each transition is a
significant adjustment where individuals cut their ties from one group
and replace these connections with people in a different environment.
This kind of chronic dislocation would be upsetting and disorienting for
anyone, let alone people with mental illness (Miller & Rahe, 1997).
Another concern is consumers, who have expressed dissatisfaction with
stepwise services. Research suggests most consumers prefer to quickly
move into their own apartment or house rather than to move up the ladder
from protected housing to living independently (Tanzman, 1993).
PLACE-TRAIN MODELS
The social work profession embraces some of the assumptions of a
medical model. A major function of social work is to help people find
relief from psychological distress (Gambrill, 1997). Most social work
professionals would consider the biological bases (for example, genetic
etiology and neurochemical correlates of positive symptoms of
schizophrenia) and psychological history of the individual in developing
a plan that would yield relief from distress. Hence, notions of
train-place are not entirely foreign to the training and experience of
clinical social workers. Nevertheless, a focus on the individual and
biological level is only one of many levels through which people and
their problems may be understood. Equally important from the social work
perspective is the impact of community and societal factors on the
disabilities of people with mental illness (Turnbull & Cahalane,
1994). The ecosystems perspective of Meyer (1983), for example, views
interventions that yield a better adaptive fit between the person and
his or her environment as central to social work. This can include
modifying the environment and helping people develop coping and
adaptation strategies for that environment. Related to these
system's level of analyses is a concern that disparity between
social groups, and the prejudice and discrimination that results from
this disparity, may be an important cause in an individual's
problem and psychological distress (Gambrill). Concerns like these led
to a place-train paradigm for psychiatric rehabilitation.
Recognizing that the problems of real-world work and independent
housing rest within people's community as well as their mental
illness, innovators have proposed place-train programs as more effective
for helping people achieve their life goals (Bond, Drake, Mueser, &
Becker, 1997; Wehman, 1986). The essence of this paradigm is to first
place individuals in real-world situations that help them meet their
vocational or independent living goals and then provide training and
support to achieve these goals. In this way, the communal and societal
factors that impede work and housing goals are no longer abstractions
but immediate and present issues that must be dealt with. For example,
instead of first completing a sheltered workshop, an individual would
immediately be placed on the job, which meets their needs for industry,
accomplishment, income, and interactions. Instead of residing in a group
home until they show they can succeed independently, people with
psychiatric disabilities would be placed in an apartment or house with
roommates or family members of their choice. Place-train programs
address consumer dissatisfaction with lengthy prevocational and
group-home programs that forestall actual work or independent living
(Bond, 1998; Wehman, 1986,1988). The real-world demands of work or
housing are likely to make skill learning and adjustment more
compelling.
Despite such benefits, the risk in place-train approaches, from the
traditional perspective, is obvious; people will be placed in situations
with which they are unable to cope. Instead of making great strides
towards personal goals, they become overwhelmed and relapse. This is one
protection offered by a continuum of care. Yet, the research does not
seem to support this caution.
Place-Train Programs and Work Goals
Several studies have examined the impact of programs that
incorporate place-train principles in work goals (Table 1). Our purpose
is not to review the methods or outcomes of these studies in depth; four
recent reviews have done this (Bond et al., 1997, 2001; Drake, 1998;
Drake, Becket, Clark, & Mueser, 1999). We outline the body of
evidence supporting place-train services and summarize key findings for
our assertions about place-train programs. Nevertheless, the reader
should be critical of our brief summary or of any review of the
empirical literature. Readers should note methodological characteristics
of a study when judging its significance, including type of research
design (experimental versus quasi-experimental), selection of outcome
measures (and whether they reflect independent living goals as well as
symptom remission), inclusion and exclusion criteria, fidelity
assessment (to ensure the intervention of interest is conducted per
evidence-based manuals), and length of follow-up.
Research suggests that the rate of employment almost tripled for
participants in place-train vocational programs from the 10 percent
baseline commonly found in individuals with psychiatric disabilities who
do not receive some kind of supported employment services (Table 1, Bond
et al., 1997). Participants in these programs earned a significantly
greater income and kept their jobs much longer than did comparison
groups. Of equal importance, these kinds of programs have not been found
to lead to greater hospitalization (Bond et al., 1997). This last
finding contradicts the train-place fear that demands of competitive
work will overwhelm individuals with limited coping skills, exacerbated
symptoms, and require rehospitalization.
Several studies have examined the efficacy of train-place versus
place-train employment programs. Bond and colleagues (1995) found that
59 percent of participants in a place-train program obtained competitive
employment compared with 29 percent in a train-place program. Results of
a second study showed no difference in rates of employment between
place-train and train-place programs (Bond & Dincin, 1986). However,
duration of employment was significantly greater for participants of the
place-train service. It might be expected that employment rates and
duration of employment would equalize across groups when the train-place
participants have spent time in the training program and "caught
up" to the place-train participants. However, three-year follow-up
data in Bond and colleagues' (1995) study showed the place-train
participants working at a significantly greater rate. Findings from the
recently completed Center for Mental Health Services (CMHS) Employment
Intervention Demonstration Program further support the benefits of
supported employment programs compared with the train-place format.
Results of the CMHS study completed in South Carolina (Meisler, Gold,
Kelleher, & Williams, 2000) and Connecticut (Mueser, Clark, &
Drake, 2000) showed participation in place-train programs led to far
greater return to competitive employment with no negative effects in
terms of symptoms or disabilities. Despite these promising data, a
recent study suggests a limitation to place-train programs. In an
exploratory study, Rollins and colleagues (2002) reported that
participants of train-place programs reported better relationships with
colleagues than participants of supported-employment programs in which
people were rapidly placed on the job.
Another set of studies examined what happens when the continuum of
care is challenged. These investigations evaluated the effect of
changing day treatment programs to place-train vocational programs
(Bailey, Ricketts, Becker, Xie, & Drake, 1998; Drake et al., 1994;
Drake, B ecker, Biesanz,Wyzik, & Torrey, 1996). If the cautions of
the train-place approach are correct,we might hypothesize that the
radical restructuring would yield significant exacerbation of symptoms
and disabilities. Findings across these studies showed little change in
the status of an individual's disabilities but three times as many
place-train participants obtained competitive work compared with those
in more traditional programs.
Place-Train Programs and Educational Goals
Before entering the job market, many people with psychiatric
disabilities seek an education that will provide them the knowledge and
skills for a personally fulfilling vocation. A variety of place-train
programs support people with psychiatric disabilities in school settings
while they pursue educational goals (Table 1). Although studies that
have tested these programs do not show the same rigor as research on
supported employment (for example, lack of randomized control groups),
their findings suggest that place-train approaches help people stay in
school and maintain a respectable grade point average. Moreover,
research has not reported that participants in supported education
programs suffer a relapse.
Place-Train Approaches to Independent Living
Just as in the work and educational setting, independent living
programs have been developed to help people with psychiatric
disabilities achieve goals related to housing and community
reintegration (Table 1). Two similar, yet distinct, research programs
addressed place-train programs for independent living: supported-housing
programs and programs of assertive community treatment (PACT).
Supported-housing programs spelled out many of the basic principles of
the place-train approach, including placing people with psychiatric
disabilities in real-world housing with the roommates of their choice
and then providing comprehensive support to keep them in those programs
(Ogilvie, 1997). Although research on supported-housing programs has not
typically involved experimental paradigms, findings have shown that
participants are able to live independently in these programs without
risking significant exacerbation of their disorders (Carling, 1995).
A more rigorous body of research has been completed on the PACT
model, first outlined and tested by Stein and Test (1980) in the 1970s.
Three of its principles parallel the place-train paradigm: (1) Services
should be provided in settings that are convenient and relevant to the
consumer (for example, their apartment, church, or a local restaurant).
(2) The breadth of services needed to promote independent living should
be provided by the PACT team. (3) Services should be provided for an
unlimited period of time. Recent reviews of PACT have listed 21
investigations that included randomized controlled trials (Mueser, Bond,
Drake, & Resnick, 1998; Phillips et al., 2001) (Table 1). Interested
readers should see the reviews for a more complete list and analysis.
Two interesting trends are evident in these studies. First,
returning people to their community seemed to yield marked decrements in
rehospitalization rates. These effects seemed to occur regardless of a
person's diagnosis, recent hospitalization history, prior level of
functional impairment, or housing status (for example, homeless).
Second, the group of studies showed PACT to have effects on a few other
outcome variables. Most notable among these was housing
stability--individuals in PACT were able to succeed in the residence of
their choice--and quality of life. Also interesting was the finding that
PACT had little effect on social variables such as vocational
functioning and involvement with the legal system. This is consistent
with the specificity principle of place-train approaches; namely,
positive effects of place-train services are related to the setting and
goals on which these services are focused.
Despite the promising evidence of PACT and other place-train
programs, there are several limitations and caveats to be noted.
Research on PACT has its criticisms, such as whether it is basically a
coercive intervention and whether its outcomes are limited to reduced
hospitalization or include better ability to attain independent living
goals (Gomory, 1999, 2001). Phillips and colleagues (2001) listed
several barriers to realizing place-train models, including redirecting
public funds to support these programs, transforming community
organizations into effective service teams, and changing the
community's expectations of mental illness so that stigma and other
barriers to life opportunities are removed.
ROLE OF PLACE-TRAIN IN RECOVERY
A paradigm shift occurred recently in understanding the course of
individuals with psychiatric disability: Recovery is not only a
possibility, but the goal (Ralph & Corrigan, 2004). The notion of
recovery is contrary to the traditional perspective of psychiatry,
summarized in the classic nosology of Kraepelin (1913) that manifests
itself in various forms of modern psychiatry (American Psychiatric
Association, 1980, 1987). Namely, serious mental illnesses such as
schizophrenia are marked by a progressively downhill course such that
most people end up debilitated and unable to care for themselves.
Careful research does not support the traditional perspective. Long-term
follow-up studies suggest that two-thirds of people with serious mental
illness are able to leave the mental health system and obtain most
independent living and vocational goals (Harding, 1988; Moller & von
Zerssen, 1995).
Train-place and place-train programs have somewhat different views
of recovery. Service providers conducting train-place programs seem to
view recovery as an outcome that must be accomplished before vocational
and independent living goals can be achieved (Ralph & Corrigan,
2004). The outcome is marked by a period of time when symptoms and
disabilities are controlled or absent. Hence, the goal of psychosocial
treatment programs is to help people recover from their psychiatric
symptoms and disabilities so they can be placed in demanding work and
independent living settings. Inherent in this approach is the danger of
paternalizing, because treatment professionals frequently believe they
are to determine when the individual is ready for independence. It is
important to note that providers in place-train programs may fall victim
to similar paternalistic notions, against which they must also be
vigilant.
Place-train proponents view recovery more as a process than as an
outcome. According to this perspective, recovery occurs when individuals
pursue their personal goals despite experiencing symptoms and
disabilities (Deegan, 1988; Ralph & Corrigan, 2004). Defining
recovery as a process has two advantages over the outcome view. First,
it divorces recovery from benchmark changes in symptoms and disability.
Instead, recovery is defined as the normal capacity to achieve the
breadth of opportunities that define individuals as human beings. In
this way, recovery as a process provides an avenue to achieve goals for
individuals with serious mental illness who may never be totally free of
symptoms.
Second, this definition changes the focus of services. Viewing
recovery as an outcome places the individual with his or her problems at
the center of treatment (Anthony, 1993). The goal is to help the person
fit better in the worlds of work and independent living. Viewing
recovery as a process suggests that individuals, their goals, and the
disabilities that block these goals can only be understood in the
context of the surrounding environment and community. Hence, recovery at
work only happens when the person is on the job at real-world
employment. Recovery in independent living is realized when individuals
are in homes of their own.
The role of the community is different in the train-place and
place-train paradigms (Rapp, Shera, & Kisthardt, 1993). The goal of
the train-place provider is to teach the person how to fit into his or
her community; individuals need to learn how to manage their
disabilities so they can achieve their goals in a demanding society.
Place-train providers believe the community needs to be a partner in
helping people recover. They look to the spirit of the Americans with
Disabilities Act of 1990 (P. L. 101-336), which requires employers to
provide reasonable accommodations so that employees with serious mental
illness can be successful on the job. These reasonable accommodations
include reallocating marginal job functions, permitting the use of
accrued paid leave or unpaid leave for treatment, changing work
schedules, and providing reassignment to a position that more closely
parallels the abilities of the employee with disabilities (Equal
Employment Opportunity Commission, 1999). The different descriptions
proffered by place-train and train-place models clearly approach
psychiatric services and recovery from distinct perspectives that
require continued in-depth analysis and study.
Table 1: Selected Studies that Examined Place-Train Programs in Three
Domains: (1) Employment, (2) Education, and (3) Independent Living
Place--Train
Research Reference Service Research Outcomes
Employment
Bond & Dincin, 1986 Placement in Better rates of
(RCT) competitive job paid full-time
environment employment for
longer periods of
time
Bond, McGrew, & Rapid referral to More people re-
Feckette, 1995 (RCT) supported employ- turned to work
ment program for longer pe-
riods of time and
earned more money
Drake et al., 1994 Comprehensive Doubled the
place--train return-to-work
program rate
Drake, Becker, Biesanz, & Comprehensive Increased
Wyzik, 1996 place--train return-to-work
program rate
Drake, McHugo, Becker, Comprehensive More people re-
Anthony, & Clark, 1996 place--train turned to work
(RCT) program for longer
periods of time
and earned more
money
* Drake, McHugo et al., Comprehensive More people re-
1999 (RCT) place--train turned to work
program for longer
periods of time
* Lehman et al., 2002 Comprehensive More people re-
(RCT) place--train turned to work,
program but not neces-
sarily for longer
periods of time
Meisler et al., 2000 (RCT) Comprehensive More people re-
place--train turned to work
program
Mueser et al., 2000 (RCT) Comprehensive More people re-
place--train turned to work
program
Education
* Cook & Solomon, 1993 Comprehensive More people re-
place--train ported better
program educational
functioning
* Mowbray, 2000 Comprehensive More people com-
place--train pleted classes
program and reported
higher quality of
life
Unger & Pardee, 2002 Comprehensive More people com-
place--train pleted classes
education program with better than
a 3.0 grade-point
average
Independent Living
Stein & Test, 1980 (RCT) PACT Improvements in
hospitalization,
symptoms, social
adjustment,
housing stabi-
lity, medication
compliance, voca-
tional function-
ing, and quality
of life
* Bond, Miller, Krumweid, PACT Improvement only
& Ward, 1988 (RCT) in hospitaliza-
tion
* Bond et al., 1990 (RCT) PACT Improvement in
hospitalization,
symptoms, housing
stability jail,
arrests, and
vocational
functioning
* Lehman, Postrado, & PACT No significant
Rachuba, 1993 (RCT) improvement found
in any measure
* Lehman, Dixon, Kernan, PACT Improvement in
DeForge, & Postrado, hospitalization,
1997 (RCT) symptoms, housing
stability, jail,
arrests, and
vocational func-
tioning
* Marks et al., 1994 (RCT) PACT Improvement in
hospitalization,
symptoms, social
adjustment, and
patient and
family satisfac-
tion
* Rosenheck, Neale, & PACT Improvement in
Frisman, 1994 (RCT) hospitalization
* Shern et al., 1996 (RCT) PACT Improvement in
symptoms, housing
stability, and
quality of life
* Solomon & Draine, 1995 PACT No significant
improvement found
in any measure
* Sosin, Bruni, & Reidy, Supported housing Higher level of
1995 residential
stability
* Test, 1992 (RCT) PACT Improvement in
hospitalization
* Tsemberis, 1999 Supported housing Longer retention
in housing
Notes: RCT = randomized control trial. PACT = Programs of Assertive
Community Treatment. * Denotes that study was not cited in the text.
REFERENCES
American Psychiatric Association. (1980). Diagnostic and
statistical manual of mental disorders (3rd ed.). Washington, DC:
Author.
American Psychiatric Association. (1987). Diagnostic and
statistical manual of mental disorders (3rd ed., rev.) Washington, D.C:
Author.
American Psychiatric Association. (1997). Practice guideline for
the treatment of patients with schizophrenia. American Journal of
Psychiatry, 154 (Suppl. 4), 1-63.
American Psychiatric Association. (2000). Practice guideline for
the treatment of patients with major depressive disorder. American
Journal of Psychiatry, 157 (Suppl. 4), 1-45.
Americans with Disabilities Act of 1990, P. L. 101-336, 104 Stat.
327.
Anthony, W. A. (1993). Recovery from mental illness: The guiding
vision of the mental health service system in the 1990s. Psychosocial
Rehabilitation Journal, 16, 11-23.
Bachrach, L. L. (1982). Program planning for young adult chronic
patients. New Directions for Mental Health Services, 14, 99-109.
Bachrach, L. L. (1988). On exporting and importing model programs.
Hospital and Community Psychiatry, 39, 1257-1258.
Bachrach, L. L. (1993). Continuity of care and approaches to case
management for long-term mentally ill patients. Hospital and Community
Psychiatry, 44, 465-468.
Bailey, E. L., Ricketts, S. K., Becker, D. R., Xie, H., &
Drake, R. E. (1998). Do long-term day treatment clients benefit from
supported employment?. Psychiatric Rehabilitation Journal, 22, 24-29.
Bebbington, P. E., Bowen, J., Hirsch, S. R., & Kuipers, E.A.
(1995). Schizophrenia and psychosocial stresses. In S. R. Hirsch &
D. R. Weinberger (Eds.), Schizophrenia (pp. 587-604). Oxford: Blackwell
Science Ltd.
Bickman, L., Guthrie, P. R., Foster, E. M., Lambert, E.W,
Summerfelt, W T., Breda, C. S., & Heflinger, C.A. (1995). Evaluating
managed mental health services: The Fort Bragg experiment. NewYork:
Plenum Press.
Bond, G. (1998). Principles of the individual placement and support
model: Empirical support. Psychiatric Rehabilitation Journal, 22, 11-23.
Bond, G., Becker, D. R., Drake, R. E., Rapp, C., Meisler, N.,
Lehman, A., Bell, M., & Blyler, C. (2001). Implementing supported
employment as an evidence-based practice. Psychiatric Services, 52,
313-322.
Bond, G. R., & Dincin, J. (1986). Accelerating entry into
transitional employment in a psychosocial rehabilitation agency.
Rehabilitation Psychology, 31, 143-155.
Bond, G. R., Drake, R. E., Mueser, K.T., & Becker, D. R.
(1997). An update on supported employment for people with severe mental
illness. Psychiatric Services, 48, 335-346.
Bond, G. R., McGrew, J. H., & Fekette, D. M. (1995). Assertive
outreach for frequent users of psychiatric hospitals: A
meta-analysis.Journal of Mental Health Administration, 22, 4-16.
Bond, G. R., Miller, L. D., Krumwied, R. D., & Ward, R. S.
(1988). Assertive case management in three CMHCs: A controlled study.
Hospital and Community Psychiatry, 39, 411-418.
Bond, G. R., Witheridge, T. F., Dincin, J., Wasmer, D., Webb, J.,
& DeGraaf-Kaser, R. (1990). Assertive community treatment for
frequent users of psychiatric hospitals in a large city: A controlled
study. American Journal of Community Psychology, 18, 865-891.
Carling, P.J. (1995). Return to community: Building support systems
for people with psychiatric disabilities. New York: Guilford Press.
Cook, J., & Solomon, M. (1993). The Community Scholar Program:
An outcome study of supported education for students with severe mental
illness. Psychosocial Rehabilitation Journal, 17, 83-97.
Deegan, P. E. (1988). Recovery: The lived experience of
rehabilitation. Psychosocial Rehabilitation Journal, 11, 11-19.
Drake, R. E. (1998). A brief history of the individual placement
and support model. Psychiatric Rehabilitation Journal, 22, 3-7.
Drake, R. E., Becker, D. R., Biesanz,J. C., Torrey, W. C., McHugo,
G. J., &Wyzik, P. F. (1994). Rehabilitative day treatment vs.
supported employment: I. Vocational outcomes. Community Mental Health
Journal, 30, 519-532.
Drake, R. E., Becket, D. R., Biesanz, J. C.,Wyzik, P. F., &
Torrey, W. C. (1996). Day treatment versus supported employment for
persons with severe mental illness: A replication study. Psychiatric
Services, 47, 1125-1127.
Drake, R. E., Becker, D. R., Clark, R. E., & Mueser, K.T.
(1999). Research on the Individual Placement and Support model of
supported employment. Psychiatric Quarterly, 70, 289-301.
Drake, R. E., McHugo, G. J., Bebout, R. R., Becker, D. R., Harris,
M., Bond, G. R., & Quimby, E. (1999). A randomized clinical trial of
supported employment for inner-city patients with severe mental
disorders. Archives of General Psyctliatry, 56, 627-633.
Drake, R. E., McHugo, G.J., Becker, D. R., Anthony, W. A., &
Clark, R. E. (1996). The New Hampshire study of supported employment for
people with severe mental illness. Journal of Consulting & Clinical
Psychology, 64, 391-399.
Equal Employment Opportunity Commission. (1999). EEOC enforceraent
guidance on reasonable accomodation and undue hardship under the
Americans with Disabilities Act (EEOC Publication No. 915.002).
Washington, DC: Author.
Gambrill, E. (1997). Social upork practice : A critical
thinker's guide. New York: Oxford University Press.
Goldstein, M. J. (1987). Psychosocial issues. Schizophrenia
Bulletin, 13, 151-171.
Gomory, T. (1999). Programs of Assertive Community Treatment
(PACT): A critical review. Ethical Human Sciences and Services, 1,
147-163.
Gomory, T. (2001). A critique of the effectiveness of assertive
community treatment [Letter]. Psychiatric Services, 52, 1394.
Harding, C. M. (1988). Course types in schizophrenia: An analysis
of European and American studies. Schizophrenia Bulletin, 4, 633-642.
Kraepelin, E. (1913). Lectures on clinical psychiatry (3rd ed.) New
York: William Wood.
Lehman, A. E, Dixon, L. B., Kernan, E., DeForge, B. R., &
Postrado, L. T. (1997). A randomized trial of assertive community
treatment for homeless persons with severe mental illness. Archives of
General Psychiatry, 54, 1038-1043.
Lehman, A. F., Goldberg, R., Dixon, L. B., McNary, S., Postrado,
L., Hackman, A., & McDonnell, K. (2002). Improving employment
outcomes for persons with severe mental illnesses. Archives of General
Psychiatry, 59, 165-172.
Lehman, A. F., Postrado, L. T., & Rachuba, L. T. (1993).
Convergent validation of quality of life assessments for persons with
severe mental illnesses. Quality of Lye Research, 2, 327-333.
Marks, I. M., Connolly, J., Muijen, M., Audini, B., McNamee, G.,
& Lawrence, R. E. (1994). Home-based versus hospital-based care for
people with serious mental illness. British Journal of Psychiatry, 165,
179-194.
Meisler, N., Gold, P. B., Kelleher, J., & Williams, O. (2000,
October). Rural-based supported employment approaches: Results from the
South Carolina site of the Employment Intervention Demonstration
Project. Paper presented at the Fourth Biennial Research Seminar on
Work, Matrix Research Institute, Philadelphia.
Meyer, C. N. (Ed.). (1983). Clinical social work in the ecosystems
perspective. New York: Columbia University Press.
Miller, M.A., & Rahe, R. H. (1997). Life changes scaling for
the 1990s. Journal of Psychosomatic Research, 43, 279-292.
Miller, N. S. (Ed.). (1995). Treatment of the addictions:
Applications of outcome research for clinical management. Binghamton,
NY: Haworth Press.
Minkoff, K. (2001). Level of care determination for individuals
with co-occurring psychiatric and substance disorders. Psyclliatric
Rehabilitation Skills, 5, 163-197.
Mintzer, J. E., Colenda, C., Waid, L. R., Lewis, L., Meeks, A.,
Stuckey, M., Bachman, D. L., Saladin, M., & Sampson, R. R. (1997).
Effectiveness of a continuum of care using brief and partial
hospitalization for agitated dementia patients. Psychiatric Services,
48, 1435-1439.
Moeller, H., & von Zerssen, D. (1995). Self-rating procedures
in the evaluation of antidepressants: Review of the literature and
results of our studies. Psychopathology, 28, 291-306.
Mowbray, C. (2000). The Michigan Supported Education Program.
Psychiatric Services, 51, 1355-1357.
Mueser, K. T., Bond, G. R., Drake, R. E., & Resnick, S. G.
(1998). Models of comnunity care for severe mental illness: A review of
research on case management. Schizophrenia Bulletin, 24, 37-74.
Mueser, K.T., Clark, R. E., & Drake, R. E. (2000, October). A
comparison of the individual placement and support model with the
psychosocial rehabilitation approach to vocational rehabilitation for
consumers with severe mental illness: The results of a controlled trial.
Paper presented at the Fourth Biennial Research Seminar on Work, Matrix
Research Institute, Philadelphia.
National Association of Social Workers. (1996). Code of ethics.
Washington, DC: Author.
Ogilvie, R. J. (1997). The state of supported housing for mental
health consumers: A literature review. Psychiatric Rebabilitation
Journal, 21, 122-131.
Oliver, J. P, & Mohamad, H. (1992). The quality of life of the
chronically mentally ill: A comparison of public, private, and voluntary
residential provisions. British Journal of Social Work, 22,391-404.
Phillips, S. D., Burns, B. J., Edgaer, E. R., Mueser, E. T.,
Linkins, K. W., Rosenheck, R. A., Drake, R. E., & McDonel Herr, E.
C. (2001). Moving assertive community treatment into standard practice.
Psychiatric Services, 52, 771-779.
Quaytman, M., & Sharfstein, S. S. (1997). Treatment for severe
borderline personality disorder in 1987 and 1997. American Journal of
Psychiatry, 154, 1139-1144.
Ralph, R. O., & Corrigan, P. W. (2004). Recovery in mental
ilhwss: Broadening our understanding of wellness. Washington, DC:
American Psychological Association Press.
Rapp, C. A., Shera, W., & Kisthardt, W. (1993). Research
strategies for consumer empowerment of people with severe mental
illness. Social Work, 38, 727-735.
Reamer, F. G. (2001). Ethics and values in clinical and comnmnity
social work practice. In H. E. Briggs & K. Corcoran (Eds.), Social
work practice: Treating common client pralderas (pp. 85-106). Chicago:
Lyceum.
Rollins, A. L., Mueser, K. T., Bond, G. R., & Becker, D. R.
(2002). Social relationships at work: Does the employment model make a
difference? Psychiatric Rehabilitation Journal, 26, 51-61.
Rosenheck, R., Neale, M., & Frisman, M. (1994). Issues in
estimating the cost of innovative mental health programs. Psychiatric
Quarterly, 66, 1-23.
Sanderson, W. C., & Woody, S. (1995). Manuals for empirically
validated treatments: A project of the task force on psychological
interventions. Oklahoma City: American Psychological Association,
Division of Clinical Psychology.
Sauter, A. W., & Nevid, J. S. (1991). Work skills training with
chronic schizophrenic sheltered workers. Retlabilitation Psuhology, 36,
255-264.
Schreter, R. K., Sharfstein, S. S., & Schreter, C. A. (Eds.).
(1997). Managing care, not dollars: The continuum of mental health
services. Washington, DC: American Psychiatric Press.
Shern, D. L.,Tsemberis, S., Anthony, W, Lovell, A. M., Richmond,
L., Felton, H. C.,Winarski, J., & Cohen, M. (1996). Serving street
dwelling individuals with psychiatric disabilities: Outcomes of a
psychiatric rehabilitation clinical trial. Unpublished manuscript,
University of South Florida, Tampa.
Solomon, P., & Draine, J. (1995). The efficacy of a consumer
case management team: Two-year outcomes of a randomized trial. Journal
of Mental Health Administration, 22, 126-134.
Sosin, M. R., Bruni, M., & Reidy, M. (1995). Paths and impacts
in the progressive independence model: A homelessness and substance
abuse intervention in Chicago. Journal of Addictive Disease, 14, 1-20.
Stein, L., & Test, M. (1980). Alternatives to mental hospital
treatment: I. Conceptual model, treatment program, and clinical
evaluation. Archives of General Psychiatry, 37, 392-397.
Tanzman, B. H. (1993). Researching the preferences for housing and
supports: An overview of consumer preference surveys. Hospital and
Community Psychiatry, 44, 450-455.
Test, M.A. (1992).Training in community living. In R. P. Liberman
(Ed.), Handbook of psychiatric rehabilitation (pp. 153-170). New York:
Macmillan.
Tsemberis, S. (1999). From streets to homes: An innovative approach
to supported housing for homeless adults with psychiatric disabilities.
Journal of Community Psychology, 27, 225-241.
Turnbull, J. E., & Cahalane, H. (1994). Use of PIE in
outpatient mental health settings. In J. M. Karls & K. E.Wandrei
(Eds.), Person-in-environment system (pp. 43-57). Washington, DC: NASW
Press.
Unger, K.V., & Pardee, R. (2002). Outcome measures across
program sites for postsecondary supported education programs.
Psychiatric Rehabilitation Journal, 25, 299-303.
Wehman, P. (1986). Supported competitive employment for persons
with severe disabilities. Journal of Applied Rehabilitation Counseling,
17, 24-29.
Wehman, P. (1988). Supported employment: Toward equal employment
opportunity for persons with severe disabilities. Mental Retardation,
26, 357-361.
Patrick W. Corrigan, PsyD, is professor and director, and Stanley
G. McCracken, PhD, is associate professor, Center for Psychiatric
Rehabilitation, Northwestern University. Address correspondence to Dr.
Patrick Corrigan, 1033 University Place, Suite 450, Evanston, IL 60201;
e-mail: p-corrigan@uchicago.edu. Special thanks to Gary Bond and Beth
Angell for comments on an earlier draft of this article.
Original manuscript received January 2, 2003
Final revision received June 28, 2003
Accepted November 19, 2003