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