Recent trends in vocational rehabilitation for people with psychiatric disability

Judith A. Cook

This article reviews recent developments in psychiatric vocational rehabilitation program design and evaluation research. Topics addressed include: new directions in vocational assessment; the link between psychiatric symptoms and employment; effects of work on self-esteem and life satisfaction; employer and coworker relationships; new vocational service delivery approaches; the development of consumer-provided vocational services; and tailoring of services for women, minorities, and youth. Implications for the future direction of the field are also discussed.

Current developments in vocational services for people with mental illness suggest a shift from viewing this disability as the "last frontier" for the field of rehabilitation (Ruffner, 1986, p. 35) to a more normalized perspective recognizing the untapped employment potential of persons with mental illness. Acknowledging that unique features of psychiatric disorders require specialized service delivery approaches (Cook, Jonikas, & Solomon, 1992), recent program development and model testing offer new information about how best to assist aspiring workers with psychiatric disabilities. To complement this vocational trend, a small wave of supported education efforts has shown the effectiveness of postsecondary education for career advancement (Unger, 1994). Legislatively, the impact of the Americans with Disabilities Act (ADA) on employment outcomes for people with mental illness has the potential to be far-reaching and profound (Solomon, 1993). The consumer/psychiatric survivor movement and growth of consumer run businesses and vocational services have added to the development of this field. These and other forces are described in what follows, concluding with a look toward the future as the field nears the end of the 20th century

New Directions in Psychiatric Vocational Rehabilitation

An overview of recently published research and program descriptions suggests a number of areas of development in employment services for people with psychiatric disabilities. These include: how best to conduct vocational assessments given psychiatric symptoms and potential cognitive impairments; linkages between psychiatric symptoms, diagnosis, and employment success; the effects of employment on workers' self-esteem, job satisfaction, and morale; ways employers and coworkers treat workers with mental illness, especially around ADA issues such as reasonable accommodations; new vocational models emphasizing individualized approaches and ongoing job supports; the development of consumer-run businesses and other consumer-provided vocational services; and, finally, the tailoring of vocational service models for special populations, such as women, ethnic minorities, and youth with mental illness.

Vocational assessment. There is general recognition that vocational assessment for persons with mental illness may be complicated by medication side-effects, psychiatric symptoms, and cognitive impairments that may occur with these disorders. Moreover, persons with psychiatric disability are known to perform differently in different environments, supporting the need for situation-specific assessments. Complicating the picture somewhat is the fact that many vocational assessment procedures were designed for those with physical disabilities or mental retardation.

The use of computerized work sampling batteries might be expected to surmount many of these problems, given their emphasis on assessing actual skills in multiple domains. Work sampling batteries contain tests of a number different dimensions, such as visual-spatial ability, motor skills, social skills, and intelligence. Yet recent studies of one such battery--the McCarron-Dial-confirm earlier research (Fortune & Eldredge, 1982) suggesting that its predictive validity is weak among persons with psychiatric disabilities (Cook & Razzano, 1994). In addition, female clients with mental illness scored significantly lower than their male counterparts on this battery (Razzano & Cook, 1994) even though their eventual employment outcomes (employment status and hourly salary at both 6 and 12 months post-testing) were not significantly poorer, as had been predicted by their test results. Since this battery is composed of subtests that have documented race and gender biases (Razzano & Cook, 1994), this increases the likelihood that its predictions will be significantly biased as well.

Other evidence suggests that situational assessment may provide the most useful, valid, and reliable method of vocational assessment for people with psychiatric disabilities (Rogers, Sciarappa, Anthony, 1991). Situational assessment is the longitudinal observation and rating of job behaviors and attitudes in actual or simulated work settings (Cook, Bond, Hoffschmidt, Jonas, Razzano, & Weakland, 1991). Use of situational assessment in tandem with other methods may offer greater accuracy while broadening our knowledge about assessments helpful to clients themselves in making their own decisions about goals and desired services (Bond & Dietzen, 1993). Another suggestion is to use situational assessment to further explore areas that do have a demonstrated link to employment outcomes, such as social skills and motor abilities (Razzano & Cook, 1994). Multiple assessment methods can target areas of strengths and weaknesses, pointing rehabilitation professionals to services that are tailored to the particular job and client. To assist in this effort, a manual has been developed at the Thresholds National Research and Training Center (TNRTC) on Rehabilitation and Mental Illness (Cook et al., 1991) presenting a series of vocational assessments used in clinical settings and in research studies. This manual describes each type of assessment along with illustrations of its use, information on reliability and validity, and pertinent literature citations for further reading.

Linkages between psychiatric symptoms, diagnoses, and employment outcomes. An issue of interest to those in rehabilitation is the connection between employment outcomes and client symptoms and diagnoses. Prior studies in this area had suggested no significant relationship between psychiatric symptomatology, diagnosis, and work performance (Anthony & Jansen, 1984). Yet, recent work suggests that clients' hospitalization histories and diagnoses as "schizophrenic" or "psychotic" (versus other broadly-defined categories, such as "nonschizophrenic" or "neurotic") are associated with poorer vocational outcomes (Grusky, Tierney, Manderscheid, & Grusky, 1985; Liberman, 1989).

One recent study examining work skills, symptomatology, and diagnoses among clients in a psychosocial rehabilitation (PSR) program (Anthony, Rogers, Cohen, & Davies, in press) found higher levels of symptoms, especially negative ones, such as withdrawal or blunt affect, among those subsequently unemployed, although these differences became nonsignificant at the 6- and 12-month assessments. Moreover, clients with higher symptom severity had significantly poorer work skills. No differences were found by diagnosis. In another study, clients most likely to be unemployed at 12 months were those with schizophrenia versus all other types of diagnoses (Fabian, 1992a). Anecdotal evidence in a forensic mental health program (Evans, Souma, & Maier, 1989) suggests that those with personality disorders benefitted more from inpatient work and community volunteer placements than did those with schizophrenia.

There still is much to be learned about the interaction of diagnosis, symptoms, skills, and job environment. Moreover, additional information is needed about the operation of important covariates such as psychiatric treatment status, individual abilities, prior job skills training, prior work history, rehabilitation services, and traditional labor force predictors, such as ethnicity, gender, education, and social class (U.S. Congress, Office of Technology Assessment, 1994). Because the severity of symptoms does not necessarily correspond to an individual's functional limitations, it is important to develop a better understanding of how psychiatric symptoms and diagnosis impact vocational outcomes.

Effects of employment on self-esteem and life satisfaction. Increasing emphasis is being placed on development of vocational services and rehabilitation plans that reflect consumer choice (Cook, 1992a). This has resulted from a critique of many of the vocational opportunities offered to people with mental illness, especially entry level employment, a mainstay of many psychiatric rehabilitation programs (Furlong, Jonikas, Cook, & Goode, 1994). This critique, along with the consumer empowerment movement, has focused attention on the aspects of employment that are found to be esteem enhancing, dignifying, and rewarding, as well as financially remunerative (Fisher, 1994; Harp, 1994). This shift has turned attention to outcomes such as life satisfaction, quality of life, and job satisfaction and how these are influenced by work experiences.

Several studies have explored the connection between self-esteem and the employment of people with psychiatric disabilities. One such study examined how the employment status of 88 mental health consumers affected their feelings of self-esteem, life satisfaction, and coping mastery (Arns & Linney, 1993). All three of these personal satisfaction measures were significantly higher among those who had experienced positive changes in employment, such as becoming employed or moving to better jobs. The theoretical model derived from this research was that improvement in vocational status increases feelings of self-efficacy, thereby improving self-esteem, which, in turn, improves life satisfaction. In another study (Hatfield, Huxley, & Mohamad, 1992) those expressing the most dissatisfaction with their unemployment were those living in the community with friends or family. The authors argue that this suggests the important role of social context in defining what individuals will find satisfying in the employment realm.

Another study examined the effects of employment status on quality of life outcomes of 110 mental health consumers (Fabian, 1992b). Results indicated that having a supported employment job was associated with higher satisfaction on dimensions such as work and finances but not areas such as family, safety, or health. Noting the specificity of effects on some life domains but not others, these researchers warn service providers about the dangers of using work as a panacea for all of a client's problems.

In a separate analysis, employed men but not women with psychiatric disabilities were more satisfied than their nonworking counterparts (Fabian, 1989). This may be due to the fact that life satisfaction for working women is mediated by a number of factors, such as quality of home life and child care, which may lower satisfaction for employed versus nonemployed women with psychiatric disorders. This has been echoed by others (cf., for example, Holstein & Harding, 1992), who argue that the stresses of multiple work roles for women (i.e., home and labor force) are not adequately assessed in level of functioning scales such as the Global Assessment Scale.

A focus on job satisfaction among workers with mental illness is long overdue, given its importance to vocational outcomes in the general population (Cook et al., 1991). Clients in one supported employment program (Danley, Rogers, MacDonald-Wilson, & Anthony, 1994) had especially low levels of job satisfaction, which the authors suggested was possibly due to their underemployment at jobs below their skill levels. In another study, those receiving job placements within a month had higher job satisfaction (especially with pay) than those who participated in unpaid crews for 4 months (Bond, Dietzen, & McGrew, in press). Both studies noted that satisfaction was higher among clients who were placed more quickly. While this relationship may be causal, with shorter time to placement leading to job satisfaction, it is also possible that both outcomes (higher satisfaction and shorter time to placement) are associated with being higher functioning. This bears further investigation, especially to determine whether any clients need lengthy prevocational assessment and preparation periods and, if so, which clients, and how to target them.

An outgrowth of this focus on satisfaction and quality of life is to view aspiring workers with psychiatric disabilities as similar to any American workers, responding to the same social and personal forces. By deriving satisfaction and self-esteem from their employment in ways similar to other workers, mental health consumers find themselves in a less stigmatizing framework. Such a perspective also encourages researchers and pro ram designers to consider the ways workers with psychiatric disabilities are influenced by regular labor market conditions and constraints (Cook & Razzano, 1995).

Employer/coworker relationships. Increasing attention is being turned to the often unacknowledged "partners" of vocational rehabilitation: the supervisors and coworkers of the client (Cook, Razzano, Straiton, & Ross, 1994). Employers are important actors given their influence on a wdrker's job tenure (Cook, 1992b) and their central role in making reasonable accommodations for their employees (Solomon, 1993). Coworkers comprise the social context at the workplace and are important sources of support and informal learning (Cook, Jonikas, & Solomon, 1992). There is enhanced recognition that both groups are or should be recipients of vocational services along with their disabled coworker, signalling what has recently been called a "paradigm shift" in the field of rehabilitation services (Molinaro & Walls, 1987).

One type of service to employers and coworkers is training and education, which is part of many of the new vocational models being developed in the psychiatric rehabilitation field. Fabian and Luecking (1991) describe a program designed to train employers to provide long-term job coach supports to workers with psychiatric disabilities. Dauwalder and Hoffman (1991) present another program in which psychoeducational approaches are taught to coworkers and job supervisors. Providing direct services to a worker's so-called "natural supports" is part of the new approach to modifying the job environment for certain workers.

The turn toward natural supports has meant the enlistment of coworkers and supervisors in relationships and arrangements not previously tried for workers with psychiatric disabilities. Promoting mentoring relationships along with ongoing consultation to both mentors and clients is an approach described in one workplace-based program (Fabian & Luecking, 1991). Use of peer job coaches to supervise small work crews in commercial settings has been described in another vocational program (Cook, Jonikas, & Solomon, 1992). This use of interpersonal support may be somewhat unique to psychiatric disability, which seldom requires structural accommodations such as ramps or technological modifications such as assisted communication. Instead, accommodations may more often involve use of interpersonal relationships by adjusting supportive, supervisory, and training interactions to meet the worker's needs (Mancuso, 1991). Future studies are needed to explore the kinds of reasonable accommodations workers with psychiatric disabilities request along with employers' and coworkers' reactions to them.

Given the importance of employers' attitudes about worked with psychiatric disabilities, researchers have continued a line of attitudinal research dating back to the 1950's (Olshansky, Grob, & Ekdahl, 1960). Much of this earlier research indicated extremely negative attitudes on the part of current or potential employers; in several of these earlier studies, workers with mental illness were ranked last on desirability in comparison to workers with other types of disabilities (Cook et al., 1994). However, a recent study reveals more positive attitudes than might have been suspected from prior research. This study compared the attitudes of a group of 62 employers and matched non--employers of persons with mental illness (Cook et al., 1994). Multivariate analysis revealed that employers had fewer concerns than non-employers about workers with mental illness; they saw these workers as easier to accommodate than did non-employers and were less likely to see employees with mental disorders as having skill or behavior deficits relative to nondisabled coworkers. These authors conclude that those who knowingly hire persons with psychiatric disabilities have more positive reactions to accommodating their disabilities and to working directly with them than a highly similar group of non-employers. If these results are replicated, it may be that longer term exposure to the quality of these workers enhances employers'opinions as "familiarity breeds respect" after direct exposure.

Passage and enactment of ADA has also meant greater scrutiny of the ways in which employers treat workers with disabilities, including those with psychiatric disorders. Data on ADA charges filed between July 1992 through October 1993 indicate that mental illness was the second most frequently cited disability (cited in 10 percent of all complaints). Psychiatric disability had a frequency only lower than back impairments, a disability cited in 19 percent of all filings, and was named twice as often as the next most frequent condition, heart impairments, which comprised 4 percent of all filings (Equal Employment Opportunity Commission, 1994). This leads to several questions: Do workers with psychiatric disabilities experience disproportionately more discrimination than workers with other disabilities? Are workers with psychiatric disabilities more likely to file ADA complaints than those with other disabilities? Are the types of accommodations requested by workers with psychiatric disabilities being rejected with greater frequency by employers than the ramps, interpreters, and aids requested by other disabled workers? The uncovering of any systematic discrimination against workers with psychiatric problems may be documented by research on this and related topics.

Those interested in the implications of ADA note that it necessitates disclosure of one's disability to employers in order to support a request for an accommodation (Mancuso, 1993). Such disclosure can have highly negative consequences because extremely high levels of social stigma and rejection accompany psychiatric disorders. For example, a nationwide survey by Louis Harris and Associates, Inc., (1986) found that respondents were least comfortable with persons who had mental illness compared to all other types of disabilities. The "hidden" nature of disabilities such as mental illness and learning disability means that employers may be unaware of the disability before there is a need and request for a reasonable accommodation (Solomon, 1993). The simultaneity of disclosure and request for accommodation may make the process more complex and difficult for all participants. To address this, Mancuso (1993) has prepared a manual of case studies describing different types of reasonable accommodations requested by workers with psychiatric disabilities, along with potential employer reactions. By laying out the rationales of employers who refuse requests for accommodations under the law, the manual offers suggested compromises and resolutions.

On the other hand, disclosure can carry positive benefits, such as diminished shame, enhanced self-esteem, and permission for coworkers to offer support (U.S. Congress, Office of Technological Assistance, 1994). One study of vocational rehabilitation clientele with psychiatric disabilities found that disclosure was related to significantly longer job tenure (Fabian, Waterworth, & Ripke, 1993). Future studies of the disclosure process and outcomes of that process will undoubtedly reveal much about ways in which the timing and nature of disclosure affects reasonable accommodations.

Growth of individualized models providing ongoing vocational support. The literature contains many examples of new models designed to take specific account of the nature of mental illness and to be more sensitive to clients' preferences regarding when they are placed and at what kinds of jobs. Two common features shared by many of these models are their individualized nature and the availability of ongoing supports. These characteristics respond to consumers' desires for employment that is nonstigmatizing, with natural supports rather than obtrusive professional job coaching. Also apparent is the movement away from work in groups, which may draw unnecessary attention to workers' disabilities, to individualized models that are more natural and less stigmatizing.

The availability of ongoing supports is echoed in many of these models, stimulated perhaps by the importance of supported employment (Cook & Razzano, 1992) as well as a tradition within PSR programs of offering life-long "membership" (Cook & Hoffschmidt, 1993). Research suggests that the availability of ongoing assistance is critical (Bond & Boyer, 1988). In one study of 550 PSR clients who received vocational rehabilitation (Cook & Rosenberg, 1994), a logistic regression analysis predicting employment status 6 months after program exit found that ongoing support was a significant factor in a model including education, ethnicity, and types of job supports received. Another study of a model program at the same agency (Cook & Razzano, 1992), found that providing as needed, workplace-based employment support to those who held at least one paid job raised the employment rate from 50 percent to above 80 percent throughout the 36-month program period. A comparative study of 2-day programs providing sheltered work to ex-psychiatric patients (Drake, Becker, Biesanz, Torrey, McHugo, & Wyzik, 1994) found that the one converting to a supported employment approach had superior vocational outcomes compared to the program that continued its original sheltered work model. Clearly, the twin services of community job placement and ongoing supports have advantages over sheltered workshop and timelimited models. However, much more information is needed before we can understand the meaning of some of these findings as principles of service design.

Another principle embodied by many model programs is the importance of swiftly placing clients who are seeking employment. For example, one randomized study (Bell, Milstein, & Lysaker, 1993) found that clients placed into community jobs immediately had better vocational outcomes than those who participated in prevocational crews before placement. Another randomized study found that those supported employment clients who were placed in jobs immediately (Bond, Dietzen, & McGrew, 1993) reported superior outcomes (higher employment rate, higher job satisfaction) than those receiving prevocational services prior to their first jobs. Despite high levels of client satisfaction in one small supported employment program (Danley et al., 1994), participants were most dissatisfied with the amount of time it took to obtain employment. This suggests that the prevocational phases of most models should be examined for usefulness and altered if necessary.

Development of postsecondary education models. Along with normalization of work as a goal for mental health consumers has come a growing acceptance of postsecondary education and training for people with psychiatric disability. Given the age of onset of severe mental disorders in the late teens and young adult years, education is a developmentally appropriate goal for this consumer group (Cook, Solomon, Farrell, Koziel, & Jonikas, in press). But beyond this has come the recognition that career changes may be necessitated by the occurrence of this disability such that without re-education many are forced into entry level employment (Cook et al., 1992). In one study of people with schizophrenia (Navin, Lewis, & Higson, 1989) over one-third (35 percent) had attempted formal education while less than one-tenth (9 percent) had completed their course of study. There is evidence that adults with mental illness need remedial work in reading and mathematics along with ongoing supports for attempting mainstream college or vocational technical training. For example, screening of one group of clients entering a supported education program (Cook & Solomon, 1993) indicated that over half had reading and mathematical computation skills below the 12th grade level. Yet, postsecondary education is a service seldom suggested for persons with psychiatric disabilities, even though it is commonly used in the rehabilitation of people with physical and communication disabilities (Unger, 1994).

Outcome studies have confirmed the usefulness of postsecondary approaches including academic supports along with mental health services (Jacobs & Glater, 1993; Ryglewicz & Glynn, 1993) in models commonly referred to as "supported education" (Unger, 1994). These programs typically offer remedial and preparatory education, counseling aid advocacy, and ongoing support for a variety of educational and case management needs. In one study of 68 supported education students and a group of matched clients receiving identical clinical but no educational services (Hoffman & Mastrianni, 1993), participants were significantly more likely than the comparison group to return to college and to do so fun-time. In a followup study of 52 supported education clients (Unger, Anthony, Sciarappa, & Rogers, 1991), significant increases over baseline were found in college class enrollment, competitive employment, and self-esteem. A third outcome study of 102 supported education students (Cook & Solomon, 1993) found that 78 percent of the participants were employed during the program and showed significant increases in both hourly wages and number of hours worked per week. Compared to their scores at pretest, these clients also had significantly higher self-esteem and coping mastery after participating in the program.

As with employers, postsecondary education involves the cooperation of silent partners, such as faculty, administrators, and other students. Several programs have explored the role of faculty inservice training for integrating students into college and vocational education settings (Jacobs & Glater, 1993; Wolf & DiPietro, 1992). Results of one field test of a faculty inservice on working with students with psychiatric disability (Cook, Yamaguchi, & Solomon, 1993) revealed that training significantly improved knowledge levels and attitudes toward these students.

As the field begins to look beyond entry level employment for people with psychiatric disabilities, the role of supported education services will become increasingly important. Past experience has indicated that many people with psychiatric disabilities need assistance to succeed at college or technical training. Now that the techniques for providing this support are available, it remains to be seen whether or not they become readily available to clients who need them.

Consumer-delivered vocational services. Another recent trend in vocational service design is consumer-delivered employment services, including consumer-run businesses (Warner & Polak, 1993), use of consumers in vocational staff positions such as job coaches (Cook, Jonikas, & Solomon, 1992), and consumer-run vocational rehabilitation programs (Allen, 1994). These types of approaches build on recent findings (McGill & Patterson, 1990; Sherman Porter, 1991; Solomon & Draine, in press) indicating the effectiveness of consumers as providers of mental health services. Extending these results to provision of vocational rehabilitation services, new programs around the country are exploring ways in which consumers can offer employment training and supports.

One report describing the establishment of nine Pennsylvania Department of Mental Health-funded consumer-run drop-in centers (Kaufmann, Ward-Colasante, & Farmer, 1993), detailed the vocational components of their programming. With quite minimal funding (the average center award totaled just $16,500 per year), each center helped its consumers prepare resumes, obtain job leads, negotiate the job search process, and maintain jobs over time. Some offered supported work, training in word processing, or job placement services. A followup report on the nine projects 1 year after startup (McCormack, 1992) found that 18 percent of all clients (N=123) had participated in some form of unpaid work performing drop-in center functions; 7 percent (N=48) had received job seeking skills training; and 4 percent (N=25) had received assistance following up job leads. Regarding employment outcomes, 4 percent (N=25) acquired full- or part-time jobs outside their centers while another 5 percent (N=29) were employed within their centers. The followup study noted that scarce financial resources and limited vocational training of center staff and volunteers were impediments to development of more effective services. Also noted was an extremely high level of vocational interest among center clients coupled with frustration among consumer staff because limited resources prevented them from providing higher quality employment services.

Another project, based in Pittsburgh and called The Self Help Employment Center, uses a model combining peer supports in conjunction with professionally provided vocational services (Kaufmann, Roth, & Cook, 1992). Consumers in this project provide job skills training and counseling to program clients coupled with job development and ongoing supports from nonconsumer providers. In a randomized study comparing this model to "customary vocational services," preliminary results indicated that those in the experimental condition showed significant improvements in employment status over time in comparison with control group clients (Kaufmann, 1995).

A project in upstate New York uses consumers to train other consumers as crisis workers in a hospital diversion program (Dumont, Shern, & Blanch, 1993) and is being evaluated using a randomized design. A consumer-run cooperative in Boulder County is described by Warner and Polak (1993), in which consumer and nonconsumer staff work together in a property maintenance and repair business contracted by the local community mental health center. In Washington, D.C., the On Our Own Computer Center uses consumer staff to train mental health consumers for computer careers and employs them directly in contract work arranged with local businesses (Allen, J., personal communication, July 26,1994).

As part of its growing role in shaping mental health and rehabilitation services, the consumer/survivor empowerment movement has encouraged the development of consumer-delivered vocational services. Such approaches offer the benefits that come from providing peer role models for vocational rehabilitation clients, as well as staff with the insight that comes from direct experience as consumers. While studies are underway to investigate the effectiveness of these approaches, new projects continue to be developed using consumers as rehabilitation service providers.

Special populations: Women, ethnic minorities, and youth. Along with normalization of employment for persons with psychiatric disabilities has come recognition of diversity among this clientele. Increasing awareness of how gender, race, and age impact the employment outcomes of those with psychiatric difficulties has spurred interest in these groups.

The focus on women stems from the new research on female clients with mental illness and their comparative outcomes with men. A study of employed and unemployed mental health consumers (Fabian, 1989) found the highest satisfaction among employed men and the lowest among employed women. This latter finding has been attributed to the multiple roles occupied by women more often than men, such as domestic and child rearing responsibilities (Fabian, 1989). In a similar vein, Holstein and Harding (1992) argue that most level of functioning assessments fail to adequately measure the stresses associated with women's greater likelihood of multiple roles. This failure to assess more than the formal work role misses symptoms and stressors associated with childcare, housework, and family care. This, in turn, may contribute to less accuracy in research on women mental health consumers.

Research concerning the impact of gender on employment outcomes has been inconclusive. Earlier research had found a lower proportion of women employed at significantly lower income than men (Test & Berlin, 1981). A follow up study of 260 women 6 months after discharge from psychiatric hospitalization (Goering, Cochrane, Potasznik, Wasylenki, & Lancee, 1988) found no differences in employment status; however, women were more likely to be employed in clerical or sales positions while men were more likely to work in skilled or semi-skilled occupations. Other studies have found that gender was not a significant predictor once other factors such as marital and parental status had been controlled (Cook & Rosenberg, 1994; Razzano Cook, 1994). However, several studies across many different types of disabilities have shown that, as a group, women with disabilities have significantly lower employment rates and lower salaries than their male counterparts (Danek, 1992; Menz, Hansen, Smith, Brown, Ford, & McCrowey, 1989; Vash, 1982).

Several studies suggest that client ethnicity influences employment outcomes. In a discriminant function analysis of 653 clients in a PSR transitional employment program (TEP) (Cook & Razzano, 1995), minority participants (80 percent of whom were African American) were significantly less likely than their white counterparts to have graduated from TEP placements to competitive employment. In multivariate models predicting hourly salary and job level (Cook & Roussel, 1987), Caucasians earned significantly more and achieved higher level jobs than minorities (predominantly African Americans) despite controlling for characteristics such as work history, illness history, and demographic features.

If ethnic minority clients receive lesser benefits from vocational rehabilitation efforts, they may be more dissatisfied with the jobs they obtain through these services. It is perhaps not surprising, therefore, that higher life satisfaction was found among unemployed than employed minority mental health consumers in one study (Fabian, 1989) while the opposite was true among Caucasian consumers.

Increasing attention has been focused on transition aged youth with emotional and behavior disorders. This has stemmed from federal policy initiatives for decreasing service fragmentation and overutilization while improving standards of mental health care for children and adolescents (Collins & Collins, 1990; Weithorn, 1988). Additional impetus has been provided by the passage of recent legislation mandating the transition of youths with disabilities from school to employment or postsecondary school settings (Cook, Jonikas, & Solomon, 1992; Wermuth & Cook, 1992; Will, 1985). The challenges of comprehensive service delivery to this population stem from the need to coordinate several large systems of care: mental health, education, and rehabilitation.

In a number of statewide studies in which special education students were followed up after high school, youths with severe emotional disturbances (SED) and behavior disorders (BD) have poorer outcomes than comparison groups (Mithaug, Horiuchi, & Fanning, 1985; Neel, Meadows, & Levine, 1988). In 1987, a National Longitudinal Transition Study (NLTS) of Special Education Students began, mandated by the U.S. Congress and funded through the Office of Special Education Programs (OSEP), U.S. Department of Education (Wagner, 1989). Conducted by SRI International, this study is producing the first national information about the secondary and postsecondary experiences of youth with disabilities, including those classified with SED (Wagner, 1989). Results thus far indicate that among 12 types of disability, students with SED constituted the highest proportion of high school dropouts, the highest proportion of students with one or more failing grades, and the fourth lowest percentage of students in postsecondary education (higher only than students with multiple disabilities, those who are deaf/ blind, and those who are mentally retarded). The most recent data from this study (Wagner, 1993) indicate that SED youths made fewer gains in employment and had more unstable work histories than all other subgroups.

In addition to poor outcomes for youth classified as SED/BD, this same research reveals poorer results for female than male youths with disabilities. Earlier followup studies of special education students (Mithaug & Horiuchi, 1983) found that females were less likely to be working, to have received bonuses for working, or to have left a job to take a better one. This has been confirmed recently by the NLTS finding that female respondents were less likely to be working full time or to be earning more than $6.00 an hour and less likely to see friends frequently or be involved in groups (Wagner, 1993). Results regarding gender differences among the SED/BD subgroups have not yet been published.

A Look Toward the Future

After years of benign neglect by the fields of mental health and rehabilitation, psychiatric rehabilitation is coming into its own as we near the end of the 20th century First, it has shed the mantle of lowered expectations in which persons with psychiatric disability were viewed as those for whom entry level employment was deemed a "success" because of its integrated nature. The notion of careers for workers with psychiatric disabilities is being explored in many fields, including the social and rehabilitation service professions. Today, public attitudes toward people with a wide range of disabilities and their roles as workers are changing. Such shifts in work force attitudes are likely to benefit mental health consumers who battle the stigma surrounding their disability. This shift in opinions about who belongs in the workplace could be responsible for increasing levels of acceptance of workers with psychiatric disabilities by others.

The development of drug regimens which are effective for many workers (though not without troublesome side effects) (Rutman, 1994) and increased knowledge about how to develop jobs and provide onsite supports for workers with psychiatric disabilities (Furlong et al., 1994) have opened up a wider range of employment opportunities. This trefid, in turn, is being bolstered by provisions of ADA which mandate fair hiring practices and reasonable accommodations for these workers. Along with this, a movement of mental health consumer activism has led to consumer-run businesses and other vocational services delivered by and to consumers. These, in turn, have nurtured the employment goal for a wider and wider range of clientele.

How the vocational rehabilitation field responds to this newly politicized, increasingly assertive, and more "service-savvy" group of consumers remains to be seen. The use of older models in which clients engage in long periods of prevocational preparation or where they are offered sheltered or temporary work before integrated, permanent jobs may be questioned by these clients. Also viewed with skepticism will be vocational assessments with limited predictive validity and demonstrated gender and ethnic biases. Clients may increasingly demand supported education services to complete interrupted schooling or acquire needed postsecondary training. All of these trends suggest that client choice will become more and more important in the near future. A strong emphasis on client choice is contained in the provisions of the recently reauthorized Rehabilitation Act (Furlong-Norman, 1993), which affords client preferences and goals a primary place in the rehabilitation planning process. It remains to be seen how much choice clients will actually have, however, in an era of shrinking service delivery dollars, organizational downsizing, and cutbacks in funding.

The field of vocational rehabilitation for people with psychiatric disabilities is characterized by tremendous potential. Yet the growth of new approaches has heretofore been hindered by a lack of valid, reliable knowledge about effective rehabilitation practices and how to encourage them. The most recent research offers many promising and suggestive avenues for program development and further study.

This research was supported, in part, through a cooperative agreement (#H133B00011) with the National Institute on Disability and Rehabilitation Research, U.S. Department of Education, and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. The contents of this paper do not necessarily reflect the views of these agencies and do not imply endorsement by the U.S. Government.

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Dr. Cook is Director and Dr. Pickett is a Principal Investigator at the Thresholds National Research and Training Center on Rehabilitation and Mental Illness, Chicago, IL.

COPYRIGHT 1994 U.S. Rehabilitation Services Administration
COPYRIGHT 2004 Gale Group