Recent trends in vocational rehabilitation for people with psychiatric disability

American Rehabilitation,  Winter, 1994  by Judith A. Cook,  Susan A. Pickett

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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.