An Overview of Vocational Research Activities Conducted by the Boston University Center for Psychiatric Rehabilitation.
(1979 - 1999)

These research activities are funded by the National Institute of Disability and Rehabilitation Research and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

The vocational research conducted by the Center for Psychiatric Rehabilitation is only a part of its research focus, but it provides a good example of the programmatic emphases that the Center can bring to a given topic area. This research is complemented by the Center's training capacity, which assists in the immediate dissemination of the research results generated by the Center, as well as the translation of the empirically-derived knowledge into usable technology.

The fruits of the Center's programmatic vocational research are found throughout the literature in books, book chapters, and journals in rehabilitation, psychology, psychiatry, mental health, psychosocial rehabilitation, etc., as well as in hundreds of presentations by Center staff. The purpose of this report is to highlight the contributions to the field of psychiatric vocational rehabilitation. This research was sponsored by various federal agencies -- including the NIDRR, RSA, NIMH, and CMHS -- thematically linked by the Center's overarching mission and capacity.

Summary

One of the most beneficial aspects of the Center is its capacity to address a particular area of concern over the long term, through a series of interrelated projects. Such a research program effort employs a variety of research strategies, all based on the scientific method. These strategies include experimental and quasi-experimental research, survey research, evaluation research, exploratory data analysis, and so forth. Programmatic research of this type results in the development of innovative, empirically-derived program models, conceptual models, research instruments, training strategies, and research hypotheses.

Another advantage of the Center's research program is that the training capacity of the Center allows the research data to drive the development of an intervention technology that is ultimately researchable. Also, a number of training projects are focused on the vocational area. In addition, the research, training, and technical assistance capacity of the Center makes it an attractive collaborator with other research centers in mounting joint research projects in the vocational area (Anthony, 1994; Drake, Becker, & Anthony, 1994; Shern , Tsemberis, Winarski, Cope, Cohen, & Anthony, 1997).

While the vocational research activities of the Center for Psychiatric Rehabilitation are only a part of its overall operation, the Center plans to continue to conduct programmatic research efforts in the vocational area. In doing so, the Center will respond to federal, state, and local vocational research priorities with a variety of research strategies tied together by an integrative, programmatic focus and an allegiance to the scientific method as a means to advance our knowledge of psychiatric vocational rehabilitation.

Vocational Research Activities

Examined the relationship between symptom, function, and disability.

Findings that showed the lack of a strong relationship between psychiatric symptoms and measures of function and handicap (Cohen & Anthony, 1984; Dellario, 1985; Dellario, Anthony & Rogers, 1983; Dellario, Goldfield, Farkas & Cohen, 1984; Dion & Dellario, 1988; Dion, Cohen, Anthony & Waternaux, 1988; Anthony, 1994; Anthony, Cohen, Rogers & Davies, 1995) substantiated the need for a rehabilitation approach to address the vocational difficulties of persons with psychiatric disabilities. Based on this research it is expected that the traditional symptom-reducing therapies (i.e., chemotherapy, psychotherapy) would have a minimal impact on vocational functioning and disability. The implication of the research for program and system planners who wished to target vocational outcomes is that they should support the development of rehabilitation interventions rather than therapeutic interventions. Furthermore, these empirical findings supported the rehabilitation model of impairment-dysfunction-disability-disadvantage as a logical conceptual foundation for the psychiatric vocational rehabilitation field. The Center has taken the leadership role in introducing this conceptual model to the literature (Anthony, 1982, 1992, 1993; Anthony, Cohen & Danley, 1988; Anthony & Liberman, 1986; Danley, Rogers & Nevas, 1989).

Examined the predictors of vocational rehabilitation outcome.

Data from early Center studies on the relationship between psychiatric symptoms, functioning and handicap, as well as integrative, comprehensive research reviews by Center staff, resulted in the identification of a set of predictors of vocational outcome (Anthony & Jansen, 1984). These data became the research rationale for the change in how the Social Security Administration evaluated persons with psychiatric disabilities. The Center's research analysis was reprinted in the proceedings of the U.S. Senate and House of Representatives, and was used in a number of class action suits which resulted in SSA revising their disability assessment procedures to be more consistent with the research literature developed and analyzed by the Center. Later studies and reviews have further clarified these predictors (Anthony, 1994; Rogers, Anthony, Cohen, & Davies, 1997).

Established the vocational outcome base rates for persons who are severely psychiatrically disabled.

Through a series of research studies (Dion et al., 1998; Farkas, Rogers, & Thurer, 1987; Spaniol & Zipple, 1987; Unger & Anthony, 1984) and regular comprehensive reviews of the literature (Anthony, Howell, & Danley, 1984; Anthony, Cohen, & Danley, 1988; Dion & Anthony, 1987) the Center has essentially defined the vocational outcome base rate figures for persons who are severely psychiatrically disabled (0-15% employed at any follow-up period). Researchers in the field now use these figures as comparison data for their own empirical studies; program evaluators use the base rates as benchmarks in their program evaluation; system planners use these figures to document the need for vocational rehabilitation funding and program development.

Studied the impact on client vocational outcome of collaborative activities between state Departments of Mental Health and Divisions of Vocational Rehabilitation.

A Center-sponsored conference of Department of Mental Health and Vocational Rehabilitation state and federal leaders identified, among other issues, the need for studies of DMH/VR collaboration and its effect on client vocational outcome (Cohen, 1981). Two research projects of the Center in two different states examined the issue. Results supported a positive relationship between measures of DMH/VR collaboration and client vocational rehabilitation outcomes using VR outcome statuses as the outcome measures (Dellario, 1985; Rogers, Anthony, & Danley, 1989). The implications for the field are that outcomes can be increased without additional dollars. Existing resources, acting collaboratively, can improve outcome. These two Center research projects were the first studies to relate VR client outcome data to measures of DMH/VR collaboration.

Identified situational assessment as the preferred vocational assessment methodology for persons who are psychiatrically disabled.

A variety of assessment tools have been used on persons with psychiatric disabilities. Based on the Center's own research into the correlates of vocational outcome, as well as comprehensive literature reviews of this subject area (Anthony & Jansen, 1984; Anthony, Cohen, & Nemec, 1987), the Center concluded that the situational assessment methodology would collect the client data most relevant to vocational functioning. The Center confirmed this conclusion through a nationwide survey of vocational evaluators who, consistent with the empirical data, identified situational assessment as the most valid approach to psychiatric vocational assessment (Hursh, Rogers, & Anthony, 1988).

Developed and field tested a new situational assessment instrument.

Based on previous research studies that identified situational assessment as the preferred assessment approach, the Center has developed a reliable situational assessment method (Rogers, Hursh, Spaniol, & Kielhofner, 1990; Rogers, Sciarappa, & Anthony, 1991). The instrument, complete with a scoring and training manual, can be used in assessments requested by state Divisions of Vocational Rehabilitation counselors and Social Security disability determination specialists. Settings for the assessment can be psychosocial rehabilitation centers, workshops, and transitional employment placements. The situational assessment instrument is based on the psychiatric rehabilitation model, and emphasizes consumer involvement in identifying the appropriate assessment situation and tasks.

Studied the vocational outcomes of psychosocial rehabilitation centers.

Psychosocial rehabilitation centers are major sites for vocational programming. The Center embarked on the first longitudinal, multi-center, multi-dimensional study of their impact on persons with psychiatric disabilities. The study assessed client demographics and symptoms, program characteristics, and client vocational, social, and symptomatic outcome (Rogers, Anthony, Toole, & Brown, 1991). Results suggest that relationships between various client variables (e.g., disability benefits, employment history, symptomatology) and vocational outcome may be different from the findings of previous studies. In contrast to other studies, this study sample is limited to only clients engaged in vocational programs, and thus is a more relevant population to study (Anthony, 1994). These data can be extremely useful for systems level personnel, researchers, and program evaluators in that instruments and data exist on which to base their future research and evaluation efforts.

Developed the supported education approach as a viable alternative to day programming and as an innovative vocational development intervention.

Based on the Center's analysis of the very limited vocational outcomes for persons with psychiatric disabilities, a new intervention model has been developed, field tested, evaluated, and disseminated by the Center (Hutchinson, Kohn, & Unger, 1989; Unger, Danley, Kohn, & Hutchinson, 1987; Unger & Anthony, 1984). Based in part on the Center's leadership role in this initiative, a variety of supported education model programs are sprouting up around the country (Mowbray, Brown, Furlong-Norman, & Sullivan, 1999; Unger, 1990). Helping persons with psychiatric disabilities access normal university, community college and postsecondary vocational training settings is a concept whose time has come. Supported education, as developed by the Center, is an innovative and non-stigmatizing response to the poor vocational and educational development of many adults with psychiatric disabilities (Anthony & Unger, 1991).

Studied the vocational outcomes of psychosocial rehabilitation centers.

Psychosocial rehabilitation centers are major sites for vocational programming. The Center embarked on the first longitudinal, multi-center, multi-dimensional study of their impact on persons with psychiatric disabilities. The study assessed client demographics and symptoms, program characteristics, and client vocational, social, and symptomatic outcome (Rogers, Anthony, Toole, & Brown, 1991). Results suggest that relationships between various client variables (e.g., disability benefits, employment history, symptomatology) and vocational outcome may be different from the findings of previous studies. In contrast to other studies, this study sample is limited to only clients engaged in vocational programs, and thus is a more relevant population to study (Anthony, 1994). These data can be extremely useful for systems level personnel, researchers, and program evaluators in that instruments and data exist on which to base their future research and evaluation efforts.

Developed the supported education approach as a viable alternative to day programming and as an innovative vocational development intervention.

Based on the Center's analysis of the very limited vocational outcomes for persons with psychiatric disabilities, a new intervention model has been developed, field tested, evaluated, and disseminated by the Center (Hutchinson, Kohn, & Unger, 1989; Unger, Danley, Kohn, & Hutchinson, 1987; Unger & Anthony, 1984). Based in part on the Center's leadership role in this initiative, a variety of supported education model programs are sprouting up around the country (Mowbray, Brown, Furlong-Norman, & Sullivan, 1999; Unger, 1990). Helping persons with psychiatric disabilities access normal university, community college and postsecondary vocational training settings is a concept whose time has come. Supported education, as developed by the Center, is an innovative and non-stigmatizing response to the poor vocational and educational development of many adults with psychiatric disabilities (Anthony & Unger, 1991).

Developed and implemented a methodology for a benefit-cost analysis of supported employment for persons with psychiatric disabilities.

This is the first study of supported employment for persons who are psychiatrically disabled that examined benefits relative to costs of a currently operating program (Rogers, Sciarappa, MacDonald-Wilson, & Danley, 1994). The methodology developed was based on the generally accepted principles of benefit-cost analysis, and is described in detail. Results of the project indicated that the program did not quite achieve cost efficiency with a ratio of .90 benefits to costs, even though participants experienced significant monetary and non-monetary benefits including a reduction in the use of several mental health services, increased wages, and time in integrated employment settings. The methodology has value for program evaluators, policy makers, and planners of supported employment services for persons with psychiatric disabilities (Rogers, 1997).

Developed and implemented a methodology to determine vocational/educational preferences of people with psychiatric disabilities.

Survey instruments were developed with the assistance of an advisory committee, the majority of whom were consumers and family members. The survey instrument is unique in several respects: a) the survey instrument is designed to be administered by trained consumer interviewers; b) survey items focus on people's preferred vocational lives and goals, and not simply what existing service categories people want or need; and c) in addition to the vocational and educational domain, residential and social domains are surveyed using the same format. The survey instrument was field tested, revised, field tested again, and then used in a statewide study of consumer preferences (Rogers, Walsh, Masotta, Danley, & Smith, 1991; Rogers, Danley, Anthony, Martin, & Walsh, 1994). Results in the vocational/educational domain strongly suggests the need for supported employment and supported education services.

Developed and evaluated the Choose-Get-Keep (CGK) approach to vocational rehabilitation.

A description of the CGK approach was first published in 1984, and modified, extended, and refined over the years in numerous applications (e.g., Anthony, Cohen, & Danley, 1988; Anthony, Howell, & Danley, 1984; Danley and Anthony, 1987; Danley, Sciarappa, & MacDonald-Wilson, 1992; Macdonald-Wilson, Mancuso, Danley, & Anthony, 1989; Sullivan, Nicolellis, Danley, & Macdonald-Wilson, 1993; Unger, Danley, Kohn, & Hutchinson, 1987).

The CGK approach is based on the values of psychiatric rehabilitation, such as consumer choice, individual planning, and consumer involvement in the rehabilitation process (Farkas & Anthony, 1989), as well as the technology of psychiatric rehabilitation, such as how to set goals with consumers, how to "connect" with consumers, how to teach skills to consumers, and how to develop resources with and for consumers (Cohen, et al., 1985; 1986; 1988; 1990).

The CGK approach has been evaluated in a variety of community applications. In a multi-site comparison of the CGK approach in three psychosocial rehabilitation centers in Virginia, Georgia, and Oregon, competitive employment was achieved for 41% of the 275 subjects; in addition, skills increased and symptoms decreased for those who became employed (Rogers, Anthony, Toole & Brown, 1991). At Boston University, a supported education program model incorporating the CGK approach was developed and demonstrated with 52 young adults who were psychiatrically disabled. Results from this prospective, longitudinal study indicated that over the 2-1/2-year follow-up period, employment and self-esteem significantly increased and hospitalizations significantly decreased (Unger, Anthony, Sciarappa & Rogers, 1991).

A non-experimental study of the CGK program model of supported employment was implemented at Boston University (Danley, Sciarappa & MacDonald-Wilson, 1992) and its impact shown on hours worked, earned income, vocational status (over 70% obtained competitive employment) and community tenure (Danley, Rogers, MacDonald-Wilson & Anthony, 1994). The most recent evaluation of the CGK approach was carried out during a hospital-downsizing project in Oregon. A combined supported employment/supported living program achieved a 96% community living rate and a 47% competitive employment rate for individuals discharged from lengthy (over 1 year on average) hospitalizations (Anthony, Brown, Rogers, & Derringer, in press).

The Center for Psychiatric Rehabilitation and the Massachusetts Department of Mental Health conducted a clinical trial with 135 persons with severe mental illness randomly assigned to the experimental, on-campus CGK approach or to a modified State Division of vocational rehabilitation service intervention (Jacobs, 1997). All subjects received SCID diagnoses, and were assessed using various psychological, social, psychiatric and vocational instruments. The follow-up period was one to two years, depending on the time of the subject's entrance into the study. Both groups' vocational performance increased significantly over time, with the CGK approach also showing increased educational involvement as well (Jacobs, 1997). An additional study will follow these subjects for a period of four or more years using both qualitative and quantitative measures (Spaniol & Gagne, in preparation). The adaptation of the CGK model for Hispanic people is currently being investigated (Restrepo-Toro & Spaniol, 1998).

CGK is documented in a manual entitled, "The Choose-Get-Keep Approach to Employment Support: Operational Guidelines" (Danley & MacDonald-Wilson, 1996), and is available from the Center for Psychiatric Rehabilitation. Earlier versions of this manual have been available for studies since the late 1980s. The manual describes the CGK approach with respect to mission, primary operating principles, program operations, service activities, and program structure.

The accumulation of systemic empirical knowledge about
the optimal vocational functioning of people with psychiatric
disabilities and about work’s potential to enhance the
overall process of psychosocial adjustment.

An almost completed study (Ellison & Russinova, 1997) and a brand new study (Russinova & Spaniol, 1998) are examining the vocational experiences of people with psychiatric disabilities who are successfully employed over a long term. This data will contribute to: a) the further correction of the long-held myths about the course and the outcomes from mental illness, b) the development of a better theoretical understanding of the nature and they dynamics of the psychosocial adjustment of people with psychiatric disabilities; and, c) the further improvement of vocational and psychosocial rehabilitation programs through the consideration of the factors determining maintenance or interruption of long-term employment of people with psychiatric disabilities.

Developed and tested rehabilitation readiness assessment technology.

Rehabilitation readiness technology is designed to help consumers feel more confident, aware, and committed to the particular rehabilitation course they choose (Cohen, Anthony, & Farkas, 1997). Assessing and developing rehabilitation readiness is a Medicaid reimbursable service in New York State (Lamberti, Melburg, & Madi, 1998) and a part of the managed care service benefit package in Iowa (Ellison, Anthony, Sheets, & Yamin, submitted). Assessment scales based on the concept of readiness to change have predicted attrition in a vocational rehabilitation project (Rogers, Martin, Danley, Anthony, & Crean, submitted). Diagnosis appears unrelated to readiness. Particularly in this managed care era, helping service recipients to assess and develop their commitment to use a particular service, before they use it, is one way to manage resources effectively and efficiently.

Developed and tested supported employment services combined with other rehabilitation support programs.

In order to achieve more comprehensive services, supported employment can be combined with other supported approaches. The Center has conducted two program evaluations. A combined supported housing/supported employment program achieved a vocational outcome of 47% percent employed for consumers released from a long inpatient stay. The percentage of days spent in the community was 96% (Anthony, Brown, Rogers, & Derringer, in press).

A combined supported education/supported employment project trained consumers in a 10-month computer program followed by a 2-month internship and 6 months of supported employment services (Hutchinson et al., in preparation). State DVR provided program support. Employment outcome at 18 months was 69%, and the cost of the entire program was $8500. It appears that a combination of supported employment and other comprehensive rehabilitation services works well for many people with psychiatric disabilities.

Defined and studied the concept of empowerment.

Empowerment has received increasing attention as an effective and appropriate approach to structuring service interventions for persons with psychiatric disability; however, until now, little research had been conducted to describe and define the concept (Ellison, Danley, Crean, & Rogers, 1996). By utilizing consumers to define empowerment and empowering practices, we developed scales that are able to tap issues relevant to the effective recovery of persons with psychiatric disability (Chamberlin, 1997). These scales are being disseminated nationally as measures for quality assurance and empowerment (Rogers, Chamberlin, Ellison, & Crean, 1997). The psychosocial rehabilitation field, and many human services, are now able to quantify this heretofore nebulous concept, which is helping to propel personal empowerment as a meaningful measure of program success.

Examined the involvement of persons with psychiatric disability in the vocational rehabilitation system.

In a survey of all 50 state agencies of vocational rehabilitation and consumers of mental health services across the U.S., the Center was able to define and describe the level of involvement of consumers in the rehabilitation process. The state-federal vocational rehabilitation agencies have been under increasing mandate to promote the involvement of people with disabilities as both clients and advisors. Survey results showed wide discrepancies between agencies and consumers regarding their perceptions of involvement activities at these agencies. Data suggested that to promote better outcomes, agencies should redirect involvement activities away from an advisory function at "the top" and instead move toward advocacy for individual clients at the service level. Results of these activities can be used to enhance the practice and purpose of involvement efforts in state vocational rehabilitation agencies.

Investigated the types, frequency, characteristics, and best practices of reasonable workplace accommodations.

We have investigated the relationship between reasonable accommodations, demographic variables and employment information of supported employees, and employer and service provider characteristics in one of the only studies using empirical evidence of accommodations provided to employees with psychiatric disabilities (MacDonald-Wilson, Crean, Abramson, Fishbein, & Miller, in press). Descriptions of the types of accommodations, the functional limitations and employer demands giving rise to the need for the accommodations can be useful to service providers, consumers and employers attempting to accommodate people with psychiatric disabilities in the workforce. Specific procedures and best practices of defining and implementing accommodations can provide guidelines for employers and the service providers working with them to comply with Title I of the ADA (MacDonald-Wilson, Crean, Abramson, Fishbein, & Miller, in press).

Developed and analyzed the process of choice and self-determination in psychiatric rehabilitation.

Consumer choice and self-determination have always been important concepts in psychiatric rehabilitation philosophy and technology (Anthony, 1979). The Center has developed a methodology to measure the psychiatric rehabilitation process, and in particular to assess the time and effort placed on the choice process (Rogers, MacDonald-Wilson, Danley, Martin, & Anthony, 1997). Additionally, research on the Center’s practitioner training technology (Cohen, et al., 1985, 1986, 1988, 1990) by independent investigators has confirmed, through concept mapping techniques, the fidelity of model transfer from Center trainers to program staff (Shern, Trochim, and LaComb, 1995). Furthermore, Lovell and Cohn (1998) used ethnographic techniques to analyze how practitioners trained in choice technology implemented this ideographic concept of choice in normatively-oriented service organizations.

The emphasis on choice and self-determination cannot be assumed to exist in practice simply because programs say they value choice. Practitioners’ ability to implement choice technology can be measured, as can the choice process itself, the fidelity of model transfer with respect to choice, and the implementation barriers to choice within a service setting.

Evaluated the integration of psychiatric rehabilitation practitioner technology into existing program models.

The ACT technology and clubhouse technology are excellent examples of specific program standards. The psychiatric rehabilitation technology is designed to help practitioners practice more skillfully—no matter in what program model they are working. Practitioners trained in psychiatric rehabilitation technology can effect employment outcomes in psychosocial rehabilitation centers (Anthony, Brown, Rogers, & Derringer, in press; Rogers Anthony, Toole, & Brown, 1991) and days spent in the community in ACT programs (Kramer, Anthony, & Rogers, submitted).

Many initiatives in the treatment and rehabilitation of persons with long-term mental illness initially stressed either the personnel, program, or system dimension (Anthony, Cohen, & Farkas, 1990). As the initiatives matured, other dimensions were also emphasized. For example, both ACT and the clubhouse model originated as new program models, but also placed increasing emphasis on personnel and system features. Psychiatric rehabilitation technology originally emphasized improving personnel skills and knowledge and later began stressing program and system technologies.

As new initiatives in the field continue to grow, they begin to reach beyond their initial focus and incorporate other ingredients of change. Another way the field grows is by the blending of initiatives that originated from different sources. The contributions of each are melded, and the combined intervention that emerges uses the unique features of each separate initiative. Three initiatives that would appear to blend particularly well together are the clubhouse model originally developed by Beard and his colleagues, the ACT program initially developed by Stein and Test, and the psychiatric rehabilitation practitioner technology initially developed by Anthony and his colleagues.

Examined the integration of psychiatric rehabilitation technology into statewide managed care benefit packages.

Psychiatric rehabilitation practice needs to be a component of managed care service benefit packages (Anthony, 1996, 1997, 1998). Iowa’s managed care initiative has created an Intensive Psychiatric Rehabilitation Service (IPR), with specific service delivery structures, process measures tied to a reimbursement schedule, personnel training requirements, and an evaluation plan. Using the IAPSRS Toolkit as an outcome measure, the Center is completing an evaluation of process implementation, service utilization, and rehabilitation outcome (Ellison, Anthony, Sheets, & Yamin, in preparation). A methodology for operationalizing, implementing, and evaluating psychiatric rehabilitation within managed care has been developed. This methodology can serve as a model for future rehabilitation research within managed care.

Conducted longitudinal prospective studies of the recovery and the functioning of individuals previously exposed to vocational rehabilitation interventions.

The short-term recovery process (approximately 5-9 years after the rehabilitation intervention) is being examined from the consumers' perspective in two studies (Ellison, Danley, Bromberg, & Palmer-Erbs, in press; Spaniol & Gagne, 1999).

Spaniol and Gagne (1999) have been following 77 consumers and collecting data in such measures as educational status, employment status, quality of life, empowerment, and self-esteem. Additionally, 19 consumers participated quarterly in an open-ended recovery interview. The researchers are examining functional indicators of recovery and analyzing aspects of the process itself. Most tasks and indicators of recovery have little to do with psychiatric symptoms or mental health programming.

Ellison, et al. (in press) followed up 84% of participants of a psychiatric rehabilitation intervention 5-9 years after baseline data collection. The participants showed a maintenance of initial gains in vocational and educational status, self-esteem, and hospitalization (e.g., 57% engaged in work or school). Knowing the recovery process, its common barriers and facilitators, is key to creating and supporting opportunities that are helpful to recovery.

Synthesizing the Data

The following points are speculations about the meaning of data that are being accumulated in this field. They reach beyond data from one individual study, but it is that stretch past segments of what we know that pushes and prods the field to consider what must be done -- not only in future research, but in current practice. The points to ponder are meant as a guide to both future research and present policy and practice.

1. State-of-the-art psychiatric vocational rehabilitation interventions can double and triple the base rate for those who choose to enter the vocational program.
   
   
2. Pre-and quasi-experimental studies in which people serve as their own controls are becoming more meaningful -- not less important.
   
   
3. Half of the people who consider entering a vocational program do not, for reasons such as timing or the program match.
   
   
4. Vocational "readiness" factors may be more important empirically and clinically than demographic factors in predicting who can benefit.
   
   
5. Sixty to seventy percent of people would like help in achieving their vocational or educational aspirations.
   
   
6. Vocational-educational outcomes are legitimate mental health goals for policy makers.
   
   
7. Departments of Mental Health must assume the leadership role in providing comprehensive psychiatric vocational rehabilitation programming.
   
   
8. Effective programs can account for more outcome variance than demographic factors.
   
   
9. Psychiatric vocational rehabilitation can have a therapeutic effect on people's symptoms.
   
   
10. Psychiatric vocational rehabilitation can have a positive impact on reducing use of expensive mental health services.
    
    
11. Psychiatric vocational rehabilitation can have a beneficial impact on one's recovery.
    
    
12. For certain types of individuals, supported employment should be provided in concert with other rehabilitation services such as supported housing or supported education.
    
    
13. Emphasis on client choice exists mostly in theory rather than practice.
    
    
14. State DVR services can impact vocational outcome if services are supported, collaborative, and targeted.
    
    
15. Psychiatric vocational rehabilitation must be an integral component of state managed care benefit contracts; if not, the state is medically, empirically, and politically ignorant.
    
    
16. Whether or not to offer psychiatric rehabilitation services is a question of values, not empiricism. Research helps us do rehabilitation more effectively and efficiently.
    
    
17. The resources of psychiatric rehabilitation should not be spent assessing client pathology.
    
    
18. Service integration can occur at the level of system, program, and personnel. Integration that is closer to the client level (e.g., personnel) has the greatest potential for impacting client outcome.

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