The International Journal of Psychosocial Rehabilitation

The Role of Work in Therapy:
Results from a Survey of Licensed Clinicians in New Jersey

 
 
Robert Gervey, Psy.D.
University of Wisconsin-Madison
 
Norma Cordeiro, M.S., C.R.C.
New Jersey Division of Vocational Rehabilitation Services

 

Citation:
Gervey R & Cordeiro N. (2009). The EMILIA project: The Role of Work in Therapy: Results from a Survey of 
Licensed Clinicians in New Jersey. International Journal of Psychosocial Rehabilitation. Vol 14(2).  3-14.


Author Contact Information:
Robert Gervey, Psy.D. is an Assistant Professor in the Department of Rehabilitation Psychology and Special Education within the School of Education at the University of Wisconsin- Madison. The data collection was conducted when he was on the faculty of the Department of Psychiatric Rehabilitation and Behavioral Sciences in the School of Health Related Professions at the University of Medicine and Dentistry in New Jersey.
 
Correspondence should be sent to: Dr. Robert Gervey, Dept. of Rehabilitation Psychology and Special Education,
 432 East Campus Mall, Room 424, Madison, WI 53706, or sent to: gervey@wisc.edu.
Requests for the survey questionnaire should be addressed to the first author.
 
Note: Norma Cordiero was a graduate student at the time of this study in the Department of Psychiatric Rehabilitation
within the School of Health Related Professions at the University of Medicine and Dentistry in New Jersey.

 Acknowledgements: 
This project was funded in part, through a Summer Research Internship grant received from the 
School of Health Related Professions at the University of Medicine and Dentistry of New Jersey.


Abstract

The purpose of this study is to explore the integration of work and therapy in the treatment of outpatients served by licensed clinicians. The relationship between clinicians’ beliefs concerning the work capacity of persons with and without schizophrenia is explored. This study uses a mailed questionnaire survey to collect information from New Jersey licensed clinicians (psychiatrists, psychologists, social workers, counselors). More than 2,100 survey questionnaires were returned, yielding a return rate of about 19%. Most clinicians (84%) indicate that they ‘usually to always’ inquire about work-related issues affecting their clients. Clinicians that expressed the belief that persons with schizophrenia were not capable of working were significantly more likely to recommend sheltered workshop placements whereas clinicians that expressed the belief that persons with schizophrenia were capable of work were significantly more likely to recommend competitive or supported employment placement. Implications for supported employment programs are discussed.
Terms: schizophrenia, supported employment, evidence-based practices, employment issues


 Introduction

Most supported employment services for persons with psychiatric disabilities fail to fully implement evidence-based practices (Bond et al., 2001; Campbell, Bond, Gervey, Pascaris, Tice & Revell, 2007; McHugo et al, 2007). Among the least adhered to evidence-based supported employment principle is the integration of clinical and vocational services (Campbell et al, 2007). The Individual Placement and Support (IPS) supported employment evidence-based fidelity scale has 3 items that operationally define mental health-vocational integration (Bond, Vogler, Resnick, 2001). Specifically, integration is measured on the IPS fidelity scale by:  (1) the extent to which mental health and vocational treatment plans are contained in one record, (2) the degree to which vocational and mental health staff meet to discuss treatment plans and issues, and (3) the degree to which the mental health and vocational services are located within the same treatment facility. Implicit in these scale items is the notion that mental health clinicians need to ‘buy into’ the concept that competitive employment is a legitimate and vital part of mental health treatment for clients with severe mental illness.

 The concerns and myths that clinicians harbor concerning the placement of persons with severe mental illness in competitive employment have been well articulated (Harding & Zaniser, 1994; Torrey, Bebout, Kline, 1998; Torrey, Becker, Drake, 1995). Dispelling these myths and concerns is one of a number of challenges faced by researchers and program administrators as well as consumer advocates in successfully disseminating and implementing evidence-based supported employment services.

The purpose of this study is to explore the role that work plays in the mental health treatment of clients served by licensed clinicians in the private and public sector. Four sets of questions guided the construction of the study questionnaire and subsequent data analyses. First, do the four licensed clinical disciplines (psychiatrists, psychologists, social workers, counselors) differ in their use of work issues during: the initial assessment phase of treatment, the treatment and goal planning phase of treatment, and the assessment of client progress in treatment? Second, does therapeutic setting (private vs. agency setting) play a role in the use of work as a treatment issue with clients? Third, do clinicians differ in their use of work issues in therapy as a function of client diagnosis (clients with schizophrenia vs. clients without schizophrenia)? And finally, does clinicians’ general assumptions about the work capacity of persons with schizophrenia impact the treatment recommendations that they prescribe for clients with schizophrenia?

Method

A mailed questionnaire survey was sent to all New Jersey licensed clinicians (psychiatrists, psychologists, social workers, counselors) asking about their beliefs and practices concerning the role of ‘work’ in their treatment of outpatient clients.

Sample

According to the New Jersey Division of Consumer Affairs (NJ DCA) and the New Jersey Chapter of the American Psychiatric Association at the time of the study there were approximately 11,200 licensed mental health clinicians in New Jersey: 6,240 licensed social workers, 2,387 licensed psychologists, 1,940 licensed counselors (i.e., licensed professional counselors, certified rehabilitation counselors), and 704 licensed psychiatrists. Survey questionnaires were mailed to all of these individuals.

Procedure

The mailing list for each group of licensed clinicians, with the exception of psychiatrists, was obtained from the New Jersey Division of Consumer Affairs (NJ DCA). The list of licensed psychiatrists was obtained from the New Jersey Chapter of the American Psychiatric Association. The survey instrument and the method used to collect the survey data was approved by the Institutional Review Board at the University of Medicine and Dentistry in New Jersey.

Measure

A self-report survey questionnaire was designed specifically for this study. The survey instrument consists of 12, closed-ended questions. The questionnaire was completed anonymously, however the questionnaire was color coded so that returns could be identified in terms of the respondent’s profession. Question #1 determined whether the respondent was a practicing clinician as opposed to an administrator or teacher. Practicing clinicians are those providing direct clinical services to clients. Question #2 categorized the setting in which ‘practicing clinicians’ delivered therapy (i.e., private practice, agency setting, or both). Question #’s 3 through 7 asked about caseloads and practices, thus non-practicing clinicians were asked to skip these questions. For example, Question #3 asked respondents to estimate the percentage of persons with schizophrenia on their caseload. Question #’s 4 through 7 asked about the extent to which ‘work issues’ come up in the treatment of persons with and without schizophrenia (such as, the percentage of cases that have a work goal). All respondents were asked to complete Questions #’s 8 through 12. These last four questions asked respondents to provide information about their attitudes and beliefs about the work capacity of persons with schizophrenia. For example, Question #8 asked respondents to choose the most appropriate response to a person with schizophrenia that expresses an interest in work. Question # 11 asks about the perceived relationship between work behavior and psychiatric symptoms. Finally, a clinical vignette was presented describing a person who has just re-entered therapy after a brief psychiatric hospitalization and expresses a desire not to return to the day treatment program but instead wants to pursue employment. Respondents were asked to choose from a variety of options ranging from returning to the day treatment program, entering a sheltered workshop, being referred to the State VR system, a supported employment program or encouraged to find their own employment.

Data analyses

Data analyses include descriptive statistics of the study sample and frequency and percentages of item responses. Non-parametric statistics (Chi-Squares) are used to compare responses between the study’s primary grouping variables: professional discipline (psychiatrists, psychologists, social workers, and counselors), clinical setting (private practice vs. agency), and client population (clients with and without schizophrenia). Post hoc analyses are performed when appropriate.

Results

Description of Sample

A total of 2,103 survey questionnaires were returned, yielding an overall return rate of nearly 19%. Return rates were similar across the four professional disciplines thus providing the study with a proportional representation of the licensed clinicians practicing within New Jersey.  That is, of the survey respondents approximately 52% are licensed social workers, 24% are psychologists, 18% are counselors, and 6% are psychiatrists.

Eighty-seven percent of the respondents defined themselves as practicing clinicians. Nearly one-quarter (24.1%) reported working in agency/hospital setting, 43% reported working in private practice settings, and 19.8% reported working in both private and agency settings. Psychologists were more likely to be in private practice (67.7%) and rehabilitation counselors were more likely to be in agency settings (32.9%) or no clinical practice (20.7%) (x2 (9, N = 2103) =258.33, p < .001).

Persons with Schizophrenia on Caseload

Individuals with schizophrenia comprise a very small percentage of the caseloads served by the licensed clinicians responding to the survey questionnaire. Ninety-two percent of the clinicians working in private practice reported that less than 5% of their caseloads are comprised of individuals with schizophrenia. Eighty-two percent of agency-based clinicians reported that individuals with schizophrenia represent less than 25% of their caseloads.

Among the four disciplines, psychiatrists are more likely to have the highest percentage of persons with schizophrenia on their caseloads both within the private practice setting (x2(12, N = 1278) = 29.53,  p < .01) and the agency setting (x2(12, N = 901) = 52.37,  p < .001).

Table 1

Frequency in which Employment Issues are Raised with Clients with Schizophrenia During Assessment Phase of Treatment: Comparisons Between Professional Disciplines

Professional Discipline

Never to Sometimes

Usually to Always

Total

N

(%)

N

(%)

Social Worker

212

31%

471

69%

683

Psychologist

82

24.9%

247

75.1%

329

Counselor

79

31.9%

169

68.1%

248

Psychiatrist

17

14.9%

97

85.1%

114

Total

390

28.4%

984

71.6%

1374

Note. Psychiatrists inquire about the work related issues of clients with schizophrenia
more routinely (85%) than their clinical counterparts (x2(3, N = 1374) = 17.31, p < .001).


Employment Issues Raised in Treatment

            Comparisons between professional disciplines and diagnostic groups. According to survey respondents, employment-related issues are raised quite frequently in therapy. Eighty-four percent of licensed clinicians indicated that they ‘usually to always’ inquire about work-related issues affecting their clients without schizophrenia. Table 1 reveals that 71.6% of licensed clinicians indicated that they ‘usually to always’ inquire about work-related issues within their clients with schizophrenia. Psychiatrists inquire about the work related issues of clients with schizophrenia more routinely (85%) than their clinical counterparts (x2(3, N = 1374) = 17.31, p < .001). 

            Agency v. private practice settings. Licensed clinicians in private practice reported raising employment issues significantly more often (86.3% vs. 76.7%) than agency-based clinicians when working with clients without schizophrenia (x2(1, N = 1296) = 17.59, p < .001); and with clients with schizophrenia (79.2% vs. 62.6%), (x2(1, N = 1005) = 33.35, p < .001.

Table 2

Percentage of Clients with Schizophrenia with Explicit Employment-Related Treatment Goal: Comparisons Between Clinicians Working in Agency-Based v. Private Practice Settings

Practice Setting

Less than 50%

Greater than 50%

Total

N

(%)

N

(%)

Agency-Based

344

78.7%

93

21.3%

437

Private Practice

361

70.2%

153

29.8%

514

Total

705

74.1%

246

25.9%

951

Note. Clinicians in private practice reported significantly more clients with schizophrenia
have a specific work-related treatment goal compared to clinicians working in agency
settings (x2(1, N = 951) = 8.43, p < .01).


Explicit Employment-Related Treatment Goals

            Comparisons between professional disciplines and diagnostic groups. The majority of clinicians reported that for most clients (with or without schizophrenia) employment-related treatment goals are not explicitly included in the treatment plan. Only one-quarter of the respondents reported that more than 50% of their clients with or without schizophrenia have a specific work-related treatment goal. Among the disciplines, social workers reported the lowest percentage of clients with work goals for clients with schizophrenia (x2(12, N = 1305) = 30.34, p < .01).

            Agency v. private practice settings. Private practice clinicians indicated that they include work-specific goals in the treatment plan of clients with schizophrenia significantly more frequently than clinicians working in agency settings. Table 2 shows that 29.8% of licensed practitioners in private practice reported that 50% or more of their clients with schizophrenia have a specific work-related treatment goal compared to 21.3% of clinicians working in agency settings (x2(1, N = 951) = 8.43, p < .01).

Table 3

Frequency in which Treatment Progress of Clients with Schizophrenia is Evaluated Based on Employment Status and Work Adjustment: Comparisons Between Professional Disciplines

Professional Discipline

Never to Sometimes

Usually to Always

Total

N

(%)

N

(%)

Social Worker

188

27.6%

494

72.4%

682

Psychologist

60

18.4%

266

81.6%

326

Counselor

59

24%

187

76%

246

Psychiatrist

14

12.3%

100

87.7%

114

Total

321

23.5%

1047

76.5%

1368

Note. Psychiatrists reported using this criteria with their clients with schizophrenia
significantly more frequently than other disciplines (x2(3, N = 1368) = 20.25, p< .001).


Evaluating Treatment Progress Based on Employment Status of Patient    

Comparisons between professional disciplines and diagnostic groups. Most clinicians reported using the client’s employment status and/or work adjustment in evaluating client progress in treatment. Eighty-eight percent of clinicians reported that they ‘usually to always’ use employment status and work adjustment in evaluating treatment progress with their clients without schizophrenia. Table 3 shows that 76.5% of clinicians reported that they ‘usually to always’ use employment status and work adjustment in evaluating treatment progress with their clients with schizophrenia. A significantly higher percentage of psychiatrists (87.7%) reported using this criteria with their clients with schizophrenia compared to the other disciplines (x2(3, N = 1368) = 20.25, p< .001).

 Agency v. private practice settings. Private practitioners compared to agency-based practitioners were significantly more likely to use employment status and work adjustment information in evaluating treatment success in clients without schizophrenia (91.9% v. 78.3%) (x2(1, N = 1304) = 47.14, p< .001); and in clients with schizophrenia (87% v. 64.1%) (x2(1, N = 1002) = 71.80, p< .001).

Table 4

High v. Low Expectations of Persons with Schizophrenia in Terms of Work Capacity: Comparison Between Professional Disciplines

Professional Discipline

Low Expectation Less than 50%

High Expectation

Greater than 50%

Total

N

(%)

N

(%)

Social Worker

531

52.5%

480

47.5%

1011

Psychologist

202

44.4%

257

56%

459

Counselor

167

52%

167

48%

348

Psychiatrist

79

60.8%

51

39.2%

130

Total

993

51%

955

49%

1948

Note. Psychologists were more optimistic and psychiatrists were less optimistic than
other licensed disciplines (x2(3, N = 1948) = 15.08, p< .01).

Capacity of Persons with Schizophrenia to Work

Survey respondents were sharply divided in terms of their beliefs concerning the work capacity of persons with schizophrenia. On average, nearly half (49%) of the respondents believed that persons with schizophrenia are capable of holding a job and indicated that the employment rate for persons with schizophrenia should be greater than 50%. The other half was less optimistic and indicated that the employment rate for persons with schizophrenia should be less than 50% (averaging closer to 15% to 25%).  Table 4 reveals that psychologists (56%) were more optimistic and psychiatrists (39%) were less optimistic than other licensed disciplines (x2(3, N = 1948) = 15.08, p< .01).

Subsequent analyses revealed that practicing clinicians with higher work capacity expectations of clients with schizophrenia: (1) raised employment issues more frequently with these clients (x2(1, N = 1322) = 26.15, p< .001), (2) evaluated treatment success more frequently in terms of the employment status of these clients (x2(1, N = 1319) = 34.51, p < .001), and (3) reported a higher percentage of explicit work-related treatment goals for these clients (x2(1, N = 1264) = 40.86,  p< .001).

Table 5

Treatment Recommendations of Clinicians with High and Low Work Capacity Expectations for Persons with Schizophrenia

Work Capacity Expectations

Treatment Recommendations: Client wishing to work following a brief hospitalization should be referred to a:

Day Treatment Program

Pre-Vocational Program

Sheltered Workshop

Supported Employment Program

DVRS office

Other *

Total

Low

265

60.9%

299

52.6%

155

60.5%

146

37.2%

49

43%

74

42.3%

988

High

170

39.1%

269

47.4%

101

39.5%

247

62.8%

65

57%

101

57.7%

953

Totals

435

22.4%

568

29.3%

256

13.2%

393

20.2%

114

06%

175

09%

1941

Note. Clinicians with high work capacity expectations are significantly more likely to refer clients to supported employment whereas clinicians
with low work capacity expectations are more likely to refer the client back to their original day treatment program (x2(5, N = 1941) = 66.03, p< .001).

* = Other category includes referral to seek competitive employment on their own, some combination of two or more categories, and other
(write-in suggestions).

Clinicians’ Recommendation to an Individual with Schizophrenia Recently Discharged from a Brief Hospital Stay Who Indicates an Interest in Pursuing Competitive Work Instead of Returning to Day Treatment Program: Clinical Vignette

Responses to the clinical vignette are presented in Table 5. The most frequent recommendation was to encourage the client to enroll in a pre-vocational program (29.3%). The next most common recommendation was for the client to return to their day treatment program for a period of symptom stabilization (22.4%), followed next by suggestions to enroll in a supported employment program (20.2%). Thirteen percent recommended that the client enroll in a sheltered workshop program, and 6% suggested that the person register with the state vocational rehabilitation agency. Only one-half of one-percent (10/1941) recommended the client to immediately pursue competitive employment. There were no significant differences between the disciplines in responding to this case vignette (x2(15, N = 2069) = 21.16, p < .13) nor between clinicians working in different work settings (agency v. private practice) (x2(7, N = 1390) = 6.46, p < .48) . However, clinicians with high expectations were twice as likely to recommend competitive and/or supported employment for the individual with schizophrenia as compared to clinicians that held low work capacity expectations (x2(1, N = 1941) = 7.66, p < .05).

Discussion

Despite the relatively low response rate obtained on the questionnaire, and the small percentage of clients with schizophrenia served by the respondents, the findings of this study remain of high interest and value given that the respondents are proportionately representative of licensed clinicians in the State of New Jersey and represent a sample that is rarely recruited for studies related to vocational mental health issues. In fact, this is the only empirical study known to date that collects data from private practitioners concerning the role that work plays in the therapeutic relationship. One of the many refreshing findings that come out of this survey is the role that employment and work-related issues seem to play in the treatment of clients, including those with schizophrenia. Not only do the study sample consider employment relevant to their assessment of clients coming into treatment, but over 75% of these clinicians report that they ‘usually to always’ consider the client’s employment status in assessing client progress in treatment. Nonetheless, only a quarter of clinicians report developing a specific work-related treatment goal for at least half of their client caseload. The good news however is that clients with schizophrenia are just as likely to be included in that group as persons without schizophrenia.

Given the lack of integration of vocational and clinical services in the public mental health sector (McHugo et al, 2007), the fact that this study finds clinicians integrating work issues into mental health treatment is extremely encouraging. Nonetheless, several familiar patterns emerge from the data. First, there is a general tendency for the licensed clinicians in this sample to assess employment status and work adjustment less routinely within their clients with schizophrenia than with clients without schizophrenia. Second, while psychiatrists in this sample consider work issues more frequently than their colleagues, they are, on the other hand less optimistic than their colleagues in terms of the work capacity of individuals with schizophrenia. Third, agency-based clinicians consistently consider work issues less frequently than private practitioners, regardless of client diagnosis. And fourth, the overwhelming experience of clinicians in both private and agency settings is that persons with schizophrenia in treatment are unemployed.

Seventy-five percent of all survey respondents report employment rates of less than 25% for their clients with schizophrenia with most indicating employment rates of less than 5%. This contrasts with more than 75% of clinicians reporting employment rates of at least 50% for their clients without schizophrenia. As expected, private practitioners report a significantly higher employment rate for persons with and without schizophrenia on their caseloads. While this might suggest a treatment setting effect in regards to how clinicians view the work capacity of persons with schizophrenia, the data suggests otherwise. After controlling for the employment rate of caseload clients with schizophrenia, both agency-based and private practice clinicians rate the work capacity of persons with schizophrenia similarly. That is, clinicians across therapeutic settings are just as likely have low work capacity expectations for persons with schizophrenia when caseload employment rates are under 25%. Conversely, clinicians across therapeutic settings report high work capacity expectations when caseload employment rates are over 50%. Consequently, there is a significant positive correlation between clinicians’ work capacity expectations of persons with schizophrenia and clinicians’ reported caseload employment rates of clients with schizophrenia. As the percentage of clients with schizophrenia on a clinician’s caseload rises in terms of employment, there is a rise in the clinician’s level of expectation of work capacity for this population. More importantly, there appears to be a tipping point in terms of reported confidence in the work capacity of persons with schizophrenia. When caseload employment rates approach 50%, the percentage of clinicians reporting confidence in the work capacity of persons with schizophrenia jumps from 38% to 61%.

In contrast, clinicians’ work capacity expectations are significantly negatively correlated with the percentage of persons with schizophrenia on caseloads. That is, the larger the caseload of persons with schizophrenia, the lower the expectation of work capacity. Given that most individuals with schizophrenia receiving treatment are reported to be unemployed, it stands to reason that high caseloads of unemployed clients with schizophrenia reinforces the notion that this population is not work ready.

These findings suggest that clinicians’ personal beliefs and attitudes about a client’s work capacity may be influenced by direct observation of the client’s working behavior at the time of treatment. These observations may also influence clinicians’ inquiry of, and responsiveness to work-related issues in treatment. That is, clinicians that have a significant number of clients with schizophrenia employed may be more willing to regard the work capacity of clients with schizophrenia as ‘reasonable’. Clinicians that have a low percentage of clients with schizophrenia employed may be more likely to hold a more negative belief about the work capacity of clients with schizophrenia and be less interested in, and more dismissive of the employment-directed goals of these clients. In fact, survey respondents that reported a low work capacity expectation of clients with schizophrenia also tended to assume a strong relationship between schizophrenic symptoms and work behavior. Therefore, these clinicians’ may be reluctant to support the employment goals of clients with schizophrenia in the service of trying to help these clients stave off symptom exacerbation or relapse. Consistent with this assumption, clinicians in this study reporting low work capacity expectations for clients with schizophrenia were more likely to prescribe the more conservative, segregated and restrictive vocational treatment options available to them in the clinical vignette that had a client with schizophrenia requesting help in obtaining competitive employment after being discharged from a brief psychiatric hospitalization.

There are several practical, policy and research implications of the study findings. On a practical level, supported employment programs might be well served to target clinicians that have relatively high employment rates for persons with schizophrenia on their caseloads. This group may be more likely to believe in the work capacity of clients with schizophrenia and therefore more likely to refer clients to supported employment programs. Targeting clinicians with exceptionally large caseloads of unemployed clients with schizophrenia, while seemingly an efficient strategy for recruitment, might actually turn out to be counterproductive. This group of clinicians may in fact be among the least optimistic in terms of the work capacity of persons with schizophrenia.

On a policy level, supported employment programs might be more successful in helping to transform mental health clinicians’ attitudes about the work capacity of persons with schizophrenia by making it a program goal to increase clinicians’ caseload employment rates for persons with schizophrenia to at least 50%. This probably will require a change in recruitment strategy whereby programs would need to restrict the number of clinicians that they work with so that these clinicians might more readily experience the needed jump in employment associated with high work capacity expectations for persons with schizophrenia.

The hypotheses generated by this study suggest various lines of future research. For example, do clinicians who refer to supported employment programs have higher work capacity expectations of clients with schizophrenia than clinicians who do not refer to the program? Do clinicians who refer to supported employment programs and who witness a sizeable increase in their caseload employment rates demonstrate an increase in their work capacity expectations of clients with schizophrenia? Does mandating clinicians to inquire about work and setting work goals and monitoring clinicians’ evaluation of their clients’ progress in work behavior lead to increased work capacity expectations?

Finally, the limitations of this study must be acknowledged. While the response to the survey yield a proportional representation of professional licensed disciplines within New Jersey, over 80% of the target population did not participate in the survey. Thus, the study sample cannot be described as representative of licensed clinicians in New Jersey or elsewhere for that matter. It is quite possible that the sample consists of a disproportionate number of clinicians interested in the topic of work, thus making the study findings spurious. Furthermore, the fact that most respondents report serving small numbers of clients with schizophrenia puts into question the relevancy or validity of the data. In other words, should the reader accept the fact that clinicians who serve a small number of clients with schizophrenia provide a significant insight into supported employment and the issue of work capacity expectations for persons with severe mental illness? And lastly, the survey questionnaire itself is somewhat suspect in terms of reliability and validity since it was developed specifically for this study and did not undergone psychometric testing prior to administration.

Despite these obvious limitations, the authors believe that the findings offer the field a way to move a step closer toward understanding the mechanisms involved in helping to transform clinician attitudes toward work issues and setting work goals in the mental health treatment of persons with schizophrenia. 


References

Bond, G.R., Vogler, K.M., & Resnick, S. G. (2001). Dimensions of supported employment:     Factor structure of the IPS fidelity scale, Journal of Mental Health, 10, 383-393.

Bond, G.R., Becker, D.R., Drake, R.E, Rapp, C.A., Meisler, N., Lehman, A.F., Bell, M.D. &  Blyler, C.R. (2001). Implementing supported employment as an evidence-based practice,  Psychiatric Services, 52, 313-322.

Campbell, K., Bond, G.R., Gervey, R., Pascaris, A., Tice, S. & Revell, G. (2007).   Does type of  provider organization affect fidelity to evidence-based supported employment? Journal   of Vocational Rehabilitation, 27, 1-11.

Harding, C.M.&  Zahniser, J. H. (1994). Empirical correction of seven myths about schizophrenia with implications for treatment, Acta Psychiatrica Scandinavica  Supplementum, 90(384),140-146.

McHugo, G. J., Drake, R. E., Whitley, R., Bond, G. R., Campbell, K., Rapp, C. A., Goldman, H.H., Lutz, W., & Finnerty, M. (2007). Fidelity outcomes in the National Evidence-Based  Practices Project, Psychiatric Services, 58, 1279-1284

Torrey, W C., Becker, D. R, & Drake, R. E. (1995). Rehabilitative day treatment vs. supported employment: II. Consumer, family and staff reactions to a program change. Psychosocial Rehabilitation Journal, 18, 67-75.

Torrey, W.C. Bebout, R., & Kline, (1998). Practice guidelines for clinicians working in programs providing integrated vocational and clinical services for persons with severe mental disorders. Psychiatric Rehabilitation Journal, 21, 388-393.







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