Vocational rehabilitation in psychiatry:

a re-evaluation
Philip Morris, Chris Lloyd

Objective: To highlight the vocational gap in the provision of psychiatric rehabilitation, to

outline the goals and conceptual framework of psychiatric rehabilitation, and to discuss
rehabilitation interventions with specific reference to vocational rehabilitation and the
evidence base for supported employment.
Conclusions and service implications: Vocational psychiatric rehabilitation has been
a neglected area of practice in Australian psychiatry. Psychiatric treatment needs to adopt a
more balanced approach in the provision of a range of services, including vocational
rehabilitation, in order to improve long-term outcomes for people suffering from psychiatric
disability. A vocational focus should be included in psychiatric rehabilitation and better
integration between mental health services and vocational services needs to take place.
Supported employment is an evidence-based practice that is designed to help people with
psychiatric disabilities participate as much as possible in the competitive job market.
Key words: vocational rehabilitation, rehabilitation intervention, vocational services,
supported employment.

Australian and New Zealand Journal of Psychiatry 2004; 38:490–494

As a result of mental health reform, there have been necessary to adopt a better balance of approaches to
widespread changes to service delivery. However, improve long-term outcomes for individuals suffering
concerns have been raised that current services fall far from chronic mental illness.
short of the strategy vision for Australia [1]. As one A study by Jablensky et al. [2] provides information on
of the future directions that should be prioritized, the the mental health status and the needs of the Australian
Evaluation of the National Mental Health Strategy population. The study highlighted the fact that psychotic
recommended strengthening rehabilitation and personal disorders represent a major public health challenge in
recovery [1]. This report stated that, for many people Australia. They found that there was a serious lack of
with psychiatric disability, effective treatment of symp- community-based rehabilitation services that could
toms needs to be accompanied by approaches that provide occupational therapy, social skills training and
emphasize personal recovery, social integration, and psycho-education. It was a matter of concern that less than
rehabilitation. It was noted that the skills required to 20% of their study sample of individuals suffering from
assist people with psychiatric disability to adapt to living psychotic illness had participated in any rehabilitation
with a chronic illness are under-emphasized in favour of activities in the past year. This report suggested that there
models promoting the treatment of acute symptoms. It is was a need to strengthen partnerships to better provide
accessible and flexible accommodation, employment,
Philip Morris, Adjunct Professor (Correspondence) legal aid services, vocational training, andcommunity-
Health Sciences, Bond University, PO Box 1570, Burleigh Heads, based rehabilitation services. Without investment in effec-
Queensland 4220, Australia. Email: pmorris@iprimus.com.au
tive treatments in the coming decade, direct mental health
Chris Lloyd, Senior Lecturer
costs will top $1 billion, and many people with chronic
Division of Occupational Therapy, University of Queensland, Brisbane,
Queensland Australia psychotic disorders will still be living on the edge of
Received 9 May 2003; second revision 26 March 2004; accepted 29 March Australian society, with only limited opportunities to be
2004. healthy and participating members of the community [3].

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 P. MORRIS, C. LLOYD 491

Work and employment are of primary importance for lead to significant disability and handicap. Disability is a
people with psychiatric disability. There are many bene- restriction or lack of ability of the individual to perform
fits associated with working and having a job. These a function. Handicap is a disadvantage from a disability
include increased satisfaction and self-esteem and an that limits a role that can be performed by the individual.
opportunity to socialize and communicate. Importantly, Unemployment is a prime index of handicap. For exam-
employment breaks the cycle of poverty and economic ple, employment rates of only 8–15% for people with
dependence [4]. The literature on psychiatric rehabilita- severe mental illness are generally cited and unemploy-
tion argues in favour of interventions that lead to the ment is thus the norm [6]. Stigma and discrimination can
re-entry of the individual into competitive employment, worsen handicap and are barriers to employment [3]. It
and a service management system that incorporates can be seen therefore that the impairments, disabilities
well-defined pathways to recovery involving psychiatric and handicaps of people with psychiatric disability are
rehabilitation and disability support services [4]. related to their psychiatric symptoms and to their voca-
The aim of this article is to: (i) highlight the gap tional and social deficits.
between psychiatric services and employment/vocational The stress-vulnerability-protective factors model of
services; (ii) outline the conceptual framework of psy- mental illness is a helpful method of understanding
chiatric vocational rehabilitation; and (iii) review the influences that give rise to and perpetuate psychiatric
evidence for supported employment as a recent develop- illness as well as the ways that the individual can be
ment for effective vocational intervention. assisted in recovering from psychiatric illness [5]. Stress
can be psychosocial, but may also be biological (e.g.
Psychiatric rehabilitation: definitions and goals infections). Stress can precipitate psychiatric illness in a
dramatic way (e.g. following psychological trauma), but
Rehabilitation is the process of helping people with chronic stress can also lead to psychiatric illness (e.g.
psychiatric disability to make the best use of their resid- chronic work stress, marital problems or interpersonal
ual abilities to function at an optimal level in as normal difficulties). Vulnerability to psychiatric disorder is usually
a context as possible. The goal of psychiatric rehabilita- understood as a genetic (or biological) predisposition.
tion is to ensure that the person with the psychiatric However, vulnerability can also be produced by chronic
disability can perform those physical, emotional, social difficulties in childhood (e.g. childhood physical, emo-
and intellectual skills needed to live, learn and work in tional or sexual abuse) leading to disturbed attachments
the community with the least amount of support neces- and personality problems. Heightened vulnerability can
sary from helping professionals and carers [5]. Methods make an individual more susceptible to acute or chronic
employed in psychiatric rehabilitation include teaching stress so that in very vulnerable individuals low levels of
people specific skills and developing community and stress may induce psychiatric illness.
environmental resources needed to support levels of Protective factors are important in protecting the
functioning. A fundamental tenet of the psychiatric individual against illness and/or assisting the individual
rehabilitation approach is that rehabilitation is designed recover from illness and preventing relapse. Protective
to improve the person’s competencies [5]. factors include personal resilience, effective coping
The goals of rehabilitation centre on adjustment to strategies and social supports. Use of effective medi-
everyday life. Comprehensive rehabilitation involves cation and compliance (adherence) to treatment can
assessment, training and modification of living environ- prevent relapse and maintain remission. Rehabilitation
ments in those areas of function relevant to personal and and vocational programmes can also be seen as pro-
community life. These areas include self-care (including tective factors assisting recovery and preventing relapse
medication and symptom management), family rela- [7]. Vocational activities contribute to the recovery
tions, peer and friendship relations, vocational and process in two major ways. Work is perceived as a
employment pursuits, money management and con- means of self-empowerment and a sense of self-
sumerism, residential living, recreational activities, actualization [7].
transportation, food preparation and choice and use of
public agencies [5]. Rehabilitation interventions

Conceptual framework for rehabilitation Assessment forms the foundation on which all psy-
chiatric rehabilitation is built. Assessment involves a
Psychiatric impairment is a loss or abnormality of full medical and psychiatric diagnosis, a functional
psychological function. These impairments can limit a assessment of the individual looking for strengths, weak-
person’s social and vocational roles. Such impairments nesses and deficits and a resource assessment of the

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492 VOCATIONAL REHABILITATION IN PSYCHIATRY

individual’s social field and environment. A functional Principles of psychiatric rehabilitation:

assessment identifies impairments, disabilities and hand- vocational aspects
icaps that affect the individual’s ability to engage in
the repertoire of roles, relationships and occupations During the period of the community mental health
required in the course of daily life. movement there was the realization that a proportion of
Multi-dimensional treatment involves a number of institutionalized individuals would never return to full
treatment domains (biological, psychological and social), psychosocial function. These individuals would need
which are determined by the type and stage of the dis- continued support and accommodation and their voca-
order that is present. Treatments are designed to reduce tional capacity would be substantially limited. In
impairments and disabilities and to enhance community response to these needs, self-help clubs developed in the
support and environmental resources, in order to reduce US (e.g. Fountain House and Horizon House), often run
handicap and to diminish stigma and discrimination. by ex-patients [11,12]. These centres provided social and
A substantial improvement in impairments for many vocational support for ex-patients of mental hospitals.
psychiatric disorders can be obtained through drug Transitional employment (TE) programmes in psychi-
therapy. Specific psychotherapies can also reduce atric rehabilitation emerged from the clubhouse model
impairments. Cognitive behaviour therapy and inter- developed by Fountain House in 1948 [11]. The majority
personal therapy are two of many psychotherapies of these TE programmes have begun since 1980 [12].
designed to reverse deficits brought about by psychiatric Transitional employment is a time-limited, supported
illness [8]. Psychological treatments for psychotic dis- work experience that provides a sequence of transitional
orders can yield indirect benefits by enhancing the use of experiences in work for people with psychiatric dis-
other treatments or by improving compliance with drug abilities. Transitional employment programmes typically
treatment. Although reduction of impairment is impor- operate out of clubhouses. However, clubhouses do have
tant, it is salient to note that there is only a weak a number of other functions, for example providing their
correlation between impairment and disability in psychi- members with a meaningful day, educational opportuni-
atric disorders. ties, in-house vocational training and social/recreational
Research on psychosocial skills training models shows options. In a TE programme, the clubhouse owns the
that targeted skills can be trained and maintained over positions rather than an individual owning the position.
time [9]. Skills training can improve disability through These positions are filled consecutively by individuals
the basic observation that people with psychiatric dis- who are clubhouse members, usually over a 6-month
ability are able to learn new behaviours. It is worth period and frequently in a part-time capacity [5]. If the
noting that premorbid and postmorbid social competence experience in a TE placement is successful, the person
is a major predictor of response to psychiatric rehabilita- may graduate to competitive employment in a part-time
tion and vocational success [5]. Two types of skills are or full-time capacity. The Australian approach to TE
targeted in skills training programmes: goal directed approximates the standard clubhouse model and reflects
coaching and problem solving skills [9,10]. Efforts are the close links between Australian clubhouses and Foun-
directed to provide the individual with supporting per- tain House [13]. There are 10 clubhouses in Australia
sons, supportive settings (or environment) and ideally, that have been certified by the International Centre for
both. Clubhouse Development (ICCD), in addition to a
Skills training is the core of psychiatric rehabilitation. number of other clubhouses that operate without certifi-
People with psychiatric disabilities can learn skills and cation [14].
skills acquisition is related to general rehabilitation out- Many people with psychiatric disabilities have deficits
come. Skill development improves rehabilitation results, in the skills that are needed for social interaction and
diminishes the demand for clinical services and increases vocational success. The skills training era of psychiatric
the likelihood of gaining employment [3]. The prelimi- rehabilitation developed in the 1980s and 1990s. A large
nary outcomes from the Blankertz and Robinson study body of research supports the efficacy of psychosocial
[6] of people with severe mental illness, suggested that skills training for people with psychotic disorders [10].
individuals with psychiatric disabilities can improve Skills training methods are based on social learning
their vocational status within a relatively short period principles and human resource development training
of time by either attaining competitive employment or methods and have a vocational rehabilitation focus.
becoming involved in training or work experience to Skills training uses active-directive learning principles,
prepare for competitive employment. These authors which focus on work skills, work preparation and
suggested that vocational rehabilitation should be an enhancing interpersonal skills [10]. Deficits are assessed,
integral part of the psychiatric rehabilitation process. but the sources (aetiology) of deficits are less important

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 P. MORRIS, C. LLOYD 493

than the remedial training required to help develop psychiatric disabilities for rehabilitation. The findings
coping strategies. The application of skills training for suggest that lack of referral by clinicians is a key factor
vocational rehabilitation has been limited by the lack of in the under-utilization of rehabilitation programmes,
well-trained clinicians who can impart these skills. thereby withholding from people with psychiatric dis-
Supported employment (SE) programmes became a abilities important choices about the levels of support
prominent part of vocational rehabilitation in the 1990s. available to them. We suggest that it is time to integrate
Similarly to TE, SE is another model of service delivery vocational rehabilitation services within mental health
that was imported from the US to Australia. The indi- services by either co-location of services or by having
vidual with a psychiatric disability is placed in a full or dedicated staff within mental health services, whose
part-time job and is then supported by an employment brief it is to provide supported employment.
consultant in order to help the person succeed in the
position and retain the position indefinitely. There is Supported employment: evidence-based
usually a minimum of prevocational training. The major practice
aim is to get the individual into a job and then support
the individual as they perform their duties. A number of Over the past 10 years a substantial amount of
techniques have been developed and used to facilitate evidence has been accumulated demonstrating the
this process, including ‘choose-get-keep’, ‘job coach’, effectiveness of SE for vocational rehabilitation in
assertive community treatment and individual placement chronically mentally ill populations. Results from SE
and support [15]. Unlike in the US, SE has become the programmes are better than standard or traditional voca-
most prevalent form of vocational rehabilitation for tional rehabilitation approaches. There now have been
people with mental illness in Australia by gaining a eight randomised controlled trials and three quasi-
major advantage over TE in funding arrangements [13]. experimental studies demonstrating the effectiveness of
In practice, TE has a minor role compared with SE in SE [15]. A number of common features link SE in all
providing vocational rehabilitation. these studies. The following are characteristics of SE
In Australia, there has been a separation of clinical programmes that provide successful vocational out-
treatment (provided by hospital and community-based comes: commitment to a competitive employment goal
services funded by Commonwealth and state health (not day treatment or a workshop placement); rapid job
departments) and disability support (provided by a mix search and placement; jobs selected on the basis of
of government and non-government services funded by individual preference and the skills and experience of the
several Commonwealth and state departments) [13]. person; follow-up employment consultant support and
Role delineation limits mental health services to pro- case management is maintained indefinitely; and there is
viding clinical treatment and mainstream services to close integration of SE programmes with mental health
providing vocational rehabilitation. As a result, there is a teams [15].
low level of integration between mental health services Among SE programmes, prior work history is the
and vocational services, which limits successful voca- most important predictor of ultimate success. However,
tional rehabilitation. This separation of clinical and characteristics that have been shown to be important in
rehabilitation services appears to disadvantage people other vocational rehabilitation settings (such as age, sex,
with a mental illness. It could be argued that people with diagnosis, hospital admission history) have not shown to
psychiatric disabilities require more specialist services be predictors in the SE setting [15]. It is recognized that
that address their need to enter the paid workforce. not all people with psychiatric disabilities benefit from
These rehabilitation interventions need to be inte- SE programmes. In particular, those who do not have an
grated so that gains made through psychiatric rehab- employment goal are not likely to succeed. Finally, most
ilitation are carried over into vocational rehabilitation SE jobs are part-time. Full-time employment is not the
outcomes. This can only be achieved where mental most common outcome of SE or, indeed, other forms of
health services have a rehabilitation focus and are psychiatric vocational rehabilitation. The most salient
closely integrated with vocational rehabilitation ser- therapist characteristic for successful vocational rehab-
vices. Unfortunately, this is a situation that occurs only ilitation is that the therapist has a positive view of work
rarely in Australia. SANE Australia’s Gap Project found and does not see this as an additional stress or burden for
a ‘rehabilitation gap’ in services for people suffering the person with psychiatric disability.
from mental illness, with over 80% of those who might The implementation of SE across a whole system of
benefit from rehabilitation not attending programmes care has shown that the rate of competitive employment
[16]. This study identified that in the great majority placement and retention can be increased substantially.
of cases (92%), psychiatrists did not refer people with In the US state of New Hampshire, SE programmes were

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494 VOCATIONAL REHABILITATION IN PSYCHIATRY

introduced state-wide in 1990 and over the following 2. Jablensky A, McGrath J, Herrman H et al. People living with
10-year period the rate of competitive employment for psychotic illness: an Australian study 1997–98 – an overview.
Canberra: Commonwealth of Australia, 1999.
people with chronic psychiatric disabilities undergoing 3. SANE Australia. Schizophrenia: costs – an analysis of the
rehabilitation went from 7% to 37% state-wide [15]. burden of schizophrenia and related suicide in Australia.
Melbourne: SANE Australia, 2002.
4. New South Wales Health Department. Framework for
Conclusions
rehabilitation for mental health. Sydney: NSW Health
Department, 2002.
In Australia, psychiatric rehabilitation has been under- 5. Anthony W, Liberman R. Principles and practice of psychiatric
utilized in favour of acute care service delivery models. rehabilitation. In: R Liberman, (ed.) Handbook of psychiatric
rehabilitation New York: Macmillan; 1992, 1–29.
Many people living with psychiatric disabilities are not 6. Blankertz L, Robinson S. Adding a vocational focus to mental
gaining access to treatments and supports necessary to health rehabilitation. Psychiatric Services 1996; 47:1216–1222.
enable them to achieve stability and progress with 7. Provencher H, Gregg R, Mead S, Mueser K. The role of work in
the illness and lead a satisfying and fulfilling life in the the recovery of persons with psychiatric disabilities. Psychiatric
Rehabilitation Journal 2002; 26:132–144.
community. There is a need for a re-orientation of 8. Thornicroft G, Susser E. Evidence-based psychotherapeutic
mental health services to include psychiatric rehabilita- interventions in the community care of schizophrenia. British
tion and to increase the rate of referral to these services. Journal of Psychiatry 2001; 178:2–4.
The vocational aspect of psychiatric rehabilitation is an 9. Scott JE, Dixon LB. Psychological interventions for
schizophrenia. Schizophrenia Bulletin 1995; 21:621–630.
important but neglected area of psychiatric practice. 10. Heinssen RK, Liberman RP, Kopelowicz A. Psychosocial skills
Clinicians often underestimate the need for vocational training for schizophrenia: lessons from the laboratory.
services or fear that work will be too stressful for Schizophrenia Bulletin 2000; 26:21–46.
patients. Attitudes need to change. The separation of 11. Beard JH, Propst RN, Malamud TJ. The Fountain House model
of psychiatric rehabilitation. Psychosocial Rehabilitation
mental health services from vocational services means Journal 1982; 5:47–53.
that many people who might benefit from vocational 12. Besancon V, Zipple AM. From day program to clubhouse:
assistance are denied this opportunity. Mental health Practical strategies for supporting the transformation.
Psychosocial Rehabilitation Journal 1995; 18:7–15.
services (both public and private) and vocational rehab-
13. Waghorn G, King R. Australian trends in vocational
ilitation services need to be better integrated to provide rehabilitation for psychiatric disability. Journal of Vocational
optimal rehabilitation results. New methods of voca- Rehabilitation 1999; 13:153–163.
tional rehabilitation such as supported employment hold 14. International Center for Clubhouse Development. ICCD
clubhouse directory 2001. New York: ICCD; 2001. Available at:
promise for improving the placement of people with http://www.iccd.org/newdirectory.asp#Australia Last accessed:
psychiatric disabilities in competitive employment 28 March, 2004.
positions. 15. Bond G, Becker D, Drake R et al. Implementing supported
employment as an evidence-based practice. Psychiatric Services
2001; 52:313–322.
References 16. SANE Australia. The Gap Project. Melbourne: SANE Australia,
1998.
1. National Mental Health Strategy Evaluation Steering Committee.
Evaluation of the National Mental Health Strategy – final report.
Canberra: Commonwealth of Australia, 1997.

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