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PubMed2001

Vocational rehabilitation for people with severe mental illness.

BACKGROUND: Unemployment rates are high amongst people with severe mental illness, yet surveys show that most want to work. Vocational rehabilitation services exist to help mentally ill people find work. Traditionally, these services have offered a period of preparation (Pre-vocational Training), before trying to place clients in competitive (i.e. open) employment. More recently, some services have begun placing clients in competitive employment immediately whilst providing on-the-job support (Supported Employment). It is unclear which approach is most effective. OBJECTIVES: To assess the effects of Pre-vocational Training and Supported Employment (for people with severe mental illness) against each other and against standard care (in hospital or community). In addition, to assess the effects of: (a) special varieties of Pre-vocational Training (Clubhouse model) and Supported Employment (Individual Placement and Support model); and (b) techniques for enhancing either approach, for example payment or psychological intervention. SEARCH STRATEGY: Searches were undertaken of CINAHL (1982-1998), The Cochrane Library (Issue 2, 1999), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1887-1998). Reference lists of eligible studies and reviews were inspected and researchers in the field were approached to identify unpublished studies. SELECTION CRITERIA: Randomised controlled trials of approaches to vocational rehabilitation for people with severe mental illness. DATA COLLECTION AND ANALYSIS: Included trials were reliably selected by a team of two raters. Data were extracted separately by two reviewers and cross-checked. Authors of trials were contacted for additional information. Relative risks (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated. A random effects model was used for heterogeneous dichotomous data. Continuous data were presented in tables (there were insufficient continuous data for formal meta-analysis). A sensitivity analysis was performed, excluding poorer quality trials. MAIN RESULTS: Eighteen randomised controlled trials of reasonable quality were identified. The main finding was that on the primary outcome (number in competitive employment) Supported Employment was significantly more effective than Pre-vocational Training; for example, at 18 months 34% of people in Supported Employment were employed versus 12% in Pre-vocational Training (RR random effects (unemployment) 0.76 95% CI 0.64 to 0.89, NNT 4.5). Clients in Supported Employment also earned more and worked more hours per month than those in Pre-vocational Training. There was no evidence that Pre-vocational Training was more effective in helping clients to obtain competitive employment than standard community care. REVIEWER'S CONCLUSIONS: Supported employment is more effective than Pre-vocational Training in helping severely mentally ill people to obtain competitive employment. There is no clear evidence that Pre-vocational Training is effective.

Employment↗
PubMed1987

Vocational development following severe spinal cord injury: a longitudinal study.

Vocational development of individual with spinal cord injury was studied from shortly after injury to two years after discharge from inpatient rehabilitation. Objectives included examining differences in the course of vocational development by level of functional independence, and predicting vocational outcomes two years after injury. Thirty-three spinal cord injury patients (17 quadriplegics, 16 paraplegics) were followed during the study. The Goldberg Scale of Vocational Development was used to measure changes in vocational development over time. The Barthel Index was used to measure level of functional independence. Results revealed that vocational development was markedly depressed during initial inpatient rehabilitation and for six months after injury. Gradual improvement occurred after six months, but two years after discharge the level of vocational development remained lower than that before injury. Changes in vocational development over time did not differ significantly by level of functional independence. Best predictors of successful vocational outcomes were educational attainment, educational plans made before injury, and origin of interests in work.

Activities of Daily Living↗
PubMed2003

Predictors of success for state vocational rehabilitation clients with traumatic brain injury.

OBJECTIVES: To determine the characteristics of individuals with traumatic brain injury (TBI) who request state vocational rehabilitation services and to determine the best predictors of their successful vocational outcomes. DESIGN: Observational study. SETTING: Vocational services data from the Missouri Division of Vocational Rehabilitation (DVR). PARTICIPANTS: Seventy-eight individuals with TBI who requested services from the Missouri DVR. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic, injury severity, neuropsychologic variables, vocational services offered, and vocational status at time of case closure (successful, unsuccessful, services interrupted, no services provided). RESULTS: Individuals requesting DVR services were primarily men (71%), white (82%), single (47%), of low average intelligence (Wechsler Adult Intelligence Scales-III full scale IQ score, 84.8), and of limited education (11.8 y). The majority experienced a significant TBI (ie, 66% were hospitalized after their TBI; 56% reported loss of consciousness; 37% reported posttraumatic amnesia; 32% reported multiple TBIs; avg time since injury, 9.2 y). At DVR case closure, 17% were rated as being successfully employed, with nearly all working in industrial, service, or clerical positions (2 in a sheltered workshop, 1 in a professional position). Stepwise logistic regressions indicated that delivery of DVR services (ie, vocational guidance and counseling, on-the-job training) predicted vocational outcome and demographic, injury severity, and neuropsychologic variables did not. CONCLUSIONS: DVR clients have multiple impairments that affect them several years postinjury; the provision of DVR services may be more important in determining vocational outcomes than traditional medical, psychologic, and demographic variables.

Adult↗
PubMed2006

Predictors of engagement in vocational counseling for methadone treatment patients.

Employment enhances the outcomes of substance dependency treatment. Unfortunately, although unemployed methadone treatment patients frequently state they are interested in a job, many fail to participate in vocational services when available. Unless patients become engaged, vocational services do not have an opportunity to be effective. This is the first study to explore a broad array of factors that may be associated with differential engagement in vocational services among methadone patients. The study was conducted in two methadone programs in New York City during 2001-2004. Unemployed methadone patients (n = 211) were voluntarily randomly assigned to either of two vocational counseling programs (standard vs. experimental) and followed for 6 months. The sample was 59% male, 75% minority group, aged 45 years on average, and in methadone treatment for 5 years on average. Being engaged in the vocational counseling programs was defined as five or more sessions with the counselor in the first 6 months after study entry. In multivariate analysis, the factors associated with higher engagement in vocational counseling were being non-Hispanic, having more education, a drug injection history, a crack use history, having chronic emotional/mental problems, better work attitudes, and assignment to the experimental vocational program. The results indicate that it is often the most "needy" unemployed methadone patients who become more engaged in vocational counseling. A vocational counseling model which emphasizes assertive outreach and attends to nonvocational clinical issues as well is more likely to engage patients.

Adult↗
PubMed1996

Adding a vocational focus to mental health rehabilitation.

OBJECTIVES: The study examined the effect of adding two employment specialists to the staff of a community mental health center; their sole responsibility was to develop the skills and positive work attitudes that clients with severe mental illness need to enter the state vocational rehabilitation system or to seek employment. METHODS: A total of 122 clients were randomly assigned to a program with an employment specialist or to a control group with no specialized vocational services. Clients in the program were taught work skills and attitudes in group and individual sessions and through a trial work experience. A schedule of rewards reinforced positive changes. Outcomes measured were skill gains, changes in work attitudes, attainment of employment, and entry into the state vocational rehabilitation system. RESULTS: At nine months, 34 of the 61 clients in the program achieved positive changes in vocational status that included competitive employment, participation in training and evaluation programs operated by the state vocational system, and formal referral to the system. Only one client in the control group was linked to the state system. Skill gains and positive changes in work attitudes were found for all program clients. Logistical regression suggested that program participation, rather than client characteristics, was an important predictor of a positive outcome. CONCLUSIONS: Over a relatively short time period, targeted vocational programs can help clients with severe mental illness develop the skills and attitudes necessary to attain employment or entry into the vocational rehabilitation system. Vocational rehabilitation can be an integral part of the rehabilitation process for all mental health clients.

Activities of Daily Living↗
PubMed1989

[Vocational and occupational counseling of handicapped patients--a comprehensive social federal responsibility].

The extensive vocational and employment information and counselling possibilities available in the framework of our social services system in the FRG, are aimed at attaining optimum vocational integration of the disabled clients. The legal foundations are in particular to be found in the Social Code and the rehabilitation adjustment act. Servicing some 80% of all disabled clients in this field, the Federal Employment Institute is the main financially responsible administration in vocational rehabilitation. The services and benefits provided are based on the employment promotion act and the directive of the Institute's governing body concerning industrial and vocational rehabilitation of disabled persons (AReha). Successful vocational counselling outcomes presuppose client participation; counselling contacts are free of charge to the rehabilitee, and are sought on a voluntary basis. The local employment office's medical and/or psychological services will in many cases by called in by the counsellor. If these services do not arrive at a satisfactory proposal either, vocational assessment and work testing measures in vocational training or retraining centers are indicated. Vocational preparation may in addition be useful, e.g. in the form of promotional courses and/or pre-rehabilitation courses. The catalogue of services and benefits available is complex and adjustable to individual needs. The rehabilitation measures provided invariably are aimed at achieving entry into long-term employment. When necessary, the disabled clients are followed-along by the counsellors until this goal is attained.

Chronic Disease↗
PubMed1990

[Course and outcome of vocational training in young adults].

Presented are the findings of vocational training data analysis concerning the 91,241 disabled young people who had entered vocational training in the period 1982-87 carried by the Federal Employment Institute within the scope of "Anordnung Rehabilitation" (AReha). 77% of the young rehabilitees successfully concluded their vocational training at the first attempt; 22% dropped out, and 2% failed at the exams. Of those who had dropped out prematurely, some 39% participated in other types of vocational rehabilitation measures; no data are contained in the statistics concerning the whereabouts of the remainder. The majority of the young people, i.e. 77%, underwent vocational training in a recognized training occupation, the others in line with section 48 BBiG (vocational education act) or section 42 b HwO (handicrafts ordinance) to reduced requirements. 61% of the training measures were industrial ones, 23% provided in a vocational training centre, and the remaining 16% in some other non-industrial rehabilitation facility. The greatest single population among the young rehabilitees were those with learning disabilities, with a share of 63%. The Federal Employment Institute's statistics containing no data beyond the termination of training, information relative to vocational integration after training completion could only be gained on the basis of other, empirical investigations.

Adolescent↗
PubMed1987

Vocational rehabilitation with the industrially injured worker.

The field of vocational rehabilitation has broadened beyond the traditional federal-state model into the private sector primarily through funding by the insurance industry via workers' compensation coverage. Most disabilities encountered by private vocational rehabilitationists are musculoskeletal injuries resulting from traumatic industrial accidents rather than congenital disabilities most often seen by the state's Department of Vocational Rehabilitation. In many cases reduction in physical tolerances, extremity use, and/or chronic pain results in the industrially injured worker not being released by the attending physician for return to work in the previous occupation. To be effective, private vocational rehabilitationists working with the industrially injured worker must have a working knowledge of residual tolerances associated with various disabilities, as well as knowledge of legal parameters of the vocational workers' compensation law for each state worked in. In addition, the ability to communicate effectively with attending physicians, attorneys, claims examiners, occupational and physical therapists, and rehabilitation nurses is concomitant with successful positive movement in the vocational rehabilitation process. As with federal and state vocational rehabilitation counselors, the ability to assess transferability of past work skills and current aptitudes is paramount in determining transferability of work skills to alternate occupations. Finally, growing networking between rehabilitation nurses, therapists, physicians, and vocational rehabilitationists is needed to improve the injured worker's ability to maximize his or her physical tolerances in viewing return to work in a position as close as possible to that performed at the time of injury.

Accidents, Occupational↗
PubMedDate not supplied

Vocational services for traumatic brain injury: treatment definition and diversity within model systems of care.

OBJECTIVE: To examine characteristics and diversity among vocational treatment services in model programs for traumatic brain injury (TBI) rehabilitation. SETTING: Vocational or postacute treatment components of 16 TBI Model System (TBIMS) centers. PARTICIPANTS: Vocational director/coordinator from each TBIMS surveyed in semistructured phone interview. MEASURE: Survey of vocational services for people with TBI, with about 100 closed and open-ended questions on vocational assessments; pre- and postjob placement treatments; program philosophies; funding; and integration of cognitive, behavioral, family, and medical rehabilitation interventions. RESULTS: Great diversity was found among the vocational services of the 16 TBIMS. Programs fell into 3 clusters emphasizing medical rehabilitation services, supported employment, or a combination of these with an emphasis on case management. Job coaching was identified as a key intervention, but there was great variability in intensity, availability, and funding of coaching services. CONCLUSION: Diversity in vocational services appears related to funding differences and "parallel evolution" rather than strong treatment philosophy or scientific evidence base. Multicenter research on effectiveness or establishment of best practices in vocational rehabilitation after TBI must deal with substantial existing variability in treatment models and specific interventions, and must examine the relationship of treatment variations to case-mix factors.

Brain Injuries↗
PubMed1997

[Considerations for the continuing development of vocational rehabilitation from the viewpoint of the Federal Institute for Employment].

The law on enhancing growth and employment (Wachstums- und Beschäftigungsförderungsgesetz-WFG) of September 25, 1996 has entailed fundamental changes in the law governing vocational rehabilitation under the employment promotion act (Arbeitsförderungsgesetz-AFG). While a legal entitlement existed so far, vocational rehabilitation benefits, as of January 1, 1997, on principle are granted as discretionary benefits. In the employment promotion reform bill (Arbeitsförderungs-Reformgesetz-AFRG) awaiting passage in 1997, the former legal entitlement is reestablished in those cases where special vocational rehabilitation benefits and services are needed due to the type or severity of disability, or for safeguarding rehabilitation success. The WFG is to bring about a 500 million DM reduction in vocational rehabilitation spending by the federal employment service Bundesanstalt für Arbeit (BA). This targetted economy also is adhered to notwithstanding the said major expansion of legal entitlement. Already before passage of the WFG, the BA's governing board had set up a working group to look into the issue of developing vocational rehabilitation further. Subjects dealt with had included cooperation among rehabilitation agencies; participant structure in vocational retraining centre programmes; programmes offered; quality assurance; and cost structures in retraining centres. In the wake of the working group's deliberations, the board passed revised provisions for programme participation in vocational retraining centres, and decided on December 18, 1996 that, as of April 1, 1998 a new settlement procedure should be introduced with the vocational rehabilitation facilities, with specific programme-related prices on the basis of agreed quality standards.

Cost Control↗
PubMed1989

Models of vocational assessment of handicapped students.

During the last twenty years, increasing emphasis has been placed upon the provision of comprehensive vocational assessment to disabled and disadvantaged persons to assist them in obtaining employment. Vocational evaluation programs have proliferated in rehabilitation facilities, manpower programs, vocational-technical schools and public schools. An increasing body of literature and research has delineated service-delivery models and competencies needed by vocational evaluation specialists. Increasing numbers of universities have implemented graduate training programs in vocational evaluation; and a national professional certification process has been developed. Most of this activity has been centered at rehabilitation facilities at the same time that public schools are becoming the norm for educating disabled students. As vocational assessment for disabled students moves into this relatively new setting, it is being modified. This article explores models of vocational assessment for disabled students which incorporate modifications to suit the special needs of the public school setting.

Persons with Disabilities↗
PubMed1990

[Occupational rehabilitation yesterday, today and tomorrow as exemplified by the vocational retraining centers].

Developed in the 1960s, the concept for vocational rehabilitation in the vocational retraining centres has proven its worth also in the face of the great challenges of the 80s. Not all of the partly profound changes which have taken place in the environs of vocational rehabilitation over the last few years had been positive ones. Before this background, it must therefore be asked how the standard attained by the vocational retraining centres is to be viewed and which route the vocational rehabilitation field is going to take in the 90s. The process of societal and technological change over recent years is likely to further accelerate in the 90s, with numerous implications for vocational education and disability policies. Even more so than in the past, this process will require adjustments to be made, but equally give rise to innovative efforts and developments. The demands to be faced by the facilities are therefore going to increase, and major re-structuring processes will have to take place also in the vocational retraining centres.

Germany, West↗
PubMed1995

[Occupational rehabilitation of psychiatric patients in the Michaelshoven/Cologne vocational training center--an integrated overall concept].

Vocational retraining centres, sui generis, belong to those vocational rehabilitation facilities where disabled adults are afforded an opportunity for comprehensive occupational reorientation, facilities that operate on the principle of "dual training under one roof", i.e. combine practical and theoretical contents, which documents their close linkage with the mainstream vocational education system practiced in Germany. An essential modification has for some years now been introduced at the Michaelshoven/Cologne vocational retraining centre: the traditional conveyance of skills and knowledge (i.e., acquisition of technical competence) has been replaced by attainment of occupational action competence as the focus of rehabilitative efforts. Hand in hand with this concept rooted in the principle of client-concentration, comes implementation of the principles of integration and holistic approach. Integration means that rehabilitees with mental illness participate in the rehabilitation programmes alongside rehabilitees without mental illness. The holistic approach is expressed in a number of closely coordinated elements ensuring that the specific configuration of persons with mental illness and their way of life are taken into consideration from the very beginning of their stay in the Michaelshoven/Cologne vocational retraining centre. Along with in-depth talks at entry and specific vocational guidance for individuals with mental illness, these elements inter alia include: pre-rehabilitation adjustment, pre-rehabilitation course, an extramural industrial practical, action-oriented training methods throughout, and systematic placement assistance and support--in line with the vocational retraining centre's motto of "picking up our rehabilitees right where they stand".

Adolescent↗
PubMed2002

Vocational rehabilitation in patients with chronic rheumatic diseases: a systematic literature review.

OBJECTIVE: To describe the effectiveness of vocational rehabilitation programs for patients with chronic rheumatic diseases by means of a systematic review of the literature. METHODS: Data were obtained by a computer-aided and manual search of the literature from 1980 until May 2001. Vocational rehabilitation programs had to be clearly defined interventions specifically aimed at having patients with rheumatic diseases reenter or remain in the work force. The vocational rehabilitation programs had to be executed by one or more health professionals. Outcome of the intervention had to be described in terms of vocational status (work disability, sick leave, job modification, paid occupation, retraining). RESULTS: Six studies were identified. All were uncontrolled studies. Follow-up periods ranged 2-84 months. Five of six vocational rehabilitation programs consisted of multidisciplinary intervention and 15% to 69% of the patients successfully returned to work. CONCLUSIONS: Although 5 of 6 studies showed a marked positive effect of vocational rehabilitation on work status, proof of the benefit of these interventions is limited, mainly due to methodologic differences and shortcomings. RELEVANCE: Work disability is a major consequence of the disease in patients with rheumatic conditions. More and more attention is being paid to preventing disability and promoting return to work. Knowledge regarding the effectiveness of vocational rehabilitation programs is insufficient. Semin Arthritis Rheum 32:196-203.

Chronic Disease↗