Copyright 2001 by the American Psychological Association, Inc.

0022-006X/01/S5.00 DOI: 10.1037//0022-006X.69.3.489

Journal of Consulting and Clinical Psychology

2001, Vol. 69, No. 3, 489-501

Does Competitive Employment Improve Nonvocational Outcomes for

People With Severe Mental Illness?
Robert E. Drake, Haiyi Xie, and
Gregory J. McHugo

Gary R. Bond and Sandra G. Resnick

Indiana University-Purdue University Indianapolis

Dartmouth Medical School

Richard R. Bebout
Community Connections

The authors examined the cumulative effects of work on symptoms, quality of life, and self-esteem for
149 unemployed clients with severe mental illness receiving vocational rehabilitation. Nonvocational
measures were assessed at 6-month intervals throughout the 18-month study period, and vocational
activity was tracked continuously. On the basis of their predominant work activity over the study period,
participants were classified into 4 groups: competitive work, sheltered work, minimal work, and no work.
The groups did not differ at baseline on any of the nonvocational measures. Using mixed effects
regression analysis to examine rates of change over time, the authors found that the competitive work
group showed higher rates of improvement in symptoms; in satisfaction with vocational services, leisure,
and finances; and in self-esteem than did participants in a combined minimal work-no work group. The
sheltered work group showed no such advantage.

proven elusive with traditional vocational approaches (Bond,

1992; Bond, Drake, Becker, & Mueser, 1999). Given the modest
improvement in employment outcomes, the secondary goal of
improving nonvocational outcomes through employment has been
largely a moot point.
Recently, a new vocational approach, known as supported employment, has been developed. It involves a rapid, individualized
search for community jobs tailored to each client's strengths and
preferences, ongoing support on a time-unlimited basis, and close
coordination between vocational and mental health treatment staff
(Drake & Becker, 1996). For clients with SMI, supported employment has yielded substantially higher competitive employment
rates than have traditional vocational services (Bond, Drake,
Mueser, & Becker, 1997). Given these findings, the question of the
impact on nonvocational outcomes is especially timely.
Nevertheless, controlled research has failed to show significant
improvement in nonvocational domains for supported employment
clients, compared with clients receiving traditional vocational services (Bond et al., 1997). Two confounding factors may explain
the lack of findings: First, even in the most successful supported
employment programs, a significant proportion of clients are not
working at any given time, and second, even without the assistance
of effective vocational programs, some clients with SMI achieve
competitive employment. If employment is the active ingredient
for achieving better nonvocational outcomes, our analysis of nonvocational outcomes should focus on comparisons between employed and unemployed clients, rather than on enrollment in a
supported employment program.
Nonexperimental studies regarding the relationship between vocational and nonvocational outcomes have been ambiguous. Longitudinal studies of the course of schizophrenia have found only

Rates of competitive employment among people with severe

mental illness (SMI) are abysmally low, with most studies reporting rates less than 15% (Anthony & Blanch, 1987). Over the past 5
decades, a variety of vocational rehabilitation approaches (e.g.,
preparation for employment through skills training, prevocational
work crews, sheltered employment, and temporary jobs) has been
developed to improve vocational functioning for this population
(Bond, 1992). Beyond the obvious goal of increasing employment
outcomes, most approaches also have aimed at the broader goal of
community integration, including functioning outside the work
place (Lehman, 1999). The underlying assumption has been that
"work is therapy" (Black, 1988). In other words, working is
assumed to benefit clients in nonvocational domains, for example,
by increasing self-esteem, better controlling psychiatric symptoms,
and improving quality of life. Unfortunately, the goal of increasing
employment rates, particularly competitive employment, has

Gary R. Bond and Sandra G. Resnick, Department of Psychology,

Indiana University-Purdue University Indianapolis; Robert E. Drake, Department of Psychiatry and Department of Community and Family Medicine, Dartmouth Medical School; Haiyi Xie, New Hampshire-Dartmouth
Psychiatric Research Center, Dartmouth Medical School; Gregory J. McHugo, Department of Community and Family Medicine, Dartmouth Medical
School; Richard R. Bebout, Community Connections, Washington, DC.
This article was supported by Grant MH51346 from the Substance
Abuse and Mental Health Services Administration and by Grants
MH00439 and MH00842 from the National Institute of Mental Health.
Correspondence concerning this article should be addressed to Gary R.
Bond, Department of Psychology, Indiana University-Purdue University
Indianapolis, 402 North Blackford Street, Indianapolis, Indiana 462023275. Electronic mail may be sent to gbond@iupui.edu.

489

490

BOND ET AL.

modest correlations between different domains of functioning

including work and symptoms (Cook & Razzano, 2000; Gaebel &
Pietzcker, 1987; McGlashan, 1988; Moller, von Zerssen, &
Wuschner-Stockheim, 1982; Strauss & Carpenter, 1977). Other
studies have examined the relationship between vocational and
nonvocational outcomes cross-sectionally or with very brief
follow-up periods (Arns & Linney, 1993, 1995; Brekke, Ansel,
Long, Slade, & Weinstein, 1999; Brekke, Levin, Wolkon, & Sobel,
1993; Holzner, Kemmler, & Meise, 1998; Kemmler, Holzner,
Neudorfer, Meise, & Hinterhuber, 1997; Scheid, 1993; Solinski,
Jackson, & Bell, 1992). These studies have variously concluded
that clinical functioning (usually assessed by severity of symptoms) predicts success in obtaining and holding a job or, conversely, that employment leads to better nonvocational outcomes,
such as higher self-esteem, better quality of life, and reduced
symptoms. Psychiatric symptoms have predicted poorer employment outcomes for clients enrolled in vocational programs (Anthony, Rogers, Cohen, & Davies, 1995; Hoffmann & Kupper,
1997; Lysaker & Bell, 1995). Some evaluations of vocational
programs also have found that improvement in vocational functioning was associated with improvement in symptoms (Anthony
et al., 1995; Bell & Lysaker, 1997; Bell, Lysaker, & Milstein,
1996).
Finally, it is often noted that work can be stressful, and in fact,
clinicians are often leery of encouraging clients to seek employment, for fear that they will be adversely affected (Blankertz &
Robinson, 1996; Braitman et al., 1995; Marrone & Golowka,
1999). However, studies evaluating the conversion of day treatment programs to supported employment have not found increased
rates of adverse clinical outcomes (e.g., hospitalizations, suicide
attempts; Drake, 1998; Drake, Becker, Biesanz, Wyzik, & Torrey,
1996). Moreover, other studies have not found increased hospitalization rates for clients participating in employment programs
(Bond, 1992; Bond et al., 1997).
One major limitation in the literature has been the lack of clarity
regarding the active ingredients explaining improved nonvocational outcomes as a result of working. One unanswered question
concerns the type of employment that might have such benefits. Is
competitive employment more potent than sheltered employment
for improving nonvocational outcomes? On the basis of research in
nonpsychiatric populations, Lamberti and Herz (1995) concluded
that "employment in actual employment settings is better for
developing self-esteem and competence in individuals than work
in sheltered settings" (p. 725), a conclusion consistent with Estroff s (1981) ethnographic observations. Studies that examined
the effects of sheltered work on nonvocational outcomes have been
mixed (Bell & Lysaker, 1997; Bell et al., 1996; Dick & Shepherd,
1994; Griffiths, 1974; Kates, Lambrina, Baillie, & Hess, 1997;
Whittington, Wilson, & Doherty, 1997). Another question not
answered in cross-sectional designs is whether observed differences between unemployed and employed groups are a result of
the negative effects of sustained unemployment and inactivity
(e.g., demoralization, loss of hope; Hayes & Halford, 1996; Marrone & Golowka, 1999; Scheid, 1993; Warr, 1987) or the result of
the positive effects of employment. If unemployment is a negative
factor, we should see deterioration with continued unemployment;
if employment is a positive influence, we should see improvement
with continued employment. A final set of issues concerns the
impact of the duration of employment. From longitudinal studies

of schizophrenia, we know change often occurs in small increments (Strauss & Carpenter, 1977). Although obtaining a job may
provide an immediate boost in morale, a larger impact may be
realized after a sustained period of employment. Thus, we hypothesize that the effects of employment are cumulative, such that the
effects will be stronger the longer a person is working.
Two randomized controlled trials of supported employment
have examined nonvocational outcomes at multiple follow-up
points for working and nonworking clients. One found that clients
who were working had fewer psychiatric symptoms than those
who were not working at each follow-up assessment (McFarlane et
al., 2000). The supported employment model implemented in this
study, however, required that clients be clinically stable before
they entered competitive employment, so the findings may reflect
a selective delay of entry into competitive employment for more
symptomatic clients. No such restrictive criteria were used in a
New Hampshire study comparing two supported employment approaches (Drake, McHugo, Becker, Anthony, & Clark, 1996). In a
secondary analysis of this study, Mueser et al. (1997) examined the
relationship of work to nonvocational outcomes over an 18-month
period for 143 clients with SMI. At follow-up, clients who were
working had lower rates of psychiatric symptoms, higher selfesteem, and greater satisfaction with finances and vocational services than unemployed clients did, even after controlling for baseline levels of functioning.
The current article is a partial replication of the analysis conducted by Mueser et al. (1997). It is a secondary data analysis of
a second randomized study of the Individual Placement and Support (IPS) model of supported employment, conducted in Washington, DC (Drake et al., 1999). Like the earlier New Hampshire
study, the DC study showed substantially better competitive employment outcomes for clients assigned to IPS, compared with a
control group receiving traditional vocational rehabilitation services. Although the goal of both conditions was to help participants obtain competitive employment in community settings, the
control condition offered participants an array of sheltered workshop and work adjustment experiences as a first step toward
competitive employment. Thus, the current study afforded an
opportunity to examine the differential effects of sheltered and
competitive work experiences on nonvocational outcomes.
We hypothesized that among baseline characteristics, both work
history and severity of symptoms would predict employment outcomes over the follow-up period. However, on the basis of the
weak findings for these factors in the literature, we hypothesized
that the size of these effects would be small. We did not expect to
find differences on other client background variables.
Our main hypothesis concerned the effects of work on nonvocational outcomes. We hypothesized that the cumulative effects of
competitive employment would have a positive effect on nonvocational outcomes. Specifically, positive effects should be found
only for those who achieve a sustained period of working competitively, rather than for those who work minimally or not at all.
We predicted no differences between those working minimally and
those working not at all. We had two secondary hypotheses regarding sheltered employment: (a) that sustained participation in
sheltered work would result in better nonvocational outcomes than
would minimal work or not working at all and (b) that competitive
work would result in better nonvocational outcomes than would
sheltered work. In other words, we presumed that sheltered work

WORKING AND NONVOCATIONAL OUTCOMES

would have an intermediate effect between competitive and minimal or no work. Because of the hypothesized intermediate status
for sheltered work, we further expected that the size of the effects
for these latter two hypotheses would be small.
On the basis of theory and empirical research, the prediction of
an impact of working on nonvocational outcomes is more compelling in some domains than others. Thus we predicted that
employment would improve symptoms (Mueser et al., 1997),
quality of life (Fabian, 1989, 1992; Mueser et al., 1997), and
self-esteem (Arns & Linney, 1993, 1995; Matthews, 1980; Mueser
et al., 1997; Van Dongen, 1996, 1998). Because of assumptions
made by many clinicians and because of their practical importance,
several possible adverse outcomes were also examined. Working
was not predicted to affect these areas, either positively or negatively. The literature on people with SMI suggests that working has
no impact on rates of psychiatric hospitalizations (Bond, 1992;
Bond et al., 1997; Crowther, Marshall, Bond, & Huxley, 2001) and
that there are no associations between work and alcohol and drug
use (Sengupta, Drake, & McHugo, 1998). Little is known about
the relationship between working and homelessness (Kirszner,
McKay, & Tippett, 1991) or between working and involvement in
the criminal justice system, although one study found that criminal
history was negatively correlated with future employment (Rogers,
Anthony, Cohen, & Davies, 1997).
Method

Study Participants
Study participants were recruited at Community Connections, an intensive case management agency serving clients with SMI in southeast Washington, DC. Participants met the following inclusion criteria: SMI (i.e., a
major mental illness, such as schizophrenia or bipolar or depressive disorder, and 2 years of major role dysfunction), unemployed at time of study
admission, willingness to give informed consent, lack of medical or cognitive problems that would interfere with completing research interviews,
and attendance at four informational groups. All clients at the agency were
encouraged to attend informational groups explaining the study procedures
and the two vocational approaches (Bebout, Becker, & Drake, 1998). Of
the 309 clients receiving case management at the study site during the
study enrollment period, 152 (49%) participated in the study. Two participants with incomplete vocational data and 1 participant who could not be
classified on his pattern of employment (explained below) were excluded
from the current analyses. Characteristics of the final sample of 149
participants are shown in Table 1.

Data Collection Procedures

Data collection procedures are described elsewhere (Drake et al., 1999).
Briefly, most outcome measures were obtained during client interviews by
two bachelor-level research assistants who were independent of the clinical
services. The research assistants were initially trained during a 2-day
orientation by staff at the New Hampshire-Dartmouth Psychiatric Research Center and subsequently monitored by a clinical psychologist (R. R.
Bebout) for the life of the project. For monitoring purposes, 36 clients were
administered the same interview twice within a 2-week period. R. R.
Bebout conducted all the diagnostic interviews.

Measures Used
Background measures. Background measures included demographics,
psychiatric diagnosis, which was determined on the basis of a diagnostic

491

interview using the Structured Clinical Interview for DSM-HI-R (Spitzer,

Williams, Gibbon, & First, 1988) prior to study entry, and the Global
Assessment Scale (GAS; Endicott, Spitzer, Fleiss, & Cohen, 1976).
Outcome measures. Nonvocational outcomes were measured at baseline and at 6, 12, and 18 months after study admission. Overall life
satisfaction, satisfaction with finances, leisure, vocational services, and
financial support adequacy were measured with portions of the Quality of
Life Interview (Lehman, 1983). Psychiatric symptoms were measured with
the expanded (24-item) Brief Psychiatric Rating Scale (BPRS; Lukoff,
Liberman, & Nuechterlein, 1986). In addition to the total BPRS score, we
used five subscales derived from an unpublished factor analysis of 601
clients with SMI (McHugo, 1999): Affect, Anergia, Thought Disorder,
Activation, and Disorganization. The total BPRS score (sum of all items)
ranged from 24 to 168, whereas subscales (average of component items)
ranged from 1.0 to 7.0, with higher scores indicating greater severity. A
previous study of clients with SMI reported test-retest reliability coefficients as follows: Affect (.78), Anergia (.68), Thought Disorder (.93),
Activation (.59), and Disorganization (.78; Drake, McHugo, et al., 1996).
The Rosenberg Self-Esteem Scale is a 10-item self-report measure of
global self-worth (Rosenberg, 1965). It is the most widely used self-esteem
measure (Blascovich & Tomaka, 1991). Scores on the Rosenberg Scale
range from 10 to 40, with lower scores indicating greater self-esteem.
Reliability coefficients from previous studies of clients with SMI found
internal consistency coefficients (Cronbach's alpha) exceeding .80 and
test-retest reliability of .87 (Torrey, Mueser, McHugo, & Drake, 2000).
Alcohol use and drug use were measured using clinician ratings on the
Alcohol Use Scale (AUS) and Drug Use Scale (DUS; Drake et al., 1990).
Participants' case managers were trained to complete these scales using
multiple data sources to rate alcohol and drug use over the prior 6-month
period. Both scales range from a low of 1 (abstinent) to a high of 5 (severe
dependence), with a 3 or higher indicating a current substance abuse or
dependence problem. Drake, Mueser, and McHugo (1996) reported AUS
test-retest reliabilities close to 100%. They also reported agreement between raters (kappa coefficients) for the AUS and DUS ranging from .80
to .95.
The number of days clients spent in psychiatric hospitals was tracked by
Community Connections' management information system. Days spent in
jail, in prison, or as homeless were measured by client self-report through
direct questioning. These variables were assessed for the previous 1-year
period at study entry and for the preceding 6-month period at each
follow-up.
Independent measure: Typology of work activity. Employment status
and job type were tracked by vocational staff at the participating agencies
and then verified through bimonthly research interviews with participants.
Jobs were classified as either competitive, defined as regular community
jobs, in integrated settings (i.e., with nondisabled coworkers), paying at
least minimum wage, or sheltered, defined as paid work activity licensed
by the Department of Labor in which workers are paid on a piece-rate
basis. Most jobs fit unambiguously into one of these two categories.
However, 6 participants were employed for a substantial amount of time in
jobs secured through the National Industries for the Severely Handicapped
(NISH) program (Black, 1988). NISH jobs have characteristics of both
sheltered and competitive work and, therefore, are less clearly classifiable.
The jobs are reserved for those with disabilities and, thus, are like sheltered
work. However, these jobs were classified as competitive for the purposes
of these analyses for the following reasons: (a) NISH positions involve
working in community settings (e.g., offices of government agencies); (b)
clients working these jobs receive wages commensurate with those in
competitive employment, which are always above minimum wage; (c)
clients' self-perceptions are that they are working "real" jobs, not protected
jobs; and (d) coworkers are often people without disabilities.
To test the hypothesis that differences in type of work activity would
differentially affect nonvocational outcomes, participants were categorized
into one of four groups on the basis of their cumulative employment

492

BOND ET AL.

Table 1
Background Characteristics by Group at Study Entry
Characteristic
Gender (%)
Female
Male
Race n (%)
African American
Other
Marital status n (%)
Never married
Ever married
Education n (%}
<High school diploma
High school diploma
Psychiatric diagnosis n (%)
Schizophrenia spectrum
Bipolar spectrum
Depressive disorders
Other Axis I
Alcohol use n (%)
Abstinent or minimal use
Abuse or dependence
Drug use n (%)
Abstinent or minimal use
Abuse or dependence
Homeless in prior 12 months n (%)

No

Yes

No work
(n = 44)

Minimal work
(n = 50)

Sheltered work
(n = 24)

Competitive work
(n = 31)

Total
(N = 149)

24 (55)
20 (45)

35 (70)
15 (30)

13 (54)
1 1 (46)

19(61)
12 (39)

91 (61)
58 (39)

36 (82)
8(18)

43 (86)
7(14)

20 (83)
4(17)

24 (77)
7(23)

123 (83)
26(17)

29 (66)
15 (34)

33 (66)
17(34)

16 (67)
8(33)

19(61)
12 (39)

97 (65)
52 (35)

12 (27)
32 (73)

17 (34)
33 (66)

13 (54)
1 1 (46)

9(29)
22(71)

51 (34)
98 (66)

29 (66)
6(14)
8(18)
1(2)

33 (66)
9(18)
6(12)
2(4)

20 (83)
0(0)
4(17)
0(0)

17 (55)
6(19)
7(23)
1(3)

99 (66)
21 (14)
25(17)
4(2)

36 (86)
6(14)

46 (92)
4(8)

23 (96)
1(4)

30 (97)
1(3)

137(92)
12(8)

36 (82)
8(18)

44 (88)
6(12)

22 (92)
2(8)

27 (87)
4(13)

129(87)
20(13)

37 (84)
7(16)

36 (72)
14 (28)

16 (67)
8(33)

22(71)
9(29)

1 1 1 (74)
38 (26)

42 (95)
2(5)

48 (96)
2(4)

22 (92)
2(8)

31 (100)
0(0)

143 (96)
6(4)

27 (61)
17 (39)
40.1 (6.8)
4.6 (94)
41.9(9.6)
22.9 (32.6)

23 (46)
27 (54)
38.5 (6.7)
5.6 (7.9)
41.0(10.1)
28.6 (62.8)

1(4)
23 (96)
42.2(10.0)
8.8 (10.6)
39.6 (6.7)
23.8 (44.5)

23 (74)
8(26)
37.8 (4.8)
13.6(12.6)
47.2 (9.0)
16.5 (27.8)

Time in jail or prison in prior 12 months n (%)

No
Yes
Group assignment" n (%)

IPS
Control group
Age, M (SD)
Months in paid employment (prior 5 years),6 M (SD)
GAS, M (SD)C

Days in hospital (prior year), M (SD)d

74 (50)
75 (50)
39.5 (7.1)
7.5 (10.4)
42.3 (9.5)
23.7 (46.0)

Note. Findings are nonsignificant unless otherwise noted. IPS = Individual Placement and Support model; GAS = Global Assessment Scale.
X2(3,N= 149) = 30.0, p< . 001. b F(3, 148) = 5.93, p = .001; competitive > no work, minimal work. c F(3, 148) = 3.87, p = .011; competitive >
minimal work, sheltered work. d ns = 42, 49, 23, 29, and 143, respectively.

earnings over the 18-month study: competitive employment, sheltered

employment, minimal work activity, and no work activity. Classification of
the sample into this typology followed these steps: First, we calculated total
competitive employment earnings and total sheltered employment earnings
for the entire study period. Next, using data from only those individuals
with competitive earnings, we calculated the median for competitive earnings. The analogous procedure was used for sheltered earnings. This
resulted in a median of $1,894 for competitive earnings and $1,223 for
sheltered earnings. Then, participants were classified on the basis of their
cumulative earnings over the 18-month period as follows: competitive
work, for participants earning more than $1,894 in competitive employment; sheltered work, for those earning more than $1,223 in sheltered
employment; minimal work, for those who had worked in either competitive or sheltered employment, but earned below the respective median; or
no work, for participants who had no earnings over the 18-month period.
Classification was done without regard to study condition assignment in
the parent study.
We used earnings from employment as a proxy for sustained involvement in work. Among those who worked competitively at some time
during the follow-up period (n = 52), earnings correlated .99 with hours
worked and .83 with weeks worked, which suggested that the measure of

earnings was a reasonable choice for classifying duration of employment.

Data on hours and weeks worked in sheltered employment could not be
obtained from several agencies; thus, the corresponding correlations cannot
be reported.

Analysis
The first step was to construct the typology, as just described. We then
examined differences in the four groups on background characteristics.
Analysis of variance and chi-square statistics were used to examine group
differences at baseline. In addition, baseline nonvocational measures and
work history measures were examined as predictors of vocational and
nonvocational outcomes at each follow-up period.
We examined each of our outcome measures separately, using univariate
two-tailed tests and p < .05 as alpha for each comparison. In the symptom
area, we stipulated a priori that we would examine the total symptom score,
and if it was significant, we would then examine subscales.
Our main analysis focused on the prediction of nonvocational outcomes
from employment status on the basis of the typology. Depending on the
distribution of our dependent measures, we used either a parametric statistical model (described below) for measures that roughly approximated a

493

WORKING AND NONVOCATIONAL OUTCOMES

Table 2
Group Comparisons on Work Outcomes
Minimal work
( = 50)

Employment outcome
Competitive employment
Any competitive job
n
%
Any NISH job
n
%

Wages earned (competitive or NISH)

M
SD
Hours worked (competitive or NISH)b
M
SD
Weeks worked (competitive only)0
M
SD
Days to first job (competitive only)0
M
SD

Sheltered employment
Any sheltered job
n
%
Wages earned
M
SD
Total earnings
M
SD

Sheltered work*
(n = 24)

Competitive work
(n = 31)

25
50

26
84

2
4

6
19

$607
$503

$5,631
$3,724

Test of significance

X2 = 9.4d

.002

t = 7.43

.0001

116.9
94.9

923.7
612.4

t = 7.23

.0001

8.5
9.0

38.1
20.9

t = 6.62

.0001

187.5
166.1

103.0
78.1

t = 2.3

.027

X2 = 30.6e

.0001

29
58

24
100

8
26

$239
$306

$3,341
$2,760

$167
$396

F = 50.2

.0001

$554
$417

$3,350
$2,764

$5,799
$3,751

F = 45.2

.0001

Note. NISH = National Industries for the Severely Handicapped program.

a
This group had 1 person who worked competitively, earned $225 in wages, worked 45 hr during 1 week of employment, with 338 days until beginning
the job. b For minimal work group, n = 26; for competitive work group, n = 31. For minimal work group, n = 25; for competitive work group,
n = 26. d ( l , A f = 5 1 ) . e (2, N = 61).
normal distribution at baseline or chi-square tests for measures that were
dichotomized because their distributions were heavily skewed (mostly
zeros).
Because data on nonvocational variables were obtained semiannually
throughout the study period, group differences over the 18-month period
were analyzed using mixed-effects regression analysis (SAS PROC
MIXED; Singer, 1998; Wolfinger & Chang, 1995) as a means of modeling
longitudinal data. Specifically, this analysis compared the rate of change
(i.e., the slope of the regression line) for each of the four employment
groups. In essence, mixed-effects regression analysis tests differences
between groups in the baseline level of a dependent measure, through
estimation of intercepts, and examines differences between groups in the
rate of change over time, through estimation of slopes. These effects are
independent of each other, thereby enabling interpretation of longitudinal
change apart from initial differences.
Each nonvocational outcome measure was examined in a separate
mixed-effects regression analysis. We made the following a priori predictions regarding the rate of improvement in nonvocational outcomes:
Hypothesis 1: No differences between minimal work group and no
work group
Hypothesis 2: Sheltered work group > combined minimal work
group-no work group
Hypothesis 3: Competitive work group > sheltered work group
Hypothesis 4: Competitive work group > combined minimal work
group-no work group

Supplementing our statistical analyses was an examination of the effect

size (ES) for the group differences in the Hypothesis 4 comparison, defined
as the difference between the 18-month means divided by the pooled
standard deviation (Lipsey, 1990), and the within-group ES, defined as the
difference in the means at baseline and at 18 months divided by the
baseline standard deviation, after correcting for the correlation between
baseline and 18-month assessments (Becker, 1988). Lipsey (1990) has
developed empirical norms for treatment studies to describe the magnitude
of ESs: A value less than .33 is "small," a value between .33 and .55 is
"medium," and a value above .55 is "large."

Results
Typology
Of the 150 participants from the parent study (Drake et al,
1999), we used 149 (99%) in the current analysis. Of these, we
easily classified 140 using the work typology, because they either
had been employed in only one work category (sheltered or competitive), had earned less than the median income levels on both
wage categories, or had no paid employment during the follow-up
period. However, 10 individuals had worked both a competitive
and a sheltered job over the 18-month period and earned above the
median for at least one type of job. Of these, 8 were placed in the
competitive work category and 1 in the sheltered category because
earnings in their predominant job type consisted of 70% or greater

494

BOND ET AL.

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comparison of competitiv
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support adequacy. d Lov

BPRS total score0

No work
Minimal work
Sheltered work
Competitive work
Total
BPRS Affecte
No work
Minimal work
Sheltered work
Competitive work
Total

Outcome

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496

BOND ET AL.

of their total earnings for the study period. One participant could
not be classified because of a 60-40% split in total earnings
between competitive and sheltered employment and was therefore
dropped from the analysis, as noted above.
This typology resulted in four subgroups: competitive work
(n = 31), with mean earnings of $5,799 (SD = $3,751); sheltered
work (n = 24), with mean earnings of $3,350 (SD = $2,764);
minimal work (n = 50), with mean earnings of $554 (SD = $417);
and no work (i.e., no paid work over follow-up; n = 44). Group
comparisons are shown in Table 2. Other indicators of duration of
employment were consistent with the typology. For example, the
competitive work group averaged 32 weeks of competitive employment over the 18-month follow-up period, compared with an
average of less than 5 weeks for any of the other groups. Conversely, mean earnings from sheltered employment were 10 times
greater for the sheltered work group than was the mean for any
other group. Therefore, the typology successfully classified participants into distinct groups.
The groups were similar on most background characteristics, as
shown in Table 1. However, GAS scores were significantly higher
for the competitive work group (M = 47.2) than for the minimal
(M = 41.0) or sheltered (M = 39.6) groups, F(3, 148) = 3.87, p =
.011. Also, in the 5 years prior to study intake, the groups differed
in months competitively employed, F(3, 148) = 5.93, p = .001.
Converting these data to an annualized rate, the competitive work
group averaged 11.8 weeks per year in competitive employment
over the preceding 5 years, compared with 7.6, 4.8, and 4.1 weeks
per year, respectively, for the sheltered, minimal, and no work
groups. Thus, most participants in all four groups were unemployed for a large proportion of time during the 5-year period prior
to the study.
We also examined whether the two conceptually distinct subgroups within the minimal work groupthose who worked minimally in competitive work and those who worked minimally in
sheltered workdiffered on background measures or on any nonvocational outcomes during follow-up. Our analyses (not shown)
indicated that they did not.
Inspection of the response distributions for the outcome measures at baseline suggested that the quality of life measures, the
symptom measures, and the self-esteem measure were reasonably
well behaved and that these were suited for parametric analyses.
However, five measures were highly skewed: those measuring
alcohol use, drug use, homelessness, psychiatric hospitalizations,
and time in jail. We therefore dichotomized each as either indicating the presence or the absence of the problem. We report the
findings for these dichotomized measures first.

Chi-Square Analyses
The baseline rates for the dichotomized variables were low, as
shown in Table 1. As we previously noted, the groups did not
differ at baseline on these variables. We then examined betweengroups differences in these rates at each of the three follow-up
periods, using 2 X 2 chi-square analyses, with group comparisons
constructed according to the study hypotheses. None of the 12
chi-squares was statistically significant. Overall, there was a slight
tendency for the competitive work group to function better on
these variables than the no work and minimal work groups did,
both at baseline and thereafter. For example, across the 18-month

period, the rate of alcohol abuse ranged from 3% to 7% for the

competitive work group and ranged from 11% to 20% for the no
work-minimal work group. The sample as a whole did not improve over time on any of these measures, nor was there any
evidence that any of the four subgroups improved. Therefore, we
conclude that working did not have any impact on functioning in
these areas.

Mixed-Effects

Regression Analyses

Means and standard deviations for the remaining nonvocational

measures are shown in Table 3. At baseline, there were no significant differences between the groups on any of these variables. All
groups showed significant changes over the course of the study on
most outcomes, with significant time effects suggesting improvement on all of the quality of life measures and self-esteem, and
worsening of symptoms on the total BPRS score and the Anergia
subscale.
As hypothesized, we found no differences between the no work
and minimal work groups for any nonvocational measure, and so
these two groups were combined for the remaining analyses.
Contrary to prediction, there were no differences between the
sheltered work group and the competitive work group (Hypothesis
2), nor were there any differences between the sheltered work
group and the no work-minimal work group (Hypothesis 3).
However, several measures showed differences between the competitive work group and the no work-minimal work group (Hypothesis 4). All of the differences were in the predicted direction.
The strongest differences were seen with those variables most
directly related to working. Over the 18-month period, the competitive work group was increasingly more satisfied with vocational services, ?(427) = 3.43, p = .0007; ES = 0.80, with their
finances, t(433) = 3.00, p = .0029; ES = 0.80, and with their
leisure activities, f(431) = 2.57, p = .011, ES = 0.60, than were
those in the combined no work-minimal work group. Those working competitively showed a greater improvement in self-esteem,
f(433) = -2.07, p = .039, ES = 0.19, than those not working or
working minimally. Differences in the rates of improvement in
symptoms favoring the competitive work group over the no workminimal work group were also observed. This was true for total
BPRS symptoms, f(432) = -2.17, p = .031, ES = 0.70, as well
as the Affect, ?(433) = -2.16, p = .032, ES = 0.48, and Disorganization, f(433) = -1.99, p = .047, ES = 0.54, subscales.
To understand the patterns for individual measures, we graphed
each of the means of outcome measures for the work groups over
time. The graphs for the Rosenberg Self-Esteem Scale and for
BPRS total scores are shown in Figures 1 and 2, respectively.
Figure 1 suggests that self-esteem improved between baseline
and 18 months for the competitive work group (within-group
ES = 1.17), with relatively little net change for the other three
groups (within-group ESs ranging from 0.14 to 0.47). By contrast,
Figure 2 suggests that the competitive work group was unchanged
on the BPRS total from baseline to 18 months (within-group
ES = 0.21), whereas the no work group deteriorated substantially
(ES = 1.12). The patterns for the remaining outcome measures
were variable. For example, the competitive work group had large
within-group ESs reflecting improvement in self-esteem
(ES = 1.17), overall life satisfaction (ES = 0.90), and satisfaction
with finances (ES = 1.45), leisure (ES = 0.61), and services

497

WORKING AND NONVOCATIONAL OUTCOMES

- * no work
> minimal work
A sheltered work
competitive work

22.0
21.5
21.0
20.5
20.0
19.5
19.0
18.5
en
18.0
17.5 -

17.0 X
Baseline

6 months

12 months

18 months

Figure 1. Group means on Rosenberg Self-Esteem Scale over the course of the study. Lower scores indicate
greater self-esteem.

(ES = 2.24), whereas the ESs for the symptom subscales were
generally smaller: Affect (ES = 0.46), Thought Disorder
(ES = 0.27), Activation (ES = 0.00), and Disorganization
(ES = 0.59), with one ES in the direction of worsening symptoms,
Anergia (ES = 0.44). Averaging across the eight outcome measures listed in Table 3 (using only the BPRS total for the symptom
domain), the within-group ESs for the no work, minimal work,
sheltered work, and competitive work groups were 0.02, 0.01,
0.19, and 0.74, respectively.

Discussion
Clients with SMI who worked in competitive employment for
an extended period of time showed a greater rate of improvement
in several nonvocational outcomes, which partially replicated the
findings in Mueser et al. (1997), who found improvement in some
of the same nonvocational domains. Perhaps the most significant
area of convergence in the two studies was in reduction in psychiatric symptoms. Because of the lack of baseline differences and

^ no work
- - minimal work

46 i

sheltered worik

competitive work

44
42 H
40

34 -

32 1
Baseline
Figure 2.
severity.

6 months

1
12 months

1
18 months

Group means on Brief Psychiatric Rating Scale (BPRS) total scores. Higher scores indicate greater

498

BOND ET AL.

the statistical model used, we believe the findings are not simply
a result of better functioning clients being more successful in
achieving and maintaining competitive work. Instead, we conclude
that this study offers preliminary support for the view that competitive employment nurtures positive personal changes outside
the work domain. However, this conclusion must be qualified. For
some of the findings, the improvement in the competitive work
group was significant, whereas in other cases, the statistical difference reflected deterioration in the minimal-nonworking group.
Studies have frequently not distinguished between these two scenarios. Accordingly, we recommend that future studies routinely
indicate whether differences are a result of the improvement with
working or of deterioration as a result of not working.
The current study also offers a refinement over most previous
research by suggesting that the impact of employment on nonvocational outcomes is evident only for an extended period of employment, not merely for exposure to work. Research should
examine whether longer periods of employment result in further
incremental gains in other life domains, as one would expect
intuitively.
As has been widely found in studies of people with SMI (Bond
et al., 1997), we found most competitively employed clients in the
current study worked part time, and some held a series of shortterm jobs. This pattern of partial employment is consistent with the
stress tolerance level for this population, as well as with strategies
clients use to avoid the disincentives of the disability benefits
system, which reduce benefits when earnings exceed specified
limits (Walls, Dowler, & Fullmer, 1990; Warner & Polak, 1995).
Regarding the widely held assumption among clinicians that
employment may cause stress and therefore lead to poorer nonvocational outcomes, there was no evidence that the competitive
work group, on average, deteriorated over time in any outcome
domain. The single exception was a slight increase in BPRS
Anergia. The major thrust of the findings, including those for
psychiatric hospitalization, substance use, and total symptoms, is
that working competitively generally does not adversely affect
people with severe mental illness.
Consistent with most prior research (Anthony & Jansen, 1984;
Bond, 1992; Mueser et al., 1997; Rogers et al., 1997), client
background characteristics mostly did not predict employment
outcomes in this study. The fact that symptoms at baseline did not
predict later employment outcomes is at variance with some of the
literature, although studies are not consistent on this point. We
speculate that symptoms are less of a barrier in programs that
assertively help clients find jobs, as was true for clients receiving
IPS services in this study. We also note that the study participants
were generally less symptomatic than clients in many of the
published studies examining this relationship. Given the mounting
evidence that negative symptoms are especially predictive of
poorer vocational functioning in people with schizophrenia (Hoffmann & Kupper, 1997; Lysaker & Bell, 1995), it is of interest that
the BPRS factor of Anergia (blunted affect, emotional withdrawal,
and motor retardation) did not predict employment outcome.
One set of comparisons not previously examined in prior research concerned the differential impact of competitive and sheltered work. In the parent study, Drake et al. (1999) found that the
experimental conditions participants had similar earnings from
employment, with the difference being that virtually all of the
employment outcomes for the IPS condition were in competitive

employment, whereas virtually all of the employment outcomes

for the comparison condition were in either sheltered employment
or NISH jobs. Thus, one might argue that both conditions were
equally successful with regard to work outcomes, because both
increased employment, and that the only difference was the type of
employment. However, the pattern of results in the current study
suggests a distinctive advantage of programs that focus on competitive employment. Although the direct comparisons between the
competitive work and sheltered work groups were not significant,
the mean within-group ES for the competitive work group was
large (0.74), whereas it was negligible for the sheltered work group
(0.19). Moreover, there was no evidence that even an extended
period of sheltered employment resulted in better nonvocational
outcomes than did not working or working very little. Thus, IPS
programs may be more likely to yield improved nonvocational
outcomes for clients who achieve employment than are programs
that provide sheltered work.
It is important to note that this study investigated only one type
of sheltered employment, namely, piece-rate employment in a
workshop setting. In addition to sheltered employment, psychiatric
rehabilitation programs offer many different protected employment opportunities, including transitional employment (Macias,
Kinney, & Rodican, 1995), agency-run businesses (Chandler,
Levin, & Barry, 1999), mobile work crews operated by a rehabilitation agency in which clients work in community settings (Schultheis & Bond, 1993), and many other arrangements that resemble
competitive employment in some respects and sheltered employment in other respects (Bond et al., 1999; Shimon & Forman,
1991). The hypothesis forwarded in this study, that sustained
employment in competitive work leads to better nonvocational
outcomes, does not identify the active ingredientsIs it payment
of a decent wage? Is it working in an integrated work environment? Is it the fact that the client "owns" a job? Is it the fact that
the job is permanent?
Studies should examine whether the apparent advantage for
competitive work over sheltered work can be extended to other
forms of protected employment, such as agency-run businesses
and work enclaves. Such research will test a key premise of
diversified placement approaches, which hypothesizes that meaningful activity is more important than the specific type or location
of work (Bond et al., 1999).
Assuming that working competitively increases self-esteem and
improves clinical functioning, what is the mechanism of change
for the individual? Is the primary factor the change in role status
with employment, so that a client reinterprets his or her identity to
incorporate a more positive self-image (Lysaker & France, 1999)?
Does the structure provided by the routine of working and by the
work environment help combat symptoms (Marrone & Golowka,
1999)? Or is it the socialization that occurs with the integration
into the work place that is critical (Gates, Akabas, & Oran-Sabia,
1998; Mank, Cioffi, & Yovanoff, 1997)? Probably a variety of
mechanisms account for the findings, with no single explanation
holding for all people at all times.
Another factor that prevents a simple interpretation of the effects of working is the idiosyncratic course of psychiatric disorders. Strauss, Hafez, Lieberman, and Harding (1985) argued that
the course of recovery in schizophrenia is characterized by moratoriums, "change points," and other nonlinear patterns. The group
data in Figures 1 and 2 mask individual variation, but it is clear that

499

WORKING AND NONVOCATIONAL OUTCOMES

the patterns in this study are not simple linear trajectories. Also, a
more long-term perspective than the 18-month follow-up period in
our study may be required to see patterns.
A final comment concerns the clinical significance of the study
findings. It has become increasingly standard practice for psychotherapy researchers to include information on normative comparisons of their outcomes (Jacobson, Roberts, Berns, & McGlinchey,
1999; Kendall, Marrs-Garcia, Nath, & Sheldrick, 1999). In principle, our study could have attempted to document what percentage of clients in each group exceeded some normative criterion.
Unfortunately, the psychiatric rehabilitation field has lagged behind psychotherapy research in thinking through the issue of
clinical significance and has not yet begun to address the thorny
question of what might constitute adequate comparison groups.
Given the nonlinear course of psychiatric illnesses, cutoff scores
based on general population norms (when they are available)
might very well represent a misapplication of the concept of
clinical significance that experts in this area have warned us
against (Jacobson et al., 1999; Kendall et al., 1999). Further
complicating the picture is the suggestion that there may legitimately be instances in which a clinically significant change can be
said to have occurred even when there has been no change in
symptoms (Kazdin, 1999). Given the lack of conceptualization of
clinical significance for the study population, we have opted not to
pursue this methodology in the current report, although we urge
consideration of it in future work.
One limitation of our study concerns the relatively brief
follow-up period. Although longer than many studies, 18 months
may be shorter than the time needed to observe changes in target
domains (Gerden, 1998). The mean duration of employment for
the competitive work group was 32 weeks, which is less than
optimal for fully testing the study hypothesis. A second limitation
is the modest sample sizes for the four groups, limiting statistical
power. A third limitation concerns the relatively large number of
outcomes examined. Although our findings are bolstered by a
priori hypotheses (and our partial replication of the Mueser et al.,
1997, study), an inflated Type I error rate (Wilkenson & Task
Force, 1999) nonetheless is a concern. A fourth limitation is that
statistical significance is not the same as clinical importance. For
example, despite significant differences in symptom ratings, most
participants experienced subclinical levels of symptoms throughout the follow-up period. Floor effects for some clinical variables
may have precluded the detection of any improvement. A fifth
limitation concerns the questionable validity of the self-esteem
measure (Torrey et al., 2000). A sixth limitation concerns the
sampling characteristics. Study participants were inner-city clients,
primarily African American, and all indicated an interest in employment and received excellent vocational services. Although
drawn from a severely disabled population, the participants' severity of symptoms and level of substance abuse were low. The
findings may not generalize beyond this context.
A further limitation of our study is the absence of subanalyses
for demographic subgroups. For example, given the gender difference in the course of schizophrenia (McGlashan, 1988) and the
fact that men and women view employment differently (Cook &
Roussel, 1987; Goering, Cochrane, Potasznik, Wasylenki, & Lancee, 1988), the relationships between working and nonvocational
outcomes may differ for men and women. Further inquiry is

warranted in samples with sufficient statistical power to address

these questions adequately.
Finally, as in any correlational study, we must be cautious in
imputing causation. There is no experimental way to answer the
question of the impact of work on nonvocational outcomes, because not everyone afforded the chance to work actually works.
Therefore, the best way to determine the impact of work on
nonvocational outcomes may be to examine a pattern of results
over a series of studies. The fact that the groups differed little on
background characteristics increases our confidence that the findings are not merely an artifact of selection biases in which higher
functioning participants were more successful in holding competitive jobs as a result of greater control of symptoms prior to study
entry.

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[1999, September 13].

Received March 2, 2000

Revision received August 7, 2000
Accepted September 3, 2000