A Working Life for People With Severe Mental Illness

Patients, family members, clinicians, and administrators increasingly recognize employment as an essential element in the quality of life of an individual with severe mental illness. Treatment guidelines and evidence-based treatments (1) identify enhancement of work outcomes as an important target for treatment. Overshadowing older views of treatment successes as defined by rates of hospitalization or even levels of symptoms, real-life outcomes, such as employment and education, are now the standards for assessing the long-term success of a treatment.

Mental health clinicians can thank patient advocacy groups and family organizations such as the National Alliance for the Mentally Ill for the shift of emphasis from hospitalizations to functioning. Now, those of us in the clinical and administrative fields can thank the authors of A Working Life for People With Severe Mental Illness for this clear, practical book on integrating work into clinical treatment. The authors, both well-known leaders in clinical and research aspects of vocational rehabilitation of persons with severe mental illness, set out to lay to rest the notion that only work in a sheltered environment—or perhaps no work at all—is appropriate for people with severe mental illness.

Becker and Drake push the reader to move beyond traditional services that focus on skills training and sheltered workshops and define the individual placement and support approach to work. Stressing the importance of integration and of establishing hopefulness, the authors define individual placement and support as a rapid job search and placement in competitive employment that matches the individual's skills and preferences. Individual placement and support then supplies the ongoing support necessary to succeed in the job or to develop skills that will apply to the next job.

The book is divided into three sections. The first section provides the student with a historical perspective on the role of vocational rehabilitation services for persons with severe mental illness. The second section demonstrates to the professional working in the field how this approach can be successfully integrated into treatment. Finally, the third section attends to special issues, such as persons with dual diagnoses and individuals who are highly trained. The text provides a readable balance of literature reviews as well as case scenarios and how-to material.

Although the authors do attend to some obstacles to the implementation of individual placement and support on a widespread basis, they may be overly optimistic—or overly fortunate—in their experience. Books such as this, and the research reviewed therein, can change the attitudes of professionals. Staff can become expert in the ways that work need not overly interfere with individuals' disability benefits and health insurance. The real obstacles to implementing individual placement and support may arise from the entrenched funding for existing vocational rehabilitation programs and the inability of most clinical systems to absorb the costs of services not directly reimbursed by Medicaid, Medicare, and the attendant managed care payers.

Becker and Drake have written an inspiring and thoughtful challenge to those of us working in mental health care—our patients can work, and there is an evidence-based practice that will support them to succeed.

Ms. Minichiello is a vocational specialist on the PACT team at UMass-Community Healthlink in Worcester, Massachusetts. Dr. Stovall is assistant professor of psychiatry and of family medicine and community health at the University of Massachusetts Medical School in Worcester.