PERSPECTIVES
WORK FOR PSYClllATRICALLY DISABLED CLIENTS
Susan Lang, MBA, OTR, ATR Occupational Therapy Consultant San Francisco, California
The promotion of work and work-related activities has been part of occupational therapy since its inception. Historically, vocati~nal aspects of occu pational therapy treatment focused on physically disabled persons. In the past 20 years interest in, and speculation about, the integration of psychiatrically disabled individuals into work arenas has increased. Programs have been initiated, assessments developed, and clients placed in a broad variety of work settings. Our current attitudes have as their underpinnings the way work has been viewed historically by our profession.
THE HISTORICAL PERSPECTIVE: AHEAD TO THE PAST During what is termed the era of "moral treatment" in the 1800s, work was seen as a means of focusing attention, increasing morale, and promoting discipline. In the early 1900s, in the
so-called occupational paradigm stage, work was thought to lead to increased general productivity, normalized routines, and increased work tolerance. The occupational paradigm addressed the patient's intrinsic sense of productivity rather than focusing on paid employment as the only goal. Crafts were extensively used. In time, however, clinicians in the field became uncomfortable with the use of modalities that were sometimes unrelated to the patient's sense of values. Clinicians of the 1950s identified the need for a more scientific approach to work and work evaluation in keeping with the generally reductionist philosophy, then developing in the medical world, that human behavior was a biological and physiological function. In the early 1960s, occupational therapists, while adopting a more scientific focus, developed programs centered around evaluation and industrial therapy. Work became more narrowly defined and often synonymous with gainful employment. The "therapeutic" part of work programs often referred to the prework evaluation portion of the program, which became increasingly complex as therapists established work samples and evaluation methods. In the 1970s and into the early '80s, work remained a function of occupational therapists who saw themselves as specialists in work evaluation, work placement, and promotion of work tolerance and work adjustment.! During these years, vocational services for psychiatric clients were often provided in programs that primarily served the physically disabled. It was not until the late '70s and early '80s that work programs exclusively for psychiatric clients became common. With
Work for Psychiatrically Disabled Clients
the exception of a few programs, the focus was on placing the most functional clients in gainful employment with little attention given to those with more disabling illnesses. This attitude was perpetuated by the funding agencies, which used job placement as the primary criteria for distribution of grant money. However, in the early and mid 1980s, several programs attempted to develop work slots for clients of varying functional capacities, laying to rest the assumption that the so-called lower-functioning clients could work only in sheltered workshops. It appeared that for many clients a supportive environment could be provided in the community with proper preparation. 2,3 This shift in philosophy is not unlike the deinstitutionalization movement of the '60s to return clients to the community. This time, however, the community-based programs are more organized and are accepting clients as they are able. This time, funding agencies are also being considerably more responsive. Current philosophies vary concerning the role that occupational therapists should take in vocational arenas in the future. Opinions range from advocating a more specialized role in vocational areas, such as assessment, to the belief that a more generalized definition of . work to include areas such as non-employmentrelated productive activity, would reflect more appropriately what occupational therapists can do and what is needed by our clients. Regardless of the direction or philosophy adopted by a majority of therapists, work will certainly remain a vital consideration for occupational therapists. In the psychiatric arena, work may provide a new focus for therapists who have difficulty defining their role among a host of other clinical providers. Work will, without a doubt, cause the profession to revisit some of the philosophies of the past. We have gone full circle back to the 1940s with the suggestion that the definition of work be broadened to include notions of intrinsic productivity. A return to some of these values might be welcome in today's world of financial pressures and highstress jobs.
7
JOURNAL TITLE SAYS IT ALL: WORK PREVENTION, ASSESSMENT, AND REHABILITATION The very existence of this journal is strong evidence of the growing interest in work as a viable and crucial component of rehabilitation. That the journal in its title addresses prevention and assessment as well as rehabilitation speaks to the breadth and credibility now given the area of work by clinicians. That this issue of the journal is devoted to vocational rehabilitation for persons with psychiatric illness strongly suggests an expanding concept regarding the potential and level of functioning of which many psychiatric clients are capable. It is also tacit recognition that work as a component of psychiatric rehabilitation has not been given the attention it deserves. Other literary indications that work is becoming an important topic in psychiatric rehabilitation are the increased number of publications in the past five years on work and psychiatric rehabilitation and the space given to psychiatric clients in general literature on vocational rehabilitation. 3-6 The word prevention is not one that has been generally used to describe a function of work even though it is a basic tenet of occupational therapy that "activity" has both curative and preventive facets. Work, however, has been seen as an activity at the most functional end of a continuum for which many other activities are preparatory. Work has been something that people do after they have been "assessed" and "trained." Now, in this journal and elsewhere, we find words such as assessment, prevention, and rehabilitation describing the world of work. We acknowledge that work actually provides these treatment-like functions. It is not solely what comes after them. This concept enables a more fluid visualization of the whole rehabilitation process and suggests a constant give and take between curative elements (what we as providerssay we do) and community-environmental influences (such as work or family). The scope of articles in this issue points out the wide variety of conditions or situations that can have emotional difficulties associated with
8
W 0 R K / WINTER 1991
them: people with stress disorders, developmental disabilities, adjustment reactions, depression, and pain, to name those discussed here. We are also reminded that emotional illness is not limited to one age group, nor are vocational concerns. Also addressed here are vocational programming for both adolescent and geriatric clients. To round out the considerations, this issue also discusses the need for a level of cooperation among providers and administrators that has not been achieved before.
PAST PROBLEMS FOR PSYCHIATRIC CLIENTS IN THE WORK WORLD Psychiatric rehabilitation has always lagged behind physical rehabilitation in terms of inroads into the work world. There are clear reasons for this. The psychiatrically disabled have been far less successful than other disabled groups in getting and keeping jobs. We cite such reasons as poor job history, inadequate coordination among providers of services, criteria for funding, and the fluctuating nature of some emotional disorders. We as providers may also have been slow to realize the needs of this group. 7 In addition, from a broader perspective, it may be that part of our lack of success with previous approaches for psychiatric clients is that we have not effectively utilized some basic clinical concepts that we know are true for this population, such as the importance of providing ongoing support. Wethington and Kessler point out that it is actually the degree of support the clients perceive to be available that is a crucial variable in the client's ability to deal with stressful events. s This simple concept coupled with a renewed alliance between many state departments of rehabilitation and mental health agencies and a more vigorous effort to educate employers provides at least a structure on which to base some new strategies for psychiatric rehabilitation during the last decade of the century. Whatever the cause, the effect of underemployment of psychiatric clients has been evident for some time. As early as 1975, it was estimated
that unemployed schizophrenic persons alone accounted for $10 billion annually in lost productivity. 9 During the 1970s and 1980s, the costeffectiveness of various treatment modalities was of extreme importance in the allocation of funding resources. It is unlikely that this will change in the 1990s. As we are able to demonstrate the cost-effectiveness of job placement programs, funding resources will increase and, theoretically, less cost-effective programs can be partially supported by ones that are financially more viable. In the past there has been an effort to separate work from therapy in the psychiatric domain. At the day treatment center one discussed problems; on the job one worked. Additionally, in the traditional sheltered workshop model, clients with emotional difficulties frequently worked side by side with developmentally disabled clients. This situation in and of itself caused problems because the two disability groups essentially frightened each other. There was little clinical intervention to help each group understand the strengths of the other. Lowerfunctioning clients, regardless of disability, were in a category called inconsequential producers. The title alone is enough to make a good occupational therapist cringe. Fortunately, these distinctions are melting away, as is the assumption that psychiatrically disabled clients could not or should not be integrated into the workplace. In most cases, work and tqerapy sites will remain distinct geographically. However, there has been a willingness to acknowledge the effect of one on the other and to recognize a continuum of functioning that has resulted in a far more flexible system. This system does not just cater to the client who has been "rehabilitated," but also serves to integrate into work settings a client who may be less functional or who may have initial or ongoing difficulties. The notion that clients of varying functional abilities could work cooperatively in different settings was begun by programs such as Fountain House some years ago. 6 Fountain House and other programs that have branched out from this "clubhouse" model have provided valuable insights about the capabilities of our clients and now suggest directions for future efforts.
Work for Psychiatrically Disabled Clients
EVOLVING PROVIDER ATTITUDES Those involved in psychiatric rehabilitation have watched the vocational rehabilitation system evolve from a model of exclusivity where only the most functional were considered, to one approaching inclusivity through multidisciplinary efforts in a variety of clinical and community settings. 10 The Department ofRehabilitation in many locations is now willing to work with clients for whom part-time work is appropriate, a definite change from past policies. It has also grown from a model where the client was the "oh-so-fortunate" recipient of our services to one where clients make choices about vocational needs and we, the clinicians, strive to help them actualize these goals. The age of the "client as consumer of services" is truly with us. We have watched the service delivery system change from a focus on the sheltered workshop to one where a broad array of modalities are employed: community-based work crews, cottage industry models, enclaves in industrial and corporate settings, and even paid work in day treatment centers. 7 Most clearly, our progress is evidenced by the tremendous efforts being made in the area of supported employment for psychiatric clients, and the successes that the clients themselves are enjoying. Programs such as those at McLean Hospital in Massachusetts 2 and Portals and Crossroads in California have shown that vocational skills can be assessed in a variety of settings including on the job, and that clients can be placed in work settings according to their needs and job goals. The degree to which supported employment will turn out to be the approach of choice for all psychiatric clients remains to be seen. It seems reasonable that there will be an important role to be played by "sheltered settings," but they will look very different from the workshops of the past. Interest in the client's functioning, rather than diagnosis, has become the domain of not only the occupational therapist or the rehab counselor, but also of funding agencies such as NIMH, physicians, program developers, administrators, and (perhaps most impor-
9
tantly) employers. Whole agencies are being essentially redesigned according to what many call a psychosocial rehabilitation model, one that has new terms attached to it but is essentially what occupational therapists have been doing all along. The addition of employers to the roster of players in the vocational arena is of utmost importance. They can make or break efforts of the most well designed programs. There is still a vast gap in employers' understanding the capabilities of the so-called "psychiatrically challenged." Still, employers have been sufficiently exposed to developmentally disabled clients for a positive concept of this group to have emerged. The word psychiatric, the term emotional disability, or anything that suggests to an uneducated employer the image of "unstable" (or worse yet, "crazy") can quickly defeat the efforts of a well-intentioned clinician. This lack of awareness on the part of employers presents perhaps the biggest challenge to psychiatric rehabilitation clinicians seeking to place clients in employment. In this arena, some skills not thought to be part of occupational therapy training will come into play, the biggest of which is marketing. Some practitioners do not like the term marketing, and may choose to call the skill education. Whatever the name, this information will help employers understand the strengths of this group of clients. Success, however, will not come quickly and must be accompanied by actual achievement on the part of our clients. Great strides have been made in changing our society's beliefs about work and the emotionally ill, but there is still a long way to go. The silver lining in the admittedly large amount of work that lies ahead is that, potentially, everyone benefits. Clinicians will have better relationships with fellow workers in other disciplines; employers will learn a great deal about both our client's capabilities and the kind of fairness and practices that they must extend to all employees; clients will be treated as people with perhaps special needs who can educate their own fellow workers. None of this will occur overnight, but it is beginning. What is
10
W 0 R K / WINTER 1991
happening in the arena of work is really a capsulated version of what is occurring in psychiatric treatment in general: gradual and real integration of our clients into the world that has been previously reserved for the "normal" folks.
REFERENCES 1. Harvey-Krefting L: The concept of work in occupational therapy: A historical review. Am ] Occup Ther 1985; 39(5):301-307. 2. Palmer F, Gatti D: Vocational treatment model. Occup Ther in Ment Health 1985; 5: 1. 3. Black BJ: Work and Mental Illness. Baltimore: Johns Hopkins University Press, 1988. 4. Ciardello JA, Bell, MD: Vocational Rehabilitation of Persons with Prolonged Psychiatric Disorders. Baltimore: Johns Hopkins University Press, 1988.
5. Hertfelder S, Gwin C: Work in progress. Am] Occup Ther 1989. 6. Jacobs K: Occupational Therapy: Work Related Programs and Assessments. Boston: Little, Brown, 1985. 7. Lang S, Care E: Vocational integration for the psychiatrically disabled. Hosp and Commun Psychiatry 1989; 40(9):890-892. 8. Wethington E, Kessler RC: Perceived support, received support and adjustment of stressful life events. Health Soc Behav 1986; 27:78-89. 9. Gunderson JG, Mosher LR: The cost of schizophrenia.Am] Psychiatry 1975; 132(9):901-906. 10. Dellario DJ: The relationship between mental health, vocational rehabilitation interagency functioning and outcome of psychiatrically disabled persons. Rehabilitation Counsel Bull 1985; (March): 166-170.
WORK FOR PSYClllATRICALLY DISABLED CLIENTS
Susan Lang, MBA, OTR, ATR Occupational Therapy Consultant San Francisco, California
The promotion of work and work-related activities has been part of occupational therapy since its inception. Historically, vocati~nal aspects of occu pational therapy treatment focused on physically disabled persons. In the past 20 years interest in, and speculation about, the integration of psychiatrically disabled individuals into work arenas has increased. Programs have been initiated, assessments developed, and clients placed in a broad variety of work settings. Our current attitudes have as their underpinnings the way work has been viewed historically by our profession.
THE HISTORICAL PERSPECTIVE: AHEAD TO THE PAST During what is termed the era of "moral treatment" in the 1800s, work was seen as a means of focusing attention, increasing morale, and promoting discipline. In the early 1900s, in the
so-called occupational paradigm stage, work was thought to lead to increased general productivity, normalized routines, and increased work tolerance. The occupational paradigm addressed the patient's intrinsic sense of productivity rather than focusing on paid employment as the only goal. Crafts were extensively used. In time, however, clinicians in the field became uncomfortable with the use of modalities that were sometimes unrelated to the patient's sense of values. Clinicians of the 1950s identified the need for a more scientific approach to work and work evaluation in keeping with the generally reductionist philosophy, then developing in the medical world, that human behavior was a biological and physiological function. In the early 1960s, occupational therapists, while adopting a more scientific focus, developed programs centered around evaluation and industrial therapy. Work became more narrowly defined and often synonymous with gainful employment. The "therapeutic" part of work programs often referred to the prework evaluation portion of the program, which became increasingly complex as therapists established work samples and evaluation methods. In the 1970s and into the early '80s, work remained a function of occupational therapists who saw themselves as specialists in work evaluation, work placement, and promotion of work tolerance and work adjustment.! During these years, vocational services for psychiatric clients were often provided in programs that primarily served the physically disabled. It was not until the late '70s and early '80s that work programs exclusively for psychiatric clients became common. With
Work for Psychiatrically Disabled Clients
the exception of a few programs, the focus was on placing the most functional clients in gainful employment with little attention given to those with more disabling illnesses. This attitude was perpetuated by the funding agencies, which used job placement as the primary criteria for distribution of grant money. However, in the early and mid 1980s, several programs attempted to develop work slots for clients of varying functional capacities, laying to rest the assumption that the so-called lower-functioning clients could work only in sheltered workshops. It appeared that for many clients a supportive environment could be provided in the community with proper preparation. 2,3 This shift in philosophy is not unlike the deinstitutionalization movement of the '60s to return clients to the community. This time, however, the community-based programs are more organized and are accepting clients as they are able. This time, funding agencies are also being considerably more responsive. Current philosophies vary concerning the role that occupational therapists should take in vocational arenas in the future. Opinions range from advocating a more specialized role in vocational areas, such as assessment, to the belief that a more generalized definition of . work to include areas such as non-employmentrelated productive activity, would reflect more appropriately what occupational therapists can do and what is needed by our clients. Regardless of the direction or philosophy adopted by a majority of therapists, work will certainly remain a vital consideration for occupational therapists. In the psychiatric arena, work may provide a new focus for therapists who have difficulty defining their role among a host of other clinical providers. Work will, without a doubt, cause the profession to revisit some of the philosophies of the past. We have gone full circle back to the 1940s with the suggestion that the definition of work be broadened to include notions of intrinsic productivity. A return to some of these values might be welcome in today's world of financial pressures and highstress jobs.
7
JOURNAL TITLE SAYS IT ALL: WORK PREVENTION, ASSESSMENT, AND REHABILITATION The very existence of this journal is strong evidence of the growing interest in work as a viable and crucial component of rehabilitation. That the journal in its title addresses prevention and assessment as well as rehabilitation speaks to the breadth and credibility now given the area of work by clinicians. That this issue of the journal is devoted to vocational rehabilitation for persons with psychiatric illness strongly suggests an expanding concept regarding the potential and level of functioning of which many psychiatric clients are capable. It is also tacit recognition that work as a component of psychiatric rehabilitation has not been given the attention it deserves. Other literary indications that work is becoming an important topic in psychiatric rehabilitation are the increased number of publications in the past five years on work and psychiatric rehabilitation and the space given to psychiatric clients in general literature on vocational rehabilitation. 3-6 The word prevention is not one that has been generally used to describe a function of work even though it is a basic tenet of occupational therapy that "activity" has both curative and preventive facets. Work, however, has been seen as an activity at the most functional end of a continuum for which many other activities are preparatory. Work has been something that people do after they have been "assessed" and "trained." Now, in this journal and elsewhere, we find words such as assessment, prevention, and rehabilitation describing the world of work. We acknowledge that work actually provides these treatment-like functions. It is not solely what comes after them. This concept enables a more fluid visualization of the whole rehabilitation process and suggests a constant give and take between curative elements (what we as providerssay we do) and community-environmental influences (such as work or family). The scope of articles in this issue points out the wide variety of conditions or situations that can have emotional difficulties associated with
8
W 0 R K / WINTER 1991
them: people with stress disorders, developmental disabilities, adjustment reactions, depression, and pain, to name those discussed here. We are also reminded that emotional illness is not limited to one age group, nor are vocational concerns. Also addressed here are vocational programming for both adolescent and geriatric clients. To round out the considerations, this issue also discusses the need for a level of cooperation among providers and administrators that has not been achieved before.
PAST PROBLEMS FOR PSYCHIATRIC CLIENTS IN THE WORK WORLD Psychiatric rehabilitation has always lagged behind physical rehabilitation in terms of inroads into the work world. There are clear reasons for this. The psychiatrically disabled have been far less successful than other disabled groups in getting and keeping jobs. We cite such reasons as poor job history, inadequate coordination among providers of services, criteria for funding, and the fluctuating nature of some emotional disorders. We as providers may also have been slow to realize the needs of this group. 7 In addition, from a broader perspective, it may be that part of our lack of success with previous approaches for psychiatric clients is that we have not effectively utilized some basic clinical concepts that we know are true for this population, such as the importance of providing ongoing support. Wethington and Kessler point out that it is actually the degree of support the clients perceive to be available that is a crucial variable in the client's ability to deal with stressful events. s This simple concept coupled with a renewed alliance between many state departments of rehabilitation and mental health agencies and a more vigorous effort to educate employers provides at least a structure on which to base some new strategies for psychiatric rehabilitation during the last decade of the century. Whatever the cause, the effect of underemployment of psychiatric clients has been evident for some time. As early as 1975, it was estimated
that unemployed schizophrenic persons alone accounted for $10 billion annually in lost productivity. 9 During the 1970s and 1980s, the costeffectiveness of various treatment modalities was of extreme importance in the allocation of funding resources. It is unlikely that this will change in the 1990s. As we are able to demonstrate the cost-effectiveness of job placement programs, funding resources will increase and, theoretically, less cost-effective programs can be partially supported by ones that are financially more viable. In the past there has been an effort to separate work from therapy in the psychiatric domain. At the day treatment center one discussed problems; on the job one worked. Additionally, in the traditional sheltered workshop model, clients with emotional difficulties frequently worked side by side with developmentally disabled clients. This situation in and of itself caused problems because the two disability groups essentially frightened each other. There was little clinical intervention to help each group understand the strengths of the other. Lowerfunctioning clients, regardless of disability, were in a category called inconsequential producers. The title alone is enough to make a good occupational therapist cringe. Fortunately, these distinctions are melting away, as is the assumption that psychiatrically disabled clients could not or should not be integrated into the workplace. In most cases, work and tqerapy sites will remain distinct geographically. However, there has been a willingness to acknowledge the effect of one on the other and to recognize a continuum of functioning that has resulted in a far more flexible system. This system does not just cater to the client who has been "rehabilitated," but also serves to integrate into work settings a client who may be less functional or who may have initial or ongoing difficulties. The notion that clients of varying functional abilities could work cooperatively in different settings was begun by programs such as Fountain House some years ago. 6 Fountain House and other programs that have branched out from this "clubhouse" model have provided valuable insights about the capabilities of our clients and now suggest directions for future efforts.
Work for Psychiatrically Disabled Clients
EVOLVING PROVIDER ATTITUDES Those involved in psychiatric rehabilitation have watched the vocational rehabilitation system evolve from a model of exclusivity where only the most functional were considered, to one approaching inclusivity through multidisciplinary efforts in a variety of clinical and community settings. 10 The Department ofRehabilitation in many locations is now willing to work with clients for whom part-time work is appropriate, a definite change from past policies. It has also grown from a model where the client was the "oh-so-fortunate" recipient of our services to one where clients make choices about vocational needs and we, the clinicians, strive to help them actualize these goals. The age of the "client as consumer of services" is truly with us. We have watched the service delivery system change from a focus on the sheltered workshop to one where a broad array of modalities are employed: community-based work crews, cottage industry models, enclaves in industrial and corporate settings, and even paid work in day treatment centers. 7 Most clearly, our progress is evidenced by the tremendous efforts being made in the area of supported employment for psychiatric clients, and the successes that the clients themselves are enjoying. Programs such as those at McLean Hospital in Massachusetts 2 and Portals and Crossroads in California have shown that vocational skills can be assessed in a variety of settings including on the job, and that clients can be placed in work settings according to their needs and job goals. The degree to which supported employment will turn out to be the approach of choice for all psychiatric clients remains to be seen. It seems reasonable that there will be an important role to be played by "sheltered settings," but they will look very different from the workshops of the past. Interest in the client's functioning, rather than diagnosis, has become the domain of not only the occupational therapist or the rehab counselor, but also of funding agencies such as NIMH, physicians, program developers, administrators, and (perhaps most impor-
9
tantly) employers. Whole agencies are being essentially redesigned according to what many call a psychosocial rehabilitation model, one that has new terms attached to it but is essentially what occupational therapists have been doing all along. The addition of employers to the roster of players in the vocational arena is of utmost importance. They can make or break efforts of the most well designed programs. There is still a vast gap in employers' understanding the capabilities of the so-called "psychiatrically challenged." Still, employers have been sufficiently exposed to developmentally disabled clients for a positive concept of this group to have emerged. The word psychiatric, the term emotional disability, or anything that suggests to an uneducated employer the image of "unstable" (or worse yet, "crazy") can quickly defeat the efforts of a well-intentioned clinician. This lack of awareness on the part of employers presents perhaps the biggest challenge to psychiatric rehabilitation clinicians seeking to place clients in employment. In this arena, some skills not thought to be part of occupational therapy training will come into play, the biggest of which is marketing. Some practitioners do not like the term marketing, and may choose to call the skill education. Whatever the name, this information will help employers understand the strengths of this group of clients. Success, however, will not come quickly and must be accompanied by actual achievement on the part of our clients. Great strides have been made in changing our society's beliefs about work and the emotionally ill, but there is still a long way to go. The silver lining in the admittedly large amount of work that lies ahead is that, potentially, everyone benefits. Clinicians will have better relationships with fellow workers in other disciplines; employers will learn a great deal about both our client's capabilities and the kind of fairness and practices that they must extend to all employees; clients will be treated as people with perhaps special needs who can educate their own fellow workers. None of this will occur overnight, but it is beginning. What is
10
W 0 R K / WINTER 1991
happening in the arena of work is really a capsulated version of what is occurring in psychiatric treatment in general: gradual and real integration of our clients into the world that has been previously reserved for the "normal" folks.
REFERENCES 1. Harvey-Krefting L: The concept of work in occupational therapy: A historical review. Am ] Occup Ther 1985; 39(5):301-307. 2. Palmer F, Gatti D: Vocational treatment model. Occup Ther in Ment Health 1985; 5: 1. 3. Black BJ: Work and Mental Illness. Baltimore: Johns Hopkins University Press, 1988. 4. Ciardello JA, Bell, MD: Vocational Rehabilitation of Persons with Prolonged Psychiatric Disorders. Baltimore: Johns Hopkins University Press, 1988.
5. Hertfelder S, Gwin C: Work in progress. Am] Occup Ther 1989. 6. Jacobs K: Occupational Therapy: Work Related Programs and Assessments. Boston: Little, Brown, 1985. 7. Lang S, Care E: Vocational integration for the psychiatrically disabled. Hosp and Commun Psychiatry 1989; 40(9):890-892. 8. Wethington E, Kessler RC: Perceived support, received support and adjustment of stressful life events. Health Soc Behav 1986; 27:78-89. 9. Gunderson JG, Mosher LR: The cost of schizophrenia.Am] Psychiatry 1975; 132(9):901-906. 10. Dellario DJ: The relationship between mental health, vocational rehabilitation interagency functioning and outcome of psychiatrically disabled persons. Rehabilitation Counsel Bull 1985; (March): 166-170.
