Assessing readiness of clients with disabilities to engage in job seeking behaviors. (Readiness of Clients).

Since the 1950s, fostering the employment of individuals with disabilities has been the central role and function of rehabilitation counselors (Salomone, 1996). The Rehabilitation Act Amendments of 1998 included within the Workforce Investment Act outline the need to enhance employment outcomes and re-emphasize the need for rehabilitation counselors to support the independence of persons with disabilities through the attainment of high quality employment (Pusch, 1998). In the past 10 years, research has examined a number of client factors that influence the manner in which vocational counselors support and facilitate independence of persons with disabilities (Hansson, Bostroem, & Harms-Ringdahl, 2001; Joy, Lowy, & Mansoor, 2001; Loisel, Gosselin, Durand, Lemaire, Poitras, & Abenhaim, 2001; Schwab & Fenoglio, 1992; Van Der Giezen, Bouter, & Nijhuis, 2000; Young, Alfred, Rinrala, & Hart, 1994). Also attracting attention in the literature has been research on employment expectations (Millington & Reed, 1997), counselor tasks (Mullins & Roessler, 1998), and job placement function (Ford, 1999). According to a national poll of 1,000 adults with disabilities, only 29% of disabled persons of working age reported working full or part-time, as compared to 79% of the non-disabled population. The survey also found that 72% of adults with disabilities who were not employed indicated that they would prefer to work (Louis Harris and Associates and the National Organization on Disability, 1998). Despite increased efforts in the 1990s to understand and improve employment outcomes for clients with disabilities, employment rates remain rather low (Millington & Reed, 1997).

Rhode Island workers who have been injured on the job are eligible for a range of restorative physical, psychological, and rehabilitative services under the 1992 Rhode Island Workers' Compensation Law (Rhode Island State Law 28-33-41). Occupational, educational, and traditional vocational counseling services augment these services. Vocational counseling services include vocational testing, career exploration, rehabilitation planning, career counseling, skills training, job search and job placement. Integral to the vocational counseling process is the counselor's initial assessment of a client's readiness to seek employment (Bolton, Bellini & Brookings, 2000).

In order to develop individualized vocational plans, rehabilitation counselors typically rely on their clinical judgment to determine their clients' readiness to seek employment (Strohmer & Leierer, 2000). Rehabilitation counselors who work with spinal cord injured workers must process volumes of complex client information that include medical and psychological information as well as education, employment, and social histories (Strohmer, Pellerin, & Davidson, 1995). Counselors tend to have difficulty processing verbal and non-verbal stimuli that comprise the initial stage of the counselor/client relationship (Spengler, Strohmer, & Prout, 1990). Clinical judgment is prone to error and biases that can negatively impact counseling outcomes (Strohmer & Leierer, 2000). Moreover, Strohmer et al. (1995) have found that rehabilitation counselors tend to favor negative client factors (i.e., client incapacities) over more positive client factors. Furthermore, more negative factors are related to more unfavorable client status judgments while more positive client factors are related to more favorable judgments (Strohmer et al., 1995). Although more research is needed, the implication is that an overemphasis on client incapacity by rehabilitation counselors may contribute to a restriction of access to employment opportunities for persons with disabilities. This assertion is further supported by research that identified the importance of client "optimism" as a key psychological factor associated with successful return-to-work outcomes for persons with disabilities (Chapin & Kewman, 2001).

Despite the challenges that face the rehabilitation counselor/client working partnership and its effectiveness, the counselor's task is to support and facilitate the client's transition to independence from physical and psychological rehabilitation to gainful employment in the workforce (Mullins, Roessler, Schriner, Bellini, & Brown, 1997). The importance of early return-to-work experiences for spinal cord injured clients has been stressed in the literature as a key factor that increases long-term vocational success (Crewe, 2000; Marhold, Linton, & Melin, 2001; V;mder Kolk & Vander Kolk, 1990). A valid assessment of client readiness to return to work would help counselors to more effectively help their clients transition to employment and independence.

The Transtheoretical Model of Change

The Transtheoretical Model (TTM, also known as the "stage model"), one of the leading models of health behavior change (Prochaska, DiClemente, & Norcross, 1992; Prochaska, Norcross, & DiClemente, 1994), offers a systematic and empirically based approach to conceptualizing and assessing readiness to return to work following a disabling injury. Briefly, the TTM understands change as progress, over time, through a series of stages: Precontemplation, Contemplation, Preparation, Action, and Maintenance. Stage of change measures based on the TTM can provide sensitive assessments of readiness to seek employment and guide the development of individually tailored vocational counseling plans that can reduce counseling dropout and increase the likelihood of successful job placement. The TTM systematically integrates four theoretical constructs central to change:

1) Stage of Change        Readiness to take action
2) Decisional Balance     Pros and Cons associated with
                          a behavior's consequences
3) Self-Efficacy          Confidence to make and sustain
                          changes in difficult situations,
                          and temptation to slip back into
                          old patterns
4) Processes of Change    Ten cognitive, affective, and
                          behavioral activities that facilitate
                          change.

Stage of change is the TTM's central organizing construct. Studies of change have found that people move through a series of five stages when modifying behavior on their own or with the help of formal intervention (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992; Prochaska, Velicer, Fava, Rossi, & Tsoh, 2001). In the first stage of change, the Precontemplation Stage, individuals deny they have a problem; thus, they are resistant to making changes, are unaware of the negative consequences of their behavior, believe the consequences are insignificant, or have given up the thought of changing because they are demoralized. Precontemplators are not intending to take action in the next six months. Individuals in the Contemplation Stage are more likely to recognize the benefits of changing. However, Contemplators continue to overestimate the costs of changing and, therefore, are ambivalent and not quite ready to change. Contemplators are seriously considering taking action within the next six months. Individuals in the Preparation Stage have decided to make a change in the next 30 days and have already begun to take small steps toward that goal. Individuals in the Action Stage are overtly engaged in modifying their behaviors or acquiring new, healthy behaviors. Individuals in the Maintenance Stage have been able to sustain change for at least six months and are actively striving to prevent relapse. The stages form a simplex pattern in which adjacent stages are more highly correlated with each other than with more distant stages (Prochaska, DiClemente, Velicer, Ginpil, & Norcross, 1985). For most people, the change process is not linear, but spiral, with several relapses to earlier stages before they attain permanent behavior change (Prochaska, Norcross, et al., 1994).

The stage construct has received empirical support across studies of behavior change in several areas, including alcohol abuse (DiClemente & Hughes, 1990), psychological distress (Prochaska, Rossi, & Wilcox, 1991) and safe sex practices (Prochaska, Redding, Harlow, Rossi, & Velicer, 1994). For example, smokers in Preparation are twice as likely to be abstinent at one month post-treatment than are Contemplators, who in turn are twice as likely to be abstinent than Precontemplators. The pattern continues at six months post-treatment (DiClemente et al., 1991). Research comparing stage distributions across behaviors and populations finds that about 40% of pre-action individuals are in Precontemplation, 40% in Contemplation, and only 20% in Preparation (Laforge, Velicer, Richmond, & Owen, 1999; Velicer et al., 1995). These data suggest that if action-oriented interventions were offered to all workers who are disabled, the majority who are not prepared to seek employment would be mis-served. Stage-matched interventions can have a greater impact than action-oriented, one-size-fits-all programs by increasing participation and increasing the likelihood that individuals will take action. Stage-matched interventions for smokers more than double the smoking cessation rates of the best traditional interventions available (Prochaska, DiClemente, Velicer, & Rossi, 1993). Stage-matched interventions have out-performed one-size-fits-all interventions for exercise acquisition (Marcus et al., 1998), dietary behavior (Campbell et al., 1994) and mammography screening (Rakowski et al., 1998). Workers who are disabled might be assigned to stage-matched orientation sessions or psychoeducational groups or might be provided with stage-matched interventions in traditional one-on-one vocational counseling.

Application of the TTM to Vocational Counseling

The development of measures of readiness to change is the first step in the application of the TTM to vocational counseling among disabled workers. Psychometrically sound and valid measures provide the tools for assessing change over time and guiding client-treatment matching to increase the impact of interventions. The present study focuses on the development and initial validation of a stage of change measure that assesses readiness of clients with disabilities to engage in job seeking behaviors.

Stage of change can be assessed using continuous measures that represent each of the different stages. Although individuals progress from one stage to another, they can have attitudes and exhibit behaviors that characterize more than one stage at the same time. Their profiles or patterns of scores on the various measures characterize their readiness to change. The first measure of this kind, the University of Rhode Island Change Assessment (URICA), was developed to assess psychotherapy patients' readiness to address the "problem" (unspecified) that brought them to treatment (McConnaughy, DiClemente, Prochaska, & Velicer, 1989; McConnaughy, Prochaska, & Velicer 1983). More recently, a URICA designed specifically to assess domestic violence offenders' readiness to end their violence was developed and validated (URICA-Domestic Violence; Levesque, Gelles, & Velicer, 2000). Both measures predict treatment completion and premature termination (Brogan, Prochaska, & Prochaska, 1999; Levesque & Chell, 1999). Both URICA measures have four dimensions representing Precontemplation, Contemplation, Action, and Maintenance. The instruments' developers found that subjects did not discriminate Preparation from Contemplation and Action (items designed to measure the Preparation dimension tended to load on the other two dimensions). Thus, the developers excluded the Preparation items and dimension from the scale. However, they identified profiles of URICA scores that represent the Preparation stage (McConnaughy et al., 1983; Levesque et al., 2000).

Development and Validation of the URICA for Vocational Counseling

This paper focuses on the development and validation of the URICA-Vocational Counseling (URICA-VC), a brief measure for stage classification based on the URICA. This measure was designed specifically to assess vocational counseling clients' readiness to engage in job seeking behaviors. Following the sequential method for scale development described by Jackson (1970, 1971) and Comrey (1988), the task was broken down into five steps:

1) item generation-develop a list of assessment questions representing Precontemplation, Contemplation, Action, and Maintenance;

2) measure administration-collect data from a sample of individuals with disabilities;

3) measure refinement-examine the dimensionality of the scales (e.g., are there four dimensions representing Precontemplation, Contemplation, Action, and Maintenance?) and select a small number of final items that best represent each of the underlying dimensions while maximizing each subscale's internal reliability;

4) subtype analysis-identify different clusters of clients based on their patterns of scores on the separate URICA-VC dimensions;

5) validation-examine the external validity of the measure by examining the relationship between the URICA-VC stage clusters and behaviors that should vary systematically by stage in a manner predicted by the TTM. Specifically, it was hypothesized that individuals in the later stage clusters would be more likely than individuals in the earlier stage clusters to remain in counseling and to find employment during a follow-up period.

Each of these steps is described in more detail below.

Method

Item Generation

At the outset, the URICA (McConnaughy et al., 1983) and conceptual definitions of the stage of change constructs from the TTM guided item generation for the Precontemplation, Contemplation, Action, and Maintenance scales of the URICA-VC. Case records of previous clients who participated in vocational counseling at the center were selected randomly and reviewed to identify client quotes representing each of the stages of change. Ninety-six items were generated. Sample items included: "I don't understand why I need to look for a job" (Precontemplation); "I have started to consider my career and employment options" (Contemplation); "I am really working hard to look for a job" (Action), and "I have been continuing to look for a job, but I am not sure if I can keep up the effort" (Maintenance). The Maintenance scale assesses concern about relapse to old behavior patterns.

To assess content validity, three senior rehabilitative counseling experts from a state rehabilitation center sorted items into four categories based on the conceptual definitions of the stage dimensions. Items that were sorted into different categories by the experts were dropped from the item pool. The three senior rehabilitation counselors also assessed the extent to which the items might represent the experiences of vocational counseling clients with disabilities. The experts questioned whether items representing the Maintenance scale would be meaningful to clients. Unlike individuals who are struggling to maintain the kinds of behavior changes studied in other TTM research (e.g., quitting smoking, starting a new exercise routine), workers with disabilities who return to work may not experience much concern about relapsing to old behaviors. At the recommendation of the experts, Maintenance items were re-written to represent the client's intention or confidence to continue job-seeking behaviors until successful.

Measure Administration

Participants

Participants were 155 adults who had been referred to vocational counseling services at a state rehabilitation center. The mission of the center is to provide comprehensive services to injured workers within the workers' compensation system. These services include case management, physical and occupational and rehabilitative therapy, psychological counseling, as well as educational support and vocational counseling services. Vocational counseling sessions include vocational skill building activities such as career awareness and career exploration, skill and aptitude testing, vocational interest assessments, resume development, informational interviewing, networking training, mock interviewing and eventually job placement. Inability to return to work with a pre-injury employer is the sole criterion for admission to vocational counseling.

All clients (n=169) referred to vocational counseling services between September 1999 and October 2000 were invited during their initial counseling session to participate in the study; 92% (n=155) agreed to participate. Of study participants, 81% were white non-Hispanic, 7% were black non-Hispanic, 10% Hispanic, and 2% "other." The mean age was 41.8 years. Sprain was the most common form injury (50%), followed by inflamed or disjointed joint (26%), contusion (15%), fracture (4%), and "other" (5%). Forty-three percent of participants had experienced injuries to their back.

Procedure

Vocational counseling clients were invited to complete the URICA-VC after they had completed the agency's standard interview and assessment. They were given a brief overview of the research study and asked to review the informed consent form. Clients were informed that the completed survey would remain secured at all times and would not become part of their record; responses would be coded and all identifying information would be removed at the end of the study. Those who agreed to participate and signed the consent form were given a paper and pencil survey to complete. The instructions for the URICA-VC stated: "Please indicate how much you disagree or agree with each of the following statements. Base your response on how you are feeling and acting now. Please answer using a five- (5) point scale with 1 = Strongly disagree to 5 = Strongly agree." The survey also asked participants to record their race, gender, age, injury type, injury area, and ,counseling start date. At the end of the 13-month study period, counselors recorded whether or not participants had remained in counseling, the counseling termination date and reason for termination for clients who had not remained in counseling, and vocational outcome. These measures were included to evaluate the construct validity of the URICA-VC. The length of follow-up ranged from 0 to 54 weeks, with a mean of 27 weeks.

Measure Refinement

Principal Components Analysis (PCA) with varimax rotation, followed by item analysis, were used to determine the dimensionality and content of the URICA-VC. Component interpretability, component loadings, and Coefficient Alphas including and excluding particular items determined the final number of components to retain and their composition. Complex items (items that loaded >.40 on two or more components), items with low loadings (loadings of <.40 on all components), and items that contributed negatively to the reliability of the scale were deleted.

Subtype Analysis

A clustering process was used to classify vocational counseling clients into a small number of groups based on their URICAVC score profiles. Squared Euclidean distance was selected as the similarity/dissimilarity measure, and Ward's method (1963) as the clustering method. Before beginning, participants' scores on the separate URICA-VC dimensions were summed and standardized by converting them to T-scores (mean=50, standard deviation=10). Without standardization, variables with higher means tend to have more influence than variables with lower means (Everitt, 1980). Since there are no completely satisfactory methods available for determining the number of clusters to retain (Everitt, 1980), the decision in this case was based on hierarchical dendrogram inspection and profile interpretability (Aldenderfer & Blashfield, 1984). Three- to ten-cluster solutions were specified and examined.

Validity of the URICA-VC

Analyses of variance and chi square tests were conducted to evaluate the construct validity of the URICA-VC stage clusters by examining their relationship to demographics and two measures expected to vary with stage in a manner predicted by the TTM: continued involvement in counseling and return to work. URICA-VC stage cluster was the grouping variable in all analyses.

Results

Item Generation

A final list of 48 URICA-VC items was selected for administration on the basis of clarity of expression, appropriateness for vocational counseling clients, lack of redundancy with other items, and the degree to which they represented the four stages as conceptually defined. Twelve items represented each of the four stage dimensions.

Measure Refinement

Using PCA and item analysis to determine the content and dimensionality of the URICA'VC, optimal results were achieved for a three-component solution. The three components represented Precontemplation, Contemplation, and Action. Maintenance did not emerge as a separate dimension (its items tended to load on the Action dimension). Four items were retained in each scale to satisfy the competing goals of keeping the measure as brief as possible while preserving the internal reliability of the individual scales. Results of the PCA performed on the final 12 URICA-VC items are summarized here.

All retained items loaded heavily on their respective components (average loading = .73) and did not load heavily on other components (average absolute values of loadings=.16). The three components accounted for 63% of the total variance. Scale scores for each of the URICA-VC components were calculated by summing the final items comprising the components. Scale Alphas, means, standard deviations, and scale intercorrelations are presented in Table 1. Coefficient Alphas ranged from .66 for the Precontemplation and Contemplation scales to .93 for the Action scale.

Subtype Analysis

Cluster analysis yielded a three-cluster solution. The mean T-scores on the URICA-VC Precontemplation, Contemplation, and Action scales for the three clusters are presented in Figure 1. The three clusters are described below in an order that appears to represent a progression from the least to the most advanced in the change process.

[FIGURE 1 OMITTED]

(a) Reluctant Cluster. This cluster is composed of 32 individuals who scored higher than average on the URICA-VC Precontemplation scale and lower than average on the Contemplation and Action scales, suggesting that they are not engaged in job seeking behaviors. Individuals with this profile are likely to retain the status quo.

(b) Reflective Cluster. Compared to individuals in the previous cluster, the 49 individuals in the Reflective cluster scored lower on the Precontemplation scale and higher on the Contemplation scale. However, they remained below average on the Action scale. They are thinking more about seeking work but are not quite ready to do so.

(c) Participative Cluster. The 74 individuals in this cluster were similar to individuals in Reflective cluster on the Precontemplation and Contemplation scales, but scored above the mean on the Action scale, suggesting that they are more actively engaged in job seeking behaviors.

The Reluctant cluster seems to represent Precontemplation, the Reflective cluster Contemplation and possibly Preparation, and the Participative cluster Action.

Validity of the URICA-VC

Chi square tests were conducted to assess differences among the three URICA-VC stage clusters on demographic and injury variables presumed to be unrelated to stage to change: race, gender, injury type, and injury area. A one-way analysis of variance examined the relationship between stage cluster and age. Stage of change was unrelated to all demographic and injury variables except race/ethnicity. Clients who were Black, non-Hispanic were over-represented in the Participative cluster. This finding should be considered unreliable, however, given the small number of Black, non-Hispanic participants (n=10) in the sample.

The next set of analyses examined differences among the three URICA-VC stage clusters and two behavioral variables expected to vary by stage cluster in a manner predicted by the TTM: whether clients had remained involved in vocational counseling, and whether they had returned to work during the follow-up period. Findings are summarized in Figures 2 and 3. Individuals in the Reflective cluster were about twice as likely to remain in counseling as individuals in either the Reluctant and Participative clusters (51% vs. 28% and 28%, respectively, [chi square] (2,N=155)=7.56, p<.05). Individuals in the Participative cluster were about three times as likely to return to work as individuals in either the Reluctant and Reflective clusters (39% vs. 13% and 10%, respectively, [chi square] (2,N=155)=15.06, p<.001).

[FIGURES 2-3 OMITTED]

Discussion

As the first step in the application of the TTM to vocational counseling among workers with disabilities, a stage of change measure, the URICA-VC, was developed to assess disabled workers' readiness to engage in job seeking behaviors. The URICA-VC is composed of three 4-item scales that measure three correlated but distinct constructs representing Precontemplation, Contemplation, and Action in individuals receiving vocational counseling. The internal reliability of the three scales ranges from fair to very good. Three major profiles emerged when clients were clustered on their three URICA-VC scale scores: (a) Reluctant, (b) Reflective, and (c) Participative.

The stage clusters were related to two behaviors that should vary systematically by stage, continued involvement in counseling and return to work. As hypothesized, individuals in the Participative cluster were more likely than individuals in the Reluctant and Reflective clusters to return to work. However, individuals in the Reflective cluster and not the Participative cluster, as hypothesized, were most likely to remain in counseling. Perhaps individuals in the Reflective cluster, who are considering returning to work, are ideal candidates for vocational counseling activities like career exploration, career planning, and skill training; individuals in the Participative cluster may be more eager to move on and into the work force. However, vocational counselors might want to be alert to individuals in the Reflective cluster who become "stuck." Longitudinal TTM research on other behaviors has found that some individuals become "chronic Contemplators" and remain in the Contemplation stage for years. Stage clusters were unrelated to all demographic and injury variables examined with the exception of race and ethnicity, though this finding must be considered unreliable given the small number of minorities in the sample.

Overall, results provide preliminary evidence for the construct validity of the stage of change measures and the applicability of the TTM to this area. There are three steps in the application of the TTM to job seeking among disabled workers: (a) development of TTM measures; (b) model testing; and (c) development and testing of TTM-based interventions. To complete the first step, more work is necessary to improve weaker scales, to examine further the relationship between race and ethnicity and the stage clusters, and to develop measures of other core dimensions of the TTM, namely decisional balance, self-efficacy and the processes of change.

Model testing was begun by assessing the relationship between stage of change and future behavior, but more work is necessary to examine whether the relationships among TTM constructs found in TTM research on other behaviors characterize job seeking as well. For example, do the Pros of engaging in job seeking behaviors, level of self-efficacy, and use of certain processes of change increase as individuals progress through the stages? Do the Cons of engaging in job seeking behaviors decrease? The final step in the application the TTM to job seeking behaviors involves the development and testing of TTM-based interventions.

Implications

The TIM offers a useful framework for understanding the attitudes, behaviors, and individual vocational counseling needs of clients with disabilities. The URICA-VC provides rehabilitation counselors with a tool that can complement clinical judgment in assessments of readiness. A scoring sheet allows counselors to sum the URICA-VC scales and plot the profiles quickly. Counselor sensitivity to readiness can help reduce resistance, increase self-efficacy, and increase the likelihood of successful vocational outcomes among clients who have experienced disabling injuries.

Assuming that the present model profiles can be replicated with other similar samples, the utilization of the Transtheoretical Model and the associated stage cluster profiles could provide rehabilitation counselors with an empirical basis to support or contradict their assumptions regarding client readiness. This knowledge will enable counselors to measure client progress along a stage-based continuum toward a return-to-work objective.

Table 1

URICA-VC Psychometric Properties and Inter-Correlations

                                                Correlations

Scale                   a     Mean      SD     PC         C

1) Precontemplation    .66     7.43    2.83
2) Contemplation       .66    16.55    2.55    -0.41 *
3) Action              .93    13.20    4.75    -0.37 *    0.37 *

PC=Precontemplation, C=Contemplation

* p<.001

References

Aldendeffer, M.S., & Blashfield, R.K. (1984). Cluster analysis. Newbury Park, CA: Sage.

Bolton, B.F., Bellini, J.L., & Brookings, J.B. (2000). Predicting client employment outcomes from personal history, functional limitations, and rehabilitation services. Rehabilitation Counseling Bulletin, 44 (1), 10-12.

Brogan, M.M., Prochaska, J.O., & Prochaska, J.M. (1999). Predicting termination and continuation status in psychology using the transtheoretical model, psychotherapy, 36, 105-113.

Campbell, M.K., DeVellis, B.M., Strecher, V.J., Ammerman, A.S., Devellis, R.E, & Sandler, R.S. (1994). Improving dietary behavior: The effectiveness of tailored messages in primary care settings. American Journal of Public Health, 84, 783-787.

Chapin, M.H., & Kewman, D.G. (2001). Factors affecting employment following spinal cord injury: A qualitative study. Rehabilitation Psychology, 46 (4), 400-416.

Comrey, A.L. (1988). Factor-analytic methods of scale development in personality and clinical psychology. Journal of Consulting and Clinical Psychology. 56, 754-761.

Crewe, N.M. (2000). A 20-year longitudinal perspective on the vocational experiences of persons with spinal cord injury. Rehabilitation Counseling Bulletin, 43 (3), 122-133.

DiClemente, C.C., & Hughes, S.O. (1990). Stages of change profiles in outpatient alcoholism treatment. Journal of Substance Abuse, 2, 217-235.

DiClemente, C.C., Prochaska, J.O., Fairhurst, S.K., Velicer, W.F., Velasquez, M.M., & Rossi, J.S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59, 295-304.

Everitt, B. (1980). Cluster analysis (2nd ed.) New York: Halsted Press.

Ford, L.H. (1999). Job placement and rehabilitation counselors in the state-federal system. Rehabilitation Counseling Bulletin, 42, 354-362.

Hansson, M., Bostroem, C., & Harms-Ringdahl, K. (2001). Living with spine-related pain in a changing society: A qualitative study. Disability and Rehabilitation: An International Multidisciplinary Journal, 23 (7), 286-295.

Jackson, D.N. (1970). The dynamics of structured personality tests. Psychological Review, 78, 229-248.

Jackson, D.N. (1971). A sequential system for personality scale development. In C.D. Spielberger (Ed.), Current topics in clinical and community psychology (vol. 2) (pp.61-96). Orlando, FL: Academic Press.

Joy, J.M., Lowy, J., & Mansoor, J.K. (2001). Increased pain tolerance as an indicator of return to work in low-back injuries after work hardening. American Journal of Occupational Therapy, 55, 200-205.

Laforge, R.G., Velicer, W.F., Richmond, R.L., & Owen, N. (1999). Stage distributions for five health behaviors in the USA and Australia. Preventive Medicine, 28, 61-74.

Levesque, D.A., & Chell, D. (1999, November). Stages of change and attrition from batterer treatment. Paper presented at the 51st Annual Meeting of the American Society of Criminology, Toronto, Canada.

Levesque, D.A., Gelles, R.J., Velicer, W.F. (2000). Development and validation of stages of change measure for men in batterer treatment. Cognitive Therapy and Research, 24, 175-199.

Loisel, P., Gosselin, L., Durand, P., Lemaire, J., Poitras, S. & Abenhaim, L. (2001). Implementation of a participatory ergonomics program in the rehabilitation of workers' suffering from subacute back pain. Applied Ergonomics, 32 (1), 53-60.

Louis Harris and Associates & The National Organization on Disability. (1998). The N.O.D./Harris survey on employment of people with disabilities. New York: International Center for the Disabled.

Marcus, B.H., Bock, B.C., Pinto, B.M., Forsyth, L.H., Roberts, M.B., & Traficante, R.M. (1998). Efficacy of an individualized, motivationally-tailored physical activity intervention. Annals of Behavioral Medicine, 20, 174-180.

Marhold, C., Linton, S.J., & Melin, L. (2001). A cognitive-behavioral return-to-work program: Effects on pain patients with a history of long-term versus short-term sick leave. Pain, 91 (1-2), 155-163.

McConnaughy, E.A., DiClemente, C.C., Prochaska J.O., & Velicer, W.F. (1989). Stages of change in psychotherapy: A follow-up report. Psychotherapy, 26, 494-503.

McConnaughy, E.A., Prochaska, J.O., & Velicer, W.F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368-375.

Millington, M.J., & Reed, C.A. (1997). Employment expectations in rehabilitation counseling: Factors of employment selection. Rehabilitation Counseling Bulletin, 40, 215-223.

Mullins, J.A. & Roessler, R.T. (1998). Improving employment outcomes: Perspectives of experienced counselors regarding the importance of counselor tasks. Journal Of Rehabilitation, 64, 12-19.

Mullins, J., Roessler, R., Schriner, K., Bellini, J., & Brown, P. (1997). Improving employment outcomes through quality rehabilitation counseling (QRC): Responding to the 1992 amendments. Journal of Rehabilitation, 63 (4), 21-31.

Prochaska, J.O., & DiClemente, C.C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology 51, 390-395.

Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applications to the addictive behaviors. American Psychologist, 47, 1102-1114.

Prochaska, J.O., & DiClemente, C.C., Velicer, W.F., Ginpil, S., & Norcross, J.(1985). Predicting change in smoking status for self-changers. Addictive Behavior, 10, 395-406.

Prochaska, J.O., DiClemente, C.C., Velicer, W.F., & Rossi, J.S. (1993). Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychology, 12, 399-405.

Prochaska, J.O., Norcross, J.C., & DiClemente, C.C. (1994). Changing for good. New York: William Morrow and Company, Inc.

Prochaska, J.O., Redding, C.A., Harlow, L.L., Rossi, J.S., & Velicer, W.F. (1994). The transtheoretical model of change and HIV prevention: A review. Health Education Quarterly, 21, 471-486.

Prochaska, J.O., Rossi, J.S., & Wilcox, N.S. (1991). Change processes and psychotherapy outcomes in integrative case research. Journal of Psychotherapy Integration, 1(2), 103-119.

Prochaska, J.O., Velicer, W.F., Fava, J.L., Rossi, J.S., & Tsoh, J.Y. (2001). Evaluating a population-based recruitment approach and a stage-based expert system intervention for smoking cessation. Addictive Behaviors, 26, 583-602.

Pusch, B. (1998). Workforce investment act: Full service or no service. Independent Living News. Fall Issue.

Rakowski, W., Ehrich, B., Goldstein, M.G., Rimer, B.K., Pearlman, D.N., Clark, M.A., Velicer, W.F., & Woolverton, H. (1998). Increasing mammography screening among women aged 40-74 by use of a stage-matched, tailored intervention. Preventive Medicine, 27, 748-756. http://www.workers compensation.com/calendar/wccal_form.html

Rhode Island Workers' Compensation Law (1992). Rhode Island General Law, Section 28-33-41.

Salomone, P.R. (1996). Career counseling and job placement: Theory and Practice. In E.M. Szymanski & R.M. Parker (Eds.), Work thd disability: Issues and strategies in career development and job placement. Austin TX: Pro-Ed.

Schwab, J. & Fenoglio, J. (1992). The Texas rehabilitation commission system for measuring quality rehabilitation. Journal of Applied Rehabilitation Counseling, 23, (2), 21-25.

Spengler, P.M., Strohmer, D.C., & Prout, H.T. (1990). Testing the robustness of the overshadowing bias. American Journal on Mental Retardation, 95, 204-214.

Strohmer, D.C. & Leierer, S.J. (2000). Modeling rehabilitation counselor clinical judgment. Rehabilitation Counseling Bulletin. 44 (1) 3-11.

Strohmer, D.C., Pellerin, M.F., & Davidson, K.J. (1995). Rehabilitation counselor hypothesis testing: The role of negative information, client disability, and counselor experience. Rehabilitation Counseling Bulletin, 39 (2), 82-93.

Van der Giezen, A. M., Bouter, L.M., & Nijhuis, F.J.N. (2000). Prediction of return-to-work of low back pain patients sick listed for 3-4 months. Pain. 87 (3), 285-294.

Vander Kolk, C.J., & Vander Kolk, J.K. (1990). Follow-up of persons with litigation related injuries. Journal of Rehabilitation, Fall Issue, 36-40.

Velicer, W.F., Fava, J.L., Prochaska, J.O., Abrams, D.B., Emmons, K.M., & Pierce, J.P. (1995). Distribution of smokers by stage in three representative samples. Preventive Medicine, 24, 401-411.

Ward, J.H. (1963). Hierarchical grouping to optimize an objective function. Journal of the American Statistical Association. 58, 236-244.

Young, M.E., Alfred, W., Rinrala, D., & Hart, K.A. (1994). Vocational status of persons with spinal cord injury living in the community. Rehabilitation Counseling Bulletin, 37 (3), 229-243.

Janice M. Prochaska, MSW, Ph.D., Pro-Change Behavior Systems, Inc., P.O: Box 755, West Kingston, RI 02892. E-mail: [e-mail]