Consumers of vocational rehabilitation services diagnosed with psychiatric and substance use disorders.

"Substance abuse is the most common and clinically significant co-morbid disorder among adults with severe mental illness" (Drake, Becker & Bond, 2003). Serious or severe mental illness (SMI) is terminology typically utilized to identify individuals with a psychiatric diagnosis, as defined in the Diagnostic and Statistical Manual Version IV Text Revision (DSM-IV TR; American Psychiatric Association, 2000), which is persistent in duration, and also which may cause behavioral functioning which interferes substantially with the primary activities of daily living (Bond & Campbell, 2008). In 2003, there were an estimated 19.6 million adults aged 18 or older with serious mental illness (SMI), representing 9.2 percent of all adults (Substance Abuse and Mental Health Services Administration; SAMHSA, 2004). The 2003 SAMHSA National Survey on Drug Use and Health also indicated a high correlation between SMI and substance dependence or abuse. According to this report, among adults with SMI in 2003, 21.3 percent (4.2 million) were dependent on or abused alcohol or illicit drugs. The prevalence of persons with co-occurring disorders is apparent.

Individuals with a psychiatric disorder appear to be at an increased risk for having a co-morbid substance use disorder. Previous studies indicate that at minimum, at least 20% of all persons with mental disorders have met the criteria for a substance use disorder at some time in their past and that experiencing a mental disorder increased the odds of having a substance use disorder by 2.7 times (Evans & Sullivan, 2001; Hollar, 2008; Robinson, 2005). Individuals abusing or dependent on drugs or alcohol can develop symptoms similar to those seen in many psychiatric disorders, including psychotic symptoms, depression, anxiety, mood swings, isolation and withdrawal (Evans & Sullivan; Twamley, Jeste, & Lehman, 2003). Therefore, engaging persons with dual diagnoses in treatment and counseling can be especially difficult. In addition, many dually diagnosed persons have enhanced challenges with efforts to comply with treatment or to benefit from standard interventions because of the complications of both illnesses.

Employment and the nature of work are important, if not essential, to the lives of most people. Beyond the economic compensation associated with employment, a sense of productivity, contribution and worth tend to be associated with work. Employment also appears to be an effective intervention to facilitate positive recovery outcomes. A NIDA funded research project (DA11240-01, P.I. Alexandre Laudet, Ph.D.) found that medical treatment and symptom control are key factors to recovery for persons who are dually-diagnosed, but long-term rehabilitation must also include vocational services (Laudet, Magura, Vogel & Knight, 2000). This study also indicated employment as a key area of importance to participants and an important goal. Moreover, in a study examining psychosocial approaches to people with dual diagnoses, Drake & Mueser (2000) identified employment as a key support in the movement toward recovery.

Over a decade ago, the National Alliance for the Mentally Ill (NAMI; Noble, Honberg, Hall & Flynn, 1997) reported on the relative dearth of employment success for the population of persons with SMI within the vocational rehabilitation system. This research confirmed the reality of low employment rates and provides evidence that persons with severe mental illness experience less success at becoming vocationally rehabilitated than most other persons with disabilities (Rogers, Anthony, Toole, & Brown, 1991). NAMI (2004) contended that the state-federal public rehabilitation program has failed through their service delivery program to increase the employment rates of persons with severe mental illness. More recently, an Institute on Rehabilitation Issues (Dew & Alan, 2005) report on vocational rehabilitation for persons with psychiatric disabilities stated, "this serious public health challenge is under-recognized as a public health burden" (p. 10). Given this assertion, the public health responsibility for researchers to further examine these issues is apparent and necessary. Further investigation as to how apt current research trends (e.g., Evidence-Based Practices) are to meet the subjective needs of persons with dual-diagnoses in the Vocational Rehabilitation system warrants further investigation.

The Vocational Rehabilitation System

The history of vocational rehabilitation (VR) in the US is interwoven with the history of wartime efforts and labor needs, and has evolved to serve a broad and complete range of persons with disabilities requiring employment training, restoration, and placement needs, including those requiring mental health treatment (Drebing, et al., 2002; Robinson, 2005). Today, the federal-state vocational rehabilitation system relies mainly on conventional and evidenced-based practices, such as prevocational training, restoration planning and supported employment (Dew & Alan, 2005; Twamley et al., 2003).

While several aforementioned studies indicate that in the general population at least 20% of all persons with SMI meet the criteria for substance abuse disorders, investigations of the VR system have estimated substance abuse disorders affecting approximately 25-50% of all vocational rehabilitation (VR) consumers (Heinemann, Lazowksi, Moore, Miller, & McAweeney, 2008: Janikowski, Lawrence, & Donnelly, 2007). Despite these numbers and on-going research, the success of employment outcomes for persons with substance use disorders in vocational rehabilitation has yielded mixed outcomes in the literature (Drake & Mueser, 2000; Drebing et al., 2002; Garske & Stewart, 1999; Heinemann et al.). Due to the great variance in the literature about the proportion of individuals with dual diagnoses who seek service in the VR system and the success of their rehabilitation outcomes, we found it critical to investigate this issue further in the current study.

Dually-Diagnosed Populations

Across various service systems, substance use disorders are found to co-exist most often with psychiatric disabilities (Drake et al., 2001; Janikowski et al., 2007). "Dual Diagnosis" is the general designation used to describe those individuals who experience co-morbid substance abuse/dependence and a psychotic, affective, behavioral, or severe personality disorders and is used interchangeably with the term "co-occurring" (Evans & Sullivan, 2001). Recent, evidenced-based efforts in the vocational rehabilitation program (most notably supported employment) have been shown to improve employment rates for individuals with mental illness and substance abuse (Twamley, et al., 2003). There are multiple benefits of work rehabilitation and employment for consumers with mental illness and substance abuse, which include increased income, achievement of a valued social responsibility, greater socialization, enhanced opportunities to use skills and abilities, and improved self-esteem (Twamley, et. al, 2003).

Laudet, Magura, Vogel, and Knight (2000) suggested that "in the general population, persons with lifetime co-morbidity are more likely than those with only one disorder to experience major impairments in economic (unemployment) and social roles (community integration)" (p. 322). Furthermore, co-occurring psychiatric and substance use disorders present unique challenges for vocational rehabilitation service provision. It is clear that this "dual disadvantage" and factors that amplify it require a concerted examination into its impact on recovery outcomes. Investigating the prevalence of this "dual disadvantage" in the vocational rehabilitation system and the impact on overall recovery outcomes is imperative. Researchers need to expand research into "'recovery related" outcomes, such as empowerment and community integration as key aspect of recovery and their relationship to employment outcomes.

Recovery Related Factors

Recovery is a multifarious, intense and personal journey that has been reviewed as both a process and an outcome (Deegan, 1988: Ralph, 2000). There is a lack of unanimity on how "recovery" is defined as a construct (Laudet, 2007) in the field of psychiatric rehabilitation. Despite on-going difficulty in defining "recovery," it has become the focus of evidence-based practices (EBP: Bond & Campbell, 2008). The current study was an attempt to research variables related to recovery and to further explore the relationship between recovery-related factors and employment outcomes.

There are several facets that are inherent to the construct of recovery which can be measured such as empowerment and community integration. While empowerment is often used synonymously in discussions of recovery, we assert that community integration is equally relevant to understanding the concept. The term "empowerment," like many significant psychological terms is one that has yet to be clearly defined, yet, has been shown to be instrumental in the concept of recovery for persons with SMI (Rogers, Chamberlin, Ellison, & Crean, 1997) and closely related to the construct of self-esteem. A strong sense of self (i.e., high self-esteem) can be empowering and has been linked to factors such as employment and recovery (Beale & Lambric, 1995: Young & Ensing, 1999). Thus an examination of self-esteem as it relates to empowerment should be included in any investigation of recovery outcomes.

Similarly, community integration is a pertinent component of recovery. Bond, Salyers, Rollins, Rapp & Zipple (2004) have likened it to the "concrete manifestation of the recovery experience" (p. 571). Community-based rehabilitation programs, such as vocational rehabilitation and competitive employment, assist persons who are dually-diagnosed with assuming positive roles in the community (Drake & Mueser, 2000). Community integration thus implies a full immersion into work, play and daily life in the same fashion as those individuals without disabilities. Deegan (1997) further defined integration into the community as a deeper level of meaning and "a way of being in relationship with one, another" (p. 14). Hence, one could assume the value of employment is enhanced by not only providing economic gains, but also by increasing a sense of self and social worth (Laudet et al., 2000). However, further examination of these recovery-related outcomes and their relation to the domain of employment is warranted (Bond et al., 2004).

The current investigation contends that there is a need to focus on the inherent benefit of work in the lives of persons with co-occurring disorders (Drebing et al., 2002) and the relationship between employment and recovery related outcomes (e.g., self-esteem). Employment has been viewed as a key factor in the process of recovery for persons with psychiatric disabilities and has been shown to be a promising approach for facilitating community integration for persons who are dually diagnosed (Deegan, 1988; Drake & Mueser, 2000; Drake et al., 2003; Robinson, 2005).

This inquiry examined characteristics of persons who access vocational rehabilitation services and are dually-diagnosed with severe mental illness and substance use disorders. Additionally, recovery related factors (self-esteem, locus of control, aspects of community integration and client satisfaction with services) were also examined. The project seeks to understand:

1) What is the prevalence of co-occurring psychiatric and substance use disorders among a sample of persons receiving vocational rehabilitation services?

2) What factors are associated with employment outcomes for VR consumers who have dual psychiatric and substance use disorders?

Method

Data from a sample of vocational rehabilitation program consumers who were dually-diagnosed with primary diagnosis of a psychiatric or substance use disorder and a secondary diagnosis of a psychiatric or substance use disorder--with differing primary and secondary diagnoses--were examined. The data were pulled from the public-use Longitudinal Study of the Vocational Rehabilitation Services Program (LSVRSP; Cornell University ILR School, Employment and Disability Institute, 2003) sponsored by the Rehabilitation Services Administration (RSA). The LSVRSP data allowed for a longitudinal set of data on vocational rehabilitation consumers to be examined (Capella-McDonnall, 2005). LSVRSP data were collected from more than 8,500 consumers at all stages of the vocational rehabilitation process, from application to three years after their cases were closed. A multistage, complex design was used to select the sample. Multiple contacts with individuals were held to collect comprehensive data on experiences and outcomes of participants in the vocational rehabilitation system. The study's rigid design yielded a nationally representative sample of vocational rehabilitation consumers over a five-year period (1995 2000). It mandated that comparisons between those persons who do and who do not obtain services be examined (Pasternak, 2002). Data were collected on each consumer's work history, functioning, vocational interests and attitudes, community integration, psychological characteristics, and perspectives on the vocational rehabilitation experience. To date, the LSVRSP database represents the richest source of information on vocational rehabilitation consumers that has ever been assembled.

Participants

The LSVSRP utilized a two-stage stratified random probability sampling design to obtain a nationally representative sample of VR consumers and allowed for evaluations of both VR and post-VR experiences for up to three years following case closure. The study implemented a multistage design that involved selection of a random sample (with probability proportional to size) of 40 local VR offices (located in 32 state VR agencies in a total of 30 states). A final total sample of 8,818 applicants, current and former consumers of VR services were included. The study implemented a cohort design that involved randomly selecting 25 percent of the sample from the population of persons at application to VR, 50 percent of the sample from the population of persons who were already accepted for and receiving services, and 25 percent of the sample from the population of persons at or after they exited VR services (Hayward & Schmidt-Davis, 2002). This sampling procedure allowed for representation of "the population of persons with disabilities who applied for VR services and those who proceeded through the VR program during the years of 1994 through 2000" (LSVRSP, 2003, p. 4).

The current study consists of individuals who were dually diagnosed with a psychiatric and substance use disorder. The LSVRSP data included respondents with a primary disability code (n=2304) of either psychiatric disorders (500-517, 522) or substance use disorders (from 520-521, 523) and secondary disability code (n=1170) of either psychiatric disorders (500-517, 522) or substance use disorders (from 520-521, 523). There were 597 individuals with dual diagnoses of psychiatric disorder and substance abuse disorder included for the current examination. Those with only one diagnosis of either a psychiatric disability (n=190) or substance use disorder (n=87) or with missing data for one or both diagnosis codes (n=57) were excluded. This reduced the number of participants to 263. This population of individuals dually-diagnosed with both a psychiatric disability and substance abuse represented 3.0% of the 8,818 persons included in the LSVRSP data set.

Instruments

LSVRSP data were collected through baseline and annual interviews with consumers at various points in the VR process in addition to extrapolating data from case file information (LSVRSP, 2003). Several LSVRSP study instruments were compiled from well-known and established psychological measures. This was the case for the recovery-related items reviewed in the current study (self-esteem, locus of control and selected community integration items).

The self-esteem variable was comprised of items from the Rosenberg Self-Esteem Scale (Rosenberg, 1979). The locus of control variable was comprised of items from Levenson's (1973) Locus of Control scale. Finally, community integration items were comprised of several items from the ICD/Harris Poll. The International Center for the Disabled (ICD)/Harris Poll conducted a survey of one thousand Americans with disabilities, Bringing Disabled Americans into the Mainstream. in cooperation with the National Council on the Handicapped (Harris & Associates, 1998).

The Rosenberg Self-Esteem Scale (RES). The RES (Rosenberg, 1979) is a 10-item scale used to measure self-esteem in social science research. Self-esteem indicates a positive or negative orientation toward oneself and is much like one's self-assessment of worth. The instrument is scored by summing the individual items after reverse scoring the negatively worded items. In the LSVRSP study, items such as "At times I think I am no good at all" were answered using a 5-point Likert-type scale ranging from "strongly agree" to "strongly disagree". The self-esteem items from the LSVRSP study and utilized in the current study indicated a relatively high internal consistency of .82.

Locus of Control Scale (LCS). The locus of control scale was developed as a measure to "assess expectancies of control as they relate to adjustment and clinical improvement" among persons with psychiatric disorders (Levenson, 1973, p. 397). The LCS consists of 3 scales; Self-efficacy, Internality and Powerful Others. Normative data for scale scores was unavailable, however for each scale, a larger score is indicative of the belief of having more control in their lives. Across the three subscales, each item requires a 3-point Likert-type response, ranging from agree to disagree. The self-efficacy scale measures the degree to which a person believes that chance affects his or her experiences and outcomes and includes items like, "to a great extent, my life is controlled by accidental happenings". This scale had a Cronbach's alpha of .75.

The internality scale measures the extent to which people believe that they have control over their own lives and this subscale includes items like, "when I make plans, I am almost certain to make them work". This particular scale yielded a low alpha of .54; however, we maintained its use in the current investigation because of the perceived connection between control and consumer empowerment. The final scale, powerful others, concerns the belief that other persons control the events in one's life. This scale produced a Cronbach alpha = .72 and included items like, "I feel like what happens in my life is mostly determined by powerful people".

Community Integration Items. The items selected from the ICD/Harris Poll Community Integration instrument for the LSVRSP study focused on consumer attendance at cultural, sporting and religious events, as well as socialization with family, neighbors and friends, and included such items as, "how often do you socialize with close friends, relatives or neighbors"? The selected items appeared to be most congruent with Bond et al. (2004) and Deegan's (1997) assertion that community integration is best represented by active engagement and belongingness with full access similar to those persons without disabilities. For the present study, four questions were examined:

1) Approximately how many times did you go to the movies in the past 12 months?

2) Approximately how many times did you go to live music performances in the past 12 months?

3) Approximately how many times did you go to live theater performances in the past 12 months?

4) Approximately how many times did you go to a sports event in the past 12 months?

These questions were selected because of their focus on community events and interactions in larger settings. The LSVRSP User's Guide (LSVRSP, 2003) did not provide psychometric properties for the Community Integration Items, thus total scale scores were not utilized.

Given the descriptive focus of this initial exploration, in addition to gathering frequency data, a series of t-tests and chi square analyses were utilized to assess the existence of significant differences between employment status and other demographic characteristics. Additionally, the relationship between recovery related variables (self-esteem, locus of control) and employment status was examined.

Results

The respondents who are dually-diagnosed represented 3.0% (N=263) of the individuals in the LSVRSP data. Several consumer characteristics of interest were taken from data collected at entry in the VR program (gender, age, ethnicity/race, marital status, educational attainment, residential status, and source of referral). The impact of employment on several other variables (self-esteem, locus of control and select community integration items) were also examined.

Question 1. What is the prevalence of co-occurring psychiatric and substance use disorders among a sample of persons receiving vocational rehabilitation services?

The demographic characteristics of this population are presented in Table 1. For the purposes of this study, "current status in VR" accounted for employment status which included 49.5% (n=97) employed (Status 26) and 50.5% (N=99) unemployed (Status 28 and 30) consumers with dual diagnoses. The employment status variable was not collected at entry, and was instead examined at a later point in the data collection. The population examined was mostly male (58%), ranging in age from 46-55 years old (40%), and were predominately white (77%). Persons from all other racial/ethnic groups were combined into one group, Persons of Color, due to overall low numbers across the different populations, and represented 22% of individuals in the study.

Another point of interest includes the residential status of the participants. This variable was also modified for later analyses. Due to the small observed count, this variable was aggregated into a dichotomous variable of "private" and "non-private" residential status. Overwhelmingly, a large portion of the respondents (82%) lived in private residences. Additionally, consumer assessment of severity of disability was not examined in the current inquiry. One final interesting descriptive finding involved sources of referral. For the purposes of the current study, this variable was also aggregated into 3 categories. The category, educational/residential institution (ERR) included educational institutions, residential institutions and other agencies or organizations. Rehabilitation or other health facility (RHR) included rehabilitation facilities, and hospital, physician, or other health organization. Lastly, self/personal (SPR) included referrals from family member or friend, self-referral and other referrals. With these groupings, the referrals were almost equally spread across the three categories with 32% receiving referrals from ERR; 33% receiving referrals from RHR and; 35% self-referring or receiving referrals from SPR sources. It was anticipated that referrals from RHR (assuming these organizations/agencies are able to assess recovery progress) would have a higher rate of referral than the two other categories of ERR or SPR.

Question 2. What factors are associated with employment outcomes for VR consumers who have dual psychiatric and substance use disorders?

Chi-square analysis and t-tests were run to assess if there were any significant differences among the demographic variables for those persons who were employed versus those who were unemployed. In general, no significant differences were detected. However, the chi-square tests of independence suggests that the clients' employment status is associated with their gender ([X.sup.2](2, N=196) = 8.3, p = .016). Men with dual-diagnoses were more likely to be employed than were women.

Variables deemed "recovery related outcomes" included: self-esteem, locus of control, and selected community integration items. Rosenberg (1979) asserts that self-esteem scores that range between 15 and 25 are within the normal range; while scores below 15 suggest low self-esteem. The total scale score which can be achieved is 30. Respondents ranged in score from 10 through 30. Of the participants who responded to this instrument, 55% scored in the range which suggested low self-esteem; 37% scored in the normal range; and 7% scored in the high self-esteem range. Table 2 contains the mean scores on the self-efficacy, internality, and powerful others scales for employed and unemployed participants. While there was no significant difference between groups on either scale, respondents scored lower overall on the internality scale as compared to the self-efficacy and powerful others scales.

Additional analyses were examined to assess the impact of employment status on recovery-related outcomes. The results for these variables were non-significant as well. With regard to the impact of employment status on the clients' locus of control, MANOVA indicates that the employment status does not have a significant effect on the three subscales (internality, powerful others and self-efficacy). An ANOVA showed that the effect of employment status was also not significant upon the client's self-esteem (F(2,65) = .251, p=.779). However, for one community integration item regarding the average frequency of attending a sports event, an ANOVA did show that the average frequencies of going to sports event were different across the two employment groups (F(2,124) = 8.720, p<0.001), with persons who were unemployed attending more frequently.

Discussion

Based on the results of this study, it appeared that individuals with dual diagnoses of a psychiatric and substance use disorder did not access vocational rehabilitation services at a high rate. Perhaps the most interesting note about the results of this study is the small number of persons with dual diagnoses that were participating in the VR system (3%). This contradicts the majority of the literature describing the prevalence of persons with co-occurring psychiatric and substance use disorders across several service settings (Heinemann et al., 2008; Hollar, 2008; Janikowski et al., 2007; SAMHSA, 2004). Previous investigations estimated substance use disorders affecting approximately 25-50% of vocational rehabilitation (VR) consumers (Heinemann et al., 2008: Janikowski et al., 2007). Furthermore, Janikowski et al., specifically found that psychiatric disabilities were the most prevalent co-existing disorder with substance use at a rate of 33% in the population, considerably more than in the LSVRSP population.

There could be several plausible explanations for this phenomenon that have been well documented in the literature. For instance NAMI (2004) asserts that access and utilization of service systems poses a significant barrier for persons who might have dual diagnoses. However, this might also be indicative of challenges the VR system faces in adequately gathering diagnostic information on persons with psychiatric and substance use disorders. Heinemann et al. (2008) posited that due to challenges in screening and assessment, undiagnosed substance abuse issues can negatively affect service provision. We assert that undiagnosed or misdiagnosed disorders might have also yielded the low prevalence of persons in this population with co-occurring psychiatric and substance abuse disorders.

This sample, which consisted mostly of males: was predominately between the ages of 46 through 55 years: the majority had never been married; and most tended to enter the vocational rehabilitation program with a high school diploma or LIED. This sample also tended to live in private residences and more frequently either self-referred themselves or were referred by family member or friend. One of the few significant findings indicated that men with dual diagnoses were employed at a higher rate than their female counterparts. This could also be a result of having a slightly larger proportion of men in the sample versus women.

Given the aforementioned benefit of work, Wolkstein, Bausch & Weber (2000) further contend that "work is becoming increasingly recognized as a critical component of recovery and therefore requires that treatment services provide vocational and educational services to individuals in treatment" (p. 3). This possibly calls for VR services to enhance its outreach services as an agency that supplies training and opportunity toward this key factor in recovery for persons who are dually diagnosed. It is also likely however, that persons with dual diagnoses are not accessing the VR systems as frequently, because the construct of "recovery" does not appear to be a main focus of the agency. Community-based rehabilitation programs or mental health programs with "'recovery" as a central theme might be a more appealing option for persons with dual-diagnoses. Researchers should examine ways in which to develop more "comprehensive VR services ... and addressing more individualized contextual factors" (Hollar, 2008, p. 28) to better address recovery related themes that are not currently embedded in the VR system philosophy. Consequently, a presentation of employment as a component of recovery and not an outcome in itself might facilitate greater participation by persons with dual diagnoses.

Surprisingly, there were also very limited significant findings in regard to the community integration items. Here again, it is possible that while community integration could result from successful employment outcomes, this is not a key focus of the current VR system. The scale items which focused on community integration centered on attendance at social events. While this attendance might indicate accessing community activities and services, they might not have been the most accurate assessment of integration within the community. Bond et al. (2004) assert that community integration not only includes aspects of play, but also the course in which they live, work and lead their daily lives. This would include interpersonal interactions and relationships with persons in the community outside of the mental health system. Community integration emphasizes "being of the community and not just in the communities" (Bond et al., p. 572). These items were not comprehensive in assessing these relationships either.

While the current scale did assess aspects of "play", it did not factor the cost limitations that might exist for persons who are dually diagnosed and access government services. Attendance at sporting events, live theatre and live music performance might be cost prohibitive for persons who are dually diagnosed. The incomes of the participants in the current study were not examined; however, this could provide some insight into potential ability to participate in these activities and should be investigated in future efforts reviewing community integration.

While this investigation's findings did not support previous research which suggests that targeting specific potential barriers such as self-esteem, locus of control, and community integration to be particularly effective in assisting this group to return to competitive work, this is still a critical area to discuss. Young and Ensing (1999) emphasized the relevance of "becoming self-empowered" for persons who are dually diagnosed. This aspect of self-empowerment is closely related to the constructs of self-esteem and locus of control, examined during this investigation. Deegan (1997) suggested that "integral to the concept of empowerment is a profound reverence for the fundamental value of each human being" (p. 14). It is plausible that this aspect of empowerment was not present among the study participants and thus did not present a significant relationship. However; it is also relevant to highlight one of the limitations of the LSVRSP as well to explain these findings. Hollar (2008) indicated that the non-experimental data collection and lack of using identical measures at follow-up were problematic. It is possible that these scores were assessed prior to successful employment experiences or those which would enhance the "self-esteem" of the respondents. Still, it is relevant to note the low levels of self-esteem reported by more than half of the participants. While no causal relationship can be drawn, one could speculate on the relationship between these numbers of participants with low self-esteem and the 50.5% unemployment rate of the population in the current study. This seems to indicate an area that requires further exploration by researchers.

This study did not yield any significant relationship between employment status and the recovery-related concepts examined. Respondents tended to score lower on the internality sub-scale of the locus of control scale indicating a limited belief in their ability to have control over things in their life. This lack of perceived control can also present challenges to successful recovery and enhanced recovery outcomes. Laudet (2007) asserts that increased motivation for change requires a concept of ability to change. This concept appears to be critical in enhancing the consumer's belief in successful employment outcomes. Employment has been identified as a motivational factor for persons who are dually-diagnosed (Alverson, Becker, & Drake, 1995). Future research efforts should focus on assessing the interconnectedness of these concepts for the dually-diagnosed population. If self-esteem and the belief of having control over one's life are central to promoting positive employment outcomes, then the nature of service delivery for the population in the vocational rehabilitation system may need to be shifted to allow more in-depth and accurate assessment of these factors for consumers.

The LSVRSP database, while substantial, was limited by missing data which caused the exclusion of a number of participants. The database was also unclear in the administration of the surveys at follow-up and how those corresponded with consumer's current status in VR at any point in time. Again this lack of using identical measures at follow-up can detract from the overall purpose of tracking consumers' information and employment statuses over time (Hollar, 2008; Singer & Willett, 2003). A final significant limitation could be the diagnostic codes for psychiatric disabilities and substance use disorders. The diagnostic codes presented often diverged from the disability code text. More specifically, during the extraction of the current sample, participants whose disability code text and disability code number were incongruent, were excluded from the study. This incongruence, not only reduced the number of participants, but also represents the challenges faced in the VR system with assessment and understanding of diagnoses (Janikowski et al., 2007; NAMI, 2004).

Conclusion

This study sought to investigate the prevalence of co-occurring psychiatric and substance use disorders among a sample of persons receiving vocational rehabilitation services and to explore "recovery-related" factors and their association with employment outcomes for VR consumers who have dual psychiatric and substance use disorders. The findings suggest that consumers with severe mental illness and coexisting substance abuse are not accessing the public vocational rehabilitation program at a rate proportionate to their prominence in the general population. There was also no support illustrated for the relationship between "recovery-related" factors and employment outcomes. While several study limitations likely impeded any significant results, it is also relevant to examine the VR system and to further research the benefit of a "recovery"-themed platform in the VR system. Fully incorporating this construct could "create the possibility of a radically more responsive and effective service system" (Torrey, Rapp, Van Tosh, McNabb, & Ralph, 2005, p. 98). Future research which explores the potential utility of emphasizing "recovery" as a key aspect of the VR system and which further seeks to operationalize recovery-related concepts is imperative to continued success of persons with co-occurring psychiatric and substance abuse disorders in the VR system.

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Chandra M. Donnell

Michigan State University

Nathalie D. Mizelle

East Carolina University

Yan Zheng

Michigan State University

Chandra M. Donnell, Counseling, Educational Psychology, & Special Education, 459, Erickson Hall, Michigan State University, East Lansing MI 48824.

Email: [e-mail]

Table 1.
Baseline Demographic Characteristics of Dually-Diagnosed
Participants (N = 263)

     Characteristics                             n     %

Gender
       Male                                     152   57.8
       Female                                   111   42.2
Age
     29-35                                       25    9.5
     36-45                                       72   27.4
     46-55                                      104   39.5
     56-65                                       56   21.3
     66 and higher                                6    2.3
Ethnicity/race
       White                                    202   76.8
       Persons of Color                          57   21.7
Marital status (at entry)
       Married                                   37   14.1
       Widowed                                    5    1.9
       Divorced                                  64   24.3
       Separated                                 29   11.0
       Never married                            128   48.7
Educational attainment
     (highest degree obtained at entry)
       High School or GED                       172   65.4
       Two-year Associate's Degree               13    4.9
       Four-year Associate's Degree               9    3.4
       Master's Degree                            4    1.5
Current Status in VR
     Status 26 (employed)                        97   48.0
     Status 28 (unemployed)                      72   35.6
     Status 30 (unemployed)                      27   13.4
Residential Status
       Private residence                        217   82.5
       Non-private residence                     45   17.1
Source of Referral
     Educational/Residential Institution         83   31.5
     Rehabilitation or other Health Facility     86   32.7
     Self/Personal                               93   35.4

Table 2.
Means and Standard Deviations or Internally, Powerful Others, and
Self-efficacy Scale Scores

Group        N     Self-Efficacy   Internality   Powerful Others

                     M      SD      M      SD       M      SD

Employed     66     16.9   4.09    12.4   3.73     18.9   4.25
Unemployed   61     16.1   3.60    13.1   2.77     19.0   3.45
Total        127    16.5   3.87    12.7   3.33     18.9   4.0