Work, Workers, and Workplaces: A Qualitative Analysis of Narratives of Mental Health Consumers.
Despite the generally positive findings around the relationship of work to mental health consumers, little is known about the meaning of work to individuals with mental illness. There is a general assertion in the psychiatric rehabilitation literature that work contributes to and improves quality of life for individuals with severe mental illness (Anthony & Blanch, 1987). However, the few studies in this area present complex and divergent results. Bell and Lysaker (1995) found that, although individuals in paid work experiences reported feelings of well-being and personal satisfaction, about half dropped out of the paid work experience and close to one third chose to engage in no productive activity in the six months following completion of the experience. While Mueser et al. (1997) did find higher satisfaction with vocational services and finances among working consumers, results failed to show a relationship between work and overall life satisfaction. Thus, the authors concluded that "employment does not lead to a generalized improvement in subjective quality of life" (p. 424). Although Lehman (1983) found that work variables were highly correlated with perceived well-being in a chronically mentally ill population, this relationship applied only to a small number of participants who were employed. Similarly, Fabian (1992) found an increase in scores on subjective quality of life scales in individuals with severe mental illness engaged in supported employment as compared to nonworking individuals. This finding, however, is in direct contrast to findings in her earlier work (Fabian, 1989) in which she found no significant differences on objective or subjective quality of life indicators when comparing two samples of employed and nonemployed consumers.
The inconsistency of these results with those of studies on "normal" populations brings into question the universality of the work benefit. The difficulty in characterizing and capturing the meaning of work is further illustrated in Scheid and Anderson's (1995) qualitative study of working consumers. Although all 10 participants in this study felt work was important to their sense of self-identity, some of them also identified work as a source of stress and feared that full-time work might be too overwhelming. Thus, the true meaning and impact of work on the lives of mental health consumers remains unclear. As suggested by Scheid (1993), further studies that access work experiences over time are needed to determine whether work "improves self-esteem and psychiatric state or is a source of additional stress that can result in reduced self-worth and depression" (p. 775). Furthermore, Fabian (1992) emphasized the need for qualitative research to complement quantitative methods in light of the independence of objective and subjective quality of life scales.
Not only do gaps exist in the literature regarding the meaning and impact of work on mental health consumers but the effects of the workplace have also been largely ignored. Few, if any, researchers have attempted to analyze contextual aspects of workplaces as they impact upon persons with mental health problems. Moreover, the work that does exist is largely speculative in nature. The literature suggests that, like workplaces for other persons, desirable work sites for persons with mental health problems are those that attend to employees' needs and that celebrate diversity (Akabas, 1994). Influential components of the workplace have included both structural aspects such as proximity to home and potential for flexible work schedules, and psychosocial characteristics such as communication patterns and trust (Kirsh, 1996).
The purpose of this research is to examine the meaning of work and important elements of workplaces as perceived by mental health consumers. Through analysis of interview data focusing on consumers' work-related experiences and perceptions, several themes are presented which facilitate a deeper understanding of these experiences.
The research described in this paper comprises a component of a larger study on factors associated with work integration for mental health consumers. The full research study used a mixed methodology (quantitative and qualitative approaches) to examine several variables and to explore consumer perspectives on work. The purpose of this paper is to report the qualitative findings in order to understand the meaning of work and the impact of the work environment on mental health consumers.
Participants in this study were consumers of mental health services. These consumers had been previously hospitalized for mental illness on at least one occasion, and had gone through the process of work integration; that is, they had looked for and attained employment subsequent to their illness. Thirty-six participants were recruited (N=36) and assigned to one of two groups: (a) those who were working in mainstream employment for a period of at least six months (n=17) and (b) those who had left their integrated employment settings within the six-month period prior to recruitment (either because they were required to leave or because they chose to leave: n=19). The groups were very similar in demographic characteristics. The employed group was 59% male and 41% female with a mean age of 42.4 years and a mean of 6.4 hospitalizations. In the employed group, 53% reported a diagnosis of affective disorder, 35% reported schizophrenia or schizoaffective disorder, and 12% reported anxiety disorders. The unemployed group was 47% male and 53% female with a mean age of 42.2 years and a mean of seven hospitalizations. In this unemployed group, 67% reported a diagnosis of affective disorder, 22% had schizophrenia or schizoaffective disorder, and 11% had anxiety disorders.
Each participant completed a demographic questionnaire along with four other instruments to collect quantitative data. They then participated in a confidential, tape-recorded interview. The interview guide was developed following a review of literature on employment, mental health and consumerism and the completion and analysis of a pilot study on influences on employment for mental health consumers (Kirsh, 1996). The interview focused on personal empowerment, skills, and environmental supports which were perceived to be influential on the process of work integration. The semi-structured format provided a consistent framework of questions and probes for each interview and, at the same time, allowed flexibility to pursue viewpoints of respondents in depth (Fry & Keith, 1986; Marshall & Rossman, 1989; Patton, 1980).
The text of the interviews was examined through inductive analysis; that is, categories of meaning were derived from the data as opposed to imposing a defined coding system. The data were indexed and analytic categories were created. These categories were analyzed further and were amalgamated or subdivided to form the central themes and subthemes of the study. This method of inductive analysis has been suggested by many qualitative researchers, for example, Glaser and Strauss (1967), Miles and Huberman (1984), and Strauss (1987).
Themes relating to the meaning of work and the effects of the workplace emerged from data analysis. Each one had its own set of secondary themes or subthemes. These themes frame relationships among work, workers, and workplaces as they impact upon work integration processes and outcomes. Three themes emerged: (a) the meaningfulness of work to consumers, (b) the impact of the organization on job satisfaction and tenure, and (c) the importance of supervisory and coworker relationships and attitudes.
I. The Meaningfulness of Work
Both working and non-working participants related employment to positive effects on health and self-esteem, although there were, in some cases, qualifiers to this relationship. Some individuals spoke of the need to find a balance between the positive effects, such as structure, productivity, and improved economics and the negative effects, such as work stress. Generally speaking, however, individuals expressed the wish to be competitively employed in some capacity in order to feel personally satisfied and fulfilled. The sense of general wellness associated with work was contrasted to subjective feelings associated with unemployment and even underemployment. These states were described many times, in many ways. Robert stated: "when you're working you have pride in yourself and you feel important and you feel very good about yourself, when you're not working, you're down and you're depressed and it's lonely." John reflected on being not only unemployed but underemployed:
being underemployed is very frustrating, it caused me to feel anger: I would work quite hard and not be paid very much money and not have enough to make ends meet and I found it very frustrating ... I went back to school.... at one point I offered to work for nothing for one or two months to get experience and I was turned down, so I felt really, really badly ... I just felt like giving up and it was actually after that I started to get depressed about being unemployed because it was dragging on longer and longer ... I became totally withdrawn ... you know, things when you're depressed, sometimes they feel hopeless.
In accordance with the vast literature on employment and well being, mental health consumers described work as a vehicle which enabled fulfilment of numerous human needs. These descriptions have been analyzed and categorized into secondary themes: (a) work as contribution to society; (b) work as distraction and "normalization"; and (c) work as challenge, achievement and self-worth.
Work as Contribution to Society. Both working and nonworking participants spoke about the importance of "giving back" to a system, of knowing and having others know that they are active participants within a collective. Randy emphasized that being a contributor is even more important to him as a person who may require assistance:
I basically like to be a contributor to the system, instead of taking away from it ... even though I have a legitimate right with an illness, I just feel better about being part of the people who are making an effort ... people will understand that I am doing what society asks and trying to rebuild my life ... they'll go to bat for me in a sense.
Consumers, who have long been advocating for deeper integration into mainstream society, are clearly stating that full community participation is the order of the day. They view work not only as an opportunity for self advancement, but also as a set of "citizenship behaviors" to enhance the life of the community at large.
Work as Distraction and "Normalization." Work was emphasized as an activity which shifts one's focus from differences which exist between persons with mental illnesses and others to similarities. As Susan stated, "There, I'm a worker who does a good job, gets paid and earns a living like anybody else. I'm almost normal." In fact, work was seen by some to be the link that maintained all other elements of an integrated and satisfying life. For example, Ann reflected:
not having a job seemed scarier to me than just about anything ... when I was most depressed the vision that would go through my head would be well, I won't be able to keep my job and so now I won't have enough money to keep my apartment and the like and I don't want to lose contact with my friends, and a whole scenario would result from that ...
For many mental health consumers, the ability to work offered hope for and realization of the goal of reintegrating into mainstream life. At the same time, in a very concrete sense, work put forth a new set of demands and activities that interrupted the pattern of attentiveness to pathology which had previously occupied so much time and energy. A shift from a focus on illness to a focus on wellness was facilitated.
Work as Challenge, Achievement, and Self-Worth. As is true for many people, mental health consumers described work as a set of opportunities to seek out and meet new challenges and to experience a sense of accomplishment, thereby validating and developing self-esteem and a sense of self-worth. For consumers, virtually all of whom described experiences related to illness, stigma, and marginalization as damaging to self-esteem, the rebuilding of the self was seen to be critical and connected to work. Working and non-working consumers alike spoke of the interplay between the challenges of employment and self-worth. Louise described how work enabled the development of self-awareness and affirmation of ability:
It gives me a sense of accomplishment, to work again, putting in the hours and realizing that I can do that and not fall apart and give up. Something wonderful has been happening in the past two years, because I have started to believe that I can actually work in a job and receive a pay check for that ... so there's a certain worth there, that's been growing, that's gotten stronger and stronger. That good feeling keeps me going back and back.
Consistent with literature on motivation and self-efficacy, it appears that satisfaction derived from achievement and mastery serves to foster the development of self-esteem, perceived self-efficacy and motivation to persist.
The Impact of the Organization on Job Satisfaction and Tenure
The nature of the workplace was identified as an important factor which affected maintaining employment and reaping the benefits thereof. All participants interviewed spoke about the interactions of work environments with illness and coping, resulting in various levels of satisfaction and stress. Findings in this area have been categorized into three subthemes: (a) balancing challenge and predictability in search of satisfaction, (b) psychosocial characteristics experienced at the workplace, and (c) needs and accommodations in the workplace.
Balancing Challenge and Predictability. Many consumers discussed the dilemma of, on the one hand, wanting to protect themselves from the stresses of risk-taking, and on the other hand, feeling the frustration of minimizing challenge at work. Ann, for example, stated:
in order to hold a job it had to be something that was sort of mechanical enough or automatic enough that I could perform it when I wasn't well. That meant it couldn't involve too much creative thinking, or too high a level of responsibility, or a whole range of other things, except that meant something that in fact was sort of below what my professional ability is.
Finding work which offered the right balance of challenge and predictability or the flexibility to shift emphasis was difficult for consumers. The effects of imbalance in this area on job satisfaction are evident; the question of whether job performance and maintenance are affected warrants further exploration.
Psychosocial Characteristics of the Workplace. As expected, a wide range of workplace characteristics was experienced and described along with highly individualized opinions and reactions to them. However, most consumers emphasized the importance of a friendly, respectful, communicative work environment with a culture of flexibility and inclusion. Many stated they enjoyed a relaxed, easy-going environment with a minimum of competition. Unfortunately, many consumers in both groups conveyed examples of stigma and prejudice at the workplace. These examples were particularly intense for those who left their jobs, in some cases with stories of unjust treatment.
An atmosphere of respect and caring and an ability to see beyond the illness appeared to be most valued for participants. Randy stated:
My employer stuck by me while I was on disability, and they challenged me to come back to work ... I worked amongst people who ignored the fact that I had a weird appearance but I did the job and they stuck by me.
Inclusion in the life of the organization was also described as an important factor contributing to job satisfaction and commitment. Susan, a clerk in an accounting firm enjoyed sharing her examples of social inclusion:
After tax season ... the firm gives a tax party and they can let off steam and bash ... everybody goes to this party.... I used to hate it because I couldn't join in because of my medication ... And now I leave early. I stay for dinner and even though I leave early I enjoy it. And then there's golf day which is my favorite day of the year ... we all go golfing ... it's a fun day out, it's outside and then you get a free lunch and dinner ... I won the trophy a couple of times.
Some consumers who left their jobs complained that their peers and coworkers treated them differently once the mental health issues became clear. Maggie stated:
... there seems to be the assumption that we're not quite people. That you've got to treat us with kid gloves, otherwise we'll get all depressed, you know. Once you treat me the same as everybody else, that lets me know that I'm here and I'm OK and then I can be like everybody else. If you start treating me differently, saying "you better get that coffee for Maggie, didn't she say she was manic-depressive - she might go off the wall. Or if she doesn't have her caffeine, maybe she'll have a reaction to the drugs ..." If you start treating me differently, then we're not going to talk anymore. This is my experience.
In contrast to working consumers who described a climate of acceptance, respect, and recognition of their personhood, such stories point to the wide array of responses to mental illness and the negative effects of intolerance at the workplace.
Needs and Accommodations in the Workplace. The development of awareness of personal needs along with accommodations in the workplace to meet these needs were described by working participants as facilitators to work. Interestingly, however, those who left or lost their jobs articulated very little on this topic, presumably because accommodations were not components of their work experiences.
Stories of accommodations were told with great importance attached to them, often tempered with statements around balancing personal and employers' needs. (Ann, for example, advised consumers: "Know what you need to know, negotiate the working situation ... that's what we're entitled to, and on the other side be aware that there are limits.") Accommodations related to time flexibility and restructuring of job duties were cited frequently and in many ways as factors enabling continued participation in the workforce. John described the process that enabled him to continue working through his illness:
My manager made accommodation for me, gave me some time off and reduced the hours ... I started sleeping better so I was getting back up to par because to be honest with you when I wasn't sleeping it was hard to concentrate. I feel like I'm doing a better job now. But they were willing to work with me - they didn't just tell me to take two months and go away, they helped me work through it and stay on the job. My hours were reduced, some of my paperwork was put on hold and now I'm just starting to get caught up. I was still at the workplace -- on reduced duties but nevertheless I was still there.
Accommodations to the job not only were helpful in managing the stresses of work and coping with illness, but also served to convey attitudes of concern and caring from employers. Undoubtedly, this in turn fostered greater job satisfaction and a deeper commitment to work.
The Importance of Supervisory and Coworker Relationships and Attitudes
The nature of supervisory and coworker relationships was a factor affecting quality of work life and maintenance of the job itself. Some consumers paid tribute to their supervisors and coworkers for their qualities and efforts; others pointed to the need for education and change. This theme has been categorized into subthemes reflecting; (a) the influential nature of supervisors' and coworkers' qualities and behaviors, and (b) the dilemma of disclosure.
The Influential Nature of Supervisors' and Coworkers' Qualities and Behaviors. Virtually all consumers interviewed spoke about their supervisors and coworkers and the impact of these relationships on their ability to stay at work with some degree of satisfaction. In general, consumers valued supervisor qualities such as willingness to provide feedback and to communicate openly, fairness, commitment, supportiveness, a sense of humor, and an ability to convey the worth of the employee. Robert talked about the support he experienced from his supervisor:
I have a female supervisor and she's very supportive ... When I started she was the one that helped me, she was the one that took me under her wing and showed an interest in me. She made me realize that this was really a nice job, she really takes the time to ask you little stuff, she's a very nice person ... (when I became ill) I'd be crying and she'd give me tissues and be asking if I'm OK. And of course I don't want to say anything so I'd be saying, yeah, I'm fine ...
Non-working consumers had different feedback about their supervisors and the relationships or absence of relationships with them. Most of them described a lack of support from their supervisors and, in many cases, attributed increased stress at work directly to their supervisors. John explained that "I could not use (my supervisor) as a support or confide in him ... I'd look at him and put myself down immediately, just like I'm not doing good enough and it would cause major anxiety."
The effects of the supervisor on work life have been widely documented in management literature. The qualitative research findings of this study concur with research pointing to the significance of this factor and underscore the importance of social factors in work integration outcomes.
In similar fashion to relationships with supervisors, some consumers described supportive, friendly relationships with their coworkers while others described quite the opposite. Once again, working consumers were more likely to fall into the former category. Consumers valued coworkers who demonstrate attributes which contribute to positive work climates. For example, Randy explained how the culture of acceptance at his workplace emanates from his coworkers:
The people I work with, they understand I have an illness, and sometimes if I say something strange, and it just doesn't register with them, you know, they'll just say, that's OK Randy, I mean that's the way you feel about it, they accept me as I am.
Relationships with supervisors and coworkers clearly had an impact on self-esteem, quality of work life, and, in some cases, ability to maintain the job.
The Dilemma of Disclosure. The decision to disclose or not to disclose mental health problems at the workplace was described by most consumers as a difficult one, one which carried consequences in both directions. Although disclosure relieves the burden of secrecy and often leads to accommodations to be made to the job, consumers hesitate to disclose, all too aware of societal stigma and the range of potential reactions. As stated by Linda, "I haven't felt comfortable about (telling), I mean I wish I could in a way, but I don't know how they would receive it." Matt further described the difficulty:
Somewhere it feels wrong to say nothing, but then in another way it feels wrong to say something, I don't quite know how to reconcile the issue of disclosure. I guess that comes from being burned by the issue of disclosure ... I wasn't fired but it was a leave of absence.
Some consumers described the decision to disclose as a function of the workplace climate. They believed careful assessment of the culture is warranted before making this important decision. Gary, for example, held down two part-time jobs and made different decisions at each one:
I know that the one department I'm in, the bosses that I have, my illness doesn't seem to worry them or cause them any concern. Now another part-time job that I have ... I wouldn't breathe a word that I have a mental illness, because I knew if I did, I'd be long gone out of there ... I see what happens to people who get sick there.
Some consumers made the decision to take the risks associated with disclosure because the stress of keeping it quiet was too great. Linda stated:
I knew for me personally, I had to be in a place that knew. I wasn't going to hide it anymore. I couldn't - it was too hard to hide all those years that I was working in accounting, and I wasn't willing to go on hiding it anymore.
Many working consumers who disclosed their illnesses were subsequently able to accommodate their jobs to meet their needs and therefore described disclosure as a positive step:
I had to tell them, and I was glad I did, because now I've got a job that I can do and there's flexibility and there have been allowances made and I can do the job to the best of my ability, whereas if I had been in a situation where my boss didn't know, I probably would have been out the door the first time I was sick.
The dilemma of disclosure in and of itself is reported to be a source of tremendous stress at work. The difficulties associated with this decision are the result of lived experiences reflective of societal attitudes and stigma. Workplaces whose norms do not accommodate diversity, acceptance, and other positive psychosocial attributes are less likely to foster honesty in this area among their employees. Consequently, energies are devoted to hiding the illness and managing components of the job which may not "fit" well, thereby minimizing the likelihood of successful and satisfying work.
There are a number of major implications of the findings of this study for mental health professionals, vocational rehabilitation practitioners, employers, consumers and organizational researchers. The importance of employment to the health and quality of life for mental health consumers was supported. Relationships between work, workers and workplaces were revealed through themes emphasizing interactions between persons and environments as they relate to work integration. In contrast to previous research on predictors of employment, which has generally concerned itself with demographic and clinical variables, this research promotes a shift in focus from individual pathology to the dynamic interrelationships among the work, the people, and the environment in understanding the process and outcomes of work integration for mental health consumers.
An important theme in this study was the difficulty consumers experienced in balancing challenge and predictability at work, the conflicted wishes to meet their potential, placed against a backdrop of fear of recurrence of illness. This finding is interesting and revealing when considered alongside research from management literature which suggests a relationship between level of work demands and job tenure. The Whitehall II study, for example, measured work characteristics and found high job demands, including conflicting tasks, work overload, role conflict, and high work pace, to be associated with increased risk of psychiatric disorder for both men and women (Stansfeld, Fuhrer, Head, Ferrie & Shipley, 1997). Also revealed was the protective nature of skill discretion (a measure of job variety and opportunity for use of skills at work) and decision authority (the amount of control over work) in men against psychiatric absence, leading the investigators to conclude that "interesting and varied jobs tend to encourage people to stay at work at the time of mental health difficulties, rather than take absence" (p.78). When considered in light of studies such as the Whitehall II, the importance of finding, not simply a job that one is capable of, but rather one that offers a satisfying balance between challenge and predictability, becomes a critical area of focus in work integration.
Consistent with the results of a limited number of studies on factors external to the individual consumer and work (Akabas, 1994; Gates, 1993), the importance of supervisory and coworker relationships in the creation and transmission of positive workplaces emerged as another important finding. Again, much has been written within organizational theory to make sense of this principle. Mayo and his colleagues, Roethlisberger & Dickson, (as cited in Walsh & Tseng, 1998) explained that their findings of increased output under a variety of conditions were a result of workers' needs for acceptance and attention from their superiors and argued that supervisors should be trained to be more sensitive to worker needs and that doing so would increase satisfaction and effort at work. More recently, the Whitehall II study revealed that support from colleagues and supervisors at work was protective of mental health in both men and women as measured by the General Health Questionnaire and short absences for psychiatric reasons (Stansfeld et al., 1997). The investigators pointed out direct implications for management and work organization, stating that "attention to support of employees by supervisors is likely to improve mental health and reduce rates of short spells of sickness absence and thus may lead to an overall increase in productivity" (p.78). Similarly, in this study, positive relationships with supervisors and coworkers were highly influential forces in the work lives of the participants and were seen by consumers to be factors which promoted continued employment.
Not unrelated to coworker and supervisory relationships is the dilemma of disclosure, discussed in depth by participants in this study. The fears and anxieties associated with disclosure, the benefits which resulted for some consumers, and the stigma experienced by others, point to the complexity of this issue and underscore the importance of attending to the decision around disclosure with great care. Roberts, Rotteveel and Manos (1995) discussed disclosure for mental health consumers as professionals and cautioned that the decision around when, how, and how much to disclose depends on the culture of the workplace. They advised that consideration be given to ways in which staff support one another, formal or informal mechanisms that enable such support to be experienced, and the level of tolerance for discussing personal information. As emphasized by this study, the magnitude of the issue of disclosure and its impact on work is a call for assistance for consumers in the throes of the decision.
The effects of the work environment on individual behavior and attitudes within organizations have been demonstrated within the general population and are well documented within management literature (Ostroff, 1993). Some research in the area of work integration does emphasize social or environmental factors, such as support on the job (McHugo, Drake & Becker, 1998) in facilitating employment for people with mental illnesses. The findings of this study also reveal a relationship between employment and workplace climate. The psychosocial environment of the workplace and the extent to which individual needs can be accommodated were identified by consumers as determinants of the work trajectory.
The meaningfulness of employment to consumers of mental health services was an important and pervasive theme which emerged from this work. Participation in the workforce was seen as a health promoting life role which enabled a shift from pathology to productivity and a development of self-worth and life satisfaction. Consistent with findings associating employment with health and well-being within the general population, consumers in this study described improved mental health and self-esteem and a more integrated, "normalized" way of life. The relationship of work to health has once again been highlighted and, to this end, further research on factors facilitating employment is needed.
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Bonnie Kirsh, Ph.D. Assistant Professor, Department of Occupational Therapy, Faculty of Medicine, University of Toronto, 256 McCaul St., Toronto, Ontario, Canada M5T1W5
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|Publication:||The Journal of Rehabilitation|
|Date:||Oct 1, 2000|
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