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INTRODUCTION Scientific efforts to advance the practice of vocational rehabilitation (VR) for adults with the full range of disabilities have made remarkable progress over the past two decades. The number of published evaluations of vocational interventions has grown at an encouraging pace, and though the number of clinical trials has been fairly small, it is steadily increasing. Moreover, the level of methodological and statistical sophistication has improved substantially. To a significant extent, these trends have been driven by research studies seeking to carefully evaluate the use of the Individual Placement and Support model of supported employment (IPS SE) for adults with psychiatric disorders. There have been more than 20 clinical trials of IPS SE over the past 20 years, and more than 25 percent of all empirical evaluations of vocational services (VS) published in 2009 represent evaluations of IPS SE. These efforts have coincided with growing agreement among policymakers, clinicians, and researchers that clinical programming should be guided by principles of evidence-based practice (EBP) [1-2]. While IPS SE is one of the practices with a sufficient evidence base to be included on the list of EBPs, relatively few of the range of common vocational interventions have been the focus of controlled trials. Of those that have been, the populations studied have typically been a subset of the disability groups using VS. As VS research matures, it is necessary for the field to review its progress and identify any important gaps in measurement and methodology that may hamper its ability to answer key questions. Moreover, articulating larger strategic issues may help direct future research toward particularly relevant and compelling concerns. To encourage progress, we have identified (1) ways to increase consistency in measurement of employment outcomes, (2) emerging patterns and lingering gaps in the range of variables and measures commonly used in VS research, (3) broader methodological patterns and needs in the area of study design and sampling, (4) interventions that warrant additional study, and (5) broad strategies to increase the overall amount and quality of VS research. We make recommendations in each of these five areas. These recommendations vary in terms of the audience they are relevant to and the potential benefit they may produce. Given these variations in focus, audience, and potential benefit, we have not tried to prioritize them in terms of importance but instead offer them all as potential ways to enhance different aspects of current research. Note that this article is not intended to be a comprehensive review of the literature, measures, or methodology in VS research. Instead, we have tried to highlight trends in the literature and make recommendations for the field as it moves forward. In particular, the final section of this article focusing on broad strategies for enhancing research could easily include extensive discussion of each strategy--an approach that is beyond the scope of this article. COMPETITIVE EMPLOYMENT OUTCOMES AND MEASURES As a field, VS profits from the relative luxury of having a single primary outcome: competitive employment. Competitive employment is defined by the Department of Labor (DOL) as work in the competitive labor market that is performed on a full-time or part-time basis in an integrated setting and for which an individual is compensated at or above the minimum wage [3]. While the stated goals of vocational interventions may be framed in a range of ways, the overall objective for most is to help participants obtain and maintain their own competitive job in the community. The singular focus on competitive employment as the primary outcome of VS and as a key outcome for rehabilitation should continue for a number of reasons. Deterioration in functioning in competitive employment is a central element in the definition of disability (see the World Health Organization's International Classification of Functioning, Disability, and Health [4]), as evidenced by its central use in the compensation determination processes. …

Vocational services (VS), particularly supported employment models, have clear advantages for assisting adults with severe mental illness (SMI) in returning to the workplace, but a majority of eligible individuals with SMI do not receive any type of VS. The reasons for nonparticipation in VS remain poorly understood, and the potential contribution of cognitive impairment as a barrier to entry has not been explored. The present study uses a pathways-to-care design to examine the specific contribution of cognitive functioning to entry into VS among veterans with SMI. We examined 179 veterans with both SMI and un- or underemployment who completed a work history, the Pathways To Care Inventory, and the Trail-Making Test, Part B. Analysis revealed that veterans with SMI and moderate to severe cognitive impairment took significantly longer to progress through pathways-to-care than those with SMI and mild or no cognitive impairment. These results suggest that identifying veterans with SMI and cognitive impairment early and providing them with integrated and adjunct services may help them navigate VS.

We begin by thanking the Editor of the Journal of Rehabilitation Research and Development (JRRD) for commissioning a special issue on psychosocial rehabilitation (PSR) for persons with serious mental illnesses. For many years, the conventional wisdom in the field of mental health has been that serious mental illnesses result in inevitable deterioration. Professional practice has therefore focused on managing psychopathology and its symptoms. A wider variety of outcomes has been identified as critical over the past 30 years, however, particularly for individuals with schizophrenia [1-4]. These outcomes include regaining functioning over the long term, developing friendships, and living satisfying lives [5-9]. Thirty years of empirical evidence, as well as first-person accounts [10-13], support the notion that recovery from serious mental illnesses is possible. As a result, governments in several countries have convened expert panels to review the evidence and recommend policy about the kinds of services that are best for those with serious mental illnesses. In the United States, the three most widely recognized of these are the 1999 report of the Surgeon General on mental health [14], the recommendations of the President's New Freedom Commission on Mental Health [15], and the Institute of Medicine's report on mental health and substance abuse [16]. The single most potent recommendation is to introduce a vision of recovery into the mental health system, a vision based on the accumulated evidence of what is possible. The result is that nothing less than recovery from serious mental illnesses has become the guiding force behind policies and practices in many U.S. Federal and state mental health systems, as well as those of other countries such as Canada and New Zealand [15,17-19]. * PSYCHOSOCIAL REHABILITATION IN CONTEXT OF RECOVERY The vision of recovery should be the unifying mission of all mental health services [9,15,20]. Each service should clearly identify the recovery outcomes for which it holds itself responsible. In this context, PSR or psychiatric rehabilitation services contribute to recovery by focusing on outcomes related to role functioning in the "real-world" community [20]. Rehabilitation of any kind (i.e., physical, psychiatric, social, etc.) is an ecological approach ("person-environment fit") that fits the framework of the consequences of disease and the goals of health proposed by the World Health Organization (WHO) (i.e., classifying intervention effects in terms of their contribution to health, activity, and participation) [21]. PSR is concerned with return of functional capacity and participation in valued societal roles. The dictionary definition of rehabilitation is "the restoration of someone to a useful place in society" (http:// www.thefreedictionary.com/rehabilitation). Rehabilitation thus has two goals: facilitating success and satisfaction in the performance of personally preferred and valued roles and creating or promoting an increase in opportunities for participation in society. These goals are accomplished by ensuring that the person has the skills and supports necessary for success and satisfaction, a basic principle of PSR [20]. Techniques designed to promote role competencies, support for role success, and interventions to increase empowerment and societal opportunities and reduce discrimination are all within the pantheon of recognized rehabilitation techniques [22]. The PSR field is relatively young and still at the earliest stage of researching the interventions that constitute it. While well-executed randomized clinical trials (RCTs) are considered the "gold standard" for rigorous research, recent caveats have emerged about RCTs, especially in psychosocial intervention [23-24]. These caveats particularly apply when the goal is recovery, as opposed to more limited outcomes, such as preventing relapse or rehospitalization, for example. …

In this random-assignment trial, we evaluated the efficacy of using a contingency management (CM) intervention to enhance job acquisition and tenure among participants of a vocational rehabilitation (VR) program. The CM intervention offered participants cash incentives up to $1,170 for completing tasks related to sobriety and job search and maintenance. Participants were 100 veterans with comorbid psychiatric disorders and substance dependence who were randomly assigned either to VR only or VR + CM. Relative to participants in the VR-only group, those in the VR + CM group showed more intense job searches and transitioned to competitive employment faster and at higher rates. No significant difference was found in job tenure, though this may be due to the limited follow-up period. Abstinence rates were significantly better in the VR + CM group during the first 16 weeks of follow-up but not significantly different in subsequent follow-ups. No relationship was found between relapse and employment. These results suggest that rehabilitation outcomes may be enhanced by adding CM to current programming or by restructuring traditional work-for-pay contingencies to include direct financial rewards for achievement of clinical goals.