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Article Excerpt
"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,...
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