Comparing & Contrasting Article

3 pages, Pacific Instruction, APA style

Comparison Paper
: Each student will write a brief 2-3 page, APA style paper (title page, abstract, and reference pages are not included in page count) comparing two course sources (book chapters, articles, etc.). The paper will include at least two references as you will be comparing two sources.

Attitudes-Towards-Employment-and-Employment-Outcomes

Stigma as a Barrier to Substance Abuse and Mental Health Treatment.

Stigma as a Barrier to Substance Abuse
and Mental Health Treatment

Les McFarling, Michael D’Angelo, and Marsha Drain

U.S. Army Center for Substance Abuse Programs, Alexandria, Virginia

Deborah A. Gibbs and Kristine L. Rae Olmsted
RTI International, Research Triangle Park, North Carolina

This article provides an overview of stigma associated with mental health and sub-
stance abuse treatment in military settings and discusses articles included in this is-
sue. These articles examine the predictors of and barriers to treatment entry; assess
the influence of military culture and unit influences on attitudes toward treatment;
examine unique challenges associated with reserve personnel; and address policy
changes to improve access to care. We review challenges associated with reducing
stigma and the importance of policy, culture, education, and leadership to effect the
desired changes.

Numerous studies have addressed the attitudes and beliefs contributing to stigma-
tization of mental health issues generally (Corrigan, 2000; Corrigan & Watson,
2002; Vogel, Wade, & Haake, 2006; Vogel, Wade, & Hackler, 2007) and within
military populations (Dickstein, Vogt, Handa, & Litz, 2010; Hoge et al., 2004; Sci-
ence Applications International Corporation [SAIC], 2010). However, stigma as-
sociated with substance abuse is less well understood. If evidence suggests that
stigma has prevented soldiers from seeking essential help with substance abuse is-
sues, it is critical to effectively reduce stigma so that soldiers can receive the help
they so urgently need. The articles in this issue are intended to broaden the body of
knowledge about stigma and to stimulate solutions by which it can be reduced.

We see the development of stigma as a systemic issue, deeply rooted in the tra-
ditions of the military. From basic training to their first duty assignment, soldiers

MILITARY PSYCHOLOGY, 23:1–5, 2011
Copyright © Taylor & Francis Group, LLC
ISSN: 0899-5605 print / 1532-7876 online
DOI: 10.1080/08995605.2011.534397

Correspondence should be addressed to Dr. Mike D’Angelo, 4501 Ford Ave., Alexandria, VA
22302. E-mail: michael.s.dangelo@us.army.mil

are conditioned to be physically strong and mentally tough—in other words, ma-
cho. This ethos is exemplified by such military service marketing slogans as
“Army Strong” and “The Few, the Proud, the Marines.” The value placed on
strength within military culture creates the risk of stigma for any situation in which
weakness is perceived. Accordingly, if substance abuse treatment is associated
with weakness, servicemembers may be ridiculed by peers to the point that treat-
ment seeking becomes untenable.

Military policy toward substance abuse and its treatment has evolved in
response to a changing situational context (Department of the Army, 2009). Some-
times these changes have resulted in unintended consequences, including the cre-
ation of stigma for treatment. In the post-Vietnam era, drug use among service-
members was quite common and did not engender the stigma that it does today. As
military acceptance of drug use ceased, stigma associated with drug use increased.
Attitudes toward alcohol abuse have also shifted over time. In the mid-1980s, se-
nior Army leaders recognized that heavy drinking had reached unacceptable lev-
els. By using policies of compassionate treatment and deglamorization, they were
able to reduce heavy drinking without stigmatizing those affected (Department of
the Army, 1985, 2009). However, in the post–Cold War drawdown of forces of the
1990s, substance abuse behaviors were sometimes used to disqualify members
from service—thus introducing the stigma that we live with at present. Today, 10
years of war and its consequences may have mitigated the stigma associated with
seeking combat-related mental health treatment. However, the stigma associated
with substance abuse treatment remains, albeit for different reasons than one might
expect.

The articles in this issue address an important question raised by a clinician dur-
ing a focus group session on stigma—in the current military environment: Is it
“better to be drunk or crazy?” To this we add a follow-up question: What can be
done to reduce barriers to treatment for both substance abuse and mental health is-
sues among military personnel? The articles in this issue describe stigma from a
variety of perspectives. In doing so, they lay the groundwork for responding to the
normative attitudes toward substance abuse and mental health issues, as well as
ameliorating the factors that undercut efforts to treat associated problems. Spe-
cifically, they describe the prevalence of harmful drinking, barriers to treatment,
determinants of perceived stigma for treatment, predictors of treatment entry, per-
ceptions of treatment programs, and novel ideas for treatment of substance abuse.

As shown by Ramchad and colleagues (this issue), a significant proportion of
military personnel in need of treatment services for either substance abuse or
mental health issues do not seek them. As military personnel return from deploy-
ments, they may abuse alcohol for numerous reasons, including the desire to
cope with uncomfortable feelings or memories, deal with stress, or facilitate ca-
maraderie with other personnel. Ramchand and colleagues present new, nation-
ally representative data to examine the prevalence of harmful drinking behaviors

2 MCFARLING ET AL.

in military personnel, as well as how those behaviors vary with respect to military
status (Guard/Reserve, active duty, and veterans). The authors place these data in
context by comparing rates of alcohol abuse among deployed military personnel
with those of a similar civilian population, as reported in nationally representative
samples.

Who is at risk for substance abuse and behavioral health issues, and is that risk
a valid predictor of treatment entry? The answer to this question has the potential
to inform screening and referral effort, as well as planning for treatment re-
sources. Clinton-Sherrod and colleagues use extant data from Post Deployment
Health Reassessment (PDHRA) records to determine risk for substance abuse
and/or behavioral health issues. They evaluate the degree to which that risk
relates to actual treatment entry and identify discrepancies between rates of treat-
ment for substance abuse and mental health issues. Their findings point to
several important questions about how these issues are addressed within the
military.

In what ways might military culture provide context for attitudes toward alco-
hol abuse and/or mental health issues? How do these attitudes influence the ways
that soldiers think about treatment? Gibbs and colleagues use focus group inter-
view data to describe distinctions between alcohol abuse and mental health issues
within the military and examine how these differences shape attitudes regarding
treatment for each condition. The authors examine the degree to which perceptions
of responsibility for the condition and danger to others influence stigma. They also
suggest opportunities to address negative attitudes toward treatment for alcohol
abuse.

Soldiers in treatment for behavioral health or substance abuse issues may
perceive barriers to care differently from their counterparts who are not receiv-
ing treatment. Logic suggests that those in treatment would have lower percep-
tions of stigma associated with their care than soldiers who are not in treatment,
based on their understanding of their condition. Alternatively, they may per-
ceive greater stigma, based on reactions they have experienced from others.
Which model is supported by data? Rae Olmsted and colleagues compare per-
ceptions of stigma among soldiers in treatment and those not in treatment.
Their findings, which suggest that the very people who need treatment the most
may be least likely to seek it, have important implications for efforts to encour-
age treatment.

Attitudes toward treatment among active duty servicemembers are understand-
ably influenced by the military environment in which they live and work. But what
factors prevent veterans from seeking care? Kim and colleagues examine negative
beliefs about treatment and the impact of those beliefs on treatment-seeking be-
haviors among veterans of Iraq and Afghanistan operations. Their results may
guide efforts to reduce negative attitudes that may keep veterans from seeking
needed care.

STIGMA, MENTAL HEALTH, AND SUBSTANCE ABUSE 3

Conceptual theories and paradigms can often be used to understand and address
complex social and behavioral phenomena. Britt and colleagues propose the the-
ory of planned behavior as a useful tool for application to this difficult question.
They analyze data from a survey of Reserve Component veterans to identify be-
liefs about psychological problems and attitudes toward treatment. Their findings
are discussed in terms of novel interventions that can be used to modify percep-
tions of behavioral health problems.

Negative attitudes toward treatment seeking are frequently based on soldiers’
perceptions of how others will respond to their treatment status. Gibbs and col-
leagues look at an innovative pilot program that combats stigma by offering sol-
diers treatment for alcohol abuse without command notification. These prelimi-
nary data suggest that the option of confidentiality may encourage self-referral to
services among soldiers who are motivated to seek treatment.

As evidenced in the articles in this issue, stigma in any form is a problem for
the military because it potentially diminishes individual and unit effectiveness.
Moreover, if stigma creates a barrier to treatment, dramatic changes will be re-
quired to make it acceptable for servicemembers to receive treatment. One effort
has already taken hold: rewording questions for security clearances to make it
less damaging for a servicemember to have received counseling for substance
abuse issues. Similarly, the innovative confidential treatment pilot initiated in
July 2009 has seen success in the number of soldiers coming forward for help
(Steele, 2010). The vision for future service delivery and policy may include sep-
arating treatment from the commander’s use of military discipline for substance
abuse infractions. This is a worthy goal because it would pave the way to reduc-
ing stigma and would foster a supportive environment for soldiers asking for and
receiving assistance.

Effectively removing barriers to treatment will also entail a change in military
culture. It will take time to establish the belief, beginning in basic training, that it
takes courage to ask for help. Doing so will require all military leaders to take posi-
tive, progressive, and consistent steps to remove stigma for those seeking help
with a problem. The military has led the civilian world in addressing prejudice in
other areas, such as desegregating the military force and becoming a champion of
equal opportunity (Moskos, 1966). Time will tell whether we can achieve the so-
cial, policy, and cultural challenges necessary to reduce stigma for substance
abuse and mental health treatment.

REFERENCES

Corrigan, P. W. (2000). Mental health stigma as social attribution: Implications for research methods
and attitude change. Clinical Psychology – Science and Practice, 7(1), 48–67.

4 MCFARLING ET AL.

Corrigan, P. W., & Watson, A. C. (2002). The paradox of self-stigma and mental illness. Clinical Psy-
chology – Science and Practice, 9(1), 35–53.

Department of the Army, Chief of Staff. (1985). Letter, 25 March 1985, subject: Department of the
Army Alcohol Policy. Washington, DC: Author.

Department of the Army. (2009). Army Substance Abuse Program (ASAP): Army Regulation 600-85.
Washington, DC: Author.

Dickstein, B. D., Vogt, D. S., Handa, S., & Litz, B. T. (2010). Targeting self-stigma in returning mili-
tary personnel and veterans: A review of intervention strategies. Military Psychology, 22(2),
224–236.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Com-
bat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal
of Medicine, 351(1), 13–22.

Moskos, C. C., Jr. (1966). Racial integration in the Armed Forces. The American Journal of Sociology,
72(2), 132–148.

Science Applications International Corporation. (2010). Stigma associated with seeking behavioral
health care: Reducing stigma/assessing efforts to reduce stigma. Washington, DC: Author.

Steele, D. (2010). Inspired care for the invisible wounds. Army: The Magazine of the Association of the
United States Army, 60(7), 65–67.

Vogel, D. L., Wade, N. G., & Haake, S. (2006). Measuring the self-stigma associated with seeking psy-
chological help. Journal of Counseling Psychology, 53(3), 325–337.

Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and the willingness to
seek counseling: The mediating roles of self-stigma and attitudes toward counseling. Journal of
Counseling Psychology, 54(1), 40–50.

STIGMA, MENTAL HEALTH, AND SUBSTANCE ABUSE 5

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American Journal of Psychiatric Rehabilitation

ISSN: 1548-7768 (Print) 1548-7776 (Online) Journal homepage: http://www.tandfonline.com/loi/uapr20

Attitudes Towards Employment and Employment
Outcomes Among Homeless Veterans with
Substance Abuse and/or Psychiatric Problem

ALVIN S. MARES & ROBERT A. ROSENHECK

To cite this article: ALVIN S. MARES & ROBERT A. ROSENHECK (2006) Attitudes Towards
Employment and Employment Outcomes Among Homeless Veterans with Substance Abuse
and/or Psychiatric Problems, American Journal of Psychiatric Rehabilitation, 9:3, 145-166, DOI:
10.1080/15487760600961451

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Attitudes Towards Employment and
Employment Outcomes Among
Homeless Veterans with Substance
Abuse and=or Psychiatric Problems

Alvin S. Mares and Robert A. Rosenheck

Northeast Program Evaluation Center, VA Connecticut
Healthcare System, West Haven, Connecticut, USA and
Department of Psychiatry, School of Medicine, Yale
University, New Haven, Connecticut, USA

This study examines the relationship between attitudes towards employment
and employment outcomes among homeless veterans with psychiatric and
substance abuse problems. Attitudes towards employment among over 300
homeless veterans participating in a study of vocational outcomes were char-
acterized using factor analysis. Mixed linear regression was then used to
examine the association between each of five employment attitudes and num-
ber of days employment throughout the two-year follow-up period, net of
potentially confounding baseline characteristics.

Veterans who worked more than others scored higher on a subscale
reflecting favorable attitudes towards work and, unexpectedly, on a subscale
indicating that they did not like the kind of jobs they could obtain. In contrast,
veterans who scored higher on a subscale indicating that they perceived work
as helpful in coping with mental health problems, worked more days than
others. However, the magnitude of these effects was small, explaining only
an additional 1% of the variation in employment outcomes observed
(R-squared) beyond the 10–16% of variation accounted for by client demo-
graphic and clinical characteristics at program entry. Measured attitudes only
weakly predicted employment outcomes, thus supporting the policy of
offering vocational assistance to all who express interest in it.

Address correspondence to Alvin S. Mares, Northeast Program Evaluation Center (182), VA
Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA. E-mail:
alvin.mares@yale.edu

145

American Journal of Psychiatric Rehabilitation, 9: 145–16

Taylor & Francis Group, LLC # 2006

ISSN: 1548-7768 print=1548-7776 online

DOI: 10.1080/15487760600961451

Keywords: Employment outcomes; Homelessness; Mental illness; Veterans; Vocational

rehabilitation

There has been considerable interest in recent years in helping
individuals with psychiatric and substance abuse problems
return to competitive employment (Priebe, Warner, Hubschmid,
& Eckle, 1998). Enhanced vocational rehabilitation treatment
has been found effective in developing job skills and molding
attitudes necessary to attain employment or entry into more
intensive vocational rehabilitation (Blankertz & Robinson, 1996).

As part of these efforts, several studies have examined the relation-
ship of pretreatment attitudes towards employment on employment
outcomes. In a randomized clinical trial of family psychoeducation
for persons with schizophrenia, those who expressed a desire to work
at baseline were found to be one and a half to three times more likely
to be employed at one- and two-year follow-up than those who
expressed no desire to work at baseline (Mueser, Salyers, & Mueser,
2001). Among those who expressed no interest in working, 10–11%
were employed at one- and two-year follow-up, compared with
31%–32% of those who expressed interest in working and had made
efforts to find work at baseline, and 14–20% of those who expressed
interest in working but had not made any efforts to find work at base-
line. Thus, both expressed interest in working and participants’ recent
efforts to find work at baseline were significantly associated with
being employed one to two years thereafter.

In contrast to the traditional approach that prepares people for
the job market by developing job readiness and preparedness skills,
and offering pre-employment training experiences, recently
developed models of supported employment such as the Individual
Placement & Support (IPS) model emphasize rapid placement
directly into competitive jobs with individualized support and
on-the-job training as-needed (Becker & Drake, 1993; Becker &
Drake, 1994; Drake & Becker, 1996; Drake, 1998). Advocates of this
approach generally believe that it can work for most persons with
serious mental illness and thus seek to operate with minimal
exclusion criteria (Gervey, Parish, & Bond, 1995; Bond, Becker,
Drake, & Vogler, 1997; Bond, 1998; Bond et al., 2001). Underlying
this ‘‘no rejection’’ policy is the assumption that employment out-
comes are, for the most part, unpredictable and thus there is no rea-
son to target supported employment to specific subpopulations.

146 A. S. Mares and R. A. Rosenheck

One of the only studies to empirically test this ‘‘no rejection’’
approach to vocational rehabilitation was part of the U. S. Depart-
ment of Health & Human Services Substance Abuse Mental Health
Services (SAMHSA) Employment Intervention Demonstration
Program (EIDP) (Center for Mental Health Services, 2005). Among
166 unemployed adults with serious mental illness enrolled at the
two sites in Worchester, Massachusetts and randomly assigned
supported employment, 30% expressed no interest in getting a
job at baseline (Macias, DeCarlo, Wang, Frey, & Barreira, 2001).
The competitive employment rate two and a half years after the
start of the EIDP project among those not interested in working
was 29%, compared to 51% among those who expressed interest
in working at baseline. Competitive employment rates were higher
for both uninterested (48%) and interested (68%) groups who
became engaged in vocational treatment after entering the pro-
grams. Thus, both interest in work and engagement in vocational
treatment were found to be positively associated with attaining
subsequent competitive employment. While general interest in
work is thus strongly associated with employment outcomes, no
study has examined whether subtleties in work attitudes among
people who express interest in work predict vocational outcomes.

The Therapeutic Employment Placement and Support (TEPS

)

Program is a multisite, nonexperimental clinical demonstration
project study of vocational outcomes among over 300 recently
homeless veterans with psychiatric and substance abuse problems
who expressed interest in employment at the time of program
entry. TEPS was ultimately designed to evaluate the effectiveness
of the IPS model of vocational rehabilitation (Becker & Drake,
1993, 1994; Drake & Becker, 1996) among homeless veterans receiv-
ing health care services through the Veterans Health Administra-
tion, and referral to more conventional (non-IPS) vocational
rehabilitation services (Drebing et al., 2002; Drebing, Rosenheck,
Schutt, Kasprow, & Penk, 2003; Kashner et al., 2002; Rosenheck &
Seibyl, 2005). Outcomes of a sample of veterans who did not have
access to IPS will eventually be compared to outcomes of a cohort
who received IPS services at the same site.

This report uses data from TEPS, including information on
attitudes towards work and employment outcomes systematically
collected over a two-year follow-up period, which are examined
for the purposes of (1) characterizing attitudes towards work and
their correlates, and (2) examining the association between attitudes

Attitudes Towards Employment 147

towards work and employment outcomes, independent of other
factors.

We thus seek to extend the lessons learned from previous
empirical studies (Mueser et al., 2001; Macias et al., 2001) by exam-
ining the association of a more specific set of employment attitudes
on both noncompetitive and competitive employment outcomes
among a more general population of homeless veterans with sub-
stance abuse and=or psychiatric problems who expressed interest
in obtaining employment.

METHOD

Participants

Participants in this study were homeless veterans receiving a range
of medical, psychiatric, substance abuse, and vocational rehabili-
tation services normally available through local Veterans Associ-
ation (VA) medical centers. Most were recruited through the
Healthcare for Homeless Veterans program at each site, which
operated homeless outreach teams and which facilitated access to
available VA physical health, mental health, substance abuse treat-
ment, housing, and vocational rehabilitation services using a bro-
kered case management model.

Most participants were male (93%), 46 years of age, and had
some college education. Over 60% were non-Caucasian (58% Black
and 4% Hispanic). Two-thirds (67%) had been married previously,
in contrast to only 5% that were married upon entry into the pro-
gram. On average, participants’ total monthly income was just
under $875 per month. They worked an average of eight days a
month—five days in competitive jobs and three days in noncompe-
titive jobs (Table 1). The sociodemographic characteristics of this
sample of homeless veterans were comparable to those reported
in previous studies of homeless veterans (Leda & Rosenheck,
1992; Rosenheck, Frisman, & Gallup, 1995).

The sample for this study only included all veterans enrolled into
the usual care pre-IPS cohort of the TEPS program (N ¼ 309). Thus,
subjects in this study received usual health care and vocational
rehabilitation services from the VA, while each site was preparing
to implement the IPS-like model of vocational rehabilitation (i.e.,
the ‘‘TEPS’’ program). Participants in the IPS implementation group
were excluded from the analyses presented here because all were

148 A. S. Mares and R. A. Rosenheck

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151

enrolled in supported employment, which could confound the natu-
ralistic examination of the relationship between attitudes towards
employment and employment outcomes.

Participants were recruited through VA homeless outreach pro-
grams located at VA medical centers in Augusta, GA; Cincinnati,
OH; Dallas, TX; Houston, TX; Los Angeles, CA; Pittsburgh, PA;
Rochester, NY; Tampa, FL; and West Haven, CT.

Eligible veterans were (1) currently homeless, (2) not currently
receiving VA health services, (3) expressed some interest in seeking
competitive employment, and (4) agreed to be interviewed quar-
terly during a two-year follow-up period by VA research staff. Part-
icipants were considered currently homeless if they had an intake
assessment from a specialized VA homeless program in the pre-
vious 90 days. Interest in competitive employment was assessed
by asking prospective participants, ‘‘Are you interested in working
for pay in the community—somewhere other than at the VA?’’ Indi-
viduals who responded ‘‘yes’’ to this question and presented to the
interviewer as being genuinely interested in the possibility of com-
petitive employment were eligible.

Baseline interviews were administered by independent research
assistants, lasted an average of one and a half hours, and consisted
of approximately 200 questions covering demographic characteris-
tics, physical and mental health status, housing, military status and
perceived risk of homelessness post-discharge, and other infor-
mation. Patients gave written informed consent and were paid
$10.00 for their time. Institutional Review Board approval was
obtained at the authors’ parent institution and at each of the nine
VA medical center facilities participating in the study.

Measures

Adjustment to community living was measured by the size of social
support networks and by lifetime incarceration. Clients were asked
how many people they felt close to in each of nine relationship cate-
gories (e.g., parents, siblings, friends, health care providers). A con-
tinuous social support variable was computed by summing the
number of persons in each of these nine relationship categories,
indicating the total number of persons to whom the client felt close.

Clinical status items included psychiatric diagnoses, symptoms,
medication, lifetime psychiatric hospitalization, substance abuse,
and physical health. Primary psychiatric diagnoses were based on

152 A. S. Mares and R. A. Rosenheck

clinical assessments by homeless outreach staff. Subjective distress
was measured with 33 items from the SCL-90 (Derogatis, 1993).
Further questions addressed use of medication, side effects, and
past hospitalization. Use of alcohol and illicit drugs was assessed
using composite indexes from the Addiction Severity Index
(McLellan, Luborsky, & Woody, 1980). Clients rated their physical
health using a five-point scale (Lehman, 1988) and identified the
number of physical health problems out of a possible 13 conditions
for which they had received treatment (including the taking of pre-
scribed medication) during the past 60 days. A chronic medical
problems index was created by summing client responses to each
of these 13 conditions, which included 0 ¼ no problem, 1 ¼ had
problem but received no treatment, and 2 ¼ had problem and
received treatment. Thus, the medical problems scale ranged from
0 to 26 points.

Sociodemographic and clinical status data were collected at base-
line and then used to predict longitudinal employment outcomes
data.

Employment Outcomes

Employment outcomes were represented by the number of days in
the past 30 in which the veteran worked in any employment, com-
petitive employment, and noncompetitive employment. Competi-
tive employment was defined as ‘‘working for pay at a regular
job.’’ Noncompetitive employment was defined as either ‘‘working
for pay at a casual, irregular, or temporary job’’ or ‘‘working in a
work therapy program.’’ Any employment was defined as the total
number of days worked in either competitive or noncompetitive
employment.

Employment outcome data were collected quarterly over a two-
year follow-up period after entering the program

Analyses

First, factor analysis was used to identify and create measures for
the five attitudes towards employment—the primary inde-
pendent variables of interest. The mean score for all items
belonging to a given factor (employment attitude) was then used
as an independent variable in subsequent multivariate analyses.
Thus, there were five primary independent variables of

Attitudes Towards Employment 153

interest—a mean score for each type of employment attitude
identified through factor analysis. Then ordinary least squares
linear regression was used to identify correlates of each attitude
towards employment. Five regression models (one for each
employment attitude) used the same 32 baseline characteristics
(14 sociodemographic measures, 13 health status measures, three
measures of community adjustment, and two measures of inter-
est in vocational treatment) that were entered as blocks, using
stepwise entry method to identify a parsimonious set of baseline
characteristics significantly associated with each employment
attitude The inclusion and exclusion criteria for both selecting
and removing variables was p < .10.

Next, bivariate mixed model regression analyses were used to
identify baseline characteristics associated with the three longi-
tudinal, continuous measures of employment outcomes (days
employment)—the dependent variables in this study. The mixed
models are referred to as ‘‘bivariate’’ analyses because no covari-
ates were included; rather, each baseline characteristic was
regressed exclusively on each dependent variable using mixed
model regression.

Finally, multivariate analyses were used to examine the associ-
ation of attitudes towards employment and employment outcomes,
net of baseline characteristics correlated with each employment
outcome.

To examine factors significantly associated with longitudinal
employment, repeated-measures with mixed-effects analytic strat-
egy was used to adjust for potentially confounding covariates
identified previously. This method was chosen to allow use of all
available data from each client during each quarterly follow-up
interval over the two-year follow-up period. The repeated-mea-
sures mixed-effects model approach was chosen because it allowed
comparison of client employment outcomes averaged across all
points in time (i.e., area under the curve) and adjusted for the cor-
relation of data within subjects. These analyses were conducted
using the MIXED procedure of SPSS 11.0 (SPSS Incorporated,
Chicago, IL, 2001), with alpha <.05. Unstandardized regression coefficients are reported.

Ordinary least squares regression multiple r-squared statistics
were also used to estimate the proportion of variance in employ-
ment outcomes explained by employment attitudes beyond that
of baseline characteristics.

154 A. S. Mares and R. A. Rosenheck

RESULTS

Employment attitude data were complete, so the number of cases
included in this factor analysis was 309—the total sample size.

Attitudes Towards Work

A factor analysis of the 21 attitudes towards work items (varimax
rotation) produced a five-component solution in which 19 of
21 items had loading scores of .50 or higher. These five types of
employment attitudes included both positive and negative atti-
tudes, with both internal (inward) and external (outward)
focus=locus of control (Table 2). The ‘‘I can’t work’’ attitude
reflected various reasons why clients felt they were unable to work,
such as being too old or too sick to work, and being too nervous and
tired to work in a work rehabilitation program. This first factor
explained 15% of the variation observed among employment atti-
tude items. In contrast, factors two and three characterized clients
as wanting to work, and viewing work as helpful in coping with
problems, respectively. These two positive factors each explained
10% of the variance among items observed.

Interitem reliability analyses of these first three factors having an
internal focus (locus of control) confirmed internal consistency
among included items, which loaded 0.43 to 0.74. Cronbach alpha
values ranged from .61 to .77 (Table 2).

Like the first factor, the last two factors represented negative
attitudes towards work. In contrast, each exhibits an external locus
of control. The fourth factor, ‘‘I don’t like the jobs I get,’’ was gen-
erally pessimistic regarding the availability of jobs and the effec-
tiveness of work rehabilitation programs. The fifth attitude
towards work found was ‘‘Others expect me to work,’’ expressed
concern that others would view the client negatively if he=she
did not work. While factor loadings for these two negative cate-
gories were generally high (0.53 to 0.74), interitem reliability analy-
ses indicated less cohesiveness among items within these two
factors (with Cronbach alphas of .39 and .55). These two factors
explained an additional 18% of variation among employment atti-
tude items.

Mean subscale scores ranged from 1.70 for the ‘‘can’t work’’ fac-
tor to 3.60 for the ‘‘wanting to work’’ factor, on a scale from 1
(strongly disagree) to 4 (strongly agree) (Table 2). Bivariate

Attitudes Towards Employment 155

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157

correlations among subscales ranged from an absolute value of .01
to .44. Of the ten inter-correlations, three were less than .10, two
were between .10 and .19, two fell between .20 and .29, one fell
between .30 and .39, and two were between .40 and .44.

Correlates of Employment Attitudes

Clients who viewed themselves as being unable to work had less
education were more likely to be planning to apply for disability
benefits, have a personality disorder, have more serious psychiatric
problems, and have criminal records than other clients (Table 1). In
contrast, clients viewing themselves as capable of working and
wanting to work were younger, less likely to be planning to apply
for disability benefits, less likely to have a diagnosis of schizo-
phrenia, and had fewer psychiatric problems.

Clients who viewed employment as a means of helping to cope
with their problems, those dissatisfied with the types of job
they obtained in the past, and those who felt pressured to work
by others were more distressed by psychiatric symptoms than
other clients. Those viewing employment as a means of coping
with problems also expressed greater interest in receiving tra-
ditional vocational treatment, in contrast to those dissatisfied with
past jobs who expressed less interest in receiving such treatment
(Table 1).

Baseline Correlates of Employment Outcomes

Clients who were younger, male, single, recently housed, and who
had worked more days at the time of entering the program (i.e., at
baseline) worked a greater number of days during the two-year
follow-up period than other clients (Table 3). In contrast, those
who were either intending to apply or were already receiving dis-
ability benefits at program entry were less likely to work through-
out the two-year follow-up period. Clinically, clients diagnosed
with a serious mental illness, those experiencing subjective distress
due to psychiatric symptoms, and those having more serious
psychiatric problems were also less likely to work, whereas clients
having substance abuse problems and those in better physical
health were more likely to work.

Somewhat surprisingly, clients who experienced less stability
in their family of origin and those having less current social support

158 A. S. Mares and R. A. Rosenheck

TABLE 3. Bivariate correlates of baseline characteristics and longitudinal (two-year)
employment outcomes (Regression coefficients from bivariate mixed regression
models, without the inclusion of any covariates)

No. of Days
Any Type Work

(N ¼ 298)

# Coefficient

No. of Days
Competitive

Work

(N ¼ 302)
Coefficient

No. of

Days
Non-Competitive

work
(N ¼ 298)

# Coefficient

Sociodemographics

Age �0.08�� 0.09�� 0.01
Male 5.80�� 3.51�� 2.20��

Race=ethnicity
Caucasian �0.05 �0.05 �0.26
Black 0.02 �0.02 0.18
Hispanic �0.47 0.23 0.05

Marital status
Married �3.88�� 2.41�� 1.53�
Divorced=widowed �0.01 0.45 �0.43
Single (never married) 1.04� 0.14 0.88�

Education (yrs.) 0.10 0.25� �0.16
Days homeless (past 30) �0.02� �0.04�� 0.02��
Duration of homelessness

Less than six months 0.03 0.06 �0.06
6–12 months �1.11 �1.01 0.11
>one year 0.44 0.36 0.01

Quality of life
(overall) (1–7)

�0.05 �0.11 0.14

Intending to apply
for disability

�6.70�� 4.09�� 2.26��

Receiving disability
benefits

�6.78�� 4.21�� 2.22��

Disability income �0.001� �0.001� �0.00004
Total income (past 30) 0.001�� 0.001�� 0.0001
Days competitive work

(past 30)
0.17�� 0.23�� 0.08��

Days noncompetitive
work (past 30)

0.15�� 0.04 �0.25��

Days work (any)
(past 30)

0.26�� 0.19�� 0.11��

Health status

Diagnoses
Schizophrenia �0.05�� 0.03 �0.03�
Mood disorder �1.17� �0.90� �0.31
PTSD �1.37 �0.83 �0.29

(Continued)

Attitudes Towards Employment 159

were more likely to work than other clients. One possible
explanation for this is that clients with smaller social support net-
works have fewer people whom they can depend on to provide
assistance when needed, and thus may have greater motivation in
finding employment to support themselves.

TABLE 3. Continued

No. of Days
Any Type Work

(N ¼ 298)
# Coefficient

No. of Days
Competitive
Work
(N ¼ 302)
Coefficient
No. of Days
Non-Competitive
work
(N ¼ 298)
# Coefficient

Personality disorder �1.21�� 2.06�� 0.53
Substance abuse
(Alcohol or drug)

0.05 0.01 0.17

Symptom burden
(SCL–30=0–4)

�1.06�� 0.92�� 0.25

Mental health status
(SF–12=0–100)

0.06�� 0.05�� 0.01

Psychiatric problems
(ASI-psych=0–1)

�2.76�� 2.51�� 0.58

Drug problems (ASI-drug=0–1) 3.54� 2.01 1.12
Alcohol problems

(ASI-alcohol=0–1)
1.80� 0.54 1.05

Used alcohol (past 30) 0.97� 0.17 0.79�

Days used alcohol 0.08�� 0.02 0.04��

Used illicit drugs (past 30) 0.28 �0.36 0.67�
Days used drugs �0.04 �0.04 0.00

Physical health status
(SF–12=0–100)

0.13�� 0.10�� 0.02

Community adjustment

Family instability (0–14) 0.18� 0.11 0.03
Ever arrested & charged 1.04 1.25� �0.41
Social support (0–10) �0.27� �0.16 �0.07
Interest in vocational treatment

Traditional (0–100) �0.01 �0.01 0.002
IPS (0–100) 0.01 0.01 0.01

# Noncompetitive employment outcome data were missing for four participants

(e.g., 304�4 ¼ 298).
�p < .05. ��p < .01. ��p < .001.

160 A. S. Mares and R. A. Rosenheck

Multivariate Analysis of Predictors of Employment

Eighteen baseline characteristics bivariately found to be associated
with employment outcomes (Table 3) were included in multivariate
regression models (Table 4). These included age, gender, marital
status, educational attainment, length of most recent period of
homelessness, lifetime incarceration, disability status, income, psy-
chiatric diagnosis, subjective distress=burden caused by psychiatric
symptoms, mental health status, psychiatric problems, and physical
health status.

After adjusting for these 18 potentially confounding baseline
characteristics, four attitudinal factors remained significantly
associated with overall employment: two with competitive employ-
ment, and one with noncompetitive employment (Table 4).
Veterans who worked more than others scored higher on a subscale
reflecting favorable attitudes towards work and, unexpectedly, on a
subscale indicating that they did not like the kind of jobs they could

TABLE 4. Association of attitudes towards employment and longitudinal (two-year)
employment outcomes (adjusting for potential confounding baseline client
chartacteristics)

Attitudes towards
employment

Days Any
Employment

(N ¼ 302)
Coefficient

Days Competitive
Employment

(N ¼ 302)
Coefficient
Days
Non-Competitive

Employment
(N ¼ 302)
Coefficient

I can’t work �1.45� �1.02 �.18
I want to work 1.51� .84 .35
Work helps me cope

with my problems
�1.68�� 1.19�� .20

I don’t like the jobs that I get .71� .60� <�.01 Others expect me to work .72 �.09 .58�

Incremental R-squared #
Demographic &

clinical characteristics
.169 .132 .104

Employment attitudes .013 .009 .004

# Calculated using linear regression in which all potentially confounding baseline

characteristics were entered as first block of predictors, followed by all five employ-

ment attitude factors as second set of predictors.
�p < .05. ��p < .01. ��p < .001.

Attitudes Towards Employment 161

obtain. Perhaps the actual stressors of working more than offset the
perceived coping and related mental health-promoting advantages
of working, resulting in these clients working less throughout the
entire two-year follow-up period.

In contrast, veterans who scored higher on a subscale indicating
that they perceived work as helpful in coping with mental health
problems, worked more days than others. Given the relatively
low-pay, and high-demand jobs that formerly homeless indivi-
duals with psychiatric and substance abuse problems are likely
to attain, it is plausible that clients might not like such jobs, but
perhaps had to work at them to support themselves. Clients
who felt obliged to work due to expectations of family members
and friends worked more days than other clients who were in
noncompetitive jobs only.

However, the magnitude of these effects was small, explaining
only an additional 1% of the variation in employment outcomes
observed (R-squared) beyond the 10–17% of variation accounted
for by client demographic and clinical characteristics at program
entry (Table 4).

DISCUSSION

These findings provide support for those advocating minimal
inclusion and exclusion criteria for vocational rehabilitation ser-
vices for persons with psychiatric and substance abuse problems
who express interest in seeking competitive employment. Although
attitudes towards employment were found to be significantly asso-
ciated with employment outcomes, the effect sizes were small and
together explained about 1% of the variance in the number of days
worked over the two years following entry into the program.

Additionally, few nonattitudinal client characteristics were
found to be significantly associated with employment outcomes;
although, significant effects were noted for the number of days
worked during the month prior to entering treatment, intended
application or receipt of disability benefits, and levels of mental
and physical health functioning. These and other client characteris-
tics accounted for 15% of the variation observed in the number of
days worked overall, and suggest that the possibility of predicting
which clients will be more likely to attain employment after enter-
ing treatment is quite limited.

162 A. S. Mares and R. A. Rosenheck

Although employment rates were not the dependent variable
used in this study and in the bivariate and multivariate analyses
presented above, we calculated one- and two-year employment
rates among this sample to allow for comparison with previous
empirical studies examining the association of employment
attitudes on employment outcomes. Among the 215 clients for
which 12-month employment outcome data were available, 37%
were competitively employed and 23% were noncompetitively
employed. Employment rates decreased to 27% and 20%, respect-
ively, at 24-month follow-up, among the 205 clients for which
employment data were available.

Competitive employment rates averaging around 30% observed
among this sample of homeless veterans were comparable to those
of persons with schizophrenia treated in a family psychoeducation
program who expressed interest in work and who made efforts
to find work, but who did not receive supportive employment
(Mueser et al., 2001). Yet, these rates were well below those of per-
sons with serious mental illness randomly who were randomly
assigned to one of two widely implemented service models—a Pro-
gram of Assertive Community Treatment or a club-house program
certified by the International Center for Clubhouse Development,
Inc.—each of which includes vocational rehabilitation treatment
components. Employment rates in these two programs ranged from
50% among those who expressed no initial interest in work to 68%
among those interested in work (Macias et al., 2001).

Furthermore, the employment rates reported here are also less
than the 40–60% range of employment rates among people with
serious mental illness receiving supported employment as reported
in a recent review of the supported employment outcomes litera-
ture (Bond, 2004).

Limitations

The major limitation of this study is its limited generalizability. The
unavailability of comparable data from domiciled veterans, the
inclusion of only homeless veterans receiving VHA treatment,
and those who expressed interest in obtaining competitive employ-
ment limit the generalizability of these findings beyond formerly
homeless veterans with psychiatric and substance abuse problems
receiving services from the VHA who are interested in seeking
competitive employment. Also, the findings of this study may not

Attitudes Towards Employment 163

apply to vocational rehabilitation programs based on supported
employment or IPS models.

In addition, our measurement of employment attitudes was
based on the limited items developed for the Social Security
Administration’s Project NetWork. A wider range of items, such
as the 43-item Employment Readiness Scale (Alfano, 1973), might
have more successfully predicted employment outcomes.

Furthermore, the validity of self-report measures and clinician-
rating=observation measures (e.g., diagnosis) is uncertain.

Finally, any comparison of findings from this study to previous
studies of supported employment among people with serious men-
tal illness must acknowledge important differences in the target
population.

CONCLUSION

Attitudes towards employment are significantly associated with
employment outcomes, albeit of small magnitude. Further examin-
ation of factors associated with employment outcomes, as well as
other therapeutic outcomes, may eventually assist vocational
rehabilitation specialists and program managers in matching sub-
groups of mental health consumers with various approaches to
vocational treatment, but at present these data support the policy
of offering vocational assistance to all who express an interest in it.

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