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Case Report of Integrated Supported Employment for a Person With Severe Mental Illness

KEY WORDS•  employment, supported•  interpersonal relations•  mentally ill persons•  rehabilitation, vocational•  social adjustment

Ashley S. M. Chan, MPhil, HKROT, is Occupational Therapist, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong.

Hector W. H. Tsang, PhD, OTR, is Associate Professor, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong; rshtsang@inet.polyu.edu.hk

Sally M. Y. Li, HKROT, is Occupational Therapist, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong.

OBJECTIVE. We illustrate the implementation of an integrated supported employment (ISE) program that augments the individual placement and support model with social skills training in helping people with severe mental illness (SMI) achieve and maintain employment.

METHOD. A case illustration demonstrates how ISE helped a 41-year-old woman with SMI to get and keep a job with support from an employment specialist. An independent, blinded assessor conducted data collection of employment information, including self-efficacy and quality of life, at pretreatment and at 3-month, 7-month, 11-month, and 15-month follow-up assessments.

RESULTS. The participant eventually stayed in a job for 8 months and reported improved self-efficacy and quality of life.

CONCLUSION. The case report suggests that ISE could improve the employment outcomes of people with SMI. Moreover, changes in the participant’s self-efficacy and quality of life were shown to be driven by the successful employment experience.

Chan, A. S. M., Tsang, H. W. H., & Li, S. M. Y. (2009). Case report of integrated supported employment for a person with severe mental illness. American Journal of Occupational Therapy, 63, 238–244.

Ashley S. M. Chan, Hector W. H. Tsang, Sally M. Y. Li

Employment plays an important role in the rehabilitation of people with severe mental illness (SMI). Apart from generating income, work is associated with

positive mental health because it provides opportunities for skills development, social contacts, and participation in the community (Ruesch, Graf, Meyer, Rossler, & Hell, 2004). People with SMI are known to have a diminished self-concept and a distorted sense of self-efficacy (Davidson & Strauss, 1992). Strong (1998) found that the act of working is powerful in creating and facilitating change in a person’s self-concept and self efficacy. Strong (1998) concluded that one way to facilitate recovery is to help people with mental illness link meaningful occupations and experience challenges and successes in the context of meaningful work. Obtaining and maintaining employment are difficult for people with SMI, however, as reflected in findings that only 15% to 30% of adults with SMI are employed (Anthony, Cohen, Farkas, & Gagne, 2002; Equal Opportunities Commission, 1997; Rosenheck et al., 2006). The individual placement and support (IPS) approach, a specific model of supported employment, is an evidence-based vocational rehabilita-tion approved for people with SMI (Bond, 2004; Crowther, Marshall, Bond, & Huxley, 2001; Drake & Becker, 1996; Drake, McHugo, et al., 1999; Lehman et al., 2002). This approach assists people with psychiatric disabilities with rapidly and directly obtaining competitive employment (Drake & Becker, 1996). With the introduction of IPS, the employment rate of people with SMI was reported to reach 56% (Bond, 2004). IPS, however, has limitations in helping employed participants sustain their jobs (Drake, Becker, Clark, & Mueser, 1999; Tsang, 2003; Twamley,

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Jeste, & Lehman, 2003; Wallace, Tauber, & Wilde, 1999). Researchers have suggested that further improvements should be made so that IPS will result in more positive out-comes and long-term employment (Cook et al., 2005; McGurk, Mueser, & Pascaris, 2005; Twamley et al., 2003; Wallace et al., 1999).

Integrated Supported Employment ApproachPeople with schizophrenia and other forms of SMI have deficits in social functioning (Bond, Drake, & Becker, 1998). The literature has documented that social competence is one of the most significant and consistent predictors of employ-ment outcome among people with mental illness (Tsang, Lam, Ng, & Leung, 2000). Moreover, problems with job retention have been found to be related to social functioning. Studies have shown that interpersonal difficulty is the most frequently reported job problem (58%; Becker et al., 1998; Mak, Tsang, & Cheung, 2006). Tsang (2003) therefore developed the integrated supported employment (ISE) approach to help people with SMI acquire the social skills necessary in the workplace and also to support them in obtaining and maintaining competitive employment. The service protocol consists of two basic intervention compo-nents: IPS and work-related social skills training (WSST; Tsang & Pearson, 1996).

In a randomized controlled trial, Tsang (2007) found that significantly more ISE participants (78.8%) than IPS participants (53.6%) obtained competitive employment. In addition, ISE participants worked longer than IPS partici-pants (25.12 weeks vs. 11.95 weeks, respectively) after 15 months’ follow-up service. This study bolstered our hypoth-esis that ISE participants would have better vocational out-comes than IPS participants. Because ISE has been shown to be effective in developing social skills and improving voca-tional outcomes, it likely exerts a positive impact on the recovery process of people with mental illness.

ISE ProtocolThe implementation of ISE follows the steps of a typical IPS program (Becker & Drake, 1993). WSST is provided to ISE participants before they obtain employment. In addi-tion to the WSST sessions, a skills generalization approach is used throughout the follow-up process. The skills gener-alization approach places special emphasis on providing assistance to participants in developing and maintaining good and cooperative working relationships with their supervisors, fellow workers, and customers. The ISE proto-col is shown in Figure 1.

Although ISE has been empirically tested (Tsang, 2007), this testing does not mean its innovative protocol translates automatically into clinical practice. This article illustrates with a case vignette how an employment specialist helped a participant go through different stages of the ISE service and supported her in obtaining and maintaining competitive employment. We hope this article serves as an exemplary case that rehabilitation professionals such as occupational therapists, psychologists, and social workers will consult when applying ISE in their settings.

Case DescriptionMs. L was a 41-year-old woman who had experienced depression since 1990. She came from a highly educated and middle-income family.

Assessment

An independent assessor unaware of the details of the case conducted data collection. Assessment was conducted at pretreatment, and follow-up assessments were conducted 3, 7, 11, and 15 months after Ms. L participated in ISE service (the protocol has been described in Tsang, 2007). Assessment included the Vocational Social Skills Scale (Tsang & Pearson, 2001), the Chinese Job Stress Coping Scale (Tsang, Chan, Wong, & Liberman, in press), the Personal WellBeing Index (Lau, Cummins, & McPherson, 2005), and the Chinese General Self-Efficacy Scale (Zhang & Schwarzer, 1995). The 10-item Vocational Social Skills Scale measures participants’ perceived competency in handling work-related situations. This checklist has demonstrated good internal consistency (.80) and moderate to very good test–retest reliability (.35 to .78; Tsang & Pearson, 2001). The 21-item Chinese Job Stress Coping Scale assesses participants’ coping strategies when faced with job stress using a 5-point response scale ranging from 1 (hardly ever do this) to 5 (almost always do this). The 9-item Personal WellBeing Index measures par-ticipants’ subjective well-being. This scale has good internal consistency (.80) and structural validity (Lau et al., 2005). The 10-item Chinese General Self-Efficacy Scale assesses participants’ general self-efficacy and has good internal con-sistency (0.92–0.93) and test–retest reliability (0.75–0.94; Zhang & Schwarzer, 1995).

Treatment

Referral. Ms. L was referred to the ISE service of our research team at the Hong Kong Polytechnic University by a nongovernment organization in 2005. On admission, Ms. L had been unemployed for more than 10 years. She did not know how to obtain a job and what kinds of jobs would be suitable for her.

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Figure 1. Protocols of integrated placement and support (IPS) and integrated supported employment (ISE).

Note. WSST = work-related social skills training.

Building a Relationship. In the first meeting, the employ-ment specialist introduced the purposes of ISE service and her role in the service protocol. She explained how ISE could help Ms. L in job hunting and dealing with her difficulties in the workplace.

Vocational Assessment. The employment specialist initi-ated assessment to find out how well Ms. L could work in a competitive job in the community. She focused on under-

standing Ms. L’s educational background, work history, work skills, strengths and weaknesses, and preference. In addition, the employment specialist assessed Ms. L’s social competence in getting and holding a job. According to Ms. L, she had worked as a secretary in a law firm for 2 years after graduation from a university and had no employment record afterward. In this previous job, her main duty was to assist her supervisor in preparing documents. Although she was

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able to cope with her job duties, she had a poor relationship with her coworkers and high anxiety when interacting with them. She often requested urgent leave, which might be interpreted as avoidance behavior, and finally quit her job because of her poor mental state.

The employment specialist also obtained information on Ms. L’s likes, dislikes, and job preferences. Ms. L expressed that she felt easily fatigued and was therefore unable to cope with jobs requiring long working hours and a heavy work-load. She liked following others’ instructions, and she described herself as a hard-working person, but she disliked communication with strangers. She had mastered basic com-puter skills and hoped to find a clerical job. On the Vocational Social Skills Scale, she gave herself ratings ranging from 3 (sometimes difficult) to 1 (always difficult) on most of the 10 items. Items that she rated as “always difficult” included “participate appropriately in a job interview,” “resolve a con-flict with supervisor,” and “resolve a conflict with a col-league.” Her total score on the self-administered checklist was 20, which reflected that she had high social anxiety when talking to others. During the role-play exercise, Ms. L appeared to be nervous and uncomfortable. She paused and hesitated frequently when asked about her work experiences. Ms. L’s total score on the role-play test was 59, suggesting that she had insufficient interpersonal skills in the workplace.

Individual Employment Plan. The employment specialist then formulated an individual employment plan for Ms. L. First, WSST was provided to enhance her social skills. Ms. L expressed that she wanted to obtain a part-time clerical job. The ultimate goal of the individual employment plan was to maintain employment and prolong job tenure.

WSST. Ms. L lacked the necessary social skills and social competence to get and keep a job (Cook & Razzano, 2000; Tsang, 2003; Tsang & Pearson, 2001). Before her job search, Ms. L participated in the manualized WSST (Tsang, 2001) to enhance her ability to seek and maintain employment. WSST consisted of 10 sessions, each lasting from 1.5 to 2 hr, covering basic social and social survival skills, interview skills, and communication skills with supervisor, coworkers, and customers. Each WSST session included warm-up activ-ities, instruction, demonstration, role-playing, feedback, and homework.

Ms. L was attentive and cooperative throughout the WSST. However, she was usually quite passive and did not comment on or join in the discussion with other partici-pants. In the job interview skills session, Ms L was required to look for a job advertisement according to her preference and role-play a job interview exercise. Throughout the pro-cess, Ms. L gradually came to better understand the require-ments of clerical work in the competitive job market. She

finally found a job advertisement for a part-time office assis-tant for which she met all job requirements. Through dem-onstration and modeling, Ms. L was equipped with appro-priate job interview skills and work-related social skills. Ms. L then practiced these skills with the employment specialist so that her social skills could be consolidated and generalized from the WSST sessions to her workplace. Appreciation and encouragement were given to Ms. L after the role-play exer-cises to establish the motivation for learning and applying the skills. Also, the importance and value of work, including better quality of life and a larger social network, were dis-cussed in WSST.

After 10 WSST sessions, Ms. L’s social skills had signifi-cantly improved. Her total score on the self-administered Vocational Social Skills Scale after 10 sessions increased from 20 to 34. She gave herself ratings ranging from 4 (occasionally difficult) to 3 (sometimes difficult) on most of the 10 social skills items. The total score of the role-play test for Ms. L jumped from 59 to 85, signifying improvement in her social competence in the workplace.

Obtaining Employment. The employment specialist regu-larly accompanied Ms. L to the Labor Department to search for job vacancies and encouraged her to apply for jobs in which she was interested. Generalization of the skills learned in WSST was applied to the process of obtaining employ-ment, following the steps set out in Figure 1. She encouraged Ms. L to prepare herself before each job interview by review-ing WSST content regarding job interview skills. Ms. L’s preference was a part-time office assistant position. The employment specialist discussed this preference with Ms. L and set a behavioral goal of performing well during the inter-view and obtaining the job. Through several guided prac-tices, Ms. L became more familiar with the interview process.

Unfortunately, the first interview ended in failure, so Ms. L reviewed her performance with the help of the employ-ment specialist. Ms. L thought the main problem was that she did not know how to respond to the interviewer when asked about her employment history. The employment spe-cialist discussed with her how she could better handle this question and did a behavioral rehearsal with Ms. L.

Six months later in the job-hunting process, Ms. L sought a job as a part-time office assistant. With the job interview skills she learned in WSST and the experience she gained in previous job interviews, she performed well this time, especially when explaining her employment history to the interviewer.

Follow-Along Support. An important task for the employ-ment specialist at this stage is to help clients generalize the social skills learned in WSST and improve their relationships with supervisors and coworkers. This task constitutes one of

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the most important differences between ISE and IPS and accounts for ISE participants’ longer job tenures (Tsang, 2007). The following sections illustrate how the employ-ment specialist helped Ms. L cope with her interpersonal difficulties in the workplace.

Helping Ms. L Improve Her Relationship With Her Supervisor. Ms. L was perplexed by the interpersonal difficul-ties she had with her supervisor. For example, she was unable to finish her job duty because her computer was out of order. Ms. L was so stressed that she cried helplessly in front of the employment specialist and thought of quitting. During their regular meetings, which usually took place at restaurants or parks near Ms. L’s work site, the employment specialist taught her how to report her problem to her supervisor using the social skills acquired in the WSST sessions. The employ-ment specialist first reminded Ms. L of the WSST content regarding communicating with one’s supervisor. She then discussed communication with Ms. L and set a behavioral goal for her to successfully seek the supervisor’s advice. The employment specialist also discussed with Ms. L any appro-priate behavior that would help her achieve the behavioral goal and helped her perform the appropriate behaviors through role play and performance appraisal. After complet-ing guided exercises on several occasions, Ms. L was able to master the social skills to report problems to her supervisor and seek necessary help.

During the follow-along contact, Ms. L reported to the employment specialist that her supervisor understood her difficulties and assigned her to another job duty, thus solv-ing the problem.

Helping Ms. L Improve Her Relationship With Coworkers. To improve her relationship with her coworkers, the employ-ment specialist suggested that Ms. L join them regularly for lunch. She first reviewed the WSST content regarding com-municating with coworkers, then worked with Ms. L to set a behavioral goal of improving her social relationships with coworkers. On the basis of the problems Ms. L faced in the working environment, the employment specialist and Ms. L discussed and identified appropriate behaviors to improve her relationship with coworkers, such as inviting her cowork-ers for lunch.

The employment specialist encouraged Ms. L to imple-ment the social skills learned in the WSST sessions by pro-viding behavioral and performance appraisal. Ms. L expressed

that her main problem was that she had no common topics to talk about with her coworkers. The employment specialist suggested that Ms. L could explore some topics to discuss with her coworkers, including interests, leisure activities, and TV programs. Through guided practice and feedback, Ms. L was able to perform the social skills well. During the follow-up contact, Ms. L expressed that her relationship with coworkers had improved.

Evaluation of ISE Program

After 7 months of the ISE program, Ms. L successfully obtained competitive employment. More important, she was able to work in the same job for 8 months continuously with follow-up support until the ISE was terminated according to our research protocol. Ms. L was satisfied with her job and expressed that she was able to maintain a good relationship with her supervisor and coworkers. Moreover, Ms. L reported that her self-efficacy and personal well-being improved after working as a part-time office assistant. We believe the improvements were supported by changes in the outcome measures (Table 1). Ms. L’s scores suggested that she per-ceived improvement in her job stress coping, personal well-being, and self-efficacy after completing the ISE program.

It is interesting that Ms. L’s personal well-being and self-efficacy improved after she attended the WSST. We believe this improvement was associated with her improved work-related social skills. Ms. L perceived herself as having higher competence in real-life situations. However, Ms. L reported low personal well-being and self-efficacy before she obtained her job in the 7th month, data suggesting that unemployment had adverse effects on her personal well-being and self-efficacy. Because Ms. L had not successfully obtained a job after 4 months of searching, continuity of unemployment might have led to the deterioration of her mental health. Ms. L’s personal well-being and self-efficacy improved after she obtained employment as a part-time office assistant. The job stress coping results are reported at the 11-month follow-up when Ms. L worked as an office assistant. We think the results are accounted for by skills generalization during the ongoing support period that focused on solving Ms. L’s relationship problems with her supervisor and coworkers. This work, in turn, reduced her stress in dealing with interpersonal difficulties in the workplace.

Table 1. Comparison of the Scores at Pretreatment and Follow-Along

Measure Pretreatment 3rd Month 7th Month 11th Month 15th Month

Chinese Job Stress Coping Scale  3.14 2.81 3.19 3.52 3.23Personal WellBeing Index 6.11 7.33 6.44 7.33 7.44Chinese General Self-Efficacy Scale 2.20 2.40 2.30 2.60 2.40

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Conclusion

We demonstrated how ISE was associated with the success of a person with SMI in obtaining and sustaining employment. Although Ms. L had been unemployed for more than 10 years, our innovative ISE approach helped her achieve continuous employment as a part-time office assistant for 8 months.

We propose that the major factor contributing to her successful job search was improved job interview skills, which were essential for getting a job. Participants learned interview skills during the WSST sessions, and Ms. L practiced these skills before attending job interviews. Joining the WSST may also have improved her motivation to gain competitive employment. This finding is consistent with Tsang and Pearson’s (2001) report regarding technical guidance during follow-up services after WSST and its role in helping par-ticipants defuse the potential difficulties and obstacles that reduce job-seeking attempts.

Ms. L stayed in the job for 8 months before she was discharged from our study. Although we do not have fur-ther follow-up data, it is possible that she may have remained in the job for a longer period of time. This out-come represents a job tenure longer than that reported by other vocational programs (Drake, McHugo, et al., 1999; Wong, Chiu, Tang, Chiu, & Tang, 2006). The ISE pro-gram’s strength in this aspect was that WSST and efforts targeted at skills generalization throughout the entire follow-up process enhanced participants’ job-retaining social skills. Participants received social skills training, including training in maintaining a good working relation-ship with one’s supervisor and coworkers (Tsang, 2003). These skills equipped participants to cope with interper-sonal conflicts in the workplace that might have caused them to leave their jobs. In the case of Ms. L, follow-up support focused on solving her relationship problems with her supervisor and coworkers. Because ISE fills this post-employment support gap, she was able to get through the problems and keep her job for 8 months.

Although the ISE program is associated with positive benefits, it is still not widely used as a program for people with SMI. The principles that contribute to its success seem simple and clear. However, implementing the pro-gram well involves the employment specialist’s practicing a wide range of clinical skills. An effective learning package with specific implementation guidelines and demonstra-tions is thus urgently needed to equip health and rehabilita-tion professionals with the clinical skills to implement and master ISE. In view of this need, our group is now develop-ing an online e-learning package that will focus on case management concepts and techniques required by employ-ment specialists. We hope that with this package, the ISE

approach may be better disseminated to and implemented by clinicians and therapists to further improve their voca-tional outcomes. s

AcknowledgmentThis study was funded by the Health Services Research Fund, Health, Welfare and Food Bureau, Hong Kong Special Administrative Region (Project No. S121014). We are grateful to the Baptist Oi Kwan Association of Hong Kong from which we recruited our participants.

ReferencesAnthony, W. A., Cohen, M., Farkas, M. D., & Gagne, C.

(2002). Psychiatric rehabilitation (2nd ed.). Boston: Center for Psychiatric Rehabilitation.

Becker, D. R., & Drake, R. E. (1993). A working life: The indi-vidual placement and support (IPS) program. Hanover, NH: Dartmouth Psychiatric Research Center.

Becker, D. R., Drake, R. E., Bond, G. R., Xie, H., Dain, B. J., & Harrison, K. (1998). Job terminations among persons with severe mental illness participating in supported employment. Community Mental Health Journal, 34, 71–82.

Bond, G. R. (2004). Supported employment: Evidence for an evidence-based practice. Psychiatric Rehabilitation Journal, 27, 345–359.

Bond, G. R., Drake, R. E., & Becker, D. R. (1998). The role of social functioning in vocational rehabilitation. In K. T. Mueser & N. Tarrier (Eds.), Handbook of social functioning in schizophrenia (pp. 372–390). Boston: Allyn & Bacon.

Cook, J. A., Lehman, A. F., Drake, R., McFarlance, W. R., Gold, P. B., Leff, H. S., et al. (2005). Integration of psychiatric and vocational services: A multisite randomized, controlled trial of supported employment. American Journal of Psychiatry, 162, 1948–1956.

Cook, J. A., & Razzano, L. (2000). Vocational rehabilitation for persons with schizophrenia: Recent research and implications for practice. Schizophrenia Bulletin, 26, 87–103.

Crowther, R. E., Marshall, M., Bond, G. R., & Huxley, P. (2001). Helping people with mental illness to obtain work: Systematic review. British Medical Journal, 322, 204–208.

Davidson, L., & Strauss, J. S. (1992). Sense of self in recovery from severe mental illness. British Journal of Medical Psychology, 65, 131–145.

Drake, R. E., & Becker, D. R. (1996). The individual placement and support model of supported employment. Psychiatric Services, 47, 473–475.

Drake, R. E., Becker, D. R., Clark, R. E., & Mueser, K. T. (1999). Research on the individual placement and support model of supported employment. Psychiatric Quarterly, 70, 289–301.

Drake, R. E., McHugo, G. J., Bebout, R. R., Becker, D. R., Harris, M., Bond, G. R., et al. (1999). A randomized clini-cal trial of supported employment for inner-city patients with severe mental illness. Archives of General Psychiatry, 56, 627–633.

244 May/June 2009, Volume 63, Number 3

Equal Opportunities Commission. (1997). A baseline survey on employment situation of persons with a disability in Hong Kong. Hong Kong: Author.

Lau, A. L. D, Cummins, R. A, & McPherson, W. (2005). An investigation into the cross-cultural equivalence of the Personal Wellbeing Index. Social Indicators Research, 72, 403–430.

Lehman, A. F., Goldberg, R., Dixon, L. A., McNary, S., Postrado, L., Hackman, A., et al. (2002). Improving employment out-comes for persons with severe mental illnesses. Archive of General Psychiatry, 59, 165–172.

Mak, C. S., Tsang, H. W. H., & Cheung, L. C. C. (2006). Job termination among individuals with severe mental illness participating in a supported employment program in Hong Kong. Psychiatry: Interpersonal and Biological Processes, 69, 239–248.

McGurk, S. R., Mueser, K. T., & Pascaris, A. (2005). Cognitive training and supported employment of persons with severe mental illness: One year results from a randomized controlled trial. Schizophrenia Bulletin, 31, 898–909.

Rosenheck, R. A., Leslie, D., Keefe, R., McEvoy, J., Swartz, M., Perkins, D., et al. (2006). Barriers to employment for people with schizophrenia. American Journal of Psychiatry, 163, 411–417.

Ruesch, R., Graf, J., Meyer, P.C., Rossler, W., & Hell, D. (2004). Occupation, social support and quality of life in persons with schizophrenic or affective disorders. Social Psychiatry and Psychiatric Epidemiology, 39, 686–394.

Strong, S. (1998). Meaningful work in supportive environments: Experiences with the recovery process. American Journal of Occupational Therapy, 52, 31–38.

Tsang, H. W. H. (2001). Applying social skills training in the con-text of vocational rehabilitation for people with schizophrenia. Journal of Nervous and Mental Disease, 189, 90–98.

Tsang, H. W. H. (2003). Augmenting vocational outcomes of supported employment by social skills training. Journal of Rehabilitation, 69, 25–30.

Tsang, H. W. H. (2007). Enhancing employment opportunities of people with mental illness through an integrated supported employment (Dissemination Report S121014). Hong Kong: Health and Health Services Research Committee.

Tsang, H. W. H., Chan, A., Wong, A., & Liberman, R. P. (in press). Vocational outcomes of an integrated supported employment program for individuals with persistent and severe mental illness. Journal of Behavior Therapy and Experimental Psychiatry.

Tsang, H. W. H., Lam, P., Ng, B., & Leung, O. (2000). Predictors of employment outcome of people with psychiatric disabilities: A review of the literature since mid-80s. Journal of Rehabilitation, 66, 19–31.

Tsang, H. W. H., & Pearson, V. (1996). A conceptual framework on work-related social skills for psychiatric rehabilitation. Journal of Rehabilitation, 62, 61–67.

Tsang, H. W. H., & Pearson, V. (2001). A work-related social skills training for people with schizophrenia in Hong Kong. Schizophrenia Bulletin, 27, 139–148.

Twamley, E. W., Jeste, D. V., & Lehman, A. F. (2003). Vocational rehabilitation in schizophrenia and other psychotic disorders: A literature review and meta-analysis of randomized con-trolled trials. Journal of Nervous and Mental Disease, 191, 515–523.

Wallace, C. J., Tauber, R., & Wilde, J. (1999). Teaching funda-mental workplace skills to persons with serious mental illness. Psychiatric Services, 50, 1147–1153.

Wong, K. K., Chiu, R., Tang, B., Chiu, S. N., & Tang, J. L. (2006). A randomized controlled trial of a supported employ-ment program on vocational outcomes of individuals with chronic mental illness (Dissemination Report). Hong Kong: Health Services Research Committee Dissemination Report.

Zhang, J. X., & Schwarzer, R. (1995). Measuring optimistic self-beliefs—A Chinese adaptation of the General Self-Efficacy Scale. Psychologia, 38, 174–181.