A randomized trial comparing a facility-based Clubhouse (N=83) to a mobile Program of Assertive Community Treatment (PACT; N=84) tested the widely held belief that competitive employment improves global quality of life for adults with severe mental illness. Random regression analyses showed that, over 24 months of study participation, competitively employed Clubhouse participants reported greater global quality of life improvement, particularly with the social and financial aspects of their lives, as well as greater self-esteem and service satisfaction, compared to competitively employed PACT participants. However, there was no overall association between global quality of life and competitive work, or work duration. Future research will determine whether these findings generalize to other certified Clubhouses or to other types of supported employment. Multi-site studies are needed to identify key mechanisms for quality of life improvement in certified Clubhouses, including the possibly essential role of Clubhouse employer consortiums for providing high-wage, socially integrated jobs.

Objective-In a randomized controlled trial, a vocationally integrated program of assertive community treatment (ACT) was compared with a certified clubhouse in the delivery of supported employment services.Methods-Employment rates, total work hours, and earnings for 121 adults with serious mental illness interested in work were compared with published benchmark figures for exemplary supported employment programs. The two programs were then compared on service engagement, retention, and employment outcomes in regression analyses that controlled for background characteristics, program preference, and vocational service receipt.Results-Outcomes for 63 ACT and 58 clubhouse participants met or exceeded most published outcomes for specialized supported employment teams. Compared with the clubhouse program, the ACT program had significantly (p<.05) better service engagement (ACT, 98 percent; clubhouse, 74 percent) and retention (ACT, 79 percent; clubhouse, 58 percent) over 24 months, but there was no significant difference in employment rates (ACT, 64 percent; clubhouse, 47 percent). Compared with ACT participants, clubhouse participants worked significantly longer (median of 199 days versus 98 days) for more total hours (median of 494 hours versus 234 hours) and earned more (median of $3,456 versus $1,252 total earnings). Better work performance by clubhouse participants was partially attributable to higher pay.Conclusions-Vocationally integrated ACT and certified clubhouses can achieve employment outcomes similar to those of exemplary supported employment teams. Certified clubhouses can effectively provide supported employment along with other rehabilitative services, and the ACT program can ensure continuous integration of supported employment with clinical care.Supported employment is designed to help adults with serious mental illness obtain jobs in socially integrated settings that pay at least minimum wage (1-3). Randomized controlled trials have established supported employment as an evidence-based practice on the basis of higher employment rates for specialized supported employment teams compared with interventions NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript that do not provide supported employment (4-9). The effectiveness of supported employment has been partially attributed to rapid job placement, which bypasses prevocational training, trial jobs, and sheltered work (9-12).However, being hired does not guarantee success on the job. Enrollees express interest in employment when entering a supported employment program, yet typically average only a few months of employment after finding a job (1,8,11,(13)(14)(15)(16). One explanation for brief work tenure is the failure of many supported employment specialists to work closely with treating clinicians (17). Encouraging integration of supported employment with case management and other rehabilitation services, such as supported housing or supported education, also seems beneficial (18,19). Research suggests...

Random assignment to a preferred experimental condition can increase service engagement and enhance outcomes, while assignment to a less-preferred condition can discourage service receipt and limit outcome attainment. We examined randomized trials for one prominent psychiatric rehabilitation intervention, supported employment, to gauge how often assignment preference might have complicated the interpretation of findings. Condition descriptions, and greater early attrition from services-as-usual comparison conditions, suggest that many study enrollees favored assignment to new rapid-job-placement supported employment, but no study took this possibility into account. Reviews of trials in other service fields are needed to determine whether this design problem is widespread. © Springer Science+Business Media, LLC 2009Correspondence to: Cathaleene Macias. NIH Public Access Author ManuscriptAdm Policy Ment Health. Author manuscript; available in PMC 2009 December 20. The validity of research in any field depends on the extent to which studies rule out alternative explanations for findings and provide meaningful explanations of how and why predicted outcomes were attained (e.g., Bickman 1987;Lewin 1943;Shadish et al. 2002;Trist and Sofer 1959). In mental health services research, participants' expectations about the pros and cons of being randomly assigned to each experimental intervention can offer post hoc explanations for study findings that rival the explanations derived from study hypotheses. Unlike most drug studies that can 'blind' participants to their condition assignment, studies that evaluate behavioral or psychosocial interventions typically tell each participant his or her experimental assignment soon after randomization, and being assigned to a non-preferred intervention could be disappointing, or even demoralizing (Shapiro et al. 2002), and thereby reduce participants' interest in services or motivation to pursue service goals (Cook and Campbell 1979;Shadish 2002). On the other hand, if most participants randomly assigned to one experimental condition believe they are fortunate, this condition may have an unfair advantage in outcome comparisons.Reasons for preferring assignment to a particular experimental condition can be idiosyncratic and diverse, but as long as each condition is assigned the same percentage of participants who are pleased or displeased with their condition assignment, then there will be no overall pattern of condition preferences that could explain differences in outcomes. The greater threat to a valid interpretation of findings occurs when most study enrollees share a general preference for random assignment to one particular condition. Greater preference for one experimental condition over another could stem from general impressions of relative service model effectiveness, or from information that is tangential, e.g., program location on a main bus route or in a safer area of town. Even if random assignment distributes service preferences in equal proportions across conditi...