Journal of Rehabilitation Research & Development
Volume 42, Number 1, Pages 35–46
The Indianapolis Vocational Intervention Program: A cognitive
behavioral approach to addressing rehabilitation issues in schizophrenia
Louanne W. Davis, PsyD;1* * Paul H. Lysaker, PhD;1–2 Rebecca S. Lancaster, MS;3 Gary J. Bryson, PsyD;4–5
Morris D. Bell, PhD4–5
1Roudebush Department of Veterans Affairs (VA) Medical Center, Indianapolis, IN; 2Psychiatry Department, Indiana
University School of Medicine, Indianapolis, IN; 3Indiana University—Purdue University at Indianapolis, Indianapolis,
IN; 4VA Health Care Connecticut, West Haven, CT; 5Yale University School of Medicine, New Haven, CT
Abstract—Despite wishing to return to productive activity,
many individuals with schizophrenia enter rehabilitation with
severe doubts about their abilities. Negative beliefs in schizo-
phrenia have been linked with poorer employment outcome.
Accordingly, in this paper, we describe efforts to synthesize
vocational and cognitive behavior therapy interventions into a
6-month manualized program to assist persons with schizo-
phrenia spectrum disorders overcome negative beliefs and
meet vocational goals. This program, the Indianapolis Voca-
tional Intervention Program (IVIP), includes weekly group and
individual interventions and is intended as an adjunct to work
therapy programs. The IVIP was initially developed over a
year of working with 20 participants with Structured Clinical
Interview for the Diagnostic and Statistical Manual-I (SCID-I)
confirmed diagnoses of schizophrenia or schizoaffective disor-
der who were actively engaged in 20 hours a week of work
activity. For this paper, we explain the development of the
treatment manual and the group and individual interventions
and present case examples that illustrate how persons with
severe mental illness might utilize the manualized intervention.
Key words: cognitive behavior therapy, dysfunctional beliefs,
manualized intervention, schizoaffective disorder, schizophre-
nia, veterans, vocational rehabilitation.
Despite the wish to return to productive activity  and
the clinical benefits associated with productive activity ,
many individuals with schizophrenia spectrum disorders
also simultaneously enter rehabilitation with severe doubts
about their own abilities [1,3–4]. Because of factors includ-
ing stigma [5–6] and the devastating effects of illness,
many with schizophrenia view themselves as having little
competence, social value, and chance of success at work,
even with assistance [7–9]. They may believe they have
minimal ability to influence their lives [10–12] and have
developed a personal narrative in which failure in social
and vocational contexts is expected . They anticipate
difficulties at work and see no real gains from persevering
Abbreviations: CBT = cognitive behavior therapy, HVLT =
Hopkins Verbal Learning Test, IVIP = Indianapolis Vocational
Intervention Program, PANSS = Positive and Negative Syn-
drome Scale, SCID-I = Structured Clinical Interview for the
Diagnostic and Statistical Manual-I, SD = standard deviation,
VA = Department of Veterans Affairs, WBI = Work Behavior
Inventory, WCST = Wisconsin Card Sorting Test.
This material was based on work supported by the Depart-
ment of Veterans Affairs (VA), Veterans Health Administra-
tion, Rehabilitation Research and Development Service,
*Address all correspondence to Louanne W. Davis, PsyD; Roude-
bush VA Medical Center, Psychiatry Research, 1431 West 10th
Street, Indianapolis, IN 46202; 317-554-0000, ext. 4523; fax:
317-554-0056, email: email@example.com
JRRD, Volume 42, Number 1, 2005
during trying times. Thus, the negative beliefs people with
schizophrenia hold regarding their self-efficacy further
hinder their rehabilitation and become an independent
source of continuing psychosocial decline.
Consistent with this and paralleling studies of persons
without severe mental illness , negative beliefs about
the self in schizophrenia have been found to predict poorer
employment outcome [15–16]. One prospective study
found that even after controlling for negative symptoms,
dysfunctional beliefs about giving up significantly pre-
dicted poor rehabilitation outcome . Negative beliefs
about the self have also been linked to other behaviors that
may compromise vocational function, including more
avoidant coping [10,17], poorer participation in treatment
, and generally poorer social function [8,19].
This literature poses a challenge to service providers
and researchers. Given the link between dysfunctional
beliefs and vocational outcomes in schizophrenia, can
interventions be devised to help persons combat and
reverse these beliefs in the context of work? As programs
are now being developed to address other barriers to
work, including cognitive deficits [20–21] and stigma
, can programs be developed that apply new or exist-
ing technologies as an adjunct to work therapies to help
persons with schizophrenia overcome their negative
beliefs and meet their vocational goals? In response to
this challenge, we have sought to develop a treatment
manual by applying and adapting a wide range of exist-
ing cognitive behavior therapy (CBT) didactic materials
and techniques to target dysfunctional beliefs affecting
work function. In designing this intervention, we chose to
rely on CBT principles to address dysfunctional beliefs
because CBT has helped persons in general alter a wide
range of cognitions. More importantly, research has indi-
cated over the last decade that CBT can help people with
schizophrenia reduce negative symptoms, as well as
increase community tenure [23–27].
For this paper, we describe our efforts to synthesize
vocational and CBT interventions into a 6-month manu-
alized program for persons with schizophrenia spectrum
disorders that we call the Indianapolis Vocational Inter-
vention Program (IVIP). The IVIP offers weekly group
and individual CBT sessions targeted at dysfunctional
beliefs about self (e.g., “I cannot succeed”) and work
experiences (e.g., “Since my supervisors criticized my
work, they must not like me”). The group therapy inter-
vention includes didactic content and skills training and
is complemented by the individual therapy intervention
that involves active and personalized application of
group material to beliefs participants hold about them-
selves and their work experiences. The IVIP is intended
as an adjunct to work therapy programs, including those
that provide paid work placements to participants. These
programs include Incentive Therapy, Veterans Industries,
and Compensated Work Therapy and are available at
more than 101 Department of Veterans Affairs (VA) sites
across the country . This type of setting provides a
unique laboratory to study work performance in more
depth than is possible in competitive work settings where
multiple barriers to detailed observation and supervisor
interviews are present.
In what follows, we first describe methods for creat-
ing the treatment manual and then provide an overview of
both the group and individual interventions. Next, two
case vignettes illustrate how we employed this manual-
ized intervention. Both cases were chosen because of a
history of long-term poor vocational function and
because they represent potentially “difficult cases,” each
suffering from a pattern of deficits commonly seen in
rehabilitation settings that are linked by the literature to
poor vocational function. Finally, we summarize the pro-
gram and explore directions for future research.
Development of IVIP Treatment Manual
The IVIP was developed while working with 20 par-
ticipants with Structured Clinical Interview for the Diag-
nostic and Statistical Manual-I (SCID-I) confirmed
diagnoses of schizophrenia or schizoaffective disorder.
Participants were recruited from outpatient clinics at a
VA medical center and were in a postacute or stable phase
of their illness, defined as having had no changes in psy-
chiatric medication or housing in the previous month. On
average, they were 46 years old (standard deviation (SD)
= 8.1) with histories of 12 psychiatric hospitalizations
(SD = 15.4), the first occurring at an average age of 23
(SD = 10.8). Fourteen participants were Caucasian and
six were African American. All but one was male. The
modal participant had not been employed for 5 years and
on average participants had 12.85 years of education
(SD = 1.309). As an indication of the level of cognitive
impairment, participants’ average number of categories
correct was 3.30 (range 0–6, SD = 2.473) for the Wiscon-
sin Card Sorting Test (WCST) . Of the 20 partici-
pants, one withdrew before receiving a work placement
or any other services and another withdrew during the
first week because of a medical emergency. Therefore,
their participation data was not considered.
DAVIS et al. Indianapolis Vocational Intervention Program
After obtaining written informed consent, participants
were provided with a work program that was modeled
after the VA’s Incentive Therapy programs . This
included a 26-week job placement in entry-level medical
center positions with supervision by the regular job site
supervisors and payment of $3.50 per hour for up to
20 hours a week of work activity. Participants were also
assigned to attend weekly CBT group and individual ther-
apy sessions that were video- or audiotaped with the aim
of identifying successful and unsuccessful attempts at
implementing aspects of the developing manual.
Prior to beginning the manual, we defined key treat-
ment parameters, such as format, frequency, and duration,
with consideration given to participants’ levels of cogni-
tive impairment and varying symptom presentations. For
example, the program consists of both group and individ-
ual components to facilitate tailoring instruction and
application of concepts to individual preferences in learn-
ing style, as well as differences in cognitive ability and
problems related to work. The duration of the weekly
group and individual sessions are a maximum of 1 hour to
optimize participants’ attentiveness and performance
required by the cognitive demands of CBT. Participants
contract with their individual therapists regarding the
length of individual sessions that range from 30 to
60 minutes. A group leader and cotherapist facilitate
groups limited to 4 to 6 participants to ensure all members
can fully participate. The group curriculum is presented at
least three times during the 6-month program. In addition
to the advantage of providing more impaired participants
with multiple exposures to the didactic material, the repe-
titions accommodate participants who want to enter the
program immediately and enable those who miss work to
make up the material later when the session is repeated.
Following the model that manualized treatments best
arise from incremental modifications to existing methods
, we identified two criteria derived from the treat-
ment rationale previously described to guide our adapta-
tion of existing CBT manualized interventions:
1. The intervention directly or indirectly must advance
the work of modifying dysfunctional cognitions that
interfere with work.
2. The intervention must be accessible to participants of
varying educational backgrounds and levels of cogni-
To this end, group interventions were developed around
the CBT model (the feedback loop of thoughts affecting
feelings which, in turn, affect behaviors). The particular
model we chose to help participants conceptualize the
process of intervening with dysfunctional cognitions was
what is referred to as the 4 A’s:
1. Be aware of dysfunctional cognitions.
2. Answer dysfunctional cognitions by constructing and
bringing to mind more accurate and/or helpful thoughts.
3. Act on the more accurate and/or helpful thoughts.
4. Accept imperfection .
Individual therapy sessions conducted during the manual
development phase were offered between group sessions
and modeled on CBT interventions described by Beck,
Rush, Shaw, and Emery ; Beck ; and Miller and
The IVIP Group Intervention
As detailed in Table 1, the format of the 1-hour group
therapy sessions follows a standard agenda composed of
three sections: check-in, intervention, and wrap-up. The
primary objectives of the 10- to 15-minute check-in are:
1. To assist participants to identify potential problems at
2. To give participants positive social reinforcement for
3. To provide a bridge from the last session.
4. To assess how well participants understand the didac-
tic material while reinforcing major concepts.
A seven-item “Weekly Self-Appraisal Form” assists par-
ticipants in this process by asking them to rate the quality
of their work, emotional responses to work, and relation-
ships with coworkers and supervisors using a 5-point
Likert scale. Although the IVIP employs standard agenda
items typical of CBT, the group leader collaborates with
participants to finalize the session agenda.
The next section of each group session—the inter-
vention—comprises the bulk of the session, generally 30
to 40 minutes, and involves three activities:
1. Teaching the week’s didactic material.
2. Assisting participants to put the didactic material into
practice with some type of application exercise.
3. Giving work feedback to participants.
As adapted from other sources [31,35–40], the IVIP
didactic curriculum is organized into four 2-week mod-
ules (total of eight sessions). These are presented in order
and repeated at least three times during the participants’
6-month program. The content of each of these modules
is summarized in Table 2.
JRRD, Volume 42, Number 1, 2005
During the didactic presentation, the scheduled mate-
rial is presented both abstractly and applied to partici-
pant’s actual work experiences. For example, if the
weekly topic is “coping with anger,” anger is defined in
terms of the CBT model and participants are taught how
to become more aware of angry thoughts, how to answer
angry thoughts with more helpful thoughts, and how to
act based on those more accurate, adaptive thoughts in a
Group session format in IVIP.
Phase Time (min)Tasks
Check-In10–15Participants complete “Weekly Self-Appraisal Form.”
Participants describe work experiences that week.
Successes and problems are noted.
Agenda is set collaboratively, incorporating relevant issues.
Participants offer recollections, questions, and comments about previous didactic material.
Intervention 30–40 Presentation of didactic material.
Assessment of participant learning.
Application of didactic material to work-related situations.
Exercises, if applicable (e.g., relaxation, videotaped role-play).
Presentation of work performance feedback.
Wrap-Up 10–15 Participant summary of group session.
Distribution and explanation of practice (homework) assignments.
Participants complete group session evaluation.
Participants complete posttest.
IVIP = Indianapolis Vocational Intervention Program
Description of IVIP group didactic modules.
Module TitleSession Number and Title
(Examples of Concepts and Skills to be Addressed)
Recognize impact of negative thinking.
Identify automatic thoughts that impact work.
Modify dysfunctional cognitions using 4-A model.*
Apply 4-A model to participants’ work experiences.
Identify existing or potential barriers to work.
Employ problem-solving steps to work barriers.
Define emotional states that threaten work.
Learn CBT skills to manage difficult emotions.
Differentiate constructive and destructive criticism.
Apply steps for responding to feedback at work.
Learn assertive communication principles.
Practice giving effective feedback in work settings.
1. Thinking errors and work
2. Modifying self-defeating thinking
3. Problem-solving barriers to work
4. Coping with emotions
5. Accepting and learning from feedback
6. Effective self-expression
7. Thinking about capabilities and limitations Identify thinking errors compromising self-appraisal.
Identify strengths, limitations, and necessary accommodations.
8. Managing success Define failure and success via the cognitive model.
Modify dysfunctional cognitions regarding work failures.
*The 4-A model emphasizes connections between being “aware,” “answering,” “acting,” and “accepting.”
IVIP = Indianapolis Vocational Intervention Program
CBT = cognitive behavior therapy
DAVIS et al. Indianapolis Vocational Intervention Program
work context. Following the didactic presentation,
cotherapists engage participants in an application exer-
cise about experiences they have had recently at work
related to anger. The manual allows for a wide variety of
application exercises, including using scripted, video-
taped, and spontaneous role-play, practicing progressive
muscle relaxation, and generating in-session thought
Work feedback, the last aspect of the intervention
section, is derived from the Work Behavior Inventory
(WBI) , an instrument completed by a trained rater
who has observed participants at work and interviewed
their supervisor. The five WBI scores of sociability,
cooperativeness, work habits, work quality, and personal
presentation are shared with the participant and group in
the form of a line graph along a continuum ranging from
“poor” to “excellent.” In presenting work feedback, the
leader begins with the participants’ strengths leading to
areas needing improvement. The cotherapist observes cli-
ents’ responses and helps them to verbalize their reac-
tions. The group leader then directs any issues that are
raised back to the group, who in turn provide support,
reinforce success, or assist with problem-solving. WBI
feedback is given to participants every other week for the
first 8 weeks and then monthly.
The final section of the group session is the 10- to
15-minute wrap-up, during which the group leader asks
participants to summarize what they have learned and/or
to identify what made the most impact on them. The
group leader may also provide feedback to group mem-
bers about their participation, in addition to bridging to
the didactic topic for the next week. Weekly written
practice assignments are distributed and briefly
explained. Practice assignments are one-page written
exercises that participants complete in an average of
15 minutes and are targeted for completion by the next
individual session. Practice assignments provide an
opportunity for participants to apply group material to
their individual situation and make up any missed group
sessions while giving group and individual therapists
a measure of how well participants are grasping the
The manual allows for increased complexity during
the second and third exposure to the didactic material
through more challenging application exercises and prac-
tice assignments. During their final exposure to the mod-
ules, participants are also assisted by their individual
therapists to prepare two brief presentations. The first pre-
sentation involves explaining how they applied the CBT
model to dysfunctional thoughts about work, and the
second, how they applied any of the module content to
their work experience. At the completion of the program,
a “graduation” takes place, at which participants share
their gains from the program and dreams for the future.
During manual development, 61 percent of the partici-
pants attended more than 50 percent of group sessions,
while 39 percent joined in two to six sessions. Results of
participant evaluations of the group session and the work
experience were generally positive. Using a 5-point Likert
scale ranging from 1, “not at all,” to 5, “very much,” partici-
pants indicated that group sessions helped identify problems
at work and find ways to solve them ( = 3.66, SD = 0.34)
and offered support in working ( = 3.82, SD = 0.34).
Participants also reported that working contributed to feel-
ing good about themselves ( = 4.07, SD = 0.32), in spite
of not always feeling comfortable ( = 2.33, SD = 0.25).
Cotherapists completed a group record form weekly to
monitor aspects of participation by group members on an
anchored 5-point Likert scale. Results confirmed that group
members were positively engaged in the group process:
attentiveness = 4.00, SD = 0.40; willingness to participate
= 3.83, SD = 0.31; level of self-disclosure = 3.8, SD =
0.36; on-topic participation = 4.17, SD 0.36; and support-
ive to other group members = 3.48, SD = 0.36.
The IVIP Individual Intervention
The individual counseling component of the IVIP is
designed to be an opportunity for participants to review
and apply didactic materials from groups and to learn to
identify and conceptualize concerns using the cognitive
behavioral model. Sessions generally begin the week
before work, with the first two sessions conceived as
These introductory sessions have at least four
1. Begin to establish a therapeutic alliance.
2. Orient participants to program routines and schedules.
3. Assess participants’ current expectations of work.
4. Address immediate and/or potential barriers to suc-
cess at work.
During this phase, therapists employ primarily behavioral
techniques to help participants identify and overcome
any initial barriers to working. Throughout the next few
sessions, therapists and participants collaboratively for-
mulate goals for therapy. Examples of early goals include
confronting the expectation of not being able to complete
JRRD, Volume 42, Number 1, 2005
the program or testing ways to respond to the expectation
that one will be humiliated at work. Therapists also help
participants develop an initial list of beliefs about them-
selves and others that may affect work function.
Individual sessions comprise the same three sections
as the group session: check-in, intervention, and wrap-up.
Before the therapy session begins, participants rate the
strength of their conviction and extent of impact for up
to four beliefs that participants and therapists have collabo-
ratively identified. Next, during the “check-in” section,
participants report to what extent they worked on and
accomplished a mutually agreed-upon between-session
assignment and give a brief update of the past work week
including any mental health concerns. The therapist also
reviews the written practice assignment from the last group
session. Generally, 15 minutes is needed to complete writ-
ten practice assignments, with more cognitively impaired
participants needing more time. As an incentive for each
completed written practice assignment, participants are
given credit for an hour of paid time they can use to offset
future time off from work. During manual development, a
bimodal distribution of successful assignment completion
was calculated. More than half of the participants com-
pleted the vast majority of assignments ( = 18.0), while
the others completed relatively few ( = 3.0). Strategies
consistent with CBT addressed the lack of assignment
completion, such as challenging dysfunctional thinking
about assignments and problem-solving. Check-in culmi-
nates with a collaboratively constructed and prioritized
agenda that usually includes work on previously identified
During the intervention section of individual sessions,
the focus may be old or new material related to an event
or issue. At some time during the intervention section,
dysfunctional cognitions about work or that ultimately
impact work are addressed, and the participant is con-
tracted to apply over the next week at least one specific
skill taught in group. To track the success of interventions,
participants rate by session’s end the accuracy of the dys-
functional and alternative cognition. Finally, during the
wrap-up section, the therapist and participant reflect on
the session. This may involve a summary provided by the
therapist and/or the participant sharing observations and
level of satisfaction with progress. During manual devel-
opment, 61 percent (n = 11) attended 12 to 24 individual
sessions, while the remaining 39 percent (n = 7) attended
3 to 9 individual sessions and were considered dropouts.
Reasons for dropping out included marital discord, finding
other productive activity, and substance abuse relapse. Of
the seven dropouts, six left the program in its early stages
while the manual was still being developed.
As examples of how different persons responded to
the IVIP, we present two case vignettes. These cases are
intended to illustrate how these procedures “came to life”
and were chosen on the basis of their representation of the
significant levels of impairments present in the partici-
pants who helped us to develop this program.
Case Vignette No. 1
Bill (all subject names used in the manuscript are fic-
titious) is a 43-year-old Caucasian male with schizoaffec-
tive disorder and a long history of substance abuse. When
he entered the program, he had not worked in the previ-
ous 10 years and had instead wandered aimlessly from
city to city, often homeless and isolated from others. At
baseline he had significant deficits commonly found in
rehabilitation settings that have been linked to poorer
work function. These included high levels of negative
symptoms on the Positive and Negative Syndrome Scale
(PANSS) , as well as impairments on the WCST ,
a measure of executive function, and on the Hopkins Ver-
bal Learning Test (HVLT) , a test of verbal memory.
When he entered the program, he requested a job that
required little physical exertion and he was offered a
placement in a clerical office where he prepared and
sorted a variety of documents. Bill’s two initial goals in
individual therapy were to “not drop out” of the program
and to become more able to think about himself in “flexi-
ble and positive” ways.
As Bill participated in treatment, these goals were
specified to include challenging “paranoid thoughts,”
episodic desires to quit his job, perceptions that others
were “getting in my way,” and fears of being “over-
whelmed” as he took on more responsibilities.
During group therapy sessions, Bill received and
accepted feedback from his peers regarding his distrust of
others and his overreactions to constructive feedback.
He attributed his struggle to grasp the didactic content to
limitations in his memory and processing of verbal informa-
tion, and consequently had difficulty independently com-
pleting written homework assignments. However, as this
material and its rationale was reviewed in individual thera-
py, he came to understand his proneness to a variety of cog-
nitive distortions, including “either/or” thinking, personaliz-
ing, and jumping to conclusions. He practiced testing the
accuracy of these distortions and became increasingly will-
ing to see how he misinterpreted others’ motives and
ignored evidence of his capabilities and limitations. He
DAVIS et al. Indianapolis Vocational Intervention Program
came to conceptualize his habitual withdrawal and hostility
as behavior whereby he set himself up to fail while at the
same time blaming others. He was able to see issues related
to his poor hygiene, alcohol use, and spotty medication
adherence as further ways in which he “hurt” his own
cause. Bill was assisted in individual therapy to identify
specific dysfunctional cognitions and find ways to respond
to them. For example, he learned to answer thoughts such as
“Everything I do turns to s***” with “Things are currently
going pretty well for me,” and “It isn’t me to be successful”
with “Maybe I’m not as much of a screw-up as I thought I
was.” Interestingly, we observed that here and in other
cases, individual therapy did not silence negative thinking,
but stimulated and enriched internal arguments and discus-
sions by adding other points of view. Thus, enhanced meta-
cognition occurred, or thinking about thinking, adding to a
richer array of individual thoughts as Bill considered how to
respond to issues at work.
In the last month of the IVIP, Bill identified the fol-
1. Improved relationship with his supervisor.
2. More consistent work performance and attendance.
3. Increased self-confidence.
Twice during the program, he took extended leaves and
missed several weeks. However, on both occasions he
returned to work and again began examining his thoughts
and behaviors. During the 20 weeks Bill worked, he aver-
aged 17 hours a week and evaluations of his work perform-
ance with the WBI revealed significant improvements. For
instance, as displayed in Figure 1, in biweekly ratings of
Cooperativeness, the work domain that was perhaps the
greatest focus in his therapy, a significant linear trend was
observed (r = 0.94, p < 0.0001) with performance increas-
ing over time. Other evidence of improvement depicted in
Figure 2 includes concurrent decreases on the PANSS
Negative Symptom component (r = –0.62, p < 0.05). Of
note, a research assistant blind to his goals in therapy rated
the WBI or PANSS.
Case Vignette No. 2
Dan is a 51 year-old Caucasian male with schizoaf-
fective disorder and a history of homelessness, social
alienation, and limited response to antipsychotic medi-
cation. When he entered the program, Dan had not
worked for 18 years. At baseline Dan, like Bill, also had
multiple deficits commonly associated with impairments
in function, including high levels of cognitive symptoms
and impairments in executive function on the WCST
and poor verbal memory on the HVLT.
Dan expressed interest in working around people and
was offered a placement as a receptionist in a clinical set-
ting. Dan’s initial two goals were to increase his social con-
nections and improve his coping with anxiety and
depression. As therapy progressed, these goals were further
refined in terms of specific work behaviors, including stay-
ing attentive, carrying out job responsibilities effectively,
initiating appropriate communication, and consistently
passing on phone messages.
Dan was an active participant during group sessions,
frequently making supportive comments to other group
members. Although at times he struggled to make sense
of the didactic material, he asked questions, took notes
Biweekly ratings on WBI (Work Behavior Inventory) category of
Cooperativeness for Case No. 1 (Bill).
Concurrent decreases on PANSS (Positive and Negative Syndrome
Scale) Negative Symptom component for Case No. 1 (Bill).
JRRD, Volume 42, Number 1, 2005
that he referred to later, and worked diligently on the
written practice assignments. Once he grasped the mate-
rial, however, the anxiety and depression aroused by dis-
cussing his problems often interfered with his applying
the material, even with assistance from his individual
therapist. Eventually, Dan came to recognize and con-
front negative cognitions that were at the root of his fears.
He realized that he was intensely afraid of making a mis-
take and displeasing others. He also concluded that his
tendency to magnify his problems and predict the worst
possible outcome made it more likely that he would fail
to implement problem-solving plans developed during
individual therapy. At one point during the program,
Dan’s struggle with suicidal ideation related to his sense
of hopelessness and expectations of disaster threatened
his ability to continue working. Weekly therapy sessions
focused on helping Dan address dysfunctional thinking
that interfered with his applying problem-solving skills
learned during group sessions. For instance, he learned to
answer the anxiety-provoking thought: “If I don’t plan
for everything, I’ll make a mistake and be homeless” with
“I’ve done the best I can” and “Right now, gains are
greater than losses.” Dan also found it helpful to practice
reminding himself that “Work is important to me because
it helps me to maintain my emotional stability” rather
than focusing on other’s impressions of him at work.
When thoughts linked with avoidant behavior such as
“People won’t accept me because I have a mental illness”
became too strong, he learned to intervene further by tell-
ing himself “Whether or not people accept me is ulti-
mately not my responsibility.”
In the last month of the IVIP program, Dan identified
the following gains:
1. Learning to evaluate his thoughts and increase his
focus on more rational and positive thoughts when
beset with fears of catastrophe.
2. Learning to engage in pleasant activities to positively
impact his thoughts and feelings.
3. Monitoring how “jumbled” his thinking was and
learning to take a break to halt the stress cycle.
He was also able to apply problem-solving skills to
move to a new residence that was less demanding and
less socially isolating. At work, Dan averaged 19.5 hours
per week and did not miss a day. As revealed in Figure 3,
results of his WBI evaluations further validated improve-
ment in his biweekly ratings of Work Habits (r = 0.57;
p < 0.05), the domain of greatest focus in his therapy. As
in the case of Bill from week 1 to week 20, a pattern of
linear decrease in symptoms as rated biweekly was
detected, this time on the PANSS Cognitive Symptom
component (r = –0.69; p < 0.05, Figure 4). As in the pre-
vious case vignette, a research assistant blind to his goals
in therapy rated the WBI or PANSS.
Given the links between dysfunctional cognitions and
work outcome in schizophrenia, we have developed a
Results of WBI (Work Behavior Inventory) Work Habits evaluation
for Case No. 2 (Dan).
Results of PANSS (Positive and Negative Syndrome Scale) Cognitive
Symptom component for Case No. 2 (Dan).
DAVIS et al. Indianapolis Vocational Intervention Program
manualized CBT program called the Indianapolis Voca-
tional Intervention Program. This program specifically
assists persons with schizophrenia to think more adaptively
about themselves and work and differs from other cogni-
tive behavior therapy programs in that it endeavors prima-
rily to enhance function.
As Rounsaville et al. has noted , the evaluation
of new and developing treatments should include patient
acceptance of the new treatment, the ability of research-
ers to recruit sufficient numbers from the target popula-
tion, and feasibility of treatment delivery. Evidence that
the IVIP meets the first criterion can be found in the posi-
tive responses to concurrent group evaluation question-
naires that indicated participants found the sessions
helpful and supportive. In addition, group therapist eval-
uations indicated that group participants overall were
focused, engaged, and involved. As for the second and
third criteria, we were easily able to quickly recruit the
20 participants needed for manual development, with full
support from the medical center, participants, and front-
Although we have been able to implement the IVIP
within our setting with patients accepting of and willing
to participate in the program and, as illustrated by the
case vignettes, persons with significant impairments who
have experienced some gains, the effectiveness of the
IVIP remains to be tested in a randomized controlled
study. We are currently in the final phases of completing
a randomized study with 50 participants and hope soon to
publish our findings on the effects of the IVIP versus
standard support services for persons with schizophrenia,
with outcomes including work performance, cognitions
about helplessness and hopelessness, and other symp-
toms. As previously noted, seven failed to participate in a
sufficient number of IVIP sessions and were considered
dropouts. We are also carefully studying dropout rate, as
well as any additional interventions that could be
included within our framework for promoting retention.
Methodological limitations exist in this paper. First,
the IVIP was developed with primarily male participants
in their 40s. In future studies of the program, adaptations
may need to be made for female participants or those in
other age groups. Rolling admissions offer flexibility, but
at the same time pose challenges to group cohesiveness.
The intervention was only for 6 months, irrespective of
need. Based on individual differences, however, some
may benefit from more exposure or receive the maximum
benefit earlier. As we continue to improve the IVIP, we
anticipate addressing how to tailor the treatment accord-
ing to various characteristics of participants, such as level
of cognitive impairment, insight into illness, comorbid
conditions, and varying mood states.
Participants in this paper were placed in temporary
entry-level jobs in a VA medical center and, in keeping
with supported employment principles, were placed
immediately with consideration given to participants’
interests. As numerous programs throughout the VA sys-
tem provide identical services to those we have
employed, our program is potentially directly exportable
to them. These placements seem a valid object of study
given that they do represent actual work experiences that
can be a part of vocational hopes and dreams, even
though the participant does not become an employee of
the hospital. Unknown are what modifications are neces-
sary for application in other vocational settings, including
those that use a supported employment model.
Employing CBT as a treatment strategy for persons
with schizophrenia is a relatively new and innovative
endeavor, particularly to enhance vocational function. In
fact, this is the first attempt of which we know to apply
CBT specifically to work. This endeavor can be particu-
larly challenging. It has its moments of both success and
setback and may require careful and patient navigation in
the face of traditionally daunting barriers, such as nega-
tive symptoms and cognitive impairment. Implementing
these procedures requires agencies to provide vocational
rehabilitation services along with resources for individual
and group therapy and therapist supervision. Yet, with
further research guiding treatment development, pro-
grams such as the IVIP may be able to help those with the
least successful outcomes.
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Submitted for publication May 21, 2003. Accepted in
revised form February 9, 2004.
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