02/01/2016

Career Development of Individuals with First Episode Psychosis: Limitations and Opportunities

By Christa Boychuk

Psychosis is a debilitating medical condition in which an individual loses contact with reality. It affects 3% of individuals during their lifetime, and is most often associated with mental illnesses that include schizophrenia, bipolar disorder, and major depression. Psychosis involves the presence of symptoms such as hallucinations, delusions, disorganized thinking, and disorganized behavior (Compton & Broussard, 2009). First episode psychosis (FEP) often emerges during adolescence or early adulthood, when individuals are working toward important educational and career aspirations that can be disrupted due to emotional, social and cognitive impairments.

Career Development Issues, Influences, and Implications
Education and employment are crucial for young people trying to establish career paths. For individuals with FEP, successful participation in the realms of education and employment are associated with better management of symptoms, fewer hospitalizations, and less substance abuse (Bertolote & McGorry, 2005). Despite these encouraging findings, individuals with serious mental illness, including those with FEP, continue to experience high rates of unemployment and underemployment, and disengagement from education.

Newly diagnosed young adults are at a particularly high risk of becoming vocationally derailed by FEP, since they are forced to deal with developmental transitions and search for success strategies amidst diminishing personal capacities while coping with risk factors (Woodside, Krupa, & Pocock, 2007). Those with FEP are also at risk of vocational disruption due to early dependence on government assistance, limited availability and quality of vocational services, stigma, and beliefs by family and mental health professionals that employment may cause undue stress that limits recovery (Gioia, 2005).

Several factors have been found to be associated with competitive employment (i.e., work in integrated employment settings, making at or above minimum wage) and educational participation of individuals following their first episode of psychosis. Short durations of untreated psychosis, older age, and high levels of social support are associated with higher levels of competitive employment and education participation, whereas, receipt of government disability benefits and negative symptoms are associated with disengagement from competitive employment and education (Norman et al., 2007; Turner et al., 2009).

Best Practice for Intervention
The Individual Placement and Support Model (IPS) is a best practice supported employment program that has been effectively used with individuals who have different types of psychiatric disabilities, including those with FEP. IPS practice principles include:

• No individual who wants to work is excluded;
• Competitive employment is the primary goal;
• Job searching commences immediately after a client expresses interest in work;
• Decisions about work and support are based on an individual’s preferences, strengths, and experiences; and
• Continuous individual support and benefits counseling is facilitated by an employment specialist.

IPS programs are integrated into mental health services with clients referred by mental health staff to employment specialists within the same mental health facility who work closely with case managers, psychiatrists, and other professionals to help clients achieve their employment goals. IPS has been shown to help individuals increase their entry and return to competitive employment and education, weekly hours worked, number of jobs acquired, and longevity of employment (Rinaldi et al., 2010). Supported employment programs with high fidelity to IPS principles have successfully facilitated employment relative to programs with low fidelity or traditional vocational training (Bond, Drake, & Becker, 2012; Corbière & Lanctôt, 2011).

Suggestions for Future Practice
Although IPS is a best practice in vocational rehabilitation, it is not standard practice. It is unavailable to most individuals with FEP who want to work or attend school, due to small numbers of programs confined to urban mental health programs and hospitals. Often, only a patchwork of financially strapped, non-integrated community agencies or hospital-based early FEP early intervention programs are available to individuals with FEP. These programs are ill-equipped to assist individuals with their employment challenges, as they emphasize medical management instead of vocational rehabilitation, which would be an important component of recovery.

To improve the career and educational outcomes of individuals with FEP, increased emphasis needs to be placed on program development, access and integration. Specifically:

• Career development interventions should focus on developing, evaluating and delivering manualized and affordable employment and education programs, if accurate comparisons are to be made across programs and effective programs are to be developed and delivered to individuals with FEP;
• Integrated services and working relationships need to be developed between community-based mental health and employment agencies, to improve access to vocational services; and
• FEP early intervention programs and community mental health agencies should focus on the development and delivery of strengths-based, in-house vocational facilities that are accessible to individuals within their facilities and the community.

Achieving Ambitions
Psychosis is a debilitating medical condition where an individual loses touch with reality, with the first episode of psychosis often occurring during late adolescence or early adulthood, when individuals are trying to establish and achieve career and educational ambitions. Though vocational interventions such as IPS have improved employment outcomes of those with first episode psychosis, there needs to be greater development, access, and integration of existing mental health and vocational services to best serve career clients. For more information and resources, please visit the Early Assessment and Support Alliance and Foundation for Excellence in Mental Health Care: Program Directory of Early Intervention Psychosis Programs.

References
Bertolote, J. & McGorry, P. (2005). Early intervention and recovery for young people with early psychosis: Consensus statement. British Journal of Psychiatry, 17, s116-s119.

Bond, G. R., Drake, R. E., & Becker, D.R. (2012). Generalizability of the Individual Placement and Support (IPS) model of supported employment outside the US. World Psychiatry, 11(1), 32–39.

Compton, M. T., & Broussard, B. (2009). The first episode of psychosis: A guide for patients and their families. New York, NY: Oxford University Press.

Corbière, M., & Lanctôt, N. (2011). Salient components in supported employment programs: Perspectives from employment specialists and clients. Work, 39(4), 427–439.

Gioia, D. (2005). Career Development in Schizophrenia: A Heuristic Framework. Community Mental Health Journal, 41(3), 307–325.

Rinaldi, M., Killackey, E., Smith, J. S., Shepherd, G., Singh, S. P., & Craig, T. (2010). First episode psychosis and employment: A review. International Review of Psychiatry, 22(2), 148-162.

Norman, R. M. G., Mallal, A. K., Manchanda, R., Windell, D., Harricharan, R., Takhar, J., & Northcott, S. (2007). Does treatment delay predict occupational functioning in first-episode psychosis? Schizophrenia Research, 91, 259-262.

Turner, N., Browne, S., Clarke, M., Gervin, M., Larkin, C., Waddington, J. L., & O'Callaghan, E. (2009). Employment status amongst those with psychosis at first presentation. Social Psychiatry and Psychiatric Epidemiology, 44, 863-869.

Woodside, H., Krupa, T., & Pocock. (2008). How People Negotiate For Success as Psychosis Emerges. Early Intervention in Psychiatry, 2, 50–54.

Christa Boychuk is a PhD candidate in Rehabilitation Science at Queen’s University at Kingston, in Ontario, Canada. Prior to her doctoral studies, Christa studied and worked in the U.S. and Canada. She has been previously employed as a Mental Health Counselor and Epidemiologist. Her research and practice interests include: the lived experience of mental illness, especially, the employment experiences of individuals with mental illness, with a focus on the career decision making of individuals with first episode psychosis. You can contact Christa by email at: christa.boychuk@queensu.ca