Early intervention programs fail to help psychosis patients rebuild careers

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A new article published in the Community Mental Health Journal finds service users who had experienced psychosis and received early intervention in psychosis services (EIS) had significant problems finding and maintaining employment during their recovery.

This research, headed by Nev Jones from the University of Pittsburgh, reports the most common vocational outcomes for service users were unemployment and low-wage, short-term employment. Additionally, the current work reports that EIS emphasized quick placement in low-wage jobs over career development. The authors write:

“Approximately half of the participants in our sample were not in employment, education, or training (NEET) and had applied for or were receiving disability benefits (SSI/SSDI). Among those participants who were working, the majority reported short-term, low-wage work. Thematic findings elucidate factors underlying the erosion of vocational identity, as well as ways in which both participant-reported vocational service characteristics and socioeconomic background shape different pathways to college, work, and disability benefits both during and following discharge from EIS.”

The goal of the current research was to generate a qualitative description of vocational barriers faced by service users who had experienced psychosis and worked with EIS, as well as to explore EIS’s role in assisting service users in their vocational paths. To accomplish this goal, the researchers recruited 30 participants (25 service users and five family members of service users) to take part in open-ended interviews. Eligibility to participate in the current research was limited to former EIS clients and their family members.

The researchers recruited participants through letters sent to former EIS clients and flyers distributed to EIS groups. All interviews were conducted over the phone, audio recorded, and transcribed. After every 4-5 interviews, researchers reviewed the data and formulated new questions for future interviews. The interview questions were open-ended and revolved around service user’s experience of work/school before, during, and after their involvement with EIS, career goals, and disability benefits.

The present work found significant derailment of vocational paths following the initial onset of psychosis. Many participants who had been employed lost their jobs as a result of symptoms or taking time off for hospitalization. Most participants who were enrolled in college reported falling grades that often resulted in dismissal from their programs.

This pattern continued for many participants after their enrollment with EIS. Most participants chose not to disclose their diagnosis/experience with psychosis to employers or teachers. In some cases, those participants who had spoken to faculty about their psychosis experienced discrimination in the form of colleges refusing readmission after medical leave or hospitalizations.

In addition to the derailment of vocational paths, participants commonly experienced lowered expectations from family members. This can be exemplified in one participant’s report of their partner pushing for them to apply for disability benefits. While applying for such benefits was essential to ensure bills could be paid in case of a relapse, the participant reported that their partner’s push to apply for benefits underscored a lack of trust, which in turn eroded the participant’s faith in their recovery.

As a result of the derailment of their vocational paths and the lowered expectations of the people around them, participants experienced lowered self-expectations and significantly reduced clarity and motivation toward professional pursuits.

To exemplify this, the researchers point to a participant who had been studying to become a doctor before the onset of psychosis. Though his grades had plummeted after the initial onset of psychosis, he had completed his Bachelor’s degree after discharge. Despite his education, at the time of the current research, he was working in a hospital cafeteria. While he was still considering a career in medicine, the participant conveyed reduced self-confidence and doubt about his ability to continue his education.

During his interview, he said, “I [now have] such a hard time studying. So, that kind of makes me think, Hm, should I keep studying or [just] quit?

In response to losing self-confidence and clarity in terms of their vocational paths, many participants looked towards disability benefits and low-wage jobs as a temporary placeholder. While service user participants mainly viewed disability benefits as a temporary option to buy time as they figured out what to do next, their family members often considered these benefits a long-term solution to their family member’s circumstance.

The most promising path forward, as reported by service users, was postsecondary education and training. This was mostly true for participants who pursued a specific degree or a training course toward a specific trade. Conversely, participants who pursued education and training without a particular goal or degree in mind were less likely to be successful in their pursuits and more likely to give up on education, further undermining their self-confidence.

Participants described the support they received from EIS in terms of career development as mostly pushing them towards low-wage and temporary work. Many participants reported they never met with their support, education, and employment specialist (SEES) as they were already employed. They could see no utility in a meeting outside of being sent to pursue low-wage jobs and temporary work.

Some participants described active vocational discouragement during their time working with EIS. For example, the researchers point to one participant who was told not to take academic courses as they would be too difficult for her. Some participants reported positive interactions with SEES, such as receiving help filling out applications, having someone help them see what they needed to do to get organized, and having someone to report to. Following discharge from EIS, most participants received no vocational-related support.

The authors acknowledge several limitations to the current research. It is possible that participants with negative experiences of EIS were more likely to participate in interviews, possibly biasing the data towards a negative interpretation of EIS. The participant reports are highly context-dependent and may not be generalizable to other EIS programs. There were no measures of “functional status,” symptom-related impairment, etc., of participants during their work with EIS.

There was also no comparison of participants in the current study to other young people who had not experienced psychosis, meaning the lack of vocational direction observed in the present work could be a quirk of this generation of young people rather than directly related to the experience of psychosis or utilization of EIS.

The authors conclude:

“Within our sample, marked differences emerged between the career development activities of participants pursuing low-wage work and receiving disability benefits versus those able to access higher education or other postsecondary training. Overall, these findings underscore the importance of greater attention to strengthening career development supports during and following EIS and improving access to postsecondary education and training, particularly for youth from disadvantaged backgrounds. Ultimately, long-term socioeconomic mobility rather than short-term gains should serve as the ultimate goal of early psychosis services.”

Past research has shown that early intervention programs for psychosis often arrive too late to make a difference and do not adequately address childhood adversity. Early intervention for people at “ultrahigh” risk for psychosis has been shown to be ineffective. There is also no difference in symptom severity ten years after the initial onset of psychosis between those who receive early intervention and those who do not. Researchers have also questioned the ethics of early intervention in psychosis programs.

 

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Jones, N., Pagdon, S., Ebuenyi, I. et al. Recovering the Vocational Self?: Service User Accounts of Barriers to Work and School and the Role of Early Psychosis Services in Supporting Career Development. Community Ment Health J 59, 1452–1464 (2023). https://doi.org/10.1007/s10597-023-01149-3  (Link)

 

Editor’s note: This post was originally published on our sister site Mad in America, and is republished with permission here 

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Richard Sears teaches psychology at West Georgia Technical College and is studying to receive a PhD in consciousness and society from the University of West Georgia. He has previously worked in crisis stabilization units as an intake assessor and crisis line operator. His current research interests include the delineation between institutions and the individuals that make them up, dehumanization and its relationship to exaltation, and natural substitutes for potentially harmful psychopharmacological interventions.