Career Decision-Making Processes of Young Adults With First-Episode Psychosis

Abstract

The first episode of psychosis often emerges during young adulthood, when individuals are pursuing important educational and career goals that can become derailed because of the development of major impairments. Past research has neglected the developmental nature of employment and education decisions that young adults with first-episode psychosis make within the context of their lives. The purpose of this grounded theory study was to advance a model of the career decision-making processes of young adults with first-episode psychosis, and the influences that affect their career decision-making. The career decision-making of young adults with first-episode psychosis emerged as a multistaged, iterative process that unfolded over three phases of illness, and was affected by several internal and environmental influences. These findings suggest the phase of illness and career decision-making stage should be considered in future vocational programming for young adults with first-episode psychosis.

Keywords

adolescents youth young adults mental health and illness careers decision-making recovery qualitative grounded theory North America Canada

Psychosis is a condition that results in an individual losing touch with reality (Reed, 2008). Symptoms can include hallucinations, delusions, disorganized thinking, disorganized behaviors, or negative symptoms (Compton & Broussard, 2009). Psychosis is a prevalent concern associated with serious mental illnesses (SMIs), which are mental health disabilities that are distinguished by symptoms of severe and long duration which can substantially affect functioning in important life areas (Krupa, 2011). SMIs most often associated with psychosis include schizophrenia, schizoaffective disorder, bipolar disorder, and major depressive disorder (Ontario Ministry of Health and Long-Term Care, 2011).

Individuals often experience the first episode of psychosis (FEP) during late adolescence or early adulthood when they are working toward education and career goals that can become derailed as a result of cognitive, emotional, and functional impairments (Bassett, Lloyd, & Bassett, 2001; Ontario Ministry of Health and Long-Term Care, 2011; Ramsay, Stewart, & Compton, 2012; Reed, 2008). Disruptions can include social isolation (Bassett et al., 2001; Boydell, Stasiulis, Volpe, & Gladstone, 2010), difficulties in work and academic performance, and poor access to educational programs that lead to skilled work (Killackey, Alvarez-Jimenez, Allott, Bendall, & McGorry, 2013; Killackey, Jackson, Gleeson, Hickie, & McGorry, 2006; Rinaldi et al., 2010; Roy, Rousseau, Fortier, & Mottard, 2009). On average, 50% of individuals who experience FEP do not complete secondary school (Bowman, McKinstry, & McGorry, 2016; Killackey et al., 2013). Also, within the first year of receiving services from early intervention programs, young adults increasingly disengage from employment, as approximately 30% of individuals will make application for disability income and 60% within 5 years (Krupa et al., 2012).

In response, there has been increased literature about the vocational rehabilitation of young adults with FEP. Unfortunately, this research has neglected the developmental nature of the vocational decisions of young adults with FEP and their contextual influences. Specifically, research has not focused on the career decision-making of young individuals with FEP. Moreover, existing career decision-making theories have been primarily developed for and tested on White, non-disabled men (Blustein, 2001).

The purpose of this study was to advance a theoretical model that illustrates the career decision-making processes of young adults with FEP and the contextual influences that affect their career decisions.

Description of FEP

FEP often begins during adolescence and early adulthood with symptoms not often recognized until individuals come to the attention of mental health service providers. For instance, “the psychotic features of schizophrenia typically emerge during late adolescence and the mid-30s, with the peak age of onset for FEP in the early to mid-20s for men and the late-20’s for women" (American Psychiatric Association [APA], 2013, p. 102). Typically, individuals with schizophrenia have poorer premorbid adjustment and prognosis compared to those with other SMIs such as schizoaffective disorder (Saracco-Alvarez, Rodríguez-Verdigo, García-Anaya, & Fresán, 2009; Tarbox, Brown, & Haas, 2012), bipolar disorder (Heslin et al., 2016; Parellada, Vallejo, Burdeus, & Arango, 2017), and major depressive disorder (Crebbin, Mitford, Paxton, & Turkington, 2008; Heslin et al., 2016). Also, young adults with early onset (ages 14–24 years) are more negatively influenced by FEP than those with late onset (ages 25–35 years) because of psychosis-related experiences that result in protracted vocational and social development (Krupa, Woodside, & Pocock, 2009; Woodside & Krupa, 2010). In contrast, young adults with late onset are more established in their careers prior to becoming ill, with more employment experience and skills than individuals with early onset (Krupa et al., 2009; Woodside & Krupa, 2010). FEP affects more men than women (Compton & Broussard, 2009; Preston, Orr, Date, Nolan, & Castle, 2002; Thorup et al., 2014). Compared with women, men typically experience poorer premorbid functioning with respect to school adjustment, school performance, social functioning (Preston et al., 2002; Thorup et al., 2014), lower educational achievement (APA, 2013), and more unemployment than women (Thorup et al., 2014).

Substance abuse is also common among young adults with FEP (Wisdom, Manuel, & Drake, 2011). For instance, compared with young adults diagnosed with primary psychiatric disorders, those with substance induced psychosis have higher rates of substance use disorders and anxiety (Fraser, Hides, Philips, Proctor, & Lubman, 2012). In addition, there is higher prevalence of substance abuse among men than women with FEP (Compton & Broussard, 2009; Yung & McGorry, 1996). Specifically, among those diagnosed with substance induced psychosis, men experience worse premorbid adjustment and an earlier age of onset of drug use than women (Caton, Xie, Drake, & McHugo, 2014). Also, young adults with FEP who abuse substances experience decreased social participation compared to young adults with FEP who do not abuse substances (Woodside, Krupa, & Pocock, 2007). The presence of co-existing conditions (i.e., non-substance abuse-related conditions) such as attention deficit hyperactivity disorder (ADHD) or learning disabilities also negatively influences the educational performance, participation (Rho et al., 2015), and attainment (Cotton et al., 2017) of young adults with FEP. Young adults with FEP and ADHD often feel uncomfortable in academic settings, have poor academic performance, are truant from school, or drop out of school altogether (Rho et al., 2015). Following psychosis onset, young individuals with ADHD also show less improvement in social and vocational functioning compared with those without ADHD (Levy, Traicu, Iyer, Malla, & Joober, 2015; Rho et al., 2015). Furthermore, young adults with FEP and low levels of education are more likely to have self-reported histories of learning disabilities than young adults with FEP who have higher levels of education (Cotton et al., 2017).

The onset of FEP is often gradual, as young adults can experience social isolation, deterioration in functioning, and slowly developing symptoms that might last several months or years (Häfner & Maurer, 2001; Iyer et al., 2008; McGorry, Killackey, & Yung, 2007), with the course of illness typically worse for individuals with schizophrenia compared with those with other SMIs (Crebbin et al., 2008; Heslin et al., 2016; Parellada et al., 2017; Saracco-Alvarez et al., 2009; Tarbox et al., 2012). During the prodrome phase, an individual might begin to experience changes within themselves, but not experience clearly recognizable psychotic symptoms (Yung & McGorry, 1996). Young adults might begin to socially withdraw and experience declines in vocational activities (Yung & McGorry, 1996). Declines can include decreased job performance, loss of income, and poor academic performance (Brown, 2011; Woodside et al., 2007). Once young adults experience an acute onset of FEP, they experience additional declines in vocational and social participation, with limited social engagement, accompanied by disengagement from work and school (Brown, 2011; Roy et al., 2009; Woodside et al., 2007).

The path of recovery is variable. Once treatment begins, some young adults slowly improve while others will go through a period of delayed progress (Menezes et al., 2009; Robinson, Woerner, McMeniman, Mendelowitz, & Bilder, 2004; Wunderink, Systema, Nienhuis, & Wiersma, 2009), with functional recovery more challenging to achieve than symptomatic recovery (Hodgekins et al., 2015). Young adults begin to reengage in social and vocational roles with increasing competency, employing strategies such as creating new plans and developing new skills, matching their participation to their competencies, and learning to participate within changing social contexts (Krupa et al., 2009). Influences associated with poor functional recovery include the following: substance use (Shah, Chand, Bandawar, Benegal, & Murthy, 2017), being male, early onset, poor premorbid adjustment, negative symptoms, and belonging to an ethnic minority (Hodgekins et al., 2015).

Career Development Theories

Career development is the “lifelong psychological and behavioral processes as well as contextual influences shaping one’s career over the life span” (Niles & Harris-Bowlsbey, 2005, p.12). Career development theories provide foundations that conceptualize career development processes and contextual influences that affect career progress. Most were developed in the 1980s, with applicability limited to certain contexts. Three career development theories outlined in this section have remained predominant in current research and career development practice and are relevant to the career development of young adults with disabilities.

According to the life span, life-space theory, individuals select occupations that allow them to express themselves, or their self-concepts (Super, 1980). To develop and implement their self-concepts, individuals move through a series of life stages in a sequence of roles with different developmental tasks to be completed during each stage (Herr, 1997; Super, 1980). Movement through life stages can be discontinuous because of illness or disability (Hackett, Lent, & Greenhaus, 1991; Herr, 1997). The primary strength of the life span, life-space theory, is its developmental approach to understanding career progression throughout one’s lifetime. The main limitation is that it overlooks the impact of social and psychological influences on career development (Hodkinson & Sparkes, 1997).

Social learning theory suggests that individuals’ career choices and work-related behaviors evolve through the interaction of genetic influences and special abilities (including disabilities), cognitive processes, emotional processes, and environmental conditions (Feller, Honaker, & Zagzebski, 2001; Krumboltz & Worthington, 1999). Social learning theory suggests that career selections are based on what individuals learn from their environments (Feller et al., 2001; Krumboltz, Mitchell, & Jones, 1976). Although this theory has been incorporated into programs that focus on the development of career readiness among young adults (Krumboltz & Worthington, 1999), critics have argued that the heavy focus on learning experiences have overshadowed the contextual influences on career selection (Hodkinson & Sparkes, 1997).

Social cognitive career theory, adapted from Bandura’s (1986) social cognitive theory, theorizes that one’s self-efficacy or beliefs about their vocational abilities, beliefs about the outcomes of their career behaviors, and personal goals shape their career development (Albert & Luzzo, 1999; Fabian, 2000; Lent & Brown, 1996). An individual’s work-related self-efficacy is developed through their past accomplishments, vicarious learning opportunities, social influences, and physiological and emotional states (Lent & Brown, 1996; Lent, Hackett, & Brown, 1999). Self-efficacy is considered central to work readiness, career exploration, and workforce engagement (Lent & Brown, 1996; Lent et al., 1999). A strength of this theory has been the extensive research and empirical support for the self-efficacy construct and its predictive influence on career-related behaviors, with application to individuals with SMI (Fabian, 2000; Smith & Milson, 2011). Although this theory acknowledges the dynamic interaction between contextual supports and barriers and their influences on career-seeking behaviors, their interactions have not been explored in depth (Lent et al., 1999).

Career Decision-Making Theories and Models

Career decision-making is an important component of career development and is the “process by which individuals make career and educational decisions” (Swanson & D’Achiardi, 2005, pp. 360-361). Career decision-making theories are used to describe or explain choices individuals make when selecting career options (Tiedeman, 1961). They gained prominence starting in the 1960s and have evolved with time, and consist of two major categories of theories: rational and alternative.

Rational career decision-making theory assumes career decision-making is logical and systematic (Phillips, 1997). According to Tiedeman (1961) career decision-making is movement through a series of stages that results in one option being selected. Furthermore, a decision-maker can cycle back to an earlier stage of career decision-making (Tiedeman, 1961). Harren (1979) also suggested that specific issues must be addressed during each stage prior to moving to a subsequent stage. Although rational models provide useful career decision-making heuristics, they lack explanatory power and fail to consider relational and emotional contexts (Blustein, 2001). Moreover, rational models have been developed and primarily tested on Caucasian, non-disabled men which potentially limits their applicability to disabled populations (Blustein, 2001).

In contrast, alternative career decision-making theory suggests individuals use intuition, emotion, and subjectivity in making decisions, and to account for unplanned events and consultation with others (Amundson, 1995; Krieshok, Black, & McKay, 2009; Mitchell, Levin, & Krumboltz, 1999; Murtagh, Lopes, & Lyons, 2011). The interactive model of career decision-making developed from alternative career decision-making theory (Amundson, 1995). According to Amundson (1995), decision actions are determined by knowledge of rational decision-making, consideration of context and decision prompts, and evaluation of decision options. Although alternative career decision-making theory has contributed to a greater awareness and understanding of career decision-making, it only has one model that has been developed which does not take emotional contexts into consideration (Murtagh et al., 2011).

Research Questions

In light of these limitations, our goal was to develop a more comprehensive theory taking into consideration broad contextual influences. Specifically, the following research questions were addressed:

Research Question 1: What are the career decision-making processes of young adults with first-episode psychosis?

Research Question 2: What internal and environmental influences affect the career decision-making processes of young adults with first-episode psychosis?

Research Question 3: How do these internal and external influences affect the career decision-making processes of young adults with first-episode psychosis?

Method

Research Design

Grounded Theory is a research strategy used to derive a theory that explains a process, action, or interaction generated from data gathered and analyzed (Creswell, 2009; Denzin & Lincoln, 1994). As the purpose of this study was to generate a substantive theory of the career decision-making processes of young adults who experienced FEP, Grounded Theory resonated well with the study goals. In particular, the Grounded Theory approach of Strauss and Corbin (1990, 1998) was used to guide this study’s design, sampling, and analysis because of its systematic approach and analytic procedures.

Study Setting and Participants

Three early intervention psychosis programs—clinics established to reduce the time between the onset of psychosis and the commencement of care—located in the province of Ontario, Canada were included in this study. Participants included young adults with FEP, family members of young adults with FEP, and early intervention staff with direct client contact, who were recruited through posters listed in the common areas and offices of each early intervention facility. To facilitate recruitment, meetings were conducted at each facility with clients, family members, and staff to build their comfort and familiarity with the primary author and the study. Recruitment was an ongoing process that started in August 2013 and concluded when saturation was reached in June 2014. All participants were eligible to participate in this study if they had the ability to communicate in English and were willing to participate in a one-on-one interview. Additional criteria for young adults included the following: (a) being 18 to 35 years old, (b) experiencing FEP during the previous 3 years, (c) currently receiving treatment from an early intervention team, and (d) having work or education as a goal. Criteria for staff included the following: (a) being employed by an early intervention program, and (b) working directly with young individuals who experienced FEP.

The study sample consisted of 36 participants (19 young adults, nine family members, and eight staff). The majority of young adults were men (n = 15). Most young individuals (n = 14) were less than 25 years old and five were 25 years and older. Almost one third of the young adults (n = 7) had experienced FEP within the past year, while the remainder (n = 12) experienced FEP within the past 1 to 3 years. Young individuals had a variety of primary diagnoses that included the following: schizophrenia (n = 2), schizoaffective disorder (n = 2), bipolar disorder (n = 2), psychosis (n = 5), drug-induced psychosis (n = 3), depression (n = 1), and unknown/undetermined diagnosis (n = 4). Most (n = 13) completed “some college,” ‘some university’ or “some high school.” Five had completed high school and one had completed university. Seven young adults were students and nine were employed (full- or part-time), whereas five were unemployed. Finally, most young adults resided with parents (n = 15).

Most family members were mothers (n = 7) who had completed postsecondary education (college or university; n = 6), were married (n = 6) and employed either full-time or part-time (n = 6). In addition, staff were primarily women (n = 6). Most had completed postsecondary education (college, university, or graduate school; n = 7), and had worked for several years in social sector jobs as follows: care coordinator (n = 1), registered nurse (RN) care coordinator (n = 1), psychologist (n = 1), case manager (n = 1), RN case manager (n = 2), and family support worker (n = 2).

Procedures

Prior to data collection, this study was evaluated and ethically cleared by the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board, Hamilton Integrated Research Ethics Board, and Canadian Mental Health Association- Haliburton, Kawartha, and Pine Ridge Ethics Committee. Multiple sources and types of data were collected which included the following: demographic questionnaires, semi-structured interviews, documents from each early intervention program (e.g., program brochures, handouts of community employment, and social services resources), researcher memos, and a reflexive research journal.

After completion of informed consent, each participant completed a demographic questionnaire, which was followed-up by a one-on-one interview based on a semi-structured interview protocol. Interviews were audio-recorded and transcribed, with each interview lasting 1 hour on average, and were conducted at a location mutually agreed on by the participant and primary author. An honorarium of a Can$15 gift card was provided to each participant at the termination of the interview. Interview transcripts were then anonymized to protect participants’ privacy and confidentiality (Denzin & Lincoln, 1994). After each interview, the primary author wrote a case-based memo reflecting on what was learned during the interview (Strauss & Corbin, 1998). These memos contained the primary author’s reactions and impressions about each participant’s experiences as well as systematic questioning of pre-existing ideas related to what was said in the interview (Sbaraini, Carter, Evans, & Blinkhorn, 2011). After a few interviews, this process facilitated comparisons among memos (Sbaraini et al., 2011). Throughout the study, the first author kept a reflexive journal to detail thinking about the study and how it might influence data analysis (Strauss & Corbin, 1998).

Once initial data were gathered and analyzed, theoretical sampling was used to determine who to select, what additional data to collect (Draucker, Martsolf, Ross, & Rusk, 2007), and what questions to ask during interviews (Strauss & Corbin, 1998). This process occurred until all of the concepts under development could be substantiated in the data, or when repetitive data or no new data were obtained (Creswell, 2009; Strauss & Corbin, 1998).

Analysis

The analysis involved immersion in data and repeated sorting, coding, and constant comparison between passages of text and emerging categories, within and between participants and programs (Creswell, 2009). Analysis began with open coding, which involved breaking down, examining, comparing, conceptualizing, and categorizing segments of text line-by-line (Strauss & Corbin, 1998), to ensure that details were not overlooked. This process promoted the discovery of categories (Draucker et al., 2007; Strauss & Corbin, 1998) along with their properties and dimensions (Strauss & Corbin, 1998). Categories and the concepts were documented as code notes (Strauss & Corbin, 1998).

Open coding was then followed by axial coding, which puts data “back together in new ways by making connections between categories” (Strauss & Corbin, 1990, p. 97). From this process, categories emerged and were assigned labels (Strauss & Corbin, 1998). Each category was developed in relation to its causal conditions, context, action strategies used to manage it, and the outcomes of actions carried out (Strauss & Corbin, 1998). Code notes were used to document the development of each category, assumed connections between them, and areas for additional investigation (Strauss & Corbin, 1998).

Selective coding followed. This was the integrative process of “selecting the core categories, systematically relating it to other categories, validating those relationships by looking for confirmatory and disconfirmatory examples, and filling in categories that needed further development” (Strauss & Corbin, 1990, p. 116). Codes and categories were sorted, compared, and contrasted until no new information emerged (Strauss & Corbin, 1998). QSR NVivo 10 computer software was used to help code, sort, and organize text and generate reports (QSR International, 2012).

During the analysis, young adults with FEP were distinguished between those with an early or late onset based on their life stage and illness. These groupings were based on late onset age limits used in a study by Woodside and Krupa (2010), and six criteria set forth by Häfner, Hambrecht, Löffler, Munk-Jorgensen, and Riecher-Rössler (1998). The six criteria included the following: finished school, completed occupational training, employment, own income, partnership, and own accommodation (Häfner et al., 1998). Based on these criteria, four participants were considered late onset psychosis as they were 25 years or older at the onset of their first episode and met the majority (at least four) of Häfner et al.’s (1998) six criteria. Regardless of age, participants who did not meet the majority of Häfner et al.’s (1998) criteria were considered to have early onset psychosis. Overall, 15 young adults had early onset and four had late onset.

Trustworthiness

Several methods were used to establish the trustworthiness of the findings. Credibility was established through triangulation of multiple data methods and sources, and prolonged engagement at each study site to build rapport and trust with participants. In addition, member checks were conducted with participants once initial results were attained, to ascertain if the findings characterized the career decision-making experiences of young adults with FEP. Confirmability was established through creation of an audit trail of documentation, and use of a reflexive journal by the primary author to document observations and biases. Finally, dependability was established through external audits conducted by the co-investigators to determine the accuracy of this study’s findings, interpretations, and conclusions.

Results

Model Overview

A substantive model of the career decision-making process of young adults with FEP is described in this section. The following overview will present career decision-making as it unfolded for young adults with FEP as they progressed through relatively distinct phases of pre-illness, illness onset, and reengagement, including the demographic and contextual factors that shaped the course and outcome of the process.

Pre-illness

Young adults engaged in several activities to discover a career path during pre-illness career exploration. These activities included improving self-awareness, skill development, and discovering interests and values, which were often engaged in simultaneously. An individual’s self-awareness or perception of their strengths and limitations, thoughts, beliefs, and attitudes was an important career exploration activity, as discussed by one staff member:

Self-awareness is a really big piece of it. If you don’t know who you are or what you are, how do you find out? Sometimes you just have to try out something to find out if is for you or it isn’t. The younger people who haven’t had those years of accumulating experience yet are often doing the same thing.

In addition, one parent discussed how her daughter developed transferable employment skills through her personal network:

. . . Because she went to these community organizations and is involved in networks, that’s where a lot of the opportunities did come up. She actually had one-on-one interviews for other jobs where there was no sort of—didn’t know anybody; but they never actually ended up in a job and it was always through the networking element that people got to work with her, knew her, and then recommended her for something.

Also, young adults explored a depth and range of interests in search of a career path. One mother shared that her son explored several interests but was indecisive:

I even said—are you sure you want to take it? Because he liked this and he liked this, and then he liked this. And I always put it off as a lot of kids don’t know what they want and I mean he waited awhile—a year—to go to school.

Young adults also considered what was valuable to them during career exploration. For instance, one young man discovered an area of interest he incorporated into his value system. He shared,

I had a strong drive and valued higher education . . . I discovered philosophy through taking courses which provided me with a precedent for what I wanted to do for the rest of my life.

Illness onset and decline

During the initial onset of symptoms, young adults experienced decreased energy and motivation, insomnia, reduced concentration, irritability, and anxiety. These symptoms were associated with declines in work and school responsibilities. One staff member mentioned specific symptoms most often associated with decreased vocational and social functioning of his clients. “It’s almost always anxiety, depression, some social anxiety or other issues surrounding their decreased functioning at school or work.” In addition, one parent’s son experienced difficulties relating to others and maintaining a job. “He didn’t understand sometimes when people were talking to him and he felt as though they don’t understand him when he speaks, which made it difficult for him to keep a job.”

Following the initial onset of symptoms, young adults experienced FEP, which included symptoms such as hallucinations, delusions, disorganized thinking, and disorganized behaviors of various intensity and duration, and could result in hospitalization. One mother shared how her son was fired from jobs because of delusional thinking. She said,

Well, he lost his job. He was fired from the job that he had, so that’s the second one that he’s been fired from because he was having like symptoms—like this person was following him and physically harming him, so he couldn’t stay and finish his job.

After the onset of FEP, young adults experienced additional vocational and social decline. Most found it difficult to focus and concentrate, or plan and make goals. Others were unable to perform their work or school responsibilities. One staff member explained that the impact of psychosis on career development often depended on the age of an individual:

Younger participants were more negatively impacted than older participants, because of their lack of education and fewer life experiences, whereas, older participants were often more established in their careers before they became ill. I mean if we’re talking about somebody really young, maybe they haven’t had the opportunity to really start thinking about what they might like to do regarding career. And for others, they’ve given a lot of thought to what they’d like to do; and perhaps in some cases they have already pursued career goals and then if and when they become unwell, they perhaps weren’t able to continue with their education, or they had to leave their jobs because of unwellness.

After the onset of FEP, most young adults vocationally and socially disengaged. That is, they either left school, became unemployed, and/or received income assistance from the government or their family. For instance, one parent discussed how her son disengaged from employment because of his delusional thinking:

Then the next week he was helping me pick up a car— he started telling me about how he had broken up a child porn ring and that his dying friend actually had resolved this whole issue and that he’d been under police protection . . . . The next day he said he had a job interview with a big company and a good starting salary, and was going for a double interview for two positions. And I’m thinking—he’s lost touch with reality . . . But he went and he was supposed to start the job in January, which didn’t happen.

Reengagement

Although the same types of career exploration activities occurred before and after FEP, they often presented differently after illness onset. Most young adults developed a renewed interest in vocational and social activities as they continued to engage in treatment, their symptoms improved and they learned to manage their illness. One young man shared that he decided to obtain work in a factory because he grew tired of engaging in unproductive activities:

I work in a food plant. I’m one of the workers that is in charge of vegetable prep and I work along with my brother-in-law, and that’s the person that got me the job . . . I was kind of unhappy about my lifestyle—just sitting at home playing games, doing nothing.

Also, most young adults engaged in career exploration depending on their continued engagement in treatment, severity of their illness, and their readiness to engage in vocational activities. Early in his recovery, career exploration provided one young man with opportunities to explore different interests and career options. He shared,

When I was going through my rehabilitation—coping with my disorder—I first wanted to study theology. And then I wanted after that to study sciences and maybe go and be a chemist. And then I was thinking of doing a program where it was for a medical tech. And then now I’m moving back into culinary.

In contrast, some young adults chose to return to prior employment and not engage in further career exploration. For instance, one young man returned to carpentry after his illness because of his familiarity and comfort with this type of work. “The main reason I do carpentry work is because I’ve been brought up around it. My dad builds houses and sells them. We live in them for a year or two and then we usually sell them.”

Some young adults remained in the career exploration stage, whereas others moved forward to goal progression, which included goal selection, action, evaluation, and advancement. That is, young adults selected a career goal and took action to achieve it through various means such as vocational services, volunteering, networking, or entering school or training programs. Once a young adult took action, they evaluated progress toward their career goal, some achieving incremental progress. A staff member shared that one of her current clients was working full-time, and was interested in returning to university, but realized he needed to pursue his goal slowly and monitor himself. She said,

Another fellow was at university and then he had his break; and so now he’s working full-time and wants to return to finish university, but it’s dicey. He’s very sensible and organized because he’s saying—I’m going to do this, this month; and then next month I’m going to take a course again and see how that goes. And he’s done that within himself probably with some support and monitoring and talk over the months.

If an individual did not make measureable progress toward their career goal, they could either make modifications, such as decreasing their work or school responsibilities to help them move forward, or shift to an earlier step in goal progression or back to career exploration. One mother shared that her daughter pursued a career in creative writing, but started to explore alternative careers because of financial considerations:

. . . She planned on being a creative writer. But now I think she’s being more practical in recognizing she needs to earn money and understands from exposure to writers that they don’t make big money . . . At this point, she is exploring other career possibilities.

Internal Influences

From the pre-illness through reengagement phases, several internal influences affected the career decision-making of young adults with FEP. Internal influences included substance use, co-existing conditions, self-esteem, self-stigma, maturity, and motivation.

Substance abuse

Young adults who excessively used psychoactive substances struggled with skill development. For instance, some young men who abused substances engaged in limited skill development after the onset of illness. One mother mentioned that her son struggled at his part-time job because of substance abuse. She said,

He’s had a part-time job with a local moving company two days a week . . . He has some money, but that’s about it . . . He tended to binge; he would get some—a bottle and drink it at night . . . But the next day, because he was up maybe at 3:00 or 4:00 in the morning if he has to go do something the next day, he couldn’t function.

Before and after the onset of illness, career exploration and employment became less valued for some young individuals dealing with substance abuse. One young man explained how he lost several jobs because of substance abuse:

Drugs have always been a big part of my issues. The problem is I work and have all this money, then I slip up, and spend the money on drugs and end up getting fired.

Alternatively, young adults who stopped abusing substances returned to career exploration during their recovery. For one young man, quitting drugs was essential to attending school and moving toward a career in social services. He said,

Prior to becoming sick I kind of—like I’d stay up late all night drinking and smoking weed so I didn’t have to work. And now I actually wake up excited every day to go to school . . . I am also completing my Social Service Work diploma, which I will soon be finished. Next, I’m thinking of going to [University A]—they’re opening, or possibly opening, a B.S.W. course.

Co-existing conditions

Young adults with co-existing conditions such as learning disabilities were more likely to occupy unskilled jobs. One father described how his son struggled with a learning disability and worked in entry level jobs:

Even prior to psychosis, it was very hard for him to do anything other than a minimum wage, basic job . . . he had a lot of issues with executive functioning, sort of planning and making things happen, and being places on time.

In addition, young adults with learning disabilities, ADHD, and social anxiety struggled to complete their studies before the onset of illness, and often chose not to finish their studies after the illness stabilized, which was described by one staff member:

There’s a sizable amount that have had some difficulties with school. Some of it is learning disabilities, ADHD, or social anxiety. They never felt comfortable in a school setting and don’t want to return at a later time.

Self-esteem

Young individuals’ self-esteem, or attitude about themselves, influenced their career outlook after the onset of illness. For instance, one young man’s low self-esteem contributed to depression and negative perception of his life and career. He said,

I have struggled a lot with self-esteem. Like I said, the low self-esteem turned into depression, and that factor influenced how I look at life and what I want to do.

Self-stigma

Self-stigma, or one’s beliefs and acceptance of others’ negative labels about mental illness, also influenced the career decisions of young adults as they often reevaluated their identity and potential based on their diagnosis. Often self-stigma remained challenging for clients even though their goals were still attainable. According to one staff member,

The stigma trickles down to them and then they find out. I mean, once they sit around here demanding a diagnosis—why? Why do you want a diagnosis? Let’s move away from it and live your life. A mental illness is such a debilitating thing to them and to our society sometimes; and it’s a tougher job to achieve your career goals when you are battling one. But the goals are still attainable and I’d like to put that into the heads of the clients that I work with.

Maturity

A young adult’s maturity, or knowledge and ability to make decisions that serve their best interests, was vital to developing career goals after the onset of illness. According to one staff member, young adults were often unready to develop career goals because of their lack of maturity:

There are some that are quite comfortable with how they are and their goal is not necessarily working or moving forward at this point in time . . . I think when they get a little bit older and more mature they might have more vocational and educational goals.

Motivation

The career decisions of young adults were influenced by the level of motivation after the onset of illness. Some were vocationally active because of extrinsic rewards such as income, while others were intrinsically motivated by personal interest. For instance, during her recovery, one young woman was motivated to pursue teaching, despite unfavorable labor market conditions. She said,

But then again, if you’re really in love with something . . . you shouldn’t give up based on the fact that it looks like gods are against you. Like I said, It’s something I’m interested in. I know the job facts and figures are looking negatively toward teaching, but I plan on pursuing it.

Environmental Influences

In addition, from the pre-illness through reengagement phases, several environmental influences affected the career decision-making of young adults with FEP. Environmental influences included demographic features, income, the labor market, and social support.

Demographic features

During the pre-illness phase, demographic features affected the early evolution of career decision-making by providing career exploration activities that included personal experiences and information gathering. These features included previous employment experiences, educational attainment, and geographic region of residence. In terms of prior employment experiences, many young adults worked in a variety of entry-level jobs for short durations, and these appeared to inform future career decision-making. For example, one young woman shared that she worked in the hospitality and customer service industries after she completed high school, to explore potential careers:

I was a cook in a restaurant. I was an assistant at a steel, metal processing plant. What else did I do? I worked at a car wash doing auto detailing. I worked at a denture clinic and I worked in retail . . . These jobs seemed interesting and something I might like to pursue further. If they didn’t work out, I just left.

Most young adults with early onset were not completely focused on a career, as it was perceived as something occurring in the distant future. This was the case of one young man, whose goal was to become a chef; he recognized, however, it would take time and additional education before he could work in his desired career. He said,

I have to get training in how to do it properly and everything, so that’s probably like 10 years down the road or something like that. But that’s respectable, I think. Just before that I want to get to college, graduate, and start training under some chefs.

Geographic region of residence also influenced young adults’ career exploration. A staff member expressed that one client’s pre-illness desire was to achieve career-based employment, but he felt constrained by his small community:

He was working full-time, but wanted to be doing more—to finish school and get a career . . . And so for him, he wanted more of a career-based, long-term employment. Sometimes it’s just the area, because it is small and rural we don’t have a lot of jobs and you take what you can get.

Income

The amount of income young adults received after illness onset also influenced career choice. A staff member mentioned that many of her clients with early onset who were ill for several years had difficulty completing postsecondary education because of a lack of income. She also stated that families were often unable to contribute additional income to help clients/family members complete their education, and often student loan funding was exhausted:

There’s a number of young people who have been ill for a number of years and they’re in their 6^th and 7^th year of university and family is saying enough already, we can’t finance this. The Ontario Student Assistance Program (OSAP) is saying no more funding. Or they just have not had a long enough period of wellness to be able to find work, make money to afford academics—another semester or two or three of academics. So money sometimes is a big factor.

Labor market

The supply and demand for labor in a geographic region also influenced the career decisions of young adults after illness onset. One young man expressed doubts about pursuing advanced education, because of the potential impact of the labor market on his career and finances:

Probably just job markets or how likely it would be for me to get a job, just in case I don’t—well, I don’t want to get into a career and being having to pay off student loans if I can’t even find a job for myself.

Social support

Young adults often relied on family to provide them with emotional support following the onset of illness, which was critical to their forward progress. One mother described how family members supported her daughter’s career decision-making during her recovery:

Her family members are supportive and we’ve always tried to encourage her to look at and try new things related to different careers. We haven’t—like we have never said “do this or do that.” It’s about trying to give her options to choose from.

Discussion

Young adults with FEP engaged in career decision-making processes that varied across three illness-related phases and were affected by several contextual influences. Pre-illness and reengagement career exploration consisted of activities that included building self-awareness, exploration of interests and values, and skill development. In this study, young adults with FEP developed self-awareness through age, life experiences, and receipt of mentorship. According to Super (1980), self-awareness is an important component of self-concept. The development and implementation of one’s self-concept is significant to career exploration, career choice, and achievement of career satisfaction (Super, 1980). Moreover, Lent and Brown (1996) considered self-efficacy, or the belief one has in their vocational abilities, important to developing self-awareness. In addition, Fabian (2000) suggested self-efficacy related to the vocational performance of those with SMI is influenced by personal factors, disability factors, and environmental influences, and can be improved by past accomplishments, vicarious learning opportunities, social influences, and physiological and emotional states (Lent & Brown, 1996; Lent, Hackett, & Brown, 1999). Overall, these findings suggest strategies that build self-awareness should be incorporated in vocational interventions for youth with FEP.

Similar to the findings of this study, skill development is a prevalent factor in social learning theory, which asserts that learning experiences occur through social interactions, institutions, and environmental events (Feller et al., 2001; Krumboltz et al., 1976). Skill development helped young adults identify their interests and abilities as well as build transferable skills. Young adults’ interests were diverse and explored through hobbies, school, and nonschool activities, which allowed them to explore work-related activities. This finding is consistent with the exploration stage of career development in the life span, life-space theory, where young adults engage in different vocational tasks to develop their interests and skills (Super, 1980).

Values also played a role in the career decisions of young adults with FEP. Consistent with prior literature Super (1980), values were explored through extracurricular activities and educational and employment experiences, and served as guideposts to help young adults with FEP determine the importance of the careers they contemplated. The influence of values was also cited by de Waal, Dixon, and Humensky (2017), who evaluated ratings of importance (ROI) across life domains in a sample of young adults in an FEP recovery program at baseline and after 12 months. They found the life domain participants rated most important at baseline was school and work functioning which predicted work and school participation after 12 months, after controlling for baseline participation, educational attainment, symptoms, and demographic characteristics. Together, these findings stress the importance of exploring the values of young adults being treated for FEP, as many life domains are affected, notably, work and school.

During illness onset, young adults experienced a progression in symptoms that made it difficult to continue with school and maintain employment, as found in other studies (Bassett et al., 2001; Roy et al., 2009, 2016; Woodside et al., 2007). Similar to other FEP samples, young adults in this study became financially dependent on their family or government assistance (Dewa, Trojanowski, Cheng, & Loong, 2012; Killackey et al., 2006; Rinaldi et al., 2010; Roy et al., 2016). Akin to Brown (2011) and Hansen, Stige, Davidson, Moltu, and Veseth (2018), many young adults in this study knew little about psychosis and did not seek early assistance, as they experienced the onset of symptoms for months or years and often normalized these experiences. Furthermore, the decline in vocational and social participation affected individuals with early onset more than those with late onset because of interrupted development of work skills and interpersonal skills that limited their educational attainment and work experiences. These findings highlight the need for increased vocational intervention during early phases of FEP that target young adults with early onset. In addition, these findings also suggest that early mental health screening and management of young adults’ mental health concerns in school settings could potentially minimize the disablement and vocational disengagement of young adults with FEP. Mental health teams and mental health screening have demonstrated positive impacts on social and academic achievements (Haynes, 2002; Husky, Sheridan, McGuire, & Olfson, 2011). Moreover, these challenges also indicate that the development and delivery of vocational interventions, such as the rapid placement approach advocated by the individual placement and support (IPS) model (Bond, 2004), could potentially reduce disability and economic hardship for young adults with FEP.

During the reengagement phase, young adults gradually participated in vocational and social activities, and subsequent career exploration, depending on treatment engagement, improvements in symptoms, their skill at managing their illness, and their vocational readiness. Some began working or attending school part-time and remained on government assistance to keep their benefit entitlements if work or school participation was unsuccessful. These findings imply FEP intervention programs should facilitate clients’ learning of self-care and social skills as well as teach them to manage vocational activities within changing environmental contexts (Woodside et al., 2007) to encourage vocational engagement.

As career exploration proceeded, participants engaged in goal progression which included different developmental tasks such as selecting a career goal, taking action, evaluating progress, and advancement toward their goal which was similar to other findings (Amundson, 1995; Amundson, Borgen, Iaquinta, Butterfield, & Koert, 2010). Few young individuals reached the goal progression stage because of early onset, substance abuse, and other co-existing conditions which disrupted career decision-making. This suggests vocational interventions are needed to target and engage these specific subgroups. Action steps young adults took to move toward their career goal included accessing vocational services, part-time work, entering school or training, volunteering, and networking, which aligns with the findings of Amundson (1995). He theorized individuals consider different career options before choosing a career goal and taking a course of action. Once action steps were taken to move toward a career goal, young adults could advance toward their goal, make modifications, or move to an earlier stage of career decision-making, if they were not satisfied with their progress. Modifications employed by young adults in this study included reducing their work hours, decreasing their academic course loads, and making workplace modifications. These findings are consistent with rational (Harren, 1979; Tiedeman, 1961) and alternative theories of career decision-making (Amundson, 1995). Together, these findings imply career decision-making is a staged series of processes.

Several internal influences affected the career decision-making processes of young adults with FEP. Young adults who abused substances struggled with skill development compared to young adults who did not abuse substances, as those who abused substances placed increased value on substance use and less on skill development. However, it was reported that young adults engaged in career exploration activities if they quit abusing substances. Luciano and Carpenter-Song (2014) found young individuals with FEP who were treated for substance abuse were more engaged in treatment services if they participated in vocational activities and developed career goals. Overall, these findings suggest substance use treatment facilities should consider providing vocational activities to support the career development of young adults with FEP as a strategy to engage them in treatment.

Young adults with co-existing conditions including ADHD, learning disabilities, and social anxiety had limited education and employment experiences. Similar to other research (Levy et al., 2015; Rho et al., 2015), this study found young adults with FEP and ADHD had lower academic achievement and poorer vocational and social functioning when compared with those without ADHD. Similar to Cotton et al. (2017), this study found young adults with FEP and learning disabilities had lower levels of education than individuals without learning disabilities. Also, young adults with FEP and social anxiety had less vocational participation than those without social anxiety, which has not been specifically examined in other research. Together, these findings suggest individuals with substance abuse and co-existing conditions are unique subgroups that are inadequately served by existing vocational intervention services, and should be examined in future research.

Youth experienced declines in their self-esteem as psychosis-related symptoms limited their ability to establish and carry out vocational and social activities, which concurs with other research (Bassett et al., 2001; Brown, 2011; Lucksted & Drapalski, 2015). This highlights the need for mental health professionals and vocational specialists to address self-esteem with clients by enhancing their self-efficacy, which in turn can facilitate their vocational participation (Lent & Brown, 1996). Potential interventions could include psychoeducation programs to help clients develop coping skills, and teach them to acknowledge and challenge inaccurate self-beliefs and negative outcome expectations. In addition, vocational programs could provide work experiences that have performance-based and vicarious learning experiences (Fabian, 2000).

Self-stigma experienced by young adults was based on internalizing messages and beliefs that society and their families held about mental illness, and personal fears of having a mental illness label. This description was comparable to the stigma experiences described by participants in Franz et al.’s (2010) FEP sample as well as other disability groups (Megivern, Pellerito, & Mowbray, 2003; D. Stewart et al., 2010). Self-stigma was a large concern for participants because it contributed to them reorganizing their thinking about their competencies. As a result, they often negatively reevaluated their identity and potential based on their diagnosis, even when their career goals were attainable. Self-stigma initiatives that provide psychoeducation, cognitive and narrative techniques, and empowering experiences can challenge mental illness stereotypes, improve self-esteem (Yanos, Lucksted, Drapalski, Roe, & Lysaker, 2015), and encourage individuals with FEP to engage in career decision-making activities.

Young adults with early onset were less vocationally mature than young adults with late onset, likely because of chronological age differences, lower education levels, and fewer employment skills and experiences. These influences afforded them less opportunity to develop their career decision-making competency. Similar to other research (Woodside & Krupa, 2010), young adults in this study were extrinsically motivated to return to employment out of financial need, whereas intrinsically motivated participants were vocationally engaged because of personal interest. Moreover, those who were intrinsically motivated were more active and persistent in working toward their education and career goals than those who were extrinsically motivated. This finding is consistent with Blustein (1988) and Paixão & Gamboa (2017) who report that internally motivated individuals more readily engage in career exploration relative to those who are externally motivated. Overall, these findings highlight the need for different vocational intervention practices based on differing motivational profiles. For instance, Paixão & Gamboa (2017) suggest that internally motivated young adults might benefit from independence during the career exploration process, whereas externally motivated young individuals might benefit from structured career exploration.

Demographic features, income, the labor market, and social support were environmental influences that affected the career decision-making of young adults with FEP. During the pre-illness phase, demographic features such as educational attainment, previous employment, and geographic region affected the early progress of young adults’ career decision-making. This study found that young adults with low levels of educational attainment and few employment experiences had limited opportunities to develop careers, compared with young adults with more education and employment experience. This finding is similar among other individuals with FEP (Dewa et al., 2012; Tapfumaneyi et al., 2015) and without disabilities (Chambers, Rabren, & Dunn, 2009; Human Resources and Development Canada, 2010; Winn & Hay, 2009). Based on these findings, developers of vocational interventions for this population should focus on educational development and access to diverse employment experiences.

Prior to illness, young adults who resided in rural geographic regions had few employment opportunities and limited education because of restricted vocational choices and opportunities for learning and skills obtainment, similar to others with FEP (Bowman et al., 2016) and without disabilities (Kumar, Jones, Naden, & Roberts, 2015). Because of the limited focus on service delivery in rural regions, the economic and educational disparity observed among those with FEP in rural regions warrants additional examination in future studies. Also, most young adults were financially dependent on their families or government assistance because of significant impairments. Similarly, young adults without disabilities often financially rely on their families, because of increased education and delayed career entry (Andres & Adamuti-Trache, 2008; Beaujot & Kerr, 2007; Rojewski & Kim, 2003). This suggests both disabled and nondisabled young adults experience protracted transitions into adulthood because of different factors. The structure of government assistance programs also compromised the financial independence and career development of individuals with FEP in this study, as many found it a disincentive to work. In addition, some were unstable early in their recovery and continued collecting government assistance for fear of losing health coverage, as found elsewhere (Canadian Mental Health Association Ontario and Centre for Addiction and Mental Health, 2010). These findings suggest future policy changes in government income support programs should focus on developing and delivering vocational supports that promote the career development of FEP income recipients.

Labor market conditions also influenced the career decision-making of young adults after illness onset. Young individuals with FEP who resided in rural labor markets earned lower wages and had limited opportunities to develop their skills and build career opportunities compared to participants who resided in urban labor markets. Similarly, Bowman et al. (2016) found young adults with FEP who lived in rural areas had limited access to career-related services, lower educational aspirations, and fewer individuals completing secondary school compared with individuals with FEP residing in urban areas. These findings demonstrate the need for enhanced funding to develop and evaluate FEP interventions for vocational programming in rural labor markets.

Similar to Hansen et al. (2018), this study found support from family members, employers, and mental health service providers (K. D. Stewart, 2012) was crucial to young adults with FEP. Social support primarily had a positive impact on the career decisions of young adults following the onset of illness. Support persons contributed to young individuals improving their career decision-making competence by providing validation of thoughts and feelings, advice, information and encouragement, which is consistent with findings from non-disabled samples (Phillips, Christopher-Sisk, & Gravino, 2001; Schultheiss, Kress, Manzi, & Glasscock, 2001). Similar to Rinaldi et al. (2010), this study found some young adults had parents who discouraged their vocational reengagement, as they believed it would jeopardize their loved one’s recovery, which in turn, decreased young adults’ career decision-making competence. These findings highlight the need for vocational programming to include psychoeducational programs to teach families about psychosis, facilitate their access to resources, provide stigma education and support, and build resilience (McFarlane, Dixon, Lukens, & Lucksted, 2003).

Limitations and Future Research

This study was limited to young adults, family members, and staff who were associated with three early intervention clinics in one Canadian province. This could result in limited transferability of findings to other clinics and geographic jurisdictions where differences in systems and service factors might affect career decision-making.

Next, this sample was underrepresented by women and young adults with late onset psychosis, which potentially limited the theoretical development of the career decision-making processes of these subgroups. In addition, this study was cross-sectional, which could have resulted in a limited understanding of the career decision-making processes of this sample, as participants were not followed through their individual journeys of recovery and career entry.

Future research should explore whether differences in career decision-making exist based on gender and psychosis onset. Another line of inquiry is to examine how supported employment programs such as IPS influence the career decisions of young adults with FEP. Specifically, what components of these programs support career decision-making and what program components should be modified to optimize career decision-making? Finally, additional inquiry should investigate the career decision-making of young adults with FEP who reside in other jurisdictions, to ascertain the comprehensiveness of this model.

Conclusion

In this study, we used Grounded Theory methods to advance a model of the career decision-making processes of individuals with FEP, as existing career decision-making models have overlooked the complexity of young adults’ vocational behaviors and considered limited contexts. The results indicate career decision-making involved multistaged iterative processes that occurred over three phases of illness and were affected by several contextual influences. Consequently, more research is needed to test the comprehensiveness of this model in other jurisdictions, and to explore the impact of gender, psychosis onset, and vocational interventions on the career decision-making of young adults with FEP.

Footnotes

Acknowledgements

The authors thank the clients, family members, and staff from each research site who participated in this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Christa Boychuk is a researcher and mental health counselor who recently completed her doctoral studies in Rehabilitation Science at Queen’s University in Kingston, Ontario, Canada.

Rosemary Lysaght is an associate professor in the School of Rehabilitation Therapy and chair of the Occupational Therapy program at Queen’s University in Kingston, Ontario, Canada.

Heather Stuart is a professor in the Departments of Public Health Sciences, Psychiatry, and School of Rehabilitation Therapy at Queen’s University in Kingston, Ontario, Canada.

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