Abstract
During the first half of the nineteenth century in America, moral treatment demonstrated that employment can improve outcome in schizophrenia. 1 In the 1960s in England the three hospital comparative study showed symptoms of schizophrenia were less in hospitals with less social deprivation. 2 International epidemiological surveys started in the late 1960s and, spanning 30 years, demonstrated that outcome for treated schizophrenia was better in low-income countries than high-income countries. 3–6 This is attributed to better social support, greater employment and greater tolerance of deviance in the low-income countries. 3–6
Over the last 15 years, emanating from the USA, supported employment has gained an evidence base for helping people with schizophrenia achieve competitive employment. 7–9 Supported employment has the benefits of social inclusion, and improved self esteem, symptom control and quality of life. 7,9 Indefinite support is provided and there are no exclusion criteria. 7 Job placements are direct and often in simple level occupations. 8
Longitudinal studies spanning between 23 and 37 years have shown a course of significant improvement for the majority of people with chronic schizophrenia with widely heterogeneous levels of functioning, even within the same person. 10–13 Diagnostic criteria are relatively non-specific in predicting long-term outcome. 13
The recovery movement stems from ex-users of mental health services and human rights movements in the USA. 14–16 In this movement, recovery is the lived experience of a person who makes a self-determined and meaningful life in the community as they face and overcome the challenges of an enduring mental illness and disability. 14,15 Effective person-centred care in mental health services can also involve attempts at clinical recovery running in parallel with supporting attempts at personal, functional and social recovery. 16
Rehabilitation is the process of mental health services helping a patient optimize their residual abilities to function at an optimal level in as normal a social context in the community as possible. 17
Despite the message of hope for people with schizophrenia from scientific studies, the Australian study on low prevalence disorders, 10 years ago, reported:
“The majority live in extreme social isolation and adverse socioeconomic circumstances. Among the many unmet needs, the limited availability of community-based rehabilitation, supported accommodation and employment opportunities is particularly prominent.” 18
The majority of people with severe mental illness have the desire and capacity to work. 19 It a right of Australian citizenship to have access to work. 19 Employment can contribute to mental health through social inclusion, a sense of purpose, role, identity and status. 20
This paper explores processes involved in social reintegration through work in schizophrenia.
METHOD
A study of an individual case was chosen to explore the topic.
A man in his early fifties with a well-established diagnosis of schizophrenia had lived in a psychiatric hostel for the past 12 years. As a young adult, he had been married with children and working in the construction industry. After suffering a serious accident, eventually requiring a hip replacement, he was in and out of psychiatric hospitals in the early phase of his illness. He still contacted his wife and children, mainly by mobile phone, and had a supportive father.
The psychiatric hostel team referred him to a mental health unit for exclusion of dementia because of a 12-month deterioration in his mental state associated with confusion, disorientation and falls. During the initial and subsequent interviews, despite poverty of speech, he persistently stated he wanted to work. After assessment, dementia was excluded and schizophrenia and institutionalism were diagnosed. 21,22
His four psychotropic drugs were stopped. His confusion, disorientation and gait instability resolved. Aripiprazole was commenced. He kept saying he wanted to work. His father, a retired businessman, thought he was capable of part-time work, but reinforced he would need supported accommodation and help with budgeting.
Two rehabilitation services excluded him and then an employment officer from an agency, providing supported employment for the disabled, accepted him. An inpatient psychiatric rehabilitation unit excluded him because his expectation to work was unrealistic, he had too many executive functioning deficits needed for work, and during the interview he was socially inappropriate, picking his nose and feet. A group home with day support workers reported he needed to be participating in a training program at least 2 hours a week to be accepted. The employment agency accepted him because there were no exclusion criteria.
Under the care of the same hostel team, he was discharged to a hostel, general practitioner and employment officer.
The author interviewed the hostel team nurse, the community mental health nurse and the employment officer 3 months after discharge to learn more about his progress.
RESULTS
The employment officer had helped him move into better supported accommodation and earn a competitive wage. Picking up his aripiprazole weekly from the local chemist, he was supported by a community nurse. His father helped with budgeting.
With indefinite support, he was working 4 hour days, 5 days a week assembling sprinkler parts for a small company. Delighted with the extra money, he was able to keep in closer contact with his family. Previously, the hostel had taken nearly his entire pension. Now he could buy his own food and clothes. Living in a large newly renovated house, he now had his own room with a lock and a shared kitchen. Other residents were mainly recovering from alcohol addiction. Two men, who initiated the project with local church community links, were there during the day providing support.
DISCUSSION
Expectations in the mental health service seemed too low for this person with schizophrenia in regards to employment achievement. 23 The service appeared too focussed on his deficits compared to building up his strengths. 24 More hope for improvement and encouragement seemed to be required. 25
Reasons for the above might include: staff burnout; institutional resistance to change; lack of knowledge of different approaches in different settings and that people with schizophrenia can work with support; lack of performance-based funding; and lack of shared decision-making driven by the patient's goals. 26
Services can be fragmented. Strong collaboration between services allows the level or type of support, medication or work to be adjusted as required. 27
A service too preoccupied with risk minimization may retard clinical, personal, social and functional recovery 16,28 occurring through supported employment that involves risk but benefits mental health overall. Symptoms can worsen from work stress, job loss or social exclusion from not working. Reasons for excessive focus on risk minimization at the expense of personal growth may be fear, lack of knowledge, paternalism, coercive practice, or fear of legal or media processes with reputation loss and distress based on a negative event.
There is a strong evidence-base for supported employment improving symptom management and psychosocial functioning in schizophrenia. 29 Supported employment can occur in parallel and in collaboration with attempts to achieve clinical recovery. Supported employment can address social exclusion, community prejudice with job development, the common fear of pension loss, the performance problems, episodes of illness, lack of confidence, and interpersonal difficulties that are the common reasons for job failure in schizophrenia. 26
Footnotes
Acknowledgements
The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.