METHODINTRODUCTION & OBJECTIVES RESULTS

DISCUSSION

Vocational Rehabilitation Specialists’ Perspectives of Schizophrenia and Employment

Kristen Laib, M.S.1,2; Yuliana E. Gallegos, M.A.1; Dennis R. Combs, Ph.D.2; & William D. Spaulding, Ph.D.1

1Department of Psychology, University of Nebraska-Lincoln

2Department of Psychology, University of Texas at Tyler

• Schizophrenia is often a debilitating condition that negatively impacts one’s level of functioning, including employment.

• U.S. unemployment rates for individuals diagnosed with schizophrenia averages 90% (Geertsen, Davis, & Ellis, 2002). In the UK, unemployment rate averages 80-90% (Marwaha & Johnson, 2004).

• In the research literature, negative symptoms of schizophrenia are more associated with unemployment than positive symptoms (Rosenheck, et al., 2006).

• Negative symptoms may lead to microbehaviors and interview skills that are not rated favorably for employment (i.e., poverty of speech, flat affect, restriction in goal directed behavior, or avolition) (Solinski, et al., 1992).

• However, the association between negative symptoms and unemployment is not entirely clear. Part of the difficulty lies in the inability to separate certain negative symptoms from social or cognitive deficits associated with schizophrenia.

• While social/cognitive deficits are not formally included in the diagnosis of schizophrenia, the DSM-IV includes 7 references to cognitive dysfunction in the disorder (Keefe & Easley, 2006).

• Additionally, in neuropsychological testing, 27% of the population diagnosed with schizophrenia are classified as neuropsychologically normal, compared to 85% of the general population (Palmer, et al., 1997).

• Research also indicates deficits in social cognition, including theory of mind (Roncone, et al., 2002), and the identification and discrimination of facial affect (Pinkham, Penn, Perkins, & Bieberman, 2003).

• To date, research on schizophrenia and employment has considered the characteristics of the consumer to understand the various symptoms of schizophrenia that negatively affect employment. The current study focuses on the perspective of the vocational rehabilitation specialist to identify the barriers they face when working with individuals diagnosed with schizophrenia in finding employment.

This study was approved by the University of Texas at Tyler Institutional Review Board and supported by the Texas Department of Assistive and Rehabilitative Services (DARS). Participants:The Vocational Rehabilitation program of DARS serves individuals with mental and physical disabilities in obtaining employment. Participants included Vocational Rehabilitation Specialists (VRS) ,as their job duties are solely in the area of employment. A total of 171 individuals started the questionnaire. Of those individuals, 127 (75.6%) were currently employed as a VRS at the time of the questionnaire and 41 individuals (24.4%) were not employed as a VRS. Only individuals currently employed as a VRS were included in the analysis of the hypotheses.Measures:A lengthy search was conducted to identify an existing questionnaire to identify the barriers to employment for those with schizophrenia from the perspective of the vocational specialist. No measures were identified that addresses the perspective of the vocational provider. Since an appropriate questionnaire was not identified, a questionnaire was created by the examiner. The questionnaire consists of three parts. Part One includes questions about the personal and professional characteristics of the participant. Part Two of the questionnaire consists of 20 questions regarding the symptoms and/or features of schizophrenia. These questions were based on positive, negative, and social/neurocognitive features of schizophrenia. Part Three of the questionnaire asks demographic questions about the participant including race/ethnicity, gender, marital status, age, etc. Procedure:The questionnaire was converted to an online survey. Participants were requested to complete the survey by email, via the survey website.

• The 20 questions in Part 2 of the questionnaire was divided into three symptom categories based on the DSM-IV criteria for schizophrenia: positive symptoms, negative symptoms, and neurocognitive symptoms. Each of the subscales was converted to item based mean score: positive symptoms (mean = 2.97 SD = .94), negative symptoms (mean = 2.88, SD = .82), social/neurocognitive symptoms (mean = 3.12, SD = .85). A repeated measures ANOVA was conducted comparing the three subscales. The results of Wilks’ Lambda = .862, F (2, 113) = 9.05, p < .001, was significant. Pairwise comparisons between the mean subscale scores showed higher ratings for social/cognitive factors than negative symptom factors as barriers in job attainment; there was no difference with positive symptom scores. • Principal components analysis (PCA) with varimax rotation was conducted to assess the underlying structure for the twenty items in Part 2 of the questionnaire. The results of the first PCA, based on the eigenvalue greater than 1 rule, revealed a 4-factor solution as the best fit for the data . The total variance accounted for by this analysis was 71.21%. The first factor, appears to reflect disorganized and catatonic behavior, had strong factor loadings on variables 4-10. The second factor, appears to reflect decreased thought processes, had high loadings on variables13-20. The third factor, appears to reflect paranoia, loaded highly on variables 1-3. The fourth factor, appears to reflect flat affect, had high loadings of variables 11-12. • A second PCA was run with a forced 3 factor solution. The total variance accounted for by this analysis was 65.18%, which is approximately 6.03% less variance than the initial PCA. The first factor, appears to reflect catatonic and disorganized behavior, includes the same variables as in the first analysis, variables 4-10. The second factor, appears to reflect negative processing, includes variables 11-18 & 20. The third factor, appears to reflect paranoia, includes variables 1-3 & 19 (Table 3).• The 3-facotr solution was considered a better reflection of underlying constructs (see discussion). As such, based on the 3-factor solution, a repeated measures ANOVA was conducted comparing the three subscales identified in the PCA: catatonic and disorganized behavior, negative thought processing, and paranoia. The results of Wilks’ Lambda = .721, F (2, 113) = 21.89, P<.001, was significant. Pairwise comparisons between the mean subscale scores shows a significant difference between all three subscales with paranoia rated the highest, followed by disorganized and cationic behavior, and negative thought processing rated as the lowest barrier to employment.

• A questionnaire was created to identify the symptoms of schizophrenia that are the greatest barriers to employment based on the perspectives of VRS. The DSM-IV diagnostic criteria of schizophrenia is comprised of positive and negative symptoms. In addition to the DSM-IV criteria, research has identified social/cognitive deficits associated with schizophrenia. The questionnaire included 20 items which related to the three underlying constructs: positive symptoms, negative symptoms, and social/cognitive deficits (Table 2). • Research shows that negative symptoms are more associated with unemployment, as compared to positive symptoms. The presented results did not support this research finding, as the participants rated social/cognitive deficits as the greatest barrier in assisting consumers to obtain employment, when compared with positive or negative symptoms. However, it should be noted that social/cognitive features of schizophrenia are a more recent interest of research and have probably not been studied specifically as a predictor of (un)employment. It is anticipated that VRS would benefit from additional training in the area of schizophrenia and the symptom areas associated with the disorder. More specifically, VRS should receive training about the negative symptoms of schizophrenia and the effect of these symptoms on one’s ability to obtain and/or maintain employment. • PCA of the 20-item questionnaire was conducted twice. First, allowing SPSS to determine the number of factors based on eigenvalue greater than 1. Second, a three factor solution was specified based on the fact that the items were designed to index three primary constructs: positive symptoms, negative symptoms, and social/cognitive symptoms. The results of the first analysis revealed four factors, while the results of the second analysis revealed three factors. While the first factor accounted for slightly more variance (71.28%) than the second factor (65.89%), the second factor analysis is a better representation of the underlying constructs as it is more precisely aligned with the DSM-IV diagnostic category of schizophrenia. The three factors identified are paranoia, disorganized and catatonic behavior, and negative thought processes (Table 3). • Based on the second PCA (Table 3), an analysis was conducted to determine which of these subscales are rated as the greatest barrier to obtaining employment, as rated by VRS’. While the first analysis was based on the DSM-IV criteria of positive symptoms, negative symptoms, and social/cognitive deficits (Table 2); the second analysis is based on the subscales of paranoia, disorganized and catatonic behavior, and negative thought processes identified by the PCA (Table 3). The results were not consistent with the first analysis, as the symptoms of paranoia , were rated as the greatest barrier to assisting consumers in obtaining employment. This was followed by disorganized and catatonic behavior. Negative thought processes were rated as the lowest barrier to assisting consumers in obtaining employment. Notably, the positive symptom subscale includes items of paranoia, as well as disorganized speech and behavior. When separating paranoia from disorganized behavior, these symptoms are seen as a greater barrier to employment. Thus, a subset of positive symptoms, paranoia, are rated as the greatest barrier to employment in this analysis. This is not consistent with the first analysis which identified social/neurocognitive deficits as the greatest barrier. The factor analysis revealed that the symptoms of schizophrenia are not consistent with the current DSM-IV-TR diagnostic category of schizophrenia. While the diagnostic criteria of positive symptoms includes symptoms or paranoia and disorganized symptoms, the factor analysis separated these symptoms into two clusters. As such, when just analyzing paranoid symptoms alone, they are reported as the greatest barrier to obtaining employment. Further research is needed to corroborate these results. If corroborated, the underlying structure of schizophrenia symptoms should be examined.

Table 3

Factor Analysis: Three Factor Solution Disorganized & Catatonic

Behavior

Negative Thought Processes

Paranoia

1. Barrier - hear voices, noises, sounds .391 .041 .660

2. Barrier - see images or objects .543 -.023 .668

3. Barrier - have delusions .223 .275 .666

4. Barrier - incoherent speech .813 -.078 .343

5. Barrier - speech is derailed .554 .422 .347

6. Barrier - dresses in unusual manner .758 .227 .150

7. Barrier - dresses inappropriately for work .875 .212 .075

8. Barrier - grooming habits inappropriate .774 .382 -.016

9. Barrier - client is non-responsive to environment .829 .186 .331

10. Barrier - has unusual/rigid body positions .713 .242 .323

11. Barrier - has flat/restricted affect .119 .682 -.111

12. Barrier - responds in brief replies .204 .733 -.119

13. Barrier - does not engage in goal directed activity .308 .653 .071

14. Barrier - unable to maintain attention .341 .597 .359

15. Barrier - unable to learn or retain information .299 .599 .392

16. Barrier - cannot adapt to new environment .258 .682 .302

17. Barrier - slow processing speed .172 .640 .327

18. Barrier - cannot discriminate affect of others .111 .690 .447

19. Barrier - cannot identify others intentions .012 .565 .621

20. Barrier - does not find pleasure/interest -.057 .783 .208

Table 2

Positive Symptoms

1. Barrier - hear voices, noises, sounds

2. Barrier - see images or objects

3. Barrier - have delusions

4. Barrier - incoherent speech

5. Barrier - speech is derailed

6. Barrier - dresses in unusual manner

7. Barrier - dresses inappropriately for work

Negative Symptoms

8. Barrier - grooming habits inappropriate

9. Barrier - client is non-responsive to environment

10. Barrier - has unusual/rigid body positions

11. Barrier - has flat/restricted affect

12. Barrier - responds in brief replies

13. Barrier - does not engage in goal directed activity

20. Barrier - does not find pleasure/interest

Social/Cognitive Deficits

14. Barrier - unable to maintain attention

15. Barrier - unable to learn or retain information

16. Barrier - cannot adapt to new environment

17. Barrier - slow processing speed

18. Barrier - cannot discriminate affect of others

19. Barrier - cannot identify others intentions

Table 1

VRSs Demographics

n (%)

Gender

Male 38 (29.9)

Female 81 (63.8)

Age Range

23-30 yrs 13 (10.2)

31-40 yrs 23 (18.1)

41-50 yrs 29 (22.8)

51-60 yrs 40 (31.5)

61+ yrs 14 (11.0)

Ethnicity European American 69 (54.3)

African American 21 (16.5)

Hispanic/Latino 22 (17.3)

Native American 3 (2.4)

Educational Level

Some College 3 (2.4)

Bachelor’s Degree 15 (11.8)

Master’s Degree 98 (77.2)

Doctoral Degree 3 (2.4)

Marital Status

Single 16 (12.6)

Married 66 (52.0)

Separated 2 (1.6)

Divorced 22 (17.3)

Widowed 6 (4.7)