Career Transitions and Outcomes for Young Adults with First-Episode Psychosis
By Christa Boychuk & Rosemary Lysaght
The stage of development between adolescence and adulthood is characterized by change and exploration, when young individuals are often preparing for adult work roles (Arnett, 2000, 2014). It is also a time when individuals are at an increased risk of experiencing first-episode psychosis (FEP) (Killackey, Jackson, Gleeson, Hickie, & McGorry, 2006), a debilitating condition in which an individual loses touch with reality (Reed, 2008). FEP is often a prevalent feature of serious mental illnesses (SMIs) that include schizophrenia, schizoaffective disorder, bipolar disorder, and major depressive disorder (Ontario Ministry of Health and Long-Term Care, 2011). Psychosis involves symptoms such as hallucinations, delusions, disorganized thinking and behaviors (Compton & Broussard, 2009). As a result of impairments associated with these symptoms, young individuals with FEP often face interruptions in education and career development.
Though there has been an increasing volume of literature about FEP and the development of vocational programs to improve education and employment, there has been limited attention paid to the concept of career among individuals with FEP (Killackey, Alvarez-Jimenez, Allott, Bendall, & McGorry, 2013) and SMI (Gewurtz, Kirsch, Jacobson, & Rappolt, 2006; O’Day, Killeen, & Goldberg, 2006). This has resulted in a limited understanding of vocational behaviors and overlooked the developmental nature of the employment and education decisions of youth with FEP. Based on a subset of findings from the doctoral dissertation of the first author, this article will outline the career transitions of young adults with FEP, and influential factors on their outcomes.
Three early intervention psychosis programs – clinics established to reduce the time between the onset of psychosis and the start of care – located in the province of Ontario, Canada were used in this study. Participants included service recipients with FEP (ages 18-30 years), family members of clients with FEP, and staff members who had direct client contact. Qualitative data were collected from 36 participants using sociodemographic questionnaires, one-on-one interviews, in addition to documents collected from each program (e.g., program brochures, handouts of community social services), and a research journal.
Young adults with FEP moved through several illness and recovery-related transitions:
- Pre-illness Phase
They were largely asymptomatic during the pre-illness phase and focused on developing vocational identities through career exploration activities in much the same way as non-FEP individuals. “Anne”, a staff member, expressed that co-operative placements were useful tools for high school students to develop their skills and knowledge, and shape their career choices:
They were very lucky their program was a co-op, and I think that’s another valuable tool. Co-op can sometimes help you understand, not just the skill and knowledge base, but the application of it so you can see if you’re actually going to like to do it.
- Initial Onset
During the initial onset of illness, participants experienced symptoms that included depression, anxiety, sleep disturbances, concentration difficulties, and substance use, which made it difficult for them to obtain and maintain employment and education. Individuals who abused substances engaged in limited skill development. One parent, “Ralph”, shared that his son becomes less active and motivated when he was depressed or abusing substances:
When he is depressed or abusing marijuana, he kind of shifts into neutral, and I mean full neutral. He doesn’t do anything. He is doing a little bit of cursory looking for just minimum wage jobs. But that’s about it right now. I think it’s very hard for him to motivate himself much of the time.
- Loss of Reality
Once participants lost touch with reality or experienced symptoms such as hallucinations, disorganized thinking and behaviors, their work and educational performance further deteriorated, often resulting in disengagement from education and work. According to another staff member, “Tina”, clients withdraw from career exploration if they find vocational activities are overwhelming and trigger symptoms:
Some of the ones who have tried working find the stress too much and unfortunately they’ll be let go because they can’t cope with the work or they’re exhibiting some strange symptoms that are disturbing some of the other staff. Most of them are not doing well enough to be managing a full-time job.
- Recovery Phase
During recovery, most young adults slowly reengaged in roles such as volunteering and returning to work and/or education. Following the first psychosis, most youth were goal oriented and either enrolled or planned to enroll in post-secondary studies. One client, “Diane”, considered a career in education but remained open to other career options:
Well, if it turns out that I really enjoy teaching, perhaps going into education to become a teacher. If not, then I plan to go back to school, perhaps I’ll get a master’s in international development or something on the international level. So my long-term goal is probably going back to school or getting a teaching degree.
- Long-Term Focus
Some, but not all, retained a focus on longer-term career planning and visioning their future. One staff member, “Sarah”, stated that some individuals drop-out of school, and abandon their career goals after several unsuccessful attempts at completing their education.
Some people drop out of school because they’ve experienced psychosis and they don’t go back. I have one client - every time he would try to go back to school, he would relapse. Now he’s finally going back to try to complete that fourth year and I think this is the third time. I have another client – he earned two years of university and then he went to another city to complete his degree at a larger university, and now he’s chosen not to go back and complete the degree.
Internal and External Factors
Several internal and external factors impacted the career transitions of young adults with FEP. Higher self-esteem, maturity, and social support prior to the onset of illness were associated with higher educational attainment and employment participation. According to another staff member, “Linda’, one of her client’s employer’s was supportive in helping him return to work after relapses of his illness, establishing and maintaining accommodations that were supportive of his needs:
He was employed when his illness came and his employer was a great partner in helping him return to work and he’s had a couple relapses; and they’ve even kept accommodations and kind of revolved around his needs and he’s still there. So that’s a great example of how a really positive employer can make the difference.
Lower income, rural residence, and self-stigma were associated with lower levels of educational attainment and employment participation. According to another staff member, “John”, self-stigma was a large concern for young adults, because it contributed to reorganizing their thinking pertaining to their competencies:
I think that the internalization of stigma and thinking that – because I have this illness, it defines what I’m able to do – is a big issue for people. Even the delivery of a diagnosis – we try to do it very sensitively and judiciously in this program - is traumatic for people and they start to really reorganize their thinking about who they are and what they could do. I don’t know that it is something that is easy to just step aside from and move back to where you once were.
Implications for Career Development Practice
To improve the career outcomes of young adults with FEP, increased emphasis needs to be placed on career development programming. Specifically:
- Early intervention programs could facilitate clients’ recovery and career development through the inclusion of vocation-related discussions with young adults who have FEP and provision of services by vocational staff, as opposed to limiting focus to job attainment;
- Early intervention centers could introduce programming that includes career decision-making activities (e.g., evaluation of strengths and limitations, role experimentation, action plan development) that facilitate clients’ career development;
- Initiatives that combat self-stigma through psychoeducation, cognitive and narrative techniques, and empowering experiences can potentially challenge myths about mental illness, improve self-esteem (Yanos, Lucksted, Drapalski, Roe, & Lysaker, 2015), and encourage employment and education participation.
- Supported employment with educational initiatives, and emerging career-focused interventions, could be provided across all phases of illness in mental health centers, in order to diminish the vocational and social decline of individuals with FEP.
Aiding Transitions and Changing Outcomes
Future vocational practice with the youth FEP population should occur across all stages of illness, with an emphasis on the initial onset phase. In order to reduce the disability and economic hardship of this population, emphasis should be placed on helping young adults with FEP access existing vocational services, developing new programs and improving stakeholder engagement.
*Participants names were changed in order to protect privacy and confidentiality.
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Christa Boychuk, Ph.D., is a researcher and mental health counselor who recently completed her doctoral studies in Rehabilitation Science from Queen’s University at Kington, Ontario, Canada. Her main research and practice interests include: the lived experience of individuals with mental illness and addictions, particularly, their employment experiences. You can contact Christa by email at firstname.lastname@example.org.
Rosemary Lysaght, Ph.D., is Associate Professor in the School of Rehabilitation Therapy at Queen’s University in Kingston, Ontario, and Chair of the Occupational Therapy program. Her professional expertise is in the areas of work rehabilitation, assistive technologies, and program evaluation. Her primary research focuses are work participation and social inclusion of people in marginalized groups. You can contact Rosemary by email at email@example.com.