The experiences and perceptions of individuals diagnosed with schizophrenia regarding the challenges they experience to employment and coping strategies used in the open labor market in Cape Town,South Africa

Abstract

BACKGROUND:

There is limited research available regarding the coping skills of individuals living with schizophrenia and the strategies used in the open labor market, particularly from a South African context.

OBJECTIVE:

The aim of the study was to explore and describe the barriers, facilitators and coping strategies that individuals with schizophrenia use when returning to the open labor market after participating in a vocational rehabilitation program to improve work skills.

PARTICIPANTS:

Four individuals diagnosed with schizophrenia and two key informants (occupational therapists) participated in the study.

METHODS:

The research study was positioned within the interpretive paradigm, specifically utilizing an exploratory and descriptive design. Semi-structured interviews were used in order to gather data from the participants.

RESULTS:

Theme one reflects the barriers related to returning to work (i.e. society’s acceptance of an individual’s work potential). The second theme relates to the enabling factors related to returning to work (i.e. the usefulness of work preparation programs to enhance open labor market employability). Theme three relates to the coping skills that individuals with schizophrenia utilize (i.e. holistic support enhances participation in the worker role).

CONCLUSION:

In conclusion, the findings indicate individuals with schizophrenia experience barriers that prevent them from being able to adapt to their work environments. However, with the support of the occupational therapist, family, and employer, together with improvements to the vocational rehabilitation program, these barriers may be alleviated, and there could be an improvement in the reintegration of individuals with schizophrenia into the open labor market. The findings suggest that the disclosure of an individual’s medical diagnosis, in order to facilitate the return to work of an individual diagnosed with schizophrenia, could be viewed as a barrier and a facilitator.

Keywords

Open labor market schizophrenia coping skills and strategies rehabilitation

1 Introduction

The research study aims to identify the effectiveness of vocational rehabilitation on work opportunities with regard to individuals diagnosed with schizophrenia, and identifying their reintegration success into the open labor market. The global average unemployment rate of individuals with a mental illness, according to the World Health Organization [1], is approximately 90%, in contrast to that of individuals with sensorial or physical disabilities, which is approximately 50%. Again, expressed differently, only 10% of persons with a serious psychiatric background are employed globally. Due to these high levels of unemployment, individuals with psychiatric illnesses can experience economic poverty and are deprived of social networking within their communities. According to Bevan et al. [2], a substantial proportion of working age individuals with a history of schizophrenia are able and eager to work. However, this group of individuals has one of the highest unemployment rates, despite repeatedly expressing the need for vocational training, placement, and dependable support services. According to Taskila, Steadman, Gulliford, Thomas, Elston, & Bevan [3] there is a strong need for research to look at factors that advance relationship-building among colleagues. There is also a need to view research, particularly from the lived experiences of individuals with schizophrenia, about the manner in which they adapt to the worker role [4]. Currently there is a void in the literature that focuses on the adaptation and coping strategies used by individuals living with schizophrenia, particularly when being employed in the open labor market. It is therefore essential to gain an understanding of the strategies individuals with schizophrenia use to adapt to work in the open labor market. This information would be beneficial in developing vocational rehabilitation programs that aim to enhance the transition of individuals living with schizophrenia to employment in the open labor market.

2 Literature review

2.1 Incidence of schizophrenia and stigma

Schizophrenia is the ninth leading cause of disability worldwide. It is viewed as one of the most severe mental disorders. The average onset age of schizophrenia in South Africa is between 25 and 35 years of age for males and females [5]. Having a family history of mental disorders in close or distant relatives increases the risk of developing schizophrenia. It has been highlighted that 10% to 13% of individuals diagnosed with schizophrenia commit suicide. According to Dickerson, Sommerville, Origoni, Ringel, & Parente [6], many individuals with schizophrenia experience discrimination because of their mental illness. A large number of individuals with schizophrenia are of the opinion that people view them in a critical manner because of their diagnosis and many schizophrenics avoid sharing this information with other people. People with schizophrenia have stated that they have heard offensive statements and remarks made about psychiatric disorders [6]. It could therefore be argued that a lack of public awareness about schizophrenia could negatively affect the ability of a person living with the diagnosis of schizophrenia to find employment.

2.2 The importance of work as a meaningful occupation for individuals with mental illness

According to the World Health Organization [7], the link between work and one’s mental health is significantly evident. Health professionals highlight that a working environment improves one’s mental health in relation to personal identity, self-esteem, and social participation, and, for most individuals, relates to a desire or goal to obtain some form of employment or return to the industry in which they had previously worked. Lovvik et al. [8], highlights the relationship between employment and an increased anxiety due to the possible experience of not being proficient enough, not being able to cope with stressors, and not being able to reach role expectations within the work setting. Khalema & Shankar [9], agree and state that these stressors are triggers and decrease mental health. Although the World Health Organization [7], identifies the aspect of job stress to have a significant impact on one’s health and wellbeing, they too identify that employment also improves one’s mental health. The World Health Organization [7], continues to highlight the importance of further exploring the effects of unemployment on mental health. This relationship was not explored in detail, although a link between unemployment and degeneration in mental health was highlighted.

2.3 Barriers that prevent returning to work by individuals with brain injury

According to Zaprutko et al. [10], individuals living with a diagnosis of schizophrenia are often afraid to seek employment. This anxiety brings about a higher prevalence of individuals who are able to work but are currently unemployed. In addition, this fear often negatively affects motivation and drive to engage in work occupations. According to the World Health Organization [7], three factors are highlighted to help individuals return to work. The first is to return to work within a short time frame of being out of work or injured. The second is to be aware of and acknowledge the job requirements before making a decision on returning to a work environment. The third factor looks at providing an opportunity to start part-time work initially before going into full-time work, allowing flexibility and less job stress. Collin [11], further argues that factors contributing to returning to work include one’s behavior in wanting to develop oneself willingly, as well as finding meaning within the work one is doing. Developing coping skills to compensate for the difficulties experienced helps clients in returning to work if they have a supportive environment [12].

Communication between the person returning to work and the supervisor from the vocational rehabilitation program is an influencing factor on the effectiveness of the program in enabling an individual’s ability to return to work [9]. Personalized intervention that occurs immediately after the diagnosis of a condition facilitates a high rate of return to work for individuals with schizophrenia. The latter study also highlighted that the outcome of one’s ability to return to work is highly influenced by experienced symptoms. Brichford [13] indicated that, with the utilsation of interviews, he was able to gain insight into how individuals living with a diagnosis of schizophrenia adapt to the workplace, and found that the positive symptoms of schizophrenia, which include hallucinations and delusions, can be addressed and resolved through the use of medication; while the negative symptoms of schizophrenia, such as concentration and motivation, remain affected. Due to the fact that the negative symptoms are not addressed through medication, the individual’s ability to adapt to the workplace is still affected. In some cases individuals have had to change their work environment. According to Taskilaa et al. [3] other barriers that prevent individuals from maintaining their worker roles include disability benefits that demotivate the individual with regard to seeking employment, high costs related to vocational intervention, and a lack of coordination of services between health professionals.

The proposed research study explores the coping skills and strategies that individuals with schizophrenia use when returning to work in the open labor market after receiving vocational rehabilitation.

3 Aim

The aim of the study was to explore the barriers, facilitators, and coping skills that individuals with schizophrenia use when returning to work in the open labor market after participating in a vocational rehabilitation program.

4 Research design

Qualitative researchers study topics in natural settings, interpreting phenomena in terms of the significance people bring to them [14]. The current study was positioned in the interpretive paradigm specifically using an exploratory research design. Explorative research can be identified as the exploration of new phenomena in order to develop an understanding of people or events. In the current study an exploratory design enabled the researcher to obtain detailed information about the coping strategies used by people diagnosed with schizophrenia.

5 Population and sampling

Three participants were purposively sampled from the statistical records of the Occupational Therapy departments of psychiatric hospitals in the Western Cape, South Africa. Purposive sampling was used because the researcher wanted to explore the specific experiences of individuals living with the diagnosis of schizophrenia and who successfully transitioned to open labor market employment after rehabilitation. This sampling strategy is important because the majority of individuals living with schizophrenia in the South African context are dependent on a government disability grant. The participants took part in a vocational rehabilitation program of 6 weeks in duration that was focused on improving work skills. The inclusion and exclusion criteria are set out in (Appendix A).

5.1 Data collection

The researchers were occupational therapists who conducted three semi-structured interviews with each of the four participants, including the key informants (See Appendix B). The researchers had no prior contact with the participants. The names of the participants were obtained from the statistical records of one psychiatric hospital that has a work integration program. The clinicians at the hospital contacted the participants and informed them about the study, and then the participants were given the opportunity to contact the researchers themselves. When the participants contacted the researchers, the requirements of the study were described in more detail. The study participants received no financial compensation for participating in the study. The researchers used a semi-structured interview guide to ask the participants questions relevant to the study (See Appendix C). The data gathering took place at the key informant participant’s place of work and at a psychiatric hospital where treatment/intervention was received. The researchers prepared the interviewee for the interview by building a relationship and explaining the study beforehand to help the participant feel more relaxed and comfortable. Interviews were conducted with the four research participants and key informants until data saturation was achieved.

6 Data analysis and trustworthiness

The researchers used the data analysis method described by Tesch [15]. Data analysis has eight core steps in order for it to be analised effectively. First, the researcher carefully reads through the transcripts and writes thoughts in the margins. Second, it is noted that there are stand out-points referred to as codes. When that task is completed for all the documents, the researchers make a list of topics, also known as sub-categories. Step three, these topics are grouped into columns identified by their themes. Step four is to abbreviate the topics as categories and then the categories are written next to the appropriate segments of the text. For steps five through eight, the researchers decide on the most descriptive wording to become the categories’ names for the topics. Grouping the topics decreases the list and amount of sub-categories. The last step of data analysis is to recode existing data.

Strategies such as credibility, transferability, dependability and confirmability are used in order to ensure the trustworthiness of the data [16]. Credibility is ensured by the dense description of the lived experience of the research participants. Credibility is also enhanced by triangulation. Triangulation is ensured by the use of more than one source of collecting data; for example within this study, participants living with a diagnosis of schizophrenia and the key informants. Transferability is ensured by the detailed description of the research methods, contexts, and the lived experience of the participants. Dependability is ensured by means of dense descriptions, peer examination, and triangulation. The study is documented in such a manner that the readers are able to follow an audit trail. Confirmability is ensured by the process of reflexivity whereby the researcher’s own biases or assumptions are made apparent by means of a reflexive journal.

The study was approved by the Institutional Review Board of the [name of the university], the ethics number being BM/16/3/2

7 Findings

7.1 Theme One: Society’s acceptance of one’s work potential

The theme of “Society’s acceptance of one’s work potential” was of great significance to the participants because they perceived society to lack an understanding about their condition. This theme will be further described in the following categories.

7.1.1 Category: The ideal working environment

The category of “Ideal working environment” came about when the participants and the key informants described the ideal working environment for a person diagnosed with schizophrenia. A key informant described the ideal work environment for individuals diagnosed with schizophrenia:

“The type of work we doing here is, is is of-, is very often not conducive for people with schizophrenia. Number one because … it’s, it’s only factory work, so it’s very repetitive and, and we’ve got a large population of people with schizophrenia who do come from the, the higher functions … . Our setup is too big and too noisy, and too … distracting” (B1)

7.1.2 Type of work influencing work experience

This subcategory emerged when the participants expressed how each experienced different types of work, and furthermore, how these different types of work affected each of them.

“It’s nice to be there on the job … I, I, I’m a little bit … . I’m not sick now, so I can work. But the work is … a little bit difficult because we lift heavy stuff there” (A1)

7.1.3 Understanding the effects of job satisfaction

Participants indicated clearly that, when in a specific job they might or might not desire, job satisfaction can make a large difference to the working environment. A participant said:

“I cannot say no I am happy just because I work hard everyday … but there is no reward at the end of the day” (A2)

7.1.4 Category: Fear of losing one’s work

The category of “fear of losing one’s work” is emphasized due to the expression of concern from both the participants and the key informants about how society views people with mental illnesses, especially people diagnosed with schizophrenia.

“I didn’t tell the bosses that I am sick … I don’t know what they’re going to think if I tell them. Maybe I’ll lose the job, they’ll think if I tell them. Maybe I’ll lose the job, they’ll think that no, I cannot afford to work there, in their job. So I’m scared to tell them” (A1)

7.1.5 The influence of Stigma

Fear was clearly expressed by the participants in regard to stigmatization. While not all participants experienced it directly, there was a definite fear of experiencing stigmatization and prejudice.

“Because if you coming out from (name of hospital), all people they think that you are mad … . You sick, they think you’re sick if you coming here from (name of the hospital), you can’t do anything” (A1)

7.1.6 Ambivalence of the disclosure of mental health status

The participants had various feelings with regard to disclosure, some positive and others negative. The positive thoughts were emphasized when disclosure of the condition enabled the participants to not fear society and to increase co-workers understanding of the medical condition in the workplace.

“My co-workers, they know my history, they know where I’m from, but that doesn’t affect our relationship, our working relationship.” (A3)

7.2 Theme Two: The usefulness of work preparation programs to enhance open labor market employability

The prior theme expressed the important role that a well-structured work preparation program has in enabling individuals diagnosed with schizophrenia to work in the open labor market. This theme will be further described in the following categories.

7.2.1 Category: Return to work

The key informants identified aspects of the work preparation programs that assist the participants in returning to work in the open labor market.

“We equip you with the skills to find work, and to perform better at work, right, to look for work (B2)

7.2.2 Transferring of work skills in vocational rehabilitation

Specific skills such as anger management and how to prevent relapse were emphasized by the key informants. The participants identified the program as being beneficial when returning to work.

“Conflict management, anger management, stress management, right, relationships, because relationships and communication is around … not just the work environment but the home environment” (B2)

7.2.3 Category: Vocational rehabilitation program is essential in preparation for re-entry into the open labor market

The participants highlighted that rehabilitation emphasized the vocational rehabilitation aspect to prepare for returning to work and providing the skills to function independently.

“Voc. rehab, rehabilitation, has helped me in a great, great sense, you know, to be in a work area” (A3)

7.2.4 Type of therapies within vocational rehabilitation

This subcategory emerged when key informants emphasized the specific types of therapy used within vocational rehabilitation to aid clients in the development of skills for re-entering the open labor market.

“By putting him in a situation, discussing it … what would you do if this happens, and then after putting him in the role play situation where he has to practice … how he’s going to handle the situation” (B1)

7.3 Theme Three: Holistic support enhances participation in the worker role

This theme presents the participants’ views of stakeholder support when transitioning into the open labor market. The theme will be further described in the following categories.

7.3.1 Category: Therapeutic support enhances personal & work skills development

In this category, the key informants expressed the importance of providing support to the individual living with a diagnosis of schizophrenia by means of multi-disciplinary intervention in the community.

“Making contact especially with the OT’s in the community … . understanding what services are available, right and if services aren’t available in terms of OT services, looking what the other MDT services that you can offer to the client” (B2)

7.3.2 The effect of medication on an individual’s ability to function

This subcategory explores the usefulness of medication on the participants’ functioning capabilities. The participants shared the importance of taking medication to enhance functioning on a daily level.

“There’s tablets which, tablets which I … helps me to just lower the stress. I’m taking those tablets” (A1)

“Ya the medication does help” (A2)

7.3.3 True insight as an enabler for functioning

This subcategory explores both participants’ and the key informants’ views regarding the acceptance of the diagnosis, understanding what it means to have the diagnosis, and implications from having schizophrenia.

“You think maybe you doing the right thing, you feel like you are on your mind, you see there is nothing wrong with what you are doing, people can see, maybe a friend or your family can see it” (A2)

7.3.4 Category: Stakeholder support and the influence it has on coping

This category explores both the key informants’ and the participants’ views of the support currently received or required. This support may come from the participant’s family, employer, or vocational rehabilitation program.

“What are the support systems that are in place … you know, how can they access support, you know so, so again it’s about what are the skills that the patients … need, what are the things that they struggle with right, what will make it easier for them in the workplace” (B2)

7.3.5 Required support from stakeholders and the effects on the participants’ lives

This subcategory of required support is described by the participants’ point of view of the support that is not received. They described feeling that support is needed from individuals in the workplace in order to cope in the open labor market. This support is not readily available. One participant said:

“I think in a situation like this it will need some like, who, who like some that has got experience like this, such stuff, someone professional, someone who can be able to … listen to your complaints, someone who can listen to your problems” (A2)

8 Discussion

8.1 Barriers to return to work

The participants’ work environment could be either an enabler or a barrier in facilitating or hindering the successful return to work of individuals living with the diagnosis of schizophrenia. The category of “ The ideal working environment ” in the current study reveals the participants indicate a non-supportive work environment could be a barrier that does not facilitate returning to the worker role or maintaining employment in the open labor market. Satisfaction with the worker role is dependent on feelings about work and the working environment. Steadman [17] and Soeker [18], state that a supportive working environment can enable people to remain in work because they feel they are accepted and they can ask for help and support when needed. Similarly, supportive employment is seen as a strategy for individuals with physical conditions or mental health conditions to return to work and to maintain employment [4, 18].

According to Ross et al. [19], a hostile work environment can be considered a barrier and ultimately can prevent an individual from effectively returning to work. Taskilaa et al. [3] reinforce the conclusion that a lack of confidence of the treating health professional or the employer of the individual diagnosed with schizophrenia will negatively affect the motivation to return to work.

Redmond [20], states that an individual’s work experience is evaluated by the amount of satisfaction or dissatisfaction with regard to the type of work and the physical work environment. “Fear of losing one’s work” stems from the misunderstanding and the judgment of society to mental illness. The participants indicated that they become defined by their mental illness and they are seen as lesser humans rather than who they are. The participants are emotionally and psychologically affected but they are of the opinion that they never lost confidence in their own abilities. Read, Haslam, Sayce, & Davies, [21], state that negative judgments and attitudes towards those who have a mental illness are very well documented.

8.2 Facilitators to return to work

Theme two, “The usefulness of work preparation programs to enhance open labor market employability,” describes some of the facilitators that enabled the participants to return to work. Désiron, De Rijk, Van Hoof, & Donceel, [18], identify vocational rehabilitation as a treatment modality that reflects a range of return to work outcomes including voluntary employment, sheltered employment, and open labor employment. The key informants identified work preparation and skills development as key factors for successful reintegration into the open labor market. Désiron et al. [22] reinforce the finding of the current study and highlight that during vocational rehabilitation, the rehabilitation therapist works with the individual on a client-centered basis to develop, improve, and/or restore skills in order to engage and participate in work occupations. The category of “Return to work” identifies the importance of client-centered practice, making sure the individual is an active participant in the vocational rehabilitation process. Stergiou-Kita [23], states client preferences are important factors in the decision-making process. The occupational therapist should engage directly with the client and take into consideration the client’s desired outcome. The participants indicated that support and reassurance from family and the employer are beneficial for return to work.

8.3 Coping skills used by the participants in the open labor market

The theme of “Holistic support enhances participation in the worker role” describes some of the coping strategies identified by the participants. Therapeutic support in the form of use of medication is regarded as important to the participants. One of the participants went as far as stating that he does not experience any lingering symptoms when taking his medication. This is interesting because, according to Bevan et al. [2], the negative symptoms may continue to linger after the positive symptoms have subsided. The effectiveness of antipsychotic drugs has been proven for people with psychopathological symptoms by reducing rates of re-hospitalization and relapse. Non-adherence to a medication routine is a common cause of impairment, risk of suicide, longer time of remission, relapse, loss of work, violence, arrest, dangerous behavior, alcohol and substance use, poorer prognosis, and low satisfaction with life [24]. A study conducted in Japan by Shimada, Nishi, Yoshida, Tanaka & Kombayashi [25] indicates individualised occupational therapy with adherence to outpatient treatment and medication were associated with reducing the rehospitalisation of patients with diagnosis of schizophrenia.

Some of the participants in our study indicated that to disclose status about their diagnosis could either enable adapting in the workplace or could be a barrier to return to work. According to a systematic review conducted by Brohan et al. [26], the disclosure of a mental illness places job applicants at a disadvantage in securing employment when compared to applicants with a physical disability or no disability. Therefore, individuals with mental health conditions need to be careful when disclosing their status to employers. However, individuals with disability (including mental health illnesses) are protected by policies such as the South African Employment Equity Act [27] and advocacy against the discrimination of people with disability (PWD), particularly regarding employment practices.

9 Limitations of the study

One major limitation is the fact that only male participants took part in this study. Another major limitation is due to the stigma related to schizophrenia, particularly amongst people living with the diagnosis of schizophrenia who are employed, it was very difficult to recruit a larger number of participants for the current study.

10 Conclusion

Both the participants and the key informants emphasized the stigma experienced by the participants. Disclosing mental health status is one of the major barriers and increases the anxiety of the participants when returning to work. The study findings suggest that the participants are ambivalent about disclosure of their medical diagnosis in order to facilitate return to work as an individual diagnosed with schizophrenia. Disclosure is seen as a barrier and/or as a facilitator. Some of the participants indicated that a stronger support system in the workplace could be established by disclosing the mental state of the individual. The current study identified some of the barriers preventing individuals living with a diagnosis of schizophrenia from adapting to the work environment; however, we also identified some of the facilitating factors including the support of the occupational therapist, the family, and the employer, as well as the provision of good quality vocational rehabilitation programs. These factors may improve reintegration of individuals diagnosed with schizophrenia into jobs in the open labor market.

Conflict of interest

None to report.

Footnotes

Appendix A

Table One Demographics of the participants

Participants	Gender	Education	Age	Work experience	Diagnosis	Rehabilitation
A1	Male	Grade 11	35	Fast Food	Schizophrenia	OT (vocational rehabilitation)
A2	Male	Grade 09	30	No work experience	Schizophrenia	OT (Vocational rehabilitation)
A3	Male	Grade 10	40	Assistant Plumber	Schizophrenia	OT (Vocational rehabilitation)
A4	Male	Grade 10	35	General Assistant	Schizophrenia	OT (Vocational rehabilitation)
Key informants
B1	Female	BSc (OT)	38	Senior OT: 5 years of working in vocational rehabilitation
B2	Female	B Sc (OT)	55	Senior OT: 10 years of working in vocational rehabilitation

Appendix B

Inclusion and Exclusion criteria

Appendix C

Interview guide (semi-structured) - Participants

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