Effects of cognitive behavioral therapy on work outcomes in vocational rehabilitation for participants with schizophrenia spectrum disorders

https://doi.org/10.1016/j.schres.2008.10.018Get rights and content

Abstract

Designed to help persons with schizophrenia to persist and perform better at job placements, the Indianapolis Vocational Intervention Program (IVIP) is a program of cognitive-behavioral group and individual interventions. While its feasibility has been previously demonstrated, it is unknown whether IVIP assists persons to achieve greater levels of participation in vocational rehabilitation and higher levels of job performance. In this study, 100 participants with schizophrenia or schizoaffective disorder were offered a six month job placement and randomized to receive IVIP (n = 50) or support services (n = 50) matched for treatment intensity. Number of hours worked was recorded weekly and job performance was assessed biweekly using the Work Behavior Inventory with raters blind to condition. t-tests revealed that participants in the IVIP group worked a significantly greater number of weeks than those in the support condition. Also, repeated measures ANOVA revealed the IVIP group worked more hours across that 26 week period as well. And with regards to work performance, repeated measures of the 56 participants who worked for at least two-thirds of the intervention revealed that participants in the IVIP group had generally better work performance than those in the support condition. Results suggest a connection between cognitive-behavioral interventions and higher levels of work performance in people with schizophrenia.

Introduction

Many adults with schizophrenia view themselves as having minimal competence, social value or self-efficacy (Roe, 2001, Young and Ensign, 1999). These views may be seen as existing at the level of specific dysfunctional beliefs (Lysaker et al., 2004) or at the level of larger personal narratives that provide the context for interpreting daily life (Lysaker et al., 2003). As a result, many enter vocational rehabilitation with a desire to work but also with self-defeating expectations of failure (Hoffman et al., 2000). They may anticipate difficulties and be inclined to interpret ambiguities at the workplace as confirmation of existing negative expectations. These beliefs are of clinical importance not only because they are distressing to care providers, but also because they may serve as self-fulfilling prophecies that can become barriers to function independent of other social or biological factors. Low levels of self-efficacy in schizophrenia have been found to predict a poorer employment outcome (Davis et al., 2004, Renegold et al., 1999). Lecomte et al. (1999) have also found that self-defeating beliefs predicted poor rehabilitation outcomes controlling for negative symptoms, while others have linked poorer self-appraisal to maladaptive behaviors, including a preference for avoidant forms of coping (Lysaker et al., 2001), poorer participation in treatment (Brekke and Long, 2000) and generally poorer social functioning (Brekke et al., 1993, Roe, 2003).

To address these beliefs as they specifically relate to work, we adapted cognitive behavior therapy (CBT) methods to address self-defeating beliefs that may lead to quitting, while also helping participants set and achieve work performance goals (Davis and Lysaker, 2005, Davis et al., 2005, Lysaker et al., 2005). We chose to use CBT as a model for our treatment given research suggesting that persons with schizophrenia are willing to participate in CBT and that they often respond to CBT with improvements in symptoms and longer periods of community tenure (Drury et al., 1996). The clinical gains linked with CBT have been found in a variety of samples including ones composed of persons resistant to medication (Sensky et al., 2000), as well as with persons with recent onset schizophrenia (Lecomte et al., 2003, Lewis, 2002).

Following many of the principles of cognitive behavior therapy (Beck, 1994, Beck, 1995); we created a manualized intervention called the Indianapolis Vocational Intervention Program (IVIP). This program offers weekly group and individual CBT sessions targeted at dysfunctional beliefs about self (e.g. “I cannot succeed”) and work experiences (e.g. “my supervisor criticizes my work and dislikes me”). The group intervention includes didactic content and skills training and is complemented by the individual intervention that involves active and personalized application of group material to beliefs about work experiences. The IVIP is intended as an adjunct to work therapy programs including those that provide paid work placements to participants. Such programs include Incentive Therapy, Veterans' Industries and Compensated Work Therapy and are available in more than 101 VA sites across the country (Rosenheck and Seibyl, 1998). Conceptually IVIP seeks to offer an opportunity to not only correct dysfunctional beliefs but also provide a forum for thinking about thinking in the larger metacognitive sense. The program sees work as a possible context for thinking differently about oneself and one's narrative and offers interventions which allow for the development and challenging of those reflections.

To date, we conducted a feasibility study of IVIP and found that in a trial of 50 participants with schizophrenia, those randomized to receive IVIP worked significantly more weeks over a six month period compared to persons who received standard work services. They also had significantly higher scores than those receiving standard services group on non-blinded ratings of work behavior (Lysaker et al., 2005). In the current paper we present analyses of the effects of IVIP on work outcomes in a new fully-powered randomized controlled trial. This trial has sought to address previous limitations by including additional supports in the standard services condition to control for the non-specific benefits of staff attention and contact, including a larger, more diverse sample and using raters blind to condition. We predicted that participants in the IVIP condition would work more hours and weeks during the intervention period and have better work performance over time than the standard services condition.

Section snippets

Participants

One hundred participants with a SCID (Spitzer et al., 1994) confirmed diagnoses of schizophrenia (n = 67) or schizoaffective disorder (n = 33) were recruited from an outpatient service of a VA psychiatry service (n = 70) and a community mental health center (n = 30). All were receiving medication management by an assigned clinician. Age, education and psychiatric hospitalization history are presented by group in Table 1. All participants were in a post-acute phase of illness as defined by having no

Results

Demographic and baseline assessments of the IVIP and support groups are presented in Table 1. Group comparisons revealed no significant differences in age, education, lifetime hospitalization, frequency of diagnosis of schizophrenia vs. schizoaffective disorder, gender, or treatment site (VA vs. CMHC). Also, with regards to baseline assessment, group comparisons revealed no differences between participants randomized to IVIP and support on the PANSS total, CAS or SF-36 scores. A t-test

Discussion

The Indianapolis Vocational Intervention Program (IVIP) is a cognitive behavioral program created to assist persons with schizophrenia spectrum disorders to identify and correct their dysfunctional patterns of thought relevant to work with the aim of increasing their productive activity and improving their work performance. Results of this study indicate that, as predicted, participants randomized to receive IVIP demonstrated higher levels of work quantity and quality in a rehabilitation

Role of funding source

Portions of this study were funded by the VA Rehabilitation Research and Development Service. This body played no role in study design; the collection, analysis and interpretation of data, in the writing of the report; and in the decision to submit the paper for publication.

Contributors

Lysaker, Bryson, Bell and Davis were involved in literature searches. Lysaker undertook the statistical analyses. Lysaker wrote the complete first draft and all authors subsequently made meaningful contributions to the writing. All authors contributed to and have approved the final manuscript.

Conflict of interest

There are no conflicts of interest.

Acknowledgements

Research was funded in part by the Veterans Administration Rehabilitation Research and Development Service.

References (28)

  • DavisL.W. et al.

    Cognitive behavioral therapy and functional and metacognitive outcomes in schizophrenia: a single case study

    Cogn. Behav. Pract.

    (2005)
  • BeckA.T.

    Cognitive-Behavioral Therapy of Schizophrenia

    (1994)
  • BeckJ.S.

    Cognitive Therapy: Basics and Beyond

    (1995)
  • BrekkeJ.S. et al.

    Community-based psychosocial rehabilitation and prospective change in functional, clinical, and subjective experience variables in schizophrenia

    Schizophr. Bull.

    (2000)
  • BrekkeJ.S. et al.

    Psychosocial functioning and subjective experience in schizophrenia

    Schizophr. Bull.

    (1993)
  • BrysonG. et al.

    The work behavior inventory: a scale to assess work behavior in severe mental illness

    Psychiatr. Rehabil. J.

    (1997)
  • DavisL.W. et al.

    Hopelessness as a predictor of work function in schizophrenia

    Psychiatr. Serv.

    (2004)
  • DavisL.W. et al.

    The Indianapolis Vocational Intervention Program: a cognitive behavioral approach to addressing rehabilitation issues in schizophrenia

    J. Rehabil. Res. Dev.

    (2005)
  • DruryV. et al.

    Cognitive therapy and recovery from acute psychosis: a controlled trial

    Br. J. Psychiatry

    (1996)
  • HoffmanH. et al.

    Hopelessness and its impact on rehabilitation outcome in schizophrenia — an exploratory study

    Schizophr. Res.

    (2000)
  • KayS. et al.

    The Positive and Negative Syndrome Scale for schizophrenia

    Schizophr. Bull.

    (1987)
  • LecomteT. et al.

    Efficacy of a self-esteem module in the empowerment of individuals with schizophrenia

    J. Nerv. Ment. Dis.

    (1999)
  • LecomteT. et al.

    Group CBT for clients with a first episode of schizophrenia

    J. Cogn. Psychother.

    (2003)
  • LewisS.

    Randomized controlled trials of cognitive behavior therapy in early phase schizophrenia: acute phase outcomes

    Br. J. Psychiatry

    (2002)
  • Cited by (72)

    • Metacognition over time is related to neurocognition, social cognition, and intrapsychic foundations in psychosis

      2020, Schizophrenia Research: Cognition
      Citation Excerpt :

      Psychiatric symptoms were measured by the Positive and Negative Syndrome Scale (PANSS) Psychiatric symptoms at baseline were assessed by the Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) a 30 item measure rated on a 7-point scale ranging from “Absent” to “Extreme”. Research examining the psychometric properties of the PANSS in persons with schizophrenia has found the instrument to have strong inter-rater reliability (e.g., Lysaker et al., 2009). Sixty-seven participants who completed at least one follow-up assessment were included in the analyses.

    • Group cognitive behaviour therapy for supported employment – Results of a randomized controlled cohort trial

      2020, Schizophrenia Research
      Citation Excerpt :

      Although not yet studied for supported employment, a cognitive behavior therapy (CBT)-augmented SE program could yield work-relevant benefits. Lysaker and colleagues demonstrated that group CBT targeting work-related beliefs, the Indianapolis Vocational Intervention Program (IVIP) (Lysaker et al., 2005); (Lysaker et al., 2009), could improve vocational outcomes in Veterans with severe mental illness receiving traditional vocational services. Given the efficacy of SE programs, we wished to adapt IVIP to be delivered in SE context.

    View all citing articles on Scopus
    View full text