Motivational Interviewing to Improve Work Outcomes in Schizophrenia

• job acquisition and tenure [ Time Frame: 18 months ] [ Designated as safety issue: No ]
  

Many individuals with serious psychiatric illnesses wish to work, and yet employment rates for this population are lower than the general population (Cook & Razanno, 2000). IPS is a type of supported employment intervention designed to assist individuals with serious psychiatric illnesses return to work. Four randomized trials demonstrate that, in comparison to control conditions such as group therapy or referrals to traditional vocational rehabilitation services, IPS participants are three more times more likely to obtain a job during the study, and at least twice as likely to be competitively employed at any point in the study (Drake et al, 1996; Drake et al, 1999: Lehman et al, 2002; Mueser et al, submitted). Just as with the general population, the rewards of work for individuals with serious mental illness include considerably more than the financial remuneration. For example, employment appears to confer higher self-esteem, greater life satisfaction, and perhaps even better treatment compliance, symptom improvement, and insight in persons with psychiatric illnesses (Bell et al, 1996; Lysacker et al, 1995; Mueser et al, 1997; Bond et al, 1997; Kashner et al, 2002). Despite its demonstrated effectiveness, these IPS results could be improved. Most IPS participants are not competitively employed at any point in time, it takes an average of about four months to obtain a first job, a typical job lasts only approximately 20-25 weeks, and employment rates across the sample asymptote at about month 8 or 9 of participation in the trials. Furthermore, obtaining a first job seems to be an almost insurmountable impediment for approximately 35%-40% of individuals in the trials. Motivational deficits may play a prominent role in explaining the limited benefits accruing from IPS in persons with serious and persisting psychiatric illnesses, especially in those with schizophrenia. Building a successful work life requires sustained effort over months and years (Palmer, 1989). After a period of unemployment, individuals must obtain their first reemployment position, and then transition to others as circumstances arise. Many persons with schizophrenia experience high degrees of negative symptoms, demoralization, and ambivalence, which likely all interfere with the persistent efforts required to initiate and maintain a successful vocational adjustment. Enhancing already validated vocational rehabilitation programs, such as IPS, with specific techniques to address motivational deficits may be essential to increasing employment rates among persons with schizophrenia. In this study, we will test a novel strategy designed to improve motivation for positive behavior change, motivational interviewing, adapted for work-related problems, in persons with schizophrenia. With the objective of improving work outcomes, we will assign 90 outpatients with schizophrenia or schizoaffective disorder to one of two 18 month psychosocial treatment groups, traditional Individual Placement and Support (IPS) with the addition of psychoeducation about schizophrenia or with the addition of Vocationally-oriented Motivational Interviewing (VOMI). We are hypothesizing that: 1) clients with schizophrenia who participate in IPS+VOMI will have better vocational outcomes (including 1a) a greater likelihood of obtaining a first job, 1b) more total weeks worked, 1c) more total hours employed, 1d) and more wages) than clients who receive IPS with psychoeducation; 2) If they are separated from their first job, clients with schizophrenia who participate in IPS+VOMI will be more likely to obtain a second (and subsequent) job than clients who receive IPS with psychoeducation (main effect of IPS + VOMI); and 3) Regardless of their treatment condition, working clients with schizophrenia will have greater improvements in social adjustment, symptoms, and life satisfaction than those who are not working.