Career and Employment Support to Promote Recovery from Early Psychosis

Introduction to Career and Employment Support for Recovery in Early Psychosis

Career and employment support is a crucial psychosocial and vocational rehabilitation intervention for recovery in early psychosis. In this article, we will explore vocational rehabilitation for recovery in early psychosis. This will include the following topics:

• first episode psychosis;

• the role of vocational rehabilitation;

• benefits of career and employment support for recovery;

• strategies for career support;

• collaborating with mental health professionals;

• challenges and barriers to employment; and

• resources for support.

Understanding First Episode Psychosis

Psychosis describes conditions that affect the mind, leading to a loss of contact with reality. It can cause confused thinking, false beliefs, hallucinations, changes in feelings, and altered behavior. Approximately three out of every 100 people will experience a psychotic episode in their lifetime. Although it can happen to anyone, it is based on a stress-vulnerability model. It is important to remember that psychosis can be treated, and people can recover.

First episode psychosis refers to the first time a person experiences psychotic symptoms or has a psychotic episode. A person experiencing their first episode of psychosis may feel confused and distressed, not understanding what is happening to them. Mental and emotional problems can be similar to physical problems. The sooner they are treated, the better the chances of recovery. The longer psychosis is left untreated, the more the person's life is disrupted. Delays in treatment may lead to a slower and less complete recovery.

A psychotic episode can occur in three phases. The first phase is a prodromal phase, which occurs before psychotic symptoms appear. There are usually vague signs that things are not quite right and people may have a range of mild or infrequent symptoms. When it is happening, it is hard for family members, friends, and professionals to see the difference between a normal range of teenage behaviour and the early warning signs that come before a first break. The second phase is an acute phase, when the person has clear psychotic symptoms such as hallucination, delusions, or confused thinking. The person often has difficulty with daily activities and this is when they usually come in for treatment.

Recovery is the third phase, which is a gradual process. Symptoms are treatable but recovery does not mean there is a cure or disappearance of symptoms. It means some people may never have another psychotic episode, while others will experience psychosis for the long-term and must learn to manage the condition. Recovery is unique from person to person. It refers to the goal of supporting the person to reintegrate into the community and get back to a meaningful quality of life. It involves hope for the person and their family to thrive and return to their usual activities.

Promoting Recovery and the Role of Vocational Rehabilitation

Treatment and recovery for individuals who have experienced psychosis are tailored to their unique circumstances, such as age and stage of illness. It involves a variety of aspects of their life. The determinants of mental health are considered. These might include the biological, social, psychological, recreational, economic, vocational, spiritual, and intellectual aspects. Evidence-based treatment includes antipsychotic medication, psychosocial rehabilitation, case management, supportive counselling, social skills training, education, recreation therapy, housing and social services, crisis intervention, and family engagement. We are focusing on the role of vocational rehabilitation, which includes supported education and supported employment in recovery.

Career counselling and vocational rehabilitation are significant because they can help to promote recovery and get people reconnected with a community life. For youth and young adults who are just beginning to choose a career (or those who are in the middle of it), psychosis may have disrupted their progress with a career and education.

A vocational rehabilitation (VR) counsellor who is part of the treatment team can support a person with assessment, planning, and counselling. This can address the need for exploring career interests, identifying transferable skills, preparing to enter or return to work, and finding and maintaining a job. A VR counsellor can also make referrals to other employment related services and resources, such as sheltered employment or volunteer opportunities.

Benefits of Employment in Recovery

Having a job during recovery offers psychological benefits. It provides a sense of meaning, purpose, social interaction, and identity within the community. It contributes to quality of life, wellness, and preventing relapse. Although common reasons for relapse can be related to issues with medication, it can also be due to the interaction between vulnerability to stressors and protective factors like employment.

Some people may be motivated to use substances less when they are involved in a structured daily routine where there is incentive to get up and be able to function at work during the day. Chances of relapse are reduced when there is active engagement in supported employment activities and where stressors can be effectively managed. Furthermore, there are opportunities for people to develop social skills, expand their support networks, enhance self-esteem, and strengthen their sense of personal identity through employment at a workplace.

Strategies for Effective Career Support

Early intervention is crucial for effective employment support. The longer some people are away from work, the more difficult it can be to return. Being away from work can lower tolerance and conditioning for full-time shifts and schedules. Even a part-time shift of 4-6 hours can be challenging to return to (depending on the person and the work) especially if it is scheduled for multiple days in a row each week. It takes time to rebuild confidence, endurance, and work conditioning.

For some individuals supported by disability or income assistance, reliance on these programs can make transitioning back to sustainable employment challenging. Over time, it can lead to dependence and reduced incentives and motivation for returning to work. People can also experience fears and worries about the implications of earning employment income, due to potential negative impacts on their income assistance or disability benefits.

Creating a supportive work environment for people in recovery may require collaboration between employers, employees, a vocational rehabilitation counsellor, mental health treatment team, and various community or family team members. It's helpful to understand that any limitations or restrictions in the person's abilities may be temporary and could change during the process of rehabilitation and recovery. It's not unusual for employers to need lots of education and support around understanding employment and human rights laws in order to uphold their duty to accommodate employees up to the point of undue hardship. The employee in recovery deserves to have clear information to be fully informed of their rights, responsibilities, and choices.

A gradual or graduated return to work is often a beneficial way for a person in recovery to transition and adjust to a changing schedule, routine, and increasing work demands. There are a variety of ways to develop a return to work plan based on the person's health/medical condition, symptoms, functional abilities and limitations, strengths and skills, work history, education and training, job demands, and both the employee and employer needs and preferences. A gradual return can take place over a period of days, weeks, or months. There are circumstances where a plan may be implemented over 3-6 months, or even 6-12 months, depending on the uniqueness of the person and situation.

Collaboration with Mental Health Professionals

Mental health and rehabilitation professionals are crucial in facilitating employment. The goal of most treatment teams are to establish partnerships with the person in recovery and with their family members and potential employers. The team is a multidisciplinary group of health care workers which may include a psychiatrist, psychologist, nurse, social worker, occupational therapist, dietician, vocational rehabilitation counsellor, and life skills worker. The nurse, social worker, or occupational therapist may also be the most responsible clinician or case manager, involved with coordinating weekly care needs.

In a team-based model of care, these health care professionals meet regularly to review a person's progress. The psychiatrist is typically responsible for medications and assessment, diagnosis, and treatment of mental disorders. A psychologist provides assessment, diagnosis, and interpretation of psychological tests. They may also provide psychotherapy. The social worker may offer intensive family work and assist with advocacy and navigating community systems and resources. Sometimes they also provide individual or group and family counselling. A nurse provides a plan of care to promote recovery and may monitor a variety of medical and physiological issues, including blood work, cardiovascular, and metabolic concerns (among others). Dieticians assist with improving health and qualify of life by assessing nutritional risks, prescribing therapeutic diets, teaching about nutritional health, monitoring metabolic conditions, and advocating for healthy menus and meals.

The vocational rehabilitation counsellor or employment specialist supports clients with their employment goals, vocational assessment, vocational counselling, job search, job development, and more. Occupational therapists provide assessments (biomechanical, cognitive, musculoskeletal, psychosocial, and neurological) and interventions for functional skills and occupational performance in activities of daily living, which may include anything related to a person's leisure, productivity, and self-care. Life skills workers may assist with activities related to daily living and work to demonstrate and model appropriate behaviours needed for problem solving and decision making. They provide support to help develop and maintain life skills for time management, budget/financial/money management, organization and interpersonal communication, personal care, household management, menu planning and grocery shopping (or meal prep), community access and transportation, and more.

Challenges and Barriers to Employment

Individuals in recovery face common obstacles, such as warning signs of relapse. These can include feeling tense, nervous, anxious, or irritable; difficulty with concentration and attention; isolating or withdrawing from people; increased sensory sensitivities with sound and light; poor sleep; increased psychotic symptoms (bizarre or unusual thoughts, delusions, auditory or visual hallucinations, changes in mood and affect, cognitive problems); substance use; discrimination and stigma; and more. Other difficulties can include impatience with recovery, depression and social anxiety, low self-esteem and self-worth, lack of insight into their condition and situation, non-acceptance, and a lack of desire or motivation to engage with the treatment team or family members.

Job related stressors can impact recovery. Having a vocational plan in place can establish goals, intervention activities, and a way to understand a person's identified stressors or triggers, warning signs, and ways of coping that they find useful. This should be coordinated together with their treatment plan. Strategies to overcome challenges and barriers could include crisis response for self-harm and aggressive behaviours, including addressing risks of suicide or violence to self or others. In emergency situations, it is important to have a crisis intervention plan in place and to understand mental health legislation, such as the Mental Health Act. Sometimes the police may need to be involved and there can be a need for hospitalizations to the emergency and psychiatric departments. In some cases, a person can be admitted to hospital as an involuntary or certified patient, depending on whether they meet criteria.

Resources for Support

Family-focused care and involvement are essential resources for supporting individuals throughout the phases of psychosis. Stress reduction and stress management strategies may be beneficial for coping with sorrow, anger, disbelief, denial, and a range of difficult emotions. Caregivers need to remember to take care of and nurture themselves while supporting a person in recovery. Open communication should be maintained with all parties involved in supporting the person in early psychosis. It's helpful to remember to set healthy boundaries and limits so everyone can understand clearly what are acceptable and unacceptable behaviours for feeling respected, safe, and secure.

Conclusion

In summary, vocational activities such as employment play a significant role in the recovery journey for individuals experiencing psychosis. There is hope for the future and people are resilient. We hope you have learned something in our discussion about first episode psychosis, the role of vocational rehabilitation, benefits of career and employment support for recovery, strategies for career support, collaborating with mental health professionals, and challenges and barriers to employment.

We invite you to take action to engage with vocational rehabilitation professionals in your community to enhance support services for yourself or those you know who may benefit. We hope you will encourage people experiencing first episode psychosis to seek support with exploring and pursuing their career goals.

Lastly, please reach out and contact us if you would like more information on vocational rehabilitation resources for disability, medical, psychosocial, or vocational support in communities in British Columbia, Canada. There are a variety of organizations providing career and employment support for those with complex mental health challenges such as psychosis.