How does full time employment affect mental illness symptoms essay example

Paper Due Date

Introduction
Considerable research attention has been given to the problems that mentally ill individuals face in getting and keeping jobs. See, for example, Cook et al. (2007) and Gilbride et al, 2003. Little research, on the other hand, concerns outcomes for such individuals once they are employed. Job stress can affect any job holder. Does a history of mental illness or a current condition exacerbate the stress? Are individuals with a background of mental illness more vulnerable to job stress than colleagues without such a background? These are important questions for those of us who are part of the population with a history of mental issues or have friends or relatives in that population.

Literature Review

As suggested above, the bulk of the literature related to this topic takes an almost reverse causal direction from the thrust of this proposal. While this author is concerned with how employment affects mental illness symptoms, the literature is more focused on how mental illness affects employment. It is relevant to note here that in a sample of over 2, 000 employers, 54% indicated that they would never or only occasionally employ someone who was clinically depressed, 66% would not employ someone with schizophrenia, and 73% would avoid hiring an alcoholic (Brohan et al., 2012). Although different in focus, the research described in this section is representative of that current in the area of employment and mental illness. It was selected because it is relevant to either theory-building around or methodology to be applied to this author’s proposed research.
Salkever et al. (2007) used a quantitative approach based on regression analyses to study over two thousand adults diagnosed as having a schizophrenia-related illness. The participants were recruited from health care systems in geographically diverse areas in the US. The systems were community mental health centers, VA providers, psychiatric hospitals and university outpatient clinics. Data were obtained from initial baseline and follow-up interviews conducted in 1997 through 2003. The interviews included information about employment and a clinical assessment. A major finding was a low employment rate of 17% (lower than found in other studies, possibly because participants were still in treatment) and that the strongest predictors of employment outcomes were all baseline measures: age; severity of symptoms, including depression; and years of education. The regression coefficients were negative for age and severity and positive for years of education; i. e., younger, better educated participants with less severe mental illness symptoms were more likely than older, less educated participants with more severe symptoms to be gainfully employed. It is important in setting the stage for studying the effect of employment on symptoms to be aware that being employed is less likely for a good portion of mentally ill persons.
Another relevant study is that by Brohan et al. (2012). These authors were concerned with individuals’ disclosure of mental health status or history to employers. They conducted an extensive review of the research involving reasons for and reactions to disclosure of past or present mental illness. The authors’ information sources were eight bibliographic databases, Cochrane reviews foremost among them. Brohan et al. provided a detailed description of how they extracted, summarized and synthesized their findings, even reporting the terms (e. g., mental, disability, anxiety, etc.) actually used in their search.
Besides exemplifying rigorous methodology (and providing a blueprint for the methods envisioned for this author’s proposed research), the Brohan et al. (2012) study has additional relevance. They report that their search revealed some reasons why an individual might disclose a background of mental illness: to account for unusual behavior; to prevent co-workers from thinking the behavior is due to drugs or alcohol or, when medication slows them, to laziness; or to relieve the stress of keeping their illness a secret.
Livneh and Wilson (2003) investigated the role of coping strategies on adaptation to physical or mental disability. After a preliminary factor analysis of 50 items from several coping strategy scales, the authors identified three types of coping strategies: avoidance-oriented (including denial), problem-focusing (active coping), and emotion-focusing through engagement with others. Life satisfaction (subjective well-being) and psychosocial adaptation (including reintegration into everyday life) were outcome measures. Their sample was small, consisting of 121 disabled university students, approximately 10% of which had psychiatric diagnoses. Although the authors were also interested in the role of other predictors, the finding most relevant to the current proposal is that the problem-focused coping strategy was a positive predictor of both adjustment to disability and life satisfaction; avoidance as a coping strategy was a negative predictor of adjustment to disability; and emotion-focused coping was a positive predictor of life satisfaction, but not of adjustment to disability. These findings suggest that coping strategies should be taken into account when investigating how employment affects symptoms of mental illness.
Overall, the thrust of the literature is the reverse of the intent here. The overriding theme is how illness affects employment. My interest is the effect of employment on illness, or more specifically symptoms of the illness. However, an additional study should be mentioned because it has another kind of relevance. Canaff and Wright (2004) reviewed the literature relating job insecurity to counseling with the intent to recommend appropriate counseling strategies. They reported that the stress accompanying job insecurity puts its sufferers at risk for anxiety, depression, substance abuse, and physical ailments. Outcomes such as anxiety are “ normal”, whether the employees have a mental illness or not. If the employee is already prone to these symptoms, how much more stress can push them too far? How do they cope? Are their coping strategies different from those used by their colleagues? And of interest to me, as well as Canaff and Wright, how can their coping skills be altered or strengthened?
On the other hand, employment might benefit the individual with mental illness. Warner (2010) briefly reviewed studies indicating that employment improved self esteem and perceived quality of life and increased size of social networks for schizophrenics—even in competitive work environments. Warner attributed this result to empowerment, “. . . that people with mental illness may feel disempowered, not only as a result of involuntary confinement or paternalistic treatment, but also by their own acceptance of the stereotype of a person with mental illness.”
(p. 4). This suggests that, as with most situations affecting humans, we must ask if the advantages outweigh the disadvantages when considering employment of mentally ill. At this point, we do not know enough to answer that question.

Methods

It is convenient to describe the proposed research procedure using the 7-step framework of Noblit and Hare (cited by Brohan et al., 2012 and Atkins et al., 2008). The steps are: getting started, deciding what is relevant, reading the studies, determining how the studies are related, translating studies into each other, synthesizing, and expressing the synthesis. Before proceeding with a description of the steps, I need to note that a partner or partners in the proposed research is highly desirable, for both reliability, validity and competence concerns.

Getting Started (Step 1)

Specifying the overriding research question is Step 1. At least for the time being, the question is the same as the title of this paper: How Does Full Time Employment Affect Mental Illness Symptoms?

Deciding What Is Relevant (Step 2)

A good choice of search terms is all-important in using this method. Some of the following terms are taken from Brohan et al. (2012) and others added by the author. Still others will be added as they occur to the author: mental illness, mental disorder, psychiatric, disability, schizophrenia, depression, bipolar, anxiety, work, job, employment, occupation, stress, coping, strategies, instability, empowerment, self-esteem, quality of life, etc. The terms will be connected through the operators AND, OR, AND NOT, and NEAR (Barker, n. d.).
The studies thus identified will be examined first through their abstracts, When the abstracts are not sufficiently informative (perhaps lacking necessary information about methodology, participants, context, etc.) it will be necessary to pull and read full texts.
It is also during this step that quality assessment comes into play. Some studies might not appear to be methodologically sound enough to include. Or there might be concerns over reliability and validity. If they are excluded on these grounds, they should be recorded as such along with the reason for exclusion. However, Atkins et al. (2008) point out that sometimes a study can appear to be poorly conducted when it is the writing up of the study that makes it appear inadequate. They advise leniency in making exclusion decisions. Brohan et al. (2012) take a different approach. They classify each study into one of three categories: high, moderate, and low quality based on guidelines they cite in their report. Although not stated, they probably omitted studies judged to be low quality. I have not decided yet whether to follow Brohan et al. or Atkins et al. on this issue.

Reading the Studies (Step 3)

The point in “ buckling down” and actually reading the studies is to identify themes. To focus the reading, I will extract and place into a grid characteristics of each study. (This approach is adapted from a combination of Atkins’ and Brohan’s 3rd steps.) The rows would represent the individual studies and the columns would be headed: (a) characteristics of the sample; (b) design and method, (c) purpose and questions; and (d) outcome or results or conclusions. The grid would have a fifth column, (e) preliminary theme(s) or concepts(s). Atkins et al. (2008), illustrating with a medical example, used categories such as “ social factors”, disease progress” and “ financial burden” to label themes. Brohan et al. (2012) identified themes revolving around disclosure of mental illness background.
This step virtually cries out for another pair of eyes. Are the same themes identified by two or more of the project’s researchers? If not, there will be discussion, rereading and eventually a reporting of how conflicts were resolved.

Determining How the Studies Are Related (Step 4)

In Step 4, we would use the (revised?) preliminary themes to compare the studies. It will probably be necessary to reduce the number of themes to a manageable number before moving to Step 5. Atkins et al. (2008) merged categories so that their “ disease progress” became a larger category “ interpretations of illness and wellness”.
I have to admit to finding this step really murky. When I “ google-searched” for “ themes in qualitative research”, I hit upon a possibly helpful tool, an article by Ryan and Bernard (n. d.) titled Techniques to Identify Themes in Qualitative Research. The authors describe twelve techniques and give references to each. They categorize the techniques based on: (a) word analysis; (b) careful reading of larger blocks of texts; (c) analysis of linguistic features such as metaphors and connectors; and, what will probably be my favorite, (d) physical manipulation of texts (yellow-lining, pawing, and cut and sort procedures). I will explore the references given in this source before finally deciding on the conduct of Steps 4 through 7. This means that the methods listed below are subject to revision.

Translating Studies into One Another (Step 5)

Atkins et al (2008) describe their technique as doing paper by paper comparisons; i. e., arranging the papers chronologically and then comparing themes from paper 1 with themes from paper 2, noting similarities or differences between them, and then comparing the result with theme(s) from paper 3. They stress being open to newly emerging themes at this stage and also caution awareness of policy and other changes that might impact the comparisons due to starting out with a chronological arrangement of papers. The last is especially important if the papers cover a lengthy time period.

Synthesizing Translations (Step 6)

Following Atkins et al. (2008), synthesis of translations calls for a new grid or table in which are listed the themes and subthemes that appear within the first order themes. These authors were a team, and each member of the team developed his or her own model that linked the themes. The models were discussed, merged, and used to generate hypotheses. Besides requiring a team of researchers and the likelihood of diversity in models generated, this approach seems complicated and not necessarily productive.
Brohan et al. (2012) mention software, NVivo version 8, they used at this stage of the synthesis. This might bear looking into, but not until after I fully check out the techniques listed by Ryan and Bernard as well as Chapter 8 of Esterberg (2002).

Expressing the Synthesis (Step 7)

The final step is also challenging—expressing the results in a clear and cogent fashion that is faithful to the sources used. This is all the more important because I would want the results to inform employers and counselors about how to make employment a source of benefit and reward rather than a source of stress and anxiety to individuals already vulnerable. One again, I will rely on carefully chosen partners to help write and edit the report. I expect to use Chapter 10 of Esterberg (2002) to help in this portion of the project.

Reliability and Validity Concerns

One again, I must mention that a research partner is not just useful but probably essential. Whether we opt for following the steps outlined above or use an alternative source for guiding the conduct of our research, we will at several points need to establish, record, and report the processes for establishing agreement. This goes for inclusion decisions, theme and subtheme identification, and identification of study and theme relationships. This is essential in enabling us to establish (a) Lincoln’s and Guba’s (1985) criteria of credibility, transferability, dependability and confirmability and (b) the American Sociological Associations’ principles of professional competence, integrity, and responsibility.

Reflection/Self Evaluation

Rapport with the study population is not an issue because I will not be in direct contact with study participants. It is always a good idea, however, to make friends with librarians. Since I am disposed to like librarians and admire the depth and breadth of their knowledge, I expect to enlist their help in my search.
An odd advantage I have is that I am enthusiastic beginner at Boolean searching. Having just encountered the “ NEAR” operator, I am eager to use it in beginning the search involved in this project. Having steps laid out to guide the search is an advantage. It also helps to have two fairly detailed examples of these steps (Atkins et al., 2008; Brohan et al., 2012). I anticipate, however, that there will be snags and glitches within some or all of them. The newly found resource of Ryan and Bernard (n. d.) could also help—especially in the synthesis phase of the research.
Finally, patience and persistence have not always been my strongest qualities; I guess I will learn them in working through this project.

References

Atkins, S., Lewin, S., Smith, H., Engel, M., Fretheim, A., & Volmink, J. (2008). Conducting a meta-ethnography of qualitative literature: Lessons learnt. BMC medical Research Methodology 8(21) doi: 10. 1186 1471-2288-8-21.
Barker, J. (n. d.). Basic Search Tips and Advanced Boolean Explained. Retrieved from http://www. lib. berkeley. edu/TeachingLib/Guides/Internet/Boolean. pdf
Brohan, E., Henderson, C., Wheat, K., Malcolm, E., Clement, S., Barley, E. A., Slade, M., & Thornicroft, G. (2012). Systematic review of beliefs, behaviours and influencing factors associated with disclosure of a mental health problem in the workplace. BMC Psychiatry 12(11).  doi: 10. 1186/1471-244X-12-11.
Canaff, A. L. & Wright, W. (2004). High anxiety: counseling the job-insecure client. Journal of Employment Counseling41(1), 2-10.
Cook, J. A., Razzano, L. A., Burke-Miller, J. K., Blyler, C. R., Leff, H. S, et al. (2007). Effects of co-occurring disorder on employment outcomes in a multisite randomized study of supported employment for people with sever mental illness. Journal of Rehabilitation Research and Development, 44(6), 837-849.
Esterberg, Kristin G. (2002). Qualitative Methods in Social Research. New York: McGraw-Hill.
Gilbride, D., Stensrud, R., Vandergoot, D. & Golden, Kristie. (2003). Identification of the characteristics of work environments and employers open to hiring and accommodating people with disabilities. Rehabilitation Counseling Bulletin 46(3), 130.
Lincoln, Y. S. & Guba, E. G. (1985). Naturalistic Inquiry. Newbury Park, CA Sage Publications
Livneh, H. & Wilson, L. M. (2003). Coping strategies as predictors and mediators of disability-related variables and psychosocial adaptation: An exploratory investigation. Rehabilitation Counseling Bulletin46(4), 194-208.
Ryan, G. W. & Bernard, H. R., (n. d.) Techniques to Identify Themes in Qualitative Data. Retrieved from http://www. analytictech. com/mb870/readings/ryan-bernard_techniques
Salkever, D. S., Karakus, M. C., Slade, E. P., Harding, C. M., Hough, R. L., Rosenheck, R. A., Swartz, M. S., Barrio, C., & Yamada, A. M. (2007). Measures and predictors of community-based employment and earnings of persons with schizophrenia in a multisite study. Psychiatric Services 58(3), 315-324.
Warner, R. (2010). Does the scientific evidence support the recovery model? The Psychiatrist, 34, 3-5 doi: 10. 1192/pb. bp. 109. 025643.