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The hidden barrier to employment: Untreated and undiagnosed post-traumatic stress disorder.

Persons with severe mental illness have unusually high rates of exposure to trauma as well as high rates of Post-traumatic stress disorder (PTSD). Further, research has indicated that persons with PTSD have more problems with obtaining and maintaining employment. This paper proposes that untreated and undiagnosed PTSD is a hidden barrier to employment for persons with severe mental illness. Additionally, this paper uses case examples to illustrate how PTSD symptoms negatively impact the supported employment process, and proposes a theoretical pathway and two case examples for how Cognitive Behavior Therapy may help to facilitate removing the hidden barriers to employment.

Traumatic experiences are commonly experienced by individuals with severe mental illnesses (Mueser, Essock, Haines, Wolfe, Xie, 2004a). Individuals with severe mental illnesses are more likely than the general population to have experienced traumatic events prior to and after the onset of severe mental illnesses (Grubaugh, Elhai, Cusack, Wells & Frueh, 2007). In addition, the prevalence of current Post-Traumatic Stress Disorder (PTSD) is greatly elevated among persons living with severe mental illness and ranges from 19 to 43% (Mueser et al., 1998; Craine, Henson, Colliver, & MacLean, 1988; Howgego et al., 2005; Mueser et al., 2004b; Switzer et al., 1999), in contrast with an estimated current prevalence of 3.5% in the general population (Kessler, Chiu, Dernier, & Walters, 2005).

The high prevalence of PTSD among persons living with severe mental illnesses may be the result of several factors, including early childhood trauma which may predispose individuals to severe mental illnesses, and increased risk of traumatic victimization related to severe mental illnesses (Goodman, Rosenberg, Mueser, & Drake, 1997; Goodman & Fallot, 1998; Cloitre, Tardiff, Marzuk, Leon, & Potera, 1996; Mueser et al., 1998). The co-occurrence of PTSD and severe mental illness correlates with poorer functioning, suggesting that the combination worsens the outcome of both disorders (Mueser et al., 2002). Unfortunately, despite evidence that co-occurring PTSD has a strong impact on outcomes among people living with severe mental illnesses, screening for and diagnosis and treatment of PTSD in public mental health centers occurs at sub-optimal levels (Frueh et al., 2002), and treatment for PTSD among people living with severe mental illnesses is at the early stages of development (Mueser et al., 2008). Evidence indicates that co-occurring PTSD is overlooked and untreated by the vast majority of community mental health providers (Freuh, Grubaugh, Cusack, & Elhai, 2009).

A major concern people with severe mental illnesses confront is the lack of attachment to the workforce. The unemployment rate among people with severe mental illnesses is among the highest of all disability groups in the US (Cook, 2006). Being unemployed contributes to ill health and is associated with a wide array of negative consequences, including substance abuse, depression, anxiety, poverty and homelessness (Blustein, 2008; Rosenthal et al., 2012; Marrone & Golowka, 1999; Cook, 2006; Draine et al., 2002). Thus, non-attachment to the workforce is associated with poorer outcomes among persons with severe mental illnesses.

The individual placement and support (IPS) model of supported employment (SE) is an evidenced-based practice that has shown success in improving employment outcomes among people living with severe mental illnesses (Bond, 2004; Bond, Drake & Becker, 2008). SE programs with "high fidelity" to the IPS model are able to consistently help over 60% of participants return to work (Bond et al., 2008). Nonetheless, even the highest performing SE programs are often unable to assist roughly 40% of participants with obtaining an employment goal. Therefore, there is a need to identify areas responsive to intervention that can potentially increase rates of employment among persons with severe mental illnesses.

There is evidence that co-occurring PTSD might be a key predictor of lack of response to IPS. Mueser et al. (2004a) examined the relationship between co-occurring PTSD and outcomes in a sample of 204 participants with severe mental illnesses who were receiving IPS services in a two-year-longitudinal study. Weekly employment assessments were used to measure progress and outcomes which identified job type, how the job was obtained, wages, hours, and whether or not the job was competitive. Results of this study showed that the participants with co-occurring PTSD in the IPS program had significantly poorer employment outcomes than persons with severe mental illness along (Mueser et al., 2004a). This study suggests that PTSD can have a substantial impact on the effectiveness of IPS programs (Mueser et al., 2004a).

Despite evidence that co-occurring PTSD may decrease the likelihood that one will respond to IPS services, there has been little articulation of the reasons why this would occur. Nevertheless, there are many plausible connections between PTSD symptoms and barriers to getting and maintaining employment. Research on PTSD and career choices among college students suggest that avoidance symptoms (Avoidance and Numbing) had the broadest impact on one's ability to function in a job. Hyperarousal symptoms in PTSD (sleep problems, concentration difficulties, anger/irritability, and startle reactions) were also found to be related to an individual's ability to initiate a career decision making process and to commit to a specific career choice (Strauser, Lustig, & Uruk, 2006).

Statement of the Problem

This article proposes that undiagnosed and untreated PTSD is a hidden barrier to employment among people with severe mental illnesses, and may explain why a substantial number of SE participants are unable to benefit from these services. A number of mechanisms related to PTSD can impact the likelihood that one will respond to IPS services, as illustrated in the two case examples provided below.

Case Example I illustrates how PTSD avoidance interferes with the process of job- seeking. Lilly, a white women in her late 40's registered for SE services in a program in southern New Jersey. Lilly's work history was sporadic over the years; however, she did work as a bookkeeper in her early 20's before the onset of her psychiatric illness. During the initial phase of the SE process Lilly worked diligently providing her job coach, Becky, with information and discussing her career goals. Lilly indicated that she needed support with updating her resume and improving her interviewing skills. She obtained interview-appropriate clothing for an office setting and participated in several mock interviews until she felt comfortable. With her updated resume she was in a position to begin approaching employers. She worked with Becky to develop an employment plan. She felt she could approach at least 3 employers a week for entry level clerical positions. In addition, the SE program would provide job development services and help set up interviews on her behalf if there was a good job match. It was at this point in the SE process that Lilly became "stuck." She reported to her job coach that she was not able to set up any interviews with employers. When Becky asked her how many employers she called, Lilly admitted she did not call any employers. Nevertheless, the SE program was able to set up an interview on her behalf in a small office setting, which Lilly indicated was her preference. The morning of the interview Lilly called to cancel stating that she was sick. Becky rescheduled the interview for the following week, but Lilly called several days later stating that she changed her mind, and decided that she was not "ready" to return to work. It was at this time that she disclosed to Becky that she still feared going to interviews because she felt she could not deal with authority figures, as she had suffered abuse from both of her parents, several other relatives and a former boyfriend. She also stated that she had experienced harassment at a previous job, and that she still felt uncomfortable during interviews because of that experience. She said that interacting with anyone that she perceived to be in a position of power caused her anxiety. Lilly thanked Becky and the SE program for trying to help her, and she indicated that she would still consider returning to work someday.

Unfortunately, Lilly's experience in SE is quite common. Lilly expressed a negative perception of potential employers as authority figures whom she could not trust. Further, although a part of Lilly was interested in working, her past traumatic experiences with people in authority impacted her current perceptions of employers. Her avoidance symptoms, which are common in PTSD, impacted her ability to form functional career thinking and her ability to initiate and sustain the career decision-making process and her ability to engage in problem-solving.

Case Example 2 illustrates how negative alterations in cognitions and mood (symptoms of PTSD) interfere with the process of job-seeking or career advancement. Susan, a single white woman in her late 30s, became involved with SE in an effort to find full-time employment. Susan shared with her employment specialist, Travis, that she had an extensive work history as a stock checker in various locations. She was recently fired from her position due to a pattern of angry outbursts toward co-workers and her supervisor. She stated that the work was solitary, consisted of irregular hours, and her involvement was dependent on calls from "the boss" when work was available. Despite the fact that she found the work "boring and repetitive" and her co-workers hostile and unfriendly, she had maintained this pattern of employment, and was able to return to this job after each of her 7 psychiatric hospitalizations in the past 10 years, up until the past three months when she was terminated. Although it was not listed in her clinical chart, Susan shared with Travis after several months that she had developed PTSD as a result of years of sexual abuse by a family member. She also shared that she felt little hope for the future, and described herself as "angry all the time." She attributed her continued involvement with her long-time job to the fact that she was unable to be around people for any length of time without becoming angry. Being able to work "away from others," made the work tolerable for her. She stated that one of her problems on the job was feeling constantly on the defensive, awaiting some comment or action by a co-worker or supervisor to "set her off." She stated that, in the past, when she tried to find other employment she had been so ready to defend herself that she questioned everything she was told or asked to do. To address this issue, Travis worked with Susan on improving her interviewing skills at a "mock" interview with a colleague from the SE program. However, Susan even lost her temper in the mock interview situation when the mock interviewer asked her "where do you see yourself in 5 years," which is typical in job interviews. In spite of her ability to develop a trusting relationship with her employment specialist Travis, Susan began to become anxious and disappointed after attending two job interviews in clerical and retail settings. She was angry and upset when she wasn 't offered a job at either site, and, although she didn 't blame Travis for these jobs not working out, she decided that she wanted to take time off and discontinued working with the SE program.

Susan's example shows the limitations of SE services when working with job seekers with PTSD. Although Travis was a highly-skilled and well-trained employment specialist, and his team produced outcomes typical of high fidelity IPS SE programs, Travis and the team were not equipped to address and provide treatment for her PTSD symptoms, including "negative alterations in cognitions and mood" leading to guardedness and angry outbursts, during the job-seeking process.

Response to the Problem: PTSD Intervention with SE

One of the core principles of IPS SE is the integration of vocational and clinical services (Bond, 2004). However, most SE teams are ill-equipped to work with participants with a history of trauma and who may have untreated and undiagnosed PTSD. Currently, the integrated cognitive-behavioral treatment model (I-CBT) has shown evidence for effectiveness in addressing co-occurring PTSD among people with severe mental illnesses (Mueser et al., 2008; Mueser et al., 2015). However, existing versions of I-CBT for PTSD are geared toward individual psychotherapy and cannot be easily implemented in SE settings. In addition, they do not place an emphasis on specific linkages between PTSD symptoms and employment functioning. Therefore, to address the need to assist non-responders to evidence-based SE, we developed a group version of the I-CBT intervention specifically targeted toward persons receiving SE services.

I-CBT for PTSD imparts five learning and skill components to participants in order to improve PTSD symptoms and employment outcomes: 1) Personal work recovery 2) Patient education about PTSD and its relation to employment and recovery; 3) Breathing retraining (a behavioral anxiety reduction skill); 4) Cognitive restructuring (a cognitive approach and functional analysis of the link among emotions, cognitions and employment situations); 5) Coping skills for persistent PTSD symptoms such as avoidance of work-related tasks, irritability and interpersonal problems on the job. These ingredients, central to all effective PTSD therapies, are included in this manual-based treatment (Keene, 2009).

The I-CBT groups occur on-site of SE services to ensure frequent and timely communication between group facilitators and SE staff. Monthly meetings of one and a half hours occur between group facilitators and SE staff to review client's progress in SE and in PTSD treatment. Groups occur once a week for 12 weeks and include four modules, consisting of 3 sessions each. Module I, titled Overview of Trauma and Employment, concentrates on psychoeducation, breathing relaxation skills and work recovery plan. Session leaders will ask specific questions about attempts to find employment for the individuals that experience PTSD symptoms. Module II, titled, Trauma and Dreams for Tomorrow, discusses the impact trauma has on one's negative expectations of work, and begins the process of teaching cognitive restructuring skills to address PTSD related beliefs. Module III, titled, Trauma and Work Related Self-Efficacy, addresses trauma-related beliefs related to being damaged, defeated, and currently unable to attain a job. It also discusses trauma's impact on the individual's identity, self-esteem, and ability to work. Module IV is titled Trauma and Social Relations at Work. This module addresses the impact of trauma on interpersonal problems at work, such as isolation, and possible issues with authority. The next vignette is a case example that illustrates how participation in group-based I-CBT can improve employment outcomes among people with co-occurring PTSD.

Case Example 3:

Gerard is a 40 year old African American male living in a large city in the Mid-Atlantic region of the US, who attended the I-CBT for PTSD in SE group. Gerard initially stated that he was not interested in working, in spite of being enrolled in the agency's SE program. Gerard stated in the beginning that he always thought negatively about everything, and he had a history of using alcohol. The first module of the treatment program taught the skill of breathing retraining. Gerard stated that many of the ways he thought and acted in the past were directly related to his past trauma and PTSD. He never thought that his thoughts and actions could have been so influenced by his past history of trauma. Gerard stated that in the past he would get angry and walk off jobs because he thought that the supervisor was angry at him. However, the breathing retraining exercises taught him that he could step back and calm himself down before acting in a rash manner. Gerard shared in the group that it was amazing that there was a "totally natural" way to calm down, without resorting to drinking alcohol, that actually worked.

Additionally, the following modules, which focused on teaching cognitive restructuring skills, allowed Gerard to examine how his thoughts and feelings are connected, and also affect his behavior. In a group session, while talking about his history of quitting jobs, he realized that he actually never had direct evidence that his supervisor was upset with him. Yet, his reaction was always very self destructive, because he ended up quitting and becoming unemployed. Gerard made the connection between his negative thinking and his expectations of people in authority with his past history of trauma.

Throughout the group process, Gerard, who presented as angry outside the group, was always very supportive of the other group members. He stated that he felt he could be himself during the group. Additionally, although he stated he struggled with literacy, he was always able to complete the homework assigned during the group. Towards the end of the 12 week group, Gerard stated that he had a group job interview, and that the manager had to leave before finishing the individual interview session. Gerard stated that in the past he would have walked out and never returned. However, this time he was able to step back and do the breathing exercise to calm down and assess how he felt and thought about what was happening. He was then able to consider what may be happening without personalizing it, and was able to determine that the manager was very busy and that he would be happy to meet with him next week to complete the application process.

During the last group meeting, Gerard stated he not only wanted to go back to work, but he was interested in attending literacy courses to improve his reading and writing skills to become more competitive in the employment arena. Gerard statedthe 12 week group was "life changing" and that he now no longer thought negatively about everyone and everything. Additionally, Gerard's clinician later stated that the group did indeed cause a major change in Gerard, as he was now more engaged in his recovery process and actually following through on pursuing goals.

At a follow-up meeting with study staff, Gerard shared that he found an entry level part-time job in a small retail setting. He said that he felt great being able to help out around the store and also make a little extra money. Additionally, he shared with the study staff member that he still sometimes has negative thoughts but is now able to step back and utilize his new cognitive restructuring skills in the moment, and his thoughts don't spiral out of control anymore.

The above vignette demonstrates that often SE participants need skills training to help ameliorate their past trauma history, not just the typical skills training on resume development, job interviewing, and other employment specific tasks. Below is another case example that demonstrates how teaching SE participants skills to address PTSD symptoms led to a successful outcome.

Lynette, an African American woman in her 40s living in suburban New Jersey, participated in the 12 week I-CBT for PTSD group. She disclosed a history of multiple traumas dating back to her preteen years. She struggled with extreme negative thoughts of guilt and fear. Over the years, these feelings and her unresolved trauma created barriers in the employment process. During the first several sessions of the group, Lynette was able to connect much of the psychoeducational content discussed in the group to her own experiences. She recognized that some of the behaviors and thoughts that hindered her in the job-search process and at work in the past were related to her trauma history. She said it was "like a light bulb turned on," and she was able to see how these things were connected. Throughout the group, Lynette worked to recognize her automatic thoughts and began implementing the coping skills and cognitive restructuring strategies learned in the group, even prompting other members to use the strategies during group meetings when they felt strong emotions coming on. During the course of the sessions, Lynette experienced another traumatic event. However, she was able to use the coping skills she was learning in the group to manage the intense feelings and stop automatic thoughts before they derailed her progress.

While Lynette had been with the SE program for about one year prior to starting the group, she had taken few steps toward employment. However, after starting the I-CBT group, over the course of a few weeks, she was able to clarify her employment goal. By the end of the sessions, she had taken steps to research what credentials were required, set up an informational interview with someone working in the field, joined an advocacy group, and through a contact she met in the advocacy group started volunteering in her desired field in order to gain experience while she earned the credentials needed. During a follow-up meeting, the SE supervisor notified study staff that Lynette had found a position in her desired field and was scheduled to start working in the next week.

Conclusion

Teaching SE participants cognitive restructuring skills can provide them with a powerful tool to address the negative thinking patterns which are so prevalent in PTSD. The perception of negative work-related subjective experiences may constitute a barrier to employment, as a perception of negative work-related subjective experiences can induce negative affective states that may lead to avoidance of vocational activities (Waghorn, Chant, & King, 2007). As the vignettes illustrated, SE participants with a history of trauma did perceive work-related subjective experiences negatively. Further, these negative perceptions caused difficulty in participating in employment services and most importantly, actually working.

We believe that the group-based adaptation of I-CBT for people in SE can be a powerful tool for improving the employment outcomes of people with severe mental illnesses and co-occurring PTSD (we are currently conducting a randomized controlled trial to formally assess the effectiveness of I-CBT among people engaged in SE). Persons with severe mental illnesses confront numerous barriers to employment; however, by developing the capacity to effectively serve participants with undiagnosed and untreated PTSD, the field can begin to address a long hidden barrier to employment.

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Weili Lu

Rutgers University

Philip T. Yanos

City University of New York

Brittany Stone

Rutgers University

Giovanna R. Giocobbe

Rutgers University

William Waynor

Rutgers University

Ann Reilly

Rutgers University

Carolyn Bazan

Rutgers University

Philip T. Yanos, Psychology Department, John Jay College of Criminal Justice, City University of New York, 524 W. 59th St., New York, NY 10019

Email: pyanos@jjay.cuny.edu
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Author:Lu, Weili; Yanos, Philip T.; Stone, Brittany; Giocobbe, Giovanna R.; Waynor, William; Reilly, Ann; B
Publication:The Journal of Rehabilitation
Article Type:Report
Date:Apr 1, 2017
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