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week88010assignmenarticle.docxAuthors:
Alverson, Marianne . New Hampshire-Dartmouth Psychiatric Research Center, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, US Becker, Deborah R. . New Hampshire-Dartmouth Psychiatric Research Center, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, US Drake, Robert E. . New Hampshire-Dartmouth Psychiatric Research Center, NH, US
Source:
Psychosocial Rehabilitation Journal , Vol 18(4), Spr 1995. Special Issue: Making Work a Priority. pp. 115-128.
Page Count:
14
Publisher:
US : International Association of Psychosocial Rehabilitation Services and Department of Rehabilitation Counseling, Sargent College of Allied Health Professions, Boston University
Other Journal Titles:
Psychiatric Rehabilitation Journal
Other Publishers:
US : Educational Publishing Foundation US : International Association of Psychosocial Rehabilitation Services and Department of Rehabilitation Counseling, Sargent College of Health and Rehabilitation Services, Boston University
ISSN:
0147-5622 (Print)
Language:
English
Keywords:
coping strategies, mental illness, supported employment, rehabilitation, stigma
Abstract:
In response to the need for qualitative studies of mental health consumers in the process of rehabilitation and recovery, the authors conducted a one-year ethnographic study with 13 participants in the New Hampshire Supported Employment Study. Ethnographic methods included participant-observation and interviewing. Six common strategies for maintaining health and employment were identified: (I) keeping a positive outlook, (2) avoiding substance abuse, (3) using a diverse support network, (4) using medications strategically, (5) avoiding relapse of illness, and (6) overcoming stigma. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
Document Type:
Journal Article
Subjects:
* Mental Disorders ; * Mental Health ; * Supported Employment ; * Serious Mental Illness ; Employment Status ; Stigma ; Vocational Rehabilitation
PsycINFO Classification:
Rehabilitation (3380)
Population:
Human Male Female
Location:
US
Age Group:
Adulthood (18 yrs & older) Young Adulthood (18-29 yrs) Thirties (30-39 yrs) Middle Age (40-64 yrs)
Grant Sponsorship:
Sponsor: National Institute of Mental Health, Substance Abuse and Mental Health Services Administration, US Grant Number: R18-MH-47650 Other Details: US Public Health Service grant Recipients: No recipient indicated Sponsor: National Institute of Mental Health, US Grant Number: K02-MH-00839 Other Details: US Public Health Service grant Recipients: No recipient indicated
Methodology:
Empirical Study; Interview; Qualitative Study
Format Covered:
Publication Type:
Journal; Peer Reviewed Journal
Release Date:
20130429
Correction Date:
20200713
Digital Object Identifier:
http://dx.doi.org.ezp.waldenulibrary.org/10.1037/h0095476
Accession Number:
2013-13240-012
Number of Citations in Source:
26
Database:
APA PsycInfo
Translate Full Text:
An Ethnographic Study Of Coping Strategies Used by People with Severe Mental Illness Participating in Supported Employment
Contents
2. Setting
3. Study Group
4. Procedures
5. Analysis
6. RESULTS
7. 1. Keeping a Positive Outlook
8. 2. Avoiding Substance Abuse
9. 3. Using a Diverse Support Network
10. 4. Using Medications Strategically
11. 5. Avoiding Relapse of Illness
12. 6. Overcoming Illness and Stigma on the Job
13. DISCUSSION
14. CONCLUSION
15. REFERENCES
Full Text
By: Marianne Alverson New Hampshire-Dartmouth Psychiatric Research Center, Department of Community and Family Medicine, Dartmouth Medical School Deborah R. Becker New Hampshire-Dartmouth Psychiatric Research Center, Department of Community and Family Medicine, Dartmouth Medical School Robert E. Drake New Hampshire-Dartmouth Psychiatric Research Center, Department of Community and Family Medicine, Dartmouth Medical School
Biographical Information for Authors: Marianne Alverson, BA, is an ethnographer at the New Hampshire-Dartmouth Psychiatric Research Center, Department of Community and Family Medicine, Dartmouth Medical School. She conducted a one-year ethnography in the New Hampshire Supported Employment Study and a two-year ethnography in the New Hampshire Dual Diagnosis Study. Earlier in her career she completed ethnographic fieldwork in Africa which is described in her book Under African Sun (University of Chicago Press, 1987)
Deborah R. Becker, M.Ed., CRC, is a rehabilitation specialist and a research associate at the New Hampshire-Dartmouth Psychiatric Research Center, Department of Community and Family Medicine, Dartmouth Medical School. She has been the project director for several vocational research studies and has helped to develop and describe the Individual Placement and Support vocational model.
Robert E. Drake, MD, Ph.D., is director of the New Hampshire-Dartmouth Psychiatric Research Center. He is professor of Psychiatry and Community and Family Medicine.
Acknowledgement: This work was supported by US Public Health Service grants #R18-MH-47650 from the National Institute of Mental Health and the Substance Abuse and Mental Health Services Administration and #K02-MH-00839 from the National Institute of Mental Health, by the New Hampshire Divisions of Mental Health and Vocational Rehabilitation, and by consumers and staff at The Mental Health Center of Greater Manchester.
Researchers have frequently identified the need for qualitative studies on how people perceive, experience, and define their efforts to cope with the effects of chronic physical or mental disorders ( Davidson & Strauss, 1992 ; Hauser & Scharfetter, 1990 ; Lazarus, 1993 ; Müller et al., 1992 ). Ethnographic methods have led to numerous insights in the mental health field (Estroff, Lachiotte, & Illingworth, 1991; Gounis & Susser, 1990; Susser, Conover, & Struening 1990), although these efforts have not been extended to the study of vocational rehabilitation.
As part of a larger study of supported employment ( Drake, McHugo, Becker, Anthony, & Clark, submitted ; Drake, Becker, Xie, & Anthony, in press ), 13 participating mental health consumers agreed to be followed and interviewed by an ethnographer and to discuss their difficulties and coping strategies as they sought to participate in the world of competitive employment. Consumers in their discourse, as a rule, did not make sharp distinctions between work-related and not work-related coping strategies. Rather they were necessarily struggling with their mental illnesses as well as with work situations, and the coping strategies and examples cited here applied to both of these domains.
Setting
The ethnographic study took place in a small New Hampshire city of 166,000 people. Nearly 100 consumers in the local community mental health center (CMHC) volunteered to participate in a study of supported employment. Half were randomly assigned to receive services through a supported employment program, called Individual Placement and Support (IPS; Becker & Drake, 1994 ), which was located within the same mental health center. For the ethnographic study, a group of consumers were followed continuously for one year from the time they began the IPS program.
Study Group
Thirteen consumers who were participating in the IPS intervention were selected based on their representativeness in terms of sex, age, diagnosis, and job status. They included six women and seven men (most in their 30's), ranging from two in their late 20's to one in her early 60's. All were non-Hispanic white. All had histories of multiple psychiatric hospitalizations and met certification criteria of the state of New Hampshire: major mental illness, persistent disability in several areas, and need for services. All received mental health services as well as vocational services from the local community mental health center.
During the year of ethnographic study, the 13 consumers, as participants in IPS, sought competitive employment, and 77% obtained at least one competitive job. Actual job status varied among competitive jobs, transitional jobs, volunteer jobs, sheltered work, and training programs. All consumers throughout the year of study directed their energy to the goal of getting and keeping a job, and when not working, the search for work became a job.
Procedures
Ethnography, or participant-observation and interviewing, is an important method of inquiry for complementing and guiding survey questionnaires, structured observation, and formal interviewing. Documenting actual experience, which is almost always contingent, tacit, and often half-conscious, requires that study go on at the time of the action in question. What actually goes on in behavior is generally far more complex than what is “remembered.” And what is remembered is in large part supplied by habitual fantasies and norms of story-telling. Participant-observation/interviewing seeks to enter into discourse with subjects about their experience at or near the time they are experiencing it, as well as on later occasions when these experiences are recast as stories for oneself or as verbal performances for others. Participant-observation/interviewing tries to avoid the problems created by impersonal use of formal instruments ( Parry & Crossley, 1950 ) and to confirm self-reports and later self-narration by observations on the part of the ethnographer.
Participant-observation and interviewing presuppose a broad and ongoing relationship of exchange between ethnographer and consumer. The willingness of consumers to participate in research, to part with valuable information, and to reveal aspects of their lives that are not normally “public,” will only happen if a relationship of trust between ethnographer and consumer exists and there is an equity in the minds of the consumers regarding the exchange of valued outcomes.
The ethnographer for this study sought to meet these two conditions by participation in the lives of consumers largely on terms and conditions set down by them. She spent one year as participant-observer interviewing each of the 13 IPS consumer participants. Introducing herself as a research worker interested in learning about their lives and emphasizing strict confidentiality, she met with consumers in their world, on their terms. Very little of this interaction took place within the mental health center. Instead, she accompanied them during meals, work, play, and moments of reflection, spending hours or an entire day with each consumer. Incentives to share information flowed directly from opportunities for reciprocities between ethnographer and consumer: a ride for someone without a car; a meal together before or after work; a walk on a rare, sunny day; a visit in the hospital; a wait in line together to pick up a benefit check. While first meetings between ethnographer and consumer were initiated by the ethnographer, consumers soon felt free to telephone her to arrange meetings, to tell her something new, or to continue a conversation. Both ethnographer and consumer felt equally free to initiate meetings, and this proved particularly valuable after leaving the field to write up data. Any new developments were promptly reported by phone.
As a trusting relationship developed, consumers began to speak freely of their difficulties and their attempts to control their mental disorder in order to retain employment or find jobs. Indeed, coping strategies were a preoc-cupation for all thirteen consumers as they discussed their mental health and desire for employment. Consumers became as interested as the ethnographer in a thorough investigation of their difficulties and coping strategies as they pursued jobs; thus, consumers were true collaborators.
The ethnographer kept verbatim field notes and reconstructed conversations in addition to her own descriptions and observations of events. As in any research effort, the ethnographic approach must attend to the problem of altering consumers’ experience in the process of study. The ethnographer therefore attempted to document respondents’ reactions to her role and to incorporate this researcher-induced reflexivity on the part of consumers into the data as a whole.
Analysis
The ethnographer's field notes were entered into the computer and coded according to topics. All efforts to deal with common threats to health and employment, reported by consumers and observed by the ethnographer, constituted the data culled from field notes for this study.
Seeking to present consumer-initiated discourse, the ethnographer strictly adhered to consumers’ own definitions, descriptions, and categories of difficulties and coping responses. No attempts were made to break down this discourse into components that would be foreign to the consumers themselves. In general, the categories and distinctions that consumers themselves proffered were preserved.
Ethical and moral considerations have been raised concerning the authority assumed by the ethnographer in transforming consumers’ words into text for publication (Estroff, in press; Frank, 1979 ; Stoller, 1988 ). All 13 participants in this study received copies of earlier drafts of our results. All participants, while recognizing and consenting to the use of their own words in the text, expressed satisfaction that changes of names and insignificant details met their criteria for confidentiality.
All consumers in this study described employment as an important means of coping with severe mental illness. (“Work is my saving grace. If I didn’t have to go some place every morning, I’m sure I’d be depressed and suicidal. If I had nothing to think about except those thoughts, I’d blow them up the size of Texas.”) At the same time, consumers viewed employment as a measure of their success in coping with mental illness. (“I feel rewarded for hard work. Working full-time makes me feel human again. You’re just like everyone else in the mainstream. You’re not on the inside looking out or on the outside looking in.”)
While all consumers had access to the same professional support system with IPS and other CMHC staff, in their interviews with the ethnographer, they emphasized the need for several personal strategies, apart from profes-sional help, to cope with the intertwined complexities of work and illness. Even with the best jobs and excellent professional help, consumers insisted that, in the final analysis, their own coping skills and strategies made the dif-ference between job retention and job failure, health and ill health.
Difficulties commonly cited as the context for coping strategies included poverty, stigma and discrimination due to mental disorder, and poor physical health. While consumers recognized such difficulties, they identified several specific aspects of the mental illness, itself, which required constant attention: the unpredictability of onset, the seeming inevitability of the cycle of illness, the effects of symptoms, the side effects of medication, and the occasional need for short-term hospitalizations. Given these difficulties and the desire to maintain health and retain employment, consumers feared, above all, that failure of their personal coping strategies would result in onset of illness and job loss.
Consumers reported using the following six common strategies.
1. Keeping a Positive Outlook
Despite histories of crises and hospitalizations, consumers reported strenuous efforts to keep a positive outlook. For many, a history of coping with the effects of illness engendered optimism as they selectively looked to past experience, focusing not on illness, but on recovery. (“I’m a survivor. I bounce back.” “I can’t look back to having been sick. I must believe that I’m healthy and happy.”) Consumers viewed a positive outlook as paramount, a fertile ground for all other coping responses. Because these other coping responses did not always succeed, keeping a positive outlook was experienced as a necessary, willful, continuous act.
Most consumers had some private litany, words of encouragement, which they recited to themselves on or off the job in times of crisis. (“I’ll be all right. It's just hard for me now.” “God hears me.” “I’m gonna grow up.”) Additionally, all 13 summoned role models, among past or living friends, family, or public figures, as reason for optimism. Twelve of the consumers focused on particular symbols of hope to keep a positive outlook. (“My mother, at change of life, got better, went off her meds and didn’t get sick again. Maybe I’ll get better as I age.” “I think of schooling. It keeps my hope alive.”)
All consumers made efforts to appear optimistic to help them keep a positive outlook. (“When they ask me at work, I say I’m O.K. I twist things around, half-lie, if necessary.”) Consumers were observed to avoid stressful circumstance and negative talk by distancing themselves through humorous diversions, taking walks, or seeking out “positive people.” Consumers, particularly those without telephone service, stressed their need for a means of easy communication with those friends and relatives who could put them in a positive frame of mind. One consumer, working two jobs with little time for such contacts, brought the positive voice into his routine by listening to audio tapes on “Positive Stress Management” while commuting to his jobs.
2. Avoiding Substance Abuse
Consumers revealed an important irony: “coping” for them must include eliminating maladaptive coping strategies. Four consumers had no history of substance abuse, but nine of them, while still associating drink and drugs with short-term relief and pleasure, recognized their previous experience with substance abuse as detrimental to good health and employment. Because regular pay checks made drink or drugs readily available, they reported ongoing efforts to maintain sobriety. Four consumers attributed sobriety to faithful attendance at AA, NA, or ACOA meetings, but five avoided these meetings because of the “negative talk” and the stigma they felt in a setting where recovered adults frequently displayed sobriety as proof that they were never “crazy.” All nine made efforts to stay away from places and people associated with substance abuse, but they also stopped short of rejecting outright such contacts and relationships (i.e., when pressured to do so by concerned case managers) because they saw them as important resources in their support network.
3. Using a Diverse Support Network
Long-term residence in a neighborhood and association with its mental health community offered consumers a wide network of potential social and professional resources and support. All emphasized the need for a diverse network. (“You need a range of support…support from those with mental illness who understand, and those without it. I need many people to deal with different stresses. I tell different people different things. One person couldn’t handle it all.”)
Consumers contrasted the relatively transient relationships they experienced with professionals and the long-standing support they received from family and/or friends. Only two consumers did not turn to family members for support. (“My family denies the mental illness. They don’t bring it up.”) All others credited particular family members (and, in two cases, pets), for soothing tensions at work, countering feelings of worthlessness and loneliness, and aiding in a crisis.
Nine of the thirteen consumers defined themselves as living in poverty or near homelessness. They relied on their network of friends to improve communication and social skills and to find free services and opportunities to barter for things basic to their very survival.
Professionals were also important. Twelve of the consumers underscored the need for continuous therapy with their case manager while getting and working in a job. (“I really need therapy when I work. I would have walked out of these fobs without someone to talk to.”) Most consumers included regular contact with their IPS employment specialist as essential to coping with a working life, and all consumers relied on the employment specialist to help them, emotionally and logistically, through periods of unemployment and initial job contacts. (“The employment specialist explained the job thoroughly so I knew I’d be able to do the job. I didn’t have to fear the job would be too stressful—that I’d lose it.” “My employment specialist is essential to me. It would be a nightmare without her…she was very supportive during my time of crisis at work. She bolsters my ego. She's very good to talk to. Both my employment specialist and my case manager were very, very helpful to me.”)
All consumers were selective about whom they turned to for professional help, and if, after repeated consultations, they were dissatisfied, consumers felt reluctant about confiding in or going back to those individuals. In particular, they reported ambivalence about doctors and therapy groups. (“Psychiatrists don’t know us. They only see us once or twice a year. They only know what they read.”) All who attended groups run by the CMHC expressed discontent (“I don’t like the negative talk.” “I want to get away from Mental Health.” “The same people always do the talking.”), but three returned to these same groups after recovering from crises and resuming employment found value in attendance. (“I enjoy the group in that I can learn and compare myself. I see myself in a better situation. I realize, too, if I get carried away, I could end up like that.”)
4. Using Medications Strategically
All consumers reported feeling ambivalent about using medications. Only two of the thirteen consumers associated absolute compliance with good health, sobriety, lack of denial, and job retention. Both of these con-sumers frequently expressed difficulties with this strategy (“Last night I was taking my meds. The mirror was there in front of me and I saw myself. I hated myself for having to take it. Tears were rolling down. I saw myself crying. I have to accept it: That's who I am.”) and devised a routine to enforce it. (“Every morning when I drive out of the driveway to work, I think to myself: ‘Did I take my meds?’ It works. Some mornings I find I forgot and I come back.”)
The majority of consumers stressed the need for secrecy (“Don’t tell anyone, but I don’t use my meds as prescribed.”) and described their decisionmaking regarding medication use as a system of on/off use or revised doses based on the following criteria: (1) perceived needs on a given day, week, or month (“April, May.. I know it's a tough month. I have to be careful about taking meds.”); (2) fear of long-term drug dependency and desire for limited use and alternative solutions (“I was on Lithium before but I took myself off it. I don’t like putting things into my body that I don’t need…I take vitamins.”); and (3) side effects felt or feared to limit or interfere with job performance (“Meds help but they don’t work completely. The side effects slow you down. They drove me out. I get spaced out, sleepy.”) One consumer who was often confused about identifying side effects, regularly discontinued medication use to test for them. (“I don’t think it's meds that make me tired. I checked it out. I went off meds and slept plenty.”)
All consumers reported that trust in their doctor and their belief in the accuracy of their diagnosis determined how, when, or if to take medication. The majority of consumers either did not feel understood by their doctor or were not convinced of an accurate diagnosis. Criteria for deciding when to use medication included: taking medication when symptoms got closer or when a cycle of illness was expected. While a sudden symptom often prompted use of medication, it did not assure sustained use because as side effects were felt, memories of feeling better without medication came to mind.
Five consumers who reported suffering no side effects and trusting their doctor's diagnosis still sought to limit medications and to find alternatives. Having fought other kinds of addictions for health reasons, they did not want to rely on consistent, long-term use of medication of any sort. While defending their desire to limit use of prescribed medication as a healthy alternative compatible with their working life, these consumers admitted keeping this decision from professionals to avoid pressures for compliance.
5. Avoiding Relapse of Illness
Relapse of illness frequently interrupts employment. Those who experienced longer periods between episodes attributed their successful coping strategies with breaking the cycle. Consumers who claimed such success, however, did not feel they could let down their guard. They appeared to exercise no less diligence about being prepared to avoid another crisis than those consumers who did not experience a respite from their “usual cycle.” Consumers agreed on essential steps for avoiding relapses: (1) Upon feeling better, resist temptations of denial (“You must know yourself. You must be truthful with yourself.” “You must admit you’re manic, bi-polar.”); (2) Accept and anticipate the cycle of illness; recognize early warning signs (“I hope I’m learning from each episode. Early on you feel so powerful, you don’t want it to stop. It takes time to learn.” “You use pressured speech. You start having racing thoughts when you start to get sick. It helps to know what the first symptoms are so you can catch it in time…you have to nip it in the bud.” ); and (3) Increase or decrease activity; communicate for help.
Each consumer reported the need to learn when to increase or decrease activity. Some followed a set pattern. (“When I have anxiety attacks at work, the work helps, I push myself through.” “At home, if I have an anxiety attack, I go to sleep. Sleep is a refuge.”) Several reported the need to keep busy on the job. (“At work you need to keep your mind occupied, your hands occupied, and you have to force yourself to be outside yourself.”) This was also true off the job. (“At home when I get heart palpitations, shaky hands, stutter, have nervous energy, I feel it coming. I stay quiet, try to keep busy, try to isolate myself, go for a walk and avoid people.”) Consumers appeared to alternate between increased and decreased activity to avoid relapse of illness. When asked how this decision was made, one consumer offered, “I don’t believe in negative busy. If you are going to get busy to avoid an episode, it has to be a positive busy. If I can’t find a positive busy, it's better to withdraw, go to sleep, do nothing.” Indeed, those consumers who were observed to increase their activity at work and at home to avoid illness emphasized that these activities were positive experiences. Only two of the thirteen consumers confined themselves primarily to a decrease of activity when under stress and complained that because of unemployment and dire poverty they lacked the minimal resources which could provide a “positive busy” coping strategy.
While consumers called for help when under stress, all admitted that making such contact was not an easy task. (“When I’m depressed, I have difficulty speaking. I have to push myself.”) In addition, access to support proved difficult for two consumers with no telephones at home, and several times telephone malfunctions occurred at critical moments. Nevertheless, most consumers felt positive about their ability to get help in times of crisis. (“I must be wary of racing thoughts, and if I have them, call Emergency Services right away. They tell me to take extra meds. I can’t do it alone. I have to have support with the mental health system.”)
6. Overcoming Illness and Stigma on the Job
To avoid job loss, consumers made efforts to choose employment compatible with controlling symptoms during working hours and planning for absence from the workplace in case of crisis or hospitalization. Consumers were selective about disclosing these efforts to co-workers and employers because they perceived the stigma of mental illness to be pervasive and threatening to job security.
Preference for work pace varied widely in the sample. One consumer gave up lucrative work in the area of his training for a low paid maintenance job because the former work pace, fast and demanding, led to symptoms of his illness. Another consumer, in spite of multiple crises and one hospitalization, claimed rehabilitation and strength through the rigorous, fast-paced schedule her job provided.
Consumers sought ways to release tension on the job by taking breaks, engaging in play, or setting priorities. (“In the morning I get things done, make my calls. I start with whatever bothers me the most.”) Communication and social skills, important to consumers when procuring resources and support, were equally necessary on the job. At times all consumers took time off, avoiding the workplace on a scheduled workday. (“Today I’m feeling hyper, so I took a mental health day off. I’m going to read a book, take a walk, calm myself down.”) The decision to take time off did not come easily, and consumers often turned to support persons for advice. (“My strategy now is that if I don’t feel like working, I call mom or my employment specialist. My employment specialist is more lenient. She’ll say something like: ‘You can take a day off. That's not bad.’ But my mom is very tough, so I prefer to call her. Mother will say: ‘You get your buns over there…you gotta go.’ Within a half hour, she's right. When I get there I’m fine. When I’m depressed I don’t want to go, but I shouldn’t give in to that.”) Consumers forced themselves to go to work, usually when the job, itself, was a pleasant experience and had potential for providing what one consumer described as “positive busy” coping.
Consumers planned ahead for possible long-term absence from their job. Such plans included saving up vacation, personal time, and sick days for mental health leave and finding a confidant among co-workers or employers to cover for such an absence. Fearing the effects of stigma, consumers were cautious and selective when choosing a person to whom they revealed their mental disorder. Problems on the job were exacerbated when colleagues, entrusted with knowledge of their illness, abused that trust. (“And after all I’ve done for you when you were in the hospital.…”) Nevertheless, consumers were usually willing to risk such abuse in their efforts to cope with prolonged absence due to illness. One self-employed consumer found a partner to which he had disclosed his mental illness. (“I leveled with my partner about it from the start. I put up the money for the partnership in exchange for him being there when I got sick.”) Another consumer, steadily employed in a firm, confided in one discrete administrator. (“I fear getting sick, fear that if I get sick too much, I’ll lose my job. I hope the Board of Directors never finds out about my illness. The administrator covers for me. She told them I was in the hospital with a viral infection.”) During this consumer's hospitalization she received a myriad of “get well cards and wishes” from co-workers. Upon her return to work, she was greeted warmly. She viewed her confidant's cover-up not only as supportive, but as an important strategy for job retention. She remained convinced that her job would be compromised, her relationships with her co-workers altered, if they knew the true nature of her illness.
This study confirms that people with severe mental disorders use a variety of active coping strategies (Breier & Strauss, 1983; Cohen & Berk, 1985 ). Furthermore, they employ sophisticated strategies that are considered to be effective in coping with chronic physical illness: cognitive-behavioral techniques; avoidance of psychoactive drugs; management of social, familial, and professional supports; self-management of illness; relapse prevention; and management of societal prejudice regarding illness (Lazarus & Folkman, 1984; Moos, 1979 ).
These personal strategies are critical in the process of rehabilitation and recovery. Cohen (1984) noted that people with schizophrenia suffer the effects of poverty and stigma, and called for government incentives to encourage employment, arguing that the workplace is key to understanding and treating schizophrenia. A decade later, however, despite the Americans with Disabilities Act ( Center for Psychiatric Rehabilitation, 1991 ), no participants in the present study reported receiving special consideration in the workplace. Rather, in order to remain successfully employed, they rigorously engaged in a wide range of coping strategies.
Consistent with Scheier and colleagues’ (1986) contention that optimism is positively linked to problem-focused coping and is negatively related to denial, consumers in this study uniformly argued that paramount among all coping strategies is the effort to maintain a positive outlook. Similarly, consumers recognized that professional, social, and familial supports are important resources ( Cohen, 1984 ; Dauwalder & Hoffman, 1992; Davidson & Strauss, 1992 ; Parks, 1986 ), and that psychoactive drugs, including alcohol, are particularly deleterious for them ( Minkoff & Drake, 1991 ).
In relation to their treatment and rehabilitation, these consumers played a more active decision-making role than professionals have recognized. There was no evidence that they passively accepted advice from professionals. Instead, they valued professionals as one group of consultants among several and weighed their information in relation to advice from other sources and their own experiments. Our data are consistent with observations by Davidson and Strauss (1992) that developing a sense of self as an active and responsible agent is a critical aspect of improvement. Moreover, the fact that consumers did not always share their strategies (e.g., when to use medications) with professionals indicates some mistrust in the partnership. The majority of the sample reported irregular compliance with their medication while employed, similar to findings by Müller and colleagues (1992).
While previous studies have noted that patients respond to anxiety symptoms by either decreasing or increasing activity (Breier & Strauss, 1983; Cohen & Berk, 1985 ), each consumer in this study reported they not only used both strategies but, more importantly, sought to learn from his/her experience when to use each one. A consumer's use of the term “positive busy” to explain when an increase is preferred to a decrease of activity may have implications for treatment and rehabilitation.
More than a decade ago, McCue and Katz-Garris (1983) emphasized that stigma towards mental illness caused major difficulties for consumers in their adjustment to work. The consumers in this study felt that stigma was pervasive in their lives. Furthermore, they showed that they had internalized this stigma as they described the pain of recognition inherent in accepting the illness.
Because of the limitations of a one-year ethnographic study with a small sample, one cannot demonstrate generalizability. Rather, this study should be seen as a pilot effort. These ethnographic data may prove useful in other research designs by providing a basis for constructing questionnaires or structured interviews to determine the frequency, prevalence, and incidence of specific coping behaviors; and from these data, intercorrelations among difficulties and coping strategies can be ascertained. Data gathered in participant-observation/interviewing can be recast as variables in formal instruments, in experimental designs, and in statistical analysis, but the validity of such variables as proxies of experience cannot be assured without testimony from the consumer participants.
Both treatment and rehabilitation professionals have cited the need for qualitative data on consumers’ coping responses to assess functioning ( Dickie & Robertson, 1991 ), to determine treatment and rehabilitation protocols (Dauwalder & Hoffman, 1992; Davidson & Strauss, 1992 ), and to understand prognosis ( Cohen & Berk 1985 ; Hauser & Scharfetter, 1990 ). Ethnography may in fact provide professionals with insights into the consumers’ perspectives and, in so doing, a possible basis for improving both treatment and supported employment. For example, the findings of this study should cause professionals to rethink their perceptions of how consumers use professional advice and how they manage their medications.
This study supports the importance of competitive employment for mental health consumers. Work constitutes a central strategy for coping with severe mental illness as well as a tangible manifestation of successful coping. Job retention is nonetheless an extraordinarily complex task that requires managing both job and mental illness. Furthermore, this study supports the view that consumers with mental illness should be viewed as active partners in their treatment and rehabilitation. Despite contrary messages from professionals, consumers clearly operate as independent decision-makers who feel responsible for their own rehabilitation.
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