The International Journal of Psychosocial Rehabilitation
 

Development of Transitional Training Package for Active Employment in Schizophrenia

Hanif Farhan Mohd Rasdi, PhD 1,2
Muhammad Zairul Rezal Zainol Abidin, B (Hons) 1,3
Masne Kadar, PhD 1,2
Farahiyah Wan Yunus, PhD 1,2

1Occupational Therapy Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
2Centre for Rehabilitation and Special Needs, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
3Occupational Therapy Department, Hospital Kuala Lumpur, 50586 Jalan Pahang Kuala Lumpur, Malaysia

 

*Corresponding author:  Farahiyah Wan Yunus
E-mail address: farahiyahwanyunus@ukm.edu.my


Citation:
Mohd Rasdi HF, Zainol Abidin MZR, Kadar M, Wan Yunus F (2019)  Development of Transitional Training Package for Active Employment in Schizophrenia..
International Journal of Psychosocial Rehabilitation. Vol 22 (2) 131-148



Abstract
Employment for schizophrenia is seen as important part of psychosocial rehabilitation where the issue had raised concerns associated with lack of appropriate general social competence and social skills necessary in the workplace. The study aimed to generate discussion on work-transitional package consisting of training module and assessment to support active employment. A series of focus group discussions were undertaken with expert panels including clients (n=4), occupational therapists (n=7), clinical psychologist (n=1) and employers (n=4). The discussions revealed nine sections of the module and six domains for the assessment including work-related skills, communication skills, cultural norms and managing condition and relapse. Issues on requirements of training and supports and stigma in mental health were also identified. The discussion had facilitated the development of a comprehensive training package as an intervention designed for schizophrenia in succeeding active employment. Further study is required to assess the validity and reliability prior to implementation in clinical settings.

Key words: Focus group discussion, Employment program, Transitional training package, Training module, Outcome measure



 


Introduction:

Persons with psychiatric disorders especially schizophrenia are often associated with unemployment and poor job tenure due to many contributing factors such as duration and severity of illness, stigma, as well as poor social skills. Schizophrenia can be characterized by deficits in functioning, cognitive, perceptual, motor and emotional; where social dysfunction stood out among others distinctively including deterioration in interpersonal contacts, work or self-care (Dziwota et al. 2018). Social impairments such as disruptive and disorganize behaviour typically translate to difficulty in social competence required in employment (Barton Laws et al., 2012; Evans et al., 2004).

According to Marwaha and Johnson (2004) meaningful employment has been shown to improve self-esteem, decreased social isolation, and improved quality of life as well as financial gains, personal gain and improved mental health. In addition, reduced clinical symptoms may develop personal wellbeing and higher levels of functioning which is also associated with employment (Dunn, et al. 2008; Siu, Tsang, & Bond, 2010). Employment issues in people with schizophrenia had raised concern in association with the lack of appropriate general social competence and social skills necessary in the workplace (Bell & Lysaker, 1995; Tsang & Pearson, 2001; Solinski, Jackson & Bell, 1992).

Most of the employment programs are lacking in terms of intervention and assessment strategies in relation to rapid-job placement where clinician lacks strategy to decide when to place those who want real-work (Corrigan, 2001). In the local context, employment program has been part of psychosocial rehabilitation for decades where traditional vocational rehabilitation (TVR) still continue as an intervention options even though evidence no longer supports the approach such as job placement and pre-vocational training.

Nonetheless of numerous studies conducted quantitatively to examine the effectiveness of the intervention programs specifically designed to improve employment outcomes, only a handful to none of research conducted in developing training module and outcome measure as a rounded training package considering perspectives from different point of views - clients (schizophrenia clients), occupational therapist and employers who had experience in hiring employees with mental illness. Therefore, this study aimed to understand the requirements and issues related to establish a comprehensive training package to support active employment for schizophrenia clients.

Materials and Methods:

The study received ethical approval from Universiti Kebangsaan Malaysia research ethics committee (Ref No: JEP-2018-568) and Ministry of Health, Malaysia (NMRR-18-2808-44150). A series of focus group discussion with three separate sessions involving clients, occupational therapists, clinical psychologist and employers was conducted by the second author with supervision from other co-authors and was guided by the framework outlined by Dilshad and Latif (2013). The framework asserts that the elements of synergy and interaction between group members play a significant role in generating the data as focus group interviews and is a valuable tool for collecting qualitative data in planning, improvements and evaluation of certain programs. The use of open-ended questions in ‘qualitative nature’ of the study and large number of questions is outlined through brainstorming in natural flow. In focus group discussion, the technique of interview is an immense use and value in qualitative research by emphasizing the in-details and holistic description of activity or situation (Dilshad & Latif, 2013).

Participants
The focus group discussion involved sixteen participants from three target groups of population. Four (n=4) participants from the client’s group was diagnosed with schizophrenia and one with bipolar mood disorders. Participant diagnosed with bipolar mood disorders was chosen considering extensive working experiences as well as involving in the employment programs. Eight (n=8) participants from the therapists group consisted of seven occupational therapists and one clinical psychologist. Four (n=4) participants from the employers group consisted of experienced employers who had or is currently recruiting mental health related employees and one participant from the social security organization representative. All participants were selected from the at Klang Valley territories except one occupational therapist from a mental institution located at Hospital Bahagia Ulu Kinta, Perak representing the institution population.

Considered criteria needed to be fulfilled and to be included in the study are as follows: (1) client group: diagnosed with schizophrenia or bipolar mood disorders as severe mental illness (SMI) category, fluent in English or Malay language, had previous experience in undergoing any employment programs; (2) therapists group: experienced occupational therapist or clinical psychologist in psychiatry or psychosocial rehabilitation and employment programs; (3) employers group: experienced employers who had or currently recruiting employees with mental health issues.

Procedure
The focus group was conducted in a meeting room located at the campus isolated from other staff members to ensure confidentiality and anonymity of participants involved in the discussion. Invitation to the research were made via telephone calls followed by a formal letter individually at the preliminary stage. Each participant was provided with an information sheet and consent was obtained prior to the session. A list of principle questions was also provided to each participant in advance to guide throughout the discussion where the questions were developed fundamentally from a literature review and extensive deliberation between authors were involved. Three umbrella questions with sub questions was identified as the development of module and outcome measure, and other employment related issues.

Throughout the discussion, participants were allowed to discuss their point of views based on their own perspective and experience, where refreshments were provided in between sessions. The setting intended to create an environment that stimulated an easy informal discussion within participants. The second author leaded the focus group discussion as moderator with support from other authors involved. The assistant was a non-participant occupational therapist in the study who took notes based on observation and discussion from the focus group. An open format was implemented whereby the researcher’s role was to facilitate and steer the discussion towards addressing the topics highlighted by the questions. The session lasted ranging from 2 to 5 hours depending on the three-participating group of (clients, therapists and employers) where each session was voice recorded and videotaped.

Data Analysis
The data management and analysis of this qualitative study was guided by Sutton and Austin, (2015) framework. Thematic content analysis was conducted in the form of analysis for the interview and was conducted manually by the second author as the sample size for the three participant groups were relatively small and only involved a single data collection point. The voice-recording was listened several times with transcript and research notes prepared by the research assistant was done simultaneously to obtain rounded perspective for interpretation. To ensure the trustworthiness and credibility of the findings from the interview, the transcript was discussed with the research assistant occupational therapist to enhance the findings who was also the observer during the focus group discussion as part of the member-checking process. Elements of trustworthiness of the findings was later being reinforced by all authors to verify the synthesis of information conducted by the second author.

Results

The participant characteristics of sixteen (n=16) in the three group sessions were presented in table 1. Findings of the study identified three main themes and several subthemes prior to the extensive evaluation of the transcript. The following are the themes and subthemes described accordingly generated from the focus group.

Table 1. Participants characteristic (n=16)

Subject

Age

Gender

Group

Education Level

Working/Hiring
Client Experience

Other Details

A

43yo

Female

Therapist

Master’s degree

20 years

N/A

B

53yo

Female

Therapist

Diploma

30 years

N/A

C

54yo

Female

Therapist

Diploma

28 years

N/A

D

37yo

Female

Therapist

Diploma

15 years

N/A

E

32yo

Female

Therapist

Diploma

11 years

N/A

F

48yo

Female

Therapist

Bachelor’s degree

23 years

N/A

G

37yo

Female

Therapist

Bachelor’s degree

16 years

N/A

H

47yo

Male

Therapist

Master’s degree

16 years

N/A

I

32yo

Female

Employer

Bachelor’s degree

N/A

Social Security Organization

J

46yo

Female

Employer

Diploma

8 years

Pharmaceutical company

K

40yo

Female

Employer

Diploma

8 years

Pharmaceutical company

L

48yo

Female

Employer

Master’s degree

8 years

Pharmaceutical company

M

32yo

Female

Client

High school certificate

N/A

Year diagnosed: 2009

N

30yo

Male

Client

Certificate

N/A

Year diagnosed: 2009

O

37yo

Female

Client

O Level

N/A

Year diagnosed: 2002

P

50yo

Male

Client

Master’s degree

N/A

Year diagnosed: 1990

Theme 1: Development of the training module
Participants from the three groups especially therapists group produced substantial amount of data regarding the development of the module section which was later established as a training session. Overall suggestion and recommendation on the training module by the participants included an awareness program on schizophrenia aimed to reduce stigma, involvement of medical personnel actively in handling and management in the employment programs, selection of client in the training module either individual or group should be tailored to clients’ need and functioning level and the execution of the training module should be simple yet effective.

Basic Self-care for Working
Self-care including activities of daily living (ADLs) such as personal hygiene and grooming, dressing and appearance, managing condition and medication is a basic requirement to succeed in working situations. Therapist group expressed their concern to address female needs in self-care especially in menstrual care where it was proposed to be conducted separately. The use of images (graphic illustration or real photograph) in the appendix section was also being highly deliberated in the discussion that served as an effective delivery tools to the clients.

Job Interview Preparation
Preparation for a job interview with subtopics were identified including making resume, job interviewing and follow-up about a job enquiry. Skills related to the job interview was recognized as a major difficulty for clients to provide a good impression confidently along with making resume. Client group felt that by disclosing their psychiatric condition may impede and reduce the probabilities of being hired by the employers. For instance:

“I chose not to disclose my condition [schizophrenia] to my potential employer because I know I will not get hired.” (Participant O)

Employers group on the other hand felt by disclosing their psychiatric condition, employers may be able to provide necessary help within working environment such as job modifications and peer support. Disclosure can also prevent future complications such as job termination poses by the employer. By achieving full disclosure prior to job applications by the clients, promotion on mental health awareness will be required among employers.

Discussion on pros and cons of disclosure was suggested in the training module to advocate clients’ right and possible circumstances which will have direct influence on employment.

Handling Criticism and Resolving Conflicts
Psychological elements and emotional regulation skills in section five included handling criticism and resolving conflicts. Clients group expressed their difficulty in this area which often leads them to leave their job or were terminated due to unresolved conflicts and unable to accept criticism from co-workers and supervisors.

“Main reason I leave jobs were due to arguments usually with co-workers or supervisors” (Participant M)

Negotiation in Work Setting
Section six recognized the utilization of effective social skills with coping skills which included negotiation at a work setting and problem-solving skills. Clients expressed their concern in the difficulty of working together with ‘normal people’ as they were often bullied and was unable to defend themselves due to lack of negotiation skills. For instance:

“I was often being ordered by the other co-worker and supervisor to work long hours and cover them while they take their leave - making it difficult for me to continue working there.” (Participant O)

Handling Episodes of Relapse
The final section of the training module acted as the most important skills needed by the clients to sustain their work which had profound influence of illness recovery. Clients expressed their difficulty in managing their condition in terms of medication routines and follow up with the psychiatrist since working due to work commitment, afraid of exposing their condition, internal self-conflict of feeling already recovered from illness and lack of social support. They also felt episodes of relapse and other related relapse conditions are a common factor of job termination or leaving from job even though they notice changes within themselves when relapse happens. For example:

“I can feel changes in me [mood, sleep and attention span] when relapse is about to happen, but usually I will ignore it and keep pretending like nothing happen.” (Participant N)

Employers group on the other hand felt that potential employers who are willing to hire clients with psychiatric issues needed guidance and support in terms of monitoring sign and symptoms of relapse as well as ways to assist clients when relapse occurs. Therapist group expressed their concern on skills in relapse management and prevention especially in the employment program as clients typically neglect their mental health and necessary medical attention when they started working. Employers also felt a relapse checklist is needed to be developed in this section to assist care givers, employers and client themselves to monitor their current conditions.

Theme 2: Domain Development in the Outcome Measure
Assessment or outcome measure was seen as an important tool to measure client’s current level of occupational functioning related to employment. The overall total score of the outcome measure was proposed to determine expected types or categories of training or programs to the clients. The following are the subthemes for theme 2.

Meaningfulness
Domain one encompassed perspectives from the client themselves towards work and working. Five items in scale of 1 to 10 includes necessity to work, confidence to work, motivation, self-esteem, life satisfaction and readiness to work. Therapist group felt life satisfaction should be more emphasized on context related to work and its contribution rather than overall life satisfaction. For instance:

“Life satisfaction should be related to work and its contribution to life satisfaction rather than own its own.” (Participant H)

Self-care and Communal Living Skills
Domain two regulate the use of self-care and IADLs to assess client’s level of functioning such as personal hygiene, personal appearance and grooming, money management, using public transport and shopping for resources. Therapist group expressed their concern on the importance of personal hygiene and appearance which is usually being neglected by the clients while performing work.

Work and Productivity
Employment and productivity predominantly evaluate clients’ vocational and other related skills. Therapist group viewed work readiness as a distinctive feature of the domain as therapist are required to evaluate the overall vocational capability of the client which consisted of work habits, social competencies, and motivation to work. Another feature highlighted by the therapist group was the requirement of job modifications that profoundly measure the need of modifying job nature based on previous working experience.

Emotional Regulation Skills
Domain four encompassed of elements of psychological and coping skills the at workplace which involved five items including expressing feelings/emotions, handling criticism, resolving conflicts, negotiation skills and coping skills. Therapist group emphasize their recommendation on expressing feelings/emotions in the domain as it should represent skills for the client to have the ability to effectively project their positive or negative feelings or emotions to others.

Social and Cultural Norms
Cultural elements in social interaction includes three items which is norms in the public, norms in using telephone and norms at the workplace. Employers group highlighted the importance of clients to follow cultural regulations that are usually being set up by the people in the organization such as procedure for taking an annual leave, respecting authorities and occasional gathering.

Theme 3: Other Findings Related to Employment
The focus group also produce an extensive other finding related to employment or vocational needs of clients with schizophrenia. This included training requirements, challenges in hiring people with psychiatric issues, and other demographic and background findings from the clients.

Training Requirements in Employment Programs
Therapist group (all participants) agreed that persons with schizophrenia require specific training in order to attain employment. Majority of the participants from the therapist and employer group also agreed that persons with schizophrenia require a continuous training, before, during and after working. For instance, from the therapist group:

“Training related to employment should be made available for the clients at every stages of employment: before, during and after working had commenced.” (Participant B)

Employment and Employability
Findings related to employment by the employer group where companies with experience in hiring less than 10 persons with schizophrenia in a year commonly positioned them as general workers, operational and production roles. Job application are usually initiated by the client themselves, employers and rehabilitation team initiated by occupational therapist. However, common difficulties faced by employers while hiring persons with schizophrenia includes unable to sustain work, lack of support and awareness of mental illness among co-workers.

Employer group also felt that the difficulties could be overcome by establishing relationship between medical team from hospital, discussion on job matching between employers and clients, continuous client monitoring at the workplace, buddy system and specific training (suggested to be implemented in 3 to 6 months). All participants from employers group also agreed that persons with schizophrenia require training and support upon hiring including job coaching, worksite assessment and maintenance program for sustainability at work, support from employers and co-workers, and medication routine support.

Discussion

Employment has been seen as the key outcome of recovery from mental illness through any sort of vocational or employment training provided to the clients. Providing the most comprehensive and effective employment/vocational program or training for clients is necessary where employment is often linked to the concept of recovery (Mcgurk, Mueser, Derosa, & Wolfe, 2009; Zam Zam, 2010) and paid employment often associated with greater satisfaction and higher functioning than participation in other self-care activities (Eklund Hansson, & Ahlqvist, 2004; Brohan et al., 2015). Thus, developing the accurate training package according to the employment needs was significant and driven from the focus group discussion. The discussion expected to be holistic considering multiple sides of perspective from the therapists including occupational therapist and clinical psychologist, employers and clients themselves as the user.

Disclosure of mental health condition prior to employment especially during job interview process had been discussed relentlessly in the development of training program as the client commonly chose not to disclose their problems to potential employer as this would reduce their probability to get hired. They still chose to not disclose even though some of the clients were aware of further consequences of the decision that might posed to them by the employer (Tuti et al., 2009). Employer on the other hand believe that disclosure of the clients’ information on their condition should be made available as assistance and modification of job can be offered to them. This can only be achieved by creating awareness towards mental health issues to public especially employers. Brohan et al. (2015) also suggested that disclosure needed to be placed in as a greater emphasis considering the societal, employment and interpersonal influence to form basis of disclosure belief and experience.

Clients with mental health issues presumably lacked or neglected the importance of daily occupations while performing work such as personal hygiene, appearance and grooming, money management and most importantly medication routines. Medications especially antipsychotic drugs posses greatest challenge and conflicts in a long-term adherent among clients where employment commonly emerged on the later stages of recovery (Ruzanna Marhani, Parveen & Cheah., 2010). Risk factors to medication nonadherent including lack of insights, negative perception towards medications often by side effects, perceived treatment efficacy and tolerability, and past non-adherence (Riana, Osman, & Ainsah., 2008; Tranulis Goff, Henderson, & Freudenreich, 2011). Necessary skills and information in the training program regarding the conditions and medications related to employment is necessary in regard to prevent further relapse as well as long hospital admission.

Emotional regulation skills predominantly challenged clients with mental health issues in dealing with psychological and social encounters with other co-workers and supervisors at the workplace. Poor or lacked social skills especially assertive skills along with emotional regulation skills is commonly the reason clients leaving/resigning for job or terminated from job. Mak, Tsang, & Cheung, (2006) noted that the most frequent job termination problems include interpersonal difficulty and inability to cope with job demands.

Evaluating occupational functioning related to employment or work for clients with mental health issues especially schizophrenia may lead to numerous considerations from the aspects of productivity, self-care, communal living skills, social skills and personal insights on medications and conditions. Indicated by Bellack et al., (2007), functioning level can be assessed by from the perspectives of client, significant others, trained independent raters, and clinicians.

Client perspective in outcome measure developed was measured in the definition of meaningfulness of employment or work itself, derived from focus discussion. Life satisfaction can be contributed by performing work which usually had a transverse effect on other elements including confidence to work, necessity to work, motivation, self-esteem, as well as readiness to work. Clients who engage in competitive work present were more satisfied with daily occupations, perceived higher levels of health and wellbeing, and reported having less psychiatric symptoms and better overall functioning (Eklund, Hansson, & Ahlqvist, 2004).

Work readiness which also were being integrated in the outcome measure where the basis of the development of the item considered from both perspectives of client themselves and therapist to build more holistic assessment. Even though there is no guidelines in evaluating client work readiness, occupational therapist is suggested to employ their clinical observation and reasoning in the process (Choudhary, Viner & Kirsh, 2016).

Funding

This project has been funded by Universiti Kebangsaan Malaysia (GGMP-2018-006)

Acknowledgement

We would like to give our gratitude to the participants including occupational therapists, clinical psychologist, employers, clients and research assistant who participated in this qualitative study. We are grateful for the financial contribution from Universiti Kebangsaan Malaysia from the research grant of Dr. Hanif Farhan Mohd Rasdi. We would also like to extend our appreciation towards the Ministry of Health Malaysia for the research approval. This study is part of Muhammad Zairul Rezal Zainol Abidin Master study at Universiti Kebangsaan Malaysia.

Conclusion

Qualitative study of our research in developing comprehensive training package to support active employment for clients with schizophrenia driven by a series of focus group discussion on the content and overall structure of the package including module and outcome measure. Suggestions and recommendations from the discussion were taken into holistic consideration by different populations with different perspectives and point of views including occupational therapists, clinical psychologist, employers and clients themselves who may involve in the use of the package in the future.

Other findings concerning on requirements of training and supports especially in interpersonal relationship and managing condition and medications to the persons with schizophrenia was recognized along with methods to assist them. The discussion also had achieved expectation in facilitating in developing a comprehensive and effective training package as intervention approach specifically designed for persons with schizophrenia in succeeding active employment.


References    

Abdul Hamid, A. R., & Abdul Razak, O. (2010). Obsessive-compulsive disorder in schizophrenia: Clinical and neurocognitive correlates. Malaysian Journal of Psychiatry, 19(2), 1-9.

Alshowkan, A., Curtis, J., & White, Y. (2015). Factors affecting the quality of life for people with schizophrenia in Saudi Arabia: A qualitative study. Journal of Psychiatry, 18(4). https://doi.org/10.4172/2378-5756.1000295

Barton Laws, M., Beach, M. C., Lee, Y., Rogers, W. H., Korthius, P. T., Sharp, V., & Wilson, I. B. (2012). Functional impairment in people with schizophrenia: Focus on employability and eligibility for disability compensation. Schizophrenia Research, 140(1-3), 1-8. https://doi.org/10.1007/s10461-012-0143-z.

Bedell, J. R., Hunter, R. H., & Corrigan, P. W. (1997). Current approaches to assessment and treatment of persons with serious mental illness. Professional Psychology Research and Practice, 28(3), 217-228.

Bell, M. D., & Lysaker, P. H. (1995). Psychiatric symptoms and work performance among persons with severe mental illness. Psychiatry Services, 46(5), 508-510.

Bellack, A. S., Green, M. F., Cook, J. A., Fenton, W., Harvey, P. D., Heaton, R. K. Patterson, T. L. (2007). Assessment of community functioning in people with schizophrenia and other severe mental illnesses : A white paper based on an nimh-sponsored workshop. Schizophrenia Bulletin, 33(3), 805-822. https://doi.org/10.1093/schbul/sbl035

Brohan, E., Henderson, C., Murray, J., Slade, M., Thornicroft, G., Brohan, E., … Thornicroft, G. (2013). Disclosure of a mental health problem in the employment context : Qualitative study of beliefs and experiences. Epidemiology and Psychiatric Sciences, 23(03), 289-300. https://doi.org/10.1017/S2045796013000310

Choudhary, S., Viner, S., & Kirsh, B. (2016). How do occupational therapists assess work readiness among mental health consumers ? Occupational Therapy in Mental Health 31(3), 266-282. https://doi.org/10.1080/0164212X.2015.1046102

Contreras, N., Rossell, S. L., Castle, D. J., Fossey, E., Morgan, D., Crosse, C., & Harvey, C. (2012). Enhancing work-focused supports for people with severe mental illnesses in Australia. Rehabilitation Research and Practice, 1-8. https://doi.org/10.1155/2012/863203

Corrigan, P. W. (2001). Place-then-train: An alternative service paradigm for persons with psychiatric disabilities. Clinical Psychology: Science and Practice 8(3), 334-349. doi:10.1093/clipsy/8.3.334

Dilshad, R. M., & Latif, M. I. (2013). Focus group interview as a tool for qualitative research: An analysis. Pakistan Journal of Social Sciences, 33(1), 191-198.

Dunn, E. C., Wewiorski, N. J., & Rogers, E. S. (2008). The meaning and importance of employment to people in recovery from serious mental illness: Results of a qualitative study, Psychiatric Rehabilitation Journal 32(l), 59-62. https://doi.org/10.2975/32.1.2008.59.62

Dziwota, E., Stepulak, M. Z., Włoszczak-Szubzda, A., & Olajossy, M. (2018). Social functioning and the quality of life of patients diagnosed with schizophrenia. Annals of Agricultural and Environmental Medicine, 25(1), 50-55. https://doi.org/10.5604/12321966.1233566

Eklund, M., Hansson, L., & Ahlqvist, C. (2004). The importance of work as compared to other forms of daily occupations for wellbeing and functioning among persons with long-term mental illness. Community Mental Health Journal, 40(5), 465-477.

Evans, J. D., Bond, G. R., Meyer, P. S., Kim, H. W., Lysaker, P. H., Gibson, P. J., & Tunis, S. (2004). Cognitive and clinical predictors of success in vocational rehabilitation in schizophrenia. Schizophrenia Research, 70(2-3), 331-342. https://doi.org/10.1016/j.schres.2004.01.011

Kopelowicz, A., & Liberman, R. P. (2006). Recent advances in social skills training for schizophrenia. Schizophrenia Bulletin 32(Suppl 1): S12-S23. https://doi.org/10.1093/schbul/sbl023

Liu, K. W. D., Hollis, V., Warren, S., & Williamson, D. L. (2007). Supported-employment program processes and outcomes : experiences of people with schizophrenia. The American Journal of Occupational Therapy, 61(5), 543-554.

Machingura, T., & Lloyd, C. (2017). Mental health occupational therapy and supported employment. Irish Journal Of Occupational Therapy, 45(1), 52-57. https://doi.org/10.1108/IJOT-02-2017-0004

Mak, D. C. S., Tsang, H. W. H., & Cheung, L. C. C. (2006). Job termination among individuals with severe mental illness participating in a supported employment program. Psychiatry, 69(3), 239-248. https://doi.org/10.1521/psyc.2006.69.3.239

Marwaha, S., & Johnson, S. (2004). Schizophrenia and employment: A review. Social Psychiatry and Psychiatric Epidemiology, 39(5), 337-349. https://doi.org/10.1007/s00127-004-0762-4

Marwaha, S., & Johnson, S. (2005). Views and experiences of employment among people with psychosis : A qualitative descriptive study, 51(4), 302-316. https://doi.org/10.1177/0020764005057386

Mcgurk, S. R., Mueser, K. T., Derosa, J., & Wolfe, R. (2009). Work , recovery , and comorbidity in schizophrenia : A randomized controlled trial of cognitive remediation, Schizophrenia Bulletin, 35(2), 319-335. https://doi.org/10.1093/schbul/sbn182

Riana, A. R., Osman, C. B., Ainsah, O. (2008). Psychiatric morbidity and attitudes towards mental illness among patients attending primary care clinic of Hospital Universiti Kebangsaan Malaysia. Malaysian Journal of Psychiatry, 17(1), 1-14.

Ruzanna, Z., Marhani, M., Parveen, K., & Cheah, Y. C. (2010). Does psychoeducation improve insight of patients with Schizophrenia?. Malaysian Journal of Psychiatry, 19(1), 27 - 40.

Siu, P. S. K., Tsang, H. W. H., & Bond, G. R. (2010). Nonvocational outcomes for clients with severe mental illness. Journal of Vocational Rehabilitation, 32, 15-24. https://doi.org/10.3233/JVR-2010-0491

Solinski, S., Jackson, H. J., & Bell, R. C. (1992). Prediction of employability in schizophrenic patients. Schizophrenia Research, 7, 141-148

Stanghellini, G., Bolton, D., & Fulford, W. K. M. (2013). Person-centered psychopathology of schizophrenia : building on karl jaspers ’understanding of patient’s attitude toward his illness. Schizophrenia Bulletin, 39(2), 287-294. https://doi.org/10.1093/schbul/sbs154

Sutton, J., & Austin, Z. (2015). Qualitative research: Data collection, analysis, and management. The Canadian Journal of Hospital Pharmacy, 68(3), 226-231. https://doi.org/10.4212/cjhp.v68i3.1456

Tranulis, C., Goff, D., Henderson, D. C., & Freudenreich, O. (2011). Becoming adherent to antipsychotics : A qualitative study of treatment. Psyhiatric Services, 62(8), 888-892.

doi: 10.1176/ps.62.8.pss6208_0888.

Tsang, H-W. H, & Pearson, V. (2001). Work-related social skills training for people with schizophrenia in Hong Kong. Schizophrenia Bulletin, 27(1),139-148.

Tuti, M. D., Nursyuhaida, M. N., Nik Siti Fatimah, M., Faridah Hanim, Z.,Nor Akmar, S., CT Effa, F. M. F., Ruzzana, Z. (2009). Stigma arising from family members of the mentally ill patients in Hospital Taiping. Malaysian Journal of Psychiatry, 18(1), 13-22.

Zam Zam, R. (2010). Opinion the psychosocial rehabilitation (PSR) for severely mentally ills in Malaysia: The past and present. ASEAN Journal of Psychiatry, 11(1), 113-117.




Appendixes

Appendix A: Summary Details of the Training Package

Training Module

SESSION ONE: BASIC SELF-CARE FOR WORKING

  1. Dressing & Appearance – choose what to wear for occasion and appropriateness, dress code, posture
  2. Grooming – hair and make-up, facial hair, nail
  3. Personal Hygiene - body wash/ bathing, cleaning self after toileting, body odour, menstrual care, hand wash, dental & oral care
  4. Managing Condition & Medication – medication routine, follow-up with psychiatrist and therapy (if required)

SESSION TWO: JOB INTERVIEW PREPARATION

  1. Making Resume/Curriculum Vitae – preparation on making resume and details needed to present self
  2. Interviewing for Job - presenting self during interview and other related skills related to job interview
  3. Follow-up about Job Enquiry – follow-up through call or walk in to ask for feedback regarding to previous job interview after certain period of time

SESSION THREE: GOOD WORK ETHICS

  1. Self-discipline – time management, punctuality, balancing work & rest
  2. Integrity at work – trust and honesty, responsibility, respect to all, moral courage

Volition: Attributes the value of well-being, expecting and plan to execute work tasks

SESSION FOUR: TAKING INSTRUCTIONS FROM SUPERVISOR

  1. Listening Skills – effective listening skills utilizing verbal and non-verbal communication
  2. Taking Instruction from Supervisor - implementing effective listening skills to execute tasks given by supervisor

SESSION FIVE: HANDLING CRITICISM & RESOLVING CONFLICT

  1. Handling criticism – listening to understand, what can be learn from criticism, don’t take it personally, saying thank you
  2. Resolving conflict – Involved 6 steps: cool off; share, listen & check; take responsibility; brainstorm solution; choose a solution; affirm, forgive and thank you

SESSION SIX: NEGOTIATION IN WORK SETTING

  1. Negotiating at Work Setting – compromising skills with supervisor and co-workers in facilitate positive relationship, good work productivity and achievable outcomes
  2. Problem Solving – skills in solving problems systematically that will potentially contribute in stress development

SESSION SEVEN: HANDLING EPISODES OF RELAPSE

  1. Understanding Schizophrenia & Medications - information and education on the illness-related issues also medication routines
  2. Handling Episodes of Relapse – understanding early sign & symptoms of relapse and action plan to reduce hospitalization and facilitate recovery of illness

SESSION EIGHT: SOCIAL AND CULTURAL NORMS AT WORKPLACE

  1. Social Norms in General Public – shake hands when meeting, make eye contact when speaking, be polite in public conversation, use of ‘please’, ‘thank you’, and ‘sorry’; dress appropriately for environment, relieving self while in public
  2. Social Norms While Using Telephone – saying ‘hello’ and greeting when answering phone and ‘goodbye’ when ending phone call; silent phone while working or meeting, texting while working
  3. Social Norms at Workplace – call supervisor notifying if late to work, sick or emergency; dress appropriately to work, being punctual at work, work ethics

SESSION NINE: COMMUNAL LIVING SKILLS

  1. Shopping for House Resources – making inventory before shopping, budgeting, prioritizing, payment process
  2. Using of Public Transport – use of bus, taxi, commuters, LRT
  3. Money Management – budgeting for future expenses, understanding expenses and incomes, using banking facilities for saving

Outcome Measure

DOMAIN 1 (PATIENT/CLIENT): MEANINGFULNESS

  1. Work Necessity – individual insight on the importance of work and employment
  2. Work Confidence – individual confidence level of their ability to work
  3. Life Satisfaction – contribution of working towards life satisfaction
  4. Motivation - individual motivation and drive on performing and achieving goals
  5. Self-esteem – individual perception on contribution of work to self-esteem
  6. Work Readiness – clients’ perception on their work readiness

DOMAIN 2 (THERAPIST): SELF-CARE AND COMMUNAL LIVING SKILLS

  1. Personal Hygiene – body odour, cleaning self after toilet, menstrual care, bathing
  2. Personal Appearance – keeps a proper appearance including dress appropriately according to situation (choice of attire, formality) and grooming (keeping facial hair, keeping hair and make-up neat and tidy)
  3. Money Management – managing financial for economy needs
  4. Using Public Transportation – ability to use public transportation to mobile from place to place
  5. Shopping for Resources – ability to plan, prepare and perform shopping activity for home resources

DOMAIN 3 (THERAPIST): WORK AND PRODUCTIVITY

  1. Work Readiness – clients’ ability and skills related to work including work habits and motivations to work
  2. Interviewing for Job – interviewing skills for job application including preparing resume, job interview and follow up
  3. Work Ethics and Discipline – ability to be punctual and obey work regulation
  4. Communication Skills – individual use of effective communication skills (includes listening skills, verbal and non-verbal communication)
  5. Requirement for Job Modification – requirements of changes in work setting according to previous job including job nature, tasks, functions, hours of working, work site or any combination; if modification unable to meet patient/client current capacity, thus require different type of job; or no modification and changing types of job required

DOMAIN 4 (THERAPIST): EMOTIONAL REGULATIONS SKILLS

  1. Expressing Feelings/Emotions – ability to express feelings or emotions effectively according to situation
  2. Handling Criticism – ability to accept constructive criticism by others
  3. Resolving Conflicts – ability to resolve crisis and conflicts with others
  4. Negotiation Skills – ability to negotiate with others according to needs and capabilities
  5. Coping Skills – ability to cope and solve problems that could contribute in stress

DOMAIN 5 (THERAPIST): SOCIAL AND CULTURAL NORMS

  1. Norms in General Public – perform acceptable behaviour in public
  2. Norms while using Telephone – use of effective communication and perform customs while answering and using telephone
  3. Norms at Workplace – perform acceptable behaviour at workplace

DOMAIN 6 (THERAPIST): MANAGING CONDITION AND MEDICATIONS

  1. Schizophrenia and Medications – understanding schizophrenia and overall medications routines
  2. Handling Episodes of Relapse – ability to manage when relapse occurs


Appendix B: Interview Guide / Principle Questions
  1. Persons with Schizophrenia

Module

  1. Do you think the content of the module is suitable considering your needs in employment? Any additional topics/issues/elements should be included?
  2. Do you think the length of each session is enough or too long?
  3. Do you think the 9 sessions in the module is complete and enough? (Go through each content of the session in the module).
  4. How about the complementary activities such as warm up activities and appendixes?
  5. Do you think this module is at best to be conducted in groups or individually?
  6. Any more comments and feedbacks for improvement from the module?

Outcome Measure

  1. Do you think this assessment is assessing what should be assessed for your needs in employment? (Go through each content of the assessment)
  2. Do you agree with the structure of assessor in the assessment that there some part was done by clients and some parts were conducted by therapist?
  3. Do you think the domains in the assessment is suitable considering your needs? Any additional domains to be included?
  4. Do you agree with the scoring of the assessment?
  5. Do you agree with the interpretation as outcome of the assessment?
  1. Employer

Module

  1. Do you think the content of the module is suitable considering clients’ needs in employment? Any additional topics/issues/elements should be included?
  2. Do you think the length of each session is enough or too long?
  3. Do you think the 9 sessions in the module is complete and enough? (Go through each content of the session in the module).
  4. How about the complementary activities such as warm up activities and appendixes?
  5. Do you think this module is at best to be conducted in groups or individually?
  6. Any more comments and feedbacks for improvement from the module?

Outcome Measure

  1. Do you think this assessment is assessing what should be assessed for clients’ needs in employment? (Go through each content of the assessment)
  2. Do you agree with the structure of assessor in the assessment that there some part was done by clients and some parts were conducted by therapist?
  3. Do you think the domains in the assessment is suitable considering your needs? Any additional domains to be included?
  4. Do you agree with the scoring of the assessment?
  5. Do you agree with the interpretation as outcome of the assessment?
  1. Occupational Therapist

Module

  1. What is your opinion regarding to the overall presentation of the module?
  2. What is your opinion on the font and size of the writing in the module? What about the spacing?
  3. What do you think of the structure of the module? (Go through each content of the session in the module)
  4. What is your opinion regarding on the content of the module including the topics and activities? Any additional topics/issues/elements should be included?
  5. Do you think the illustration in the module is presenting the correct meaning?
  6. Do you think the length of each sessions is suitable?
  7. Do you think 9 sessions in the module is complete and enough?
  8. What is your opinion on the skills provided in the module?
  9. What is your opinion regarding on the appendixes provided in the module? Do you think the appendixes should be on each session or at the end of the module?
  10. What is your opinion about the complementary activities such as warm up activities and teambuilding activities?
  11. What do you think at best to describe the name or title should be given to this module according to its purposes?
  12. Any more comments and feedbacks for improvement from the module?

Outcome Measure

  1. What is your opinions regarding to the overall presentation of the assessment?
  2. What is your opinion on the font and size of the writing in this assessment? What about the spacing?
  3. What do you think of the structure of the assessment? (Go through each content of the assessment)
  4. Do you agree with the structure of assessor in the assessment that there some part was done by clients and some parts were conducted by therapist?
  5. Do you think the domains in the assessment is suitable considering clients’ needs? Any additional domains to be included?
  6. Do you agree with the scoring of the assessment?
  7. Do you agree with the interpretation as outcome of the assessment?
  8. Do you think the assessment is easy yet sensitive to administer?
  9. What do you think at best to describe the name or title should be given to this assessment according to its purposes?
  10. Any more comments and feedbacks for improvement from this assessment?

Appendix C: Clients Background and Demographic

Clients group conversely also had another finding regarding on their condition and employment as described as follows:

  1. Participants had significant educational qualifications ranged from high school certificates (SPM) to master’s degree at public university where usually were hired not based by their qualifications.
  2. Admission to hospital due to mental illness ranging from twice to four times during course of illness ranging from 10 to 29 years.
  3. All participants able to explain briefly their conditions and medications taken such as Aripiprazole, Epilim, Risperidone, Artane, Lorazepam, Invega, Olanzapine and Fluanxol.
  4. Most participants had job experience ranging at least 3 to 5 work experience with sustainability of employment up to 5 years. Positions hired including assistant at clinics and café, factory operators, clerks, data entry, meter reader, cashier, promoter, designer for electronics appliances, and librarian.
  5. Most participants search job own their own along with assistance from therapists.
  6. Most participants agreed that training and support is required at real workplace including supports by rehabilitation team from hospital, community awareness and acceptance on mental illness, provide workshops and assistance on establishing small business, and interpersonal training to communicate effectively with co-workers and supervisors.



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