Effects of the Indianapolis Vocational Intervention Program (IVIP) on defeatist beliefs, work motivation, and work outcomes in serious mental illness
Introduction
Less than 15% of people with serious mental illnesses are employed, yet as many as 70% want to work (Brantschen et al., 2014, Leff and Warner, 2006, Warner, 2009). There are many barriers to successful vocational rehabilitation in individuals with serious mental illness (SMI), including practical issues such as losing benefits (MacDonald-Wilson et al., 2003) or psychological obstacles such as the lack of motivation and expectations of failure (Bell et al., 2011). Beliefs such as “No matter what, I'll never be able to do this project, so why even start?” or “Nobody likes me at the office, I'll never get promoted” reflect expectations of failure termed defeatist beliefs, a type of dysfunctional attitude. Defeatist beliefs may be of particular importance to vocational rehabilitation because of their contribution to reductions in motivation for treatment and reductions in multiple domains of community functioning (Campellone et al., 2016, Couture et al., 2011, Davis et al., 2004, Fervaha et al., 2015, Granholm et al., 2014, Grant and Beck, 2009, Grant and Beck, 2010, Horan et al., 2010, Kiwanuka et al., 2014, Luther et al., 2016, Mervis et al., 2016, Quinlan et al., 2014, Rector, 2004, Ventura et al., 2014). Grant and Beck (2009) note that both stigma and cognitive functioning may contribute to self-defeating attitudes. Defeatist beliefs could also be a downstream effect of internalized stigma (Park et al., 2013), which is associated with poorer treatment engagement (Tsang et al., 2010a). However, Ventura et al. (2014) observed defeatist beliefs in first episode psychosis prior to the onset of self-stigmatization, and Luther et al. (2016) found evidence of elevated defeatist beliefs in schizotypy, together suggesting some independence from stigma processes in more advanced, serious mental illness.
The Indianapolis Vocational Intervention Program (IVIP; Lysaker et al., 2005, Lysaker et al., 2009) is a CBT-informed intervention program, delivered concurrently with vocational rehabilitation that targets defeatist beliefs that interfere with effective work function. High-quality studies on CBT-influenced targeted interventions with similar rehabilitation goals in this population exist in the literature (Fung et al., 2011, Granholm et al., 2009, Granholm et al., 2013, Granholm et al., 2014, Granholm et al., 2016, Tsang et al., 2010b, Tsang et al., 2016). The therapeutic strategies employed in IVIP focus on enhancing metacognition, as well as identifying and restructuring defeatist beliefs about self and work in particular (Lysaker et al., 2007a, Lysaker et al., 2010, Lysaker et al., 2012). To date, we are aware of only two randomized controlled trials that have evaluated the efficacy of this specific therapy, IVIP (Lysaker et al., 2005, Lysaker et al., 2009). Both trials administered IVIP over the course of 6 months of work therapy (repeating the 8-session IVIP group content three times, for a total of 24 sessions), and included a weekly individual session to reinforce lessons learned in IVIP, but there is much precedence in the literature for longer follow-up monitoring.
The control condition consisted of a weekly support group and additional weekly individual support sessions. At the end of the six month intervention, those randomized to IVIP expressed greater satisfaction with their treatment, improvements in coping and understanding one's own mental processes, and greater engagement with their IVIP and vocational rehabilitation treatment. Over the course of the six-month intervention those in the IVIP condition also worked more hours and had better work performance ratings (Davis et al., 2008, Lysaker et al., 2005, Lysaker et al., 2007a, Lysaker et al., 2009). There was also indication that adding IVIP to work therapy may serve to maintain hope and self-esteem, which otherwise decrease over the course of work therapy (Lysaker et al., 2005). In our own recent study of IVIP combined with work therapy (Mervis et al., 2016), we found that this combination of treatments led to a reduction in defeatist beliefs about work, and that a reduction in these defeatist beliefs was in turn associated with better social functioning, self-esteem and work behaviors. Although this recent study did not utilize a control group, the present study utilizes a time-matched active control condition.
While the above studies show promise for IVIP's positive effects during a structured work therapy experience, there is no information to date about the potential longer-term effects of IVIP. Once individuals are no longer enrolled in IVIP or work therapy, do improvements in defeatist beliefs and/or work motivation persist? Do individuals who receive IVIP have better work outcomes? Past randomized controlled trials with interventions featuring a prominent CBT component have shown promising effects on reducing self-stigma, which is conceptually related to defeatist beliefs and automatic thoughts, but unfortunately those effects did not show durability at a 6 month follow-up (Fung et al., 2011). In the current randomized controlled trial, we sought to add to the efficacy base of IVIP in particular and examine its impact on defeatist beliefs, motivation for work, and work performance. Importantly, we also evaluated the effects of IVIP 8 months after the end of the active intervention, including its impact on work outcomes. We hypothesized that: 1) compared to a time-matched active control, participation in IVIP would be associated with better work performance, greater reductions in defeatist beliefs and greater motivation for community employment, 2) that these improvements would be sustained at 12-month follow-up, and 3) participation in IVIP would be associated with better critical steps towards functional improvement goals as measured by percentage of those who enrolled in supported employment (SE) by time of follow-up. In a purely exploratory fashion, in the sample as a whole, we also examined the relationship between changes in defeatist beliefs and motivation for work with changes in social functioning, self-esteem, attitude about employment, and work-related behavior.
Section snippets
Participants
Sixty-four participants with schizophrenia-spectrum disorders who were deemed not ready for supported employment by their referring clinician due to their symptoms, poor employment history, and/or cognitive impairments were recruited from community mental health clinics affiliated with the New York State Psychiatric Institute. More specifically, the vocational counselors at the clinics had informed the referring clinician that the participant was not ready for supported employment due to (a)
Results
Participant characteristics for the two groups are presented in Table 1. While there were no differences between groups at baseline, education level in both groups was somewhat higher than typically reported for SMI samples. Sensitivity analysis, a form of power analysis, was conducted in G*Power Version 3.1 to address achieved power based on data from 64 participants at three time points, divided into two groups. Usual and customary conventions for the field were used for alpha (0.05) and beta
Discussion
The primary goal of this study was to examine the efficacy of IVIP and its impact on ameliorating potential barriers to successful work outcomes in people with SMI enrolled in a work therapy program. This was also the first study to investigate the impact of IVIP after the end of the intervention. We found that IVIP was more efficacious than SG in improving work performance during the 4-month work therapy placements, and that it was associated with higher rates of participation in supported
Conflict of interest
The authors report no conflicts of interest.
Contributors
JEM conducted literature searches and wrote the first draft of the manuscript in addition to subsequent drafts. JMF conceptualized the study design and co-wrote manuscript drafts. PHL conceptualized the study design and designed the intervention. TMN co-wrote manuscript drafts. LM assisted in conceptualizing study design, manuscript drafts, and developing infrastructure for data collection, while PW contributed to data collection and manuscript preparation. TP helped formulate the design of the
Role of the funding source
This study was funded in part by a NIMH K23MH086755 to Dr. Choi.
Acknowledgement
We would like to thank Carol Pauls, M.A., Jackie Helcer, M.S., Gennarina Santorelli, B.S., Elaina Montague, B.A., and Kellie Smith, M.A., for their assistance in data collection. The contents of this manuscript do not represent the views of the Department of Veterans Affairs or the United States Government.
References (47)
- et al.
Negative expectancy appraisals and defeatist performance beliefs and negative symptoms of schizophrenia
Psychiatry Res.
(2011) - et al.
Distress related to subclinical negative symptoms in a non-clinical sample: role of dysfunctional attitudes
Psychiatry Res.
(2015) - et al.
Randomized controlled trial of the self-stigma reduction program among individuals with schizophrenia
Psychiatry Res.
(2011) - et al.
Randomized controlled trial of cognitive behavioral social skills training for older consumers with schizophrenia: defeatist performance attitudes and functional outcome
Am. J. Geriatr. Psychiatry
(2013) - et al.
Asocial beliefs as predictors of asocial behavior in schizophrenia
Psychiatry Res.
(2010) - et al.
Further support for the role of dysfunctional attitudes in models of real-world functioning in schizophrenia
J. Psychiatr. Res.
(2010) - et al.
Psychological predictors of functional outcome in people with schizophrenia
Schizophr. Res.
(2014) - et al.
Effects of cognitive behavioral therapy on work outcomes in vocational rehabilitation for participants with schizophrenia spectrum disorders
Schizophr. Res.
(2009) - et al.
Metacognition and schizophrenia: the capacity for self-reflectivity as a predictor for prospective assessments of work performance over six months
Schizophr. Res.
(2010) - et al.
Internalized stigma in schizophrenia: relations with dysfunctional attitudes, symptoms, and quality of life
Psychiatry Res.
(2013)