Changing Perspectives - Living and Working With Schizophrenia
World Mental Health Day is observed on 10 October each year. With this year's theme of living a healthy life with schizophrenia, the aim is to foster positive attitudes towards this illness and highlight the success of person-centered treatment that creates resilience and recovery leading to personal autonomy.
The number of people who have had an experience of schizophrenia and are applying for life and disability insurance is small. Those that do represent a high-functioning cohort that are too often tarred with the stereotypes of poor outcome and high rates of suicide associated with the diagnosis. Rarely have these people been seen as individuals or had their risk appropriately assessed.
In recent years there has been increased focus on some of the fundamental problems experienced by those with schizophrenia in order to improve not only their abilities to cope day-to-day, but also to work. As economies recover, there is a growing realisation that work is not only a possibility, but that it brings benefits for this group. More will become economically active in the future and demanding of financial services.
Schizophrenia is one of the most severe of mental illnesses and typically chronic. It is best known for its, so called, “positive symptoms”: delusions and hallucinations but less well-known for the “negative symptoms” of apathy and social and emotional withdrawal. Until recently, the cognitive problems associated with the illness gained little attention.
Medical treatment alone is partially successful in eradicating the positive symptoms but has little impact on negative symptoms or cognitive problems. There is no particular medication that is associated with improved work outcomes.
People with schizophrenia experience deficits in neurocognition (memory, attention and executive functioning) and social cognition, the mental operations underpinning social interactions (including perceiving, interpreting and responding to the intentions and behaviours of other people). Clearly much of the success of any person at work depends on his or her ability to concentrate, remember and problem-solve, and understand the social environment they operate in.
These cognitive deficits have been found to correlate more strongly with general outcome and effective rehabilitation than positive symptoms, leading to greater focus on their management, using two distinct methods:
- "Drill and practice" — learning through repetition, with gradually increasing task difficulty, the participant develops his or her own strategies through trial and error
- "Drill and strategy" — teaching specific strategies that can then be generalised to all situations
While most studies for neurocognitive problems have used "drill and practice", those for social cognition have focussed on "drill and strategy" methods. Generally outcomes appear to be positive for these interventions, not only on day-to-day independence, but also in the ability to sustain gainful employment.
Combined with vocational rehabilitation, these programmes demonstrate a positive effect on hours worked, income levels, and the typically low (10%-20%)1 employment rates associated with the illness.2
Although detailing the complex barriers to employment, a recent report from the Work Foundation is positive in outlining the processes and structures that could meaningfully bring this group to the labour market.3
The insurance industry needs to be aware of this change in perspective for those who experience serious mental illnesses and to critically review the assumptions upon which its response to this group have so long been based.
- 1. Marwaha S and Johnson S. “Schizophrenia and employment - a review”.Soc Psychiatry Psychiatr Epidemiol. 2004,39. 337-49.
- 2. Paquin et al. “A systematic review on improving cognition in schizophrenia”. BMC Psychiatry, 2014, 14:139, p16 of 19.
- 3. Bevan S et al (2013) “Working with Schizophrenia: Pathways to Employment, Recovery and Inclusion”. The Work Foundation. London (2013).