Vocational Function Among Persons With Schizophrenia
With and Without History of Childhood Sexual Trauma
Paul H. Lysaker,
Michael A. Nees,
Rebecca S. Lancaster,
and Louanne W. Davis
This study examined whether history of childhood sexual abuse in schizophrenia is linked with severity of vocational deficits. Work performance was measured using the Work Behavior Inventory and hours of work performed in a vocational rehabilitation program and then compared for 12 participants with schizophrenia or schizoaffective disorder reporting abuse and 18 with schizophrenia with no abuse history. ANOVAs indicated that the sexual abuse group worked fewer hours during the first 4 weeks of the program and demonstrated poorer work performance overall. An interaction was found suggesting that the sexually abused group’s performance declined as the nonsexually abused group improved over time. Childhood sexual abuse may be associated with greater vocational deficits in adults with schizophrenia.
KEY WORDS: schizophrenia; psychosis; sexual abuse; psychosocial function; work.
History of childhood sexual trauma in schizophre-nia spectrum disorders has been linked with more severe deficits in adulthood including higher symptom levels, im-pairments in working memory (Lysaker, Meyer, Evans, & Marks, 2001) and greater service utilization (Newmann, Greenley, & Sweeney, 1998). These findings coupled with an incidence of childhood sexual trauma in adults with schizophrenia that exceeds that of the general population (Mueser et al., 1998) has led to hypotheses that child-hood sexual trauma may exacerbate and affect the course of severe mental illness (Goodman, Rosenberg, Muser, & Drake, 1997; Read, Perry, Moskowitz, & Connolly, 2001). Beyond this, it is unclear whether sexual trauma con-tributes to the erosion of psychosocial function. Recently we reported persons with schizophrenia with childhood sexual abuse had more difficulties sustaining role function
1Roudebush VA Medical Center, Indianapolis, Indiana.
2Indiana University School of Medicine, Indianapolis, Indiana.
3Indiana University Purdue University Indianapolis, Indianapolis,
4To whom correspondence should be addressed at Day Hospital 116H,
1481 West 10th Street, Roudebush VA Medical Center, Indianapolis, Indiana 46202; e-mail: firstname.lastname@example.org.
(Lysaker, Myers, Evans, Clements, & Marks, 2001). We hypothesized that sexual trauma could negatively effect role function in schizophrenia by reducing capacities to form attachments with others (Liem & Boudewyn, 1999), and process information in the face of painful affects (Putnam & Trickett, 1997).
Unclear from that study, however, are the implica-tions for rehabilitation intervenimplica-tions targeting role func-tion. Is reported childhood sexual abuse a risk factor for poorer function in vocational rehabilitation? Numerous factors that influence rehabilitation outcome could be im-pacted by abuse history including problem solving skills, and conformance to expectations. A fuller understand-ing of the relationship of sexual abuse history to work function seems essential for the development of future interventions.
In the current study we have, therefore, expanded our investigation by comparing work behavior between abuse and nonabuse groups during vocational rehabilitation. We hypothesized participants with abuse histories would: (1) work fewer hours at a job placement, (2) demonstrate poorer work performance, and (3) show lesser improve-ment over time.
436 Lysaker, Nees, Lancaster, and Davis Methods
Participants were 30 men with diagnoses of schizophrenia (n=16) or schizoaffective disorder (n= 14) confirmed with SCID (Structured Clinical Interview for DSM-IV; Spitzer, Williams, Gibbon, & First, 1994). Their mean age was 45 with a range of 26–62. Participants had a mean educational level of 12.4 years (SD=.62), and a mean 10.46 (SD=9.54) lifetime hospitalizations, with the first occurring on average at the age of 24.6 (SD=10.86) years. Twenty-four participants were Cau-casian and 6 were African American. Two were married, 13 were divorced, 2 were separated, and 13 had never married. With regard to housing, 11 lived in residential treatment, 9 lived alone, and 10 lived with others. Partic-ipants had been unemployed for a median of 48 months. Instruments
Childhood Abuse Questionnaire
Child Abuse Questionnaire (CAQ; Levitan et al., 1998) is a self-report questionnaire that screens for abuse history. Utilized in this study are four items, which ask participants to endorse positively or negatively whether, under the age of 18, they experienced an adult expose him/herself repeatedly, threaten to have sex with them, touched their genitals, or had/attempted to have inter-course with them. This questionnaire was developed for epidemiological research and has been used with psychi-atric populations (Bagley, 1989). Consistent with meth-ods used previously (Lysaker, Myers, Evans, Clements, et al., 2001) participants were classified as having reported sexual abuse if they endorsed at least one item.
Positive and Negative Syndrome Scale
Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) is a 30-item rating scale completed by clinically trained research staff at the con-clusion of chart review and a semistructured interview. Items are rated on a 7-point Likert scale and summed to provide measures of orthogonal domains of psychopathol-ogy. This study employed the Positive and Negative sub-scales from the five-component model (Bell, Lysaker, Goulet, Milstein, & Lindenmayer, 1994). Positive symp-toms refer to sympsymp-toms that should not be present in a mental status exam (e.g., hallucinations and delusions) while negative symptoms refer to psychological aspects
that should be present but are not (e.g. sufficient affect and volition).
Work Behavior Inventory
Work Behavior Inventory (WBI; Bryson, Bell, Lysaker, & Zito, 1997) is a 35-item inventory developed specifically to assess work behaviors among persons with severe mental illness. Trained raters complete the WBI following direct observation of participants’ work behav-ior and an interview with the participant’s supervisor. Each work behavior is rated on a 5-point Likert scale, with scores ranging on a continuum from “1” (frequent problem area) to “5” (frequent area of strength). Items are summed and averaged to generate a total score and five subscale scores: social skills, cooperativeness, work habits, work quality, and personal presentation (each of which can range from 1 to 5). Good to excellent inter-rater reliability has been reported among previous inter-raters trained by the first author along with evidence that work behavior as measured by WBI is significantly related to other assessments of work behavior (Bryson et al., 1997). Procedure
Following informed consent, diagnosis was deter-mined using the SCID and participants were administered the CAQ as part of an initial screening battery for a pilot study on the effects of Olanzapine and support services on work performance in schizophrenia. Participants were stabilized on Olanzapine and assigned a 20-hr per week job placement in the Roudebush VA Medical Center. The maximum Olanzapine dose was 20 mg per day, and the minimum was 5 mg. No participants were administered antipsychotic medications other than Olanzapine.
Available job placements involved working regularly scheduled hours at sites such as the patient escort, medical media, and environmental management services. Duties were equivalent to entry-level positions, and regular job site supervisors provided supervision. Participants were allowed to work a maximum of 20-hr per week at all sites, though if requested by participants, a minimum of 10-hr per week could be scheduled. Efforts were made to match the work placements with participants’ interests and skills. Placements were made without reference to testing.
After work began, participants attended weekly groups offering support and problem solving. Hours of work were recorded weekly, and work behavior was eval-uated using the WBI during participant’s first and third weeks of work. The first week was chosen in order to ob-tain an appraisal of initial acclimation to work. The WBI
during the third week of the program examined work per-formance after participants had been given the opportunity to acclimate to work and benefit from training and expe-rience. Previous research suggests work behavior in the third week of rehabilitation is a reliable indicator of future performance (Lysaker, Bell, Milstein, Goulet, & Bryson, 1993). WBI raters were trained bachelor or master’s level research assistants, unaware of study hypotheses and blind to CAQ responses.
Twelve of the 30 participants (40%) endorsed at least one item on the CAQ and were classified as having expe-rienced childhood sexual abuse. Of these three endorsed having had an adult expose themselves to them more than once, four endorsed having had an adult threaten to have sex with them, nine endorsed having been fondled by an adult, and seven having an adult have or attempted to have intercourse with them. None of the participants endorsed having had adults expose themselves in their presence as their sole abuse experience. No significant differences were found between the abuse and nonabuse group for age, education, hospitalization history, diagnostic classifi-cation, race, or positive and negative symptom level. Mean PANSS Positive and Negative component scores for the sample were 19.0 (SD=4.6) and 20.0 (SD=6.6). Means and standard deviations for the abuse and nonabuse groups for hours worked each week and WBI total and subscale scores for weeks 1 and 3 are presented in Table 1. To examine differences between groups over time, two re-peated measures ANOVAs were conducted. In the first, the number of hours worked by the abuse and nonabuse
Table 1.Work Performance for Participants With (n=12) and Without
(n=18) Histories of Childhood Sexual Abuse
Abuse history No abuse history
Measure Week Mean (SD) Mean (SD)
Hours worked 1 11.25 (9.57) 16.61 (4.15) 2 9.25 (9.31) 19.17 (2.90) 3 11.00 (9.00) 17.22 (5.80) 4 7.50 (9.65) 18.17 (4.90) WBI Total 1 3.28 (.22) 3.38 (.36) 3 3.10 (.36) 3.52 (.42) Social skills 1 2.81 (.60) 2.90 (.41) 3 2.76 (.58) 3.07 (.60) Cooperativeness 1 3.53 (.37) 3.58 (.60) 3 3.49 (.31) 3.83 (.47) Work habits 1 3.11 (.75) 3.44 (.54) 3 2.94 (.72) 3.66 (.67) Work quality 1 3.10 (.64) 2.92 (.60) 3 3.06 (.36) 3.31 (.71) Personal presentation 1 3.21 (.59) 3.69 (.64) 3 3.10 (.35) 3.71 (.58)
groups during weeks 1, 2, 3, and 4 were compared. This analysis revealed a significant between-group difference, F(1, 28) = 15.2, p < .001, with the nonabuse group working more hours than the abuse group. No time or interaction effects were noted. Second, WBI total scores were compared between groups. Only 27 participants were available for this analysis since three failed to work at all during the first 4 weeks and work behavior could not be rated. A significant between- groups difference was found,F(1, 22)=4.3,p=.05), with the nonabuse group demonstrating better work performance. No time effects were noted. An interaction resulted, however, with the abuse group demonstrating work performance that declined at week three as the work performance of the nonabuse group improved [F(1,22)=5.2,p <.05].
Lastly, given a finding of global differences in work performance, five ANOVAs comparing the WBI subscale scores between groups were performed. Groups differed significantly only on personal presentation, F(1, 22)= 6.73,p <.05) and work habits,F(1, 22)=5.66,p <.05. No time effects were found.
Results support the hypothesis that childhood sex-ual abuse in schizophrenia spectrum disorders may be an additional impediment to vocational function in adult-hood. As predicted, participants who reported childhood sexual abuse worked fewer hours over the first month of a work program and demonstrated poorer work perfor-mance, with a pattern of work performance that declined over time in contrast to the nonabuse group whose work performance improved. Given these findings, it seems nat-ural to ask what aspects of work were especially difficult for those with sexual abuse histories. The current study cannot offer conclusive evidence here, but analyses of WBI subscales suggest that the abuse group had greater difficulty with work habits (e.g., conformance to the ba-sic instrumental rules of the job site, e.g., taking breaks appropriately) and personal presentation (conformance to the worker role, e.g., appropriate attitude). Thus it may be that individuals with abuse histories have difficulty per-ceiving, learning, and/or following the central demands surrounding work. As a result they may appear more er-ratic and less appropriate in the workplace. This tentative conjecture is consistent with findings that traumatic expe-riences in general may be linked to emotional instability and difficulties processing information when under stress (Yehuda, 1999). It cannot, however, be ruled out that the relationships between work and sexual abuse are the result of factors not considered here.
438 Lysaker, Nees, Lancaster, and Davis
There are limitations, however. Our sample was mod-est, participants were males, generally in their 40s and sexual abuse was assessed using a brief screen only. On-set, severity, frequency, and impact of abuse were not assessed. Additionally symptoms of posttraumatic stress or dissociative disorders were not assessed. Replication should include females as well as individuals in earlier phases of illness along with a paradigm that comprehen-sively assesses sexual abuse history and other forms of symptoms commonly found among trauma survivors. As a naturalistic study, our results cannot determine causality. Future longitudinal studies are needed which comprehen-sively assess a full range of potential intervening variables. With regard to the accuracy of self-reported child abuse in psychosis, research suggests psychiatric patients tend to underreport rather than overreport abuse histories (Dill, Chu, & Grob, 1991), although the reports tend to have good test-retest reliability (Goodman, Thompson, & Weinfurt, 1999). Further, incorrect allegations of sex-ual abuse are no higher among people diagnosed with schizophrenia than in the general population (Darves-Bornoz, Lemperiere, & Degiovanni, 1995). Nevertheless, future research may include abuse assessments based on the reports of others, though again many abused persons never disclose this material.
This research was supported by a grant from Eli Lilly and Company.
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