The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.
As with any research paper, your introduction should serve as a roadmap for your readers to ascertain the scope and purpose of your study. The introduction to a case study research paper, however, should not only describe the research problem and its significance, but you should also succinctly describe why the case is being used and how it relates to addressing the problem. The two elements should be linked. With this in mind, a good introduction answers these four questions:
- What was I studying? Describe the research problem and describe the subject of analysis you have chosen to address the problem. Explain how they are linked and what elements of the case will help to expand knowledge and understanding about the problem.
- Why was this topic important to investigate? Describe the significance of the research problem and state why a case study design and the subject of analysis that the paper is designed around is appropriate in addressing the problem.
- What did we know about this topic before I did this study? Provide background that helps lead the reader into the more in-depth literature review to follow. If applicable, summarize prior case study research applied to the research problem and why it fails to adequately address the research problem. Describe why your case will be useful. If no prior case studies have been used to address the research problem, explain why you have selected this subject of analysis.
- How will this study advance new knowledge or new ways of understanding? Explain why your case study will be suitable in helping to expand knowledge and understanding about the research problem.
Each of these questions should be addressed in no more than a few paragraphs. Exceptions to this can be when you are addressing a complex research problem or subject of analysis that requires more in-depth background information.
II. Literature Review
The literature review for a case study research paper is generally structured the same as it is for any college-level research paper. The difference, however, is that the literature review is focused on providing background information and enabling historical interpretation of the subject of analysis in relation to the research problem the case is intended to address. This includes synthesizing studies that help to:
- Place relevant works in the context of their contribution to understanding the case study being investigated. This would include summarizing studies that have used a similar subject of analysis to investigate the research problem. If there is literature using the same or a very similar case to study, you need to explain why duplicating past research is important [e.g., conditions have changed; prior studies were conducted long ago, etc.].
- Describe the relationship each work has to the others under consideration that informs the reader why this case is applicable. Your literature review should include a description of any works that support using the case to study the research problem and the underlying research questions.
- Identify new ways to interpret prior research using the case study. If applicable, review any research that has examined the research problem using a different research design. Explain how your case study design may reveal new knowledge or a new perspective or that can redirect research in an important new direction.
- Resolve conflicts amongst seemingly contradictory previous studies. This refers to synthesizing any literature that points to unresolved issues of concern about the research problem and describing how the subject of analysis that forms the case study can help resolve these existing contradictions.
- Point the way in fulfilling a need for additional research. Your review should examine any literature that lays a foundation for understanding why your case study design and the subject of analysis around which you have designed your study may reveal a new way of approaching the research problem or offer a perspective that points to the need for additional research.
- Expose any gaps that exist in the literature that the case study could help to fill. Summarize any literature that not only shows how your subject of analysis contributes to understanding the research problem, but how your case contributes to a new way of understanding the problem that prior research has failed to do.
- Locate your own research within the context of existing literature [very important!]. Collectively, your literature review should always place your case study within the larger domain of prior research about the problem. The overarching purpose of reviewing pertinent literature in a case study paper is to demonstrate that you have thoroughly identified and synthesized prior studies in the context of explaining the relevance of the case in addressing the research problem.
In this section, you explain why you selected a particular subject of analysis to study and the strategy you used to identify and ultimately decide that your case was appropriate in addressing the research problem. The way you describe the methods used varies depending on the type of subject of analysis that frames your case study.
If your subject of analysis is an incident or event. In the social and behavioral sciences, the event or incident that represents the case to be studied is usually bounded by time and place, with a clear beginning and end and with an identifiable location or position relative to its surroundings. The subject of analysis can be of a rare or critical event or focus on a typical or regular event. The purpose of studying a rare event is to illuminate new ways of thinking about the broader research problem or to test a hypothesis. Critical incident case studies must describe the method by which you identified the event and explain the process by which you determined the validity of this case to inform broader perspectives about the research problem or to reveal new findings. However, the event does not have to be a rare or uniquely significant to support new thinking about the research problem or to challenge an existing hypothesis. For example, Walo, Bull, and Breen conducted a case study to identify and evaluate the direct and indirect economic benefits and costs of a local sports event in the City of Lismore, New South Wales, Australia. The purpose of their study was to provide new insights from measuring the impact of a typical local sports event that prior studies could not measure well because they focused on large "mega-events." Whether the event is rare or not, the methods section should include an explanation of the following characteristics of the event: when did it take place; what were the underlying circumstances leading to the event; what were the consequences of the event
If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experience he or she has had that provides an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of his/her experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using him or her as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem.
If your subject of analysis is a place. In general, a case study that investigates a place suggests a subject of analysis that is unique or special in some way and that this uniqueness can be used to build new understanding or knowledge about the research problem. A case study of a place must not only describe its various attributes relevant to the research problem [e.g., physical, social, cultural, economic, political, etc.], but you must state the method by which you determined that this place will illuminate new understandings about the research problem. It is also important to articulate why a particular place as the case for study is being used if similar places also exist [i.e., if you are studying patterns of homeless encampments of veterans in open spaces, why study Echo Park in Los Angeles rather than Griffith Park?] and, if applicable, what type of human activity involving this place makes it a good choice to study [prior research reveals Echo Park has more homeless veterans].
If your subject of analysis is a phenomenon. A phenomenon refers to a fact, occurrence, or circumstance that can be studied or observed but with the cause or explanation to be in question. In this sense, a phenomenon that forms your subject of analysis can encompass anything that can be observed or presumed to exist but is not fully understood. In the social and behavioral sciences, the case usually focuses on human interaction within a complex physical, social, economic, cultural, or political system. For example, the phenomenon could be the observation that many vehicles used by ISIS fighters are small trucks with English language advertisements on them. The research problem could be that ISIS fighters are difficult to combat because they are highly mobile. The research questions could be how and by what means are these vehicles used by ISIS being supplied to the militants and how might supply lines to these vehicles be cut? How might knowing the suppliers of these trucks from overseas reveal larger networks of collaborators and financial support? A case study of a phenomenon most often encompasses an in-depth analysis of a cause and effect that is grounded in an interactive relationship between people and their environment in some way.
NOTE: Evidence that supports the method by which you identified and chose your subject of analysis should be linked to the findings from the literature review. Be sure to cite any prior studies that helped you determine that the case you chose was appropriate for investigating the research problem.
The main elements of your discussion section are generally the same as any research paper, but centered around interpreting and drawing conclusions about the key findings from your case study. Note that a general social sciences research paper may contain a separate section to report findings. However, in a paper designed around a case study, it is more common to combine a description of the findings with the discussion about their implications. The objectives of your discussion section should include the following:
Reiterate the Research Problem/State the Major Findings
Briefly reiterate the research problem you are investigating and explain why the subject of analysis around which you designed the case study were used. You should then describe the findings revealed from your study of the case using direct, declarative, and succinct proclamation of the study results. Highlight any findings that were unexpected or especially profound.
Explain the Meaning of the Findings and Why They are Important
Systematically explain the meaning of your case study findings and why you believe they are important. Begin this part of the section by repeating what you consider to be your most important or surprising finding first, then systematically review each finding. Be sure to thoroughly extrapolate what your analysis of the case can tell the reader about situations or conditions beyond the actual case that was studied while, at the same time, being careful not to misconstrue or conflate a finding that undermines the external validity of your conclusions.
Relate the Findings to Similar Studies
No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your case study results to those found in other studies, particularly if questions raised from prior studies served as the motivation for choosing your subject of analysis. This is important because comparing and contrasting the findings of other studies helps to support the overall importance of your results and it highlights how and in what ways your case study design and the subject of analysis differs from prior research about the topic.
Consider Alternative Explanations of the Findings
It is important to remember that the purpose of social science research is to discover and not to prove. When writing the discussion section, you should carefully consider all possible explanations for the case study results, rather than just those that fit your hypothesis or prior assumptions and biases. Be alert to what the in-depth analysis of the case may reveal about the research problem, including offering a contrarian perspective to what scholars have stated in prior research.
Acknowledge the Study's Limitations
You can state the study's limitations in the conclusion section of your paper but describing the limitations of your subject of analysis in the discussion section provides an opportunity to identify the limitations and explain why they are not significant. This part of the discussion section should also note any unanswered questions or issues your case study could not address. More detailed information about how to document any limitations to your research can be found here.
Suggest Areas for Further Research
Although your case study may offer important insights about the research problem, there are likely additional questions related to the problem that remain unanswered or findings that unexpectedly revealed themselves as a result of your in-depth analysis of the case. Be sure that the recommendations for further research are linked to the research problem and that you explain why your recommendations are valid in other contexts and based on the original assumptions of your study.
As with any research paper, you should summarize your conclusion in clear, simple language; emphasize how the findings from your case study differs from or supports prior research and why. Do not simply reiterate the discussion section. Provide a synthesis of key findings presented in the paper to show how these converge to address the research problem. If you haven't already done so in the discussion section, be sure to document the limitations of your case study and needs for further research.
The function of your paper's conclusion is to: 1) restate the main argument supported by the findings from the analysis of your case; 2) clearly state the context, background, and necessity of pursuing the research problem using a case study design in relation to an issue, controversy, or a gap found from reviewing the literature; and, 3) provide a place for you to persuasively and succinctly restate the significance of your research problem, given that the reader has now been presented with in-depth information about the topic.
Consider the following points to help ensure your conclusion is appropriate:
- If the argument or purpose of your paper is complex, you may need to summarize these points for your reader.
- If prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the conclusion of your paper to describe your main points and explain their significance.
- Move from a detailed to a general level of consideration of the case study's findings that returns the topic to the context provided by the introduction or within a new context that emerges from your case study findings.
Note that, depending on the discipline you are writing in and your professor's preferences, the concluding paragraph may contain your final reflections on the evidence presented applied to practice or on the essay's central research problem. However, the nature of being introspective about the subject of analysis you have investigated will depend on whether you are explicitly asked to express your observations in this way.
Problems to Avoid
One of the goals of a case study is to lay a foundation for understanding broader trends and issues applied to similar circumstances. However, be careful when drawing conclusions from your case study. They must be evidence-based and grounded in the results of the study; otherwise, it is merely speculation. Looking at a prior example, it would be incorrect to state that a factor in improving girls access to education in Azerbaijan and the policy implications this may have for improving access in other Muslim nations is due to girls access to social media if there is no documentary evidence from your case study to indicate this. There may be anecdotal evidence that retention rates were better for girls who were on social media, but this observation would only point to the need for further research and would not be a definitive finding if this was not a part of your original research agenda.
Failure to Document Limitations
No case is going to reveal all that needs to be understood about a research problem. Therefore, just as you have to clearly state the limitations of a general research study, you must describe the specific limitations inherent in the subject of analysis. For example, the case of studying how women conceptualize the need for water conservation in a village in Uganda could have limited application in other cultural contexts or in areas where fresh water from rivers or lakes is plentiful and, therefore, conservation is understood differently than preserving access to a scarce resource.
Failure to Extrapolate All Possible Implications
Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings. If you do not, your reader may question the validity of your entire analysis, particularly if you failed to document an obvious outcome from your case study research. For example, in the case of studying the accident at the railroad crossing to evaluate where and what types of warning signals should be located, you failed to take into consideration speed limit signage as well as warning signals. When designing your case study, be sure you have thoroughly addressed all aspects of the problem and do not leave gaps in your analysis.
Case Studies. Writing@CSU. Colorado State University; Gerring, John. Case Study Research: Principles and Practices. New York: Cambridge University Press, 2007; Merriam, Sharan B. Qualitative Research and Case Study Applications in Education. Rev. ed. San Francisco, CA: Jossey-Bass, 1998; Mills, Albert J., Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research. Thousand Oaks, CA: SAGE Publications, 2010; Putney, LeAnn Grogan. "Case Study." In Encyclopedia of Research Design, Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE Publications, 2010), pp. 116-120; Simons, Helen. Case Study Research in Practice. London: SAGE Publications, 2009; Kratochwill, Thomas R. and Joel R. Levin, editors.Single-Case Research Design and Analysis: New Development for Psychology and Education. Hilldsale, NJ: Lawrence Erlbaum Associates, 1992; Swanborn, Peter G. Case Study Research: What, Why and How? London : SAGE, 2010; Yin, Robert K. Case Study Research: Design and Methods. 6th edition. Los Angeles, CA, SAGE Publications, 2014; Walo, Maree, Adrian Bull, and Helen Breen. “Achieving Economic Benefits at Local Events: A Case Study of a Local Sports Event.” Festival Management and Event Tourism 4 (1996): 95-106.
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This paper should be used only as an example of a research paper write-up. Horizontal rules signify the top and bottom edges of pages. For sample references which are not included with this paper, you should consult the Publication Manual of the American Psychological Association, 4th Edition.
This paper is provided only to give you an idea of what a research paper might look like. You are not allowed to copy any of the text of this paper in writing your own report.
Because word processor copies of papers don't translate well into web pages, you should note that an actual paper should be formatted according to the formatting rules for your context. Note especially that there are three formatting rules you will see in this sample paper which you should NOT follow. First, except for the title page, the running header should appear in the upper right corner of every page with the page number below it. Second, paragraphs and text should be double spaced and the start of each paragraph should be indented. Third, horizontal lines are used to indicate a mandatory page break and should not be used in your paper.
The Effects of a Supported Employment Program on Psychosocial Indicators
for Persons with Severe Mental Illness
William M.K. Trochim
Running Head: SUPPORTED EMPLOYMENT
This paper describes the psychosocial effects of a program of supported employment (SE) for persons with severe mental illness. The SE program involves extended individualized supported employment for clients through a Mobile Job Support Worker (MJSW) who maintains contact with the client after job placement and supports the client in a variety of ways. A 50% simple random sample was taken of all persons who entered the Thresholds Agency between 3/1/93 and 2/28/95 and who met study criteria. The resulting 484 cases were randomly assigned to either the SE condition (treatment group) or the usual protocol (control group) which consisted of life skills training and employment in an in-house sheltered workshop setting. All participants were measured at intake and at 3 months after beginning employment, on two measures of psychological functioning (the BPRS and GAS) and two measures of self esteem (RSE and ESE). Significant treatment effects were found on all four measures, but they were in the opposite direction from what was hypothesized. Instead of functioning better and having more self esteem, persons in SE had lower functioning levels and lower self esteem. The most likely explanation is that people who work in low-paying service jobs in real world settings generally do not like them and experience significant job stress, whether they have severe mental illness or not. The implications for theory in psychosocial rehabilitation are considered.
The Effects of a Supported Employment Program on Psychosocial Indicators for Persons with Severe Mental Illness
Over the past quarter century a shift has occurred from traditional institution-based models of care for persons with severe mental illness (SMI) to more individualized community-based treatments. Along with this, there has been a significant shift in thought about the potential for persons with SMI to be "rehabilitated" toward lifestyles that more closely approximate those of persons without such illness. A central issue is the ability of a person to hold a regular full-time job for a sustained period of time. There have been several attempts to develop novel and radical models for program interventions designed to assist persons with SMI to sustain full-time employment while living in the community. The most promising of these have emerged from the tradition of psychiatric rehabilitation with its emphases on individual consumer goal setting, skills training, job preparation and employment support (Cook, Jonikas and Solomon, 1992). These are relatively new and field evaluations are rare or have only recently been initiated (Cook and Razzano, 1992; Cook, 1992). Most of the early attempts to evaluate such programs have naturally focused almost exclusively on employment outcomes. However, theory suggests that sustained employment and living in the community may have important therapeutic benefits in addition to the obvious economic ones. To date, there have been no formal studies of the effects of psychiatric rehabilitation programs on key illness-related outcomes. To address this issue, this study seeks to examine the effects of a new program of supported employment on psychosocial outcomes for persons with SMI.
Over the past several decades, the theory of vocational rehabilitation has experienced two major stages of evolution. Original models of vocational rehabilitation were based on the idea of sheltered workshop employment. Clients were paid a piece rate and worked only with other individuals who were disabled. Sheltered workshops tended to be "end points" for persons with severe and profound mental retardation since few ever moved from sheltered to competitive employment (Woest, Klein & Atkins, 1986). Controlled studies of sheltered workshop performance of persons with mental illness suggested only minimal success (Griffiths, 1974) and other research indicated that persons with mental illness earned lower wages, presented more behavior problems, and showed poorer workshop attendance than workers with other disabilities (Whitehead, 1977; Ciardiello, 1981).
In the 1980s, a new model of services called Supported Employment (SE) was proposed as less expensive and more normalizing for persons undergoing rehabilitation (Wehman, 1985). The SE model emphasizes first locating a job in an integrated setting for minimum wage or above, and then placing the person on the job and providing the training and support services needed to remain employed (Wehman, 1985). Services such as individualized job development, one-on-one job coaching, advocacy with co-workers and employers, and "fading" support were found to be effective in maintaining employment for individuals with severe and profound mental retardation (Revell, Wehman & Arnold, 1984). The idea that this model could be generalized to persons with all types of severe disabilities, including severe mental illness, became commonly accepted (Chadsey-Rusch & Rusch, 1986).
One of the more notable SE programs was developed at Thresholds, the site for the present study, which created a new staff position called the mobile job support worker (MJSW) and removed the common six month time limit for many placements. MJSWs provide ongoing, mobile support and intervention at or near the work site, even for jobs with high degrees of independence (Cook & Hoffschmidt, 1993). Time limits for many placements were removed so that clients could stay on as permanent employees if they and their employers wished. The suspension of time limits on job placements, along with MJSW support, became the basis of SE services delivered at Thresholds.
There are two key psychosocial outcome constructs of interest in this study. The first is the overall psychological functioning of the person with SMI. This would include the specification of severity of cognitive and affective symptomotology as well as the overall level of psychological functioning. The second is the level of self-reported self esteem of the person. This was measured both generally and with specific reference to employment.
The key hypothesis of this study is:
HO: A program of supported employment will result in either no change or negative effects on psychological functioning and self esteem.
which will be tested against the alternative:
HA: A program of supported employment will lead to positive effects on psychological functioning and self esteem.
The population of interest for this study is all adults with SMI residing in the U.S. in the early 1990s. The population that is accessible to this study consists of all persons who were clients of the Thresholds Agency in Chicago, Illinois between the dates of March 1, 1993 and February 28, 1995 who met the following criteria: 1) a history of severe mental illness (e.g., either schizophrenia, severe depression or manic-depression); 2) a willingness to achieve paid employment; 3) their primary diagnosis must not include chronic alcoholism or hard drug use; and 4) they must be 18 years of age or older. The sampling frame was obtained from records of the agency. Because of the large number of clients who pass through the agency each year (e.g., approximately 500 who meet the criteria) a simple random sample of 50% was chosen for inclusion in the study. This resulted in a sample size of 484 persons over the two-year course of the study.
On average, study participants were 30 years old and high school graduates (average education level = 13 years). The majority of participants (70%) were male. Most had never married (85%), few (2%) were currently married, and the remainder had been formerly married (13%). Just over half (51%) are African American, with the remainder Caucasian (43%) or other minority groups (6%). In terms of illness history, the members in the sample averaged 4 prior psychiatric hospitalizations and spent a lifetime average of 9 months as patients in psychiatric hospitals. The primary diagnoses were schizophrenia (42%) and severe chronic depression (37%). Participants had spent an average of almost two and one-half years (29 months) at the longest job they ever held.
While the study sample cannot be considered representative of the original population of interest, generalizability was not a primary goal -- the major purpose of this study was to determine whether a specific SE program could work in an accessible context. Any effects of SE evident in this study can be generalized to urban psychiatric agencies that are similar to Thresholds, have a similar clientele, and implement a similar program.
All but one of the measures used in this study are well-known instruments in the research literature on psychosocial functioning. All of the instruments were administered as part of a structured interview that an evaluation social worker had with study participants at regular intervals.
Two measures of psychological functioning were used. The Brief Psychiatric Rating Scale (BPRS)(Overall and Gorham, 1962) is an 18-item scale that measures perceived severity of symptoms ranging from "somatic concern" and "anxiety" to "depressive mood" and "disorientation." Ratings are given on a 0-to-6 Likert-type response scale where 0="not present" and 6="extremely severe" and the scale score is simply the sum of the 18 items. The Global Assessment Scale (GAS)(Endicott et al, 1976) is a single 1-to-100 rating on a scale where each ten-point increment has a detailed description of functioning (higher scores indicate better functioning). For instance, one would give a rating between 91-100 if the person showed "no symptoms, superior functioning..." and a value between 1-10 if the person "needs constant supervision..."
Two measures of self esteem were used. The first is the Rosenberg Self Esteem (RSE) Scale (Rosenberg, 1965), a 10-item scale rated on a 6-point response format where 1="strongly disagree" and 6="strongly agree" and there is no neutral point. The total score is simply the sum across the ten items, with five of the items being reversals. The second measure was developed explicitly for this study and was designed to measure the Employment Self Esteem (ESE) of a person with SMI. This is a 10-item scale that uses a 4-point response format where 1="strongly disagree" and 4="strongly agree" and there is no neutral point. The final ten items were selected from a pool of 97 original candidate items, based upon high item-total score correlations and a judgment of face validity by a panel of three psychologists. This instrument was deliberately kept simple -- a shorter response scale and no reversal items -- because of the difficulties associated with measuring a population with SMI. The entire instrument is provided in Appendix A.
All four of the measures evidenced strong reliability and validity. Internal consistency reliability estimates using Cronbach's alpha ranged from .76 for ESE to .88 for SE. Test-retest reliabilities were nearly as high, ranging from .72 for ESE to .83 for the BPRS. Convergent validity was evidenced by the correlations within construct. For the two psychological functioning scales the correlation was .68 while for the self esteem measures it was somewhat lower at .57. Discriminant validity was examined by looking at the cross-construct correlations which ranged from .18 (BPRS-ESE) to .41 (GAS-SE).
A pretest-posttest two-group randomized experimental design was used in this study. In notational form, the design can be depicted as:
R O X O
R O O
R = the groups were randomly assigned
O = the four measures (i.e., BPRS, GAS, RSE, and ESE)
X = supported employment
The comparison group received the standard Thresholds protocol which emphasized in-house training in life skills and employment in an in-house sheltered workshop. All participants were measured at intake (pretest) and at three months after intake (posttest).
This type of randomized experimental design is generally strong in internal validity. It rules out threats of history, maturation, testing, instrumentation, mortality and selection interactions. Its primary weaknesses are in the potential for treatment-related mortality (i.e., a type of selection-mortality) and for problems that result from the reactions of participants and administrators to knowledge of the varying experimental conditions. In this study, the drop-out rate was 4% (N=9) for the control group and 5% (N=13) in the treatment group. Because these rates are low and are approximately equal in each group, it is not plausible that there is differential mortality. There is a possibility that there were some deleterious effects due to participant knowledge of the other group's existence (e.g., compensatory rivalry, resentful demoralization). Staff were debriefed at several points throughout the study and were explicitly asked about such issues. There were no reports of any apparent negative feelings from the participants in this regard. Nor is it plausible that staff might have equalized conditions between the two groups. Staff were given extensive training and were monitored throughout the course of the study. Overall, this study can be considered strong with respect to internal validity.
Between 3/1/93 and 2/28/95 each person admitted to Thresholds who met the study inclusion criteria was immediately assigned a random number that gave them a 50/50 chance of being selected into the study sample. For those selected, the purpose of the study was explained, including the nature of the two treatments, and the need for and use of random assignment. Participants were assured confidentiality and were given an opportunity to decline to participate in the study. Only 7 people (out of 491) refused to participate. At intake, each selected sample member was assigned a random number giving them a 50/50 chance of being assigned to either the Supported Employment condition or the standard in-agency sheltered workshop. In addition, all study participants were given the four measures at intake.
All participants spent the initial two weeks in the program in training and orientation. This consisted of life skill training (e.g., handling money, getting around, cooking and nutrition) and job preparation (employee roles, coping strategies). At the end of that period, each participant was assigned to a job site -- at the agency sheltered workshop for those in the control condition, and to an outside employer if in the Supported Employment group. Control participants were expected to work full-time at the sheltered workshop for a three-month period, at which point they were posttested and given an opportunity to obtain outside employment (either Supported Employment or not). The Supported Employment participants were each assigned a case worker -- called a Mobile Job Support Worker (MJSW) -- who met with the person at the job site two times per week for an hour each time. The MJSW could provide any support or assistance deemed necessary to help the person cope with job stress, including counseling or working beside the person for short periods of time. In addition, the MJSW was always accessible by cellular telephone, and could be called by the participant or the employer at any time. At the end of three months, each participant was post-tested and given the option of staying with their current job (with or without Supported Employment) or moving to the sheltered workshop.
There were 484 participants in the final sample for this study, 242 in each treatment. There were 9 drop-outs from the control group and 13 from the treatment group, leaving a total of 233 and 229 in each group respectively from whom both pretest and posttest were obtained. Due to unexpected difficulties in coping with job stress, 19 Supported Employment participants had to be transferred into the sheltered workshop prior to the posttest. In all 19 cases, no one was transferred prior to week 6 of employment, and 15 were transferred after week 8. In all analyses, these cases were included with the Supported Employment group (intent-to-treat analysis) yielding treatment effect estimates that are likely to be conservative.
The major results for the four outcome measures are shown in Figure 1.
Insert Figure 1 about here
It is immediately apparent that in all four cases the null hypothesis has to be accepted -- contrary to expectations, Supported Employment cases did significantly worse on all four outcomes than did control participants.
The mean gains, standard deviations, sample sizes and t-values (t-test for differences in average gain) are shown for the four outcome measures in Table 1.
Insert Table 1 about here
The results in the table confirm the impressions in the figures. Note that all t-values are negative except for the BPRS where high scores indicate greater severity of illness. For all four outcomes, the t-values were statistically significant (p<.05).
The results of this study were clearly contrary to initial expectations. The alternative hypothesis suggested that SE participants would show improved psychological functioning and self esteem after three months of employment. Exactly the reverse happened -- SE participants showed significantly worse psychological functioning and self esteem.
There are two major possible explanations for this outcome pattern. First, it seems reasonable that there might be a delayed positive or "boomerang" effect of employment outside of a sheltered setting. SE cases may have to go through an initial difficult period of adjustment (longer than three months) before positive effects become apparent. This "you have to get worse before you get better" theory is commonly held in other treatment-contexts like drug addiction and alcoholism. But a second explanation seems more plausible -- that people working full-time jobs in real-world settings are almost certainly going to be under greater stress and experience more negative outcomes than those who work in the relatively safe confines of an in-agency sheltered workshop. Put more succinctly, the lesson here might very well be that work is hard. Sheltered workshops are generally very nurturing work environments where virtually all employees share similar illness histories and where expectations about productivity are relatively low. In contrast, getting a job at a local hamburger shop or as a shipping clerk puts the person in contact with co-workers who may not be sympathetic to their histories or forgiving with respect to low productivity. This second explanation seems even more plausible in the wake of informal debriefing sessions held as focus groups with the staff and selected research participants. It was clear in the discussion that SE persons experienced significantly higher job stress levels and more negative consequences. However, most of them also felt that the experience was a good one overall and that even their "normal" co-workers "hated their jobs" most of the time.
One lesson we might take from this study is that much of our contemporary theory in psychiatric rehabilitation is naive at best and, in some cases, may be seriously misleading. Theory led us to believe that outside work was a "good" thing that would naturally lead to "good" outcomes like increased psychological functioning and self esteem. But for most people (SMI or not) work is at best tolerable, especially for the types of low-paying service jobs available to study participants. While people with SMI may not function as well or have high self esteem, we should balance this with the desire they may have to "be like other people" including struggling with the vagaries of life and work that others struggle with.
Future research in this are needs to address the theoretical assumptions about employment outcomes for persons with SMI. It is especially important that attempts to replicate this study also try to measure how SE participants feel about the decision to work, even if traditional outcome indicators suffer. It may very well be that negative outcomes on traditional indicators can be associated with a "positive" impact for the participants and for the society as a whole.
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Table 1. Means, standard deviations and Ns for the pretest, posttest and gain scores for the four outcome variables and t-test for difference between average gains.
Figure 1. Pretest and posttest means for treatment (SE) and control groups for the four outcome measures.
The Employment Self Esteem Scale
Please rate how strongly you agree or disagree with each of the following statements.
|1. I feel good about my work on the job.|
|2. On the whole, I get along well with others at work.|
|3. I am proud of my ability to cope with difficulties at work.|
|4. When I feel uncomfortable at work, I know how to handle it.|
|5. I can tell that other people at work are glad to have me there.|
|6. I know I'll be able to cope with work for as long as I want.|
|7. I am proud of my relationship with my supervisor at work.|
|8. I am confident that I can handle my job without constant assistance.|
|9. I feel like I make a useful contribution at work.|
|10. I can tell that my co-workers respect me.|
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