A PHENOMENOLOGICAL STUDY ON THE EFFECT OF SUPPORTED EMPLOYMENT ON INDIVIDUALS DIAGNOSED WITH BIPOLAR DISORDER by Chinedu Malcolm Ifoezeh

KIT JOHNSON, PhD., Faculty Mentor and Chair EDWARD BAKER, PhD., Committee Member RUTH BUNDY, PhD., Committee Member

Suzanne Holmes, DPA, Dean School of Public Services Leadership

A Dissertation Presented in Partial Fulfillment Of the Requirements for the Degree Doctor of Philosophy

Capella University December, 2011

UMI Number: 3489794

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 Chinedu Malcolm Ifoezeh, 2011

Abstract The following research was conducted with the intent to understand the meanings adult diagnosed with bipolar disorder attribute to their experiences in a supported employment program. Exploration of these experiences utilizing Adult Learning Theory helped discover to what extent employment helps in the management and recovery of mental illness. Fourteen individuals with bipolar disorder voluntarily participated in this study. This qualitative study utilized a phenomenological approach to fully understand participants experiences of a supported employment program. The researcher was able to determine the result of the study by the emerging themes of the participants personal accounts during a face to face semi-structured interview with the researcher. The researcher recorded interviews with an audio recorder and transcribed them into text using ATLAS.ti Qualitative Data Analysis 6.2 Software. These participants found meanings from their experiences in a supported employment program. These meanings manifested as the emerging themes of the study: accommodation, socializations, inclusion and most of all, security. Findings indicated that supported employment program helps people with Bipolar Disorder. In addition, these findings added to current literature in the human service field will provide a better understanding of how employment contributes to the management of mental illness.

Dedication I dedicate this dissertation to my late mother Christiana Ifoezeh for believing in me even when I thought education was not meant for me. I do believe her death unfortunately became an eye-opener and a wake up call for me to reinvent myself and continue with my education. You are such an inspiration mother! I also want to thank my father and my entire family for their support and prayers for me being the first to become PhD in our family. I believe that as the pioneer in this area, there would be so many other people in my family to follow my footsteps in years to come. Furthermore, I also dedicate this dissertation to all the people with mental illness around the world. It is very hard battling with mental health symptoms as well as the stigma associated with mental illness. I hope that there will come a day when no one would be afraid to disclose their mental health diagnosis due to fear of being labeled and stigmatized.

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Acknowledgments First and foremost, I give God all the glory and thank Him for the strength and endurance throughout this doctoral program. I honestly give God all the credit. I acknowledge my wonderful children who sacrificed the quality time they would have spent with me while I was writing this dissertation. I do thank my uncle Luke and my whole family as well as all my friends for all their prayers and support. I especially thank you grandma for all your prayers for me. Im also so delighted you are alive to witness this honor Im bringing to our family. I also thank my mentor Dr. Kit Johnson for putting up with me and my temper tantrums and my whole committee members for their helpful feedback. I finally acknowledge my study site for providing me with the avenue to conduct my study and to all my study participants whose voices represent millions of voiceless individuals with mental illness. May God bless you all! Amen

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Table of Contents Acknowledgements List of Tables List of Figures CHAPTER 1: INTRODUCTION Introduction to the Problem Background of the Research Problem Statement of the Problem Purpose of the Study Rationale & Significance of the Study Definitions of terms Assumptions and Limitations Nature of Study Organization of the Remainder of the Study CHAPTER 2: LITERATURE REVIEW Introduction to the Literature review Theoretical or conceptual framework: Adult Learning Theory Application of Adult Learning Theory Alignment of Adult Learning Theory Methodological Literature Specific to the Topic Review of Research Literature Review of Critical Literature Gaps in Literature v 12 12 15 17 17 20 30 31 1 3 4 5 6 7 8 9 10 iv viii ix

Justification of Methodology and Research Design Summary CHAPTER 3: METHODOLOGY Introduction Research Question Researcher's Philosophy Research Design Guide or Model Research Design Strategy Sampling Procedure Setting Measures Validity & Reliability Data Analysis & Collection Procedures Field Testing Researchers Role & Credibility Limitations of the Research Design Data Analysis Procedures Presentation of Findings & Expected Findings Ethical Issues and Considerations Data Management & Storage Summary Conclusion

32 32

34 34 35 36 38 41 42 43 44 44 47 50 51 52 53 53 54 54 55

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CHAPTER 4: DATA COLLECTION AND ANAYLSIS Introduction Sample/Data Collection Description of Study Participants Data Analysis Process Epoche/Bracketing Data Coding Process Data Analysis Results Emerging Themes Member Checking Connection to Research Questions Data Analysis Summary CHAPTER 5: RESULTS, CONCLUSIONS, AND RECOMMENDATIONS Introduction Summary of Results Discussion of Results Discussion of Conclusions Adult Learning Theory Limitation of Study Recommendations Conclusion REFERENCES APPENDIX. INTERVIEW GUIDE vii 78 78 79 82 88 89 90 90 92 108 56 57 58 61 62 63 64 66 73 74 77

List of Tables

Table 1: Participants Responses to Emerging Themes Table 2: Code Dictionary

64 67

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List of Figures

Figure 1: Flow Chart of Emerging Themes

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CHAPTER 1. INTRODUCTION Introduction to the Problem The expectation in most societies is that adults work for a living and contribute to society. Therefore, access to employment is fundamentally a basic human right for every citizen and people experiencing mental illness should not be excluded. Nonetheless, people with mental disabilities continue to face the sad reality of unemployment and underemployment (Larson, et al., 2007). Compared to the 78% employment rate for people without disabilities, only 35% of people with disabilities are employed in the United States (Strauser & O Sullivan, 2009). For the individuals with mental disabilities, the unemployment rate remains as high as 90%, even though this population has a high desire to work (Larson, et al., 2007). Many people experience discrimination and social disadvantage because of their psychiatric diagnosis. Consequently, diagnostic information has been used unfairly to deny or discriminate against people with psychiatric disabilities (OKeeffe, 1993; Casper & Carloni, 2007). Mental illness can be devastating not only to the lives of the men, women and children it affects directly, but also to their families, friends, and colleagues. People diagnosed with mental illness are faced with risk of unemployment, underemployment, losing their employment and friends, of being ridiculed, misunderstood, and being discriminated against legally, medically, and socially (OKeeffe, 1993). Therefore, there is a high need to research the additional supports that are needed to ensure employment opportunities which can contribute to help improve the lives of people with mental illness (Chan, Tsang, & Li, 2009). Due to the concern about the persistent stigma of mental illness and how mental illness has become the greatest barrier to employment, it is essential to evaluate ways to combat mental health stigma, unemployment and underemployment among people diagnosed with mental 1

illness. It is also important to study the link between mental illness and employment because studies suggest that employment contributes immensely to the management and recovery of mental illness (Kukla & Bond, 2009). Therefore, the best way to find out how to minimize unemployment among this population as well as comprehend the contribution of employment in the recovery of mental illness was to hear it from those living with mental illness. This research was conducted with the intension to expand this gap in the professional literature. In continuation, this study introduced the concept of supportive employment and explored to what extent it could help people living with bipolar disorder obtain and maintain competitive community employment. Supportive employment programs not only teach the clients employment skills, but also educate them about their rights, how to disclose their diagnosis and most of all provide valuable information about The Americans with Disability Act (ADA). The ADA is important because it protects individuals with physical and mental disabilities in their pursuit of vocational options (Dong, MacDonald-Wilson, & Fabian, 2010). The ADA does not allow medical examination until a job offer has been made (Bruyere, Erickson & VanLooy, 2004). Human service workers are encouraged to be familiar with ADA requirement to be able to help their clients avoid discrimination by invoking ADAs protections. The intent of the ADA was to assist individuals with both physical and mental disabilities to obtain and maintain employment, yet the inclusion of people with mental illness has faced enormous challenges (Goldberg & Killeen, 2005). There is a debate whether they should be able to receive job coaching as a reasonable accommodation even when they are not performing their job as well as people without a psychiatric condition (Goldberg & Killeen, 2005). Job coaching does not pose an undue hardship for the employer (Sachs & Redd, 1993). Nonetheless, it was 2

very important to hear the experiences of supported employment or lack thereof from individuals who participated in a supportive employment program on a daily basis. These findings will help educate mental health workers, employers, legislators and the clients themselves of better ways to minimize mental health stigma along with problems of unemployment, underemployment and workplace discrimination. Background of the Research Problem Approximately 14.3 million people in the Unites States suffer from mental illness (OConnor, 2003; Kukla & Bond, 2009). Consequently, it is difficult to ignore the prevalence of mental disabilities in the United States and the discrimination experienced by persons with mental disabilities in the workplace (OKeeffe, 1993). The first challenge faced by this population is unemployment and underemployment. Then secondly, the stigma of mental illness creates a barrier to securing employment and more problems when people with mental disability secure employment. In many jobs, the term disability brings to mind a picture of a person in a wheel chair or an unstable time bomb in the case of someone with a mental disability. This shows how people view mental illness in the workplace and how they continue to fuel the stigma and stereotype associated with mental illness. The impact of stigma is a huge barrier to recovery (Pinfold & Borneo, 2007). Stigma infiltrates itself into policy decisions, research allocation, access to care, and employment discriminations (Jamison, 2006). People suffering from mental illness are often recognized or stigmatized as strangers who are not allowed to find an adequate place in society (Bauman, 2007). When people appear to be different, others may view them in a negative stereotyped manner. Society does not feel comfortable dealing with mental illness and thus stigmatizes 3

people with mental illness. Although mental illness is like any other illness, in the sense that employees need extra support at work; however the misconceptions of how dangerous people with mental illness persists and can contribute to the high unemployment rate of this population (Morgan, 2005). Due to stigma associated with mental illness, the unemployment rate among this population continue to rise even though past studies have shown that people with mental disability are willing and able to work (Morgan, 2005; Larson et al., 2007). Employment is the number one social activity that best transmits sense of self-worth and social identity (Ackerman, & McReynolds, 2005). Therefore, to deny people with mental illness the opportunity to be part of a workforce creates financial deprivation, lack of self-esteem, lack of sense of self-confidence, and most of all marginalization, which is the key factor of psychiatric disabilities (Marrone, Follwy, & Selleck, 2005). Statement of the Problem As stated earlier, compared to their nondisabled peers, people with mental disabilities are often unemployed or underemployed even though this population has the highest desire to work (McQuilken et al., 2003; Goldberg & Kileen, 2005). Furthermore, there are also concerns that this population is not easily marketable in the employment community. Therefore, most employers find loopholes to avoid hiring people with mental disabilities. In addition, even some practitioners do not refer their clients to supported employment programs because it supposedly requires intensive and ongoing support, thereby creating additional stress for the clients (Cimera, 2008). However, employment does not create stress, but bring forth self-confidence and selfworth to the people with mental disabilities (Ackerman & McReynolds, 2005). Other issues along with the stigma associated with mental illness include lack of public awareness about 4

mental illness and clients not knowing their rights in regards to The Americans with Disability Act of 1990 (ADA). The disabilities covered are physical, sensory and mental. The Americans with Disability Act of 1990 (ADA) require that people with disabilities have an equal opportunity for jobs in which they are qualified, yet few employers are abiding by this law (Bruyere et al., 2004). This Law could be very difficult to enforce because employers can deny that a client is turned down for a job because of their psychiatric disability. Furthermore, the biggest barrier of all is the misconception that individuals with mental illness are not capable of working (OConnor, 2003). Even when they finally secure employment, they still have to deal with the mental health stigma at the workplace. Society can minimize this mental health stigma through education and awareness initiatives to combat the misconception that people with a psychiatric disability such as bipolar are not capable of working (OConnor, 2003). In fact, experts believe that more people with psychiatric disability are very capable of working (OConnor, 2003; Goldberg & Kileen, 2005). Although, supported employment programs are created to assist people with mental disabilities, it was not known to what extent supported employment contributes to the recovery and management of mental illness. Purpose of the Study The purpose of this study was to explore how supportive employment helps in the management and recovery of individuals with bipolar disorder. Furthermore, supported employment programs also teach individuals with bipolar disorder about their rights, how to disclose information about their disability, and how to obtain and maintain employment. Some studies show that competitive employment is a primary goal for the majority of people with 5

mental disabilities and that supported employment is effective for this population (Drake, McHugo, Becker, Anthony & Clark, 1996; Bond, 2004). More than one third of clients without jobs desire paid employment (Rogers, Walsh, Masotta & Danley, 1991; Larson et al., 2007). Study findings show that individual support job placement is very successful in helping obtain employment for individuals suffering from mental illness (Drake et al., 1996). In addition, supported employment helps improve self esteem and overall quality of life (Bush, Drake, Xie, McHugo, & Haslett, 2009). Therefore, by providing employment services, individuals with mental illness become more self-sufficient, feel more valuable and contribute more to society (OConnor, 2003). Rationale, Relevance, and Significance of the Study The rationale for this study was to explore the experiences of a supportive employment program from the perspectives of the participants. It is also important to address the issue of unemployment, underemployment, stereotypes and mental health stigma. In addition, supported employment may help clients not only improve future employment opportunities, but help them build confidence, self esteem, cooperation and communication skills, independence living skills, establish friendships and improve the overall quality of life (Bush et al., 2009). Due to limited supported employment programs, this research may help expose the importance of supported employment which might lead to the funding and development of more supported employment programs all over the United States.

Research Questions What meaning do adults diagnosed with Bipolar Disorder attribute to their experiences in a supported employment program? Corollary Questions: 1. How do adult participants engaged in a supported employment program view unemployment and underemployment? 2. What elements of supported employment program do adult participants perceive as adaptive for their specific work situation? Definition of Terms The researcher will provide operational definition of the terms and the context in which they are utilized in this study. ADA. Americans with Disability Act of 1990, which prohibits discrimination against people with mental and/or physical disabilities (Bruyere et al., 2004). Clients. In this study, the term client is used to address individuals diagnosed with persistent mental illness (Rosenthal, 2008; Rosenheck & Mares, 2007; Goldberg & Killen, 2005). Mental health stigma. Inaccurate and negative views of mental disability are known as stigma (Cook, 2006; Goldberg & Killen, 2005). Using stereotypes and labels often attached to people who suffer from mental health problems. Common labels used against people with mental illness are: they are potentially dangerous, violence, weak, unpredictable, unemployable, etc. Mental health stigma is a harsh reality for people with mental illness, because it hinders them from enjoying their lives peacefully (Goldberg et al., 2008).

Mental illness. Mental illness is a disease often caused by an imbalance in the brains chemicals that determines how an individual thinks and feels. Severe mental illnesses include major depression, schizophrenia, schizoaffective disorder, bipolar disorder, and other mental illnesses as described by the American with Disability Act (Goldberg & Killeen, 2005). Supported employment program. A program designed to enable individuals with disabilities to obtain and maintain competitive employment within the community (Cimera, 2008). The Rehabilitation Act Amendments of 1986, states that supported employment deals with competitive work in an integrated work setting with on going support for people with mental disabilities (Goldberg & Killeen, 2005; Cook, 2006). Stereotypes. Commonly held positive or negative beliefs about certain types of people or social groups (Harvey & Allard, 2005; Goldberg & Killen, 2005). Unemployment. Not being able to secure competitive community employment (Morgan, 2005). Underemployment. This happens when a person takes a job below their level of skills and expertise (Morgan, 2005). Assumptions and Limitations The assumption was that the participants will be truthful with their responses to the researcher. Another assumption was that participants were in compliance with psychiatric treatment and will provide clear answers based in reality. It was also assumed that the research environment will not hinder participants from responding to interview questions out of their own free will about the supported employment program.

In addition, it was assumed that findings from this research will reveal how supported employment program helps in the management and recovery of bipolar disorder. Finally, experiences of supported employment program by participants were positive, thus encouraging the developments of more supported employment programs in the United States. The limitation of this study was that gender, race or culture might play a role in how people perceive things such as a supported employment program. Future studies should specifically study different ethnic groups and gender and their day-to-day experiences in a supported employment program utilizing ethnographic approach. A limitation to the method was that, with the phenomenological method, the words of the participants were the single source of data and the Hawthorne affect might become a huge limitation. Hawthorne effect or reactivity occurs when participants change their behavior because they know they are in a research study (Leedy & Ormrod, 2005). Nature of the Study (or Theoretical/Conceptual Framework) This researcher conducted a qualitative study using phenomenological approach to understand the experiences of participants in a supported employment program. In an effort to understand and give meaning to mental illness and employment, phenomenological design is the best design to uncover the truth about the day-to-day experience of the participants in a supported employment program. The researcher interviewed individuals diagnosed with bipolar disorder about their day-to-day experiences in a supported employment program. The researcher utilized adult learning theory by Malcolm Knowles to show that learning is a progression that happens in and outside of the classroom, throughout a persons life (Conner, 2007;

Yukawa, 2010). The researcher utilized findings to verify to what extent supported employment helps in the management and recovery of people with bipolar disorder. The rationale was that phenomenological study is the best way to fully understand peoples perceptions, perspectives, and understandings of situations that affects their lives (Leedy & Ormrod, 2005). Phenomenological study is a type of qualitative design that basically focuses on individual experiences (Leedy & Ormrod, 2005). Brentano, who championed and pioneered phenomenology, depicted experience as the best teacher (Brentano, 1973). A researcher utilizing phenomenological approach must go through a series of steps to examine the phenomenon under investigation bias free (Descarte, 1977; Moustakas, 1994). Organization of the Remainder of the Study The remainder of this study consists of four chapters (chapter 2, 3, 4 & 5). In Chapter 2, the researcher reviewed peer journal literature related to the study. The first section introduce the literature review, the theoretical or conceptual framework (Adult Learning Theory), nature of the relationship between the people involved, bridging the gaps, unemployment among people with mental illness, definition of supported employment, mental health stigma as a barrier to employment, other barriers, review of the critical literature, gaps in literature, justification of methodology and research design and summary. Chapter 3 focuses on the qualitative research design and discusses methods employed for data collection and analysis. This chapter discusses the researcher's philosophy, the research design guide or model, the research design strategy, sampling design, measures, data collection procedures, data analysis procedures, limitations of the research design, expected findings and ethical issues. 10

Chapter 4 discusses sample and data collection, description of study participants, data analysis process, bracketing, coding, and emerging themes. Chapter 5 reports summary of results, conclusions, alignment of literature review, theory, limitations and recommendations.

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CHAPTER 2. LITERATURE REVIEW Introduction to the Literature Review The goal of this study was to explore to what extent supportive employment helps in the recovery and management of bipolar disorder. This chapter presented an overview of literature applicable to the study. It addressed mental health problems in general and specifically examined difficulties associated with having bipolar disorder. The literature review examined supported employment; described psychiatric barriers, mental health stigma, and reviewed methodologies specific to the topic. In addition, the literature review was divided into different parts to help the reader understand the problem, purpose and significance of the study. Adult Learning Theory was dentified as the theoretical framework for this study as it was applicable to the area of mental illness and supported employment. This review also discussed the significance of supported employment and the role of supported employment facilitators and other mental health professionals. Finally, a critique of previous researches in the area of interest was addressed and the limitations in these studies were explored so future studies can avoid such issues and be able to add substantial information to the existing literature in the area of supported employment and mental disabilities. Theoretical Framework: Adult Learning Theory Adult Learning Theory Learning can be concisely defined as the act or experience of gaining skills and knowledge; a continual process of helping people move from beginners to experts (Yukawa, 2010). Some believe that learning should be deemed as a progression that happens in and outside 12

of the classroom, throughout a persons life (Conner, 2007; Yukawa, 2010). In the effort to tackle the dimensions of how people learn, debates have spurred acknowledging the varieties of ways in which people learn at certain stages of life. The formation of adult learning theory directly addressed these differences and has assisted educators in better understanding and serving mature adult learners (Holton, Knowles & Swanson, 2005). Due to the current economic difficulties in the United States, the demand for continuing education in adults after elementary and secondary training has become prevalent. Moreover, science-based industries, such as pharmaceuticals require substantial training making adult education vital to production in American business. Consequently, during the 20th century, adult learning theory became increasingly popular as practices in adult education came under question. Adult learning theory is concerned with understanding the most efficient ways that adult learners learn (Knowles, 1975). The theory was founded on the principle that adults learn differently than children, suggesting that there was a need for training specifically designed for older learners (Knowles, 1984). The contributions of the theorist Malcolm Knowles, a well-known spokesperson for adult training and education, provided valuable information for the future of learning as adults (Welty, 2010). Furthermore, the training and educating of adults is referred to as andragogy, as coined by Malcolm Knowles who diligently worked to provide useful principles for instructing mature learners (Knowles, 1975). He suggested that adults are self-direct and usually take responsibility for decisions (Knowles, 1975). Knowles also believed that adults approached leaning as problem-solving, learned best when the topic was of immediate value, needed to learn experientially and needed to know why they need to learn something (Knowles, 1984). The most important aspect is that Knowles suggests that adult learning programs must accommodate 13

the fundamental aspect of adult learning theory (Knowles, 1975). In other words, instruction for adults should focus more on the process and less on the content being taught (Knowles, 1984). Learning should involve strategies such as case studies, simulations, role playing, and self evaluation. Consequently, instructors should adopt a role of facilitator or resource rather than lecturer or grader (Knowles, 1984). In addition, the principles of this theory includes that adults need to be part of the planning and evaluation of their instruction, experience provides the basis for learning activities, adult learning is problem-centered rather than content-oriented and adults are most interested in learning subjects that have immediate relevance to their job or personal life (Knowles, 1984). Therefore, any supported employment program should be able to apply this theory and its principles to be able to fully assist adult participants engaged in such programs to obtain and maintain competitive community employment. Furthermore, Knowles stressed the significant differences in the educating of adults versus that of children. He asserted that aspects along which adult learning differs from children consist of (1) experience, (2) self-concept, (3) willingness, (4) motivation to learn, and (5) orientation to learning. These dimensions were supported by Knowles notion that assumptions must be made when considering adult learning (Knowles, 1980). These suppositions included an understanding that the motivation to learn, in older learners, will be job-oriented and selfdirected. In addition, the education material collected by mature adult learners will have instant application and their experiences will be used as a learning resource (Knowles, 1980; Werth, 2009; Marmon, 2010; Welty, 2010). Consequently, Adult Learning Theory is an effort to focus on the learner and the principles that shape the learning process to be more conducive to adults. However, the nature of this theory has sparked controversy and scrutiny. Holton, Knowles, and Swanson (2005) 14

encourage avoidance of confusing the principles of adult learning with the purposes and goals for which the learning event is being executed. Ultimately, a critical element of learning, to consider when training adults, includes educators being cognizant to the reality of learning as a process that occurs throughout life. On the downside, Adult Learning Theory focuses mainly on the individual. The individuals motivation and willingness to learn play a huge part in this theory (Holton, Knowles & Swanson, 2005). However, in a supported employment program, it takes more than the individual to obtain and maintain competitive community employment. Nonetheless, Adult Learning Theory has so many strengths because the adult learner needs direct experiences to apply the learning in real work, the adult learner comes into learning with previous experiences and the adult learner can transfer learning through facilitation (Holton et al., 2005). All these strengths are essential for the clients to benefit from a supported employment program. Application of Adult Learning Theory In their attempt to assess the efficiency of online learning tools for adult learners, RenfroMichel, O'Halloran, and Delaney (2010) applied Adult Learning Theory to better understand and meet the needs of graduate students in a counselor education classroom. The researchers were able to conceptualize the needs of the adult learner and conclude that technological tools improved learning in adults as they were permitted to learn in a variety of ways, be self-directed, have increased comprehension of counseling theories, and produce higher final grade scores. Similarly, Alewine (2010), using a quasi-experimental post-test only design, implemented methods based on the assumptions in andragogy to assess the extent to which andragogical treatment could influence GED classroom mood and behavior in inmates. Utilizing Adult Learning Theory, the author collected results indicating that orientation to learning, which is one 15

aspect along which adult learning differs from children, can produce mixed results in inmates (Alewine, 2010). For example, inmates in both the treatment and control groups reflected no difference in conduct according to teacher evaluations of negative behavior; however, orientation did demonstrate usefulness in the actual conduct of students according to analysis of the electronic student record, contributing to improvement of classroom ethos. Adult Learning Theory has also been employed extensively in adult training related to medicine. Waxmans (2010) research suggested that a significant step in redesigning nursing education entailed the development of evidence-based clinical simulation scenarios. This idea aligned with the notion that learners are motivated by the need to solve realistic problems (Holton et al., 2005). The researcher found that it was useful for students to learn in safe settings that mimicked real-life situations in medical practice. Clearly, Waxman emphasized the experience aspect of Adult Learning Theory in his research. Bonney, Jones, Phillipson, and Iverson (2010) researched patient responses, as they were concerned for the willingness of older adults to consult general practice registrars. The results of their study reflected the need for training practices for registrars that would encourage patients to interact consistently with them, as they would be better prepared to assist having participated in training sessions. The researchers concluded that adult learning theory models, where the registrars could solve practical real-life problems, would be valuable to clinical practice. Further research highlighting simulation-enhanced education in health care curricula was also assessed, with consideration for adult learning theory, to promote clinical competence. Ultimately, the simulation-enhanced learning environment was accepted as an endeavor that allows for fostering adult learning theories through the support of independent learning (Gropper et al., 2010).

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The aforementioned research studies illuminate the strength of Adult Learning Theory, which primarily consist of how its core principles are applicable to all adult learning situations. However, limitations and disapproval of the theory persist. For instance, Adult Learning Theory has been criticized for its lack of focus on the discussion of the relationship of adult education to society. Furthermore, its sole emphasis on the individual is deemed a weakness. The sets of goals and purposes for different educators are also not considered by the theory generating additional disapproval of the theory (Holton et al., 2005). Despite these controversies, the foundation of Adult Learning Theory is solid and useful in various fields. Alignment of Adult Learning Theory Adult Learning Theory was appropriate for this research because this study deals with adults with mental disabilities learning how to obtain and maintain competitive community employment. Research on Adult Learning Theory suggests that instructors should adopt a role of facilitator rather than lecturer (Knowles, 1984). This approach will help adults with bipolar disorder become active participants in learning independent living skills that will help them maintain employment and become productive members of the society. Methodological Literature Specific to the Topic Different studies have utilized various methodologies in studying mental illness and supported employment. Both qualitative and quantitative approaches have been used to research the extent in which supported employment or employment in general contribute to the management of bipolar disorders. In addition, some studies have also used mixed methodologies to empirically study this topic area. Jones (2005) utilized a qualitative approach to explore the perspectives of people with bipolar disorder and investigated how employment can change their experiences of their illness. 17

A total number of 11 adults consisting of 8 men and 3 women diagnosed with bipolar disorder participated in this study (Jones, 2005). The result of the study indicated a complex interaction between bipolar disorder and work functioning. Bipolar disorder was shown to influence individuals experiences at work in detrimental ways (Jones, 2005). A meta-analytic study investigated how people with severe mental illness benefited from evidence-based supported employment. Four randomized controlled trials of individual placement support model of supported employment were analyzed to determine the magnitude of effects for clients utilizing individual placement and support model of supported employment. The result revealed that individual placement and support model produced competitive employment outcomes for people with severe mental illness (Campbell, Bond, & Drake, 2009). A ten-year follow up study of supported employment investigated the extent to which supported employment contributed in the employment outcome of people with mental illness (Salyers et al., 2004). The participants consisted of 36 clients who were currently enrolled in a supported employment program. After ten years, clients who graduated from the supported employment program were interviewed about their employment history and working affected their day-to-day lives (Salyers et al., 2004). The result in this longitudinal study revealed that clients reported that employment provided hope, increased self-esteem and more (Salyers et al., 2004). A survey research compared the perspectives of both unemployed and employed people with mental health disorders about factors influencing employment (Wu, Su, Lin, Chueh, & Su, 2009). These factors consist of environmental factors, psychiatric symptoms, ability, and work habits. Out of questionnaires distributed to 200 both employed and unemployed clients, 110 employed clients returned answers and 131 unemployed clients returned answered questionnaires 18

(Wu et al., 2009). Findings revealed that the unemployed client reported that environmental factors influence employment, while employed clients view psychiatric symptoms as the factors influencing employment (Wu et al., 2009). However, both groups unanimously agreed that employment contribute to economic self-sufficiency and psychological well-being (Wu et al., 2009). In a study titled, Work is the Best Medicine I Can Have, Gowdy (2000) utilized a mixed methodology to explore a best practice for assisting individuals with mental disabilities attain employment. The study compared two groups: five programs with high rates of clients in competitive employment and four with lower rates (Gowdy, 2000). The study utilized field visits, interviews, and surveys to gather information from both clients and administrators. Findings suggested that case managers and supported employment staff contributed immensely to clients maintaining competitive community employment (Gowdy, 2000). Studying people with mental illness and supported employment through different methodologies has been shown to be effective in previous research. Nonetheless, this researcher will utilize qualitative method because it gathers information from the direct experiences of participants involved in the study (Leedy & Ormrod, 2005). The rationale for utilizing this qualitative approach and phenomenological specifically is because phenomenological study basically focuses on individual experiences (Leedy & Ormrod, 2005). Brentano, the father of phenomenology viewed experience as the best teacher (Brentano, 1973). Any qualitative researcher will enter the research setting with open mind to interact with the participants (Descarte, 1977; Moustakas, 1994). The qualitative researcher is the instrument because data collection is based on the researchers involvement via observations and interviews (Leedy, & Ormrod, 2005; Moustakas, 1994). 19

Review of Research Literature Mental Illness Mental illness is a behavioral pattern connected with disability that happens in an individual (Bond, Xie, & Drake, 2007). This behavioral pattern does not consist of regular development or a culture of a certain society (Heinimaa, 2002; Egeland et al., 1983). People in different cultures might find certain behavior bizarre, while other cultures find the same behavior normal (Heinimaa, 2002). Therefore, the behavioral pattern must be judged based on the culture to which the individual belongs. Consequently, the definition of mental illness varies in different cultures and has changed over time, but mental illness has remained a social issue in many societies. Ancient civilization defined and treated mental illnesses years ago. The Greeks pioneered the humorism theory and coined terms like hysteria, melancholy, and so on (Angst & Sellaro, 2000). Africa, Persia, Arabia and others developed several traditional treatments for mental disorders. As a matter of fact, the first psychiatric hospitals were built in the medieval Islamic world during the 8th century (Angst & Sellaro, 2000). In the Middle Ages, the term madness emerged and many individuals with mental illness were victims of witch-hunts in the Christian Europe (Pichot, 1988). Patients were locked in madhouses, workhouses and sometimes even in jails (Pichot, 1988). Enlightenment at the end of the 17th century introduced the concept that mental illness was an organic physical phenomenon (Pichot, 1988). In this century, people slowly ceased connecting mental illness to the soul. The 18th and 19th centuries brought moral treatments, numerous classifications and the beginning of psychiatry. Consequently, this century brought a decrease to the harsh treatments in the asylum. The 19th century brought forth population 20

growth. Consequently, the population growth led to the development of many more asylums in most Western countries. The 20th century introduced Freud and psychoanalysis. This century replaced the term mad man/woman to patients and the term Asylum to psychiatric hospital (Pichot, 1988, Rosenthal, 2008). Genetics and environmental factors as well as the interplay between them plays a huge role in the epidemiology of mental illness (Ortiz, & Alda, 2010; Steinkuller, & Rheineck, 2009). One theory is that an imbalance of brain chemicals causes this disease called mental illness (Bond et al., 2007). In the United States, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) originated by American Psychiatric Association (APA) is used to classify mental disorders (Akiskal & Benazzi, 2006). Licensed mental health professionals or clinical psychologists make diagnoses utilizing the DSM-IV-TR criteria, direct observation and results of interviews during evaluations and assessments (Ortiz, & Alda, 2010; Steinkuller, & Rheineck, 2009). The two major treatment options are psychiatric medications and/or psychotherapy (Ortiz, & Alda, 2010; Parikh, LeBlanc, & Ovanessian, 2010). However, self-help, peer support and social interventions are other helpful means used in managing mental illness (Ortiz, & Alda, 2010). Bipolar Disorder Bipolar disorder is one of the classified mental disorders (Akiskal & Benazzi, 2006; Coryell et al., 2009; Galanter et al., 2009). According to the DSM-IV-TR, diagnosis of Bipolar 1 disorder requires one mixed episode or manic episode as well as major depression or hypomania episodes (APA, 1994). Bipolar II does require at least one episode of major depression and hypomania but no mixed or manic episodes (APA, 2000). However, it is important to mention that co-morbidity is common when it comes to psychiatric diagnoses since the same individual 21

can receive a diagnosis in more than one category of mental disorder (Sachs, Baldassano, Truman, Guille, 2000). In psychiatry, co-morbidity is when one or more disorders exist simultaneously with the primary diagnosis (Valderas, Starfield, Sibbald, Salisbury, Roland, 2009). Bipolar disorder is a category of mood disorders dealing with the presence of manic episodes or depressive episodes or sometimes both known as mixed episodes (Lam, Wright & Smith, 2004; Tijssen et al., 2010). Normally, depression and mania alternate rapidly and sometimes are separated by periods of normal mood (Akiskal, 1977; Lam, Wright & Smith, 2004). Bipolar disorder is divided into Bipolar I, Bipolar II, and cyclothymia, depending on the severity of mood episodes being experienced (Angst, 1978; Dunner et al., 1976; Angst & Sellaro, 2000; Yeap, Kelly, Reilly, Thakore, & Foxe, 2009). The symptoms of bipolar vary, but it mostly includes elevated manic/hypomanic and/or depressed moods (APA, 1994). In the mania phase, clients may experience increased energy, insomnia, pressured speech, racing thoughts, impaired judgment, increase of sexual drive, delusion, anxiety and aggressive behavior (Kessler, Chiu, Demler, Merikangas, Walters, 2005). In depressive phase, clients may experience guilt, isolation, anger, apathy, sadness, lack of motivation, hopelessness and in some cases, suicidal ideations (Kessler et al., 2005). Although, there are environmental factors in the epidemiology of bipolar disorder, genetic factors contribute immensely in the development of bipolar disorder (Lam et al., 2004). Twin studies have indicated genetic and environmental contributions in the development of bipolar disorder (Kieseppa et al., 2004). It is believed that bipolar disorder has organic roots, but genetic studies also depicted chromosomal regions and candidate genes appearing to relate to the epidemiology of bipolar disorder (Kato, 2007). Over five million individuals in America are diagnosed with bipolar disorder (Kessler et al., 2005). 22

Mood stabilizer medications, psychotherapy and other social intervention contribute to the treatment and management of bipolar disorder (Steinkuller & Rhineck, 2009; Parikh, LeBlanc, & Ovanessian, 2010). One essential social intervention is employment (Ackerman, & McReynolds, 2005). People with bipolar disorder are associated with the highest rates in maintaining employment (Jones, 2005). Employment does not only help minimize the psychiatric symptoms, but also helps increase self-esteem/self worth as well as in the management of mental illness (Kukla & Bond, 2009; Ackerman, & McReynolds, 2005). In addition, employment generates incomes which help alleviate financial burdens, which is one of the huge barriers faced by people with mental illness (Tse & Walsh, 2006). Economic Hardship and Bipolar Disorder Although people with bipolar disorder can work, sometimes, symptoms of bipolar can interfere with their ability to maintain employment. However, unemployment and underemployment continue to be serious problems faced by people with mental illness (Wong et al., 2008; Bond et al., 2007). With unemployment, underemployment, and manic or depressive symptoms, people with bipolar disorder suffer financial/economic problems (Wong et al., 2008). There are also insurance and family/caregiver burden (Woods, 2000). In addition, some of the clients do not qualify for social security benefits and those who qualify do not receive enough money to sustain their daily needs (Bond et al., 2007). Consequently, they are left to obtain at least a part-time job to supplement their income. Employment is essential for people with bipolar disorder because it not only increases their self worth but also alleviates economic hardship (Whitley, Kostick, & Bush, 2009; Wong et al., 2008; Ackerman, & McReynolds, 2005).

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Bipolar Disorder and Social Security Disability Benefits The Social Security Disability Insurance (SSDI) and Supplementary Security Income (SSI) are Federal programs providing assistance to Americans with different disabilities (Bond et al., 2007). People with bipolar disorder are protected under the Americans with Disabilities Act (ADA) to receive social security disability assistance as well as supplementary security income (Bond et al., 2007). However, for one to qualify for SSDI, the person must have earned enough credits based on taxable work in the past. While SSI is through general tax revenue, a person with a disability still has to meet certain criteria to qualify in order to start receiving these benefits (Bond et al., 2007). Other issues surrounding the denial and appeal process are changes of addresses and non compliance with psychiatric treatment. These issues can substantially affect their application status. In addition, a monthly payment varies for those who qualify. Not everyone is able to sustain themselves with the amount of money that they receive monthly. Consequently, part-time employment is important to be able to add to the fixed income from SSDI and/or SSI. Scott, Borenstein, and Meara (2009), indicated that employment was more effective that refining SSDI/SSI eligibility rules. Besides, employment helps in the recovery of people with mental illness by enhancing income and quality of life (Bush et al., 2009). Additionally, policy makers are prioritizing employment among people with severe mental illness due to the rising economic and social costs (Harvey et al., 2009; Bond et al., 2007).

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What is Employment? Employment can be defined as a contract between two or more parties (Malcolmson, 1999; Green & Kahn, 1983). Employees are in the service of employer(s) by contract of hire, written or verbally stated (Green & Kahn, 1983). The employer(s) offer job duties and wages by the guidelines of Federal regulations (Kreider & Pepper, 2007). In addition, employers are not supposed to discriminate based on gender, race, ethnicity or disabilities. Employment is the heartbeat of the American economy and it provides status and social role (Goodwin & Kennedy, 2005). Employment is a source of income, which could benefit people with bipolar disorder in a number of ways (Kukla & Bond, 2009; Tse & Walsh, 2006). Employment is motivating and empowers individuals (Jones, 2005). Paid employment is a high priority for people with mental illness and people with bipolar disorder have a strong desire to maintain employment, even though employment rates are relatively low for this population (Jones, 2005; Michalak, Yatham, Maxwell, Hale & Lam, 2007). Employment can improve psychological well-being and economic self-sufficiency (Wu et al., 2009; Dickerson, et al, 2004). Employment and Mental Health Stigma Working alliances between clients and vocational rehabilitation counselors lead to positive future work expectancies (Kukla & Bond, 2009). However, evidence indicates that different factors such as cognitive impairment or psychotic symptoms related to mental illness interfere with work (Mueser et al., 2004). Nonetheless, clients with mental illness who return to work experience life satisfaction (Arns & Linney, 1993). Supported employment is one of the vocational programs, which tries to assist clients with work readiness skills before being placed in work settings. Supported employment also provides maintenance support to the clients while gainfully employed. In addition, supported employment endeavors to protect clients from mental 25

health stigma in the work world (Corrigan & McCracken, 2005). One study exposed the barrier to employment, which includes societal stigma, attitudes of professionals, employers, and social insurance programs (Rogers, Walsh, Masotta & Danley, 1991). Another study also showed that adults with psychiatric disabilities are unable to obtain work due to stigma and discrimination (Link & Phelan, 2001). Attributions about mental illness yield more fear because of perceived danger when compared with physical health condition (Corrigan, Larson & Kuwabara, 2007). In other words, if mental health stigma is not effectively addressed, then it might undermine supported employment in some ways. For example, beliefs about the dangerousness of people with mental illness may affect attitudes about supported employment (Corrigan et al., 2007). In addition, if mental health stigma is not proactively addressed in supported employment programs, then clients might not be able to handle the stigma and discrimination experienced at the workplace and their reactions, in turn, might cost them their jobs. Therefore, supported employment programs should be enhanced by including stigma change strategies targeting employers (Corrigan et al., 2007). It is hard to ignore the prevalence of disability in the Unites States and the discrimination experienced by persons with disabilities in the workplace (OKeeffe, 1993; Bond et al., 2007). In many jobs, the term disability brings to mind a picture of a person in a wheel chair or a time bomb in the case of mental disability. This shows how people view mental illness in the workplace and how they continue to fuel the stigma and stereotype associated with mental illness. The impact of stigma is a huge barrier to recovery (Pinfold & Borneo, 2007). Stigma insinuates itself into policy decisions, access to care, research allocation, health insurance and employment discriminations (Jamison, 2006). People with mental illness are often are recognized or stigmatized as strangers who are not allowed to find an adequate place in society 26

(Bauman, 2007). Just because someone is mentally ill does not necessarily mean they are stupid or incapable of working. Employees with mental illness conceal their illness due to stigmatization and this further increase their symptoms. Recent research has shown that individuals who concealed their illness faced considerable stressors and psychological challenges (Pachankis, 2007). On the other hand, another study also showed that knowledge and use of ADA provisions contributed positively in the lives of working adult with schizophrenia (Gioia & Brekke, 2003). However, 10 years after the ADA became law, there is evidence that stereotyping and discriminations still persist (Gouvier, Mayville, & Sytsma-Jordan, 2003; Bond et al., 2007). Although employees with disability are generally treated unfairly at work, they respond with a better work attitude, are more productive, and have lower absenteeism, turnover and accidental rates than non-disable employees (Berry & Meyer, 1995). Stigma and discrimination add to the already difficult psychiatric symptoms these individuals endure (Stuart, 2006). Some people still believe that individuals with mental illness cannot recover and are violent; despite national studies that reveals that severe mental illness independently cannot predict future violent behavior (Elbogen & Johnson, 2009). Moreover, these types of stereotypes result in employment discrimination (Stuart, 2006). Sometimes, the media helps perpetuate negative stereotypes of individuals with mental disorders (Sieff, 2003). Mueser et al. (2004) explored the relationship between the working alliance and employment outcomes in individuals with severe mental illness who are receiving vocational services. It validates that people with severe mental illness have problems obtaining and maintaining employment. Unemployment is common among individuals suffering from all kinds of mental illnesses. Studies have reported lower rates of employment among individuals 27

suffering from mental illnesses (Anthony & Blanch, 1987; Bond et al., 2007). Corrigan et al. (2007) revealed that having mental illness could be a barrier to obtaining important life goals, especially employment. Therefore, different vocational rehabilitation programs have been created to address this barrier. However, there have been different vocational approaches, including job readiness programs developed to assist this population in the area of vocational functioning (Bond et al., 2001). Bipolar Disorder and Significance of Supported Employment Supported employment has been recognized as an evidence-based practice for people with mental disorder (Campbell, Bond, & Drake, 2009). Supported employment program involves individualized assistance in helping the client obtain competitive work and provide ongoing support in maintaining employment (Mueser, et al., 2004). The clients receives full range of vocational services, which includes engagement in services, identifying job interest, job search and support (Mueser, et al., 2004). Furthermore, supported employment has also yielded higher competitive employment rates than other vocational programs (Bond, Drake, Mueser, & Becker, 1997; Crowther, Marshall, Bond, & Huxley, 2001; Campbell, Bond, & Drake, 2009). One study shares the importance of assisting the clients to obtain competitive job placement in the community through education on skill training in job interviewing, on-site job coaching and development of job suited for each client (McFarlane et al., 2000). Another study compared two community mental health centers and discovered that a combination of multifamily group treatment, assertive community training and supported employment could achieve higher levels of competitive employment compared to conventional vocational rehabilitation (McFarlane et al., 2000; Wong et al., 2008). Mental health and policy makers focus on the primary goal of meeting the vocational needs of adults with mental illness (Danley, Rogers, McDonald-Wilson & 28

Anthony, 1994; Bond & Drake, 2008). Supported employment has proved to be beneficial to people with severe mental illness in regards to cognitive functioning and competitive employment (McGurk, Mueser, & Pascaris, 2005; Drake & Bond, 2008). Supported employment is the number one approach for reaching clients vocational need because it includes, job coaching, job placement, monitoring and follow-up (Wehman & Kregel, 1985; Becker, Whitley, Bailey, & Drake, 2007). Additionally, research studies have indicated that supported employment is more successful in assisting people with mental illness obtain competitive jobs than other approaches (Salyers, Becker, Drake, Torrey, & Wyzik, 2004; Wong et al., 2008; Campbell, Bond, & Drake, 2009). Role of Supportive Employment Facilitators and Mental health Professionals Tse and Yeats (2002) used a qualitative research design to unfold factors that could help people with bipolar disorder succeed in employment. The study indicated the importance of sense of hope and determination because it helped succeed in employment (Tse & Yeats, 2002). The findings were validated by the method of triangulation of data interpretation and sources (Tse & Yeats, 2002). Therefore, it is reasonable that mental health professionals should utilize these findings to assist clients in obtaining and maintaining employment. Mental health workers should work with other professionals under the umbrella of the human service profession. However, in the case of mental illness and supported employment, mental health workers and some employers find one another in disagreement. Social workers believe clients should be able to be given the same opportunity to obtain employment just as others in the community, while in contrast, some employers continue to discriminate against people with mental illness (McQuilken et al., 2003). Nonetheless, it is essential that human

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service professionals work towards effective solutions to this problem through mutual trust and acceptance (Stringer, 2007). Review of the Critical Literature On the upside, although the employment rate among people with severe mental illness remains over 90%, work remains an important goal for many people with bipolar disorder (Howard, et al., 2010). Study findings have demonstrated that supported employment participants had more positive working alliance than others in a traditional vocational program (Kukla & Bond, 2009; Salyers et al., 2004). Although, one study required clients to be clinically stable before entering the workforce, it also indicated that employment leads to higher selfesteem and better quality of life for individuals with mental illness (Bond, Drake, Mueser, & Becker, 1997; Wong et al., 2008). In addition, employment also help clients in non vocational areas such increasing self-esteem and socialization skills, symptom management and improving quality of life (Corrigan et al., 2007). Concisely, work can be very therapeutic (Black, 1988; Gowdy, 2000). Furthermore, studies show that stable employment promoted recovery for individuals suffering with mental illness. Stable employment not only improves clients income, but improves their self worth and overall quality of life (Bush et al., 2009). Another study also revealed that supported employment is nearly three times as effective as other employment intervention programs because one-third to three-quarters of the participants in supported employment became steady workers over longer intervals (Bush et al., 2009). It is important to reiterate that working is very essential for people with mental illness. Supported employment participants have more positive alliances than those who never experienced a supported employment program (Kukla & Bond, 2009). One study depicted how 30

working assisted professionals with severe mental illness cope with psychiatric symptoms (Van Dongen, 1996; Kukla & Bond, 2009). Therefore, employment most likely contributes to recovery from mental illness. On the downside, supported employment might not be as effective with immigrant groups like Latinos compared to other ethnic groups in the United States (Mueser, et al., 2004). Latinos have less access to education as well as participation in the labor force (Mueser, et al., 2004). In addition, effects of their mental illness combine with language barriers, discriminations, lack of resources contribute to low education, work rates and poverty (Falicov, 1998). Other immigrant groups also face these same challenges. Although study findings show that supported employment program is effective but the work setting or job position might not be satisfactory (Danley, Rogers, McDonald-Wilson & Anthony, 1994). In other words, there is a difference between training and practice. Supportive employment prepares the clients for work but their experiences at work and their job satisfaction are not considered during job readiness training. Therefore, supported employment should consider all these factors to be able to better assist all clients in obtaining and maintaining community employment. Gaps in Literature Qualitative research may yield an important understanding in the area of mental illness and supported employment but very little literature addresses the supported employment program. Job readiness programs appear frequently in literature but supported employment for individuals with mental disabilities seems to be a new program and very few literatures have addressed this program. Research is a systematic approach to investigate and find effective solutions to problems that confront everyday lives of people with mental disabilities (Stringer, 2007). Therefore, it was necessary to conduct a study on supported employment program and its 31

contribution in managing bipolar disorder. When developing solution to problems, it is important to set priorities for action by identifying major issues and organizing the issues in order of importance (Stringer, 2007). Furthermore, this researcher also addressed ways to reduce or eliminate underemployment and unemployment among people with mental disabilities. Secondly, this research presented supportive employment program as a way of minimizing unemployment among individuals with mental illness. Justification of Methodology and Research Design Qualitative study can come in the form of narrative, case study, phenomenological, ethnographic or generic qualitative inquiry, all of which can work for this particular study. However, phenomenological design is the best design to uncover the truth through the day-today experience of the participants in a supported employment program. The rationale was that phenomenological study is the best way to better understand peoples perspectives, perceptions, and understandings of a particular phenomenon (Leedy & Ormrod, 2005). Summary Most of the study articles used in the literature review utilized both qualitative and quantitative methods to better understand the phenomena being studied. One qualitative study showed that employment positively changes the clients experiences of their mental illness (Jones, 2005). Other qualitative studies depicted how people with severe mental illness benefited from evidenced-based supported employment (Campell, Bond, Drake, 2009; Gowdy, 2000). A longitudinal showed after ten years that graduates from a supported employment program reported benefiting immensely from the program (Salyers et al., 2004).

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Finally, a survey of the research revealed that both the unemployed and employed clients reported that employment contribute to economic self-sufficiency and psychological wellbeing (Wu et al., 2009). The research purpose was to explore how supported employment helps in the management and recovery of bipolar disorder. Like all the studies reviewed, data collection steps included setting the boundaries for the study, collecting information through unstructured observations and interviews, documents, and visual materials, as well as establishing the protocol for recording information (Creswell, 2009). Phenomenological design approach has proven to be the best approach because it examines the lived experiences of human beings (Byrne, 2009). Therefore, phenomenological design was the best design to uncover the truth about the experience of the participants in a supported employment program. The researcher also utilized Adult Learning Theory by Malcolm Knowles to show that learning is a progression that happens throughout a persons life (Conner, 2007; Yukawa, 2010).

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CHAPTER 3: RESEARCH METHODOLOGY Introduction The purpose of the study was to explore how supportive employment helps in the management and recovery of individuals with bipolar disorder. The primary research question: what meaning do adults diagnosed with bipolar disorder attribute to their experiences in a supported employment program was addressed utilizing Adult Learning Theory by Malcolm Knowles. This particular chapter not only depicted research methodology but also provided guidelines for the study. For this study, the researcher considered different qualitative research designs such as the narrative, case study, phenomenological and the ethnographic approaches. However, the phenomenological approach was determined to be best for this study because phenomenology examines the lived experiences of people and depicts how human beings make sense of their thoughts, feelings and perceptions (Moustakas, 1994; Byrne, 2009). The researcher utilized semi-unstructured interviews to obtain the experiences of the participants attending a supported employment program. The participants responses were recorded, documented, transcribed, coded and finally analyzed. The research findings could be applied in developing more supported employment programs to increase the unemployment rate among people with bipolar disorder and assist them in effectively managing their illness. Finally, this chapter showed how the study was conducted, which included, research methods, data collection and analysis, as well as expected findings, ethical issues and limitations.

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Research Questions The main purpose of this study was to obtain the perceptions and experiences of people with bipolar disorder who were engaged in a supported employment program. The primary research question was: What meaning do adults diagnosed with Bipolar Disorder attribute to their experiences in a supported employment program? Corollary Questions: 1. How do adult participants engaged in a supported employment program view unemployment and underemployment? 2. What elements of supported employment program do adult participants perceive as adaptive for their specific work situation? Researchers Philosophy The research philosophy is the belief about the way in which data in a study should be gathered and analyzed (Glatthorn & Joyner, 2005). For the purposes of this study, the researcher is in line with the constructive paradigm. In constructive paradigm, research participants have the opportunity to influence the research process (Glicken, 2003). This is very essential especially during the field test where similar research subjects can develop research questions. Constructive approach is concerned with democratic relationship where the research participants are involved in the research process. Constructive approach is believed to enhance research because the research subjects are involved. Additionally, the accuracy of the findings in the study is most likely high when participants are involved in the research process (Glicken, 2003). In this particular study, clients participating in a supported employment program were interviewed to discover the effectiveness of the program in preparing and securing employment 35

for these clients. Clients were also involved in the study and were provided with transcripts of the findings in the end. Furthermore, every adult has the right to competitive community employment regardless of his or her disability. This study was to show the importance of supported employment among people with a mental health disability. There are several factors that might contribute to unemployment and underemployment among people with bipolar disorder, but supported employment has yielded higher competitive employment rates than other vocational programs (Crowther, Marshall, Bond, & Huxley, 2001; Campbell, Bond, & Drake, 2009). Research Design Guide The study being a qualitative research design began with an assumption and utilized a theoretical framework to explore the meanings that people ascribe to social problems (Creswell, 2007). The qualitative researcher is the key instrument in collecting data from multiple sources through examination, observation, and interview. Qualitative researchers collect data in a natural setting and, through inductive data analysis establish themes (Creswell, 2007). In this study, the researcher conducted the study at a nonprofit rehabilitation program in a large metropolitan area in Texas, where participants were interviewed about their experience of a supported employment program. These participants were selected based on the criteria that they are diagnosed with bipolar disorder, were currently adhering to psychiatric treatment and currently working for over 90 days. This nonprofit rehabilitation program mostly accepts employee referrals from local mental health agencies to make sure the clients are in compliance with psychiatric treatment. These participants were also able to fully read and comprehend an informed consent form before participating in the study and had no guardians. In addition, the participants in this study were high functioning clients who have at least a high school diploma. 36

Some of the participants were from different professional backgrounds and showed a stable work history. Although, these participants are included as a vulnerable population, they are adults who have the right to make their own choices, sign legal biding contracts, vote, sign treatment plans, pay taxes, maintain stable housing and employment, as well as make day-to- day decisions for themselves and their families. Following Creswells research design, qualitative study should be done in a natural setting and the researcher as the key instrument (Creswell, 2007). The researcher utilized Creswells model by collecting data from multiples sources, interviewed participants at the supported employment office, and observed participants working and examined documents. One of the credibility issues is reactivity, or the Hawthorne effect, whereby participants change their behavior because they know they are being studied (Leedy & Ormrod, 2005). In an effort to minimize such a credibility problem, this researcher utilized triangulation which encourages collecting data from multiple sources with the expectation that they will all converge to support a particular theory (Leedy & Ormrod, 2005). In addition, the researcher used member checking to confirm the trustworthiness of the study. A report of emerging themes was provided to study participants to establish if they consider the themes as accurate. With this, validity of the study will be established (Creswell, 2008). The researcher also adhered to Creswells characteristic of qualitative research by focusing on participants meanings, utilizing theoretical lens, emergent design, interpretive inquiry, and by developing a holistic account of the experiences of a supported employment program.

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Research Design Strategy Qualitative research strategy was utilized because the study was conducted in a natural setting. In addition, qualitative research strategy focuses on the perceptions and perspectives of the participants being studied (Leedy & Ormord, 2005). There are different types of qualitative designs, which include case study, ethnography, phenomenological study, grounded study and content analysis (Leedy & Ormord, 2005). Several of these methods were examined and rejected. Because utilizing the narrative approach in qualitative methods often focuses on a single participant, it was not the chosen approach because this study focused on the rich description of several persons. Moreover, the fact that there were several possible candidates for this study within this learners bounded system deems the case study approach as a weaker choice when compared to other approaches. The participants in this study also varied in culture, race, and gender. Although suffering from the same illness, each participant were worthy of study thus making it challenging to employ case study. Creswell (2009) asserts that the overall analysis is diluted when more than one case is studied. The threat of less profundity is high if this researcher utilizes case study for this research. The strength of the case study approach, however, would be this researchers ability to obtain history, chronology of events, and day-by-day information of the case. The case study approach will provide the researcher with the opportunity to interview the workers at the supported employment program. In this study, the researcher could trace responses, complexities, and common themes within the case. However, when a single case is involved as it is often with case studies, findings are very difficult to be generalized to other situations (Leedy & Ormorod, 2005).

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Although, ethnography is also concerned with the lived experiences of people, it however, looks at an entire group; most specifically a group that shares a common culture in depth (Leedy & Ormrod, 2005). Though this area of study could be explored by ethnography, but ethnography is best represented when researcher study particular groups, such as, African Americans, women, Hispanics, Whites, and/or other groups. This is due to the fact that ethnography focuses on entire cultural systems or some subcultures of systems (Creswell, 2007). For example, in the case of mental health, one particular group could be studied to understand their view about a supported employment program. In addition, ethnography is concerned with the behavior, beliefs and customs of a particular culture (Leedy & Ormrod, 2005). This requires the researcher to, like phenomenology, use interviews, observational protocols and storage system(s) for organized retrieval information (Creswell, 2007). Furthermore, like phenomenology, ethnography requires the ethical responsibility of making research goals clear, learning whether or not participants want to be named in the written report of the research, and assuring safety of those involved (Genzuk, 2003). After analyzing other approaches and the historical significance of phenomenology, this researcher chose Moustakas' type of phenomenological research design for this study. It was obvious that the phenomenological design approach was the best approach for this study because it examines the lived experiences of human beings (Byrne, 2009). In an effort to understand and give meaning to bipolar disorder and employment, phenomenological design was the most appropriate design to uncover the truth through an exploration of the day-to-day experience of the participants in a supported employment program. The rationale was that phenomenological study is the best way to better understand peoples perspectives, perceptions, and understandings of situations that affect their lives (Leedy & Ormrod, 2005). Studying the experiences of these 39

participants in a supported employment program through conducting unstructured interviews enabled the researcher to gain insight into the phenomenon under investigation (Leedy & Ormrod, 2005). Moustakas describes how phenomenology can be applied to human science research. He asserts that phenomenology focuses on how things appear to be in the natural world of everyday living (Moustakas, 1994). Moustakass view of phenomenology includes wholeness, investigating entities from different sides and perspectives until a unified understanding of the experienced is attained. Description, not explanation of the experiences of a supported employment, is essential to fulfill the real purpose of phenomenology (Moustakas, 1994). In phenomenology, the research question must guide the investigation carefully and the researcher should be connected with the phenomenon (Moustakas, 1994). Phenomenological approach allowed the researcher to explore the perceptions of people with bipolar disorder about a supported employment program. Additionally, phenomenological approach also allowed the use of purposeful sampling, which aided in studying these participants for a particular purpose (Leedy & Ormrod, 2005). The researcher obtained the experiences of fourteen individuals with bipolar disorder. The participants were selected only if they were diagnosed with bipolar disorder and were in compliance with psychiatric treatment. Moreover, these individuals were actively employed and working at the study site for over 90 days. As stated earlier, the researcher selected intentionally only high functioning research participants who lives and works independently.

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Target Population and Participant Selection Sampling Procedures Purposive sampling was used to inquire information such as opinions, attitudes, or previous experiences of one or more groups of people. In purposive sampling, participants are chosen for a particular reason (Leedy & Ormrod, 2005). In this case, participants were chosen because they all were clients in a supported employment program and all of them were diagnosed with bipolar disorder. Fourteen participants were selected in a first come-first serve order. In-depth and semi unstructured face-to-face formal interviews were utilized to obtain information from these participants. Some of the participants were eliminated based on their status of employment, compliance with psychiatric treatment and functioning level. Participants who appeared to be cognitively or decisionally impaired were not included in this study. In continuation, the standard to be considered for the study was that participants had to be diagnosed with bipolar disorder, be currently in compliance with psychiatric treatment and had participated in a supported employment program for at least 90 days. Participants also had to reside in the city the study was conducted. Demographic information, such as age, gender, and ethnicity, varied since people from different demographics participate in a supported employment programs. Assessment & Exclusionary Criteria The study site mostly accepts employee referrals from local mental health agencies to make sure that the clients are in compliance with psychiatric treatment and functioning on a high level by being able to live and work independently in the community. They also satisfies the contract with the City by verifying that all the clients in the supported employment program are stable, currently in-compliance with psychiatric treatment and taking medications as prescribed. 41

Individuals with mental illness who are under psychiatric treatment are deemed to be very functional in most aspects of their lives just like those with no mental condition (Steinkuller & Rhineck, 2009; Parikh, LeBlanc, & Ovanessian, 2010). Additionally, the researcher assessed participants and took precautions of verifying that the participants were in compliance with psychiatric treatment and appeared stable. Participants who appeared to be cognitively or decisionally impaired could not be included in the study. The participants were required to be functional in all other areas of their lives, be competent and stable enough to the point where they should not be at a more than minimal risk or they would be excluded in the study. These participants were also able to fully read and comprehend an informed consent form before participating in the study. Participants who were not independent or have guardians were excluded from the study. Although this population is considered a vulnerable population, this study was classified a minimal risk because these participants were not exposed to any harm or discomfort in the research greater than that in which they already experienced in their daily lives. Besides, participants were only required to answer questions regarding employment and how it helped in managing their mental illness. Finally, the collection of sensitive information required that client show proof of bipolar disorder and compliance with psychiatric care. Co-morbidity is common when it comes to psychiatric diagnoses since the same individuals can receive a diagnosis in more than one category of mental disorder (Sachs, Baldassano, Truman, & Guille, 2000). However, only participants who had primary diagnosis of bipolar disorder were eligible to participate in this study. The researcher did not collect any sensitive documents, but the participants were required to answer questions regarding their mental health diagnosis as well as their history of mental illness and how supportive employment helped in managing their illness. 42

Setting Qualitative researchers collect data in the field at the site where participants experience the phenomena under investigation (Moustakas, 1994). The researcher met face to face with adults diagnosed with bipolar disorder in a natural setting. The interviews were conducted in an area conducive for both the participants and the researcher. This location area was at the site where the participants experience the supported employment program, which was a natural setting. The study site where the participants are provided with supported employment services designated a secure room for the interviewing to maintain confidentiality.

Measures In qualitative study, the researcher is the instrument. Therefore day-to-day experiences would be measured by utilizing open-ended questions, which reflect feedback from field test. Those questions include: (1) (2) (3) (4) (5) (6) How do you define supported employment program? What elements of supported employment program have been particularly helpful to you? Describe how supportive employment program assist in your overall work experience? Describe specific accommodations made on behalf of participants of supported employment program? Describe things you have learned from participating in the supported employment program? If you could facilitate a supported employment program, what would you do differently?

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It was anticipated that meaningful themes would be created as the participants statements and answers are grouped together (Leedy & Ormrod, 2005). A description of what was experienced, how it happened, and the combination of both, the what and how of the phenomenon, came together to give meaning to bipolar disorder and supported employment. Validity and Reliability Validity is the extent to which the instrument measures what is supposed to measure and reliability is the consistency in which the measuring instrument yields a certain result when whats being measured stays the same (Leedy & Ormrod, 2005). In this study, the threat to validity was potential researchers bias because the researcher is a mental health advocate. However, the internal validity was addressed when participants validated the researchers interpretation of their experiences. Furthermore, utilizing thick descriptions helped in drawing conclusion about transferability (Creswell, 2007). As stated earlier, reliability deals with obtaining the same result utilizing the same instrument. Therefore, in order to minimize reliability concerns, the researcher utilized a research practice called member-checking, by providing emerging themes reports to participants to verify if they are accurate (Creswell, 2008). This process known as member checking helped to confirm the trustworthiness and authenticity of the study. Data Collection Procedures In qualitative studies utilizing phenomenological approaches, the data collection process mainly consists of in-depth interviews (Creswell, 2007). The researcher first conducted a field test with experts who have experience in providing employment with individuals diagnosed with bipolar disorder. After the feedback from the field test was integrated into the interview protocol, 44

the researcher sought study sites approval. When site approval was granted, the researcher sought Capella Universitys Institutional Review Board (IRB) approval to conduct the study at the study site. After receiving final approval from Capella Universitys Institutional Review Board (IRB), the researcher met with potential participants during team meeting at the study site to inform them about the study. A team meeting at the study site normally consists of all the clients reporting at the break room every work day to be assigned their job duties for the day. If the weather will affect clients taking certain medications, those particular clients will be sent home for the day or assigned to work indoors. Furthermore, the researcher provided the recruitment handouts, and thoroughly explained the purpose of the study. The recruitment handout contained the researchers contact information so that interested participants will be able contact the researcher. Interested and qualified participants contacted the researcher and were scheduled for a face to face semi-unstructured interviews at a private office located in the study site. The interviews asked the questions listed on the interview guide and the researcher audio taped each session. Fourteen participants were interview in this study in an effort to better understand the perspectives of people diagnosed with bipolar disorder and their experiences in a supported employment program. The participants were evaluated based on questions such as what supported employment means, how it affects their lives and how these two issues (supported employment program and bipolar disorder) combined together affect their relationships with others and their overall human existence. The researcher also listened closely for subtle yet meaningful cues in participants expressions, questions, and occasional sidetracks (Leedy & Ormrod, 2005). 45

Initial Contact & Recruitment Handout Again, upon receiving approval from the Institutional Review Board, the researcher went to speak to the clients at the study site during team meeting. The researcher informed them about the study purpose and requirements, participants eligibility and means of contacting the researcher. A team meeting at the study site normally consists of all the clients reporting at the break room every work day to be assigned their job duties for the day. The researcher provided informed consent forms to all participants but only actual participants later signed the form before participating in the study. Furthermore, a recruitment handout with researchers telephone number and Capella email address were distributed to all potential participants. The recruitment handout also provided the participants with information about the study, school, researcher, research procedures, injury, informed consent and information about study findings and how the researcher will protect and discard data after the study. A blank sheet of paper and an empty envelope were handed out to all the potential participants. All participants were required to return the blank sheet of paper placed inside an envelope, but participants who are interested in participating in the study were instructed to write their names and the contact information where the researcher would be able to reach them. This served as a way to protect the confidentiality of participants who will be willing to participate in the study. Only the researcher opened the envelope to view the names and contact information of the interested participants. All the participants were allowed to take the recruitment handout with them, so that participants who might need time to think about participating in the study were able to contact

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researcher by a certain date. This was also to assure that the interested participants only disclosed their interest to the researcher. The interviews took in a private office at the job site of the participants. All interviews among the fourteen participants were recorded with two different audio recording machines. Furthermore, it is important to remember trust is one of the cornerstones in any professional relationship (Sommers-Flanagan & Sommers-Flanagan, 2007). In this study, the researcher safeguarded the information by developing trust, guarding against misconduct and conveying the purpose of the study with the participants (Creswell, 2009). Although trust, boundaries and confidentiality are interconnected, trust should dominate ethical decision making as trust ensures a higher probability of maintaining professional boundaries and confidentiality. In addition if trust is established, then participants are compelled to open up to the researcher with the assurance that the researcher would not divulge any information provided in the study and would not take advantage of their weaknesses or problems (Sommers-Flanagan & SommersFlanagan, 2007). Field Testing For the required study field test, the researcher recruited four individuals with expertise in providing employment services to people diagnosed with Bipolar Disorder. Their feedback was important to help validate the research instrument which is the interview guide. These experts consisted of one psychiatrist and three licensed vocational counselors with the Department of Assistive and Rehabilitative Services. The researcher presented the interview questions generated from the literature review to the field test participants with an open mind for modification. The goal was for the field test participants to utilize their expertise in modifying the interview guide to actually capture the phenomenon being studied. 47

Field Test Participants Out of the four field test participants contacted, only three were available for participation in the field test. These participants consisted of an African American male vocational counselor, one Indian female psychiatrists and a Caucasian female vocation/employment specialist. These participants are currently licensed as professionals in their respective fields. Part of their work involved providing employment services to individuals diagnosed with mental illness. These participants agreed during a telephone conversation to meet face-to-face at their individual offices during their lunch break to review the study questions and provide helpful feedback. The first participant was a licensed vocational counselor who has worked in the field of providing employment and vocational services to individuals with mental and physical disabilities for fifteen years. The second participant was a licensed psychiatrist who specializes mainly in working with individuals with severe mental illness. She often referred stable clients to supported employment program and other related vocational services. She has been working in the field of mental health for twenty-two years and has worked with diverse population. The final participant was a certified employment specialist who has been working with people with mental disabilities for ten years. She reported she has also specializes in working with clients who have drugs and alcohol abuse history and are jail recidivists. Field Test Analysis The researcher met face to face individually with the field test participants and presented each of them with the original study questions and interview guide as well as the theory utilized in the study. The participants were not required to answer the study questions but to provide feedback based on their experiences. 48

The first study question stated: Describe the lived experience of adults with Bipolar disorder who are participating in a supported employment program? All the participants stated that the question should be simplified and besides it is not personalized. The psychiatrist suggested the questions should focus solely on supported employment program and not on their illness. Gathering all feedback, the first question was changed to: How do you define supported employment program? The second question asked: How do you feel about receiving supported employment assistance? All stated that the researcher should not assume the participants view supported employment as assistance. So the question was revised to: What elements of supported employment have been particularly helpful to you? The third question asked how does your experience of supported employment affect your experience at work? All the field test participants agreed the question was valid but it could be rephrased to, Describe how supported employment program assist your overall work experience? The fourth question asked participants to Describe specific accommodation made on behalf of participants of supported employment program? There was a general agreement that the fourth question did not need to be revised. The fifth question asked Is there anything else about your experience of supported employment you like to share? All participants observed that the question should be modified to reflect adult learning theory. The question was rephrased to Describe things you have learned from participating in a supported employment program? All the participants thought it would be essential to add a question that revealed what the participants would do differently if given the

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opportunity to facilitate a supported employment program. The last added question states If you could facilitate a supported employment program, what would you do differently? All the participants provided extensive feedback. They made comments about how supported employment programs have been helpful to the clients and suggested that the study could be important to be able to see supported employment programs from the eyes of the participants. They also cautioned about not bringing up the mental condition of the participants during the interview and to avoid making any religious comments as well. They suggested that the researcher to maintain eye contact and speak in a mild tone. They also instructed the researcher to be mindful of body language during the interview and to ask the questions as stated so it will be simple enough for the clients to understand. They all showed interest about the study findings and requested that the researcher share findings and inform them when they study is published. Researchers Role and Participation The researcher was the only person who conducted a face-to-face study with the participants. The researcher utilizes an interview guide and audio record the entire interview process to ensure that the data gathered were accurately analyzed. The researcher was the primary instrument and remained objective to reduce researcher bias. The researcher was responsible for the participants in the study. Researchers Credibility and Qualifications The qualification of a researcher will render credibility to the study. The researcher has worked actively in the mental health profession for ten years. The researcher has worked as a supported employment specialist, rehabilitation specialist, and housing specialist. Currently the 50

researcher is working as a recidivist rehabilitation clinician in a crisis program at a local mental health clinic. Furthermore, the researcher obtained his bachelors degree in psychology and masters degree in human services. The researcher understands the importance of active listening, which is essential during the interviewing process. The researcher credibility lies in the ability to effectively listen, from day-to-day, to the needs and overall desires of clients who are mentally challenged. The researcher can also understand when a client is in crisis or not thinking clearly and can recognize if the client responses are based on reality. Finally, the researcher continues to works closely with individuals with mental illnesses and has observed first hand the need for supported employment programs. All of these experiences have contributed to the quest to conduct a study in the area of supported employment. Limitation of the Research Design The main limitation of the qualitative design was that during interview, people might change behavior and answers due to Hawthorne effect (Leedy & Ormrod, 2005). Since phenomenological study heavily relies on the perspectives of the participants, the validity of the study might be compromised if answers and behaviors are altered. Another limitation was that the researcher was the sole instrument for data collection and analysis. Interpretation of the results depended heavily on the objectivity of the researcher so that that study findings were not presented through the prism of the researchers beliefs, culture or worldview. In contrast, quantitative research suggests that researchers views are limited since results are statistically precise (Creswell, 2008). 51

Data Analysis Procedures In qualitative studies, data collected are reduced into themes through a process of coding and condensing codes. Finally, data are usually represented in figures, tables, or a discussion (Creswell, 2007). Once the researcher finished collecting data, the researcher manually transcribed participants responses into text. The researcher utilized ATLAS.ti Qualitative Data Analysis Software for organizing text and coding. The study data was analyzed utilizing ATLAS.ti Qualitative Data Analysis Software. The software provided systemic means to manage data and helped the researcher discover emerging themes (Atlas.ti, GmbH Berlin, 2010). ATLAS.ti is a window-based program that enables the researcher in organizing texts, audio as well as with coding, memos and findings, into a project (Creswell, 2007). Epoche, or bracketing in phenomenological research helps acknowledge bias and groups them, focusing on only participants experiences of the phenomenon under investigation (Moustakas, 1994). Bracketing is essential in a study especially where the researcher is close to the population or phenomenon being studied. This process helps develop objectivity and avoid researchers bias and preconceptions of influencing or tainting the research process. Therefore, this study utilized bracketing to avoid undermining the validity of the study. After bracketing, phenomenological reduction emerges to help discard unrelated or overlapping data, which are clustered into themes resulting in a textural description of the phenomenon (Moustakas, 1994). When utilizing phenomenological method, the researcher should consider the areas of instrumentation, findings representation, participants protection, data protection, and sampling (Moustakas, 1994).

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Presentation of Findings The researcher presented the findings to fit the phenomenological method procedures. These included formulated meanings, discussions and the responses of the participants to reflect the accurate lived experiences of the population studied. The researcher also utilized tables and a flow chart to present important information in the study. Expected Findings Due to a number of limitations, this study was cautiously viewed. The size of the group of participants was relatively small and each participant voluntarily participated in the supportive employment program. The results were prepared based on themes. Common themes evolved from the participants experience of a supported employment. The findings of the study would be added to the existing literature to help improve supported employment programs, not only in Texas, but also across the whole country and the world. Ethical Issues and Considerations Ethical implications lie in the researcher being careful not to place any kind of pressure on participants for information or imposing beliefs on the participants. Again, the researchers values, hopes, expectations, and feelings should be detached from the scientific inquiry (Ponterotto, 2005). An informed consent form was developed for participants to sign before they engage in the research. The purpose of the study was completely explained to all of the participants (Creswell, 2009). The participants were fully informed of their rights and choices. Researchers should reiterate confidentiality and the right of participants to disclose, or not disclose information and/or if they want to withdraw from the study (Herlihy & Corey, 2006).

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In this study, the researcher treated the participants with the utmost respect, according to the law, principles of research ethics and Capella University guidelines and procedures. The researcher communicated to the participants the purpose of the study, discussed any risks involved, and provided assurance of confidentiality. The researcher did not put participants at risk, distress, pressure for information or impose beliefs on the participants. The participants fully understood that they are free to withdraw from the study at any time. The researcher adhered to the methodology outlined in the approved proposal. The researcher did not interview any former or current client who might be participating in the supported employment program. Data Management and Storage Suggested ways that this study can maintain data responsibly are: (1) deciding where to keep the data collected, (2) locating a secured bank deposit box, (3) obtaining a sufficient sized space to store data, (4) finding a mode for backing up data that could be lost in the research process, and (5) deciding how to destroy the data when the time for preserving it is expired. The researcher protected all data information in a bank safe box where only the researcher has access to obtain the data when needed. A flash drive was utilized to back up data in case of data loss. After the study, seven years post publication; the researcher will also destroy all information and documents collected to keep participants information confidential. Summary The main purpose of this study was to obtain the perceptions of individuals with bipolar disorder about their experiences in a supported employment program. The researcher utilized emerging themes from this study to advance Adult Learning Theory. The qualitative methodology chosen helped effectively in exploring the phenomenon. The study utilized in54

depth semi unstructured interviews to gather data from participants about their experiences in a supported employment program. Finally, for the present study, the researcher kept a reflexive journal, noting some of what occurs throughout the study. However, it was crucial to be aware of the possibility of technological failure. Thus, this study aimed to conduct the research reliably by noting such details as dates of research related actions, steps in the research process, research decision rationale, descriptions of findings in the research, interpretations, and future actions and recommendations that may be necessary for the research. Conclusion Supported employment is very essential to keeping the clients occupied. Engaging the clients in more positive activities minimizes the likelihood that they will decompensate (Van Dongen, 1996). In other words, working would likely provide distraction from the everyday psychiatric symptoms (Van Dongen, 1996). This suggests that work helps in the management of bipolar disorder and mental illness in general. Therefore, supported employment can indeed help minimize unemployment among people with bipolar disorder. It was important to identify the specific elements of supported employment that creates positive results and those aspects that are not as effective. In addition, some failing parts can be changed. It is essential to address gaps in the knowledge base by upholding all working parts of supported employment programs while addressing the problems as well. Quick-fix solutions frequently fail to deal with the underlying issues that create the problems (Stringer, 2007).

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CHAPTER 4. DATA COLLECTION AND ANALYSIS Introduction The primary objective of this chapter is to depict the outcome of the data collection and analysis of fourteen adults diagnosed with bipolar disorder who participated in an interview about their day to day lived experience in a supported employment program. The primary research question to be answered was: what meaning do adults diagnosed with bipolar disorder attribute to their experiences in a supported employment program? Corollary research questions were: how do adult participants engaged in a supported employment program view unemployment and underemployment and what elements of supported employment program do adult participants perceive as adaptive for their specific work situation? The purpose of this phenomenological study was to explore the meanings adults with bipolar disorder attribute to their experiences in a supported employment program. In addition, this chapter reveals how the research methodology was utilized in data analysis, as well as how the data was transcribed and coded. The essence of the experience has been represented to show the reader, in a transparent manner, what and how the participants experienced a supported employment program at nonprofit rehabilitation facility in a large metropolitan area in Texas. The researcher has worked actively in the mental health profession for nine years as a supported employment specialist, rehabilitation specialist, and housing specialist. Currently the researcher is employed as a recidivist rehabilitation clinician in a critical time intervention program at a local mental health clinic. Furthermore, the researcher obtained his bachelors degree in psychology and masters degree in human services. The researcher understands the importance of active listening, which is essential during the interviewing process. The researcher credibility lies in the ability to 56

effectively listen, from day-to-day, to the needs and overall desires of clients who are mentally challenged. Sample/Data Collection Purposive sampling was used to identify adult participants of a supported employment program located in a large metropolitan area in Texas. In purposive sampling, participants are chosen for a particular reason (Leedy & Ormrod, 2005). The researcher delivered a presentation during a team meeting and over hundred recruitment handouts were distributed. Most of the participants volunteered to participate by placing their contact information on a blank paper and placing inside the envelopes provided. These participants were selected in the order of who stated their interest first to participate in the study and then narrowed down to individuals who met the criteria for the study. Fourteen participants, three females and eleven males were drawn from a pool of twenty-five adult participants in a supported employment program. Over the course of several weeks, in-depth semi-structured face-to-face formal interviews were utilized to obtain information from these participants. The researcher utilized a check list which made certain that the participants met the criteria for the study. In addition, the participants were provided with informed consent and the interview guide for the study prior the interview. The researcher also answered all the questions by participants before they signed the informed consent. The interviews were held in a private office at the study site. After the interview, the researcher was open for suggestions, concerns and more questions.

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Description of Study Participants Fourteen of the participants, 3 females and 11 males fit the study criteria. They each had a primary diagnosis of bipolar disorder, were in compliance with psychiatric treatment, graduated from high school, were engaged in a supported employment for more than 90 days, and were residents of the city in which the study was conducted. Participant 1 is a Caucasian Male in his early 40s who worked as a professional mechanic in a non-supportive environment before being diagnosed with bipolar disorder. He was diagnosed ten years ago and he has been in compliance with psychiatric treatment. He refuses to receive social security checks for his disability because he would rather work and earn money. He made this known when he stated: I need to work. I can get a check, like the other people do, but I would rather work because it takes up my whole day and I work five, six, sometimes seven days a week and I have no problems with that. You know, it takes up my time and keep me doing something, and not thinking. Cause if I get to thinking, thats a bad thing. My bipolar is real bad. If I get to thinking and talking, I will get out of hand if I dont watch myself. Participant 2 is an African American male who was also in his early 40s. He worked in the construction industry but has been engaged in a supported employment program after he couldnt cope with daily stress in a non supportive work environment. He reported he was diagnosed 5 years ago but he knew something was wrong with him but he was in denial and was self medicating. He used alcohol and drugs but finally sought help. He reported the importance of supportive employment program in his life now because it keeps him busy and provided him with an avenue to make friends at work. Participant 3 is an African American female in her mid 20s. She was diagnosed first with Attention Deficit Disorder and was in special education in high school. Upon turning 18 years of age, she received a diagnosis of bipolar disorder and has been in compliance with psychiatric 58

treatment. She enjoys that she has been given an opportunity to work again. She was soft spoken and stated that working has taught her how to deal with other people and how to manage her stress level and mood swings. Participant 4 is also an African American female who was very passionate about being given another opportunity to work. She was in her mid 40s and she described the importance of inclusion because people like her have been discriminated against because of their disability. She expressed how she had to lie in her applications for employment because she was embarrassed about her mental illness: Before learning of this program, I would often lie on my application for employment because I was ashamed and embarrassed about my condition and eventually with time, my employers would notice that I reacted to different situation in like a heightened manner. Participant 5 is an African male in his late 30s. He reported that one of his symptoms was crying spells and because he stutters, he would avoid argument and confrontations. He reported that supportive employment program is the best thing that happened to him because they accommodate him when his symptoms become unbearable at work. He described an instance when he experienced an episode at work: Sometimes I shake a lot and when I get to shaking when someone argue with me or something like that, I get to shaking, I get to trembling and I start crying and things like that and then Sean and Ms Ward call me and Ms Ward will calm me down a little bit, you know and probably send me home and then tell me to come back the next day or something like that. Participant 6 is a Caucasian male in his early forties. He was diagnosed in his early twenties but was in denial until he was hospitalized. He experienced difficulties with obtaining and maintaining employment until he was referred to a supported employment program. He was happy about being given an opportunity to enter the workforce again. 59

It was hard for me to get any kind of job anywhere else. Mmmh, even though I think I can make more than minimum wage here, but I still thank God I can be able to get a job and also be supported at the job. Participant 7 is a Hispanic American male who is in his early 30s. He has been battling mental illness since he was sixteen. He reported he went to college but dropped out due to his mental health symptoms. He answered questions directly and stated that supportive employment helped him to reinvent his life. Participant 8 is a Caucasian male is his early 40s. He stated he has been battling mental illness basically all his life. He stated that paid employment has been helpful in managing his bipolar disorder. He also mentioned the importance of being treated like a normal person at the supported employment program. Participant 9 is a Caucasian female in her mid 40s. She stated she has worked as a secretary for years and then was hospitalized for a long time. She reported that supportive employment provided the confidence she needed to renew her life. Even with her criminal background, she was grateful that she got a chance to work again. Participant10 is a Caucasian male is his early 40s. He also was diagnosed as a teenager and stated how difficult it has been for him to obtain and maintain employment. He stated how grateful he was to be in a supported employment program because it provided him with both work and dignity. Participant11 is also a Caucasian male who was diagnosed when he was in county jail. He is in his late 30s now but knew something was not right with him since he was an adolescent. He spoke very slowly and smiled frequently. He reported he appreciated the opportunity to work again and he was happy with both staff and co workers. He stated at one point during the interview: I recognize the opportunity. You know that helps out my esteem 60

Participant12 is an African American male who was in his mid 20s. He was diagnosed in high school. When he was in a community college, he started to use drugs and alcohol. He finally went to rehab and resumed psychiatric treatment and his case worker referred him to this supported employment program. He stated the money was good and he felt independent and normal again. Participant13 is an African American who was in his late 30s. He reported he was diagnosed early in his twenties but was in denial and thought there was nothing wring with him. He resumed treatment because of his family and stated supported employment was like a life saver. Participant14 is an African American male, who was in his mid 40s. He was diagnosed early in his 20s and has been in compliance with psychiatric treatment. He stated he receives social security income but supported employment program helps him with additional income that he needed. He spoke calmly and emphasized the importance of being independent and productive again. Data Analysis Process The qualitative researcher is the key instrument in collecting data from multiple sources through examination, observation, and interview. Qualitative researchers collect data in a natural setting and, through inductive data analysis establish themes (Creswell, 2007). In an effort to understand and give meaning to bipolar disorder and employment, phenomenological approach was the most appropriate design to explore the lived experience of adult participants in a supported employment program. The rationale was that phenomenological study is the best way to better understand peoples perspectives, perceptions, and understandings of situations that affect their lives (Leedy & Ormrod, 2005) 61

As stated earlier, the primary method of data collection was audio recording of the face-toface, semi-structured interviews. The researcher followed the interview guide (appendix A) to obtain participants responses during the study and audio recorded the participants responses. Each interview was audio recorded on two different audio machines and the researcher also made personal memo notes. All the participants were able to engage in a dialogue with the researcher and answered the questions the way they perceived and comprehended them. In some instances, the researcher had to repeat the questions, probed or redirected the conversation to reflect the original question asked. The interview always ended by asking participants if they had anything else to add or any questions or concerns. After the interview sessions were completed, the audio recorded interview responses were transcribed into text. The transcripts were uploaded to the researchers personal computer and also backed up on the researchers personal flash drive. The whole document was uploaded into Atlas.ti Qualitative Data Analysis Software for data analysis. Epoche/Bracketing Epoche is a Greek word meaning to refrain from or abstain (Moustakas, 1994). In epoche, the researcher must set aside biases, prejudices, prejudgments and preconceptions. This is particularly essential if the researcher is close to the population or phenomenon being studied. Therefore, in an attempt to derive new knowledge, it is very important to be objective and allow for new information to into consciousness as if for the first time (Moustakas, 1994). Bracketing helped the researcher to be transparent and view new emerging information with a new set of eyes in a completely open manner (Moustakas, 1994). Consequently, engaging in bracketing ensured that no position was taken and that nothing was determined in advance. Consequently, the researcher was able to view things as they appeared and described them into textural 62

language with no prejudices and/or prejudgments. Most importantly, utilizing bracketing helped prevent undermining the validity of the study. Data Coding Process After transcribing all recorded interview responses by all fourteen participants, the researcher analyzed the transcripts and highlighted emerging themes. The researcher utilized the 6.2 version of Atlas.ti Qualitative Data Analysis Software for data analysis. The interview transcripts were assigned as Primary Documents in the Atlas.ti software. The researcher was able to then engage in coding activities. Coding is a research technique that helps organize the data as well as provide the means to present the interpretation of data. The researcher was able to utilize the Atlas.ti software to assign categories, codes and concepts to areas of interest in the uploaded documents. Using the mouse to highlight certain areas of the transcripts, the researcher was able to select the open coding option, enter a code name and click the OK button. The researcher also utilized the option of writing comments and memos on Primary Documents when necessary. The researcher was able to create numerous codes utilizing the auto coding option and utilized the Open Family Manager option to organize frequency of coded information. The software allowed data to be segregated, grouped, regrouped and re-linked to fully consolidate meanings. Atlas.ti Qualitative Data Analysis Software provided data management, multi-tasking, code & link management, auto coding, code transparency, frequency of codes & words, and most of all, a password protected security option to maintain confidentiality of data.

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Data Analysis Results In continuation, a theme is a result of coding, analytic reflection and categorization (Creswell, 2007). Four themes were generated based on grouping into related families. These themes are (a) accommodation, (b) socialization, (c) inclusion, and (d) security. Although different themes emerged independently, they were somehow interconnected and each of them pointed towards program satisfaction and job security. Table 1 depicts participants response reveals how each of the participants related to the emerging themes. Most of the participants identified with each of the themes presented in this chapter, especially with the main theme of security.

Table 1. Participant Responses to Emerging Themes

Participant Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Theme 1 Accommodation * * * * * * * * * * * * * *

Theme 2 Socialization

Theme 3 Inclusion *

Theme 4 Security * * * * * * * *

* * * * * * * * * * * * * * * * * * * *

* * * * * *

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The flow chart in Figure 1 displays how all the themes linked together. The structural and textual description revealed what phenomenon was explored and how these participants experienced the phenomenon under study.

Accommodation

Socialization

Inclusion

Security

Figure 1. Flow chart of emerging themes

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Emerging Themes Accommodation This theme was identified by all of the 14 participants when asked to describe specific assistance that was made on behalf of participants of supported employment program. Most of the responses centered on the ability to attend doctors appointments, medical appointments, parole/probation appointments and other necessary appointments without the fear of being terminated from their employment. They also mentioned that some of their fellow workers receive social security benefits and can only work certain amount of hours to maintain their benefits. The supported employment program accommodated that and created flexible schedules for them. During coding, the researcher noticed that participants used words and phrases such as, accommodate, doctors appointment, appointments, social security, helpful, staff, supervisor, check-go-down and work-with-me to reference a sense of accommodation. All these frequently used words and phrases by the participants were coded and listed under the umbrella of Accommodation in the code dictionary presented in table 2.

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Table 2. Code Dictionary

Code words & phrases Accommodate, doctors appointment, appointments, social security, helpful, staff, supervisor, work-with-me, checkgo-down.

Code umbrella/themes Accommodation

Brief explanation The participants frequently used these words and phrases to reference the theme of accommodation. They communicated the idea that in a non supportive work environment, they would have been terminated from work. The participants frequently used theses words and phrases to highlight the theme of socialization. They shared the importance of building lasting relationships and working together as one family. The participants frequently used these words and phrases to highlight the theme of inclusion. They shared the sense of being able to a part of the whole society. The participants frequently used these words and phrases to reference the theme of security. They shared the comfort of security even in the climate of unpredictability.

Make friends, build friendship; trust, like, co-workers, people, get-along, comfortable, support, understanding, help, and teamwork.

Socialization

Opportunity, a chance, Change, opened doors, special people, disability, God sent, respect, dignity, and awareness.

Inclusion

Self-esteem, care, thank God, money, productive, getting paid, hourly rate, salary, minimum wage, responsible and independent.

Security

These few quotes reveal the importance of accommodation from the perspectives of the participants: You know I have to go to parole three times a month. I got two doctors appointments a month and they accommodate me on all these. They work with me on that, I mean you know any other place, I would have been fired because I miss so much work, having to go to all these meetings and whatever you know, and doctors appointments and stuff like that and they work with me. They are understanding about that. (Participant 1)

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Well here, they work with you if you have doctors appointments stuff like that, therapy or regular appointment. And some days, Im irritable and my mood go up and down, up and down and I can call I and say I cant come to work. They say okay and they wont even ask for any excuse note or anything. They understand my condition. If my medication is making me feel bad, they will tell me to go home and come back when I feel better; you know what Im saying? If you get social security income, they can adjust your time so you dont loose your check or get it cut down. If I need a ride to my doctor because I dont have a way to get there, they can take me to get my medicine, you know? (Participant 6) Well the employer understands that you have a situation you have to deal with like going to the doctors and if you are on social security. Like I said before, if you have doctors appointments or whatever, they understand that and they dont give you a hard time about that. They accommodate other people with other kinds of handicap such as, they have a driver he is in a wheelchair, they fix the truck up so he can drive and that type of thing. There are people on social security that get checks; they can work on so many hours so they dont have to work the whole 40 hours a week. (Participant 10) By coming to work here, I can choose time to work here; I can choose time to work and how many days a week I work. So they are flexible with the schedule. If Im sick, I can call in I dont feel well and not be penalized. I get my pay check with no problems. I can go to my doctor and my therapist and they work with me. You know the heat is too much here in Texas and sometimes some my medications, I cant be under direct sun and they work with me on that. If it rains, we are sent home. I like it here. (Participant 11) In sum, participants choice of words were determined to represent the need for accommodation and also provided insight into the importance of accommodation in a supported employment program. These participants mentioned that any other employer could have terminated their employment because of the appointments they have to attend. Therefore, accommodation played a vital role for the participants in a supported employment program. Consequently, the impact of accommodation provided job satisfaction and security to the participants of a supported employment program. Table 1 depicts that 14 of the participants responded directly to the theme of accommodation.

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Socialization This theme emerged from the responses of the participants highlighting the importance of socialization at work. 10 of the 14 participants discussed that making friends and building relationships are things they enjoy the most in a supported employment program. Another significant find revealed in the data was the researchers discovery that all the participants at one point or the other responded using possessive pronouns like our, we, us when responding to questions directed particularly for an individual. Interestingly, they seemed to share a sense of oneness. In addition, most of the participants are used to spending most of their time with family members, social workers, doctors offices and other community centers. However, a supported employment program has become a rendezvous for socialization for these participants. During coding, the researcher noticed that participants used words and phrases such as, make friends, build friendship; trust, like, co-workers, people, get-along, comfortable, support, understanding, help, and team-work to emphasize the theme of socialization. All these frequently used words and phrases by the participants were coded and listed under the umbrella of socialization in the code dictionary (refer to table 2). These few quotes reveal the importance of socialization from the perspectives of the participants: Yeah I have friends. I will have some donuts every Friday for my coworkers, thats just me. I like donuts. You know what Im saying? You know sometimes we buy each other donuts (Participant 2). As a participant in this program, sir, I can honestly say that I feel as if I have known everyone for along time. There are no strangers here, just friendly people with common ground like I stated many time before. We really have a good time together I mean, even when we are working. (Participant 4) Mmmmhh, I like that I meet people here who got what I got and we can share with one another. And I can trust people again, so Im my own person, I feel whole, you know? I 69

use to be afraid of people and get mad that nobody cares, but they showed me different things here, you know? It reminded me of being in the military, like family and stuff like that. There is a togetherness. (Participant 6) They are very understanding of my situation and what Im going through and I like the part that I can make friends here just like I did in school. It helps you know how to get along with other people and also other normal everyday working people. (Participant 12) Another part I like is that you can make friends here. You know I got to deal with people and I got a pretty good understanding of how to deal with people by working here (Participant 14) In sum, participants choice of words were determined to represent the need for socialization and also provided great insight into the importance of socialization in a supported employment program. These participants displayed that building relationship with others is vital at work. Consequently, the impact of socialization provided job satisfaction and security to the participants of a supported employment program. Table 1 depicts that 11 out of the 14 participants responded to the theme of socialization. Inclusion This theme emerged from the participants responses reflecting on how they perceive supported employment program as an opportunity and a chance to become a part of the whole. In a society where they feel alienated and stigmatized, they see an opened door to become part of the community. 10 of the 14 participants directly identified this theme from their responses. During coding, the researcher noticed that participants used words and phrases such as, opportunity, a chance, change, opened doors, special people, disability, God sent, respect, dignity, and awareness to reveal the theme of inclusion and a sense of becoming a part of the society as a whole. All these frequently used words and phrases by the participants were coded and listed under the umbrella of inclusion in the code dictionary (refer Table 2). These few quotes reveal the importance of inclusion from the perspectives of the participants: 70

So honestly, this program is a God sent for me because they understand me and people like me and give us opportunity to work Nobody is judging you. No one is walking around feeling different because of our disability. They acknowledge that even though we are all considered to have behavioral issues, there still remains both a need and a desire to be productive citizens in the society. I think often people think that once somebody collects a check every month, that thats all they want, but in essence thats not. We all want to feel a part, we all wanna feel as productive citizens and in some instance, this program has done that. (Participant 4) Um, I like that they are giving me a chance to work with my illness and my criminal background. They show me that they care about people like us and give us a chance when no one cares to give us a chance. Well I gave me the ability to know I can work and help special people like me. It proves that I can work with my bipolar again. (Participant 9) It gives me an opportunity to work and to focus on work instead of my mental illness. I feel useful and a part of society, kind of like Im helping (Participant 11) Giving me the chance to see what I can do for myself, you know? Especially now that the economy is bad, even regular people cant find work. They gave me an opportunity to work and I appreciate that. It helps me build my self esteem and self worth. (Participant 14) In sum, participants choice of words were determined to represent the need for inclusion and also provided insight regarding the importance of inclusion in a supported employment program. These participants mentioned that working provided a great opportunity to become a part of the society again. Some of these participants had experienced hospitalization and incarceration, but found an opportunity to reinvent themselves and reintegrate into society. Therefore the theme of inclusion played a vital role for the participants in a supported employment program. Consequently, the impact of inclusion provided job satisfaction and security to the participants of a supported employment program. Table 1 depicts that 10 of the 14 participants responded to the theme of inclusion. Security As mentioned earlier, although this theme is an independent theme, it is also interrelated and interconnected with the other themes, but also appeared to be the foundation theme. All of 71

the 14 participants identified a sense of protection and freedom from fear in their responses. Therefore, security actually serves as a main theme as well in this study because of how it is intertwined with the other themes. These participants expressed their gratitude for securing another opportunity to be in the workforce as well as having job security. During coding, the researcher noticed that participants used words and phrases such as, self-esteem; care, thank God, money, productive, getting paid, hourly rate, salary, minimum wage, responsible and independent to reference a sense of security. All these frequently used words and phrases by the participants were coded and listed under the umbrella of security in the code dictionary (refer to Table 2). These few quotes reveal the importance of security from the perspectives of the participants: Its a job that really supports my disability. I feel like I can just do my job and focus on my job instead of being scared of ooh what of I have a mood swing at work and then I will be fired but Im able to actually focus on my job. (Participant 3) Well the part of knowing you can talk to your supervisor or other people who work here to help you; and you know they got your back. I feel like I wont be fired because of my Bipolar or mental condition. Also, the sense that you feel like people care about folks like us. The understand our situation better. Well I mean it helps. I feel better you know with my self esteem, it helps my self esteem and make me believe that I am somebody (Participant 6) It is good cause it helps us build our self-esteem, it makes us feel better about ourselves and things like that. I used drugs and the medication that was given didnt do anything for me. It didnt really help. But they helped me believe in myself and now I live on my own and I have a job. I make money, mmmmhhh, I feel you know, I feel independent. I feel normal again. (Participant 12) It helps me build my self esteem and self worth. No one cares really. All the police and the judge want is to lock us up and let us waste in jail. They dont care if you get better or anything. But this program here cares and they are helpful (Participant 14). In sum, participants choice of words were determined to represent the need for security and also provided a great insight into the importance of security in a supported employment 72

program. Table 1 depicts that all 14 of the participants responded to the central theme of security. In addition, the flow chart (refer to Figure 1) further illustrate that all the other themes are linked to the theme of security. The participants responses depicted that participants are satisfied with accommodation provided to them at work, the fact that the program provides a rendezvous for socialization at work and the sense of inclusion in the workforce. Most importantly, the sense of security provides the confidence and the protection of all the other themes regardless of their condition and/or their situation. All of these participants are diagnosed with mental illness and their condition can be very unpredictable. They are likely to miss work due to situations like hospitalizations and incarcerations; but they know that their jobs are secured whenever they feel better to return to work. This is the ultimate theme and the heartbeat of the study. Consequently, the theme of security serves as the central theme in this study. Member Checking In qualitative research, the researcher uses a technique call member checking or respondent validation to improve accuracy, credibility and validity of the study (Creswell, 2008). Member checking had numerous advantages, but most importantly, it provided the researcher with an opportunity to avoid and/or correct errors from participants feedback. During the interview process, the researcher restated and summarized information to determine accuracy of the data obtained. At the conclusion of data analysis, the researcher provided the participants with a copy of the transcribed transcripts and thoroughly explained the theme and how the themes were identified. The researcher encouraged the participants to verify the accuracy of the emerging themes provided. This process known as member checking helped to confirm the trustworthiness and authenticity of the study. As stated earlier, providing a report of emerging themes to the participants helps the credibility and validity of the study (Creswell, 2008). The 73

participants read and confirmed the themes with positive responses. All the feedback from the participants has been considered as part of data analysis. Connection to Research Questions Primary Research Question: What meaning do adults diagnosed with Bipolar Disorder attribute to their experiences in a supported employment program? Corollary Questions: How do adult participants engaged in a supported employment program view unemployment and underemployment? What elements of supported employment program do adult participants perceive as adaptive for their specific work situation? Although, the findings and conclusions will be discussed in details in chapter 5, however, data analysis also provided some answers to the research questions. These participants who experienced a supported employment program found meanings in so many ways. They expressed the importance of accommodation, socialization, inclusion, but most of all security. The sense of accommodation shows the importance of flexible work schedules at work so that participants can attend different appointments as well as maintain social security benefits. All the participants found the theme of accommodation meaningful in a supported employment program. Participant 3 and 14 are the examples where participants expressed how meaningful accommodation was in their experiences in a supported employment program: If Im having a bad day, I can just call in or if my mood changes during the day while Im at work, they will send me home. Im not scared that I will get fired because Im missing work too often. Also if I have doctors appointment, they will make accommodations for me. They let me get off work early or not come in at all. (Participant 3) They help a whole lot. They allow you to go to your doctors appointment and your therapy and medical appointments. If you have social security, you can work less hours so your check stay the same. Im off my parole now but when I was seeing my probation 74

officer, I can take time off work. You see, in any regular job, you will be scared to tell them you have mental problems cause no one will want to work with you. And if you ever go to doctors appointment often, they will get rid of you. Im grateful there is a program like this to help people in our situation, in our condition. (Participant 14) Furthermore, the participants found meaning in socialization because their responses depicted the importance of building friendship at work. They reported previous problems with maintaining relationship and how essential it was to socialize at work as well as develop social skills at work. 10 of the participants directly expressed the importance of socialization. However, participants 3, 7, 8, 9 and 13 are example where the participants expressed the importance of peer relationship when they stated: I learned how to work with others and I just learned how to stay focus and keep on a daily schedule as far as taking my medications to make sure that Im able to go to work. Mmmmh, knowing that my co-workers; they are in a similar situation that I am. They have disability also, so that makes me feel more comfortable working. So, I just learned how to deal with other people and manage my stress level and mood swings (Participant 3). Im able to interact with people with the same, similar disability, illness that I have. (Participant 7) I get along with them very well. I get along with everyone; I get along with my co workers. (Participant 8) I learned to work with other people like me, like special people and get along with them and other people in the job sites. (Participant 9) I like that they are all supportive here and you can make friends with other people that been through that same thing you are going through. I learned to get along with everyone you know. I have friends here and I come to work on time. And I learned to be independent and be a team player. I also learned to also help people and stay out of trouble. (Participant 13) Inclusion was a very critical theme because of the opportunity given to these participants to work and become a part of the society. Participant 3 described how meaningful inclusion was in a supported employment program. 75

It has given me an opportunity to work a regular job. Its a job that really supports my disability. I feel like I can just do my job and focus on my job instead of being scared of ooh what of I have a mood swing at work and then I will be fired but Im able to actually focus on my job. Finally, although the theme of security emerged as independent theme, it was also the main theme because it provided protection for all the other emerging themes. The participants understand that their mental illness is a very unpredictable illness and they could be hospitalized at any given moment but they know they will always have their employment. The sense of job security provides security and protection for all the other themes. Although, all the participants expressed the importance of security, but participant 4 best described that the theme of security was very vital and meaningful in a supported employment program where she stated: In my previous work experiences, I would have a break down sooner or later and when that happens, you know the next thing is termination. But now I know without a doubt that regardless of how my mood may change, my employment will probably not change. The participants view employment as something positive and a way of inclusion into the society. However, underemployment was mentioned where some participants expressed they should be making more than minimum wage due to their previous experiences, skills and education. When asked what they would change in a supported employment program, five out of the participants stated they would increase the salary or wages. Participant 10 is an example where a participant described a view of unemployment: Participant 10: Well, maybe pay a little bit more because all the people that working here needs a little bit money to help them with what they are dealing with. Thats the only thing I can think as far as that. Add more to the hourly rate. Nonetheless, these participants even after stating that increasing the pay rate was essential still expressed gratitude for having an opportunity of being employed at a supported

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employment program. Participant 10 and 13 directly expressed the importance of employment at a supported employment program when they stated: Participant 10: It helps me to move on with me life and give me a little dignity for myself and dignity that I can go and work somewhere else like I use to do. Participant 13: But I will change nothing. You know this program is helpful. This is a kind of program that is really important for the people that have the kind of condition that I have. Finally the participants view all the themes, especially the central theme security as adaptive in their specific work situation. Data Analysis Summary This data analysis summary is the outcome of a phenomenological study exploring the effect of supported employment on individuals with bipolar disorder. The data revealed the meanings that adults with bipolar disorder attribute to their experiences of a supported employment program. First, the researcher engaged in bracketing by setting aside biases, prejudices, prejudgments and preconceptions to focus directly on research participants. The researcher engaged in horizonalization of the data (listing significant statements from data source) (Creswell, 2007). Themes that emerged from data analysis were accommodation, socialization, inclusion and security. All of these themes emerged independently but were all interconnected and interrelated with one another. Consequently, the textual description (what the participants in the study experienced) and the structural description (how the experience happened) together helped reveal the whole picture of the study. In the end, various meanings developed to build an overall description of the phenomenon under study and the essence of the participants experience.

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CHAPTER 5. RESULTS, CONCLUSIONS, AND RECOMMENDATIONS Introduction The primary purpose of this chapter is to present and discuss the results of the study. The result of this study will be discussed in relevance to the existing literature in the field. The conclusions from the study, limitations, and recommendation are also reported in this chapter. The main purpose of this qualitative phenomenological study was to explore the effect of supported employment on adult individuals diagnosed with bipolar disorder. The primary research question was: what meanings do adults diagnosed with bipolar disorder attribute to their experiences in a supported employment program? Corollary research questions were: how do adult participants engaged in a supported employment program view unemployment and underemployment and what elements of supported employment program do adult participants perceive as adaptive for their specific work situation? Fourteen participants expressed their experiences in the phenomenon explored. The responses of this participants provided insight, findings, conclusions and information for recommendation. In this study, the researcher tried to discover through participants experiences to what extent a supported employment program helps in the management of bipolar disorder. The findings will hopefully help in enhancing supported employment programs for people with disability not only across the Unites States but also around the world. Summary of Results The primary goal of the study was to explore how a supported employment program helps in the management of bipolar disorder by obtaining the perceptions of adult participants of the program. The researcher utilized in-depth semi-structured face-to-face formal interviews to obtain information from these participants. The results show that all the participants attributed 78

various meanings in their experiences in a supported employment program. The analysis of this phenomenological study depicted common themes among the participants. These themes are accommodation, socialization, inclusion and most of all, security. Furthermore, the researcher discovered that all of the fourteen participants shared the themes of accommodation and security. 10 of the participants shared the theme of inclusion and eleven of them shared the theme of satisfaction. However, findings from the study supported the fact that participants experienced over all job security. Discussion of the Results The primary Research Question was, what meaning do adults diagnosed with Bipolar Disorder attribute to their experiences in a supported employment program? Corollary Questions were: how do adult participants engaged in a supported employment program view unemployment and underemployment and what elements of supported employment program do adult participants perceive as adaptive for their specific work situation? These participants who experienced a supported employment program found meanings in so many ways. First, they expressed the importance of accommodation and how non supportive employment would not have accommodated their numerous appointments and side effects of their medications. Secondly, they shared the sense of socialization and how important it was to build relationship even at work. They also revealed the sense of security, which was the main theme of this study. However, the sense of inclusion was a very critical theme because of the participants expressed the importance of being given an opportunity given to work. If they were never given the opportunity to work at a supported employment program, they would have not been able to experience accommodation, socialization and security. Therefore, inclusion was one huge 79

meaning the participants attributed in their experiences in a supported employment program. 10 of the participants directly describe the theme of inclusion in a supported employment program (refer to Table 1). The participants answered the second research question by expressing how essential employment is in their lives and how it helps them manage their disability. Therefore unemployment according to these participants is a problem. They described how difficult it was for them to find work and expressed gratitude for being engaged in a supported employment program. Some of the participants reported how working kept them busy and kept their mind focused. In order words, employment not unemployment helped them better manage their mental illness. Consequently, work can be very therapeutic (Black, 1988; Gowdy, 2000). Participants six and fourteen are examples of where participants directly expressed how they view of employment: Well with my disease, mmmh, I mean I have some problems and I think about it; it is something that I have to deal with and it helps to keep me busy. In short, this thing here keeps me busy; it is like taking my mind off the devils workshop. It keeps my mind away from thinking negative things and I can focus on working, you see? I can wake up every morning now and go to work instead of running the streets; you know what Im saying? (Participant 6) Again, it occupies my time. I can stay focus at work instead of wasting my time doing things I have no business doing. It keeps me busy working and keeps me out of trouble. (Participant 14) Underemployment was something most of the participants expressed as an issue where they mentioned they should be at least earning more than a minimum wage due to their previous experiences, skills and education. When asked what they would change in a supported employment program, five out of the participants stated they would increase the pay rate: Participant 3: So I will increase the pay and have better quality positions. 80

Participant 6: Maybe I might increase the hourly rate you know, to be above the minimum wage, but I will mostly keep it the same. Participant 8: Just high, dont increase the pay too much but just give them a little bit more than minimum wage. Participant 13: Maybe hire more people and maybe offer to pay more salary or give them more money. Nonetheless, same participants who directly commented about underemployment in this program and other participants as well as expressed program satisfaction. When asked what they would do differently if the could facilitate a supported employment program, they responded: Participant 3: No, this is a great program. Everything they have in place is great. Participant 6: Well, there is nothing really to change, you know. Participant 8: Its just a really nice program, its helpful to people, something to help people out. Finally, these participants perceive accommodation, inclusion and socialization as adaptive in their specific work situation. However, they perceive the sense of security as most adaptive to their specific work situation. These participants suffer from unpredictable illness that could lead from short to long term hospitalizations and incarcerations; yet they still have the sense of job security. They described they could have been terminated if they were working in a non supportive work environment. This sense of job security provided them with the comfort and confidence that is essential not only for their specific job situation but their mental health in general. Participant 1, 3, 6 and 14 are examples of where the participants strongly shared the importance of sense of security in a supported employment program: Participant 1: I mean you know any other place; I would have been fired because I missed so much work, having to go to all these meetings and whatever you know

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Participant 3: Im able to go to my supervisor, Im not scared of loosing my job because I have to go home early or if I have to take my medication, go to the doctor. Im not scared that I will get fired because Im missing work too often. Participant 6: I feel like I wont be fired because of my bipolar or mental condition. If I need a ride to my doctor because I dont have a way to get there, they can take me to get my medicine, you know? Its good men, its really good. I like it. I dont think any other job do things like that. Participant 14: You see, in a regular job, you will be scared to tell them you have mental problems cause no one will want to work with you. And if you ever go to doctors appointments often, they will get rid of you. Discussion of the Conclusions in Relation to the Literature Review Based on the study results, the researcher was able to link findings to information found in the professional literature in the field. This shows that the study findings are not only reflective to some other study findings, but will also add to the existing knowledge in the field. The findings like other studies found in the literature review supported that supported employment programs help immensely in the management of bipolar disorder. Alignment of Literature Reviewed In this present study, all of the fourteen participants shared the importance of accommodation. Accommodations were made for the clients to attend doctors, medical, criminal justice related appointments without any threat to employment security. In addition, some of the clients who qualify for social security do not receive enough money to sustain their daily needs (Bond, Xie, & Drake). Consequently, they are left to obtain at least a part-time job to supplement their income. Nonetheless, if they worked more than a certain hours a month, their social security income would be reduced. Therefore, participants received flexible schedule as an accommodation to be able to manage their work hours effectively in order to maintain full

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amount of their social security income. All these accommodations contributed to the effectiveness of a supported employment program. Some of the participants reported that they would have been terminated if they were working in a regular non supportive work setting. Therefore, the researcher discovered a high sense of job satisfaction and security from the participants due to several accommodations made on their behalf. One of the participants directly mentioned the importance of accommodation: Participant 12: They accommodate you. They do, they help me with whatever I need. You know if I had a regular job, I would have been fired a long time ago. Furthermore, it was vital that the program accommodated the participants to attend all doctors appointments to maintain stability and in turn maintain employment. Even accommodations such as providing psychotherapy at the job site undoubtedly contributed to mental health and employment stability (Lysaker & France, 1999). Psychotherapy is an important element and accommodation in a supported employment program for individuals with mental illness (Lysaker & France, 1999; Wu, 2008). Consequently, accommodation and support help promote mental health recovery and employment success (Wu, 2008). Current or previous involvement with the criminal justice problems prohibit clients from obtaining or/and maintaining employment (Whitley, Kostick, & Bush, 2009). Therefore, accommodating participants to attend criminal justice related appointments is very essential. Supported employment is the number one approach for reaching clients vocational need because it provides accommodations such as, job coaching, job placement, monitoring and follow-up (Wehman & Kregel, 1985; Becker, Whitley, Bailey, & Drake, 2007). Flexible work schedule is an accommodation for the client to work a certain amount of days and hours. Studies show that people with bipolar disorder suffer financial/economic 83

problems (Wong at al., 2008; Bond et al., 2007). Consequently, they are left to obtain employment to supplement their income and alleviate economic hardship (Whitley et al., 2009; Wong et al., 2008; Ackerman, & McReynolds, 2005). However, they have to be accommodated to work a certain amount of hours to be able to maintain their social security income. These are examples where the participants reported how imperative it was to receive flexible schedule to be able to maintain their social security benefits: Participant 4: I mean they all know that we get social security checks every month and they will make the schedule to where our checks are not affected and that means a lot to me. Participant 6: If you get social security income, they can adjust your time so you dont loose your check or get it cut down. Participant 8: I was working five days a week but it was too many days for my social security for five months and they have to cut my hours to two days a week. The most I have worked is four days a week. Social security, aaahh I can only make so much a month to keep my social security. Participant 9: They make sure I work enough hours as required by social security, so that my check can stay the same and stuff like that. Because I get a certain amount of money a month, my supervisor always listen to me and work out my schedule with me. Finally, the participants expressed the importance of accommodation because staff members and counselors were supportive and accommodative in the work program. One study shows that the likelihood that a participant becomes employed depends on one-on-one supported employment services provided by the program support staff (Barreira, Tepper, Gold, Holley & Macias, 2010). In a study titled, Work is the Best Medicine I Can Have, findings suggested that case managers and supported employment staff contributed immensely to clients maintaining competitive community employment (Gowdy, 2000). In this study, socialization emerged as a vital theme. Employment helps clients in non vocational areas such increasing self-esteem and socialization skills, symptom management and 84

improving quality of life (Corrigan et al., 2007). Consequently, the researcher discovered from the participants responses that making friends and building relationships were very essential to them. When adults with disability enroll in a supported employment program, they shared a sense of collective responsibility. They also viewed a supported employment program as an avenue to socialize with others in similar condition, as well as develop socialization skills to deal with others in the real world. One study showed that employment is the number one social activity that best transmits sense of self-worth and social identity (Ackerman, & McReynolds, 2005). Another study suggested that supported employment may help clients not only improve future employment opportunities, but help them build confidence, self esteem, cooperation and communication skills, independence living skills, establish friendships and improve the overall quality of life (Bush et al., 2009). In continuation, 10 of the participants responded directly about the impact of inclusion because they were provided another opportunity to be a part of the society. The researcher discovered that a supported employment program provided a chance for these participants to reinvent themselves and become a part of the community. One of the participants strongly emphasized the important of inclusion where she mentioned: It has opened doors for me and people like myself, thats in my shoes that have been discriminated against because of our disability. Ahh, before learning of this program, I would often like lie on my applications for employment because I was ashamed and embarrassed about my condition and eventually with time, my employers would notice that I reacted to different situation in like a heighten manner. (Participant 4) This shows that providing an opportunity for these participants who reported being discriminated and alienated by the society due to their mental disability helped them in managing their mental illness. Concisely, work can be very therapeutic and an important way for 85

individuals to achieve inclusion and integration in the wider society (Currie, 1985; Black, 1988; Gowdy, 2000). One qualitative study also showed that employment positively changes the clients experiences of their mental illness (Jones, 2005). Therefore, to deny people with mental illness the opportunity to be part of a workforce creates financial deprivation, lack of self-esteem, lack of sense of self-confidence, and most of all marginalization, which is the key factor of psychiatric disabilities (Marrone at al., 2005). Finally, security was discovered to be am independent theme as well as the main theme because participants reported job security from aforementioned themes. Although, accommodation, socialization and inclusions are essential themes, security provided the protection for all the other themes. Security also provided satisfaction in the sense that the job will always be there regardless of the amount of hospitalizations and incarcerations. Study findings have demonstrated that supported employment participants had more positive working alliance than others in a traditional vocational program (Kukla & Bond, 2009; Salyers et al., 2004). Another study also revealed that supported employment is nearly three times as effective as other employment intervention programs because one-third to three-quarters of the participants in supported employment became steady workers over longer intervals (Bush et al., 2009). In addition, clients with mental illness who return to work experience life satisfaction and security (Arns & Linney, 1993). A ten-year follow up study of supported employment investigated the extent to which supported employment contributed in the employment outcome of people with mental illness (Salyers et al., 2004). The result in this longitudinal study from Salyers et. al revealed that clients reported that employment provided hope, increased self-esteem and more (Salyers et al., 2004;

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Tse & Yeats, 2002). In addition, employment is motivating and empowers individuals (Jones, 2005). Other studies have indicated satisfaction from individuals with mental illness who are engaged employment programs. Employment is essential for people with bipolar disorder because it not only increases their self worth but also alleviates economic hardship (Wong et al., 2008; Ackerman, & McReynolds, 2005). Supported employment is most helpful because they provided job security of which most of the participants claimed would have been lacking if they were in a non supportive employment setting. These participants described that they would have been terminated from their jobs instead of being accommodated in a regular non supportive work environment. Participant 1: I mean you know any other place; I would have been fired because I missed so much work, having to go to all these meetings and whatever you know Participant 3: Im able to go to my supervisor, Im not scared of loosing my job because I have to go home early or if I have to take my medication, go to the doctor. Im not scared that I will get fired because Im missing work too often. Participant 4: On the days that I cant be good at work, I can simply call in and jut say Im gonna be absent for the day without harassment or the series of questions from previous supervisors that you know a typical employee get when they call in. Participant 6: I feel like I wont be fired because of my bipolar or mental condition. If I need a ride to my doctor because I dont have a way to get there, they can take me to get my medicine, you know? Its good men, its really good. I like it. I dont think any other job do things like that. Participant 14: You see, in a regular job, you will be scared to tell them you have mental problems cause no one will want to work with you. And if you ever go to doctors appointments often, they will get rid of you. Furthermore, participants also expressed the importance of being paid to work. This is another aspect of security mentioned by some of the participants:

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Participant 1: Thats the main thing right here, to pay bills, you know keep money you know and not get in debt. Because Im here working, making a living, and paying bills. Participant 2: I gets paid! Participant 5: The program here because I like the money I can get for myself and to help for myself. You know what Im saying? And when I get ready to retire, I can put some money in my pocket; yeah every month. Participant 12: I like that I have an opportunity to work, um, I like that I can be able to make money again. Participant 14: Letting me work and making money. I can really save money and buy a car. Paid employment is a high priority for people with mental illness and people with bipolar disorder have a strong desire to maintain employment, even though employment rates are relatively low for this population (Jones, 2005; Michalak et al., 2007). Employment can improve psychological well-being and economic self-sufficiency (Wu et al., 2009; Dickerson, et al, 2004). Although, some of the participants reported underemployment and would like an increase in salary, yet they were satisfied with the opportunity of working in a supported employment program. Some stated they would not change anything at all about the program. Few who reported that minimum wage should be increased still expressed overall program and job satisfaction. Adult Learning Theory As stated before, adult learning theory is suitable for studying adults in a supported employment program. The principles of adult learning theory show that adults are autonomous and self directive. Adults have accumulated a foundation of life experiences and knowledge, goal oriented, relevancy-oriented, practical, be respected, and treated as equals in experience and 88

knowledge (Knowles, 1975). As much as learning is reciprocal, adults opinions must be free in class (Knowles, 1975). Participants in a supported employment program who participated in the study were adults who were autonomous and self directive. They emerged from different ethnic groups, previous work experiences and educational backgrounds. They appeared to be goal oriented since they found opportunity to become part of the workforce and contribute productively to society. They reported being respected not because it is required by the Law to respect employees from different walks of lives but because the employer respects their skills and contribution. Research on Adult Learning Theory also suggests that instructors should adopt a role of facilitator rather than lecturer (Knowles, 1984). The researcher did not adopt the role of a lecture because the participants views were respected as the source of data collection. In addition, just like adult learning theory purpose that adults opinions to be free, the researcher utilized a phenomenological approach to encourage free opinions of the participants. Consequently, the opinions and perceptions of the participants have been utilized to draw conclusions in this study and present findings that would add to the existing literature in the field of human services. Limitation of Study There is no such thing as a perfect study. Therefore, this study had a number of limitations. Although, the researcher sought different gender to participate in the study but 11 of the 14 participants were males. Therefore, there were limited female perspectives in the study. Secondly, although the 14 participants provided great insight to the phenomenon studied, but with a larger sample size, a wide range of data would be obtained about the lived experiences of adults in a supported employment program. 89

The final limitation is that of unexpected situations. Some of the participants did not show up on the days scheduled because of unexpected circumstances. Recommendations for Further Study The first recommendation was actually derived directly from data. This study only focused on individuals diagnosed with bipolar disorder. Future studies should include other mental disabilities, such as schizophrenia, schizoaffective, anxiety disorders and others. This will help gather broader view of individuals with severe mental illnesses. Secondly, this qualitative study utilized phenomenological approach. It is recommended that other designs be utilized, especially ethnographical design to be able to study participants as a group. This will help in effectively studying the behavior, beliefs and customs of this particular group (Leedy & Ormrod, 2005). In addition, studying this phenomenon utilizing mixed methods or specifically quantitative design would not only provide broader perspectives, but also welcome the use of statistics to represent findings. Conclusion In this qualitative study, the researcher just like other qualitative researchers explored the lived experiences of adult participants in a supported employment program. As much as specific questions were asked and specific methodology used, the researcher did not know for sure what the responses would have been before conducting the study. In other words, the study participants were the ones in the driver seat who steered the study by providing the responses that eventually led to the study findings. In this study, the participants found meanings from their experiences in a supported employment program. These meanings manifested as the emerging themes of the study: accommodation, socializations, inclusion and security.

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Security emerged as the main theme because it was the theme that protected the other themes. Security was the foundation of all the other themes because if the participants did not feel secured about their job, then all the other themes would have become less meaningful. Finally, although, this study answered the research questions to the best of its ability, there are other questions to answer and other factors to consider when replicating this study or similar studies. What role does mental health stigma play in the workforce and in the entire society today? As different groups are coming out of the closet in todays world, individuals with mental illness are still hiding their illness due to fear of exclusion, rejection and repercussion. Future studies should explore and investigate the impact of mental health stigma in the society. More supported employment programs should be created since supported employment programs are shown to be helpful among this population. Supported employment is nearly three times as effective as other employment intervention programs because one-third to three-quarters of the participants in supported employment became steady workers over longer intervals (Bush et al., 2009). Nonetheless, even though supported employment programs have proven to be effective, separate but equal remains a discriminatory technique utilized to discriminate against others different from the status quo. Therefore, there should be an ongoing effort to include and integrate individuals with mental illness into regular competitive community workforce.

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APPENDIX A. INTERVIEW GUIDE 1. How do you define supported employment program? 2. What elements of supported employment program have been particularly helpful to you? 3. Describe how supportive employment program assist in your overall work experience? 4. Describe specific accommodations made on behalf of participants of supported employment program? 5. Describe things you have learned from participating in the supported employment program? 6. If you could facilitate a supported employment program, what would you do differently?

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