Quality of Life Benefits of Paid Work Activity in Schizophrenia

Quality of Life Benefits of Paid Work Activity in Schizophrenia by Qary Bryson, Paul Lysaker, and Morris Bell Abstract In a study of work rehabilitation, 97 participants with schizophrenia or schizoaffective disorder were randomized into either a Pay or a No Pay condition to determine the impact of work activity and pay on rehabilitation outcomes. This report specifically investigates the relationship between work rehabilitation and quality of life (QOL) measures for people with schizophrenia. Previous reports have described improvements in symptoms and work outcomes for participants in the Pay condition. Results in this report reveal that randomization to the Pay condition improved ratings on the Heinrichs Quality of Life Scale (QLS). The improvements are found both in overall QLS and in the domain of Intrapsychic Foundations (motivation, sense of purpose, anhedonia, and empathy). For a larger sample (n = 114) we assessed the relationship between amount of participation and QLS improvement. Degree of participation was related to improvement on the QLS total and Intrapsychic Foundations domain. Finally, improvement in the Interpersonal Relations scale was associated with weeks of participation for the most consistent participants. How participation in work rehabilitation and its interaction with pay improves motivation, interpersonal relatedness, and overall quality of life is discussed. Keywords: Work, rehabilitation, quality of life, vocational rehabilitation. Schizophrenia Bulletin, 28(2):249-257,2002. The introduction of vocational dysfunction as part of the diagnostic criteria for schizophrenia (American Psychiatric Association 1994) has led to new interest in work rehabilitation for people with mental illness. In the last decade a number of researchers (Tsuang et al. 1979; Anthony and Blanch 1987; Goldstrom and Manderschied 1992) have begun to investigate the role of work rehabilitation in the lives of people with severe mental illness (SMI) (cf. review Bond 1992). This research focuses on employment retention rates after rehabilitation (Anthony and Blanch 1987; Andrews et al. 1992), placement rates after rehabilitation (Drake et al. 1994; Bond et al. 1995), the relationship of work to mental health service utilization (Beard et al. 1982; Bell and Lysaker 1995), or vocational skills building (Liberman et al. 1998). However, much less research has been conducted on the relationship between vocational programming and nonvocational outcomes, such as symptom level changes or quality of life (QOL) improvements. A recent review of vocational rehabilitation research (Baronet and Gerber 1998) indicates very modest emphasis on symptom, QOL, or other nonvocational outcomes and much greater emphasis on employment-related outcomes. The few studies available that have investigated nonvocational outcomes provide some interesting results. Research on the relationship between work and symptom level or symptom changes in SMI samples (Brier 1991; Bell et al. 1996; Mueser et al. 1997) has revealed that participation in vocational programs is correlated with decreases in symptoms, but researchers are not sure which symptoms. For instance, Bell et al. (1996) found that weeks of participation in a work therapy program was related to decreases in symptoms of emotional discomfort (depression and anxiety), positive symptoms, and hostility symptoms but not to decreases in negative or cognitive disorganization symptoms. Mueser et al. (1997) found that work participation was related to decreases in thought disorder, whereas Brier (1991) found that quantity of work was related to improvements in both positive and negative symptoms. Even fewer studies have investigated the relationship between work and the broader concepts of life satisfaction or QOL, and results have not indicated a strong relationship. One reason for the negative findings may be that Send reprint requests to Dr. G. Bryson, Psychology Service, 116B, VA Connecticut Healthcare System West Haven, West Haven, CT 06516; e-mail: rehab.javanet@rcn.com. 249

Schizophrenia Bulletin, Vol. 28, No. 2, 2002 G. Bryson et al. these studies relied on cross-sectional methods, which may be insensitive to such a complex relationship. For instance, both Lehman et al. (1988) and Fabian (1989) found no relationship between work status and QOL measures when concurrent measures were made. However, in a subsequent study, Fabian (1992) found improvements in QOL domain scores and overall life satisfaction when measured over 3- and 6-month periods for participants engaged in supported employment. To our knowledge, only one other report (Mueser et al. 1997) has been published on QOL improvements over time for people with SMI who are engaged in work rehabilitation. In this study, participants were randomized into one of two vocational rehabilitation programs, individual placement or group skills training. Results indicated that participants who were competitively employed at followup had more satisfaction with their finances and vocational services but no improvements in other domains such as general life satisfaction, housing, or satisfaction with mental health services. It seems intuitive that the relationship between work and QOL should be positive. In the general population, work status is a strong predictor of life satisfaction (Priebe et al. 1998). Work often brings benefits in the areas of socialization, skill acquisition, sense of selfworth, creativity, and income (Drake et al. 1994). These are precisely the psychosocial domains that are impaired for people with schizophrenia and that influence their QOL. It seems logical that engagement in work activity would improve these domains. However, people with SMI often find work extremely difficult, highly stressful, demanding, and too fast paced (Warner and Polak 1995). Therefore, such an experience of work might not be beneficial and could reduce overall QOL. In this study we systematically investigated the longitudinal relationship between participation in a work rehabilitation program and QOL as measured by the QLS (Heinrichs et al. 1984) and the Finance scale from the Quality of Life Interview (QLI; Lehman et al. 1988). We had two sets of hypotheses, one related to the effects of randomization into paid work or a volunteer condition and the other related to the degree of participation in the work program. We predicted that randomization to the paid work condition would result in improved QOL because (1) paid work may directly affect perceptions of financial well-being, a vital component of QOL, and (2) paid work may afford people access to an increased number of social activities and interactions that should influence overall QOL. Therefore, we believed that significant improvements would be found on the Finance scale of the QLI and the QLS total score for Pay participants. Our second set of hypotheses related QOL improvements to the degree of participation in the work program. We believed that consistent prolonged participation would aid in the development of interpersonal contacts and possibly assist in developing motivation, interests, and a sense of purpose in life. Therefore, we predicted that sustained participation in work activity would increase the QLS total score mainly through improvements in the Interpersonal Relations and Intrapsychic Foundations subscales. Method Participants. One hundred fourteen veterans with DSM-IV (APA 1996) diagnoses of schizophrenia or schizoaffective disorder as determined by the Structured Clinical Interview for DSM-IV (SCID, Spitzer et al. 1997) diagnosis were invited to participate in a study on the rehabilitative effects of work. Participants were eligible if they were deemed clinically stable (no housing changes, psychiatric medication alterations, or hospitalizations in the 30 days prior to intake) and never had been diagnosed with organic brain disease. The sample was primarily male (96%), with an average age of 43.37 years and 12.6 years of education. The sample was 65 percent white, 30 percent African- American, and 5 percent Latino. The diagnostic distribution for the sample was 77 percent schizophrenia and 23 percent schizoaffective disorder. The sample had an average age at first hospitalization of 26 (standard deviation [SD] = 7.8) years and an average of 12 (SD = 11.81) lifetime psychiatric hospitalizations. Current symptom levels were measured by the Positive and Negative Syndrome Scale (PANSS, Kay et al. 1987). Using a five-factor model (Bell et al. 1994) of the PANSS, this sample demonstrated a total symptom score of 73.20 (SD = 9.3), a positive symptom score of 18.55 (SD = 6.12), a negative symptom score of 16.57 (SD = 6.10), a cognitive disorganization symptom score of 18.75 (SD = 5.19), an emotional discomfort score of 11.61 (SD = 3.86), and a hostility symptom score of 7.42 (SD = 2.86). Of the 114 participants in this study, 80 (70%) had held at least one full-time position for a year or more during their lifetime. Eight (7%) had never held a full-time job, and 26 (23%) had held a full-time job for less than 1 year. Seven (5.9%) participants reported some vocational activity (volunteer work or enrollment in another vocational program) in the 2 weeks prior to starting the study. One was working part-time competitively at intake. Besides the money that participants were making from work at intake, the average participant was also receiving $1,234 (SD = $900) per month in benefits, including Department of Veterans Affairs (VA) pensions, supplemental security income (SSI), Social Security Disability Insurance (SSDI), and rent subsidies. 250

Quality of Life Benefits of Paid Work Activity Schizophrenia Bulletin, Vol. 28, No. 2, 2002 Instruments QLS. The QLS is a semistructured interview based on 21 items. Items are rated on a seven-point scale from severely dysfunctional (0) to adequate function (6). The 21 items measure four domains of QOL: Interpersonal Relations, Intrapsychic Foundations, Instrumental Role Function, and Objects/Activities. It should be noted that the QLS is not a conventional self-rating of satisfaction with current life circumstances. The ratings are made by a trained rater who elicits information regarding frequency, amount, and completeness of QOL issues. The ratings indicate the interviewer's judgment of the quality of the respondent's functioning. A rater-based method was selected for two reasons. First, we knew that degree of insight often affects pure self-report measurement. For example, increases in insight have been associated with decreases in self-report QOL ratings. Therefore, a raterbased method may allow for a potentially more accurate account of data. Second, we wanted to have similar methods of collecting symptom and QOL data. QLS ratings were obtained by four trained raters (two Ph.D.-level clinicians and two master's-level research assistants). One Ph.D.-level clinician (program director) served as the standard rater and performed ratings with each of the other raters in pairwise succession (15 pairs each). Average interrater reliabilities were calculated using the intraclass r (Cicchetti and Sparrow 1981). Intraclass r's were QLS total r = 0.92, Instrumental Role Function r = 0.91, Objects/Activities r - 0.88, Intrapsychic Foundations r = 0.84, and Interpersonal Relations r = 0.82. To avoid circular results regarding the QLS Instrumental Role Function (the treatment being a work program), this domain was eliminated from all analyses and the QLS total score was adjusted accordingly. Quality of Life Interview Finance section. The Quality of Life Interview Finance section (Lehman et al. 1988) includes four questions regarding perception of one's current financial situation. Items include how comfortable the participant feels financially, how well off the participant is, how the participant feels about money for basic needs, and how the participant feels about money for recreation. Items are rated by the participants on a seven-point scale from terrible (1) to delighted (7). This set of items was administered only at intake and 5-month followup. Procedures. After participants had been fully informed about the study on the clinical benefits of work activity and had given their consent, demographic and diagnostic information was collected using the SCID. The SCID was conducted by a Ph.D.-level project director or a trained master's-level research assistant. Questions of diagnosis were resolved through consultation with the National Center for Schizophrenia Research at the West Haven VA Medical Center. Following the diagnostic interview, participants were administered the QLS, the Finance section of the QLI, and the PANSS as part of a more comprehensive intake battery. Ninety-seven participants were then randomized to either the Pay condition ($3.40/hr) or the No Pay condition, and another 17 participants were paid for their participation at the conclusion of the randomized design. All participants were offered a 26-week job placement working alongside full-time employees at the West Haven VA Medical Center in areas such as medical records, patient transport, and the Blind Center. Each placement offered up to 20 hours of work per week and involved duties roughly equivalent to those of an entry-level position. Supervision was provided by full-time employees. Weekly productive activity was verified through timecards, which supervisors initialed. Participants also attended weekly worker support group meetings designed to focus on each participant's work experience. Weekly individual meetings for staff participants were also part of the program. These meetings were used as opportunities to assess symptom levels (PANSS) and quality of life (QLS). Complete quality of life assessments including the QLI and QLS were conducted only at intake and the 5-month assessment. Although the work program was 6 months long, the 5-month assessment was used as the final QOL measurement because 5 months was hypothesized to be sufficient for any QOL benefits to have occurred, to avoid some of the confounding effects of termination (e.g., symptoms increasing at 6 months because of distress over the work program ending) found in previous research, and to ensure temporal consistency with other variables measured at 5 months. For this study, only participants with initial assessment and 5-month followup QLS data were included. This resulted in excluding five participants who failed to complete their 5-month assessment. T tests were conducted on critical intake variables (symptoms and QLS), and no significant differences were found between participants who had the 5-month assessment and those who did not. For the secondary analyses (correlation of weeks worked with QLS scores for participators), data from participants with an intake QOL, at least four monthly QOLs, and the 5-month follow-up QOL were included. Missing monthly data were handled by interpolating scores between preceding and subsequent months (averaging the two closest data points). Analysis Three sets of analyses were conducted. The first set was an "intent-to-treat analysis" conducted to answer ques- 251

Schizophrenia Bulletin, Vol. 28, No. 2, 2002 G. Bryson et al. tions regarding the role of compensated work rehabilitation on QOL ratings. These analyses involved all 97 participants randomized into either the Pay condition or the No Pay condition. Analyses of covariance (ANCOVAs) using intake QLS and QLI ratings as a covariate were used to measure group differences at the 5-month assessment. As a post hoc comparison, we analyzed the data of participants who were randomized to the No Pay condition but subsequently obtained paid employment on their own. We used this second analysis to further clarify the role of the pay in QOL. Table 1 summarizes our findings. The second set of analyses focused on the relationship between amount of participation in work therapy and QOL. These analyses involved a larger sample (114), which included 17 participants who were not part of the Pay/No Pay randomization all were paid. As with our previous research (Bell et al. 1996), three post hoc groups were then created: (1) full participators participants who worked at least 1 hour per week in 17 or more weeks, (2) partial participators participants who worked at least 1 hour but did not reach the full participator criteria, and (3) nonparticipators participants who did not work a single hour. Seventeen weeks of work, which is participation in almost three-fourths of the intervention, was chosen as the cutoff between partial and full participators because we reasoned that it represented sufficient exposure for the QOL benefits of work to become evident. ANCOVAs using the intake QOL scores, comparing QOL measures for each group, were conducted. Furthermore, correlations between the hours of participation and QOL scores were conducted. Finally, to determine the relationship between consistent intervention exposure and QOL ratings, a correlation of weeks in program and QLS scores for the full participators was conducted. To investigate the relationship between pay and participation with respect to QLS performance, we categorized the participants into four groups: pay/work, pay/no work, no pay/work, and no pay/no work. To be considered as having worked, a participant had to log at least 1 hour of work in the program. We then conducted an ANCOVA for the QLS variables using the intake QLS score as the covariate. Results I Pay versus No Pay. Fifty-three participants were randomized to the Pay condition, and 44 were randomized to the No Pay condition. The / tests revealed that participants in the Pay condition worked significantly more hours (mean = 269.93, SD = 185.01) in their placements over the 5-month intervention than the No Pay participants (mean = 97.21, SD = 166.01; t = 5.17, df= 96, p < 0.001). Participants in the Pay condition earned more money (mean = $964.10, SD = 807.60) during the 5- month intervention period than the No Pay participants Table 1. Summary of results Analysis Focus Type of Analysis Sample Results Effects of pay on hours of work ftest 53 Pay 44 No Pay Paid participants worked significantly more hours and made significantly more money. Effects of pay on QOL variables ANCOVA 53 Pay 44 No Pay Paid participants had higher QLS total and Intrapsychic Foundations scores at 5 months. Effects of participation on hours of work ANOVA 46 full 46 partial 22 nonparticipators Full participators worked significantly more hours and made more money than partial participants and nonparticipants. Effects of participation on QOL variables ANCOVA 46 full 46 partial 22 nonparticipators QLS total ratings significantly higher for full participators. Intrapsychic Foundations ratings significantly higher for full participators. Pay and work on QOL variables Correlation Correlation ANCOVA 114 participators 46 full participators 76 pay/work 22 no pay/work 16 no pay/no work 0 pay/no work QLS total and Intrapsychic Foundations change score correlated to hours of work. For full participators there were strong correlations between weeks of work and QLS total and Interpersonal Relations scores. QLS total score significantly higher for pay/work group. QLS Intrapsychic Foundations score significantly higher for pay/work group. Note. ANCOVA = analysis of covariance; ANOVA = analysis of variance; QLS = Quality of Life Scale; QOL = Quality of Life. 252

Quality of Life Benefits of Paid Work Activity Schizophrenia Bulletin, Vol. 28, No. 2, 2002 (mean = $383.72, SD = 845.22; t = 5.47, df = 96, p < 0.001). Eight (18%) No Pay participants obtained paid work outside the program during the 5-month intervention period. On average they worked 177 hours (SD = 72.32) and earned $989 (SD = 190.23). An intent-to-treat analysis, using all participants randomized to either the Pay or the No Pay condition, was conducted to assess changes in QLS scores from intake to followup. Mean scores were calculated for the adjusted QLS total (subtracting out the Instrumental Role domain) and three domain scores for participants in the Pay or No Pay conditions. An ANCOVA comparing QLS total scores for the Pay and No Pay conditions at followup (intake QLS total score used as the covariate) revealed that Pay condition participants had significantly higher scores (F = 7.62, df= 2,94, p < 0.01; mean adjusted totals for Pay participants = 47.44 and for No Pay participants = 41.98). An ANCOVA on the individual domain scores indicated significant group differences in the Intrapsychic Foundations (F = 13.72, df= 2,94, p < 0.001) domain (figure 1). No other significant differences were found on the QLS. Comparisons of the Pay and No Pay groups on the Lehman QLI Finance section revealed no significant group differences. Results II Level of participation. We analyzed the effect of participation on QLS scores in several ways. First, we created post hoc participation groups as described in the Analysis section. Participants in the full participator group (n = 46) worked more hours (mean = 383.32, SD = 134.11) during the 5-month intervention period than either the partial participators (n = 46, mean = 104.28, SD = 126.27) or the nonparticipators («= 22, mean = 34.45, SD = 120.04; F = 77.66, df = 3,111, p < 0.001). Mean hours included all hours worked in the program and all hours worked outside of the program during the 5-month active phase. To compare changes in QLS ratings, group mean scores were calculated for the QLS total and the domain scores. An ANCOVA comparing the QLS totals at followup (with intake QLS total as the covariate) revealed significant group differences (F = 4.74, df = 3,111, p < 0.01). Multiple comparison t tests showed significant dif- Figure 1. Quality of Life Scale (QLS) by Pay and No Pay groups at 5-month followup* 50 47.44 40 30 22.36 20 **.57 18.63 17.08 10 649 Intrapsychic Found. Interpersonal Rel. 6.29 Common Objects Total Pay (n=53) No-Pay (n=44) Adjusted (least squares) means, using intake QLS scores as covariate. ** Significant differences between groups, post hoc t test, p <.05 253

Schizophrenia Bulletin, Vol. 28, No. 2, 2002 G. Bryson et al. ferences between full participators (adjusted mean = 48.4) and both partial participators (adjusted mean = 42.3) and nonparticipators (adjusted mean = 41.6). There was no significant difference between partial participators and nonparticipators. An ANCOVA for the domain scores also revealed group differences. Significant differences were found in the Intrapsychic Foundations subscale (F = 9.04, df = 3,111, p < 0.001), with post hoc t tests revealing that full participators had significantly greater scores (adjusted mean = 22.8) than both partial participators (adjusted mean = 18.87) and nonparticipators (adjusted mean = 17.99). No significant differences were found between the partial participators and the nonparticipators. ANCOVAs of the Interpersonal Relations and Objects/Activities scales were not found to differ by level of participation (figure 2). Furthermore, no group differences were found on the Lehman QLI Finance scale. We then correlated the number of hours in the program with the change in QLS (5-month QLS ratingsintake QLS ratings) for all participants. The QLS total change score was modestly correlated with hours (r = 0.21, p < 0.05), as was the Intrapsychic Foundations change score (r = 0.30, p < 0.01). The other domain change scores were not significantly associated with hours of work: Interpersonal Relations (r = 0.14, p < 0.15) and Objects/Activities (r = 0.01, ns). Finally, we wished to analyze the relationship between QLS changes and time spent in the program for our most consistent participants, the full participators. The mean QLS scores for participants at each observation was correlated with the week number of that observation. This analysis indicated that the QLS total score was significantly related (r = 0.78, p < 0.03) to program week for members who worked in the program for at least 17 weeks. The Interpersonal Relations domain was also significantly related to program weeks (r - 0.77, p < 0.04). These results indicate that the mean score for full participators on these two measures increased in a linear fashion from intake through 5 months of participation. The Intrapsychic Foundations score was not significantly related to weeks in program (r - 0.64, p < 0.13), nor was the Objects/Activities domain (r = 0.29, p < 0.53). Results III Pay and work. Participants were recategorized according to pay and participation in work. In this analysis, the pay variable is not randomization to the Pay con- Figure 2. Quality of Life Scale (QLS) by participation groups at 5-month foliowup* Intrapsychic Found. Interpersonal Rel. Participator (n=46) Common Objects Total Partial (n=46) Non-Part. (n=22) 'Adjusted (least squares) means, using intake QLS scores as covariate. ** Significant differences between groups, post hoc t test, p <.05 254

Quality of Life Benefits of Paid Work Activity Schizophrenia Bulletin, Vol. 28, No. 2, 2002 dition but rather working for pay during the 6 months. If participants worked even a single hour in the 6 months, they were considered "workers" in these analyses. If participants received pay for work, they were considered "pay" in these analyses. Therefore, the eight participants who were randomized into the No Pay condition but found paid work, on their own were classified as pay/work participants in this analysis. Seventy-six participants were in the pay/work group, and they averaged 218 hours of work (SD = 89). Twenty-two participants were in the no pay/work group, and they averaged 98 hours of work (SD = 91). Sixteen participants were classified as no pay/no work, and by definition there were zero participants in the pay/no work group. We then conducted an ANCOVA to compare the QLS scores at followup for the three groups. For the QLS Total score there was an overall significant difference by group (F = 7.22, df= 3,111, p < 0.001). The pay/work group had an adjusted mean of 48.65, the no pay/work group had an adjusted mean of 40.73, and the no pay/no work group had an adjusted mean of 38.97. There was a significant difference (p < 0.01) between the pay/work group and both the no pay/no work group and the no pay/work groups. For the QLS Intrapsychic Foundations domain there was an overall significant difference by group (F = 10.20, df= 3,111, p < 0.001). The pay/work group had an adjusted mean of 21.90, the no pay/work group had an adjusted mean of 17.64, and the no pay/no work group had an adjusted mean of 16.71. The pay/work group had significantly higher scores than the no pay/work group (p < 0.001) and the no pay/no work group ip < 0.001). For the QLS Interpersonal Relations scale there was a trend by group (F = 2.73, df= 3,111, p < 0.06). The pay/work group had an adjusted mean of 18.73, the no pay/work group adjusted mean score was 16.46, and the no pay /no work group had an adjusted mean score of 15.64. There was no significant group difference on the Objects/Activities (F = 0.24, df= 3,111, ns) domain. Discussion Our results revealed that pay has a significant effect upon participation in work activity by showing that participants in the Pay condition worked significantly more hours and weeks in our rehabilitation program. Participants randomized to the No Pay condition were unlikely, although 18 percent did, to find alternative work activity, which reflects the limited vocational opportunities available for them, even in a booming economy, outside of our work rehabilitation program. Most participants opted to not work at all rather than work in our No Pay condition. Central to our hypotheses, participants randomized to the Pay condition demonstrated greater increases in the QLS total score and the Intrapsychic Foundations subscale score than those in the No Pay condition, indicating a general improvement in overall QOL and a specific increase in motivation and sense of purpose. Additional support for the influence of pay on QLS was demonstrated by comparing the participants after being classified into pay/work, pay/no work, no pay/work, and no pay/no work. In this set of analysis there was a clear trend in QLS total scores indicating that although work itself had some beneficial effects on the QLS total (no pay/work was higher than no pay/no work), the synergy of paid work had the most benefits. Moreover, when we divided the participants into post hoc groups based on level of participation, it appeared that level of participation in work was strongly related to QOL improvements. Also, full participators had significantly greater QLS total and QLS Intrapsychic Foundations scores than partial participators or nonparticipators, regardless of their randomization into pay condition. This finding matches what participants often talked about in our workers' meetings. Workers often talked about how they felt that work enhanced their life by giving them a reason to get up each day, providing them with purposeful activity, giving them a greater connection to normal social processes, and offering greater access to opportunities for interpersonal interactions. They talked about how knowing they needed to get up in the morning to work helped them structure their time better. They were less likely to stay up late, less likely to drink alcohol or use marijuana during the work week, and more likely to approach other activities with some planning and determination. In general, participants felt a sense of accomplishment and improved self-esteem. Although we had expected participation in work activity to increase QOL scores, we did not anticipate that more of the improvement would be found in the Intrapsychic Foundations domain than in the Interpersonal Relations domain (the improvement did not reach significance in post hoc comparisons of participation groups). It seems counterintuitive that more participation would not improve interpersonal functioning, because even in the most isolated work environment there should be an increase in available social contact. However, access to more people may not translate into more social interaction if participants fail to take advantage of the opportunities or if symptoms, such as paranoia or anergia, mitigate social drive. Perhaps the correlation, for the full participators, between weeks in the work program and improved interpersonal ratings provides an alternative explanation. Although significant differences were not found among post hoc participation groups, a significant time effect for interpersonal function ratings was found for the full participators. It may be that developing relationships at work 255

Schizophrenia Bulletin, Vol. 28, No. 2, 2002 G. Bryson et al. takes time, and it probably takes more time for relationships outside of such a structured setting to develop. The 5 months provided in our work program may have been insufficient to bring about a significant between-groups effect. With more time, significant interpersonal improvements might have been found in the post hoc analysis. For example, one of our participants (we will call him Peter) described to us the evolution of his relationship with a coworker. At first Peter had felt anxious and paranoid around his coworkers. After 17 weeks on the job, Peter had a conversation about family with one of his coworkers during break. The coworker mentioned that his son would be in an upcoming karate exhibition, and Peter said that he'd like to go because he had some interest in martial arts. The exhibition was on a weekend. Tickets were $2, but Peter felt that the money he earned from work would be well spent on this activity. His coworker appreciated Peter's attending the exhibition, and this solidified their friendship. Peter experienced a meaningful improvement in the quality and quantity of peer relationships measured on the QLS. Although this process happened for Peter near the end of the 5-month time frame of our study, for others the process may be more gradual. He took initiative in a way that others find more difficult. Especially for those with negative symptoms, even tiny advances toward social interactions outside of family members can take great effort. Despite overall improvement in QLS ratings for paid participants, there were no significant differences in selfperception of financial situation on the QLI. It seems logical that because paid participants earned significantly more money, they would perceive their financial situation as better. Perhaps the modest earnings from the work program did not constitute enough income to alter overall perceptions of financial well-being. The average participant earned approximately $165 per month from the program but continued to receive more than $1,200 per month from SSDI, SSI, and VA pension programs. Therefore, it is possible that this 11 percent increase in income might not have been perceived by participants as a significant earnings improvement. This is just speculation, however, as there may be unmeasured mediating factors, such as monthly expenditures, that affect perceptions about one's financial situation. Although the results indicate that participation in paid work improves QOL, several limitations to the study must be noted. First, our subjects were almost exclusively men in their mid-40s with a lengthy treatment history. Therefore, our sample may not have been representative of the broad range of schizophrenia patients. Second, although attempts were made to have blind QLS raters at followup, this was not always possible. In fact, the average participant was interviewed by multiple raters (three or four) at the various monthly appointments over the course of the study. However, in most cases the rater of the first interview was not the rater on the 5-month interview. Although rater bias is highly unlikely, it cannot be ruled out. Finally, although pay was a randomized variable, our participation levels were constructed post hoc and therefore the ANCOVA results between levels of participation and QOL improvements should not be interpreted as causal. There may be a self-selection influencing those who end up as full participators. Thus, although participation level is associated with QLS benefits, it remains possible that some other characteristic of participators is responsible for their QOL improvement. Finally, the duration of work activity was relatively brief. 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