“High functioning schizophrenia” is not a clinical diagnosis, but it is a term that is heard often when describing how someone is managing life with schizophrenia. So what exactly does that mean? What criteria do you have to meet to be considered “high functioning”?
Host Rachel Star Withers, a diagnosed schizophrenic, and co-host Gabe Howard delve into these intense subjects in this episode of Inside Schizophrenia.
Dr. Matthew Smith joins us who is a Professor of Social Work at the University of Michigan and a researcher of high functioning schizophrenia.
Matthew J. Smith, PhD, MSW, MPE, LCSW, received his PhD from the University of Wisconsin-Madison and completed post-doctoral fellowships in psychiatric epidemiology and biostatistics at Washington University in St. Louis and in translational neuroscience at Northwestern University. Dr. Smith also completed a fellowship on leading randomized controlled trials to evaluate behavioral interventions through the Office of Behavioral and Social Science Research, National Heart, Lung, and Blood Institute. His primary research interests focus on developing and evaluating technology-based interventions that can be delivered in high schools, community mental health agencies and prisons to improve employment and mental health outcomes for transition-age youth with educational disabilities, adults with severe mental illness and/or other disabilities, and returning citizens.
Dr. Smith is currently the principal investigator on five projects funded by the National Institute of Mental Health, the National Institute of Justice, the Kessler Foundation and the Michigan Institute for Clinical & Health Research. See research link below for more information on these projects.
Dr. Smith’s research team includes full-time staff, postdocs and graduate students. Please email email@example.com about opportunities to join the research team.
Rachel Star Withers creates videos documenting her schizophrenia, ways to manage and let others like her know they are not alone and can still live an amazing life. She has written Lil Broken Star: Understanding Schizophrenia for Kids and a tool for schizophrenics, To See in the Dark: Hallucination and Delusion Journal. Fun Fact: She has wrestled alligators.
To learn more about Rachel, please visit her website, RachelStarLive.com.
Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.
Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without. To learn more about Gabe, please visit his website, gabehoward.com.
Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.
Announcer: You’re listening to Inside Schizophrenia. Hosted by Rachel Star Withers, an advocate who lives openly with Schizophrenia. We’re talking to experts about all aspects of life with this condition. Welcome to the show!
Rachel Star Withers: Welcome to Inside Schizophrenia, a Healthline Media podcast. I’m Rachael Star Withers here with my co-host Gabe Howard. Now if you’ve been diagnosed with schizophrenia for some time, you’ve probably heard the term high functioning schizophrenia. I have loved ones of people ask me regularly, how can I help my son, daughter, family member with their schizophrenia to become high functioning? And my response is always, what do you think that means?
Gabe Howard: What does that mean? Is it a medical diagnosis? Is there like schizophrenia, paranoid schizophrenia, high functioning schizophrenia is as far as I know. There’s just schizophrenia. And all these other words that we put in front of it are just words that the community fills in gaps on their own and it’s essentially meaningless.
Rachel Star Withers: High functioning is a subjective term, there isn’t even an exact definition of what do you consider high functioning? Generally, it means that a person with schizophrenia is able to carry on their daily activities and function in society, the world around us and have an occupation or is in education. To help us understand high functioning schizophrenia, we have today Dr. Matthew Smith and he is a professor of social work at the University of Michigan and also a researcher of high functioning schizophrenia.
Gabe Howard: I’m very excited that you spoke with him because he is researching high functioning schizophrenia, which lends some credence to the idea that it’s a real thing. I’m really interested to know what definitions he used and what definitions he found out in the community. So that’ll be coming up later. And Rachael gets to the bottom of that and more.
Rachel Star Withers: Yes. Within the past few weeks, twice I’ve had someone refer to me as high functioning. The first time it was, Wow, you’re really high functioning. Which honestly, I kind of feel is like a backhanded comment, like, okay, so what were you expecting? Like, Wow, you’re talking to me in complete sentences. You are so high functioning and I know the person meant it nicely, but I really it felt like a backhanded comment. And then the other time, I’ve never met someone with schizophrenia as high functioning as you. Now here’s my problem, Gabe, and I get this all the time. When people say, I’ve never met a person with schizophrenia, you’re the first. If you remember our last episode, what percentage of people have schizophrenia?
Gabe Howard: 1 to 3%, Rachel.
Rachel Star Withers: Absolutely. That’s the kind of estimate gauge. So if 1% of people have schizophrenia and you’re in a group of 100 people, mathematically there’s a schizophrenic running around in there. Now you’re probably thinking, well, Rachel, I don’t recall someone screaming wildly at the last concert I went to. Right, we’re not always.
Gabe Howard: Well, now, wait a minute. Screaming wildly? You’ve actually stumbled upon, like the perfect analogy, we think we think we know what people with schizophrenia act like.
Rachel Star Withers: Exactly.
Gabe Howard: So you said screaming wildly at the last concert I went to. But interestingly enough, if you went to the last concert and everybody was screaming wildly, you wouldn’t think schizophrenia. You’d think in the moment having fun. So we’re attributing all of these things to people with schizophrenia that may or may not be the case. And Rachel, as I’ve pointed out numerous times, do you know how many people I have introduced you to and I’m like, hey, this is my friend Rachel? And then like three years later, they see on Facebook that you have schizophrenia, probably because I’m advertising one of these podcasts or talking about a project that we’re doing and they’re like, Wait, is that the Rachel I met? Are you sure? What happened? Nothing happened. She’s the exact same person that you met. One, two, three, four, five years ago. She just didn’t lead with, Hi. I live with a persistent mental illness that I take daily medications for, and sometimes I stumble. But most of the time I’m just out there enjoying my life. I’m so glad that I could bring this up with a stranger that I just met who Gabe introduced me to. This is not the way it’s done.
Rachel Star Withers: Something else that you’re interested in, Gabe, that that we share a common like is the Rolling Stones.
Gabe Howard: We do.
And you’ve been to many of their concerts. I got to go to one for the first time last year. And there were 45,000 people there. 45,000 people that so that that number alone is like hard to imagine. So how many schizophrenics technically were probably running around in that stadium with me?
Gabe Howard: So percentage-wise you could say 450, right? 1%.
Rachel Star Withers: Yeah.
Gabe Howard: But I have a feeling that the average person listening to this would say, well, but people with schizophrenia are too sick to go to concerts.
Rachel Star Withers: Mm-hmm.
Gabe Howard: That’s the that’s the general notion that I hear from people when I give examples like this. I was like, well, statistically, if, you know, 100 people, one person has schizophrenia and they say no, because that person with schizophrenia would be at home or they would be institutionalized or I would know because of their behavior. There’s a lot of that that goes on when the reality is yes, that is possible. We do discuss symptoms of schizophrenia on this show quite often. So I’m not saying that people are wrong. And obviously, the phrase itself high functioning. We all want to be high functioning in everything. We’re just pointing out that we say this person has schizophrenia, but they’re high functioning, but we never say, hey, this mom has three kids, but she’s high functioning. You would never say that about some etc. So on one hand it is complementary. I think Rachael loves to be functioning at very high levels as we all do, but it does seem sort of pejorative that somebody has to asterisk your life with the phrase high functioning.
Rachel Star Withers: What exactly then is high functioning schizophrenia considered to be? And it depends on who you ask. If you would ask me, Rachael, I would say high functioning schizophrenia is relatively surviving at life, meaning you feel like you are a contributing member of society. Notice I said you feel, not that you are. Because that’s going to be up to what other people think. Gabe’s assumption of me contributing to society might be completely different than what my mom thinks, than what I think. So you feel you are contributing to society. You have a safe place to live, access to food, a support system, and you are actively managing your schizophrenia. To me that would be high functioning and apparently, I’m wrong. Apparently, I was completely wrong in my assumptions these years. So, here are some of the other definitions that kind of came for me a little bit, Gabe. I was like, Oh, these people don’t think I’m doing as good as I thought I was. People with schizophrenia who function at a high level typically still have the hallmark symptoms of schizophrenia, disorganized thinking and occasional breaks with reality, but are able to manage their way through them. I say, okay, that kind of fit fits with my definition. Yeah, you still have symptoms. High functioning does not mean that you are symptom free.
Rachel Star Withers: Another definition is high functioning. Schizophrenia tends to refer to the individual’s ability to manage their symptoms. That way they can engage in meaningful work and education. Oh, I feel that I, I work, you know, not full time, part-time, Gabe, doing this. I can’t work 40 hours a week. I get really weird. I can’t live alone. But so far, I felt like, yeah, I fit into those definitions. But here we get the most specific because in 2010, researchers got together and they did a presentation where they examined the characteristics of highly functioning people with schizophrenia, and this is how they defined high functioning schizophrenia. The person has been able to maintain one of the following roles for at least six months: a full-time professional, technical or managerial job, or a significant responsible position as a full-time caretaker or responsibilities as a full-time student. I don’t meet any of those at all. I have at one point in my life, but definitely not within the past 15 years. And it upsets me slightly because each of those little notes is about full-time and it’s like society decided how many hours a day I have to be functioning. And I can’t meet that level.
Gabe Howard: It’s really interesting to me to read this definition, because if you remove schizophrenia, there’s many people that I guess just cannot define as high functioning. Forget about the schizophrenia part. For example, anybody who does not have a full time job in the last six months. I guess they’re low functioning? And then where does where do we draw the line there? I mean, let’s say that I take the next year off work for whatever reason, maybe my wife is working and in that year I volunteer daily. Now it’s not full-time employment, but maybe it is, it just pays zero? Now we look at a significant, responsible position as a full time caretaker. Now, I think we can all think of somebody who is, in fact, a, quote unquote, full time caretaker or taking care of somebody who’s just doing a bad job. And have we ever seen that person? We’re like, Well, hey, you are high functioning even though you’re screwing up the care of that person. Or you’re just doing a terrible job at your full-time job.
Gabe Howard: But, hey, because you’re still employed, I guess you’re high functioning. And then finally, a full-time student. Listen, there are colleges and universities all over America where people say this D is for degree. Apparently if you are getting a D at the local community college or you are on a full ride scholarship working on your third doctorate from Harvard, you are both high functioning. It just really starts to fall apart at the seams. And notice in my definition, nobody had schizophrenia, I believe that this whole idea behind high functioning schizophrenia is a way to compliment somebody with schizophrenia, but still make sure that schizophrenia stays front and center.
Rachel Star Withers: Being high functioning isn’t like you get the label and you’re like, okay, done. I’ve made it. It can change in your life. As I said earlier, there were times, yes, where I was a full-time student when I first started in college, I was doing the maximum hours possible. By the time I was finishing college, I was barely doing the minimum and I had to be considered full-time to keep my scholarship. I was doing the absolute minimum and struggling to hold it, so that was just in four years. And I would say, Rachel, were you high functioning at the end of your college career? No, I was not. I was barely making it there. The entire thing was a blur. It’s shocking that I graduated. Yeah, and that’s just in four years I could completely be someone different. And even now, I look back on times in my life, even a few years ago, where I can be like, Wow, yeah. For a good six, seven months, I. I was barely hanging on. You know, my dad was having to check on me every day. They were worried about me because I was isolating. I wasn’t eating. You would not describe me as high functioning, whereas so many people see me and they’re like, Oh wow, Rachel, you’re doing so great. But it’s a good way to kind of gauge yourself and gauge people that you’re trying to help with schizophrenia and be like, hey, you know, a year ago you were at this level. Now you’re either doing a lot better or you’re doing a lot worse. What’s changed?
Gabe Howard: Judging yourself by a previous marker. I do think is a good thing. I think that’s really, really vital for people with schizophrenia or bipolar disorder or really any health issue. Right. Constant improvement is great. And if you step back, if you have a setback, it’s good to know that you have a setback so that you can leap forward again. But Rachel, with that in mind, when we talk about the term high functioning schizophrenia, who do you think that term has been designed for? Do you think that people with schizophrenia are using it more, or do you think that the people around people with schizophrenia are using it more? Friends, families, doctors, whomever? I’ve really never heard anybody living with schizophrenia ever once say to me, Hi, I have high functioning schizophrenia. They say, I have schizophrenia, I live with schizophrenia. I’m a schizophrenic. I never hear the term high functioning come from somebody living with schizophrenia. I always hear it from friends, families, doctors, medical providers or society at large.
Rachel Star Withers: And I actually I thought about this question and my answer is the last time I can think that I volunteered it, was I had to see a new psychologist. And she was upset about the medications I was on and she wanted to immediately change them. This is our first meeting and I remember saying, Well, I’m actually pretty high functioning. And I was saying it there as a defense because she was ready to just, I did not go back to her, by the way, change all of my medications. And one of the things she first said to me was that, look, I used to work in the E.R. with people with schizophrenia. You don’t have schizophrenia. You’re able to talk too clearly. That was a huge red flag that this lady I’m like, okay. And I even pointed out you only worked with people with schizophrenia who were in crisis mode. And you very well could have met me at that moment and thought the exact same thing. But I’m not in crisis mode right now.
Gabe Howard: It’s always very interesting to me in this discussion with high functioning schizophrenia is that when somebody sees you at a low point, they assume that that’s where you always stay. And
Rachel Star Withers: Yes.
Gabe Howard: When somebody sees you at a high point, they’re like, Oh, but you’re high functioning for the moment, or you’re having a really, really good day.
Rachel Star Withers: Earlier when I said back when I was first starting college, so back when I was a young, adorable little early twenties. Yeah, I was doing the maximum at the college that I could take. And if you were to be like, Rachel, so that’s you at high functioning, right? That’s what you’re trying to get back to? No, no, that was horrible. I there’s a reason that I suddenly went downhill after that. That was like, right before I had a major psychotic episode and everything fell apart. And I have no desire to ever get back to that stage because I couldn’t handle it mentally. I’m much happier with the schedule that I keep now. So when I say comparing yourself to pass points, that’s not always a good thing. I’ve held full-time jobs in the past. I didn’t hold them for very long and it didn’t go well. It never ended well for me, but I’ve accepted that. Yeah, for me, managing my schizophrenia does not look like holding a 40 hours a week job. It just absolutely does not because I can’t do both manage my schizophrenia and work 40 hours. Now, can I work around 15 to 20 and manage? Absolutely. I’ve learned, yes, I can. So.
Gabe Howard: Learning all of these things allows you to manage your life in the best possible way. Tying holding down that job to whether or not you’re high functioning, I do think is a devil’s errand because, for example, I think that it’s extraordinarily high functioning to say, look, I can work 20 hours, but I can’t work 40 hours or I can work 2 hours as long as I have a one hour break. I can work six days a week, but I must have one full day of rest. Like figuring out all of those little tricks to both manage your life, your career, and, of course, schizophrenia. That all seems incredibly high functioning to me. You’ve given a really detailed explanation of how you have figured out your career and how to make money and how to support yourself. That seems extraordinarily high functioning to me, but I would like to point out it doesn’t meet the criteria.
Rachel Star Withers: Right away, when you were just describing me, so many red flags popped up in my head of oh, well, that’s not actually true. One of them, you said you’re able to find a way to make money and support yourself. I live with my parents. For me to be in the situation that I am, I have an incredibly strong support system. If I didn’t, things would be very different for me. And I can guarantee you would not consider me high functioning at all. You’d be like, Wow, Rachel, you can barely keep an apartment. You can’t live by yourself. You get weird. It’s because of my support system. It’s because of other factors that I’m able to do as well as I am. And when they’ve done research into the people that they consider high functioning, a lot of the time, that’s the kind of stuff that they found. The more education you have, the more likely you are to be high functioning. Your attitude towards treatment means you’re more likely to be high functioning. And I’m assuming there they mean you’re pro treatment, which even to be you have to be at a certain mental level of knowing. Like if I’m in the middle of a psychotic episode, I can’t make the decision of yay treatments. good for me. That I have to be in touch with reality to make those decisions of, Hey, I need to go get help. There’s something very wrong with me.
Gabe Howard: Rachel, thank you for pointing out that everybody’s situation is completely different. You would have to make very different choices if you did not have the family that you have or the support system that you have, or the ability to make an income in the way that you do. Or even if you lived in a different place. And you have to make the best of the decisions for you. You have to reach those decisions. But I still want to focus in on, Rachel, the insight you just listed off every single plus and minus that you have in your life. And while I really appreciate that you always give credit to the people in your life for the things that they have done to help you manage your life.
But you’ve put all of that together and you’ve figured out your best way forward. Again, I know that you don’t work 40 hours a week, so therefore I guess you’re not high functioning. But this just seems like a remarkable amount of insight to have for somebody that isn’t meeting the definition of high functioning. I don’t even have that much insight about my life.
Rachel Star Withers: A 2016 study actually tried to zero in are what are the differences between someone high functioning and someone low functioning with schizophrenia. And it really comes down to this, the people they considered high functioning had a higher ability to observe and understand other people’s facial expressions. In other words, they were able to react more appropriately. They said that people with high functioning schizophrenia had preserved their social perceptual abilities. So it really comes down to how other people view you. It really comes down to how do other people see me, is how high functioning they think I am. If I’m in the corner talking to myself, even, let’s say if I have a full-time job, but I’m in the corner talking to myself, that’s weird. That’s weird. I don’t trust that person. They should be locked up. They shouldn’t be working. They should. Even if I’m able to do those things, if I’m able to go to college full time. But let’s say that I act odd. Let’s say I can’t work in groups. Let’s say I get lost in the hallway, which are all things that happen to me regularly. Then I don’t think she’s high functioning. She’s barely holding on. When it comes to the actual symptoms of schizophrenia, the only difference they found between high functioning and low functioning people with schizophrenia was bizarre behavior and thought disorder seem to be less common in those considered high functioning. Notice the first one was bizarre behavior, which, again, that could mean, that could mean a lot of things. You know, what you consider bizarre?
Gabe Howard: That was going to be my next question. Rachel, what is considered bizarre behavior? Depending on the area of town, your culture, your community, your family? Behaviors that are well accepted in certain cultures are really frowned upon by other cultures. So who gets to decide bizarre behavior? Who is determining this?
Rachel Star Withers: And that’s the problem. It’s up to each person how I perceive you. My opinion of you, Gabe? I might think, Hey, Gabe has it together, and then someone else looks at you and be like, What? He talks for a living. That’s not a job. That’s not. That’s not a real thing.
Gabe Howard: Oh, my god, you’re referencing my mother.
Rachel Star Withers: But, yeah, it’s everyone else’s view is what makes you bizarre or weird. A big issue I have and I’ve spoken about this before, I tend to talk out loud. It helps me think. I have to be very careful not to do that in public because I don’t want to look like the weirdo talking to themselves alone in the grocery store aisle. And you would think that’s bizarre behavior. To me, that’s actually a coping skill of mine. It helps me keep my thoughts in order. It’s something that psychologists that I visited have encouraged me to do. Like it helps me function. But yeah, someone else can look at that and be like, that’s, that’s bizarre behavior. Like this girl is talking to herself in the middle of the grocery store. You know, someone needs to come and get her. We’ve been talking about this high functioning term. I’m not a big fan. I actually came across some other terms that I liked a little bit more.
Rachel Star Withers: Another way is stable schizophrenia. I saw that in a few different research papers. Did the person have stable schizophrenia? In other words, were they still dealing with their schizophrenia but able to do life activities? They had the symptoms, for the most part, under control. Still experiencing them, but under control. And another one I really liked, because I feel that this captures the attitude of high functioning schizophrenia better. It was high levels of community functioning. In other words, how do you act in the community? Which kind of goes back to what we’re saying, how other people observe you? And the interesting thing about that is the main factor that determines how well people with schizophrenia interact with their community is the uncertainty of dealing with the environment. If I’m more comfortable, if I know everything going in, I tend to interact better. But let’s say I’m going to a place for the first time, let’s say I’m starting at a job for the first time. Let’s say I’m going to a festival where there’s going to be a lot of people and I’m a little uncertain about that. Yeah, I’m more likely to act odd. However you might see me the next day at my job I’ve been at for five years and be like, Oh wow, she’s so confident and she’s so outgoing. Whereas the day before, you would not have thought that. So I don’t know, I kind of like that definition because how you function in the different environments.
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Gabe Howard: Rachel, I think we should bring in our guest interview. You interviewed Dr. Matthew Smith. Now he’s a professor and the principal investigator in multiple studies, including virtual reality job training for people with schizophrenia, and social perception and high functioning schizophrenia.
Rachel Star Withers: Today we are talking with Dr. Matthew Smith, who is a professor of social work at the University of Michigan. And he’s actually done quite a bit of research into high functioning schizophrenia. Thank you so much for being with us today, Dr. Smith.
Matthew J. Smith, PhD: Oh, you’re welcome. Thank you so much for inviting me on.
Rachel Star Withers: Tell us a little bit about yourself and your research.
Matthew J. Smith, PhD: Sure. As you said, I’m a professor of social work. I’ve spent the last 20 years studying schizophrenia and other serious mental illnesses and ways to improve everyday functioning. One of those ways is through intervention, development and evaluation, and I’ve been doing that mostly for the last ten years.
Rachel Star Withers: When we’re discussing high functioning schizophrenia, how do you define that?
Matthew J. Smith, PhD: There’s probably more than one way to define high-functioning schizophrenia. So I can really just talk about the way that we study that. And that was through the ability to evaluate different measures of functioning, such as if somebody’s socially effective and their level of social functioning. And, you know, can folks do well when asked to complete a series of everyday living tasks like paying bills, scheduling appointments, and do folks engage in work and other fun activities? And so one way that we’re able to define high functioning schizophrenia is when somebody is able to kind of do those things pretty well, they can be socially effective. They can get things done on a daily basis that they need to get done. They’re able to work and enjoy fun, fun things.
Rachel Star Withers: Now is high functioning schizophrenia. Is that actually a medical diagnosis?
Matthew J. Smith, PhD: It is not. When we began studying high functioning schizophrenia, our study recruited 60 people with schizophrenia and we asked them to fill out a survey, perform a couple of research assessments that evaluated their ability to have conversations, that evaluated their ability to do some independent daily living tasks. And so based on how well they perform these assessments, that kind of informed whether they were doing these things in a way that was typical to somebody who doesn’t have lived experience of mental illness.
Rachel Star Withers: Have you found that people who have schizophrenia can kind of go from high functioning to low functioning, or do they tend to either stay high functioning or not?
Matthew J. Smith, PhD: Yeah, it’s a great question. We haven’t studied that specifically in the work that we’re doing. But you know, based on what I know of schizophrenia is that even if somebody is doing well, if you present them with a lot of life stressors where they don’t have the appropriate supports, you know, whether that support is work or whether that support is a social network like family and friends, you know, if they’re kind of left to themselves and presented with a lot of life stress, it can it can cause some disruption to their level of functioning. And they could, you know, have some struggles where they might be considered, quote unquote, low functioning, but through appropriate support and intervention, you know, they can climb back out of that that kind of dip that they might be experiencing.
Rachel Star Withers: Very interesting. Let me use myself as an example. I think most people, when they meet me, they would have no idea I have schizophrenia unless I tell them.
Matthew J. Smith, PhD: Sure.
Rachel Star Withers: Most like coworkers and whatnot, when they first meet me, they have no clue. Probably after working with me for a while, they might notice some kind of oddities that they would pick up on. So I tend to be considered high functioning. However, I can’t live alone. I can be alone for about two weeks and then I kind of become very weird and I social isolate. So for me to be high functioning, I have to live with someone who kind of watches over me. What then would that kind of classify me as? Would you still consider me high functioning or no, because of the stressors could bring me down so quickly?
Matthew J. Smith, PhD: Yeah. No, it’s a good question and I think it really revolves probably around your baseline, right? So in terms of somebody’s baseline, you know, if 300 days a year and this is just an example, you know, they’re living their baseline and then maybe for a month or two spread out over the course of that year, they have some tough times. I would still consider that person high functioning. If you have those symptoms yet, you’re able to develop the appropriate supports or coping strategies in order to kind of overcome the distress that those symptoms cause. And you’re able to, you know, work and hang out with friends and do all of those things that you want to be doing, then that’s high functioning. I mean, that tells me that you’re living the life that you’d like to live. And yes, there’s some challenges that you’re facing, but you’re able to able to overcome those or cope with them when they present themselves.
Rachel Star Withers: Now in some of your research, you have explored virtual reality job interview training with people who have schizophrenia. What did you find out from those studies?
Matthew J. Smith, PhD: The job interview is one of those very complex and anxiety inducing professional situations, right? That somebody can experience. Like everybody struggles with the job interview. And with respect to the tool that we evaluated, it’s sort of a virtual job interview simulator. The trainees, they get to repeatedly practice and interview with somebody called Molly Porter. She’s a virtual hiring manager and she works for a fictional company. And it’s, I would compare it to a remote meeting platform like Zoom or Teams or something like that where you’re on the computer, somebody is asking you questions. And what’s really neat about the Molly tool is that she has different personalities, any given time you can talk with Friendly Molly or in a different interview you could talk to Inappropriate Molly or you could talk to Unpleasant Molly. It gives you a range of different personalities to practice interviewing with. We recruited individuals with schizophrenia who were job seeking and living in the community. Participants completed 15 interviews with Molly, and this was what we call randomized controlled trials. So we had our group that was randomly assigned to practice with Molly, and then another group that was assigned to just kind of do their usual thing. We had our participants complete a couple of job interview role-plays before and after that we video recorded. And what we saw was that those participants who practiced with Molly actually improved their job interview skills during that time. And then we saw that they also improved improve their interview confidence during that time. And then we did a six month follow up, which is really neat. And what we saw was that within six months, the group that practiced with Molly, 48% of them actually received a job offer
Rachel Star Withers: Wow.
Matthew J. Smith, PhD: Versus only 14% who did not practice with Molly. So it’s a pretty big effect practicing with Molly. The tricky thing with research is that those folks practiced with Molly in a lab setting under ideal research conditions. And so you just don’t know how that’s going to play in real life. And so
Rachel Star Withers: Right.
Matthew J. Smith, PhD: The second study was actually a federally funded study where we were able to partner with a place in Chicago called Thresholds. Threshold has one of the gold standard supported employment programs called Individual Placement and Support or IPS for short. And what we did is we introduced Molly into this IPS program where half of the participants got to engage in their regular IPS employment services and they got the practice with Molly. And then the other half of the participants got to just engage in their IPS services as usual. And so then we compared their outcomes by a nine month follow up. What we saw was the group that practiced with Molly had significantly greater interview skills. A new finding was that they had significantly greater reductions in anxiety about the job interview and then they had a stronger employment rate again by nine months.
Rachel Star Withers: When it comes to using the Molly training, how does it actually help people with schizophrenia? Is it that it improves confidence? Is it that it helps them kind of focus?
Matthew J. Smith, PhD: I think one of the most important aspects is that for folks with schizophrenia, you know, there’s definitely it’s well known that there’s low employment rates. And part of the reason there’s low employment rates isn’t for a lack of wanting to work. As more than 70% of people with schizophrenia want to work. But there is some fear and avoidance. The job interview is anxiety provoking for just about everybody, let alone folks with schizophrenia who are already prone to experience anxiety. A lot of folks with schizophrenia have never even interviewed for a job. And so it’s something that presents them with fear, like, I don’t want to go on a job interview. I don’t I don’t really know what it’s like. And it’s sort of scary. But practicing with Molly, that helps alleviate that fear as we see in our, in our study. And in addition to just doing some research assessments with folks, we also interviewed them and to kind of heard in their own voice. And some of that information told us that they were able to finally see what a job interview is actually like when they interview with Molly. When they practice those interviews, it gives them comfort. Molly is sort of an exposure therapy where the more you practice with her, the more you became accustomed to what a job interview is like. That provided them with more confidence to say, Hey, I can do this on my own, and to go out into the community and try to find a job.
Matthew J. Smith, PhD: We do know that about technology based simulations is that when you’re trying to learn a skill, you really need to be able to practice it repeatedly. And an analogy I tend to use is the job interview is almost the symphony of social skills where there’s a lot that goes into it, you know, and if you practice a. Instrument one or two times. Do you really have the skills to go and play a song? And, you know, the job interview is much more than just a song of one instrument. There’s a lot of things that go into the job interview where you have to rely on your memory to answer questions about your strengths. You need to be able to convey that you’re a dependable employee who works well on a team. You’re trying to think about the interviewer and what is there any hidden meaning, meaning behind the questions that they’re asking you?
Matthew J. Smith, PhD: The Molly training offers is that repeated practice and not just repeated practice, but there’s actually four levels of automated feedback. So you get feedback on the specific statements you make. You get real time nonverbal cues from a job coach who’s on the screen who you see. There is several job interview skills that you’re practicing. So then at the end, after you’ve completed your interview with Molly, you get a performance assessment on how well you performed each of those skills, and then you get a numerical score. And so between the repeated practice and receiving four levels of automated feedback, it just works well to reinforce the positive things that folks are learning and their ability to apply that in a real world setting afterwards.
Rachel Star Withers: That’s awesome. Now, now I need to go ahead and ask, is Molly accessible to anybody? Or is this just like a research tool?
Matthew J. Smith, PhD: Molly is a commercial product, so it is something folks have to buy. It’s owned by a company called SIMmersion. S I M M E R S I O N. Molly is also available through employment programing. Some of the research we’re still doing is figuring out, you know, best practices on how to use Molly within community based employment programing.
Rachel Star Withers: As far as if I’m listening to this podcast right now and job interview training is something that I would be interested in, what steps would you suggest I take?
Matthew J. Smith, PhD: I would definitely, first and foremost, recommend trying to enroll or engage in a supported employment program. We know Molly is effective, and we do think that Molly will definitely help folks do well on a job interview. But trying to maintain that job is a different question. And that’s a question that can be answered by getting additional support through supported employment programs like individual placement and support. For folks that don’t have access to supported employment or IPS, trying to engage with a tool like Molly can be helpful. Right now we’re working on developing a new tool that is focused on conversations at work. So how to talk more effectively with a customer or a coworker or a supervisor.
Rachel Star Withers: That sounds like an amazing tool to be able to help people. What are the key differences that you have noticed in your research between high functioning schizophrenia, and just schizophrenia in general when it comes to social cognitive abilities?
Matthew J. Smith, PhD: Primarily we noticed that individuals with high functioning schizophrenia had a much stronger working memory ability which it’s where you hold or temporarily hold information so that your mind can process it and inform your decisions and emotions. And so we also noticed that the high functioning group had a stronger ability to kind of perceive emotional expressions and body language. And this cuts across not only social cognition, but also the way the brain works, actually. And we also conducted a functional MRI study where we observed that participants with schizophrenia who were characterized as higher functioning, they actually had greater brain activation in empathy related brain regions, which we found really fascinating in terms of these are regions that are typically involved in emotion and pain discrimination, sort of feeling empathy for somebody who’s in pain or being able to prepare a response to a stressful event. We not only see some of these behavioral differences for those with high functioning schizophrenia in terms of their kind of social perceptual abilities, but also that corresponds directly to how the brain is activating.
Rachel Star Withers: That’s fascinating. The empathy part really stands out to me. J Does any of this, do you think, kind of tie into when a person is experiencing hallucinations or delusions? To say an example, I might not be as empathetic while I’m in the middle of a psychotic state because I’m not really sure what all is real or what isn’t.
Matthew J. Smith, PhD: I think it could go both ways, where somebody who has hyper levels of empathy like really strong empathic qualities. They also could be folks that are more susceptible to some of the paranoid type symptoms because of that that that perception of what others are doing. And so they may be misperceived in what others are doing, right? Because that will contribute to the paranoia. But they’re still aware of something going on or they have that stronger awareness of something going on. It can be related in that way where if you get too empathic, then that could actually cause some difficulties with paranoia. That’s kind of more theory at this point. But if you think about it, it kind of makes sense. And on the flip side of that, we do know that for folks with high functioning schizophrenia, they have at least in the research we’ve done so far is that they have much stronger perceptual levels of empathy, kind of that emotional part of it, but not necessarily the perspective taking where you can see somebody and take their perspective as to why they might be feeling sad. Or being able to see somebody who looks like they’re thirsty, but you’re not quite sure, is it that they’re thirsty or something else? And so there’s this kind of higher level perspective taking that that still may be challenging.
Rachel Star Withers: I always tell people, get a part time job, volunteer work, whatever you can. Because, I know for me in life that’s been the biggest help with my schizophrenia is just having something to go to get out of the house.
Matthew J. Smith, PhD: You’re hitting the nail on the head, so to speak, being able to introduce that structure, staying engaged in activities. Those are things that are really going to help in the long run. And it might be a struggle at first but being able to get out and engage in those activities, I mean, it’s really going to help in the long run.
Rachel Star Withers: Well, thank you so much for talking with us today, Dr. Smith.
Matthew J. Smith, PhD: Sure.
Rachel Star Withers: Very enlightening across the board. I absolutely enjoyed this. Thank you for sharing all of your knowledge.
Matthew J. Smith, PhD: Oh, happy to. I really appreciate the opportunity to share everything with the audience.
Gabe Howard: Great interview, Rachel. I want to point our listeners to LevelUpLab.org. You can go there to explore more of Dr. Smith and his teammates’ research. That’s LevelUpLab.org. Rachel, after talking with Dr. Smith did your opinions of high functioning schizophrenia change any? How do you feel about the definition now?
Rachel Star Withers: A lot of it clearly had to revolve around a person’s ability to work. I think that was one of the key factors of what they consider high functioning is, is can this person work? Now, notice they were not stressing the how much work, what type of work. It was just going to an interview, getting good at that and then getting a job. I do like that because that’s probably like the biggest fear. Everybody hates doing job interviews. I mean, it’s just like constant rejection. I hate looking for a job and having to do that. I’m fine once I get hired, but the actual having to go repeatedly and present yourself, it can be very scary. And when you think about a lot of people with schizophrenia might have had a job, they might have had a very high position in society. And then their first psychotic episode happened and they lost it and they were hospitalized. And it’s very scary to try and go back to the workforce, the job field, when you did something like that and now you’re like, I don’t know what I can handle.
Gabe Howard: Rachel, I’m in agreement with your assessment. I did feel like a lot of this came down to your ability to earn a living, your ability to work. I’m not even saying that I disagree with that. I know that I had trouble holding down a job in the beginning. And one of the things that I worked on with my therapist was getting back to work and I had to start slowly. And we can talk for hours on end why it’s important to work for money, health insurance, resources, status in society. But all of that aside, holding down a job, it provides routine, right? It allows you to contribute to society. It gives you definition. It’s how many of us have met friends that we’ve had for years. Our whole culture is work based.
Rachel Star Withers: One of the biggest things that has helped me and that I always tell other people with schizophrenia, is get a part time job, do volunteer work, do something. Even if it’s just you go and volunteer at the Humane Society, the Red Cross for two days a week, for like a few hours, whatever. Because it helps you get out of the house. It helps you get outside of your own head. It gives you a task to do and you get to interact with people and honestly, it builds your confidence up. To me, working is part of my therapy. Forcing me to interact with people, that’s part of my therapy. It’s exposure therapy, basically. When we talk about this job stuff like it’s not just good for other people and oh, you feel you’re helping society. I honestly feel you’re helping yourself. You know, you’re helping yourself build confidence. You’re helping yourself by yes, money’s great too. But to honestly take care of yourself and manage your schizophrenia.
Rachel Star Withers: At the very beginning of this episode, I told you that I have so many people who are loved ones, family members ask me, how can I help my son, daughter, family member with schizophrenia become high functioning? And my response again is always, What do you think that means? What specifically is that person lacking that you think would make them high functioning? And a lot of times people will be like, Oh, well, well, everything, it’s this. And I’m like, No, no, no, give me one specific. What is the thing that comes? And it could be, Oh, well, they don’t work. They never leave their room. Oh, I wish they would move out. Oh, they keep getting in trouble for issues. Pick one of those things. And now what do we need to do to help that person achieve that change? And that’s what becoming high functioning is, is being able to look at where you’re at and where you want to be and taking those steps. Pick one thing. Do not try and change your entire self. If you are a loved one, caretaker, do not try and change that person overnight because that person has to want to change. You might think they absolutely need to be working 40 hours a week. If that person does not think the same as you, that’s not going to happen. So let’s start with let’s get you a job to get you out of the house a few days a week for a few hours. Let’s see how you do with that.
Rachel Star Withers: Talk with that person. Figure out for them what is high functioning. And how can they manage their schizophrenia to be able to have the life that they want? Not how other people perceive me. If my world is falling apart inside, I don’t care what you think about me. I have to deal with my own symptoms. I don’t care what my mom’s friends might think about her daughter if I’m trying to just keep myself together. That’s what it all comes down to. What do you want your life to look like? And then taking the steps to slowly make those changes.
Rachel Star Withers: So, I actually have a few resources that you can look into. If some of the things we talked about today, that’s one of your goals. So for instance, if getting a job is one of your goals, if living independently is one of your goals, and I did want to share them with you. Coursera, Course-er-a, it has a lot of free classes online that you can take in videos including job interview skills. FutureLearn.com is another one and you can actually go through different videos on these sites and they’ll have like practicing little modules. LinkedIn also has many programs that you can take and practice skills on. And the big ones I want to talk about is USA.gov. So it’s a government site, obviously, this is for people in the US and you go to USA.gov, click on disability services and there’s a lot of information there about government disability programs, including state vocational rehabilitation agencies. So it’s their job, and the states have them, where they help you get training to get a job, they help you go through interview skills and they help certain areas with placement. And another one ACL.gov, and that’s the Administration for Community Living. Again, there’s a list of all of the state independent living centers and what they do is they help people become independent in their living situations. Look into those as a great starting place for some of those goals of what you want, some of those goals of how you want your life to be. Thank you so much for listening to this episode of Inside Schizophrenia. Please like, share, subscribe and rate our podcast and we will see you next time here on Inside Schizophrenia, a Healthline Media podcast.
Announcer: You’ve been listening to Inside Schizophrenia, a podcast from Psych Central and Healthline Media. Previous episodes can be found at PsychCentral.com/IS or on your favorite podcast player. Your host, Rachel Star Withers, can be found online at RachelStarLive.com. Co-host Gabe Howard can be found online at gabehoward.com. Thank you and we’ll see you next time.