Available online at www.sciencedirect.com

Procedia - Social and Behavioral Sciences 47 (2012) 1426 – 1435

CY-ICER 2012

Working with uniqueness: optimizing vocational strengths for
people with tourette syndrome and co-morbidities
Averns, D. a, Jakubec, S.L. *b, Thomas, R. c Link, A. d
a

Alberta College of Art + Design, Calgary, Alberta, Canada
b
Mount Royal University, Calgary, Alberta, Canada
c
University of Calgary, Calgary, Alberta, Canada
d
Alberta College of Art + Design, Calgary, Alberta, Canada

Abstract
This paper shares discoveries from a grounded theory inspired study of “optimizing vocational strengths” and the unique
attributes of Tourette Syndrome and co-morbidities, including Obsessive-Compulsive Disorder and Attention Deficit
Hyperactivity Disorder (or TS/TS+), in the workplace. This one year study featured 16 participants with various levels of
workplace functioning and health status and was set in an art college. Data gathering methods included individual/group
interviews alongside observations of, and products from, studio art workshops in drawing, sculpture, performance, and creative
writing. Data collected in this way elicited a breadth and depth of representation and harnessed the uniqueness and imagination of
participants pivotal to recovery and supporting vocational optimization. The process of “optimizing vocational strengths” is
revealed both visually and textually in this paper and is instructive for educational and vocational supports for people with
TS/TS+.
©
.©2012
2012Published
Publishedby
byElsevier
ElsevierLtd.
Ltd.Selection and/or peer review under responsibility of Prof. Dr. Hüseyin Uzunboylu
* Sonya L. Jakubec (+) 403-440-5075 E-mail address: sjakubec@mtroyal.ca
Open access under CC BY-NC-ND license.

Keywords: Vocational strengths,Tourette Syndrome, Qualitative Research

1. Introduction
An innovative investigation into the process of optimizing vocational strengths people with TS/TS+ was
established between nursing/medical researchers and art educators in Western Canada. Our research used a
qualitative research design based in the grounded theory (GT) tradition (Glaser, 1992, 2003). Art workshops were a
means of data generation and products from the artistic workshops were pivotal to the group interviews and
ultimately illustrative of findings of a process of working with the uniqueness of TS/TS+ to optimize vocational
strengths.
2. Background
Tourette Syndrome (TS) is a neurological condition characterized by motor and phonic tics. Robertson (2006)
notes an incidence of TS as high as 1 in 100. Freeman’s (2000) study of 3,500 individuals with TS in 22 countries
found that 88% had co-morbidities, a condition known as TS+. The most frequently observed co-morbid conditions
are Obsessive-Compulsive Disorder (OCD), Attention Deficit Hyperactivity Disorder (ADHD), depression, anxiety,
and Sensory Integration Dysfunction (SID) (Freeman, 2000), collectively known as TS+. Challenges of selfconcept, relationships, mood, anxiety and behaviors are common in the condition (Stefl, 1984) and, given the range
1877-0428 © 2012 Published by Elsevier Ltd. Selection and/or peer review under responsibility of Prof. Dr. Hüseyin Uzunboylu
Open access under CC BY-NC-ND license. doi:10.1016/j.sbspro.2012.06.837

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1427

of co-morbid conditions and social symptoms, difficulties navigating career are not surprising for those experiencing
TS/TS+.
There is little research about what happens along the employment continuum for adults with learning disabilities
(Gerber, Price, Mulligan & Shessel, 2004), and a dearth of research specifically navigating careers with TS/TS+.
Shady (1995) found that, for most participants, TS/TS+ greatly influenced job choice, with a lesser number
reporting having been dismissed or denied employment because of TS/TS+. While there are studies of adult ADHD
and employment that address impairments in performance from a quantitative perspective (Biederman, Mick, Fried,
Aleardi, Potter & Herzig, 2005) much less is known about the process of career navigation for individuals with
TS/TS+ in adulthood. The dearth of career theorizing for this demographic is visible more practically in the field.
To address this overlooked aspect of research and practice, we posed the initial question: How do people with
TS/TS+ navigate careers?
data gathering with the deployment of art workshops to address the questions at hand.
3. Research Method: Grounded Theory and the Arts
Our research question focused on the process of career navigation for those experiencing TS/TS+, an emerging
field of study in the area of disabilities accommodations (Gerber, Price, Mulligan & Shessel, 2004) and mental
health intervention (Krupa, 2007). Grounded Theory (Glaser & Strauss, 1967, Glaser, 2003) was appropriate to
assessing the social process of career navigation at this early phase of knowledge development in the field. The
method has been utilized across disciplines as wide as nursing (Schreiber & Stern, 2001), business (Goulding, 2002)
and the arts (Marshall, 1997).
Ethical approval for the study was obtained and a team of researchers and advisors with expertise in substantive
areas served as formal advisors to the study. The criteria for participant inclusion in this study were indicators of
having TS/TS+, living in the community, concerned with vocational struggles and willing to engage with the group
interview activities of drawing, sculpture, performance and creative writing. Informed consent was received prior to
commencing data collection.
Participants were recruited through posters in libraries, health centres, specialist clinics, and academic institutions,
as well as via networking, newsletters, word-of-mouth and email canvassing from a national support group. 30
people responded to our call for participants, of which 16 (ranging in age from 19 to 78 years) met the study criteria.
One participant had a formal TS diagnosis, eleven had formal diagnoses of TS+, three had suspected diagnoses of
TS+, and one had a formal diagnosis of conditions often co-morbid with TS, i.e. chronic ADHD, depression,
anxiety. 7 participants were females and 9 were males.
3.1 Data Gathering and Analytic techniques: Four phases of Activity
In both GT and artistic projects there are a number of things happening simultaneously. The 8 months of data
gathering did not occur in a linear fashion or from a specific hypothesis. Rather, like an artistic project, pieces of the
whole picture were put together, moved around, compared and reshaped to find their final relationship in terms of a
composition. Rather than beginning by researching the literature & developing a hypothesis, data collection formed
our first steps in the study.
An incremental approach to interviewing participants occurred in four phases, including: 1) Pre-screening,
screening interview and questionnaires; 2) Art workshop/interviews 3) In-depth validation interviews, and: 4)
Feedback questionnaire. In the first phase, 30 potential participants were pre-screened by phone interviews. Lead
investigators then conducted 20 screening interviews, held in an office setting. Following screening, 16 people were
included in study. Initial screening interview data was coded for inclusion into later data collected. The codes were

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grouped into symptoms, psychological factors, vocational considerations and environments. These codes and
concepts were brought forward to aid in the structure and terms of the second phase of mentored art workshops.
In phase 2 of the study, investigators offered group art workshop interviews exclusively established for this study
and held at an art college in a mid-sized Canadian city. Art workshop interviews included discussion of work in
mediums such as: drawing, sculpture, performance and creative writing. Fourteen of the 16 individuals identified in
phase 1 consented to participation in the workshops. Topics of career navigation were explored from a wide range
of possibilities. For instance, a drawing pro

During the 10 weeks of weekly art workshops, investigators gathered data by way of direct observations, field
notes, and group interviews and review of art products with participants at the workshops. The research team was
also involved in the analysis of the findings throughout this phase, which shaped the terms used and structure of
ongoing workshops. Art workshops in phase 2 included sculpture and performance art. A clay self-portrait project
made in a small group setting enabled participants to share feelings, build trust and make connections between their
a dragon-like figure opened the group conversation to all of their symptoms,
relating to both art and career. Diana reflected on her sculpture:
craziness; it is the
and so he sleeps, you know?
Another participant used poetry to represent the way in which medications shaped her work life. Drawing
workshops encouraged participants to complete a graphed matrix, in which they compiled text entries to select
preferred media and topics. One participant, while making decisions about the use of colour or black and while
another participant, Allison, surmised that
3.2 Analysis: Uncovering the Process of Optimizing Vocational Strengths
Data was analyzed using the GT method of memo writing to develop relationships between the categories that we
found in phase 1 interviews and workshop artworks. As concepts were uncovered from the workshop data, new
categories were formed which became the basis for in-depth interviews, phase 3 of the study. These interviews were
audio recorded and transcribed, all those involved in the workshops, fourteen of the original sixteen participants,
consented to this phase of the study.
Through the emergent themes discovered in the 3 phases of data collection, researchers synthesized the processes
of career navigation through the GT method of memo writing, arriving at seven categories: Alienation, Trial and

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Error, Conflict surrounding Autonomy and Authority, Managing Symptoms, Wishing, Managing People and Finding
an Audience.
confirmed. The process determined there were no p
participants reported a wide range of vocations. Similarly, training and qualifications did not feature as important
aspects in the process of optimal navigation of career. Rather, the seven trends presented themselves as an

4. Findings: A Process of Optimizing Vocational Strengths
lves seven
categories. These are described here, including visual and textual explanations of the emergent theory.
4.1 Alienation and Feeling an Outsider
Vocational success was determined not just by occupation or career, but how comfortable participants felt within a
job or vocation. Even when participants were successful in getting the job they wanted, or the career they trained
secret.
-assessment was
often due to tics, intrusive thoughts, obsessions, compulsions, or being prone to impulsive actions. These traits
produced feelings of difference or alienation, particularly if they considered themselves socially awkward. For some
When I am in the workplace I feel
intrinsically like within different from the others because I am not as composed.
It seems like
Overall, a
sense of being wound up by oneself or another, was a graphic image of this process of alienation and being inside or
outside of the workplace norms (Figure 2).

4.2 Trial and Error in Jobs and Career Choice
In contemporary employment patterns it is common for many people to experiment with change in employment.
Individuals with mental health conditions, however, may experience more job turnover than they would like. A 1995

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survey of Canadians with TS/TS+ indicated that 20% had been dismissed from a job because of their condition and
17% said they had been denied a job due to their TS/TS+ (Shady, 1995). Our findings affirm the relevancy of the
within the process of career optimization. This aspect was found to apply to a variety
of contexts. One participant with ADHD, OCD and suspected TS experienced external barriers and considerable
personal drive towards trial and error, choosing to shift jobs regularly: all impacting career stability. This
navigation took her across a wide career canvas; she explained of her trial and error process:
I am changing constantly; I am always picking up a new career, trying it for two years,and walking

Participants tried out jobs or environments in order to find preferences and strengths. Some preferred
working with people, while others liked to work with children or animals, and some preferred indoor and
why am I here
(Figure 3).

4.3 Existing in Conflict: Autonomy and Authority
A key to optimizing workplace and career achievement, in our study, was recognizing internal causes and triggers
self, and being able to predict external triggers brought on by contact with others and the
of conflict in
environment. Conflict was commonplace for people with TS and its related conditions, often as a result of dealing
with authority figures. Reasons for conflict related to both symptoms and environment.
Symptoms leading to conflict were experienced by individuals with TS/TS+ and included anger or difficulty
maintaining an even temper, anxiety, depression, distractibility, frustration, or adverse effects of tics or addictions.
There was also a connection between alienation (described previously) and workplace conflict. Furthermore,
autonomy and attitudes towards authority were a link between symptom-related and sensory-related conflict. All
participants preferred a high degree of autonomy or self-determination in their work routines. Participants recorded
a high incidence of thinking and/or feeling that they knew the best way to do a particular task.
And it is damn good because the end product is worth it, so they should not have any issues.
Findings indicated that authority challenged all participants, requiring them to develop skills to interact with others

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disagree
like people were open [to my authority] but it just goes bad politically for you.
Acquiring skills for greater self-awareness was necessary but not easy for people with TS/TS+, OCD and/or
ADD/ADHD. Participants frequently reported that they felt urges, or acted upon impulses, to express uninvited
opinions, and urge to spontaneously react to the opinions of others. Conversely, when thoughts or feelings were
internalized, and not expressed, this also led to conflict. One participant described her process of balancing
autonomy and authority as follows:

4.4 Managing Symptoms and Self Control
Maintaining composure at work was important for achieving career success and managing individual symptoms
and sensory triggers, such as those discussed previously. Stan described the importance of composure and
considerable energy he spends managing his symptoms for the sake of fitting in to his workplace:
The worst thing in a work situation is to blow-up, blow-up or lose it in any way because then it looks
The process of self control was an individual one for our participants, what worked for one person was not
necessarily optimal for others. One common thread in this process, however, was stress, which consistently
worsened symptoms. Successfully navigating self control and symptom management was central to career success
for Joyce who explained the magnitude of adjusting to a shift change in her schedule:
They changed this shift on me, which really upset me greatly. I know me and I know what happens
miserable. What really worries me when that happens I get less sleep

I have more symptoms.

Self awareness and management of symptoms, managing stress and exercising self-control, were all attended to by
all participants who described strategies that ranged from regular breaks in a quiet place, to avoiding addictive
substances, using positive thinking, regulating obsessions and compulsions, managing sleep patterns, physical
others. Self control consistently assisted in optimizing vocational strengths for all participants regardless of
workplace. While the process required considerable energy and challenges to their sense of freedom, the rewards
of managing her
were considerable for our participants. Kathy described what she called her
symptoms and self as she discussed the process of self control: Happy. To be happy. I must control. For others, I
Self control was desirable, though again, demanding
of attention for Stan who explained:
W
be doing is being heard swearing and stuff in an office or something.
4.5 Wishing
Participants
the future were important to them in navigating through disappointments and planning for the future. This process of
wishing was useful if it produced positive fantasies, and most productive if focused on achievable goals. Janet
described this tension of fantasy and practical goal setting in her reflection on imagining things could be different:
the time in my mind: always; I always want to be better; I always feel as tho
No matter what, I feel very self critical, I guess.

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For some participants the goal setting aspect of their wishes and career aspirations assisted them in being more
resourceful or prepared for the workplace. For others, the process of wishing helped them maintain hope as they
a valuable part of his career navigation:
I have this wish for me to be more independent,
encourages me to keep going. And not give up even though sometimes you really want to.
4.6 Managing People Around You: Support from Family, Colleagues and Friends
Navigating peer relations was another process in optimizing vocational strengths. Having family, colleagues or
friends to confide in was viewed as essential, and those who had an early diagnosis reported better abilities to
address their immediate needs and long-term goals owing to better support. In terms of the process of wishing, we
found many participants wished they had been diagnosed earlier in their lives/careers; they felt they could have
accessed more support and achieved greater self-control. Participants declared emphatically that it was the people
around you that can also help with resolving conflict and managing your symptoms. This was often a process of
discernment and finding allies. Shirley illustrated the point:
It is still an iffy thing with disclosing as it is a really touchy thing. Ummm, allies, oh my God that
made a big difference [finding a colleague with a similar condition] because we help each other.
Donald went on to emphasize that:
Validation is the word. And so, validation of any sort, as an adult even now, for any creative
endeavors or whatever matters and that does a lot for me. It makes me a happy worker.
4.7 Finding an Audience for Vocational Strengths and Uniqueness
The vocations of participants in our study were many and varied and included: nursing student, tradesperson,
development student, retired realtor, self-employed businessperson, clerk/administrator, customer service
representative, and persons who were, at the time of the study, unemployed or accessing social assistance. A
number of participants indicated they felt they were not in their ideal careers. Many were self-employed or in
occupations that had a degree of predictability or control over contact with larger groups of people, including people
who taught or conducted contract work. A few of our participants indicated a preference for managing other people,
although this was noted as an area that needs further investigation.
Despite their challenges, longings and struggles, participants indicated there were many positive workplace
attributes of individuals who have TS/TS+. These attributes included high energy levels, attention to detail,
creativity, strong word skills, quickness of thought, and divergent or lateral thinking. It was suggested that with
forethought and planning, these skills could be harnessed and put to good use in jobs and careers.
\I have, in many ways, tried to find jobs where I knew I could work my particular shift, my particular way, or
alone, or whatever; I have literally tried to select jobs that I could do that kind of thing with because I know
what I can and can not do and I know my capabilities.
This quality of selfand appropriate treatment were thought to support this process of finding the right audience to optimize vocational
strengths. Their unique attributes and habits made our participants particularly adept at certain workplace tasks.
People with TS/TS+ or OCD are likely to have qualities that include checking and attention to detail. Julie
described this practice in the following account:
I over-focus sometimes and I just will re-format something until it is absolutely perfect. So if I find a
department that wants that kind of attention to detail then that is a good audience for my strength in that
vocation.

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Although perfectionism was a double-edged sword for participants, prompting obsessive thought for work that
required high degrees of accuracy, some of our participants considered themselves at a distinct advantage. Finding
the right setting and audience enabled our participants to maximize their productivity in their workplaces and
moderate clinical symptoms. Jan explained how she struggled with finding the right audience and space:
In the past I used to stay late after work on my own time when there was nobody around and I would get to
labour union job). So I am going to be demanding more of myself in that area because I am going to be
working 8:00am to 4:15pm with a half an hour for lunch and two fifteen minute breaks like a bloody robot, but
I can do it. With meds I can do it.
Noise, light and the size of a workplace were all sensory and environmental factors that, when participants could
understand them and select them for their needs, reduced conflict. Some participants were hypersensitive to many
participants expressed distinct preferences for privacy, working alone, or occupations that had a degree of
predictability as to when contact with larger groups of people would occur. Smaller settings were described as
supportive of reducing triggers, and of decreasing conflict and alienation while increasing concentration and
confidence.
5.
articulated by as a tripod-mounted video camera and screen, shown in Figure 4 (In Camera Projection).

The camera demonstrates the need for Finding an Audience, one of the social processes brought out by the
in camera
not automatically disclosing their conditions and needs in
represents an image of successful career or
workplace events deserving of projection onto the silver screen.

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The film spooli
Wishing will not make things right, Trial and Error is endemic to a
healthy process of education, training and career searching, and Alienation can be countered by the stability afforded
via the categories represented by the tripod legs. The tripod legs keep the camera balanced and directed towards a
clear and successful vision of Your Life. In setting up the tripod, if one leg extends too far or another gets stuck, it
persons with TS and/or co-morbidities, need to work towards supporting the balance of each of the three legs:
Managing Symptoms, moderating Conflict and Autonomy, and Managing People Around You.
6. Discussion and Implications
This study has taken a first step towards a wide open canvas, deploying art workshops, a technique rarely used to
gather information in health sciences research. The art workshops established as a data gathering tool for this
research enabled participants to visually communicate their process of career navigation. These workshops were not
intended to be art therapy and there was no clinical treatment component to the research, however participants
appeared to find the creative outlet a therapeutic experience. The participants in this study said that the art
workshops and the research process assisted in their personal development and awareness of vocational
optimization. Art, while not identified as an optimal career necessarily, was an important data gathering tool and
means of discovering possibilities for optimizing vocational strengths.
Through self-awareness for people with TS/TS+, as well as employers and counselors awareness, the uniqueness of
individuals with TS/TS+ can be better supported for vocational optimization. Nadeau (2005) also found that
interventions for career counseling for adults with ADHD required a focus on self-awareness and awareness of the
particular resilience factors including the management of internal and external environments.
Overall, our theory of Optimizing Vocational Strengths has provided functional and creative recommendations for
individuals, employers, educators and health care workers involved with TS/TS+ so that we can all work with
uniqueness in ways that optimize vocational strengths.
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