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Helping people with enduring mental health problems gain and retain employment: from research to practice. Miles Rinaldi. Why work?.
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Helping people with enduring mental health problems gain and retain employment: from research to practice Miles Rinaldi
Why work? • Work is central to the lives and well -being of most people, and is important in maintaining and promoting mental health - there is a particularly strong relationship between unemployment and mental health difficulties (Warr, 1987) • People with mental health problems are particularly sensitive to the negative effects of unemployment and the loss of structure, purpose and identity that it entails (Anthony et al, 1984) • Via work the quality of lives is enhanced (Hill et al, 1996) • Admission rates among those who are in work are reduced (Warner, 1994) • Employment is the most significant outcome for people who have experienced mental health problems (Kinderman and Cooke, 2000)
Unemployment and Public Health • Unemployed >12 weeks • 4-10 times prevalence of depression anxiety and physical illness • Strong relationship between suicide & unemployment in young • with 2/3 not in paid work • Evidence shows that work is good for physical and mental health and well-being • Strong evidence that worklessness is harmful to physical and mental health
Individual Perspective • Literature of Recovery ( for example, Anthony 1993) • Meaningful role • Occupation • Do people want to work? • 70-90% people want to return to work (Grove, 1999; Rinaldi & Hill, 2000; Secker & Seebohm, 2001) • 52% said they had not received any help (Healthcare Commission, 2005) • Latent effects of employment(Jahoda 1979) • Time structure on waking day • Shared experiences and contacts – social networks • Defines aspects of personal status
Less than a quarter of adults with mental health problems are in work Main barriers • fear of losing benefits • employers’ attitudes • fluctuating nature of condition • low expectations of health professionals
Comparative Employment RatesWinter 2003 - Spring 2005 (Labour Force Survey)
Secondary MH services employment rates Perkins & Rinaldi (2002) A Decade of Rising Unemployment. Psychiatric Bulletin. 26, 8, 295-98
Barriers to return to work and job retention • Wrong assumptions about work and the management of long term conditions • Negative thinking • Inflexible employment practices • Stigma, discrimination and ignorance about rights • Fear of disclosure of mental ill health • Inability/unwillingness to negotiate adjustments • Unable to self-manage stress and symptoms • Lack of timely help
The low expectations of professionals A vicious circle that erodes hope and reduces opportunity … Expert professionals say that people with mental health problems are unlikely to be able to work Employers believe that people with mental health problems cannot work – so don’t employ them People with mental health problems believe that they cannot work and give up trying to get jobs Very few people with mental health problems in employment
Research Evidence • A large proportion of people with serious mental health problems can, with support, gain and retain open employment (Drake et al, 1994, 1996, 1999; Becker et al, 1998; Bond et al, 1995, 1997, 1999, 2001) • Sheltered workshops: Universally poor vocational outcomes (Pozner et al, 1996; Grove, 1999, 2000) • Pre-vocational training: No advantage in enabling people to move into competitive employment over standard care (Drake et al, 1994, 1996; Crowther et al, 2001, 2004) • Supported employment: More effective than pre-vocational training at helping people with severe mental illness to obtain and keep competitive employment (Crowther et al, 2001, 2004)
Evidence Based Supported Employment‘Individual Placement & Support’ There is strong evidence that: • Services should be focused on competitive employment as a primary goal • Eligibility should be based on the individual’s preferences • Rapid job search and minimal pre-vocational training There is moderately strong evidence that: • Integrated into the work of the clinical team • Attention to client preferences is important • Availability of time unlimited support There is weak evidence from one study that: • Benefits counselling should be provided to help people maximise their welfare benefits (Bond, 2004)
Employment is a realistic goal Job Ready? • Diagnosis and symptoms do not predict success in gaining a job or being able to go to college • Wanting a job and believing that you can work are the best predictors of success What about my benefits? • Permitted Work • Linking rule for Incapacity Benefit • Tax Credits • Disability Living Allowance
South West London & St George’s Mental Health NHS Trust Service Outcomes Aim: • Evaluate the impact of the introduction of IPS within the Community Mental Health Teams (CMHTs) of 3 London Boroughs • IPS was introduced into 8 CMHTs: • 4 in Kingston, • 4 in Merton but, • not introduced into the 4 Sutton CMHTs
The Service January 2002 Comprised three components: • Occupational Therapists (OTs) were designated as ‘Clinical Vocational Leads’ within the CMHTs and had one dedicated session per week to fulfil this role. • Within each Borough an Employment Specialist linked with employers, Jobcentre Plus, employment agencies, colleges, etc. and provided information, advice and support to the team OTs and care co-ordinators. • Care co-ordinators were expected to provide vocational support, where appropriate, to clients on their caseload with support from the OTs and Employment Specialist
Role of Employment Specialist… • Co-ordinates vocational plans with clinical team • Works directly with clients and their care co-ordinators • Direct client interventions: • Engagement • Assessment • Helped clients to find and keep jobs / education courses • Provided welfare benefits advice • Addressed the support needs and any adjustments
Method • January 2002 - June 2005: CMHTs collected monthly data on all those clients who were receiving a vocational intervention. • Vocational status was collected on first contact with each client and thereafter on a monthly basis. Impact evaluated in two ways: • IPS was introduced at different times in Kingston and Merton - before and after - possible to ascertain whether any changes were likely to be a result of the introduction of IPS or from other factors • Sutton, IPS was not introduced in the period January 2002 to June 2005.
Royal Borough of Kingston Team OTs supported by 1 Employment Specialist across 4 teams 0.5 Employment Specialists per CMHT 1 full-time Employment Specialists per CMHT
London Borough of Merton Full time Employment Specialist in 3 of the 4 CMHTs Team OTs supported by 1 Employment Specialist across 4 teams 1 full-time Employment Specialists per CMHT
London Borough of Sutton Team OTs supported by 0.5 Employment Specialist across 4 teams
Individual experience… ‘From the start, Catherine [Employment Specialist] was a very positive influence. She always had a firm idea through our discussions about what area of industry I was best placed to go for. When I looked through the job description, it shone out as ‘the one’. At the beginning of our working relationship I would have been happy to take any job. Catherine helped me to realise that I had the potential to fulfil the level of responsibility that I am working at right now. Our frequent meetings over a long time all amounted to eventual success. I am very happy in my job and we still meet up regularly to discuss relevant issues which I find important at this stage.’
Individual Outcomes Aim: • Evaluate the individual client outcomes at 6 & 12 months Results: • 6 month follow-up data was available for 451 clients • 12 month follow-up data was available for 210 clients • remaining clients (n=241) had either not received a vocational intervention for 12 months or had left the service between 6 & 12 months
Employment Specialist and Care Co-ordinator outcomes Vocational status improvement: Employment Specialist significantly greater than Co-ordinator at 6 months (2 =17.0, d.f. 2, p<0.001) and at 12 months (2=13.7, d.f. 2, p<0.001). Similarly the vocational status of clients receiving support from Employment Specialists and Care Co-ordinators differed significantly at 6 months (2 = 61.7, d.f. 6, p<0.001), and at 12 months (2 = 32.6, d.f. 6, p<0.001).
Other outcomes Gender • At the start women were significantly more likely to be in open employment than men : 24% and 13% • At 6 months, difference was maintained : 37% of women were in open employment as compared with 24% of men • by 12 months the difference had ceased to be significant Diagnosis • There was no significant difference between the employment status of those clients with a psychotic diagnosis and those with a non-psychotic diagnosis at the start of the intervention or at 6 months or at 12 months
How does this compare? • Cochrane Review: Vocational Rehabilitation for People with Severe Mental Illness. • Drake et al (1996) • 12 months = 34% paid employment • Drake et al (1999) • 6 months = 27% • 12 months = 25% • Most studies show an average of 30% people supported in employment with IPS intervention in comparison with an average of 12% with other interventions
Comparing a traditional vocational service with an evidence based service – ‘Individual Placement and Support’
Comparing a traditional vocational service with an evidence based service – ‘Individual Placement and Support’
Comparing a traditional vocational service with an evidence based service – ‘Individual Placement and Support’
Integrating clinical and vocational service What are the benefits? • Clinically sensitive • Addresses concerns that: • Employment serves as a stressor • Will interfere with stability of client • More effective engagement and retention • Better communication • Incorporation of vocational information into care plans • Observation can convert sceptical or disinterested clinicians • Better outcomes – clinicians carry responsibility of coordination, consistency and coherence
Implementation Obstacles • Lack of early intervention • Failure to adopt best practice • Lack of focus on work resumption • Lack of integrated service / fragmented provision • Lack of case management • Low priority for clinicians • Interagency co-operation poor