Miles Rinaldi

1. Helping people with enduring mental health problems gain and retain employment: from research to practice Miles Rinaldi

2. 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)

3. 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

4. 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

5. 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

6. Comparative Employment RatesWinter 2003 - Spring 2005 (Labour Force Survey)

7. Secondary MH services employment rates Perkins & Rinaldi (2002) A Decade of Rising Unemployment. Psychiatric Bulletin. 26, 8, 295-98

8. 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

9. 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

10. 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)

11. 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)

12. 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

13. Implementing research into routine clinical practice

14. 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

15. 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

16. 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

17. 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.

18. 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

19. 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

20. London Borough of Sutton Team OTs supported by 0.5 Employment Specialist across 4 teams

21. 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.’

22. 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

23. Demographic and Clinical characteristics

24. Vocational Status at 6 and 12 months

25. 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).

26. 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

27. 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

28. Comparing a traditional vocational service with an evidence based service – ‘Individual Placement and Support’

29. Comparing a traditional vocational service with an evidence based service – ‘Individual Placement and Support’

30. Comparing a traditional vocational service with an evidence based service – ‘Individual Placement and Support’

31. 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

32. 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

33. Thank you.