- Email: [email protected]
Vocational rehabilitation
SPECIFIC COMMUNITY TREATMENTS
While work is important for everyone, it is particularly crucial for people who experience mental health problems. People with such difficulties are especially sensitive to the negative effects of unemployment and the loss of structure, purpose and identity that it brings. Work is extremely important both in maintaining mental health and promoting the recovery of those who have experienced mental health problems. From a clinical perspective, employment may lead to improvements in outcome by increasing self-esteem, alleviating psychiatric symptoms and reducing dependency and relapse (Cook and Razzano, 2000). Indeed, Bond et al. (2001) found that people in ordinary competitive employment showed more improvement in symptoms, leisure and finances and higher self-esteem than people who were not in competitive work. Work enables people to participate in society as active citizens.
Vocational rehabilitation Miles Rinaldi Rachel Perkins
The right to work is enshrined in Article 23 of the United Nations Universal Declaration of Human Rights (1948), which states that: ‘Everyone has the right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment’. Yet the majority of people with severe and enduring mental health problems continue to be denied this right. The Labour Force Survey (2003) estimates that 76% of people with mental health problems are unemployed, a rate much higher than for those with physical or sensory impairments. For people with longer-term mental health problems, the situation is even worse: unemployment rates among longer-term service users in one London borough rose from 80% in 1990 to 92% in 1999. People with mental health problems are among the most socially excluded in Britain, but in spite of this most continue to see the ability to return to work as an indicator of recovery.
Issues of employability Research into vocational rehabilitation has followed two strands: investigations of patient characteristics that predict employability and studies of the effectiveness of different service models and approaches. Reviews on studies of employability indicate that patient characteristics have little impact on vocational outcomes (Anthony, 1994). Most reviews show that there is no relationship between employment outcomes and diagnosis, severity of impairment and social skills. There is no consensus about how specific symptoms affect work performance, and while there is a relationship between history of hospitalization and work outcomes, the direction of causality is not clear. Indicators that appear to be robust predictors of work outcomes include having an employment history, but motivation and self-efficacy are more important. Wanting very much to work and believing that you can are the best predictors of work outcomes.
Individual benefits of unemployment As well as an income, work provides latent benefits such as social identity and status; social contacts and support; a means of structuring and occupying time, activity and involvement; and a sense of personal achievement. Unemployment is linked with increased general health problems, including premature death, and there is also a strong relationship between unemployment and the development of mental health problems, including an increased risk of suicide.
Approaches to employment The research literature shows that models and approaches are more important than patient characteristics in determining whether people with mental health problems are able to work (Crowther et al., 2001). Research shows that segregated sheltered workshops are relatively poor at enabling people to return to competitive employment. In spite of their intention to help increase people’s confidence and skills and thus enable them to move on to employment, there is evidence that they often confirm a person’s belief that they would not be able to manage in competitive employment. ‘Move-on’ rates have been universally poor, with people remaining in these settings rather than achieving competitive employment (Grove, 1999). Research into prevocational training (skills training and training that provides an extended period of vocational preparation before entering competitive employment) shows there is no evidence to suggest that this intervention is more effective than standard care or hospital care at helping people with mental health problems return to work (Crowther et al., 2001). In contrast, there is strong evidence in favour of evidence-based supported employment (also known as the Individual, Placement and Support approach), developed by Drake and Becker (Drake et al., 1994; 1996; Bond et al., 1997; 2001; Crowther et al., 2001), over other approaches such as sheltered workshops, clubhouses and prevocational training.
Miles Rinaldii is Vocational Services Manager for South West London and St George’s Mental Health NHS Trust, London, UK. He has published research into mental health and employment, and the self-management of manic–depression. Rachel Perkins is a Consultant Clinical Psychologist and Clinical Director of Adult Mental Health Services, South West London and St George’s Mental Health NHS Trust, London, UK. She is also a user of mental health services, vice-chair of the Manic-Depression Fellowship, a specialist adviser at the Health and Social Care Advisory Service and a member of the Disability Rights Commission Mental Health Action Group. She has written and spoken widely about services for people who are seriously disabled by ongoing mental health problems, and contributes a regular column to the magazine Open Mind.
PSYCHIATRY 3:10
54
© 2004 The Medicine Publishing Company Ltd
SPECIFIC COMMUNITY TREATMENTS
Principles of evidence-based supported employment
Workplace adjustments for people with mental health problems
• Vocational rehabilitation is a central and integral component of the work of mental health teams rather than a separate service. Front-line staff need to have a vocational orientation and there must be vocational expertise within teams if success is to be achieved
• Flexible working hours, including part-time working • Allowing longer or more frequent breaks • Time off for health appointments • Providing regular supervision and feedback on performance
• A primary goal of competitive employment in integrated settings – ‘real work’ rather than prevocational or sheltered work experiences
• A graduated return to work following a period of illness
• Rapid job-search and minimal prevocational training. Supporting people to develop work skills on the job is more effective than preparation in a sheltered environment
2
• Initial and continuing assessment and adjustment. Getting into work is not an end in itself but part of an ongoing process, and it may be necessary for a person to try a number of different jobs before they find one in which they are successful
person (including those who have experienced mental health problems) less favourably than they have treated or would treat any other person. (In April 2004 the threshold of organizations employing 15 people or more was removed, and the DDA now covers all employers.) Employers have a duty to make reasonable adjustments to the work environment or working arrangements where these put a disabled person at a substantial disadvantage. By 2001, 23% of all DDA employment cases had been taken by people with mental health problems.
• Ongoing time-unlimited support and workplace interventions – enabling people to retain employment • Attention to users’ preferences and choices – rather than providers’ judgements. If someone is helped to get a job they want, they are more likely to be committed to it
Workplace adjustments There is increasing evidence on workplace adjustments for people who have experienced mental health problems. Typically these adjustments involve little or no direct cost to employers and are similar, if not identical, to adjustments made for other groups within the workplace such as single parents or people returning to work after a long break. Examples of such adjustments are given in Figure 2. Employers are becoming more aware of the effects of mental ill-health and stress-related disorders in the workplace, and more specifically the impact on their own organizations. There is a substantial need for effective interventions or supports that help people with mental health problems to manage their mental health within the workplace.
1
The principles of evidence-based supported employment are listed in Figure 1. Studies indicate that around 58% of people with serious ongoing mental health problems engaged in programmes with these characteristics are able to gain and retain employment (Crowther et al., 2001; Bond et al., 2001b), a marked contrast to the 24% who are currently in employment. Current approaches in the UK The majority of studies on vocational interventions come from the USA and at present there is high variation in provision regionally in the UK. Supported employment programmes are slowly beginning to be developed. Early findings from the implementation of evidence-based supported employment are promising, with employment rates in one clinical team rising from 10% to 40% in the first year of operation (Rinaldi et al., 2004).
Job retention Owing to the fluctuating and episodic nature of mental health problems, job retention can be a major issue for people once they return to work. Many people with mental health problems who gain employment with the help of traditional vocational rehabilitation services do not retain it for long. Research suggests that many vocational rehabilitation programmes are able to place unemployed people with mental health problems in paid work, but the average length of employment varies from weeks to months. However, there is increasing evidence to indicate the importance of helping people to retain their existing employment through the provision of ongoing support (McHugo et al., 1998).
Employers and legislation Discrimination on the part of potential employers is undoubtedly a major obstacle to people with mental health problems gaining work, especially those with a diagnosis of schizophrenia (Manning and White, 1995). However, evidence suggests that having been detained for a period of time under the Mental Health Act 1983 does not harm future job prospects. If people are to gain and retain employment, employers need to be seen as an important resource who should be supported and nurtured rather than attacked for prejudiced attitudes; active support to employers is one element of evidence-based supported employment. The Disability Discrimination Act (DDA) 1995 (Part II, Employment Provision) makes it unlawful for employers to treat a disabled
PSYCHIATRY 3:10
Self-management at work From an individual’s perspective there is an emerging literature on the experiences of moving into and maintaining employment which details the ways in which people cope with difficulties (Alverson et al., 1995; Leete, 1989). Too little attention is given to
55
© 2004 The Medicine Publishing Company Ltd
SPECIFIC COMMUNITY TREATMENTS
Bond G R, Becker D R, Drake R E et al. Implementing supported employment as evidence-based practice. Psychiatr Servv 2001; 52: 313–22. Bond G R, Drake R E, Mueser K T, Becker D R. An update on supported employment for people with severe mental illness. Psychiatr Serv 1997; 48: 335–46. Bond G R, Resnick S G, Drake R E et al. Does competitive employment improve nonvocational outcomes for people with severe mental illness? J Consult Clin Psychol 2001; 69: 489–501. Cook J A, Razzano L. Vocational rehabilitation for persons with schizophrenia: recent research and implications for practice. Schizophr Bull 2000; 26: 87–103. Crowther R E, Marshall M, Bond G R, Huxley P. Helping people with severe mental illness to obtain work: systematic review. BMJJ 2001; 322: 204–8. Drake R E, Becker D R, Biesanz J C, Torrey W C, McHugo G J, Wyzik P F. Rehabilitative day treatment vs. supported employment. 1. Vocational outcomes. Community Ment Health J 1994; 30: 519–32. Drake R E, Becker D R, Biesanz J C, Wyzik P F, Torrey W C. Day treatment versus supported employment for persons with severe mental illness: a replication study. Psychiatr Serv 1996; 47: 1125–7. Grove B. Mental health and employment: shaping a new agenda. J Ment Health 1999; 8: 131–40. Leete E. How I perceive and manage my illness. Schizophr Bull 1989; 15: 197–200. Manning C, White P D. Attitudes to the mentally ill. Psychiatr Bull 1995; 19: 541–3. McHugo G, Drake R E, Becker D R. The durability of supported employment effects. Psychiatr Rehabil J 1998; 22: 55–60. Rinaldi M, McNeil K M, Firn M, Kolesti M, Perkins R, Singh S. What are the benefits of evidence-based supported employment for patients with first-episode psychosis? Psychiatr Bull 2004; 28: 281–4.
Barriers faced by people with mental health problems when returning to work • Low motivation and confidence • Side-effects of medication • Fear of losing welfare benefits • Employers’ attitudes • Stigma and discrimination • Low expectations of health-care professionals
3
the difficulties people report in returning to work and there needs to be greater recognition of the self-adjustments and the variety of tools and techniques that people use to self-manage their mental health at work. Psychological support Rehabilitation involves both social adaptation and psychological adjustment and, for most people, work is central to both of these. The different types of internal and external barriers that people with mental health problems face when returning to work are well documented (Figure 3). However, most traditional vocational rehabilitation programmes aim to clarify job goals, provide jobseeking or job-related skills, or to re-socialize the person to the work environment; little psychological assistance is given. It is well recognized that people with mental health problems (as well as those who are long-term unemployed), when looking to return to work, face issues surrounding reduced self-esteem, self-efficacy and reduced expectations of a successful outcome in job-seeking. Furthermore, many experience a reduced motivation to seek work at all. Evidence-based interventions such as cognitive–behavioural therapy have successfully been used with people who are long-term unemployed as an intervention for returning to work, and research is needed to test the efficacy of this intervention within vocational rehabilitation for people with mental health problems.
FURTHER READING Royal College of Psychiatrists. Employment Opportunities and Psychiatric Disability. Council Report CR111. London: Royal College of Psychiatrists, 2002. Social Exclusion Unit. Mental Health and Social Exclusion. London: Office of the Deputy Prime Minister, 2004.
Conclusion The extent to which mental health services promote confidence in relation to work is critical. Through implementing evidence-based supported employment and integrating vocational rehabilitation within routine mental health care, psychiatrists, care coordinators and employment specialists all have a role in supporting people to successfully gain and retain employment.
REFERENCES Alverson M, Becker D R, Drake R E. An ethnographic study of coping strategies used by people with severe mental illness participating in supported employment. Psychiatr Rehabil J 1995; 18: 115–28. Anthony W. Characteristics of people with psychiatric disabilities that are predictive of entry into the rehabilitation process and successful employment. Psychiatr Rehabil J 1994; 17: 3–13.
PSYCHIATRY 3:10
56
© 2004 The Medicine Publishing Company Ltd
While work is important for everyone, it is particularly crucial for people who experience mental health problems. People with such difficulties are especially sensitive to the negative effects of unemployment and the loss of structure, purpose and identity that it brings. Work is extremely important both in maintaining mental health and promoting the recovery of those who have experienced mental health problems. From a clinical perspective, employment may lead to improvements in outcome by increasing self-esteem, alleviating psychiatric symptoms and reducing dependency and relapse (Cook and Razzano, 2000). Indeed, Bond et al. (2001) found that people in ordinary competitive employment showed more improvement in symptoms, leisure and finances and higher self-esteem than people who were not in competitive work. Work enables people to participate in society as active citizens.
Vocational rehabilitation Miles Rinaldi Rachel Perkins
The right to work is enshrined in Article 23 of the United Nations Universal Declaration of Human Rights (1948), which states that: ‘Everyone has the right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment’. Yet the majority of people with severe and enduring mental health problems continue to be denied this right. The Labour Force Survey (2003) estimates that 76% of people with mental health problems are unemployed, a rate much higher than for those with physical or sensory impairments. For people with longer-term mental health problems, the situation is even worse: unemployment rates among longer-term service users in one London borough rose from 80% in 1990 to 92% in 1999. People with mental health problems are among the most socially excluded in Britain, but in spite of this most continue to see the ability to return to work as an indicator of recovery.
Issues of employability Research into vocational rehabilitation has followed two strands: investigations of patient characteristics that predict employability and studies of the effectiveness of different service models and approaches. Reviews on studies of employability indicate that patient characteristics have little impact on vocational outcomes (Anthony, 1994). Most reviews show that there is no relationship between employment outcomes and diagnosis, severity of impairment and social skills. There is no consensus about how specific symptoms affect work performance, and while there is a relationship between history of hospitalization and work outcomes, the direction of causality is not clear. Indicators that appear to be robust predictors of work outcomes include having an employment history, but motivation and self-efficacy are more important. Wanting very much to work and believing that you can are the best predictors of work outcomes.
Individual benefits of unemployment As well as an income, work provides latent benefits such as social identity and status; social contacts and support; a means of structuring and occupying time, activity and involvement; and a sense of personal achievement. Unemployment is linked with increased general health problems, including premature death, and there is also a strong relationship between unemployment and the development of mental health problems, including an increased risk of suicide.
Approaches to employment The research literature shows that models and approaches are more important than patient characteristics in determining whether people with mental health problems are able to work (Crowther et al., 2001). Research shows that segregated sheltered workshops are relatively poor at enabling people to return to competitive employment. In spite of their intention to help increase people’s confidence and skills and thus enable them to move on to employment, there is evidence that they often confirm a person’s belief that they would not be able to manage in competitive employment. ‘Move-on’ rates have been universally poor, with people remaining in these settings rather than achieving competitive employment (Grove, 1999). Research into prevocational training (skills training and training that provides an extended period of vocational preparation before entering competitive employment) shows there is no evidence to suggest that this intervention is more effective than standard care or hospital care at helping people with mental health problems return to work (Crowther et al., 2001). In contrast, there is strong evidence in favour of evidence-based supported employment (also known as the Individual, Placement and Support approach), developed by Drake and Becker (Drake et al., 1994; 1996; Bond et al., 1997; 2001; Crowther et al., 2001), over other approaches such as sheltered workshops, clubhouses and prevocational training.
Miles Rinaldii is Vocational Services Manager for South West London and St George’s Mental Health NHS Trust, London, UK. He has published research into mental health and employment, and the self-management of manic–depression. Rachel Perkins is a Consultant Clinical Psychologist and Clinical Director of Adult Mental Health Services, South West London and St George’s Mental Health NHS Trust, London, UK. She is also a user of mental health services, vice-chair of the Manic-Depression Fellowship, a specialist adviser at the Health and Social Care Advisory Service and a member of the Disability Rights Commission Mental Health Action Group. She has written and spoken widely about services for people who are seriously disabled by ongoing mental health problems, and contributes a regular column to the magazine Open Mind.
PSYCHIATRY 3:10
54
© 2004 The Medicine Publishing Company Ltd
SPECIFIC COMMUNITY TREATMENTS
Principles of evidence-based supported employment
Workplace adjustments for people with mental health problems
• Vocational rehabilitation is a central and integral component of the work of mental health teams rather than a separate service. Front-line staff need to have a vocational orientation and there must be vocational expertise within teams if success is to be achieved
• Flexible working hours, including part-time working • Allowing longer or more frequent breaks • Time off for health appointments • Providing regular supervision and feedback on performance
• A primary goal of competitive employment in integrated settings – ‘real work’ rather than prevocational or sheltered work experiences
• A graduated return to work following a period of illness
• Rapid job-search and minimal prevocational training. Supporting people to develop work skills on the job is more effective than preparation in a sheltered environment
2
• Initial and continuing assessment and adjustment. Getting into work is not an end in itself but part of an ongoing process, and it may be necessary for a person to try a number of different jobs before they find one in which they are successful
person (including those who have experienced mental health problems) less favourably than they have treated or would treat any other person. (In April 2004 the threshold of organizations employing 15 people or more was removed, and the DDA now covers all employers.) Employers have a duty to make reasonable adjustments to the work environment or working arrangements where these put a disabled person at a substantial disadvantage. By 2001, 23% of all DDA employment cases had been taken by people with mental health problems.
• Ongoing time-unlimited support and workplace interventions – enabling people to retain employment • Attention to users’ preferences and choices – rather than providers’ judgements. If someone is helped to get a job they want, they are more likely to be committed to it
Workplace adjustments There is increasing evidence on workplace adjustments for people who have experienced mental health problems. Typically these adjustments involve little or no direct cost to employers and are similar, if not identical, to adjustments made for other groups within the workplace such as single parents or people returning to work after a long break. Examples of such adjustments are given in Figure 2. Employers are becoming more aware of the effects of mental ill-health and stress-related disorders in the workplace, and more specifically the impact on their own organizations. There is a substantial need for effective interventions or supports that help people with mental health problems to manage their mental health within the workplace.
1
The principles of evidence-based supported employment are listed in Figure 1. Studies indicate that around 58% of people with serious ongoing mental health problems engaged in programmes with these characteristics are able to gain and retain employment (Crowther et al., 2001; Bond et al., 2001b), a marked contrast to the 24% who are currently in employment. Current approaches in the UK The majority of studies on vocational interventions come from the USA and at present there is high variation in provision regionally in the UK. Supported employment programmes are slowly beginning to be developed. Early findings from the implementation of evidence-based supported employment are promising, with employment rates in one clinical team rising from 10% to 40% in the first year of operation (Rinaldi et al., 2004).
Job retention Owing to the fluctuating and episodic nature of mental health problems, job retention can be a major issue for people once they return to work. Many people with mental health problems who gain employment with the help of traditional vocational rehabilitation services do not retain it for long. Research suggests that many vocational rehabilitation programmes are able to place unemployed people with mental health problems in paid work, but the average length of employment varies from weeks to months. However, there is increasing evidence to indicate the importance of helping people to retain their existing employment through the provision of ongoing support (McHugo et al., 1998).
Employers and legislation Discrimination on the part of potential employers is undoubtedly a major obstacle to people with mental health problems gaining work, especially those with a diagnosis of schizophrenia (Manning and White, 1995). However, evidence suggests that having been detained for a period of time under the Mental Health Act 1983 does not harm future job prospects. If people are to gain and retain employment, employers need to be seen as an important resource who should be supported and nurtured rather than attacked for prejudiced attitudes; active support to employers is one element of evidence-based supported employment. The Disability Discrimination Act (DDA) 1995 (Part II, Employment Provision) makes it unlawful for employers to treat a disabled
PSYCHIATRY 3:10
Self-management at work From an individual’s perspective there is an emerging literature on the experiences of moving into and maintaining employment which details the ways in which people cope with difficulties (Alverson et al., 1995; Leete, 1989). Too little attention is given to
55
© 2004 The Medicine Publishing Company Ltd
SPECIFIC COMMUNITY TREATMENTS
Bond G R, Becker D R, Drake R E et al. Implementing supported employment as evidence-based practice. Psychiatr Servv 2001; 52: 313–22. Bond G R, Drake R E, Mueser K T, Becker D R. An update on supported employment for people with severe mental illness. Psychiatr Serv 1997; 48: 335–46. Bond G R, Resnick S G, Drake R E et al. Does competitive employment improve nonvocational outcomes for people with severe mental illness? J Consult Clin Psychol 2001; 69: 489–501. Cook J A, Razzano L. Vocational rehabilitation for persons with schizophrenia: recent research and implications for practice. Schizophr Bull 2000; 26: 87–103. Crowther R E, Marshall M, Bond G R, Huxley P. Helping people with severe mental illness to obtain work: systematic review. BMJJ 2001; 322: 204–8. Drake R E, Becker D R, Biesanz J C, Torrey W C, McHugo G J, Wyzik P F. Rehabilitative day treatment vs. supported employment. 1. Vocational outcomes. Community Ment Health J 1994; 30: 519–32. Drake R E, Becker D R, Biesanz J C, Wyzik P F, Torrey W C. Day treatment versus supported employment for persons with severe mental illness: a replication study. Psychiatr Serv 1996; 47: 1125–7. Grove B. Mental health and employment: shaping a new agenda. J Ment Health 1999; 8: 131–40. Leete E. How I perceive and manage my illness. Schizophr Bull 1989; 15: 197–200. Manning C, White P D. Attitudes to the mentally ill. Psychiatr Bull 1995; 19: 541–3. McHugo G, Drake R E, Becker D R. The durability of supported employment effects. Psychiatr Rehabil J 1998; 22: 55–60. Rinaldi M, McNeil K M, Firn M, Kolesti M, Perkins R, Singh S. What are the benefits of evidence-based supported employment for patients with first-episode psychosis? Psychiatr Bull 2004; 28: 281–4.
Barriers faced by people with mental health problems when returning to work • Low motivation and confidence • Side-effects of medication • Fear of losing welfare benefits • Employers’ attitudes • Stigma and discrimination • Low expectations of health-care professionals
3
the difficulties people report in returning to work and there needs to be greater recognition of the self-adjustments and the variety of tools and techniques that people use to self-manage their mental health at work. Psychological support Rehabilitation involves both social adaptation and psychological adjustment and, for most people, work is central to both of these. The different types of internal and external barriers that people with mental health problems face when returning to work are well documented (Figure 3). However, most traditional vocational rehabilitation programmes aim to clarify job goals, provide jobseeking or job-related skills, or to re-socialize the person to the work environment; little psychological assistance is given. It is well recognized that people with mental health problems (as well as those who are long-term unemployed), when looking to return to work, face issues surrounding reduced self-esteem, self-efficacy and reduced expectations of a successful outcome in job-seeking. Furthermore, many experience a reduced motivation to seek work at all. Evidence-based interventions such as cognitive–behavioural therapy have successfully been used with people who are long-term unemployed as an intervention for returning to work, and research is needed to test the efficacy of this intervention within vocational rehabilitation for people with mental health problems.
FURTHER READING Royal College of Psychiatrists. Employment Opportunities and Psychiatric Disability. Council Report CR111. London: Royal College of Psychiatrists, 2002. Social Exclusion Unit. Mental Health and Social Exclusion. London: Office of the Deputy Prime Minister, 2004.
Conclusion The extent to which mental health services promote confidence in relation to work is critical. Through implementing evidence-based supported employment and integrating vocational rehabilitation within routine mental health care, psychiatrists, care coordinators and employment specialists all have a role in supporting people to successfully gain and retain employment.
REFERENCES Alverson M, Becker D R, Drake R E. An ethnographic study of coping strategies used by people with severe mental illness participating in supported employment. Psychiatr Rehabil J 1995; 18: 115–28. Anthony W. Characteristics of people with psychiatric disabilities that are predictive of entry into the rehabilitation process and successful employment. Psychiatr Rehabil J 1994; 17: 3–13.
PSYCHIATRY 3:10
56
© 2004 The Medicine Publishing Company Ltd