Implementing Evidence Based Supported
Employment for People with Mental Health
Problems
Rachel Perkins
BA, MPhil (Clinical Psychology) PhD, OBE
[email protected]
Challenges for implementing evidence based supported employment
Five inter-related problems 1. A reliance on ‘illness’ models of mental health conditions
2. A culture of low expectations: employment not considered a realistic goal for people with mental health problems
3. Fear on the part of health professionals, individuals and employers
4. Failure to provide the sort of support we know works: disbelieving the research evidence, investment (personal and financial) in existing ways of doing things 5. Failure to implement it properly:
6. Lack of joined up working at national and local level
1. A reliance on ‘illness models’ of mental health conditions
Illness or disability?
If we are to help with mental health conditions to work we can:
• Focus on trying to ‘change the person so they fit in’: treat symptoms and
addiction issues, remedy cognitive deficits, train people in necessary skills, reduce anxiety ...
• Focus on trying to ‘change the world so that it can accommodate the person’
assume that the person’s difficulties are ‘given’ and remove the environmental barriers - social, cultural and physical – that prevent the person from working
Mental health services tend to focus on ‘changing the person so they fit in’ – treatment and therapy to eliminate problems
It is important to try to treat symptoms BUT many people have mental health and related problems that recur or are ever present … and no amount of treatment reduces
the prejudice and discrimination that surround mental health problems
If people with ongoing or recurring problems then we need a different approach ... and we might have something to learn from the broader disability world and the
social model of disability
This argues that the barriers to participation and inclusion lie not in the individual but in our communities and society – that if a person has ongoing impairments then we must look to removing the environmental barriers that stop them working
or participating in other facets of community life
“It is attitudes, actions, assumptions – social, cultural and physical structures which disable by erecting barriers and imposing restrictions and options. Disability is not
inherent.”
“The social model of disability is about nothing more complicated than a clear focus on the economic, environmental and cultural barriers encountered by people who are viewed by others as having some form of impairment - whether physical, sensory or
intellectual”
Oliver, M (2004). If I had a hammer: the social model in action. In: J. Swain, S. French, C. Barnes and C.
Thomas, (eds). Disabling Barriers – Enabling Environments. SAGE, London.
The ongoing or recurring cognitive, emotional and behavioural problems of someone with mental health problems are parallel mobility
impairments, visual impairments, hearing impairments etc.
“For most of us, mental health problems are a given ... the real problems exist in the form of barriers in the environment that prevent us from living, working and learning in environments of our choice [the task
is] to confront, challenge and change those barriers and to make environments accessible ... environments are not just physical places
but also social and interpersonal environments ...those of us with
psychiatric disabilities face many environmental barriers that impede and thwart our efforts to live independently and gain control over our lives.”
Patricia Deegan, 1992, ‘The Independent Living Movement and People with Psychiatric Disabilities: Taking Back Control over Our Lives’
A social model of disability makes us think differently about how we can help people with mental health problems to get and keep
employment
Replace: ‘what are the person’s problems’ and how can we get rid of these’
With: ‘what are the barriers’ (attitudes, expectations, assumptions –
social, cultural and physical structures) and how can we get around these
• What support might they need? (the mental health equivalent of the wheel chair, the assistance dog or sign language interpreter ... or the ‘job coach for someone with learning disabilities)
• What adjustments might they need? (the mental health equivalent of the ramp, lift, hearing loop, signs in brail)
• How can we break down prejudice and discrimination that stop people being recruited to jobs?
In UK disability employment programmes tend to assume that:
•
People have a physical or sensory impairment and therefore need adjustments/support to negotiate the physical environment at work
•
People either have stable impairments therefore need stable level of adjustment and support - all you have to do is provide the
adjustments/support and then everything will be all right or
•
People have learning disabilities and need extra help to learn the job (a job coach)
The challenges faced by people with mental health conditions
and addition problems are different
The challenge of working with a mental health condition and addiction problems
• Affect a person’s ability to negotiate the social world of work (rather than the
physical one) – therefore need to think about adjustments/supports to access the social world of work
• Often fluctuate and it is difficult to know when fluctuations will occur – therefore need fluctuating adjustments and support
• Are not immediately obvious and engender fear because of the myths that surround them (dangerousness, incompetence etc.) – therefore need to break down myths
• Types of adjustment and support people may need less well explored – therefore need to provide more support to individuals and employers to think about what sort of adjustments and support are needed
But the biggest barriers lie not within the individual but in the attitudes
of others, the type of support that is provided, and the ways in which
health, and employment services work together …
2. A culture of low expectations …
on the part of health professionals, employers, employment agencies and society as a whole … and people with mental health conditions
‘It’s a well known fact that people with schizophrenia/addiction problems cannot work’
Nicola Oliver (2011) a woman with bipolar disorder describes the barriers she experienced …
“My first obstacle was my employer. Ten days after I
disclosed my disability I was sacked.”
“My second obstacle was my community psychiatric nurse. He was lovely but recommended I consider only low stress jobs and part time hours; maybe I could stack shelves in a supermarket! I hadn’t studied for three degrees to stack shelves.
“My third obstacle was my psychiatrist. She told me that it was unlikely that I would ever work again.”
Is it any wonder that with these messages from the ‘experts’ ...
“My fourth obstacle became my-self. I became ‘Nicola the bipolar person’: incompetent, inadequate and worthless.”
“I was offered cognitive behavioural therapy to overcome my low self-
esteem, but the psychologist became my fifth obstacle. She was
adamant that I should stop yearning to return to work.”
Many would have given up at this point ... but Nicola was
determined - despite all the negative messages she continued to try to get work ....
But employment support agencies were no better ...
“I contacted a [private] recruitment agent who told me I had a great CV ... but she quickly became my sixth obstacle. When I
explained the gap on my CV was due to bipolar disorder I never heard from her again.”
“The seventh obstacle was the charity [mental health NGO] I approached to help me get into work ... I was told ‘maybe we should wait until you are a bit better’.
“My final obstacle was a [Department of Work and Pensions Job
Centre Plus] disability employment advisor who was supposed to
help me find work. She wanted to send me on a confidence building
course! I didn’t want training, I wanted a job.”
“If only ...
… someone had helped me reassure my employer I was still worth employing.
…. they had shown conviction that I could still achieve.
… I had met other employees with bipolar disorder to inspire
me to believe that one day I too could return to work.”
3. Fear on the part of professionals, individuals, employers and employment support providers
People with mental health conditions, and the health professionals who support them, often see leaving benefits and entering the workforce as a risky
business:
Fear that working may make symptoms worse, that people will experience anticipated prejudice and discrimination, moving off benefits may threaten financial security
Uncertainty because of fluctuating condition – whether they can manage to work if condition worsens, whether former benefits will be reinstated quickly if it doesn’t work out
Employers and employment support services see employing people with a
mental health condition as a risky business:
Fear because of lack of understanding of mental health conditions and myths that surround them, that they will not be up to the job, that they will be disruptive in the workplace
Uncertainty because of fluctuating condition and lack of understanding of appropriate support and adjustments
Breaking the Conspiracy of Low Expectations and Decreasing Fear
• Demonstrating to clinicians, service users and employers that work is a realistic possibility for people with mental health problems.
Making research evidence accessible but ‘seeing is believing’: need local examples of success, pilot projects, collecting and publicising ‘journey to work’ stories
• Not just ‘them out there’ – leading by example and employing people with mental health conditions within services
If staff and service users in mental health services can see people working in their services it increases the belief that employment is possible
• Showing clinicians they have an important role.
A critical part of the solution, not ‘a problem’ (as they are sometimes viewed by employment services and employers in the UK)
• Increasing consumer demand
Making service users aware of what they should be able to expect in the way of employment support – providing them with the evidence
•
Knowing and supporting employers – not just the big ones but the small ones and the local managers
– Providing an ongoing point of contact for help and advice.
•
Dispelling myths about welfare benefits and employment
– Good benefits advice alongside employment support dispelling inaccurate
‘benefits trap’ myths among clinicians and people with mental health conditions
– Not all work is like working in health and social services understanding the sorts of jobs that are out there in the local area
•
Breaking down prejudice and discrimination more generally ...
anti- discrimination campaigns like ‘Like Minds Like Mine’ (New Zealand) ‘Time to Change’(England) ‘See Me’ (Scotland)
But raising expectations and decreasing fear must be
accompanied by the provision of the right kind of support …
4. Failure to provide the sort of support we know works
•
Too often
– People with mental health not seen as a priority for employment service programmes
– Employment not seen as a priority for mental health services
But in the UK there is also an enormous investment (personal and financial) in existing ways of doing things
on the part of service providers, people who use mental health services, politicians and the public and people with mentalhealth conditions (especially sheltered work and pre-vocational training) –
Many people are ignorant of or disbelieve the evidence
Problem: IPS evidence based supported employment principles challenge some traditional assumptions that are
commonly held among professionals, employers, the ‘general
public’ and people with mental health conditions ...
The reality:
• very few people move from segregated, sheltered settings and prolonged ‘pre- vocational’ training into open employment
• people learn that they can only work in a safe, sheltered setting and never move into work
People need ‘water wings’ – support to keep them afloat in
employment - rather than
‘stepping stones’!
Common assumption: ‘stepping stones’ - people need to build up their qualifications, skills and confidence in a safe, sheltered setting they will be able to move on to open
employment
The reality:
• If you don’t help a person to keep their job when they develop mental health
problems or relapse they are likely to lose their job and have no job to go back to when they are ‘better’
• The longer they are out of work the less likely they are to return: 6 months absence – 50% return; 12 months absence – 25% return; 2 years absence – 2% return (British
Society of Rehabilitation Medicine)
• You don’t have to be fully ‘better’ to work
• If you provide the right kind of support while the person is receiving treatment, they may well be able to stay at work
Moving from an ‘illness’ model to a ‘disability’ model means that we look at what kind of support and adjustments a person may need
to work with their mental health problems and/or return to work as quickly as they can (before they are ‘fully better’)
Common assumption: people need to be fully ‘better’
before they can return to work: we must treat people’s
mental illness before they can go back to work
Within the framework of IPS, are we providing the right kind of support at the right time? For example:
•
‘Job retention’ is as important as getting a job ... and does not
always mean staying in the same job.
Retention may mean going back to the same job, or a different job with the same employer, or changing your job. Workingpatterns are changing and we now see people change jobs more frequently.
•
Help when the person or their employer needs it.
Help needs to be there when problems occur (not having to wait for appointments): the role of telephonesupport
•
Help with all the things around work
(like getting up, getting to work etc.)•
Help to sort out problems outside work
that may jeopardise the person’s ability to work•
Help outside work (telephone, meetings before/after work/in lunch
break) ...
to resolve problems in relationships at work, problems with the demands of the job, talking through difficulties•
Someone to go in and help the person at work.
Like a ‘job coach’ for someone with learning disabilities or a sign language interpreter for someone with ahearing impairment – maybe episodically when the person’s condition fluctuates) or even someone who can work for them if they are not able to (as in Clubhouse’ approach in the USA)?
• Peer support.
Often people who have faced similar challenges are the best ones to provide support and encouragement and help people to believe they can work: sharing experience through sharing stories, mentoring, job clubs, peer led support groups,employing people with lived experience as Employment Specialists.
•
Time limited ‘work experience’ or ‘internships’
in parallel with job search and in real employment settings. Can increase the confidence of the individual and show employer that people with mental health conditions can work.• Managing symptoms and problems in a work context – a work health and well-being plan
“Having your own plan about how to cope and what you need is good for employer and employee.”
‘Surviving and Thriving at Work’
Health and well-being at work plans ...
‘A Work Health and Well- being Toolkit’
and
‘Going Back to Work After a Period of Absence’
Dr Rachel Perkins OBE
Published by Disability Rights UK [email protected]
A work health and well-being plan
What the individual and their manager can do:
– Keeping on an even keel at work
– Managing things that you find difficult at work – Managing ups and downs
– Crisis plans
– Plans for returning to work after a crisis
These plans
• Increase confidence of employee and employer
• Offer a way of managing a fluctuating condition at work and planning fluctuating adjustments and supports
• May be useful for all employees!
Within the framework of IPS, are we providing the right kind of adjustments?
• Starting work gradually and building up hours over time
• Starting small and building up. Most people start their working lives in ‘marginal’ jobs (delivering newspapers, seasonal work etc.) ... but then move on in their careers
• Not just ‘9 to 5’ . There are many ways of working ...
– working from home
– working part time (maybe only a few hours/days per week)
– self-employment
• Matching the job and the person
• Adjustments in the workplace, like:
– Additional supervision/feedback
– A mentor among other employees
– Access to a telephone to call support worker if you are having difficulties
– Adjustments in duties – relief from some ‘non-central’ parts of the job
– Written instructions
– Somewhere quiet to work ... or somewhere to go if it is all getting too much
– Working particular hours (e.g. only mornings/evenings)
– Flexible hours, monthly hours, annualised hours
5. Failure to implement IPS properly
With IPS the higher the fidelity to the model the better the outcomes – it is important to ensure that all 7 principles are met
Many existing UK services say ‘we are already doing MOST of those things’
BUT
Is employment really considered as a core part of assessment and support planning for everyone of working age from the start ... or do we leave it until later – after we have treated their
illness/addiction/other problems?
It is critical that clinical treatment and employment support occur in parallel from the start … job retention as well as helping someone to get a job
Are Employment Specialists really integrated into clinical teams (rather than being a separate service to which people are referred)?
A full member of the team like any other team member:
• Sitting in the same place
• Part of assessment and review meetings
• Writing in the same notes
• Working with individuals alongside other team members
Integrated vocational services allow:
• More effective engagement
• Better communication
• Better ‘joined up working’ around individuals
• Opportunities for clinicians to understand employment issues
• Incorporation of clinical information and interventions into vocational plans
How proactive are we at job-finding and working with employers ...
do we know local employers, how good are we at supporting them?
Or do we rarely make contact, continue to see them as ‘the enemy’?
Are we really helping everyone who thinks they might want to work ...
or are we still (implicitly or explicitly) ‘selecting’ people on the basis of our judgements about their ‘work readiness’ or ‘employability’?
Do we really have a ‘can do’ attitude ... or do we continue to ’write off’ some people?
Are we really helping everyone who wants to have a go?
Can people refer themselves?
Are we really able to offer long term support?
In the UK most people do not receive long term support from secondary services – once symptoms have been stabilised long-term support is often provided in primary care.
Many people with mental health problems are treated in primary care – do we provide employment support there?
In the UK only a few areas have Employment Specialists in primary care.
Implementing ‘Individual Placement with Support’
evidence based supported employment ...
International evidence
Keys to developing high fidelity services (Bond 2009 )
1. The state authorities provide resources and leadership 2. Technical assistance centres provide training and
monitoring
3. Discontinue old ways of doing things (e.g. close down pre- vocational training programmes)
4. Conduct ‘fidelity reviews’
Keys to developing high fidelity services (Bond 2009)
5.
Effective leadership at every level with a ‘can do’ attitude:
– confront resistance and provide rationale for new ways of doing things
– monitor performance, diagnose problems and establish action plans to resolve them
– model practitioner behaviours
6.
Count the things you want to change like employer contacts, jobs
7.
Hire the right people
8.
Establish close integration with mental health treatment teams ... this is harder when clinical treatment and
employment support are provided by different agencies
6. Lack of joined up working at national and local level
If people with mental health conditions are to receive the support they need to access and prosper in employment then joined up working is required across:
• mental health (primary care and secondary, specialist, mental health services)
• social care services
• voluntary sector/non-statutory initiatives
• generic welfare to work programmes
• specialist disability employment programmes
• generic and specialist training people for employment
• apprenticeship and internship programmes and initiatives for young people
• employers (at local and national level)
• welfare benefits systems
We must address all of people’s needs (employment, social, health etc.) We must help people to access all of the expertise and resources available
Too often in the UK
• Confused and contradictory policies and approaches that are wasteful of resources
• Confused customers and clients who are receiving contradictory messages: one plan for employment one for health and social care
There are signs that things are improving (probably driven by the ever increasing welfare bill):
• Employment is a central part of mental health strategy
• Review of DWP disability employment programmes is specifically addressing the needs of people with mental health conditions – including Mental Health and Employment Board with Department of Health and Department of Work and Pensions Officials
• Link up at ministerial level
• Local Health and Well-being Boards and the Public Health Agenda: employment is central
• Changes in welfare benefit system – Universal Credit
… but link up at local level very patchy
Better joined up working between health/social services and
employers/employment services at a local level
•
Sharing expertise in local networks. Health/social
services professionals can’t become employment experts – employers and employment advisors can’t become mental health/addictions experts ... but they can use each other’s expertise
•
