Making a reality of
employment for people with mental health problems
Rachel Perkins
BA, MPhil (Clinical Psychology) PhD, OBE
[email protected]
A view from 6 perspectives
• 33 years working in UK NHS mental health services
• 25 years using mental health services and working with a long-term mental health condition
• 15 years employing people with mental health and related conditions within UK NHS mental health services
• 15 years experience of developing evidence based programmes (IPS) to help people with more serious mental health conditions (including dual diagnosis) to gain and retain employment
• Leading a review to the UK Government ‘Realising Ambitions. Better employment support for people with a mental health condition’ (2009)
• Chairing the UK Cross Government Strategic Advisory Group on Issues Affecting Disabled People and advising on the UK Disability
Employment Strategy
Recognition of the importance of work in people’s lives is not new:
“Work is nature’s best physician and central to human happiness”
Galen, Greek philosopher and physician, 172AD
“the absence of occupation is not rest, a mind quite vacant is a mind distressed”
18th century poet William Cowper, who himself experienced periods of mental illness throughout his life and was confined to an asylum for over a year
People need two things – love and work . Work “binds the individual to reality”
Freud, 1961
“Work is the closest thing to a panacea known to medical science.”
Szasz, 1974
“The best thing you can do for someone with schizophrenia is to get them a job.”
Drake, 2006
We know the devastating consequences of unemployment for people with mental health problems
“Out of the blue your job has gone, with it any financial security you may have had. At a stroke, you have no purpose in life, and no contact with other people. You find yourself totally isolated from the rest of the world.
No one telephones you. Much less writes. No-one seems to care if you’re alive or dead .” (Bird, 2001)
or “... the early onset of distress will mean social exclusion throughout our adult lives, with no prospect of ...a job or hope of a futures in meaningful employment. Loneliness and loss of self-worth lead us to believe we are useless, and so we live with this sense of hopelessness,
or far too often choose to end our lives.” (cited by SEU,2003)
Too many people with mental health
problems become ‘I used to be’ people …
‘I used to be a student, a taxi driver, a football player, a bank manager
… but now I am just a mental patient’
The identity of ‘mental patient’ too often replaces all other valued roles
Too often people with mental health problems end up on the receiving end of help from everyone else – and this can be a very demoralising
and dispiriting place to be
Everyone who experiences mental health problems faces the challenge of recovering a meaningful, valued and contributing life … and work can
be central to this
Work …
• links us to the communities in which we live and enables us to contribute to those communities
• provides meaning and purpose in life
• affords status and identity
• provides social contacts
• gives us the resources we need to do the other things we value in life
… and it is good for our health – both physical and mental: appropriate employment reduces the risk of developing mental health problems and reduces symptoms (both positive and negative), decreases the
likelihood of relapse and decreases use of mental health services
The right to work – a human right
Article 23 of the United Nations Declaration of Human Rights (1948)
“Everyone has the right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment.”
Article 27 of the United Nations Convention on the Rights of Disabled Persons (2007) recognises “the right of persons with disabilities to work, on an equal basis with others; this
includes the right to the opportunity to gain a living by work freely chosen or accepted in a labour market and work environment that is open, inclusive and accessible to persons with
disabilities. States Parties shall safeguard and promote the realization of the right to work, including for those who acquire a disability during the course of employment.”
Article 6 and 7 of the International Covenant of Economic, Social and Cultural Rights
“States Parties to the present Covenant recognize the right to work, which includes the right of everyone to the opportunity to gain his living by work which he freely chooses or accepts,
and will take appropriate steps to safeguard this right.”
… but it remains a right denied a right denied
In the UK
People with mental health problems have the highest ‘want to work’ rate of all disabled people and the lowest
employment rate
• General employment rate = 71.6%
• Employment rate for all disabled people = 46.9%
• Employment rate for people with mental health conditions = 14.2%
(Department of Work and Pensions, 2013)
But can ‘they’ work?
Frequently asked question - what makes a person
‘employable’ or ‘work ready’?
But this is the wrong question …
The research evidence
• Characteristics of individuals like diagnosis, duration or severity of problems are not reliably associated with employment outcomes … therefore there is no
justification for selecting people on the basis of clinical history/diagnosis
• The only individual characteristics that influence employment outcomes are
‘motivation and self-efficacy – whether the person wants to work and whether they think they can – and both of these are profoundly influenced by the expectations of others – particularly the ‘experts’ in employment and mental health/addictions services
• The most important variable determining whether people can work is the type of support provided
Therefore the right question is ‘What sort of support
helps people with mental health conditions to work?’
0%
10%
20%30%
40%
50%
60%70%
80%
90%
2007 Aust
1996 NH
1994 NY
2007 IL
2004 CT
2005 HK
2006 SC
2006 MA
1999 DC
2007 CA
1995 IN
2007 EUR
2006 QUE
2000 NY
1997 CA
2002 MD
Supported employment Control
Long term outcomes are positive: 8-12 year follow up 100% had worked at least some of the time, 71% steady workers (Becker et al 2007)
There is strong evidence from at least 16 ‘randomised controlled trials’
that with the right kind of support - Individual Placement with Support evidence based supported employment – at least 60% with serious mental health problems (including dual diagnosis) can successfully get
and keep open employment
European Randomised Controlled trials of IPS evidence based supported employment
(Burns et al, 2007):
Six European Centres:
• London (UK),
• Ulm-Guenzburg (Germany),
• Rimini (Italy),
• Zürich (Switzerland),
• Groningen (Netherlands), and
• Sofia (Bulgaria)
European Randomised Controlled trials of IPS evidence based supported employment
(Burns et al, 2007):
Results
•
Significantly more people receiving IPS gained employment:
55% receiving IPS vs. 28% in existing service
•
Significantly fewer people receiving IPS dropped out: 13%
receiving IPS vs. 45% in existing service
•
Significantly fewer people receiving IPS were admitted to
hospital: 20% readmitted in IPS vs. 31% in traditional service
The 8 principles of IPS evidence based supported employment
1. Focus on open employment - real jobs – and a ‘can do’ approach 2. Do not select people on the basis of ‘employability’ or ‘work
readiness’ – help everyone who wants to have a go
3. Integrate employment support with treatment – treatment and employment support must be done in parallel and Employment
Specialists must be part of clinical teams – sitting in the same office, working together
4. Rapid job search (start within 4 weeks) rather than stepping stones first. If training/experience are necessary, these should be in
parallel with job search.
5. Job search must be personalised and based on client preferences - a person is more likely to get and keep a job that is in line with their
interests/preferences - and may involve active, individualised, work with employers
6. Employers are approached with the needs of individuals in mind – not just passive applications for jobs, but pro-active job finding - an emphasis on
building relationships with employers in order to access the ‘hidden labour market’.
7. Time-unlimited , personalised support to both employee and employer:
Employment involves a relationship between employee and employer and both parties may need support
8. High quality assistance with in and out of work welfare benefits and financial planning
Need to do all of these things to be effective –
outcomes related to fidelity
It’s not just research trials – IPS is effective in regular day to day practice
The experience of South West London Mental Health NHS Trust
Comprehensive community and inpatient mental health services for a population of 1 million people living in South West London
(approximately 2600 staff serving 15,000 people at any one time) Started recruiting Employment Specialists to work in clinical teams in
1999
By 2006 Employment Specialists in 11 Community Mental Health Teams including the First Episode Psychosis Team and the Community
Drug Team
Employment Specialists’ ensure that vocational issues are addressed as part of routine work within teams
Working with individuals
• to keep jobs they already have
• to decide what they want to do and apply for the work they want
• to access mainstream employment agencies
• in the transition to work
Work with the team:
• ensure that vocational issues are addressed at initial assessment
• ensure that mental health professionals attend to work related issues in care plans
• advise and assist other mental health workers in providing ongoing support#
Work with employers and employment agencies
• pro-active job finding – know local employers and local labour market
• link with employment agencies, job centres and welfare to work programmes
• support employers and advise them on adjustments the person may need- employment involves a relationship so need to support both parties
The results
1984 people received vocational support from the teams
1155 people successful in working/studying in mainstream integrated settings:
– 645 people supported to get/keep open employment
– 293 people supported to get/keep mainstream education/training
– 217 people supported in mainstream voluntary work
(Rinaldi and Perkins 2007)
0 20 40 60 80 100 120 140
Feb-02 Apr-02 Jun-02 Aug-02 Oct-02 Dec-02 Feb-03 Apr-03 Jun-03 Aug-03 Oct-03 Dec-03 Feb-04 Apr-04 Jun-04 Aug-04 Oct-04 Dec-04 Feb-05 Apr-05
Number of people supported
Open employment
Mainstyream education/training
Mainstream work experience/voluntary work
Team OTs supported by 1 Employment Specialist across 4 teams
0.5 Employment Specialists per CMHT
1 full-time Employment Specialist per CMHT
Open employment
Mainstream education/training
Mainstream work experience/voluntary work
Number of people supported in employment, mainstream education and voluntary work in a London borough where IPS was implemented in all community teams
Team OTs supported by 0.5 Employment Specialist across 4 teams
Open employment
Mainstream education/training
Mainstream work experience/voluntary work
Number of people supported in employment, mainstream education and voluntary work in a London borough where IPS was NOT implemented
0%
5%
10%
15%
20%
25%
30%
35%
London Borough of Wandsworth Community Drug
Team
London Borough of Merton Community
Drug Team
Addiction Treatment centre
Employment Specialist No Employment Specialist
Paid employment Education
Voluntary work
Employment rate in addictions teams with and without an employment specialist
(2009/10 data)
If we really address employment and education right from the start the results are even more impressive
Typical Picture: 50% in employment or education at first admission - only 20% a year later … but it doesn’t have to be this way
Individual Placement with Support in First Episode Psychosis
From Rinaldi et al (2010) First episode psychosis and employment: A review.
International Review of Psychiatry, April 2010; 22(2): 148–162 South West London: (mean age 21 years)
After 2 years 73% in employment (48%) or mainstream education (25%)
(Rinaldi et al, 2010)
Wholesale manager Accountant IT assistant Mental health development worker
Ward assistant Bookmaker Call centre handler
Retail assistant Receptionist Hairdresser MH advocate Occupational therapy assistant Accountants officer
Catering assistant Chambermaid Cleaner
Hotel Porter Labourer
Leaflet dropper Plumber’s assistant Post assistant Recycling assistant English Teacher Actor
Journalist Admin worker Credit controller Project worker (private sector)
IT Helpdesk Admin Assistant Civil servant - executive officer Baker x2
Carpenter Caretaker Hairdresser
Sales Assistant x8 IT Support desk Administrator Decorator Cleaner
Street cleaner Warehouse worker
Market research administrator Care assistant
Civil Servant (administrator) Production assistant
Assistant special needs teacher Administrative assistant x5 Regeneration project worker Glazier
Plumber
Catering manager IT trainer
Nurse
Health records officer
Hairdresser assistant
Indian Restaurant waiter
Leisure assistant Driver
Bar work Barista
Sales Advisor Boatyard worker Café Assistant Catering assistant Teaching assistant Social worker Youth Worker
Financial controller (Perkins et al, 2006)
And they were not all stacking shelves
By providing support we increase people’s belief that they can work
Proportion of people who had ‘written themselves off’ as unable to work because of their mental health condition
50%
33%
13%
0%
10%
20%
30%
40%
50%
60%
2008 UK National Mental Health
Service User Survey
SW London Community Mental
Health Teams where IPS implemented (Employment
Specialist in teams)
SW London First Episode Psychosis
Team where IPS implemnented
(Employment Specialist in team)
And it’s not just the results for individuals
And it works in primary care services for people who have common mental health problems
London Borough of Wandsworth Primary Care IPS Employment Service
• 1st September 2009 – 31st August 2010
– 259 referrals (93 didn’t want the service, 24 waiting to engage)
– 142 actually fully engaged
– 108 gained employment or retained employment following a period of sickness absence (74% if those who received support, 42% of total referrals)
• 1st September 2010 – 31st August 2011
– 458 referrals:
– 274 patients fully engaged (25 didn’t want the service, 159 waiting to engage)
– 231 gained employment or retained employment following a period of sickness absence (84% of those who received support, 50% of total referrals)
(Stephen Charlery, Wandsworth Primary Care Employment Service Annual Report)
But …
• Although an increasing number of mental health services in the UK are establishing Individual Placement with Support, most people do not have access to it
• A great deal of money is still invested in non-evidence based vocational services:
sheltered work, pre-vocational training
– Within health and social care services
– Within disability employment programmes run by the UK Department of Work and pensions
• Disability employment services do not offer evidence based support and do not serve people with mental conditions effectively:
– 43% of incapacity benefit claimants (IB/SDAESA) have a mental health condition
• Access to Work: 2.7% have a mental health condition (April 2013 statistics)
• Work Choice: 0.7% of those starting have ‘serious mental illness’; 10.6% have mild to moderate mental health condition (August 2013 statistics)