Implementing Evidence
Based Supported
Employment for People
with Mental Health
Problems
Rachel Perkins
BA, MPhil (Clinical Psychology) PhD, OBE
rachel.e.perkins1@btinternet.com
We know what works, so why aren’t we
doing it?
1.
Failure to prioritise employment for people with mental health
conditions
2.
A reliance on ‘illness’ models of mental health conditions
3.
Fear and a culture of low expectations: employment not considered
a realistic goal for people with mental health problems
4.
Failure to provide the sort of support we know works
5.
Failure to implement it properly
1. Failure to prioritise employment for people
with mental health conditions
• Employment not seen as a priority for health and social care services - not part
of their ‘core business’ … therefore largely ignored in treatment and support plans English national patient survey 2013
• 27% definitely received help with finding or keeping work • 43% said they would have liked help but did not get it
• People with mental health conditions not seen as a priority for ‘welfare to work’
and specialist disability employment programmes for those facing the greatest barriers to work
• 43% of people receiving out of work benefits have mental health problems • Access to Work programme (serves around 30,000 people in total): 3.2% have
a mental health condition
• Work choice programme (serves around 9,000 people in total): less than 1%
serious mental health condition, 12.8% ‘mild to moderate’ mental health condition (depression/anxiety)
2. 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
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
Parallels with physical impairment: a social model
of disability
If a person has ongoing (or recurring) impairments then we must look to removing the environmental barriers that stop them working rather than
focusing on eliminating their problems.
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 ... )
• 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?
The challenge of working with a mental health condition
are different from those facing people with physical
impairments
• 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 often lie in the type of support that is
provided, the ways in which health, and employment services work
together and the attitudes and expectations of others…
3. Fear on the part of the person, mental
health professionals, employment advisers,
employers
•
that getting a job may worsen your mental health
•
that you will experience prejudice and discrimination at work
•
that getting a job and moving off benefits may make you worse off
financially ... and what happens if it does not work out
•
that they will not be up to the job
•
that you don’t have the skills to manage their problems – better leave
it to the experts
3. 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
themselves
‘
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
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.”
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
4. Failure to provide the sort of support we
know works
In the UK there is 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 mental health 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
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 employment support while the person is receiving
treatment, they may well be able to stay at work or only take a short period off 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
Common assumption:
people need to be fully ‘better’
before they can return to work: we must treat people’s
mental illness before you think about work
What sort of adjustments and support within
the 8 principles of IPS?
•
‘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. Working patterns are changing and we now see people change jobs morefrequently.
•
Help when the person or their employer needs it ...
help needs to bethere when problems occur (not having to wait for appointments): the role of
telephone support
•
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•
Someone to go in and help the person at work.
Like a ‘job coach’ forsomeone with learning disabilities or a sign language interpreter for someone with a
hearing 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 toprovide support AND seeing what others have achieved can increase motivation and self-confidence. For example:
• employing people with lived experience as Employment Specialists
• sharing experience through sharing stories
• ‘job clubs’
• peer mentoring
• peer led support groups
•
Time limited ‘work experience’ or ‘internships’ in parallel with job
search
and in real employment settings. Can increase the confidence of the‘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 ben.kersey@disabilityrightsUK.org
•
Managing symptoms and problems
in a work context – 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
•
Starting work gradually and building up hours over time
•
Starting small and building up.
Most people start their working lives in‘marginal’ jobs (casual work, seasonal work, delivering newspapers etc.) ... but then move on in their careers
Not just jobs but careers ... the importance of mentoring in relation to career development (see RADIATE in UK as an example of peer mentoring)
•
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, for example:
– Additional supervision/feedback
– A mentor among other employees
– 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)
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 8 principles are met
Many existing UK services say ‘we are already doing MOST of those things’
but …
For example:
• Do we really have a ‘can do’ attitude?
• Are employment workers really integrated into clinical teams – there at assessment and
review meetings, writing in the same notes ...?
• Are we still ‘selecting’ who we help on the basis of our judgements about
‘employability’?
• How good are we at ‘job-finding’? Do we really know our local employers? How good
are we at supporting them?
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 we must
address all of a person’s need
(health, social, employment etc.) and
joined up working is essential
across:• mental health (primary care, secondary mental health services, specialist)
• social care services
• generic welfare to work programmes, apprenticeship and internship programmes and
initiatives for young people
• specialist disability employment programmes
• employers
• welfare benefits systems
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
In the UK there are signs that things are improving
(probably driven by the ever increasing welfare bill):
• Employment is a central part of mental health strategy: employment outcomes for
people with mental health problems are a ‘key performance indicator’ for mental health and social services
• Review of DWP disability employment programmes is specifically addressing the
needs of people with mental health
• Changes in welfare benefit system – Universal Credit
… but link up at local level very patchy
We need to get better at
• 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
• Better joined up working around individuals. Ensuring that health
treatment/social care plans and employment action plans offer consistent messages and complement each other
IPS can facilitate this – linking not only with employers but employment services and helping people to navigate these
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’
5. Effective leadership at every level with a ‘can do’ attitude
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
But most of all we must raise our expectations
“The greater danger for most of us lies not in
setting our aim too high and falling short, but in
setting our aim too low and achieving our mark.”
“... grant that I may always desire more than I can
accomplish.”
Michelangelo (1475-1564)
“There’s a better life out there ... If you just
sit back, then you won’t make it – but you
can make it if you want to. You’ve got to be
real with yourself. The power is you.”
