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Local Practice
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Mental Health and Employment- a Review of the Literature 1. Background As part of the process of developing a regional Statement of Priorities for mental health and employment in the North East a literature review has been undertaken. 2. Purpose of Report To assess the evidence base by which recommendations for practice in relation to mental health and employability in the North East will be informed. To assess the extent to which the literature deals with the issue of mental health and employment and understand the nature and authority of the current evidence base. A search was completed using the NHS ‘dialogue data star’ database for articles containing the words “mental health” and “employment” in the title or abstract. The data base returned over two thousand articles which were then limited by their titles. A number of articles which dealt with employability in general terms or those which addressed issues pertaining to client groups across a range of long term conditions were filtered out from further investigation. Abstracts were obtained for each of the remaining articles and a total of seventy-seven selected for inclusion in this review. The criteria for inclusion was to select those articles which discussed the range of issues relating to the support of individuals with mental health problems in engaging in employment. Table 1. Below shows a breakdown of the articles selected [TABLE GOES HERE] Additionally, some texts from references within the above literature, from within policy documents, new publications and local research reports were also sourced. A number of themes were emergent from the literature. Prominent themes are explored individually below. 4. Detail 4.1 The medical versus the social model The impact of the adoption of either the social recovery or medical model on effective supported employment was commonly explored within the literature (Buckle,2004; Sebohm and Secker, 2003; Secker et al, 2002). The medical model is based on the treatment of symptoms and therefore looks to individual medical interventions such as medication to treat and “cure” specific symptoms (Secker et al, 2003). Where symptoms cannot be cured this model can lead to the patient becoming dependant on the interventions of services. In contrast, the recovery model does not require a condition to be “cured” before supporting individuals to maintain or regain their life. The recovery model is a holistic approach, which acknowledges, and therefore treats, the needs of the whole person rather than focussing on the symptoms of their condition (ibid). It is acknowledged that by adopting this model individuals are encouraged to recover their life, which in itself, enables individuals to more effectively manage or recover from their mental health problems. Recovery focuses on a number of elements of the individuals’ lives including accommodation, social contact, leisure time and employment and is advocated as a way in which our mental health services ought to be developed (CSIP, 2006) as it is the most supportive model to the employability agenda. Importantly this model treats individuals as citizens first and refuses to define individuals with mental health problems by their condition. The importance of adopting this framework is summarised by the Royal College of Psychiatrists who report that the social model provides a more helpful conceptual basis for recovery and promotion of employment opportunities, better captures the experience of exclusion and discrimination, is consistent with government policy and the views of service users and also helps in dialogue with employers (Royal College of Psychiatrists, 2002) Although from as early as 1800s occupation was seen as a core part of mental health services and the 1830 Mental Health Act (cited in Buckle, 2004) required hospitals to provide “employment” (in its literal form) as well as medical attention, twenty first century services are only recently modernising to ensure that they reflect the need for meaningful inclusive occupation such as employment and volunteering and the benefits these bring as part of the recovery process (ibid). Employment itself has only recently become part of core care planning for mental health service users through the Care Programme Approach (NSF for Mental Health DoH, 1999). Despite this addition it is still felt that mental health care is too medicalised and research has shown that service users are still dissatisfied with the social aspects of their care (Buckle, 2004). The need for significant service development is requested within the literature with social inclusion through employment and the broad adoption of the recovery model at the core of modern mental health service (Secker 2005). 4.2 Barriers to employment The barriers which individuals with mental health problems face in accessing employment are well documented, the most significant are alluded to by Boardman et al (2003) who outlines the following common factors. The patient role which mental health services often encourage, causing individuals to be dependant on services to improve their condition and the “built in disincentives” of the welfare system which mean that individuals can be financially better off and more secure on benefits than in work. Boardman et al also highlight the stigma attached to mental health problems which not only discourages employers offering employment to individuals with mental health problems but also influences the attitudes of health professionals who are accused of underestimating the abilities of their clients and failing to appreciate the role of employment in recovery. The complexity of the agenda and the range of government agencies involved in mental health or employment are hindered further by the differing priorities of the key government agencies involved. Additionally, once people have secured employment, poor personal- organisational fit can pose barrier to the retention of employment (Kirsh, 2000 and Secker et al, 2002); this emphasises the importance of ensuring that individuals are supported into the right job and not any job at any cost. In addition to the personal barriers that individuals with mental health problems face in accessing employment, a number of structural and organisational barriers are also alluded to within the literature (Hayton, 2002,; Seebohm et al, 2003; Secker et al, 2002). Arguably the most important of these is that there is no single organisation nationally, regionally or locally (that could be identified) which had a clear picture of all the support available from the different agencies and how these services could be accessed (Hayton, 2002). An additional organisational concern was the short-term nature of the various funding streams which are often the backbone of employment and day services for individuals with mental health problems (Hayton, 2002). This has significant human resource implications due to the process of bidding and reporting to several funders at anyone time and can stifle the sharing of good practice due to competition for funding, resulting in instability in services. Evident within the literature was the low number of people with mental health problems in employment compared with other disabled groups (Boardman et al 2003, Grove 1999, Grove et al 2005, Hayton 2002, Royal college of Psychiatrists 2002, Centre for Economic Performance 2006). Additionally, the literature highlights the gap between those with mental health problems currently in work and those who desire to work. For example, Boardman et al, (2003) highlight The Office for National Statistics figures, which demonstrate that only 18% of people with long term mental health problems are in work (ONS, 2000) compared with 52% of individuals with physical disabilities (ibid), and they juxtapose this with an analysis of studies which have shown that up to 90% of mental health service users wish to work (Boardman et al, 2003). This is confirmed by the local study data outlined in the thematic reports (link to local study cover report). A variety of similar statistics are alluded to within the literature, all of which (although variable) conclude that significantly more individuals with mental health problems than are currently in work, both desire to work and are capable of doing so (Boardman et al 2003, Grove 1999, Grove et al 2005, Hayton 2002,). 4.3 Models of support IPS The vast majority of the literature falls into the category of examining and comparing different models of support (examples include: Becker and Drake 2006, Chalamat et al 2005, Crowther et al 2006, Dorio 2005, Hayton 2002, Sebohm et al 2003, Secker et al, 2002). A number of studies attempt to categorize the types of mental health employment support. Most commonly these are broken down into three broad categories which are largely made up of supported employment, sheltered employment and training and education. NIMHE, 2003 provides a useful break down of these services (see section 6). Whilst there is a variety of specific models available, comparative studies within the literature largely compare the provision of prevocational training and placements with the place and train approach of the Individual Placement and Support (IPS) model outlined below. Contained in both the cohort of reviews and evaluations of employment support programmes and within the general literature is an overwhelming support for the development of the IPS model (examples include: Dorio 2005, Chalamat et al 2005, Becker and Drake 2006 Hayton, 2002, Sebohm et al 2003, Secker et al 2002, Crowther et al 2006, Schnieder, 2005). Programmes which adopted this model were both well evaluated (Crowther et al, 2006) and the most commonly adopted model for pilot programmes. The IPS model has a number of distinctive features. Significantly, this model is concerned only with accessing open competitive employment for individuals with mental health problems, which means jobs that are not “earmarked” for individuals with a disability and are paid at least minimum wage. The IPS model advocates that open employment ought to be accessed for individuals without a period of job preparation or vocational training and that individuals benefit from the provision of training and support “on the job”. This has been dubbed the “place and train” rather than “train and place” model (Secker et al, 2002). There have been at least eighteen randomised controlled trials and a significant number of informal reviews of support programmes which have demonstrated that the uptake and retention of employment for individuals with severe and enduring mental health problems is most effective under this model (Crowther et al, 2006). Whilst the existing literature does attempt to demonstrate the IPS model as the most effective method of improving employment outcomes amongst individuals with mental health problems a note of caution must be added. The robustness of the evidence in this field may be questionable due to the fact that only a small number of the studies examined were subject to robust evaluation techniques such as randomised control trials (RCTs). Outside of the identified RCTs the evidence presented about the effectiveness of approaches was often anecdotal and gathered from very small numbers of service users participating in the programme. Additionally, in some cases it was argued that even the RCTs had pre selected appropriate participants for the IPS model, despite this being contested by Crowther (Cited in Boardman et al 2003). One could, therefore, argue that the evidence is biased in that those individuals, hand picked as appropriate for IPS, would have had equal chances of securing employment on any one of a number of schemes whilst those accessing sheltered employment or pre vocational training may (albeit with similar diagnoses) have been more vulnerable and less able to cope with employment or the IPS model. The third reason why this support for IPS must be subject to further research is the numbers for whom the programme has been successful. Whilst the literature undoubtedly demonstrates a number of studies in which IPS has been more successful that the comparative alternatives, the literature also shows that at twelve month follow up only around 34% of those who accessed IPS were in competitive employment (Crowther et al, 2006). Whilst this far exceeds the 12% alluded to who had received pre vocational training, (Crowther et al, 2006) one has to question whether this is the most effective intervention given Grove’s suggestion that no service users should be discouraged from exploring employment on the basis of diagnosis (Grove and Membrey, 2005). One could conclude from this that services should be in place which are able to support in excess of 34%. In light of this what IPS evaluations show us is simply that they have been more effective than the models against which they were trialled. Although the evidence base for improving employment outcomes of individuals with mental health problems is growing, it is still one which must be approached with caution and the consideration of alternative approaches ought not to be ruled out at this point. Section 5. provides an overview of recommendations for additional research which would assist with this. 4.4 Partnership working The coordination of partnerships was a central recommendation under which there were a number of individual recommendations including regional/city wide coordination under umbrella groups and strategies (Hayton, 2003). The creation of networks with others working in the field (e.g. mental health professionals and vocational specialists) was also proposed as a means of allowing individual organisations to provide specialist services and draw on the experiences of others rather than trying to be experts in everything. It was documented that, without this, there is a danger that organisations would require too broad a skills base, which would inevitably become diluted and thus less effective (Hayton, 2003). The need to work with employers and importance of their role is not heavily reflected in evaluations and trials. However, Kirsh does explore the issue of workplace culture and retention in a study (2000) which like Secker and Membrey, found that what was required to support individuals with mental health problems successfully in the work place was scarcely different from the support that all staff require (2003). Factors which influenced the success or otherwise of employment included relationships with colleagues, levels of training provided, having a job they enjoyed and an environment that was pleasant to work in, highlighting that individuals were not necessarily dependant on the provision of in work specialist support. It appears that a number of the issues outlined in the section above exploring barriers to employment could, in fact, be overcome by more effective partnership working. 4.5 Recommendations for practice Where supported employment programmes were to be developed a number of recommendations were proposed including provision of expert advice on welfare rights, the ability to address mental health issues specifically related to work, guidance support and advice for the client on managing their condition and good information for the client on opportunities for work and support locally, all very much with a focus on the individual needs of the client (Seebohm et al, 2003). Once employment was secured, pro-active, follow-on and continued in work support was highlighted as important (Secker and Sebohm, August, 2003). Additionally, it was emphasised that accessing competitive employment with rapid job search was preferable to lengthy pre-vocational training (Dorio, 2005 and as outlined in the IPS model in Chapter 1). The use of Cognitive Behavioural Therapy (CBT)1 was also advocated as a method for encouraging individuals to view work positively and cope with their mental health problems in work (Centre for Economic Performance, 2006; Sainsbury Centre, 2006) One of the weaknesses of the literature is undoubtedly that, whilst the establishment of more effective partnerships may provide solutions to a number of the barriers alluded to within the literature, that the majority of the literature evaluates individual programmes in isolation. No research was identified which adopted a more strategic whole systems approach to answering the barriers to employment for individuals with mental health problems. 5. Recommendations for future research Developing methods for robust evaluation of employment support programmes to improve the comprehensiveness and integrity of the current evidence base. Research into the effectiveness of generic employment support programmes for individuals with mental health problems (in line with the social inclusion agenda) Assessment of the extent to which job seekers with a range of physical problems require emotional/psychological support in making the transition to employment. Exploration of the impact of whole systems approach of existing services in comparison to the set up of additional highly funded “innovative” support programmes. This would help to inform where energy and resources ought to be focussed and identify the core necessary services for supporting employment of individuals with mental health problems. Additional evidence on how best to engage employers, and the business case for engaging in mental health employability agenda for a business. Research into the effective support for retention of individuals with mental health problems in work would also add value to the current evidence base. Of particular use would be information on the impact of supportive working practices on the flow of individuals onto sickness related benefits and an assessment of the extent to which in work support can prevent mental health problems becoming so disabling that individuals have to leave work and the extent to which individuals can remain in work with a mental health problem with the right flexibilities and support. 6. Employment Support Overview NIMHE at http://www.sesami.org.uk/employment_report.pdf (DoH/NIMHE) Social Firm – a business created for the employment of people disadvantaged in the labour market. At least 30% of employees fit this description. Work opportunities should be equal between disadvantaged and non-disadvantaged employees. Includes: Community Business- overseen by a group of directors whereby profits are invested in its employees and Co-operative, a legal structure for a company owned and managed democratically by its employees. Sheltered employment – people with disabilities/disadvantages are engaged in work with other people with disabilities/disadvantages. Sheltered workshop – clients are engaged in work activities in a sheltered setting and due to a variety of factors do not receive a wage at the going rate for a job, but might receive Permitted Earnings (formerly, Therapeutic Earnings). Work crews – working (building, decorating, furniture removals) in small groups of people with disabilities. Little used in UK apart from some sheltered settings. Clubhouse work-ordered day – members attend as day care, but experience a structured routine designed to facilitate moving onto Transitional Employment (see below). Rehabilitation/vocational training – clients are taught vocational skills and may gain qualifications. Projects are often located in colleges or training centres, or involve workplace training. Supported education – people with expertise in mental health issues advise and support people who wish to undertake training and education in inclusive settings (e.g. college). Not widely recognised in UK as a coherent intervention approach. Work placement and voluntary work – work in real settings but without pay or employment rights. Sometimes practised while an individual's benefits are being assessed or while clients are gaining work experience and relevant workplace skills or building confidence. Supported employment (SE) and Individual Placement and Support (IPS) – involve clients working in open employment with support from job coach or other support staff. They are paid the going rate for the job, which can be full- or part-time. In IPS the provider is an integral member of the community mental health team. All forms of working open settings for real pay, whether transitional, temporary or permanent Supported Placement Scheme (SPS): Workstep and Personal Advisor Scheme (PAS)– schemes for people with disabilities provided by the UK Department of Work and Pensions. The SPS scheme offered long-term support in the workplace; its successors after April 2001, Workstep and PAS, are time-limited, offering placement, some training and support in open employment. This service is provided mainly by voluntary organisations and individual contractors, and funded by the Department of Work and Pensions. Transitional Employment – time-limited exposure to open employment, with ‘ownership’ of job vested in Clubhouse, thus freeing service user from commitment to do work full-time. Sheltered employment -any occupational project, paid or unpaid ,in which participants are brought into contact mainly with other people with mental health problems and staff members Training and Education- interventions which are primarily educational as well as those that are employment-oriented to a greater or lesser degree, and which emphasise development of the individual’s capability to work 1 A psychological talking therapy which encourages individuals to take a positive and proactive view of their lives and future. |