New Thinking about Mental Health and Employment

What a whole system approach might look like?

 Rachel E. Perkins BA, MPhil (Clinical Psychology), PhD, OBE

13th May 2011

A view from 6 perspectives• 30 years working in mental health services • 20 years working with a long term mental health condition• 15 years employing people with mental health conditions within 

mental health services• 10 years experience of developing evidence based programmes 

(IPS) to help people with more mental health conditions to gain and retain employment

• Leading a review to 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 – Equality 2025

Employment is important for people with mental health conditions

• It is good for our health: employment reduces mental health problems and decreases the likelihood of relapse

• It links us to the communities in which we live and enables us to contribute to those communities: the opportunity to contribute is central to recovery

• It provides meaning and purpose in life • It affords status and identity• It provides social contacts• It gives us the resources we need to do the other things we value in life

Most people with mental health problems want to work ... but few have the opportunity to do so

Employment is possible for people with mental health problems

16 randomised controlled trials of ‘Individual Placement with Support’ evidence based supported employment show that an average of 60% of people with more serious mental health conditions can gain and sustain 

employment IF we provide the right support

European research compared traditional vocational service (non-integrated ‘train-place’) with IPS for people with schizophrenia (Burns et al, 2007):– 55% gained employment in IPS vs. 28% in traditional service– 13% drop-out in IPS vs. 45% in traditional service– 20% readmitted in IPS vs. 31% in traditional service

• Follow-up studies show that work outcomes improve over time

it’s not just research trials – it also works in regular day to day practice Employment Specialists in South West London Community Mental Health Teams (2007/8):

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

In a service for people with 1st episode psychosis – 73% were in employment or education after 2 years

Wholesale    managerAccountantIT assistant Mental health   development       workerWard assistantBookmaker Call centre   handlerRetail assistantReceptionistHairdresserMH advocateOccupational     therapy assistantAccountants officer

Catering    assistantChambermaidCleanerHotel PorterLabourerLeaflet dropperPlumber’s    assistantPost assistantRecycling    assistantEnglish TeacherActorJournalistAdmin workerCredit controllerProject worker    (private sector)

IT HelpdeskAdmin AssistantCivil servant  -    executive officerBaker x2CarpenterCaretakerHairdresserSales Assistant x8IT Support deskAdministratorDecoratorCleanerStreet cleanerWarehouse   workerMarket research    administratorCare assistant

Civil Servant    (administrator)Production    assistantAssistant special    needs teacherAdministrative     assistant  x5Regeneration      project workerGlazierPlumberCatering managerIT trainerNurseHealth records    officer

Hairdresser    assistantIndian Restaurant      waiterLeisure assistantDriverBar workBaristaSales AdvisorBoatyard workerCafé AssistantCatering assistantTeaching assistantSocial workerYouth WorkerFinancial controller

And it is not all stacking shelves

What is the right kind of support?

The 7 key principles of individual placement with supportevidence based supported employment

1. Competitive employment – real jobs – and a ‘can do’ approach

2. Rapid job search – ‘place-train’ rather than ‘train-place’:– helping people to get a job as quickly as possible and then supporting them in it 

rather than lengthy per-employment training/preparation  

3. Integration of employment support into support and treatment plans from the start:– employment specialists in support and treatment teams – employment integrated into the work of all mental health workers

The 7 key principles of individual placement with supportevidence based supported employment

4. Eligibility based on client choice – help anyone who wants to give it a try: – no selection on the basis of ‘job readiness’ or ‘employability – no relationship between diagnosis, severity etc. and outcome– only individual characteristics that make a difference are motivation and self-efficacy 

(whether a person wants to work and whether they think they can): both highly influenced by the expectations of others 

5. Job search based on client preferences6. On-going supports for both employee and employer

Employment involves a relationship – between employer and employee therefore have to support both parties in the relationship

4. Benefits counselling ... and a welfare benefits system that encourages people to have a go

Need to adhere to all 7 of these principlesThe higher the fidelity the better the outcomes

Other types of support that may be helpful WITHIN the 7 key IPS principles

• Time limited ‘work experience’ or ‘internships’ in parallel with job search and in real employment settings

• Peer support• Starting work gradually and building up hours over time and a benefit system that makes this 

possible• 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.”• Not just jobs but careers - starting small and building up  - most people start their working lives 

in ‘marginal’ jobs ... but then move on in their careers• Not just ‘9 to 5’ - many ways of working ... including self-employment• Not just ‘them out there’ - leading by example: public sector, health and employment services 

employing people with mental health conditions• ‘Job retention’ is as important as getting a job ... And does not always mean staying in the

same job - changing working patterns where people change jobs regularly• Breaking down prejudice and discrimination more generally ...

Implementing ‘Individual Placement with Support’ evidence based supported employment ...

Keys to developing high fidelity services (Bond 2009)

• The state authorities provide resources and leadership• Technical assistance centres provide training and monitoring• Discontinue old ways of doing things (e.g. close down pre-vocational training 

programmes) • Conduct ‘fidelity reviews’• Effective leadership at every levels with a ‘can do’ attitude:

– confront resistance and provide rational for new ways of doing things– monitor performance, diagnose problems and establish action plans to resolve them– model practitioner behaviours

• Count the things you want to change like employer contacts, jobs• Hire the right people• Establish close integration with mental health treatment teams ... This is harder 

when clinical treatment and employment support are provided by different agencies

Making evidence based employment support a reality

The barriers

• A culture of low expectations• Fear• Failure to provide the sort of support we know works 

• Lack of joined up working at national and local level

A culture of low expectations• Low expectations on the part of health professionals, people with mental health conditions, 

employers, employment support services and society as a• Ignorance of research evidence• Disbelieving research evidence – ‘Yes, but ...’

– Yes, people with mental health conditions can work BUT ‘my’ clients are different  ...– Yes, it may work elsewhere (in the USA, in London ...) BUT it is different here ....

Fear on the part of health and social care professionals, employment support providers, individuals and employers

• that getting a job worsen the person’s mental health• that people will not be able to work • that getting a job and moving off  benefits will make the person worse off• that if it doesn’t work out this will leave the person worse off  personally (the impact of failure) and 

financially

Failure to provide the sort of support we know works

• Employment not seen as a priority for mental health and social services– Very little attention to employment in care and treatment planning – employment 

is not our business– Widespread belief that

• work is bad for your mental health• need to ‘get people better’ before you can think about employment

– In challenging economic times we cannot afford it? Need to focus on core business of treatment 

– Reluctance to ‘do the government’s dirty work’ – ‘it’s all about saving money’, need to ‘protect’ people from efforts to ‘force’ people into work

• People with mental health problems not seen as a priority for employment support programmes (both generic ‘welfare to work’ programmes and specialist disability employment programmes)– In the UK 43% of people claiming incapacity benefits have a mental health condition but very 

few of those using specialist disability employment programmes have a mental health condition: 0.7% of those using Access to Work, 7% of those using Work Step (now Work Choice)

– Programmes not tailored to the needs of people with mental health conditions:– Often fluctuate and it is difficult to know when fluctuations will occur – fluctuating conditions require 

fluctuating adjustments and fluctuating support– Can affect a person’s ability to negotiate the social (as opposed to the physical) world of work – 

therefore need to look at ways of making adjustments in the social environment – Are not immediately obvious and engender fear because of the myths that surround them – therefore 

need to break down myths and stereotypes by providing support to both employer and employee

– In hard economic times focus on those who are seen as easiest to help – ‘cherry picking’

• Challenges ‘sacred cows’  and established ways of doing things:– ‘you have to build up your skills and confidence in a safe, segregated setting before you 

can go back to work’– staff and service users and local politicians investment in existing services

Do employment support programmes really offer evidence based support?

• Is employment support really integrated with clinical and social support – a core part of treatment and support plans from the start?

• Is support provided by disability employment programmes really tailored to the needs of people with mental health conditions?

• Do we really have a ‘can do’ attitude?• Are we still ‘selecting’ who we help on the basis of our judgements about ‘employability’?• How well do we support employers?  Help them to find the right person at the right time? Provide 

assistance when they are having difficulties• How good is the advice and information we offer about benefits?• Are we really able to provide longer term support for people and their employers?

By providing people with support that works we can increase expectations ...

Proportion of people who had ‘written themselves off’ as unable to work because of their mental health condition

Failure of joined up working at national and local levelIf 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 services– social care services– employment services– generic welfare to work programmes– specialist disability employment programmes– generic and specialist training really prepares people for employment– welfare benefits systems

Unless we do this we will have– Confused and contradictory policies and approaches that are wasteful of resources– Confused customers and clients who are receiving contradictory messages

In the UK there have been a number of reviews emphasising the need for a joined up approach:

– the ‘Black Review’ of the health or Britain’s working age population– the ‘Perkins Review’ of employment support for people with a mental health condition– the ‘Wolf review’ of vocational education– the forthcoming ‘Sayce Review’ of disability employment programmes more generally

Principles underpinning the ‘Perkins Review’• Appropriate employment is good for you

• An ‘employment first’ approach (including a ‘place-train’ approach and rapid job search) 

• No-one with a mental health condition is intrinsically unemployable (with appropriate adjustments and support – whether a person can work is an economic/social decision, not a clinical decision))

• The state must provide integrated, personalised and flexible support to gain and sustain work: health/social services and employment systems must work together towards common goals

• Employment involves a relationship between employee and employer: both have responsibilities and both are entitled to support in discharging these

Echoed and extended in other reviews policy initiatives:• A welfare system that makes work pay• A focus on workplace based education/training 

A new mental health strategy“No Health Without Mental Health” February 2011

Employment central to mental health and central to mental health servicesSix core shared objectives - Objective 2

“More people who develop mental health problems will have a good quality of life – greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need

for living and working, improved chances in education, better employment rates and a suitable and stable place to live.”

Employment support forms part of ‘Psychological Therapy in Primary Care’ initiative

An employment focused outcomes framework for health and social care

Public Health Outcomes Framework: Key indicators for Domain 2 (Tackling the wider determinants of ill health – tackling factors which affect health and well-being) include:

“the proportion of people with mental illness and/or disability in employment.”

The NHS Outcomes Framework: Improvement areas for Domain 2 (enhancing the quality of life for people with long-term conditions) indicator is 

“employment of people with mental illness.”

The Adult Social Care Outcomes Framework: Outcome measure for Domain 1 (Promoting personalisation and enhancing quality of life for people with support needs) outcome measure for enhancing quality of life for people with mental illness

“the proportion of adults in contact with secondary mental health services in employment.”

BUT it tells us we have to increase the employment rates of people with a mental health condition BUT it does not tell us how to do it 

local commissioning decisions will be critical

Greater focus on people with mental health conditions in employment support

• Introduction of local mental health co-ordinators in Job centres in all areas to improve local ‘joined up working’ and the service provided to customers with mental health conditions

Increased focus on outcomes in employment programmes (generic and specialist)• Differential pricing to discourage cherry-picking’ in Work Programme• Work Programme providers encouraged to sub-contract to specialist providersSpecialist disability programmes:• In government funded specialist disability programmes move towards greater 

personalisation and personal budgets• Changing ‘Access to Work’ so it can provide the type of support that people with a 

mental health condition need:– budget can be used not only for equipment but also to purchase ongoing support– piloting using budget to fund replacement worker for impairment related absence

• Monitoring of outcomes for people with a mental health condition

Training focused on workplace learning There is a general move towards apprenticeships, work experience, internships ... But will 

people with mental health conditions have access to these?  Pre-vocational for people with mental health conditions (and other disabled people) remains rather segregated)

Supporting employers• ‘Fit for Work’ pilots to provide rapid support for people who are off sick• Access to Occupational Health advice for small employers‘Mental Health First Aid Training... but support remains patchy and inconsistent – needs to be integrated with support for 

individuals

Welfare reformGreat anxiety ... but new ‘Universal Credit’ should

– simplify the system– remove benefit disincentives to employment – make every hour you work pay– accommodate fluctuations in number of hours workedand  thereby decrease some of the fear attached to returning to work

... but in all areas the proof of the pudding will be in the eating!

Helping people with mental health problems to realise their employment ambitions is important:

economically, socially and personally ....

“I have re-entered full-time employment. Over a year later I am still working. I now focus more on opportunities in life and less on my condition. I regularly socialise with my colleagues after work and actually feel content to be a taxpayer again … The support has been immeasurably important …[it] has enabled me to make the

journey towards recovery and realise my aim of contributing to society again through fulfilling employment.”

“My passion for my career is immense. A job defines you, provides money, personal fulfilment and a sense of achievement. This is what I am, this is what I do, I am no

longer a mental health condition.”

“Now I’m a contributing member of society because of my employment. It’s worth is altering the life of someone with a mental illness … helping me to change direction

from hopelessness to being worthwhile.”

If you we are to be successful we must, above all else,

work together ... and raise our expectations The biggest barriers to employment, and the development of evidence based supported employment, are low expectations and failure to join 

up different initiativesTimes are tough ... a ‘can do’ approach even more important

• If those of us with mental health conditions are to gain employment and pursue our careers we must believe in our own abilities and possibilities

• If those of us providing mental health and employment services are to help people to help people realise their ambitions we must  believe the abilities and possibilities of those whom we serve 

In the words of Michelangelo ... “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.”

 ... or a young man who was leaving a forensic mental health services“Stay positive – have hopes and dreams and aspirations and move towards them.

Anything is possible ... there are real opportunities out there.”