What are the essen*al inclusion competencies in Individual Placement and Support (IPS)?

Transcription

1 august 2015 Scandic Fornebu What are the essen*al inclusion competencies in Individual Placement and Support (IPS)? Rachel Perkins BA, MPhil, PhD, OBE Senior Consultant, Implemen=ng Recovery through Organisa=onal Change (ImROC) Co editor Mental Health and Social Inclusion Deputy Chair, Equality and Human Rights Commission Disability CommiGee

2 A view from 4 perspec*ves Over 30 years working in NHS mental health services - from clinical psychologist to director Over 30 years establishing programmes to help people with mental health condi=ons to gain and sustain employment: 16 years developing IPS programmes in the UK 25 years using mental health services and working with a long- term mental health condi=on Leading a review to the UK Government Realising Ambi9ons. Be<er employment support for people with a mental health condi9on (2009) and various advisory roles

3 We know the devasta*ng consequences of unemployment 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)

4 We know that work is good for mental health Employment reduces the likelihood of developing mental health problems and decreases the likelihood of relapse if you have them (and unemployment increases risk of suicide) It affords status and iden*ty It provides meaning and purpose in life - you can t eat drink and make love for 8 hours a day! It provides social contacts It links us to the communi*es in which we live and enables us to contribute to those communi=es It gives us the resources we need to do the other things we value in life

5 We know that work can be central to recovery rebuilding your life with a mental health condi*on Opportunity the chance to do the things you value and par=cipate as an equal ci=zen is central to recovery The opportunity to contribute to your community is par*cularly important always being on the receiving end of everyone else s help is a dispiri=ng and demoralising place to be Too oben people with mental health become I used to be... people helping people to gain/regain/retain employment is cri*cal in enabling people to become more than a mental pa*ent, a person with a present and a future

6 Employment... a human right Ar*cle 23 of the United Na*ons Declara*on of Human Rights Everyone has the right to work, to free choice of employment, to just and favourable condi9ons of work and to protec9on against unemployment. Ar*cle 27 of the United Na*ons Conven*on on the Rights of Persons with Disabili*es recognises the right of persons with disabili9es 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 disabili9es. Ar*cle 6 and 7 of the Interna*onal Covenant of Economic, Social and Cultural Rights

7 Yet too ozen it remains a right denied In the UK General employment rate = 71.6% Employment rate for all disabled people = 46.9% Employment rate for people with mental health condi=ons = 14.2% (Department of Work and Pensions, 2013) Employment rate for people with serious mental health condi=ons = 7.9% down from 8.8% the previous year (Mental Health Dashboard - Mental Health Minimum Data Set, DH, 2013)

8 august 2015 Scandic Fornebu But can they really work?

9 Frequently asked ques*ons What makes people employable or work ready? How can we make people more employable or work ready? BUT these are the wrong ques*ons: Diagnosis, dura=on, severity of problems, not reliably associated with employment outcomes The only individual characteris=cs that influence employment outcomes are mo*va*on and self- efficacy (very much affected by expecta=ons of others) Treatment and therapy to render people employable are not enough Research shows the most important variable determining whether people can work is the type of support and adjustments provided

10 Treatment and therapy to make people employable are not enough Different approaches to helping people with mental health condi=ons to work: Tradi*onally mental health services adopt a clinical model: trying to change the person so they fit in by trea=ng symptoms, remedying cogni=ve deficits, skills training, confidence building, anxiety reduc=on... The broader disability world adopts a social model: trying to change the world so that it can accommodate the person. Focus on the barriers to work and the support and adjustments people might need (wheel chair, hearing loop, ramps, assistance dog) If people have ongoing or recurring cogni*ve and emo*onal problems associated with mental health difficul*es maybe we need a similar approach?

11 Replace: what are the person s problems and how can we get rid of these With: what are the barriers (aotudes, expecta=ons, assump=ons) and how can we get around these What support might a person need? (the mental health equivalent of the wheel chair, the assistance dog, the personal assistant or sign language interpreter... ) What adjustments might they need? (the mental health equivalent of the ramp, lib, hearing loop, signs in braille) How can we break down prejudice and discrimina*on that stop people being recruited to jobs?

12 The challenges of working with a mental health condi*on are different from those facing people with physical impairments affect your ability to nego*ate the social world of work (rather than the physical one) need to think about adjustments/supports to access social world of work ozen fluctuate and it is difficult to know when fluctua=ons will occur therefore need fluctua*ng adjustments and support are not immediately obvious and types of adjustment and support people may need are less well explored therefore need to provide more support to individuals and employers to think about what sort of adjustments and support are needed

13 But ozen the biggest challenges are low expecta*ons... on the part of the person, mental health professionals, employment advisers, employers Nicola Oliver (2011) a woman with bipolar disorder My first obstacle was my employer. Ten days aqer 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 9me 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.

14 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 cogni=ve behavioural therapy to overcome my low self- esteem, but the psychologist became my fi@h 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 nega*ve messages she con*nued to try to get work... I contacted a 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.

15 So then she went to programmes who specialised in helping disabled people to get work The seventh obstacle was the charity I approached to help me get into work... I was told maybe we should wait un9l you are a bit be<er. My final obstacle was a 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 s9ll worth employing. they had shown convic9on that I could s9ll achieve. I had met other employees with bipolar disorder to inspire me to believe that one day I too could return to work.

16 But it does not have to be this way with the right kind of evidence based support in employment at least 60% of people with serious mental health problems can successfully gain open employment (see Bond et al, 2008, SCMH, 2009)

17 august 2015 Scandic Fornebu Evidence based support in employment

18 The 8 principles of Individual Placement and Support (IPS) evidence based supported employment (see Bond et al, 2008, SCMH, 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 siong in the same office, working together 4. Rapid job search - place- train rather than train - place - if training/ experience are necessary, these should be in parallel with job search

19 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 6. Employers are approached with the needs of individuals in mind not just passive applica=ons for jobs, but pro- ac=ve job finding - an emphasis on building rela=onships with employers in order to access the hidden labour market 7. Time- unlimited, personalised support to both employee and employer: Employment involves a rela=onship between employee and employer and both par=es may need support 8. Assistance with financial planning and welfare benefits

20 Need to adhere to all 8 principles because outcomes are related to fidelity And the higher the fidelity the greater the cost effec*veness (NDTi, 2014) Average cost per person supported Evidence based sites = 1,170 All sites = 1,730 Average cost per job outcome Evidence based sites = 2,818 All sites = 8,217

21 European Randomised Controlled trials of IPS evidence based supported employment London (UK), Ulm- Guenzburg (Germany), Rimini (Italy), Zürich (Switzerland), Groningen (Netherlands), and Sofia (Bulgaria) People who were unemployed and had a diagnosis of schizophrenia for over 2 years Results Significantly more people receiving IPS gained employment: 55% receiving IPS vs. 28% in exis=ng service Significantly fewer people receiving IPS dropped out: 13% receiving IPS vs. 45% in exis=ng service Significantly fewer people receiving IPS were admiled to hospital: 20% readmiged in IPS vs. 31% in tradi=onal service

22 Initial competitive employment rate Employment status at 5 years Worked continuously throughout 5 years Hourly competitive wage in last 3 years Not just significantly beler at helping people to get jobs, beler at helping them to retain employment Hoffman et al, 2014, American IPS Supported Employment Traditional vocational rehabilitation 65% 33% 43% (28% without support) (15% with support) 17% 37% 9% 10.2 Swiss francs 6.1 Swiss francs Journal of Psychiatry. 5 year follow- up (Switzerland) In addi*on those in IPS group Fewer hospital admissions (mean 0.4 vs 1.1) No hospital admission (47% vs 21%) Fewer days in hospital (mean 38.6 days vs 96.8 days)

23 Not just research trials - also everyday prac*ce South West London Mental Health Services Comprehensive community and inpa=ent mental health services for a popula=on of 1 million people living in South West London (approximately 2600 staff serving 15,000 people at any one =me) Started recrui=ng 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 In 2006, 1984 people received voca*onal support from the teams 1155 people successful in working/ studying in mainstream integrated seongs: 645 people supported to get/keep open employment 293 people supported to get/keep mainstream educa=on/training 217 people supported in mainstream voluntary work (Rinaldi and Perkins 2007)

24 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 Care assistant They were not all stacking shelves (Perkins et al, 2006) 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 Cleaner IT Helpdesk Admin Assistant Civil servant - executive officer Baker x2 Carpenter Caretaker Hairdresser Sales Assistant x8 IT Support desk Administrator Decorator Street cleaner Warehouse worker Market research administrator 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 Financial controller 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

25 If we really address employment right from the start the results are even more impressive First episode psychosis team in South West London (mean age 21 years): aber 2 years 73% in employment (48%) or mainstream educa*on (25%) (Rinaldi et al, 2010) It is effec*ve in addic*ons services Community drug team with an employment specialist: 29% in employment, 2% in voluntary work Community drug team without employment specialist: 3% in employment, 6% in voluntary work (SW London 2010 data)

26 It is effec*ve in primary care London Borough of Wandsworth Primary Care IPS Employment Service 1 st September st August 2011: 458 referrals: 274 pa=ents fully engaged (25 didn t want the service, 159 wai=ng 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) (See also Te Pou (2014) New Zealand)

27 The principles apply outside the mental health arena To people living with long term health condi*ons, injuries and disabili*es, including learning disabili*es more generally (See Sayce, 2011; NDTi, 2014; Macmillan, 2013) The type of support and adjustments may vary but the importance of focusing on open employment and a can do aotude; helping anyone who wants to have a go; integra=ng employment support with treatment and other social support; rapid, personalised job search; and ongoing support to both employer and employee (even if the person has stable impairments, jobs change so the support needed changes) remain important

28 august 2015 Scandic Fornebu What sort of support within the IPS principles?

29 What do Employment Specialists in clinical teams do? Employment Specialists ensure that voca*onal issues are addressed as part of rou*ne 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 transi=on to work Work with the clinical team to ensure that voca=onal issues are addressed at ini=al assessment ensure that mental health professionals agend to work related issues in care plans advise and assist other mental health workers in providing ongoing support

30 What do Employment Specialists in clinical teams do? Work with employers and employment agencies pro- ac=ve 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 rela=onship so need to support both par=es

31 One size doesn t fit all The 8 principles are cri*cal but within these different sorts of support may be helpful to different people Experience within the UK suggest that a number of things may be helpful Prac*cal help with CV, actually looking for jobs etc. Problem solving helping the person to find ways round difficul=es that arise Help when the person or their employer needs it... not having to wait for appointments: the role of telephone support Some=mes need someone to actually go into the workplace but most help provided outside work

32 Time limited work experience or internships in parallel with job search - can increase the confidence of the individual and show employer that people can work effec=vely. Star*ng work gradually and building up hours over *me Star*ng 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! Not just 9 to 5. There are many ways of working... working from home working part =me (maybe only a few hours/days per week) self- employment

33 Mo*va*onal interviewing (in conjunc*on with IPS) can increase employment outcomes (Craig et al, 2014) mo=va=on and self- efficacy are central therefore adding mo=va=onal interviewing to help clients and, importantly, staff explore and resolve ambivalence may be important. Peer support - oben people who have faced similar challenges are the best ones to provide support AND seeing what others have achieved can increase mo=va=on 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

34 Managing symptoms and problems in a work context a work health and well- being plan (see Perkins et al, 2009) 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 aber a crisis Can be drawn up with the manager - thus increasing confidence ofemployer and employee Offer a way of managing a fluctua=ng condi=on at work and planning fluctua*ng adjustments and supports

35 Assis*ng the person in nego*a*ng reasonable adjustments at work for example Prac=cal aids and adapta=ons Addi=onal supervision/feedback A mentor among other employees Adjustments in du=es relief from some non- central parts of the job WriGen instruc=ons Somewhere quiet to work... or somewhere to go if it is all geong too much Working par=cular hours (e.g. only mornings/evenings) Flexible hours If the person s condi*on fluctuates then these may only be required at *mes when their condi*on worsens

36 It may not be easy but it is worth it! I have re- entered full- =me employment. Over a year later I am s=ll working. I now focus more on opportuni=es in life and less on my condi=on. I regularly socialise with my colleagues a@er 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 contribu=ng 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 condi=on. Now I m a contribu=ng member of society because of my employment. Its worth is altering the life of someone with a mental illness helping me to change direc=on from hopelessness to being worthwhile.