psychology psychiatry.pdf

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Br. J. Social Wk. (1998) 28, 793-799

Critical Commentary:Psychology and Psychiatry

NICK HERVEY

User empowerment and the facilitation of access to employment, or other meaningfuldaytime activity, are two areas of service development which receive little coveragein the medical journals. The British Journal of Psychiatry for example has includednothing on user involvement or employment in the past year. However, developmentof the 'clubhouse' model of user-led services in the USA has prompted some innovat-ive thinking about the involvement of service users and the beginnings of a belief insome Trusts that empowering users might have beneficial side effects, such as animprovement in staff attitudes towards patients and their families and a reduction insome of the stigma associated with a group which traditionally has not had a widervoice.

Many psychiatrists remain sceptical about user empowerment and, indeed, fearfulof it. In some areas, the introduction of the Care Programme Approach still has notinvolved users fully. Medicme has tended to encourage passive recipients and doesnot welcome time consuming challenges to its authority. It is clear that some clientsneed more help than others to express their views and the dangers of a few vociferoususers predominating remains; nevertheless, encouraging people to express themselves,and to join each other for mutual support, has been successful with many o ther clientgroups and is one of the ways in which mental health service users can redress thepower imbalance inherent in their contact with the psychiatric system. The followingpapers look at the empowerment of users through employment schemes.R. Perkins, R. Buckfield and D. Choy, 'Access to employment: a supportedemployment project to enable mental health service users to obtain jobs withinmental health teams', Journal of Mental Health, 1997, 6, 3, pp. 307-18.In establishing the above project, the London-based Pathfinder Trust started from thepremise that work is crucial in terms of social identity and status, and from a growingawareness that the level of unemployment amongst patients within its catchment areawas escalating. Only 10 per cent of long-term service users had open employment in1997, and this had fallen from a previous figure of 20 per cent in 1990. The projectwas set up to help people with serious mental health problem s gain access to full-timeemployment within the mental health service itself. In the area concerned, unem-ployed people were eight times as likely to be referred to mental health services as

1998 British Association of Social Workers

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7 94 NICK HERVEYthose who were employed. Unemployment means low income and, despite researchshowing the beneficial effects of employment, it is only patchily available to peoplewith mental health problems, and often to those whose level of functioning is alreadyhigher.

In America, the Americans with Disabilities Act (1992) prohibits discrimination onthe basis of disability, and requires employers to make 'reasonable accommodations'for qualified applicants. The 1996 Disability Discrimination Act in the UK has asimilar requirement. However, in the USA, there is a longer tradition of employingpeople who have experienced mental health problems within services, and they pro-vide very useful role models and support.The Pathfinder project began in 1995, with Mental Illness Specific Grant money,and was expanded in 1996 through the Challenge Fund. The posts involved wereordinary full-time posts and not specially created. Those appointed included care

assistants, m ental health support w orkers, nursing assistants, physiotherapy assistants,and occupational therapy assistants. All those employed had the opportunity to gainfurther qualifications through the National Vocational Qualifications (NVQ) pro-gramme. The main difference from the regular recruitment process was in the supportoffered, with the four following provisos: (i) jobs were offered on a half-time basisin recognition that many applicants would have experienced long periods of unem-ployment; (ii) personal experience of serious mental health problems was added tothe person specification; (iii) advertising was additionally targeted on users' venues;and (iv) references from a GP or a mental health professional were accepted, sincemany people had been unemployed, but this reference was to relate to personal qualit-ie s and not to be health-related.The project has a high profile in the service, and the project worker recruited tosupport the new employees is also a former user of services. The worker's role hasincluded helping people with applications and practising interview skills, and alsosupporting them in employment. Those interviewing were unaware of who hadreceived help. Detailed guidelines were prepared for staff coming into post aboutissues such as boundaries and coping with the reactions of other staff. Mentors werealso assigned, and they received a small fee for the additional work.A clear distinction was drawn between job support, ordinary supervision at work,and psychiatric treatment. Of the fifteen people employed, thirteen have been su ccess-

ful in post. Most of those who were successful in obtaining posts had had somevoluntary work experience, so it was decided to add a volunteer programme whichwould enable people to gain experience and provide a source for references. Volun-teers were employed on the wards and in supported housing, to help extend the rangeof residents' activities, and were provided with a trained member of staff for supervi-sion.Not surprisingly, there were a number of issues which the project threw up. Con-cerns were expressed about users being both providers and recipients in the sameservice, but it was ensured they could not be receiving a service from the team inwhich they worked. For the user-employees there have been some difficult issues

around the identification of poor practices amongst professional staff, such as talkingdown to patients. However, this has led to the recognition of some important trainingneeds within the professional staff group. Some staff were reluctant to accept users'as colleagues, which highlighted the need for staff training in preparation for the start


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C R I TIC A L C O MMEN TA R Y : PS Y C H O LO G Y A ND P S Y C H I A TR Y 79 5of such a schem e. The users were able to deal with many of the staf f's negativeresponses themselves, after this was addressed in the induction process. Also, someproblems were encountered by occupational health wanting higher thresholds for user-employee acceptance, i.e. a six month preliminary contract. U ser-employees w ere alsohelped to open bank accounts, to accommodate a monthly salary system.

This project was not costly and, in time, some user-employees ceased to needproject worker support. Although not a substitute for strong user/survivor movementslocally, it did provide a whole new dimension to staff's perceptions of, and relation-ships to, users.

COMMENTAlthough this paper is mostly descriptive in nature, it outlines an extremely imaginat-ive project which ought to blaze a trail for other Health Trusts. In the UK, ex-serviceusers have been employed in the drug and alcohol field, in disabilities services andin residential child-care, but there has always been a reluctance to see the experienceof surviving mental illness as a qualification for anything. This scheme is radical, andgoes to the heart of the stigma which surrounds mental illness. It is especially wel-come in the current climate where, post-community care, mental health has replacedchild-care as the media's whipping boy. The press's constant negative imagery ofmental illness has an impact on professionals involved in the care of the mentally ill,as well as on the public. This project provided a major challenge to staff attitudes,striking right at the core of stigmatizing behaviour. All users will benefit from thechanges in staff approach which such a project will inevitably bring in its wake, andit may provide additional benefits for users from black and minority ethnic popula-tions who have suffered in the past from institutionalized racism and opp ressive prac -tice in many hospitals. This paper ought to be read by all mental health service plan-ners.B. W. McCrum, L. K. Burnside and T. L. Duffy, 'Organising for work: a jobclinic for people with mental health needs', Journal of Mental Health, 1997, 6, 5,pp . 503-13 .Research studies have generally found very low rates of success for clients with severepsychiatric disorders in returning to open employment. Where the criteria for mean-ingful daytime activity have been widened to include sheltered work and volunteering,the figures have been slightly better but, if the definitions become too broad, theconcept of employment loses meaning. Bond and Boyer (1988) found that, whereclients were given intensive support at work, they functioned better than clients incontrol groups without support. This backing is not always available, though, andmany research papers have either blamed the general economic climate or poor indi-vidual performance for mental health users' negative job outcomes.

Midgley (1990) was probably closer to the truth w hen he suggested that discrim ina-tion was the most potent factor in poor job success. He found that, where usersdeclared their disability, they were not emp loyed, that existing employees with m entalillness were more likely to be dismissed, and that they were also more likely to havetheir paths to promotion barred.



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7 9 ^ NICK HERVEYTraditional vocational rehabilitation has been based on narrow assumptions thatthere are only two kinds of employment status, competitive or sheltered, and also that

some disabled individuals could never work in ordinary work settings. It has tendedto focus solely on work-related issues. The limited nature of this approach has meantthat many individuals have never moved on into open employment, and thereforeschemes silt up. Elsewhere, some countries have mandatory quota systems, with pen-alties for employers who do not achieve them, but, in the UK, this has never beeneffective. Sheltered work schemes set up to facilitate access to open emp loyment havealso been of limited success, and have often held little appeal for younger clients withno previous work record. They have been poorly paid, and have experienced limitedsuccess in finding open employment, confirming the research finding that previousemployment is a major factor in determining success in finding work.

Supported employment is the natural extension of sheltered work but providesgreater financial rewa rds, in a more normalizing environm ent. Perhaps the best knownand most comprehensive scheme is the one in Madison, Wisconsin, where up to 50per cent of the clients are generally employed at any one time.

The Sheltered Placement Scheme in Britain unfortunately offers very few placesand the wage ceiling has been low. More significantly it does not offer employersany incentives to treat those with mental health problems preferentially, so as to allowthem to accommodate fluctuations in work performance. 'Social firms' are able toaddress these issues, but often struggle to remain viable in a comm ercial environmentduring times of recession. It is clear that some social engineering is needed to ensuresuccessful employment outcomes but, generally, social services and health trusts havefelt that such initiatives should come from central government.

This paper focused on the Antrim Job Clinic in Northern Ireland, which was set upafter a growing recognition of the lack of co-ordination between the three main age nciesinvolved in work rehabilitation. The aim w as to help users discover their job aptitudes,develop skills, and identify job opportunities. Criteria for entry to the project was theexistence of a men tal health problem and current difficulty in obtaining work .

A detailed initial interview screened applicants for a variety of work-related factors,such as punctuality, concentration, and the ability to work alone. Interviewers alsolooked for the level of social interaction a person could cope with, and their abilityto accept instructions, feedback or criticism. Following this, help was offered withapplications, interview rehearsal, and support during vocational experiences.

Seventy-seven referrals were received in the first fifteen months, over a third ofwhich were for people with a psychotic illness. Although the majority had had somework experience before, most had also experienced long spells of unemployment, andparticularly before referral to this scheme.

The Statistical Package for the Social Sciences (SPSS) was used for analysing thedata, and clients were grouped into those who went on to training, those who wentinto open or sheltered employment, and the rest (including four who entered furthereducation). The most interesting finding was that neither a psychotic diagnosis nor along period of unemployment was significantly correlated with outcome.

C O M M E N TAlthough innovative in making a more creative use of existing resources, this schemeis essentially similar to many others offering vocational advice and assistance to



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CRITICAL COMMENTARY: PSYCHOLOGY AND PSYCHIATRY 7 9 7access training, sheltered work and open employment. The finding that people withpsychotic illnesses were as likely to be successful as others in employm ent is encour-aging, although the paper's concluding paragraphs suggest that, without furtherresources to provide ongo ing supportive work and preven tative interventions in crisis,this scheme will fail, as others have done, to make a significant impact.

The Labour Government's move towards a more co-ordinated, non-competitivedelivery of health and social care means that local liaison across work schemes, inorder to ensure a variegated pattern of service provision, is essential, but even thiswill fail unless systematic help is available to support employees whilst in work. Inaddition to ignoring disabilities legislation, many employers have also failed to seethe possibilities inherent in schemes such as Investors in People for providing disabledemployees with extra training and support.

REF EREN CESBond, G. R. and Boyer, S. L. (1988) 'Rehabilitation programs and outcomes', in Ciardiello,J. A. and Bell, M. D. (eds.) Vocational Rehabilitation of Persons with Prolonged Psychiat-ric Disorders, Baltimore, The Johns Hopkins University Press.Midgley, G. (19 90) 'The social context of vocational reh abilita tion for ex-psychiatric patients,British Journal of Psychiatry, 156, pp. 272-77.G. R. Bond, R. E. Drake, K. T. Mueser and D. R. Becker, 'An Update on Sup-ported Employment for People With Severe Mental Illness', Psychiatric Services,1997, 48, 3, pp. 335-46.This paper is a literature review examining eleven descriptive and six experimentalstudies of supported employment schemes in the USA. Supported employment, alsoknown as Individual Placement and Support (IPS), was first defined during the 1980s,but systematic information about its impact is lacking. A formal definition was out-lined in the Rehabilitation Act of 1986 (revised 1992) and included the followingfactors: working for pay (preferably at the going rate for the job), working in integ-rated settings, and receiving ongoing support. It was also intended to target individualswho, because of their handicaps, would not traditionally be eligible for vocationalrehabilitation services. These federal guidelines were meant to help develop alternat-ives to traditional rehabilitation approaches, such as vocational counselling, shelteredemployment and job clubs, which have had little impact on employment for thosewith serious mental illness.

Four significant influences informed this development: the job coach model, theclubhouse model, the assertive community treatment model, and the 'choose-get-keep' model. Diverging from a more traditional 'train and then place' model, sup-ported employment aimed to place people and then provide intensive on-the-job guid-ance. Time-unlimited support was to be provided until the person was competent intheir role.Fountain House in New York pioneered the clubhouse model, with on-site workunits and also the idea of transitional employment designed to acclimatise people toa work environment. However, job positions were controlled by the clubhouse. Steinand Test's (1980) assertive community treatment (in Madison, Wisconsin) includedindividualized support to clients to obtain some meaningful occupation. The choose-

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7 9 8 NICK HERVEYget-keep model is another intensively individual model where client choice is para-mount, and career planning is built in.

The job coach model, though, has been the predominant influence on supportedemployment, although many schemes use a hybrid approach incorporating elementsfrom all the above models.

Most of the papers studied reported 'employment rates' as a percentage of clientsadmitted to a programme who obtained a paid job. Most also reported 'interval ra tes',assessing how long it took to obtain a job from induction to the project. Some of thestudies also included people in sheltered work where this was remunerated. All thenon-experim ental s tudies suggested increased rates of emp loym ent, with a job reten-tion rate of between 35 and 59 per cent after six months.In the one quasi-experimental study, a mental health centre with two rural sites hadto close one owing to budget cuts. It set up a supported work programme on that site,

whilst the other retained its traditional vocational rehabilitation service. The newscheme had a much higher employment rate. The second site subsequently convertedto the same programme, with similar results.The experimental studies generally showed significant gains for clients who enteredsupported employment schemes. The Indiana Study (Bond et al. 1995) found that, ina trial comparing people with accelerated entry into supported work and those whowent through pre-vocational training first, followed by supported employment, theformer group did better. It was also clear that, when there was no strict time limit onprevocational training, people often remained there indefinitely. A California study(Chandler et al. 1996) compared clients going into the Village, Long Beach (an IPSscheme), and a control group who went through usual services. After the first year,the controls were outperformed on virtually every measure. Those in supportedemployment earned more, had better work continuity, and moved on into openemployment in greater numbers. This study had a large sample size and a three-yearfollow-up period. A New Hampshire study (Drake et al. 1996) had findings similarto the Indiana research when comparing a group of people going into IPS againstcontrols receiving skills training from an independent agency first. The authors sug-gest that two major elements of IPSrapid job search and the integration of mentalhealth and vocational services, which were missing from the control group's skillstrainingmay be critical factors in programme design. The District of ColumbiaStudy (Drake, 1995) was a replication of New Hampshire's research, although a very

high percentage of clients were African-Americans. Similar results were found.

COMMENTThis literature review provides an excellent overview of developments in the USAand a valuable source of references for anyone interested in work programmes. Thegeneral pattern of enhanced employment outcomes is especially noteworthy, given thelimited success of past vocational approaches for people with severe mental illness.The review demonstrates clearly that schemes need to provide direct assistance infinding and keeping jobs. Skills training, case management support, and prevocationaltraining are not sufficient. Place-train models, such as that being used in the PathfinderTrust, are vastly more effective than gradual stepwise approaches, and have much



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C R ITIC AL C OM M ENTAR Y: P S YC HOLOGY AND P S YC HIATR Y 7 9 9greater appeal for clients, as they are paid rather than receiving what may seem likeunending, unpaid, prevocational training.

The lesson from all these studies would appear to be that, the more barriers thatare placed in front of clients in their goal of attaining employment, the less likelythey are to succeed. This may appear self-evident, but has been the history of muchvocational training. Another feature of successful schemes was that assertive com-munity treatment programmes which integrated work initiatives were uniformly moresuccessful than those where rehabilitation was brokered out or purchased from spec-ialist vocational schemes. Where services were separate, there tended to be commun-ication difficulties and a higher drop-out rate. This may have implications for someof the bigger agencies specializing in vocational training in the UK. Their expertiseneeds to be utilized in closer working relationships with local trusts.

Two of the studies examined also suggested that schemes which dilute the focuson competitive em ployment w ith sheltered options may undermine their overall focus.There were many other interesting findings, notably that clients who obtained jobs intheir preferred areas of skill retained those jobs for twice as long and, significantly,that, where the support element was stopped, often owing to loss of funds, employ-ment rates decreased. This would suggest that such support should be built into corefunding.

Traditional vocational training often stifled clients' progress through the system,and access to schemes was heavily controlled by professionals. In the USA, con-sumerism is more developed and some professionals would like to see clients havingeven greater control over developing their own rehabilitation plans.The big question mark for all these projects is still that clients get stuck in unskilled,entry level jobs. Supported educational opportunities may provide another avenue,but so far there is little evidence that the long-term career prospects for people withmental illness are enhanced. It is possible that the initial rewards, and the increase inself-esteem which accompanies success in obtaining a job, may evaporate in future ifdoors appear closed thereafter. Many jobs with higher salary bands carry increasedpressures, and will presumably mean further support needs, but may be in the formof mentoring schemes with colleagues.One can only agree with the authors that descriptive studies are not helpful andthat more controlled trials are required, with some standardization of the terminology

used. There also need to be improved chan nels of comm unication between other formsof daytime care and work-related projects, to increase the avenues into supportedwork.REFERENCES

Bond, G. R., Dietzen, L. L., McGrew, J. H. el al. (1995) 'Accelerating entry into supportedemployment for persons with severe psychiatric disab ilities', Rehabilitation Psychology, 40 ,pp. 91-111 .Chandler, D., Meisel, J., McGowen, M. el al. (1996) 'Client outcomes in two model capitatedintegrated service agencies', Psychiatric Services, 47, pp. 175-80.Drake, R. E., McHugo, G. J., Becker, D. R. et al. (1996) "The New Hampshire supportedemployment study, Journal of Consulting and C linical Psychology, 64, pp. 391-9 .Stein, L. I. and Test, M. A . (19 80) 'Alternative to mental health treatment, I. Conceptual m odel,treatment program, and clinical evaluation, Archives of G eneral Psychiatry, 37, pp. 393-7 .

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