‘Individual Placement and Support’evidence based supported

employment: What it is and how to flog it!

Rachel E. Perkins BA, MPhil (Clinical Psychology), PhD, OBEFreelance Consultant and Trainer

Recovery – Employment – ParticipationMind Champion of the Year 2010

rachel.e.perkins1@btinternet.com

3rd March 2011

We know it’s important ...“For some of us, an episode of mental distress will disrupt our lives so we are pushed

out of the society in which we were fully participating. For others, the early onset of distress will mean social exclusion throughout our adult lives, with no prospect

of training for a job or hope of a future in meaningful employment. Loneliness and loss of self-worth lead us to believe we are useless, and so we live with this sense

of hopelessness, or far too often choose to end our lives.” (SEU,2003)

• 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

We know what we’ve got to do ...The 7 key principles of individual placement with support

evidence based supported employment• Competitive employment – real jobs – and a ‘can do’ approach• Eligibility based on client choice – help anyone who wants to give it a try• Integration of employment support into support and treatment plans

from the start – employment specialists in support and treatment teams and employment integrated into the work of all mental health workers

• Job search based on client preferences• Rapid job search – ‘place-train’ rather than ‘train-place’• On-going supports for both employee and employer• Benefits counselling

We know it works when we do it properly ... Competitive employment rates in 16 randomised

controlled trials

So why aren’t we always doing it?

Four inter-related problems

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

works• Failure to implement it properly

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

conditions, employers and society as a whole (it’s a well known fact that people with schizophrenia cannot work)

• 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 ....

Expert professionals say that people with mental health

problems are unlikely to be able to work

Employers believe that people with mental health problems cannot work –

so don’t employ them

People with mental health problems believe that they

cannot work and give up trying to get jobs

Very few people with mental health problems in

employment

A conspiracy of low expectations

Fear on the part of professionals, 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 support we know works• people with mental health problems not seen as a priority for employment service

programmes • employment not seen as a priority for mental health services• in challenging economic times we cannot afford it• challenges ‘sacred cows’ and established ways of doing things:

– ‘you have to be better before you can go back to work’ – ‘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

Failure to implement it properlyWith IPS the higher the fidelity to the model the better the outcomes

• Is employment really considered as a core part of assessment and support planning for everyone of working age from the start?

• Are employment workers really integrated into the teams – there at assessment and review meetings, writing in the same notes ...?

• Do we really have a ‘can do’ attitude?• 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 our relationships with them? How good are

we at supporting them? • How good is the advice and information we offer about benefits?• How can we really provide ongoing support in a situation where long-term support is not provided in

secondary mental health services? (use of Access to Work?)

So how can we flog it? How can we make it happen?

Understanding the context: The times they are a-changing

An increased attention to mental health and employment

“An unholy alliance between therapeutic radicals and fiscal conservatives”

Increased concern about the HEALTH, PERSONAL and SOCIAL costs of unemployment and the right to work

AND

increased concern about the ECONOMIC costs of welfare and the rising number of people with mental health conditions receiving

out of work benefits

Less state direction and provision

• Centrally directed outcomes but not inputs/processes• Desire to increase range of providers – voluntary and

charitable sector, private sector, less provided directly by the state

• More control to individuals and communities:– Localism and local decision making– Personalisation and individual health and social care budgets,

‘right to control trailblazers’

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.”

An outcomes frameworkPublic 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.”

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

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 – collecting and publicising ‘journey to work’ stories

• Demonstrating what works to clinicians, managers and commissioners. Making research evidence accessible but again ‘seeing is believing’ – visits to services where IPS has been implemented

• Showing clinicians they have an important role. A critical part of the solution, not ‘a problem’.

• Increasing consumer demandMaking service users aware of what they should be able to expect in the way of employment support – providing them with the evidence

‘Surviving and Thriving at Work’ - toolkits for individuals and employers

‘A Work Health and Well-Being Toolkit’

‘Going Back to Work After a Period of Absence’

(author Rachel Perkins, published by RADAR The Disability Rights

Organisation)

available from nathan.jelf-mannion@radar.org.uk

• Knowing and supporting employers providing an ongoing point of contact for help and advice

• 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.”

• Dispelling myths about benefits and employment - Job Centre Plus and Mental Health Services working together

– 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

• Starting small and building up - most people start their working lives in ‘marginal’ jobs ... but then move on in

their careers – careers not just jobs

• Starting work gradually (using ‘permitted work’ rules)”• ”The supported permitted work experience has allowed me to take small steps towards reintegration in the employment

market. I am particularly grateful to my Employment Specialist in supporting me and enabling me to take this challenge on.”

• Not just ‘9 to 5’ - many ways of working ... agency/casual work, home work, ‘portfolio careers’ including self-employment

• Time limited ‘work experience’ or ‘internships’ in parallel with job search . Can increase everyone’s confidence: clinicians, service users, employers.

“It’s given me my confidence back – now I know I can get a job.“

1. The state authorities provide resources and leadership: the current government will direct outcomes, but will not direct what people have to achieve them, therefore we need to market IPS as a way of meeting centrally defined outcomes. Local leadership will be of the essence. No new money therefore identify where resources could come from within existing envelope ... and where possible create win-win solutions, for example:– closing a traditional employment service can produce savings AND allow the recruitment of

employment specialists in teams– reviewing ‘skill mix’ in teams – how many traditional professionals? STaR workers and Support

Workers or Employment Specialists?– partnerships with voluntary sector and service user organisations

2. Discontinue old ways of doing things (e.g. close down pre-vocational training programmes): ‘Never waste a crisis’: this is a time when many services are being reviewed so there is opportunity to replace existing services with IPS ... and possible ‘win-win’ scenarios: establish IPS, save money and help organisation to achieve other targets.

Implementing ‘Individual Placement with Support’ evidence based supported employment ... 8 keys to high fidelity (Bond 2009)

Implementing ‘Individual Placement with Support’ evidence based supported employment ... 8 keys to high fidelity (Bond 2009)

3. Technical assistance centres provide training and monitoring: how can we use the Centres of Excellence programme to provide this?

4. Conduct ‘fidelity reviews’: these will not be directed centrally, but could they be negotiated locally as part of the commissioning process? Built into contracts and part of the contract monitoring process?

5. Effective leadership at every level with a ‘can do’ attitude: recruit allies in influential positions e.g. Board members including non-executive directors, local elected members, local GP commissioning consortia ....

6. Count the things you want to change: as well as national employment outcomes, employment focused CQUIN targets? Maybe employer contacts, number of jobs applied for, number of interviews gained as well as jobs achieved.

7. Hire the right people: there are likely to be all sorts of people with employment expertise who are looking for jobs ....

8. Establish close integration with mental health treatment teams: more difficult with different providers but possibilities for real joint working – employment specialists from other organisations working as part of clinical teams. Need to iron out practical issues – access to information systems, who can write in notes etc.

but most of all we must foster and maintain images of possibility

One of the biggest barriers to employment, and the development of evidence based supported employment, is low expectations

From ‘yes, but ...’ to ‘yes, how ...’

Times 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 – Believe in the possibilities of establishing the evidence based services that can make these a reality

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.”