Serious Mental Illness, Work and Recovery

Success in the Workplace

Learning Objectives

You will learn:• Continuum of employment for persons with serious mental illness• Supported Employment approaches, particularly IPS (Individual Placement and Support). • Evidence for effectiveness of Supported Employment—vocational and clinical outcomes• Importance of SE programs to reduce the personal, economic and societal burden of

mental illness• Need to integrate mental health and vocational services for people with serious mental

illness including substance use problems

Outline:

What is serious mental illness?

Impact of serious mental illness:• Individuals• Families• Employers• Society

Effective practices

• Prevention

• Medications

• Psychosocial treatments

Continuum of employment for persons with serious mental illness

• What is Supported Employment?

• Evidence for effectiveness

• Recovery

Making Supported Employment available

Summary

Questions?

What is Serious Mental Illness?

Traditionally the term serious or severe mental illness has been applied to the psychotic disorders, e.g. schizophrenia and the major mood disorders, Major Depressive and Bipolar Disorder.While diagnosis is important for treatment, the focus in rehabilitation and recovery is on impairment of function.

What is Serious Mental Illness?

Preferred Definition:“Serious mental illness (SMI) is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.” (NIMH, 2020)Note--this definition focuses on impairment of functioning rather than diagnosis.

Impact of Serious Mental Illness

Serious mental illness affects everybody:• Individuals• Families• Employers• Society

The total cost from mental health problems and illnesses to the Canadian economy is significant

• A study commissioned by the MHCC makes it clear that the economic cost to Canada is at least $50 billion per year

• Health care, social services and income support costs make up most of these costs.

• It also cost business more than $6 billion in lost productivity from absenteeism, presenteeism and turnover

MHCC (2011)

Mental Illness affects everyone in Canada

• In any given year, one in five people in Canada experiences a mental health problem or illness

• More than 6.7 million people in Canada are living with a mental health problem or illness today. By comparison 2.2 million people in Canada have type 2 diabetes

• Mental health problems and illnesses hit early in people’s lives. More than 28% of people aged 20-29 experience a mental illness in a given year.

• By the time people reach 40 years of age, 1 in 2 people in Canada will have had or have a mental illness

MHCC (2011)

The impact of mental health problems and illnesses is especially felt in workplaces and among working aged people.

• People in their early and prime working years are among the hardest hit by mental health problems and illnesses• About 21.4% of the working population in Canada currently experience mental health problems and illnesses, which can affect their productivity.• Mental health problems and illnesses account for approximately 30% of short – and long-term disability claims and are rated one of the top three drivers of such claims by more than 80% of Canadian employers.

MHCC (2011)

Mitigating the impact of mental illness

What are Effective Practices in: Prevention

Medication Psychosocial approaches

Prevention

• There are two types of mental illness prevention –primary, which prevents mental illness developing in the first place, and secondary which reduces or prevents the recurrence of mental illness. There are a number of studies in the mental illness prevention literature which document the effectiveness and cost-effectiveness of primary prevention approaches. Accordingly, primary prevention programs and interventions for children, youth and individuals who are at risk for developing mental illness should be a high priority for health and human services.

• Additionally, secondary prevention may reduce the severity or acuity of any recurring mental illness. Examples of effective secondary prevention programs are ACT Teams and Supported Employment programs. These have the potential to significantly mitigate the long term impact of mental illness.

Medication

• The first effective medications for mental illness came into use in the 1950’s and, combined with the development of acute care psychiatric units and community services led to a substantial reduction and closure of large psychiatric hospitals such as Riverview.

• However, while there have been advances in the efficacy and reductions in the side effects, medications are not a panacea and recovery from serious mental illness requires a combination of medication and psychosocial approaches

Psychosocial (PSR) approaches

• A large body of research demonstrates that community programs and supports such as assertive community treatment (ACT) teams and supported employment services are effective, evidence-based approaches, particularly when combined with cognitive behavioral therapies (CBT). These approaches will significantly increase the success of community living while substantially reducing psychiatric emergency hospitalization.

• These evidence-based community approaches are not only essential to people in recovery but are also the key to reducing or avoiding the major personal, social and economic costs associated with repeated acute care admissions as well as the related police and social services costs.

Continuum of employment for persons with serious mental illness

Pre-vocational Training VolunteerPlacement/Work

Transitional Employment Supported Employment Competitive Employment

Who requires these services?

People living with serious mental illness and/or substance use problems

People living with serious mental illness and/or substance use problems

People living with serious mental illness and/or substance use problems

People living with mild to moderate mental illness and/or substance use problems People living with serious mental illness and/or substance use problems

All British ColumbiansPeople living with mental illness and/or substance use problems

What are the main features of these services?

Generally follows “train and place” modelPre-employment education and support to help client prepare for volunteer or employment rolesWork ordered day at clubhouses provides structured environmentpsychoeducation and support services to learn skills in preparation for work or volunteer roles

Supports client to choose, get, and keep volunteer positionsVolunteer role could be client’s long term goal(follows “place and train” model)Volunteer role could be preparatory for transition to paid employment(follows “train and place” model)

Often on a time-limited basisMay include work crews where clients work together to provide a service with some staffing supportClient may be placed in a

community job and the business given assurance there will be back-up to help ensure the work is completed

Place and Train approachIndividualized strengths based assessment and goal settingClient choice based on skills and job goalsSE service integrated with MHSU services

Rapid job search for competitive jobPersonalized benefits counselingFollow-along supports are continuous

WorkBC collaborates with employers and unions to develop and implement workplace supports such as self-care resources, opportunities for early identification of problems, and linkages to appropriate interventionsSelf-serve job search supports and some specialized assessment and case management also through WorkBC.Early intervention, harm reduction, stress management in collaboration with primary care physician

Pre-vocational Training VolunteerPlacement/Work

Transitional Employment Supported Employment Competitive Employment

Supported Employment and recovery

What is Supported Employment?Evidence for its effectiveness– clinical and vocational outcomes

Recovery

What is Supported

Employment?

Supported Employment (SE) is an approach to vocational rehabilitation that emphasizes helping people obtain competitive work in the community and providing the supports necessary to ensure success in the workplace. SE programs help people find jobs that pay competitive wages in integrated settings (i.e. with people who do not necessarily have disabilities) in the community.

What is Supported

Employment?

SE refers to evidence-based practices which recognize the importance of work to recovery for persons living with severe mental illness, concurrent disorders and substance use problems. Supported employment models support people to access competitive employment positions and provide individualized training and support to help the person maintain employment. These are “Place and Train” models rather than “Train and Place” approaches.

Supported Employment

models

Supported Employment models focus on:• Employment: The purpose of these programs is

employment with all the regular outcomes of having a job. Wages, working conditions, and job security are key considerations.

• Ongoing support: The focus is on providing the ongoing support required to get and keep a job rather than on getting a person ready for a job sometime in the future.

• Jobs, not services: Emphasis is on creating opportunities to work rather than just providing services to develop skills.

Supported Employment

models

Supported Employment models focus on:• Full participation: All those interested in work are

included. The assumption is that all persons, regardless of the degree of their disability, have the capacity to undertake supported employment if appropriate ongoing support services can be provided.

• Variety and flexibility: Supported employment does not lock programs into one or two work options. It is individually tailored and flexible because of the wide range of jobs in the community and the many ways of providing support to individuals in those jobs.

(Wehman, Sale & Parent, 1992)

Goal of Supported

Employment

The goal of SE is to help clients find permanent paid work within an integrated working environment with appropriate modifications/accommodations to suit the individuals’ strengths and needs, including individualized adaptations or modifications to support participants in succeeding in the particular workplace.SE is also termed Competitive or Open Employment.

Components of Supported Employment:

• Strengths based assessment• Goal setting by client• Job development• Employer outreach• Job search• Job placement• Skills training on the job• Supports to sustain employment

Individual Placement and Support (IPS)

The most widely used and researched SE model is Individual Placement and Support (IPS). IPS is a “Place and Train/Support” model that supports individuals to find competitive employment based on their goals. As with other SE approaches, IPS emphasizes rapid job search to obtain work, followed by support after placement to assure job success.

Individual Placement and Support (IPS)

The effectiveness of IPS depends on the model being implemented with a high degree of fidelity. Fidelity scales have been developed and validated by the Dartmouth Supported Employment Research Centre.

The most recent version is the Supported Employment Fidelity Scale also known as the IPS 25 (Dartmouth IPS Supported Employment Centre, 2010). In addition to its primary use in evaluating implementation fidelity, this scale is valuable as a template or guide for developing and implementing high fidelity IPS programs.

Specific Components of IPS:

• Focus on Competitive Employment: Agencies providing IPS services are committed to competitive employment as an attainable goal for people with serious mental illness seeking employment.

• Eligibility Based on Individual Choice: Participants are not excluded on the basis of readiness, diagnoses, symptoms, substance use history, psychiatric hospitalizations, level of disability, or legal system involvement.

• Integration of Rehabilitation and Mental Health Services: IPS programs are closely integrated with mental health and substance use treatment teams.

• Attention to Personal Preferences: Services are based on clients’ preferences and choices, rather than providers’ judgments. Recovery!

Specific Components of IPS:

• Personalized Benefits Counselling: Employment specialists help clients obtain personalized, understandable, and accurate information about their income assistance, healthcare benefits, and other government entitlements.

• Rapid Job Search: IPS programs use a rapid job search approach to help clients obtain jobs directly, rather than providing lengthy pre-employment assessment, training, and counselling.

• Attention to Personal Preferences: Services are based on clients’ preferences and choices, rather than providers’ judgments

Specific Components of IPS:

• Remediation Systematic Job Development: Employment specialists build an employer network based on clients’ interests, developing relationships with local employers by making systematic contacts.

• Time-Unlimited and Individualized Support: Follow-along supports are individualized and continued for as long as the client wants and needs the support.

(Dartmouth, 2013)

Effectiveness of IPS

There is substantial support for the effectiveness of the IPS model, e.g. Bond, Drake and Becker, 2012. These studies have consistently demonstrated better client employment outcomes in terms of job finding, tenure, and earnings compared to clients in traditional approaches including Clubhouses and other transitional employment interventions. The results are less conclusive in terms of other individual outcomes such as reduced symptoms and increased quality of life for people living with mental illness.

Effectiveness with

concurrent disorders

In addition to the well-demonstrated effectiveness of the IPS approach for persons living with serious mental illness, IPS has also been shown to be effective for persons with concurrent disorders (Mueser, Campbell, & Drake, 2011). Compared to traditional vocational rehabilitation interventions, the IPS intervention benefitted these participants in similar ways to the overall group. For example, these participants had comparable results in terms of how quickly a first job was obtained, how much they earned in wages, and how many hours and weeks were worked during the study period.

Canadian research on IPS

In Canadian research, Latimer et al. (2006) compared individuals who were not currently employed and wished to work who received IPS, to those receiving traditional vocational rehabilitation, which focused greater attention on preparation for employment. The results demonstrated superior employment rates for those receiving IPS services (48% vs. 18%) and more hours worked for those employed with IPS services (126 v 71 hrs. per week).

Transforming from

sheltered employment

to IPS

In a British Columbia study, Oldman, Thomson, Calsaferri, Luke, and Bond (2005) reported the results of transforming a sheltered workshop program in phases to an IPS model. While the sheltered employment program was in operation, fewer than 5 percent of participants achieved competitive employment annually. The annual competitive employment rate did not increase during a subsequent, prevocational training phase. However, in the IPS phase, 50 % of participants achieved competitive employment. These collective results suggest that the IPS model can successfully be implemented in Canadian settings.

IPS has generalized to

countries other than the

US.

• There is now a vast scientific literature to document the effectiveness of SE, particularly IPS. Books have been published as well as a large number of journal articles.

• IPS has also generalized to countries other than the US. For example, Bond, Drake and Becker (2012) compared IPS results in 9 US studies and 6 in other countries, including Canada.

• The competitive employment rate was significantly higher for the IPS condition than for controls in every one of the studies. In total, 592 (55.7%) of IPS participants obtained employment, compared with 253 (22.6%) control participants

Making IPS available

If Supported Employment, particularly IPS, is recognized as an essential service for people in recovery, how available is it in Canada?Unfortunately, at present it is not generally available.

Canada–lagging behind

• Canada has made less progress in adopting IPS as the preferred evidence based SE practice. This seems largely because the individual provinces have not adopted policies to make IPS available as an essential service which should be available to people in recovery.

• Similarly, the Mental Health Commission of Canada has not endorsed IPS.

Canada–lagging behind

Barriers to implementation:• Insufficient understanding of effective practices• lack of enabling policy• focus on acute care services• Lack of integration of mental health and

vocational services including different jurisdictions and funding streams

At Work / Au travail

“Funded by Service Canada, At Work / Au travail aims to connect motivated and qualified job-seekers to employers across the country. Our dynamic national employment program follows a strength-based approach, while supporting diversity and equity in the workplace.At Work / Au travail is being delivered in 14 communities across Canada, and has successfully connected with a wide range of employers, from small/medium sized businesses to larger corporations.

Our qualified team of At Work representatives learn about the specific hiring needs of businesses and collaborates with employers to make suitable matches with talented job-seekers.

At Work / Au travail

Our qualified team of At Work representatives learn about the specific hiring needs of businesses and collaborates with employers to make suitable matches with talented job-seekers.In an effort to maintain ongoing relationships with employers, At Work / Au travail offers various services that are tailored to reduce the time and cost of training new employees. These benefits can be tailored according to business needs.

Working in partnership with our program is a unique, time-efficient and effective means of helping to make Canada a more diversified and equitable place for people to work. Services are offered in both English and French.”

Service Canada (2020)

At Work / Au travail

• At Work/ Au Travail is a national joint initiative of Service Canada and CMHA

• Implemented in 12 sites in Canada

• It incorporates some IPS principles but has been criticized for a lack of fidelity o the researched model.

• Additionally, launched in some sites with minimal staff training.

Summary and key messages

• We need to focus more on effective community mental health services which make it possible for people to recover, including effective vocational; services across the continuum of care

• Evidence based psychiatric rehabilitation services are essential and should be available to people in recovery from serious mental illness including addictions.

• Mental health and vocational services for people with serious mental illness including substance use problems

• Supported Employment, particularly IPS has been shown to be highly effective in numerous scientific studies across a number of countries.

• Properly implemented IPS will significantly reduce the personal, economic and societal burden of mental illness

• We need much more, properly implemented IPS!

Thank you! Questions?

References

Bond, G., Drake,R. and Becker, D. (2012).Generalizability of the Individual Placement Support (IPS) model of supported employment outside the US. World Psychiatry, 2012:11:32-39

Dartmouth Psychiatric Research Centre, (2013). IPS Supported Employment Center. Retrieved from:http://www.dartmouth.edu/~ips2/styled/styled-2/page70.html

Dartmouth Supported Employment Research Center, 2017. IPS 25 Fidelity Scale. Retrieved from:https://ipsworks.org/wp-content/uploads/2017/08/IPS-Fidelity-Scale-Eng1.pdf

Latimer, E. A., Lecomte, T., Becker, D. R., Drake, R. E., Duclos, I., Piat, M., . . . Xie, H. (2006).Generalisability of the individual placement and support model of supported employment: Results of aCanadian randomised controlled trial. British Journal of Psychiatry, 189(1), 65-73. doi:10.1192/bjp.bp.105.012641

Mental Health Commission of Canada (MHCC). 2011. Making the Case for Investing in Mental Health in Canada. Retrieved from; https://www.mentalhealthcommission.ca/sites/default/files/2016-06/Investing_in_Mental_Health_FINAL_Version_ENG.pdf

Mueser, K., Campbell, K. and Drake, R. (2011) The Effectiveness of Supported Employment in People with Dual Disorders. Journal of Dual Diagnosis,7(1-2):90-102.

National Institute for Mental Health (NIMH), 2020. Definitions. Retrieved from:https://www.nimh.nih.gov/health/statistics/mental-illness.shtml

Oldman, J., Thomson, L., Calsaferri, K., Luke, A., & Bond, G. R. (2005). A case report of the conversion of sheltered employment to evidence-based supported employment in Canada. Psychiatric Services, 56(11), 1436-1440. doi: 10.1176/appi.ps.56.11.1436

Service Canada (2020). At Work / Au travail. Retrieved from http://atworkautravail.ca