Mental Health and Supported
Employment
Rachel Perkins
BA, MPhil (Clinical Psychology) PhD, OBE
A view from 4 perspectives
• 33 years working in mental health services ... from
clinical psychologist to director
• 28 years writing about mental health and mental health
services ... and campaigning and voluntary work
• 25 years being on the receiving end of mental health
services (inpatient and outpatient)
• 15 years in various government advisory
committees/roles (including leading an independent
review to Government – ‘Realising Ambitions. Better
employment support for people with a mental health
condition’, 2009)
We know the devastating
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)
or “... the early onset of distress will mean social exclusion
throughout our adult lives, with no prospect of ...a job or
hope of a futures 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.” (cited by SEU,2003)
We know that work is good for mental
health
• 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 that work can be central to
recovery – rebuilding your life with a
mental health condition
• Opportunity – the chance to do the things you value and
participate as an equal citizen is central to recovery
• The opportunity to contribute to your community is
particularly important - always being on the receiving
end of everyone else’s help is a dispiriting and
demoralising place to be
Too often people with mental health conditions
become
‘I used to be ...’ people ....
Helping people to gain/regain/retain employment is
critical in enabling people to become more than a
‘mental patient’, a person with a present and a future ...
Employment ... a human right e.g.
• Article 23 of the United Nations Declaration of Human Rights
“Everyone has the right to work, to free choice of employment, to just and
favourable conditions of work and to protection against
unemployment.”
• Article 27 of the United Nations Convention on the Rights of Disabled
Persons
• Article 6 and 7 of the International Covenant of Economic, Social and
Cultural Rights
Yet it remains a right that is denied many
people with mental health conditions
Most people with a mental health condition want to
work – highest want to work rate of all disabled
people (SEU, 2003)
But in the UK
• General employment rate = 71.6%
• Employment rate for all disabled people = 46.9%
• Employment rate for people with mental health
conditions = 14.2%
(Department of Work and Pensions, 2013)
‘But can they really work?’
Working with mental health conditions can be
challenging. They can
• affect your ability to negotiate the social world of work
(rather than the physical one) – need to think about
adjustments/supports to access social world of work
• often fluctuate and it is difficult to know when fluctuations
will occur – therefore need fluctuating adjustments and
support
• are not immediately obvious and types of adjustment
and support people may need less well explored –
therefore need to provide more support to individuals and
employers to think about what sort of adjustments and
support are needed
But often the biggest challenges are fear
and low expectations ...
Fear on the part of the person, mental health
professionals, employment advisers, employers
• that getting a job may worsen your mental health
• that you will experience prejudice and discrimination at
work
• that getting a job and moving off benefits may make you
worse off financially ... And what happens if it does not
work out that they will not be up to the job
• that they will be disruptive and difficult in the workplace
Low expectations
Nicola Oliver (2011) a woman with bipolar disorder
“My first obstacle was my employer. Ten days after 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 time 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.”
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 cognitive behavioural therapy to overcome
my low self-esteem, but the psychologist became my
fifth 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 negative
messages she continued to try to get work ....
But employment support agencies were no
better ...
“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.”
“The seventh obstacle was the charity I approached to
help me get into work ... I was told ‘maybe we should
wait until you are a bit better’.
“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 still worth employing.
• they had shown conviction that I could still
achieve.
• I had met other employees with bipolar disorder
to inspire me to believe that one day I too could
return to work.
What does the research tell us?
Frequently we ask questions like
– What makes people employment?
– How can we tell if someone is ‘work ready’?
– How ‘far from the labour market’ is this person?
These are the wrong questions – research
shows:
– Diagnosis, duration, severity of problems) not reliably
associated with employment outcomes
– The only individual characteristics that influence
employment outcomes are ‘motivation’ and ‘selfefficacy’ (very much affected by expectations of others)
The most important question: ‘what is
the right kind of support?
The most important variable determining
whether people can work is the type of support
and adjustments provided
The 8 principles of ‘Individual Placement
with Support’ evidence based supported
employment for people with mental
health conditions ....
1. 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 – sitting in the same office, working
together
4. Rapid job search (start within 4 weeks) rather than
stepping stones first. If training/experience are
necessary, these should be in parallel with job search.
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 - and
may involve active, individualised, work with employers
6. Employers are approached with the needs of
individuals in mind – not just passive applications for
jobs, but pro-active job finding - an emphasis on building
relationships with employers in order to access the ‘hidden
labour market’.
7. Time-unlimited , personalised support to both
employee and employer: Employment involves a
relationship between employee and employer and both
parties may need support
8. High quality assistance with in and out of work
welfare benefits and financial planning
Need to do all of these things to be effective –
outcomes related to fidelity
16 ‘randomised controlled trials’:
at least 60% of people with serious mental
health problems to successfully get and
keep open employment (see Bond et al, 2008, SCMH, 2009)
European Randomised Controlled trials
of IPS evidence based supported
employment
• Six European Centres: London (UK), Ulm-Guenzburg
(Germany), Rimini (Italy), Zürich (Switzerland),
Groningen (Netherlands), and Sofia (Bulgaria)
• People included if they had schizophrenia of at least 2
years duration and were unemployed
• IPS compared with existing ‘train-and-place’ vocational
rehabilitation service in each site
• Significantly more people receiving IPS gained
employment:
55% receiving IPS vs. 28% in existing service
• Significantly fewer people receiving IPS dropped out
13% receiving IPS vs. 45% in existing service
• Significantly fewer people receiving IPS were admitted
to hospital
20% readmitted in IPS vs. 31% in traditional service
It’s not just research trials
IPS is effective in regular day to day practice
The experience of South West London Mental Health NHS Trust
Employment Specialists in 11 Community Mental Health Teams
including the Community Drug Team (2007/8):
1984 people received vocational support
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
(Rinaldi and Perkins 2007)
So why aren’t we doing it?
• Employment not seen as a priority for health and social
care services- not part of their ‘core business’
• People with mental health conditions not seen as a
priority for employment services
• Employment not considered a realistic goal for people
with more serious mental health problems
• Failure to provide the sort of support we know works
• Failure to implement it properly
– Investment (personal and financial in existing ways
of doing things
– Ignorance of the research evidence
– People do not believe the research evidence
IPS evidence based supported
employment principles challenge some
commonly held assumptions...
Common assumption: people need to be fully ‘better’
before they can return to work:
treatment then rehabilitation then then work
The reality: You don’t have to be fully ‘better’ to work and
the longer they are out of work the less likely they are to
return (without special support): 6 months absence –
50% return; 12 months absence – 25% return; 2 years
absence – 2% return
(British Society of Rehabilitation Medicine)
Common assumption: ‘stepping stones’ - people
need to build up their qualifications , skills and
confidence in a safe, sheltered setting they will be
able to move on to open employment
The reality: people learn that they can only work in a
safe, sheltered setting and never move into work
People need ‘water
wings’ – support to
keep them afloat in
employment - rather
than ‘stepping stones’!
We need to ask ourselves:
Are we really adhering to all 8 principles?
For example:
• Do we really have a ‘can do’ attitude?
• Are employment workers really integrated into clinical
teams – there at assessment and review meetings,
writing in the same notes ...?
• 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 we at supporting them?
• How can we really providing access to time-unlimited e
ongoing support?
What sort of support within the 8
principles?
• Help with all the things around work (like getting up,
getting to work etc.)
• Help to sort out problems outside work that may
jeopardise the person’s ability to work
• Help when the person or their employer needs it ...
Help needs to be there when problems occur (not
having to wait for appointments): the role of telephone
support
• Peer support – often people who have faced similar
challenges are the best ones to provide support AND
seeing what others have achieved can increase
motivation and self-confidence. For example:
– employing people with lived experience as
Employment Specialists
– sharing experience through sharing stories,
– peer mentoring
– peer led support groups
• Time limited ‘work experience’ or ‘internships’ in
parallel with job search and in real employment settings.
Can increase the confidence of the individual and show
employer that people can work effectively
• 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.”
(see ‘Surviving and Thriving at Work, Disability Rights UK sarah.cosby@disabilityrightsUK.org)
• Matching the job and the person
• Starting work gradually and building up hours over
time
• Starting small and building up - most people start their
working lives in ‘marginal’ jobs (delivering newspapers,
seasonal work etc.) ... but then move on in their careers
• Not just ‘9 to 5’ .
– working from home
– working part time (maybe only a few hours/days per
week)
– self-employment
• Adjustments in the workplace
And remember that:
• ‘Job retention’ is as important as getting a job ... and
does not always mean staying in the same job
• Not just jobs but careers ... the importance of
mentoring in relation to career development (see
RADIATE in UK as an example of peer mentoring)
But most of all we must raise our
expectations
“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.”
“... grant that I may always desire more than I can
accomplish.”
Michelangelo (1475-1564)
“There’s a better life out there ... If you just
sit back, then you won’t make it – but you
can make it if you want to. You’ve got to be
real with yourself. The power is you.”
(Nash Momori, 2008)
It may not be easy but it really is worth it!
“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.”