IPS: Individual Placement and Support
Miles Rinaldi
Individual Placement & Support (IPS)
• IPS is a direct, individualised search for competitive employment
– Avoids lengthy pre-employment preparation or training
– Does not screen people for work ‘readiness’ or ‘employability’
– ‘Place and Train’ not ‘Train and Place’
• It’s evidenced-based
• Assumes people can work in ordinary competitive settings
• Directly tackles the lack of integration of mental health care and
employment services and the disconnection of different specialists
• IPS shifts the focus of the mental health system away from treatment
onto employment, by demonstrating better employment outcomes.
(OECD, 2012)
Is employment a realistic goal?
Job Ready?
• Diagnosis and symptoms do not predict success
• Having previously had a job is important but wanting a job
and believing that you can work are the best predictors of
success (Tsang et al, 2000; McDonald-Wilson et al, 2001; Catty et al, 2008)
• Shared decision-making?
Is work too stressful?
• As compared to what?
– If you think work is stressful, try unemployment
Golowka, 1999)
(Marrone &
‘Individual Placement & Support’ (IPS)
• ‘Place and train’ approach not ‘train and place’...
– Focus on competitive employment as a primary goal
– Eligibility based on the individual’s choice
– Rapid job search, minimal pre-vocational training
– Integrated into the work of the clinical team
– Attention to client preferences
– Develop relationships with employers based on client preferences
– Availability of time unlimited support
– Benefits counselling should be provided to support transition
(Bond, 2008)
Joe
“I was diagnosed with schizophrenia when I was 29 years old.
When I met with the Employment Specialist in the [clinical]
team he asked what I wanted to do. He advised me to focus
on what I would really want to do as it would be good for my
health. He then helped me on all aspects such as interview
preparation, job searching and contacting employers. He
arranged an interview with a care organisation and helped
me prepare for this. I was then offered the job which I was
very pleased about. I am now 31 and this is my first real
job. I am a healthcare support worker and my Employment
Specialist supports me and my employer”.
Competitive Employment Rates in 16 Randomised
Controlled Trials of Individual Placement and Support
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
96
NH
12
AL
07
IL
04
CT
08
HK
10
CA
08
AUST
IP S
(Bond et al, 2012)
06
SC
Cont rol
99
DC
12
SWZ
Cont rol 2
12
CA
07
EUR
06
QUE
10
HOL
02
MD
11
UK
Swedish RCT (2014)
• N=120 participants randomised to IPS or local vocational
service
• 18 month follow up
• IPS more effective:
– Gaining competitive employment: 46% (IPS) Vs 11%
(difference 36%, 95% CI 18 – 54).
– IPS participants gained employment five times quicker than
those in local vocational service
• Good fidelity
Bejerholm U, Areberg C, Hofgren C, Sandlund M, Rinaldi M. Nord J Psychiatry 2014;
Early Online:1–10.
Real world...
140
Number of people supported
120
100
1 Employment
Specialist across
4 CMHTs
1 Employment
Specialist per CMHT
0.5 Employment
Specialists per
CMHT
80
60
40
20
Apr-05
Feb-05
Dec-04
Oct-04
Aug-04
Jun-04
Apr-04
Feb-04
Dec-03
Oct-03
Aug-03
Jun-03
Apr-03
Feb-03
Dec-02
Oct-02
Aug-02
Jun-02
Apr-02
Feb-02
0
Open employment
Mainstyream education/training
Mainstream work experience/voluntary work
Rinaldi, M. & Perkins, R. (2007) Implementing Evidence Based Supported Employment. Psychiatric Bulletin 31, 244-249
Population impact: One London borough
Percentages of long-term clients engaged in work or employment
25
20
15
%
10
5
0
2003
Open employment
2004
Year
Mainstream education
Rinaldi, Montibeller and Perkins (2011) The Psychiatrist 35, 339-343.
2005
Voluntary Work
2006
Sheltered work
Young people with a first episode of psychosis
Rinaldi et al. (2010) Journal of Mental Health 19, 6, 483-491.
Challenges
• National / regional / local systems
– Health, Social Care, Welfare systems
– Welfare benefits
• Myths and assumptions
– People with severe mental health conditions cannot work...
– If they do it will be stressful and lead to a relapse...
– Our job is to protect the public and the individual....
• Local technical issues
– Adopting IPS
– Early implementation
– Persistence / sustainability of implementation
Integrated systems
• Integrating mental health support and employment support
– National, regional, local challenges
• Health: focus on treatment and cure
• Social Services: ‘care’ for those for who fail to get fully better
• Welfare services: adjudge a person’s capability to work
• Individual Placement & Support (IPS) is a paradigm shift
IPS: Integrated systems
• Health, social care and employment support is integrated
and provided in parallel
• No grounds for selecting people on the basis of their ‘work
readiness’ or ‘employability’
• Focus is on competitive employment through job matching
based on client skills and preferences, rapid job search
and ongoing individualised support
• Welfare systems support the transition to employment
Societal challenges
7th October 2013
23rd September 2013
Stigma - Prejudice - Discrimination
Clinicians’ attitudes...
• Clinicians believed that many more people were capable
of working than were actually doing so
• However, 2/3 believed their caseloads either incapable of
working or only able to do voluntary /sheltered work
• Clinicians saw helping people get back to work as a core
part of their role, but felt they had little relevant training
and limited confidence in the vocational services currently
available
Marwaha et al, 2008
Helping clinicians address ambivalence
• Cluster randomised trial. To assess whether motivational
interviewing (MI) directed at clinical staff to address ambivalence
about employment improved clients occupational outcomes.
• All teams delivered IPS but two teams were also trained in MI to
improve clinicians skills in targeting young people’s ambivalence
about work and study.
• N=159 unemployed young people who made a commitment to
consider returning to work or study were recruited.
Intervention
6 months
12 months
IPS (control)
12%
38%
IPS + MI (Intervention)
33%
65%
Craig, Shepherd, Rinaldi, Smith et al (2014) British Journal of Psychiatry 205, 145-150.
Implementation Obstacles
• Lack of early intervention
• Failure to adopt evidence based practice
• Lack of focus on work resumption
• Lack of integrated service / fragmented provision
• Lack of case management
• Low priority for clinicians
• Interagency co-operation poor
Jason
“I was on the ward for three months. I was prescribed risperidone
tablets: other patients told me not to take them, but I decided I
would. After a while, the psychiatrists said that I was OK, and that
I should think about going back to work. I met regularly with my
Employment Specialist to look for work and practice my interview
skills. I got a job and I enjoy it. I have been there 9 months now.
My routine at the moment is great, I feel healthy, happy and
positive. I play football once a week and my team is doing well. I
still see both the doctor and the Employment Specialist. I feel
positive about the future, and have set myself several goals; for
example, I would love to go on a holiday as I have never been
abroad”.
Thank you
Miles.Rinaldi@swlstg-tr.nhs.uk