Early Intervention in the Real World

Meaningful lives: supporting young people withpsychosis in education, training and

employment: an internationalconsensus statementeip_200 323..326

The International First Episode Vocational Recovery (iFEVR) Group

Orygen Youth Health Research Centre,Victoria, Australia.

Corresponding author: Dr Eóin Killackey,Orygen Youth Health Research Centre,35 Poplar Road, Parkville, Vic. 3052,Australia. Email: eoin@unimelb.edu.au

Received 31 March 2009; accepted 6June 2010

Abstract

Aim: Unemployment is the majordisability faced by people with psy-chotic illness. Unemployment rates of75–95% are found among thosewith schizophrenia. Unemployment isassociated with poorer social andeconomic inclusion, greater sympto-matology, decreased autonomy andgenerally poorer life functioning.Unemployment also makes up overhalf of the total costs associated withpsychotic illness.

Methods: A meeting was convened inLondon in June 2008. Invitees to thismeeting included people from theUSA, Canada and the UK interested invocational intervention in early psy-chosis from either a research, clinical,economic or policy point of view.From this meeting a larger group – the

International First Episode VocationalRecovery (iFEVR) group – has devel-oped an international consensusstatement about vocational recoveryin first episode psychosis.

Results: The document is a basicstatement of the rights of youngpeople with psychosis to pursueemployment, education and training;the evidence which exists to helpthem do this; and ways in whichindividuals, organizations and gov-ernments can assist the attainment ofthese ends.

Conclusion: It is hoped that theMeaningful Lives consensus state-ment will increase the focus on thearea of functional recovery and lift itto be seen in parallel with symptom-atic recovery in the approach totreating early psychosis.

Key words: early psychosis, functional recovery, vocational recovery.

INTRODUCTION

Vocational recovery, utilizing supported employ-ment for people with established schizophreniais an acknowledged evidence-based practice.1

However, there has been less attention to vocationalintervention in the early phase of illness. This isunfortunate as the early phase of illness provides anattractive target to promote long-term vocationalrecovery and the minimization of social disability.2

Despite the small amount of attention that this areahas received, there is a developing body of evidencethat shows that vocational interventions in thisphase have even better results than those interven-tions in later phases of illness.

In June 2008, a meeting of researchers, econo-mists, clinicians and policy-makers interested intargeting vocational interventions at young peoplewith a first-episode of psychosis was held inLondon. This meeting led to the formation of theInternational First Episode Vocational Recovery(iFEVR) group. The iFEVR group brought togetheran international network interested about thistopic and also included consumers and carers.From this group, via extensive email conversations,a consensus statement – Meaningful Lives – wasdeveloped highlighting the existing evidence andthe also the agenda for incorporating evidence-based vocational recovery targeting employment,education and training for young people with

Early Intervention in Psychiatry 2010; 4: 323–326 doi:10.1111/j.1751-7893.2010.00200.x

First Impact Factor released in June 2010and now listed in MEDLINE!

© 2010 Blackwell Publishing Asia Pty Ltd 323

first-episode psychosis into early intervention ser-vices. Apart from highlighting the evidence, thisstatement was created with the aim of elevating theplace of functional recovery such that it is seenas being equally important with symptomaticrecovery.

Consensus statements are important in that theymark out an area of practice where evidence exists,but where there may not yet be enough evidencefor inclusion as recommendations in methodologi-cally rigorous clinical practice guidelines. They alsohave the potential to act as a call to both furtherresearch and practice reform. A good example ofsuch a statement is the Early Psychosis Declara-tion3 which set out five key objectives for action toprovide much needed support for young peoplewho develop psychosis, including raising commu-nity awareness about psychosis and the promotionof recovery and ordinary lives.

The Meaningful Lives International ConsensusStatement sets clear goals for what we would like toachieve in relation to employment and educationaloutcomes for young people with psychosis. We high-light current challenges and potential benefits ofsupporting young people with psychosis to com-plete their education and gain employment. Weidentify key principles and processes by which thesegoals may be enabled. This requires a commitmentfor change in the way we support young people withpsychosis and how we work together across health,benefits, education and employment agencies tosuccessfully enable young people to achieve mean-ingful lives.

IMAGINE A WORLD WHERE. . .

• Young people with psychosis are not stigmatizedor discriminated against in education or employ-ment because of their mental health difficulties.

• Educators and employers are informed and sup-ported in providing meaningful education andwork opportunities for young people.

• Young people with psychosis remain in school tocomplete their education and sustain paidemployment surrounded by those who under-stand and care.

• Hopes and dreams for education, training andemployment are fulfilled.

THE CHALLENGE. . .

‘. . . can’t get a job, can’t get a girlfriend, can’t get atelly, can’t get nothing . . . it’s just everything fallsdown into a big pit and you can’t get out. . .’4

• 50% have less than 10 years of education, limitinglonger term employment prospects.5

• At first contact, 40–50% are unemployed in first-episode psychosis (FEP)6 (60–70% are unem-ployed in first-episode schizophrenia) but thisfigure rises dramatically to 75–95%.

• 20% of people with first-episode psychosis havenever worked.5

• Many young people get caught in a governmentbenefits ‘poverty trap’.

• Not working has non-financial costs in terms ofloss of social capital; exacerbation of stressors;lack of a socially valued role.2

• Lack of employment is a bar to other forms ofsocial inclusion.7

POTENTIAL BENEFITS

• Costs associated with unemployment make upover 50% of all costs associated with psychotic ill-nesses in Australia, USA and Europe.8–10

• Employment has been shown to significantlyreduce reliance on welfare benefits.5

• Successful employment is potentially associatedwith better management of symptoms, less hos-pitalization and reduced substance use.11

• Employment provides a socially valued role thathas benefits in terms of identity and self-esteem.11

• Employment provides a pathway to greatersocial and economic functioning. This directlyaddresses the social isolation experienced bymany young people with psychosis.

KEY PRINCIPLES

• All young people have a right to education, train-ing and employment.12

• All young people have a right to citizenship and abasic income which is enough to live on.12

• All young people have the right to develop a careerthat gives meaning to their lives and makes use oftheir talents.12

• Young people with psychosis should have thesame educational and vocational opportunities astheir non-psychotic peers.

• No individual should be discriminated against ordisadvantaged in relation to their educational andvocational aspirations because they have had aserious mental health difficulty.

• Educational as well as vocational outcomesshould be equally valued and supported in first-episode psychosis.13

iFEVR international consensus statement

324 © 2010 Blackwell Publishing Asia Pty Ltd

OUR GOALS

We aim to:

• Combat stigma, discrimination and prejudice ineducation, training and work settings by raisingawareness about psychosis and the crucial impor-tance of educational and vocational outcomes forlonger term mental health.

• Support young people to achieve their education,training and employment aspirations.

• Ensure that functional outcomes, such as educa-tion, training and employment are seen as equallyimportant in recovery as outcomes in symptomdomains.

• Advocate with funding agencies to appropriatelyfund evidence-based interventions that addressfunctional outcomes in relation to education,training and employment.

• Combat factors that contribute to social exclusionand unfulfilled lives.

• Encourage professional attitudes that engenderhope and optimism that young people with psy-chosis can achieve meaningful lives.

• Seek support from education, training, employ-ment and benefits agencies to assist young peoplewith psychosis to complete their education andprocure employment.

PROCESSES TO ENABLE THIS

• Active confrontation of myths that people withmental illness typically do not want to and cannotwork.

• Equal priority given to educational and workfunctioning as to symptom levels.

• Access to evidence based vocational interventionsfor young people such as the Individual Place-ment and Support model,13 for both employmentand educational goals.12

• An active and flexible research programme toensure that the best evidence is available tosupport vocational interventions for youngpeople with psychosis.

• Access to specialist educational and vocationalsupport to enable education and work goals thatare sustained.

• Incentives for employment agencies to provideearly and sustained support for employmentgoals.

• Greater understanding of the processes that con-tribute to achieving and sustaining employmentin FEP.

• Greater understanding of ethno-cultural factorsthat have an impact on individuals’ access towork, including lack of language competency, anddislocation in refugees and asylum-seekers.

• Employment interventions focusing on retainingand sustaining employment in addition to gainingemployment.

• More flexibility in employment and benefitsystems to be sensitive and responsive to the epi-sodic nature of psychosis for some young people.

• Long term protection of housing and health-carecosts when coming off benefits to return to or startwork.

• Protection of individual rights to choose not todisclose the nature of a mental health difficulty toprospective employers.

HOW CAN I SUPPORT THIS?

• Promotion of an evidence-based, recovery-oriented, clinical culture which supports andgives equal priority to educational and vocationalfunctioning as symptom and social functioning.

• Advocacy to government and funding agenciesabout the economic and social benefits of educa-tion, training and employment outcomes foryoung people with psychosis.

• Promotion of positive news stories in local mediaand with local and larger employers.

• Provision of education for employment agencies,human resource departments and other voca-tional professionals whose mental health literacymay be low.

FURTHER INFORMATION

Contributors to this iFEVR statement include: EoinKillackey (Australia), Jo Smith (UK),Tom Craig (UK),Martin Hember (UK), David Shiers (UK), GeoffShepherd (UK), Keith Nuechterlein (USA), EricLatimer (Canada), Miles Rinaldi (UK), Eric Davis(UK), Annie Lau (UK), Swaran Singh(UK), SarahSullivan (UK) and David Penn (USA).

This statement has been endorsed by the follow-ing organizations: Anding Hospital Beijing; Instituteof Mental Health in Singapore; International EarlyPsychosis Association; Ontario Working Group onEarly Intervention in Psychosis; Royal College ofNurses, UK; New Zealand Early Intervention in Psy-chosis Steering Group; New Zealand Association ofOccupational Therapists; and Employers Forum onDisability (UK).

The International First Episode Vocational Recovery (iFEVR) Group

© 2010 Blackwell Publishing Asia Pty Ltd 325

For further information about how you maysupport and endorse this international consensusstatement or be added to the iFEVR email list pleasecontact: Jo Smith (UK) joda@lineone.net; EoinKillackey (Australia and Rest of World) eoin@unimelb.edu.au; Keith Nuechterlein (USA) keithn@ucla.edu.

REFERENCES

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2. Killackey EJ, Jackson HJ, Gleeson J, Hickie IB, MCGorry PD.Exciting career opportunity beckons! Early intervention andvocational rehabilitation in first episode psychosis: employingcautious optimism. Aust N Z J Psychiatry 2006; 40: 951–62.

3. International Early Psychosis Association Writing Group.International clinical practice guidelines for early psychosis.Br J Psychiatry 2005; 187 (Suppl. 48): s120–s124.

4. Hirschfeld R, Smith J, Trower P, Griffin C. What do psychoticexperiences mean for young men? A qualitative investiga-tion. Psychol Psychother Theory Res Pract 2005; 78: 249–70.

5. Killackey E, Jackson HJ, McGorry PD. Vocational interventionin first-episode psychosis: a randomised controlled trial ofindividual placement and support versus treatment as usual.Br J Psychiatry 2008; 193: 114–20.

6. Marwaha S, Johnson S. Schizophrenia and employment: areview. Soc Psychiatry Psychiatr Epidemiol 2004; 39: 337–49.

7. Marwaha S, Johnson S. Views and experiences of employ-ment among people with psychosis: a qualitative descriptivestudy. Int J Soc Psychiatry 2005; 51: 302–16.

8. Andlin-Sobocki P, Rössler W. Cost of psychotic disorders inEurope. Eur J Neurol 2005; 12: 74–7.

9. SANE. Schizophrenia: Costs. An Analysis of the Burden ofSchizophrenia and Related Suicide in Australia. Melbourne:SANE Australia, 2002.

10. Wu EQ, Birnbaum HG, Shi L et al. The economic burden ofschizophrenia in the United States in 2002. J Clin Psychiatry2005; 66: 1122–9.

11. Rinaldi M, Perkins R, Glynn E, Montibeller T, Clenaghan M,Rutherford J. Individual placement and support: fromresearch to practice. Adv Psychiatr Treat 2008; 13: 50–60.

12. Nuechterlein KH, Subotnik KL, Turner LR, Ventura J, BeckerDR, Drake RE. Individual placement and support for individu-als with recent-onset schizophrenia: integrating supportededucation and supported employment. Psychiatr Rehabil J2008; 31: 340–9.

13. Becker DR, Drake RE. A Working Life for People with SevereMental Illness. New York: Oxford University Press, 2003.

iFEVR international consensus statement

326 © 2010 Blackwell Publishing Asia Pty Ltd