Realising Ambitions: Making Employment a Reality for People with

Mental Health Conditions

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

7th March 2011

A view from five perspectives

• Developing evidence based programmes to help people with more serious mental health conditions to gain and retain employment

• Employing people with mental health conditions within mental health services

• Leading a review to UK government ‘Realising Ambitions. Better employment support for people with a mental health condition’ (2009)

• Working with a long term mental health condition

• Member of Equality 2025: UK cross government advisory group of disabled people advising on implementation of the United Nations Convention on the Rights of Disabled Persons

We know that employment is important to mental health and to the recovery of people with a mental

health condition“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

The right to work – a human rightArticle 23 of the United Nations Declaration of Human Rights (1948)

“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 PersonsArticle 6 and 7 of the International Covenant of Economic, Social and Cultural Rights

… but a right deniedMost people with a mental health condition want to have a job – in the UK people with

mental health problems have the highest ‘want to work’ rate of all disabled people (SEU 2003)

BUT few have the opportunity to do soIn the UK• Overall employment rate stands at around 74%, • The employment rate for disabled people in general is 47%, • The employment rate for people with a mental health condition is 21%. • The employment rate for people using secondary mental health services 13.5%

(Work, Recovery and Inclusion 2009)

Can ‘they’ work?Frequently asked question - what makes a person

‘employable’ or ‘work ready’?

But is this the right question?

The research evidence• Characteristics of individuals like diagnosis, duration or severity of

problems have little impact on employment outcomes … therefore there is no justification for selecting people on the basis of clinical history/diagnosis

• The only individual characteristics that influence employment outcomes are ‘motivation and self-efficacy – whether the person wants to work and whether they think they can – and both of these are profoundly influenced by the expectations of others – particularly the ‘expert’ service providers ....

A conspiracy of prejudice and low expectations

Expert mental health professionals and employment services believe that

people with mental health problems are unlikely to be able to work

People with mental health problems believe that they cannot work and give up

trying to get jobs

Employers believe that people with mental health problems cannot work –

so don’t employ them

Very few people with mental health problems in employment

Can ‘they’ work?

Research shows that the most important variable determining whether people can work is the type of support provided

• Segregated sheltered workshops and pre-vocational skills training are not very effective at helping people with mental health problems to return to employment

• There is strong evidence that with the right kind of help the majority of people with mental health conditions – even more serious ones - can successfully get and keep work

(Anthony, 1994; Secker et al, 2000, 2001; Bond 2004)

Therefore the real question is not whether people with mental health conditions can work, but what would it

take to enable people to work?

The barriers to employment

• Prejudice and discrimination and low expectations ... health/social services and employment services, employers, the individual him/herself

• Fear ...on the part of services, potential employers and employees

• Failure to provide the support/adjustments that people with mental health conditions need– Employment programmes not tailored to the needs of people with a mental health

condition– Health and social services don’t consider employment to be part of their

business ... or a realistic possibility for most people with a mental health condition– Health/social services and employment services operate separately and often give

contradictory messages

The challengesDisability employment programmes tend to assume that people have stable

impairments that affect their ability to negotiate the physical world of work or learn the job

The challenges facing people with a mental health condition and their employers are different

• Often fluctuate and it is difficult to know when fluctuations will occur ... and fluctuating conditions require fluctuating support and adjustments

• Can affect a person’s ability to negotiate the social (as opposed to the physical) world of work ... therefore support and adjustments in the social demands of work are required

• Are not immediately obvious and the types of adjustment and support needed less well understood ... therefore employers and employees may need more assistance in identifying appropriate adjustments and support

• Engender fear because of the myths that surround them ... gross stereotypes of ‘poor incompetents’ and ‘social security scroungers’ are unhelpful and inaccurate ... therefore challenging myths and stereotypes is important ...

Making employment possible ...what is the ‘right kind of support’?

The 7 key principles of ‘Individual Placement with Support’ (IPS) evidence based supported employment

• A focus on 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 and clinical treatment:

– employment a core part of support and treatment plans from the start – employment specialists in support and treatment teams – 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 to enable people to work... Competitive employment rates in 16 randomised

controlled trials

European research compared traditional vocational service (non-integrated ‘train-place’) with IPS for people with schizophrenia (Burns et al, 2007):– 55% gained employment in IPS vs. 28% in traditional service– 13% drop-out in IPS vs. 45% in traditional service– 20% readmitted in IPS vs. 31% in traditional service

• Follow-up studies show that work outcomes improve over time• Employment associated with improved self-esteem, symptom control, quality of

life ... no changes with sustained sheltered employment

And it’s not just research trials – it also works in regular day to day practice ...

Employment Specialists in South West London Community Mental Health Teams (2007/8):

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

If we really address employment and education right from the start the results are even more impressive

Typical Picture: 50% in employment or education at first admission - only 20% a year later … but it doesn’t have to be this way

Individual Placement with Support in First Episode Psychosis

From Rinaldi et al (2010) First episode psychosis and employment: A review. International Review of Psychiatry, April 2010; 22(2): 148–162

Wholesale managerAccountantIT assistant Mental health development workerWard assistantBookmaker Call centre handlerRetail assistantReceptionistHairdresserMH advocateOccupational therapy assistantAccountants officer

Catering assistantChambermaidCleanerHotel PorterLabourerLeaflet dropperPlumber’s assistantPost assistantRecycling assistantEnglish TeacherActorJournalistAdmin workerCredit controllerProject worker (private sector)

IT HelpdeskAdmin AssistantCivil servant - executive officerBaker x2CarpenterCaretakerHairdresserSales Assistant x8IT Support deskAdministratorDecoratorCleanerStreet cleanerWarehouse workerMarket research administratorCare assistant

Civil Servant (administrator)Production assistantAssistant special needs teacherAdministrative assistant x5Regeneration project workerGlazierPlumberCatering managerIT trainerNurseHealth records officer

Hairdresser assistantIndian Restaurant waiterLeisure assistantDriverBar workBaristaSales AdvisorBoatyard workerCafé AssistantCatering assistantTeaching assistantSocial workerYouth WorkerFinancial controller

And it is not all stacking shelves

We also know that by providing support we increase people’s belief that they can work

Proportion of people who had ‘written themselves off’ as unable to work because of their mental health condition

Other types of support that may be helpful WITHIN the 7 key IPS principles

• Time limited ‘work experience’ or ‘internships’ in parallel with job search

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

• Peer support“People who have been where I have been and made it – they are my source of inspiration.”

• Starting work gradually and building up hours over time and a benefit system that makes this possible

“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.”

‘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.”

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

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

• Not just ‘them out there’ - leading by example: public sector, health and employment services employing people with mental health conditions

• ‘Job retention’ is as important as getting a job ... And does not always mean staying in the same job - changing working patterns where people change jobs regularly

• Not just jobs but careers

• Breaking down prejudice and discrimination more generally ...

Challenging prejudice and discrimination: The Time to Change Campaign in England

www.time-to-change.org.uk

Contact is central to breaking down prejudice and discrimination

Contact in conditions of equal status where• stereotypes are likely to be disconfirmed• people work co-operatively• people get to know each other properly• wider social norms support equality (Hewstone, 2003)

Any anti-discrimination campaigns must centrally involve people who have mental health conditions. This:

• facilitates the contact that is necessary for breaking down prejudice and discrimination• counteracts popular beliefs that professionals hold all the answers – a belief that deskills

communities• offers images of possibility for people and agencies in communities – what people with

mental health conditions can do and achieve

Employment offers the type of contact necessary to break down prejudice so supporting employment breaks down prejudice and

discriminationsupporting individuals – supporting employers

Suggested principles for thinking about mental health and employment(see Perkins, Farmer and Litchfield, 2009)

• Appropriate employment is good for you

• An ‘employment first’ approach

• No-one with a mental health condition is intrinsically unemployable. Whether or not someone can work is a social/economic/political decision NOT a clinical issue - employment is possible for everyone if we provide enough support

• The state should provide integrated, personalised and flexible support to gain and sustain work: health/social services and employment systems must work together towards common goals

• Employment involves a relationship between employee and employer: both have responsibilities and both are entitled to support in discharging these

If people with mental health problems are really to enjoy the right to work then

we must break down prejudice and stereotypes that prevail and provide people with the support and adjustments they need

but most of all we must raise our expectations

One of the biggest barriers to employment is low expectationsResearch shows that work IS a realistic possibility for people with even more serious mental

health conditions IF we provide the right kind of support and adjustmentsResearch has found no consistent relationship between diagnosis, severity or duration of

mental health problems ... BUTIf 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 realise their ambitions we must believe in the abilities and possibilities of those whom we serve

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.”

... and the benefits of supporting people to gain employment should never be underestimated

“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.”