What are the benefits of evidence-based supported employment for patients with first-episode psychosis?

AIMS AND METHOD

To examine the effectiveness of integrating evidence-based supported employment into an early intervention service for young peoplewith first-episode psychosis. Demographic, clinical and vocationaldata were collected over a 12-month period to evaluate theeffect on vocational outcomes at 6 months and 12 months ofthe employment of a vocational specialist, and to assess modelfidelity.

RESULTS

Following vocational profiling and input from the vocationalspecialist and the team, there were significant increases inthe proportion of clients engaged in work or educational activityover the first 6 months of the intervention, and in a subsampleover a second 6-month period. The evidence-based SupportedEmployment Fidelity Scale was used to measure the degree ofimplementation, which scored 71, signifying ‘good implementation’.

CLINICAL IMPLICATIONS

The results suggest that implementing evidence-based supportedemployment within an early intervention service increases employmentand education opportunities for patients within the service.

Introduction

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Introduction

Early intervention services provide community-based treatmentand support to young people with psychosis and their families,with an emphasis on maintaining normal social roles (Department of Health, 2001).The experience of psychosis can exclude ayoung person from a sense of autonomy, employment and youthculture (Birchwood et al, 1997). Young people aspire to socialroles and goals: employment and education provide social identityand status, social contacts and support, a means of structuringand occupying time, activity and involvement, and a sense ofpersonal achievement (Shepherd, 1989). Quite apart from themoney that can be earned, work tells us who we are and enablesus to tell others who we are (Galloway, 1991).

Poor employment outcomes are a constant finding in researchinto first-episode psychosis (e.g. Mason et al, 1995; Guptaet al, 1997; Singh et al, 2000). Evidence suggests that employmentcan lead to improvements in outcome for people diagnosed withschizophrenia through increasing self-esteem, alleviating psychiatricsymptoms and reducing dependency (Cook & Razzano, 2000).Loss of social roles and goals, especially work, has been linkedto depression and suicidal thinking in psychosis (Birchwood et al, 2000).Returning to (or establishing) a work patterncan become increasingly difficult when someone is unemployed,and the addition of a diagnosis of schizophrenia makes it evenmore difficult (Warner, 1994).

An increasing body of evidence indicates that approaches towork and employment are more important in determining vocationalsuccess than the diagnostic and demographic characteristicsof the patient (Secker & Membrey, 2000). Evidence-basedsupported employment (Drake & Becker, 1996; Bond et al,2001a) has been demonstrated to be effective in enabling peoplewith severe and enduring mental health problems to gain and retain employment.

Early intervention services are expected to provide effectivepathways to education and occupation (Department of Health, 2001),with the National Institute for Clinical Excellence (2002)recommending that supported employment should be provided forpeople with schizophrenia who wish to return to work. We implementedevidence-based supported employment into an early interventionservice by attaching a half-time vocational specialist to a newly developed service. The aims of this study were to evaluatethe vocational outcomes and assess model fidelity.

Method

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Method

Clinical team
The Early Treatment and Home-based Outreach Service (ETHOS)is an early intervention service that has been in operationwithin South West London and St George’s Mental HealthNational Health Service (NHS) Trust since June 2001. It providesa comprehensive package of community-based care for a maximumof 2 years to young people (aged 17-30 years) with a first episodeof psychosis.

Intervention
A half-time vocational specialist was integrated into the ETHOSteam to address the vocational needs of patients within theservice. This specialist (K.M.) was an integral member of themultidisciplinary team but did not carry out care coordinatortasks. She coordinated all the vocational plans with the team,and worked directly with patients and their care coordinatorsto ensure that vocational goals were given a high priority.Direct client interventions included engagement, assessingvocational need, proactively helping patients to find (andkeep) jobs and attend education courses, providing welfare benefitsadvice, addressing support needs and ensuring adjustments toenable patients to keep their jobs or remain in education.All patients within the service (n=40) received an interventionfor 6 months, and 22 clients received it for 12 months.

Data collection
Data were collected from November 2001 to November 2002 forall patients who received vocational input. This informationincluded:

demographic variables: age, gender, ethnicity;
clinical variables:primary diagnosis, duration of contact withthe team, disciplineof care coordinator.

Information on vocational status was collected on first contactwith each patient and thereafter on a monthly basis.

Patients
The vocational specialist worked with all 40 patients withinthe service; 35 had a diagnosis of schizophrenia and 5 haddiagnoses of other psychoses. The median age was 21 years witha range of 18-32 years. The demographic and diagnostic characteristicsof the cohort are given in Table 1.

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Table 1. Characteristics of the clients (n=40) who received the vocational intervention

Model fidelity
Fidelity refers to the degree of implementation of an evidence-based practice. The evidence-based Supported Employment FidelityScale is a 15-item instrument assessing the implementationof the critical ingredients of evidence-based supported employmentfor people with severe mental illness (Bond et al, 1997, 2001b).The scale consists of three sections: ‘staffing’addresses case-load size and the role of employment specialists;‘organisation’ addresses integration with mentalhealth treatment, employment specialist functioning withina vocational unit and zero exclusion to accessing vocationalsupport; and ‘services’ addresses vocational engagement,assessment, job search and development, follow-along support,community-based services, and assertive engagement and outreach.The items are rated on a five-point response scale, rangingfrom 1 (no implementation) to 5 (full implementation).

Results

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Results

Model fidelity
The fidelity of the implementation into the early interventionservice was assessed independently, and scored 71 out of apossible 75 indicating good implementation. Two items, therole of the employment specialist and job search, were eachrated 4, with one item, assertive engagement and outreach, rated3. The lower scoring of these three items was due to the limitations resulting from the part-time status of the vocational workerwithin the team.

Patient outcomes
Table 2 shows the employment status of all 40 patients withinthe service whom the vocational specialist worked with, atbaseline, 6 months and 12 months. All patients (n=40) receivedat least 6 months of the vocational intervention, and 22 ofthem received the vocational intervention for 12 months. Priorto the intervention, just under two-thirds the patients (n=27)were not engaged in any sort of work or education. Only 4 (10%)were engaged in open employment - a figure similar to thatfor the whole population of longer-term service users (Perkins & Rinaldi, 2002).

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Table 2. Vocational status of clients at baseline, 6 months and 12 months

Following vocational profiling, and input from the vocationalspecialist and the team, there was a significant increase inthe proportion of patients engaged in work or educational activityby 6 months ( ${chi}$ ²=28.4, d.f.=12; P<0.005). Only 3 clients (7%)remained without any form of work or educational activity,the number engaged in open employment rose from 4 (10%) to11 (28%), and the number engaged in educational activity remainedconstant at 13 (33%). Table 3 shows the employment status ofthe 40 clients at baseline and 6 months analysed by genderand ethnicity. Male clients demonstrated a significant increasein work or educational activity between baseline and 6 months( ${chi}$ ²=23.3, d.f.=12; P<0.05). However, for female clients thisoutcome was not significant ( ${chi}$ ²=10.0, d.f.=6; P=0.121). Therewas no difference in vocational outcome in the White ethnicgroup ( ${chi}$ ²=12.1, d.f.=8; P=0.143), but there was a significantdifference in the non-White ethnic group ( ${chi}$ ²=23.7, d.f.=12;P<0.05). Data for the 22 clients who received the vocationalintervention for a year showed that, for months 6-12:

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Table 3. Gender, ethnicity and vocational status at baseline and 6 months

everyone employed at 6 months continued to be employed;
twopreviously unemployed clients gained employment;
three patientsmoved into education or training;
three patients completedcourses, two of whom began a job search,and one gained employment.

There was a significant increase in the proportion of patientsengaged in work or educational activity between the 6-monthand 12-month assessments ( ${chi}$ ²=23.1, d.f.=12; P<0.05). Duringthis period only one patient remained without any form of workor educational activity. Between the 6-month and 12-month datapoints, no significant difference in engagement in work oreducational activity was seen in any patient group, whether classified by gender or ethnic group: male gender ( ${chi}$ ²=19.1, d.f.=12; P=0.086), female gender ( ${chi}$ ²=7.4, d.f.=4; P=0.114),White ethnic group ( ${chi}$ ²=18.0, d.f.=12; P=0.116) or broad non-Whiteethnic group ( ${chi}$ ²=9.33, d.f.=4, P=0.053).

Discussion

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Discussion

The study demonstrates that the proportion of patients who wereemployed was greater 6 months after they were taken on by theservice than when they were referred. At the point of referral,more than half (65%) were not engaged in any form of work oreducation, but after 6 months this figure had dropped to 7%and by 12 months to 5%. After 6 months of the intervention the employment rate rose from 10% to 28%.

It is important to note that the vocational specialist was notonly assisting people to gain employment and education, butalso addressing the issue of job or course retention. Seventeenpatients (43%) were engaged in employment or education at thetime of their referral to the service, and the vocational specialistalong with the team supported clients in retaining this activity.Although three vocational status time periods are presentedwithin the data, patients moved through different pathwayswithin those times. Three people lost their job and then foundanother one within the periods presented. The role of the vocationalspecialist was to enable patients to see job transitions asnormal and resume a rapid job search.

The vocational specialist did not work in isolation, but inconjunction with clinicians as part of the multi-disciplinaryteam. The positive results reflect the integration of bothclinical and vocational expertise within one team. The vocationalspecialist developed good working relationships not only withinthe team, but also with local employers, employment agencies,colleges and mainstream training providers, and with the governmentemployment service Jobcentre Plus.

The success of this intervention needs to be viewed in the contextof the small sample size and the enthusiasm of a newly developedand motivated multidisciplinary team. The lack of a comparisongroup, along with other factors that could have resulted inthe increase in employment rates, also needs to be considered.Poor employment outcomes are a constant finding in researchon first-episode psychosis (e.g. Mason et al, 1995; Gupta et al, 1997;Singh et al, 2000), with employment rates forpeople with longer-term schizophrenia reported to be as lowas 4% (Perkins & Rinaldi, 2002). O’Brien et al (2003),in their study of the effects of training clinical staff inthe practice of evidence-based supported employment withouta vocational worker integrated into the team, found that only6% of people achieved open employment thereafter, which compareswith a figure of 11% found in a naturalistic study followingpeople in a vocational rehabilitation programme (Reker et al,2000). Evidence suggests that integrating a dedicated vocationalworker with the clinical teams appears to be essential for improved occupational outcomes for people with severe mental healthproblems (O’Brien et al, 2003). These factors suggestthat integrating a vocational specialist and effectively implementingevidence-based supported employment within the early interventionservice increased employment, work and education opportunitiesfor clients within the service. Longer-term vocational outcomes need to be evaluated to assess retention rates for jobs andeducational courses and job tenure for this group.

These results lend support for an evidence-based supported employment approach where vocational rehabilitation is integrated intothe clinical team, to help people with severe mental healthproblems gain and retain employment and education. There isa national commitment to the development of early interventionservices (Department of Health, 2001), and consideration needsto be given to the successful engagement and outcomes of youngpeople with first-episode psychosis within services. If theseyoung people aspire to social roles and goals, then helpingthem to gain and retain employment and education should notonly improve longer-term outcomes but also provide a potentialkey to engagement.

Acknowledgments

We thank Helen Fisher for assisting with the literature searching,data cleaning and editing of this manuscript.

References

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