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Vocational Services, Manager, Adult Services, Main Administration Building, Springfield University Hosptial, 61 Glenburnie Road, London SW17 7DJ (tel: 020 8682 6929; fax: 020 8682 6725; e-mail: Miles.Rinaldi{at}swlstg-tr.nhs.uk)
Vocational Specialist
Service Manager, Adult Intensive Outreach Services
Research Assistant, St George’s Medical School
Clinical Director and Consultant Clinical Psychologist, Adult Mental Health Services
Consultant Psychiatrist and Senior Lecturer, South West London and St George’s Mental Health Trust, London
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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To examine the effectiveness of integrating evidence-based supported employment into an early intervention service for young people with first-episode psychosis. Demographic, clinical and vocational data were collected over a 12-month period to evaluate the effect on vocational outcomes at 6 months and 12 months of the employment of a vocational specialist, and to assess model fidelity.
RESULTS
Following vocational profiling and input from the vocational specialist and the team, there were significant increases in the proportion of clients engaged in work or educational activity over the first 6 months of the intervention, and in a subsample over a second 6-month period. The evidence-based Supported Employment Fidelity Scale was used to measure the degree of implementation, which scored 71, signifying ‘good implementation’.
CLINICAL IMPLICATIONS
The results suggest that implementing evidence-based supported employment within an early intervention service increases employment and education opportunities for patients within the service.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Poor employment outcomes are a constant finding in research into first-episode psychosis (e.g. Mason et al, 1995; Gupta et al, 1997; Singh et al, 2000). Evidence suggests that employment can lead to improvements in outcome for people diagnosed with schizophrenia through increasing self-esteem, alleviating psychiatric symptoms and reducing dependency (Cook & Razzano, 2000). Loss of social roles and goals, especially work, has been linked to depression and suicidal thinking in psychosis (Birchwood et al, 2000). Returning to (or establishing) a work pattern can become increasingly difficult when someone is unemployed, and the addition of a diagnosis of schizophrenia makes it even more difficult (Warner, 1994).
An increasing body of evidence indicates that approaches to work and employment are more important in determining vocational success than the diagnostic and demographic characteristics of the patient (Secker & Membrey, 2000). Evidence-based supported employment (Drake & Becker, 1996; Bond et al, 2001a) has been demonstrated to be effective in enabling people with severe and enduring mental health problems to gain and retain employment.
Early intervention services are expected to provide effective pathways to education and occupation (Department of Health, 2001), with the National Institute for Clinical Excellence (2002) recommending that supported employment should be provided for people with schizophrenia who wish to return to work. We implemented evidence-based supported employment into an early intervention service by attaching a half-time vocational specialist to a newly developed service. The aims of this study were to evaluate the vocational outcomes and assess model fidelity.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Intervention
A half-time vocational specialist was integrated into the ETHOS team to
address the vocational needs of patients within the service. This specialist
(K.M.) was an integral member of the multidisciplinary team but did not carry
out care coordinator tasks. She coordinated all the vocational plans with the
team, and worked directly with patients and their care coordinators to ensure
that vocational goals were given a high priority. Direct client interventions
included engagement, assessing vocational need, proactively helping patients
to find (and keep) jobs and attend education courses, providing welfare
benefits advice, addressing support needs and ensuring adjustments to enable
patients to keep their jobs or remain in education. All patients within the
service (n=40) received an intervention for 6 months, and 22 clients
received it for 12 months.
Data collection
Data were collected from November 2001 to November 2002 for all patients
who received vocational input. This information included:
Information on vocational status was collected on first contact with each patient and thereafter on a monthly basis.
Patients
The vocational specialist worked with all 40 patients within the service;
35 had a diagnosis of schizophrenia and 5 had diagnoses of other psychoses.
The median age was 21 years with a range of 18-32 years. The demographic and
diagnostic characteristics of the cohort are given in
Table 1.
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Model fidelity
Fidelity refers to the degree of implementation of an evidence-based
practice. The evidence-based Supported Employment Fidelity Scale is a 15-item
instrument assessing the implementation of the critical ingredients of
evidence-based supported employment for 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 mental health treatment, employment specialist functioning
within a vocational unit and zero exclusion to accessing vocational support;
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, ranging from 1 (no implementation) to 5 (full
implementation).
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Patient outcomes
Table 2 shows the employment
status of all 40 patients within the service whom the vocational specialist
worked with, at baseline, 6 months and 12 months. All patients (n=40)
received at least 6 months of the vocational intervention, and 22 of them
received the vocational intervention for 12 months. Prior to 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 that for the whole population of longer-term service users
(Perkins & Rinaldi,
2002).
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Following vocational profiling, and input from the vocational specialist
and the team, there was a significant increase in the proportion of patients
engaged in work or educational activity by 6 months (
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%) to 11 (28%), and the number engaged in educational activity
remained constant at 13 (33%). Table
3 shows the employment status of the 40 clients at baseline and 6
months analysed by gender and ethnicity. Male clients demonstrated a
significant increase in work or educational activity between baseline and 6
months (2=23.3, d.f.=12; P<0.05). However, for
female clients this outcome was not significant (2=10.0,
d.f.=6; P=0.121). There was no difference in vocational outcome in
the White ethnic group (2=12.1, d.f.=8; P=0.143), but
there was a significant difference in the non-White ethnic group
(2=23.7, d.f.=12; P<0.05). Data for the 22 clients
who received the vocational intervention for a year showed that, for months
6-12:
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There was a significant increase in the proportion of patients engaged in
work or educational activity between the 6-month and 12-month assessments
(2=23.1, d.f.=12; P<0.05). During this period only
one patient remained without any form of work or educational activity. Between
the 6-month and 12-month data points, no significant difference in engagement
in work or educational activity was seen in any patient group, whether
classified by gender or ethnic group: male gender (2=19.1,
d.f.=12; P=0.086), female gender (2=7.4, d.f.=4;
P=0.114), White ethnic group (2=18.0, d.f.=12;
P=0.116) or broad non-White ethnic group (2=9.33,
d.f.=4, P=0.053).
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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It is important to note that the vocational specialist was not only assisting people to gain employment and education, but also addressing the issue of job or course retention. Seventeen patients (43%) were engaged in employment or education at the time of their referral to the service, and the vocational specialist along with the team supported clients in retaining this activity. Although three vocational status time periods are presented within the data, patients moved through different pathways within those times. Three people lost their job and then found another one within the periods presented. The role of the vocational specialist was to enable patients to see job transitions as normal and resume a rapid job search.
The vocational specialist did not work in isolation, but in conjunction with clinicians as part of the multi-disciplinary team. The positive results reflect the integration of both clinical and vocational expertise within one team. The vocational specialist developed good working relationships not only within the team, but also with local employers, employment agencies, colleges and mainstream training providers, and with the government employment service Jobcentre Plus.
The success of this intervention needs to be viewed in the context of the small sample size and the enthusiasm of a newly developed and motivated multidisciplinary team. The lack of a comparison group, along with other factors that could have resulted in the increase in employment rates, also needs to be considered. Poor employment outcomes are a constant finding in research on first-episode psychosis (e.g. Mason et al, 1995; Gupta et al, 1997; Singh et al, 2000), with employment rates for people with longer-term schizophrenia reported to be as low as 4% (Perkins & Rinaldi, 2002). O’Brien et al (2003), in their study of the effects of training clinical staff in the practice of evidence-based supported employment without a vocational worker integrated into the team, found that only 6% of people achieved open employment thereafter, which compares with a figure of 11% found in a naturalistic study following people in a vocational rehabilitation programme (Reker et al, 2000). Evidence suggests that integrating a dedicated vocational worker with the clinical teams appears to be essential for improved occupational outcomes for people with severe mental health problems (O’Brien et al, 2003). These factors suggest that integrating a vocational specialist and effectively implementing evidence-based supported employment within the early intervention service increased employment, work and education opportunities for clients within the service. Longer-term vocational outcomes need to be evaluated to assess retention rates for jobs and educational courses and job tenure for this group.
These results lend support for an evidence-based supported employment approach where vocational rehabilitation is integrated into the clinical team, to help people with severe mental health problems gain and retain employment and education. There is a national commitment to the development of early intervention services (Department of Health, 2001), and consideration needs to be given to the successful engagement and outcomes of young people with first-episode psychosis within services. If these young people aspire to social roles and goals, then helping them to gain and retain employment and education should not only improve longer-term outcomes but also provide a potential key to engagement.
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Acknowledgments |
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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BIRCHWOOD, M., IQBAL, Z., CHADWICK, P., et al
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BOND, G. R., BECKER, D. R., DRAKE, R. E., et al (1997) A fidelity scale for the Individual Placement and Support model of supported employment. Rehabilitation Counselling Bulletin, 40, 265 -284.
BOND, G. R., BECKER, D. R., DRAKE, R. E., et al
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BOND, G. R., VOGLER, K. M., RESNICK, S. G., et al (2001b) Dimensions of supported employment: factor structure of the IPS fidelity scale. Journal of Mental Health, 10, 383 -393.
COOK, A. & RAZZANO, L. (2000) Vocational rehabilitation for persons with schizophrenia: recent research and implications for practice. Schizophrenia Bulletin, 26, 87-103.
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This article has been cited by other articles:
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  M. Rinaldi, R. Perkins, E. Glynn, T. Montibeller, M. Clenaghan, and J. Rutherford Individual placement and support: from research to practice Advan. Psychiatr. Treat., January 1, 2008; 14(1): 50 - 60. [Abstract] [Full Text] [PDF]
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 M. Rinaldi and R. Perkins Implementing evidence-based supported employment Psychiatr. Bull., July 1, 2007; 31(7): 244 - 249. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
