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Rehabilitation Services, The Effra Centre, Brixton, London
Health Services Research Department, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, e-mail: l.howard{at}iop.kcl.ac.uk
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Abstract |
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The aim of the study was to identify the employment rates of people using local mental health services and examine any evidence in care plans for vocational or occupational interventions. We investigated case notes retrospectively.
RESULTS
A total of 297 case notes were examined: 88% of the patients were unemployed, but there was evidence of documentation relating to vocational needs in only 18% of out-patients; 8% in patients of community mental health teams; and 39% in acute wards; 8% of patients were engaged in work schemes; 10% of patients were in education; and 9% were engaged in vocational interventions with their care coordinator; the latter was less likely if the patient was from a Black or minority ethnic group (OR=2.44, 95% CI 0.18-1.05).
CLINICAL IMPLICATIONS
Despite high rates of unemployment, patients with psychiatric disorders are not referred for vocational interventions. Growing professional awareness of vocational possibilities for patients with severe mental illness should mean that many patients could return to competitive employment and return to mainstream society.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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Method |
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Data were analysed with Stata version 8 for Windows. Simple descriptive
statistics were used; 
2 tests were used to compare differences
in proportions, and Kruskal-Wallis tests were used to test differences in
continuous measures as these were not normally distributed.
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Results |
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Overall, 88% of the patients were unemployed (77% of out-patients, 78% of patients on acute wards and 96% under the CMHTs). There was evidence of documentation relating to vocational needs in the case notes in 10 out of the 11 patients (91%) in the rehabilitation services. However, for out-patients this occurred for only 18% (17 of 94), for 8% of those under CMHTs (12 of 150) and 39% in acute wards (16 of 41).
Table 1 shows the number of patients in work or training schemes according to the service. Overall, 8% of patients were engaged in a range of work schemes, 10% were engaged in educational options, and 9% were engaged in one-to-one work with their primary worker/care coordinator. The evidence indicates that across most service areas very little or in some instances no one-to-one vocational work was being provided by care coordinators/primary workers. Of note, for the case notes available, one CMHT engaged over half its patients (15 of 29) in vocational interventions. The outcomes for this team were also much higher than any other service area: 4 (14%) were in employment, 1 (4%) was in voluntary work, 5 (17%) in work schemes and 4 (14%) in education or training.
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Any documented reasons why service users were not engaged in occupational options were recorded. The most commonly noted reasons given were drugs (n=21) and alcohol (n=9). Asylum-related problems (n=11) were also frequent, as were problems with child care or parenting (n=9). Physical problems were also cited for 8 patients.
Employment (part-time or full-time) was less likely in patients from Black and minority ethnic groups (OR=0.41, 95% CI 0.17-0.99, P=0.05), and there was a trend for these patients to be less likely to receive specific one-to-one vocational work with a primary worker or care coordinator (OR=0.44, 95% CI 0.18-1.05, P=0.07). We combined employment with engagement in or referral for voluntary work, work schemes, education or training, and specific one-to-one vocational work with primary worker/care coordinator as a ‘good employment outcome’. This outcome was not more likely in women or men (P=0.5), and did not differ significantly with age (P=0.02) or ethnicity (P=0.11), but the difference did approach significance for years in contact with services (P=0.06), with patients in contact with services for several years having the least chance of a good employment outcome.
In some case notes, staff elaborated more on individual reasons why service users were not engaged in occupational activities. These included engagement issues: ‘difficult to engage’, ‘won’t accept mental health problems’, ‘no motivation - depressed’, ‘poor personal hygiene’, and individual functional issues (e.g. ‘poor memory’, ‘cannot concentrate’, ‘decline in physical health’).
A significant lack of work history and a lack of individual interest in working emerged as a consistent theme, although the individual reasons were not described in any depth from a service user perspective (e.g. ‘has never worked, does not want to’, ‘never been employed’, ‘attempted to get on a college course/education - failed’. The available options were also identified as affecting engagement: ‘feels there is nothing to do’, ‘resisting day care’ and ‘does not want to attend rehab’). Some staff had strong opinions about whether service users could work at all, for various reasons: ‘not well enough to maintain full/part-time work’, ‘lacks insight, tried training’ and ‘finds work stressful’.
A wide range of family-related ties were cited as barriers: ‘husband supports wife, does not want her to work’, ‘lives with parents, no motivation’ and ‘looks after grandchildren, too busy to work’. An array of welfare benefits problems emerged as obstacles to engagement in work: ‘in the welfare trap, ‘happy to live on benefits’ and ‘unable to work because of benefits’.
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Discussion |
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Despite these high rates of unemployment, we found very low rates of occupational care planning, one-to-one vocational work and referrals to work projects documented in clinical case notes. Further research would be required to establish why. There was very little evidence from the case note data of occupational care planning that attempted to address the individual’s occupational needs in a structured engagement process. The data show this area of clinical work as problematic and consistent with national literature, in that staff tend to relegate or ignore occupational needs, possibly because they themselves have not received much training in this area.
There are several limitations to this study. First, unfortunately, case notes were not randomly selected. These case notes may not therefore be representative of the patients under the care of the trust in south London. Second, several categories have not been operationalised or standardised (e.g. clinical diagnosis only could be obtained from the case notes). The information was not checked, so the quality of the data has not been verified. However, the Clinical Governance Department is experienced at obtaining information from case notes, and so the quality of the information from a large sample such as this means that the data are worth studying.
The high level of unemployment and the correspondingly high level of social exclusion among people using mental health services in south London are consistent with national research findings across England. The extent of one-to-one vocational work with primary workers is low or non-existent in some areas of service provision. However, our evidence indicates that when it happens social inclusion outcomes are much better. Standard 5 of the National Service Framework for mental health set a target that by March 2002 all written care plans for people on enhanced CPA must show plans to secure suitable employment or other occupational activity. This study indicates that this is still not happening and referrals to work projects are also very low.
The Social Exclusion Unit guidance, to be published shortly by the National Institute for Mental Health in England, will require mental health trusts to negotiate vocational outcomes with commissioners and help modernise vocational services generally. Staff will require training and specialist input from dedicated professionals (occupational therapists and vocational specialists), supported by effective pathways and local vocational structures in line with good practice guidelines.
Models of vocational interventions need to be developed and researched for this group of patients, as increasing their rates of employment will decrease social exclusion and stigma. We also need to establish and clarify the evidence on which group of professionals has the optimum skills for helping a patient with severe mental illness into work. An occupational therapist has the core skills for rehabilitation of a patient with severe mental illness but not necessarily the skills to support a patient back into work, and an employment specialist has the skills for vocational assessment and job matching but not neccesarily the holistic range that may help a patient diagnosed with severe mental illness.
We are currently investigating, with Professor Graham Thornicroft (principal investigator), the effectiveness of supported employment in a randomised controlled trial, the Supported Work and Needs (SWAN) trial, funded by the Wellcome Trust. The traditional model of vocational rehabilitation uses a ‘train and place’ approach, offering training in sheltered workshops and then placing individuals in real-life work settings. The SWAN study uses the IPS model (individual placement and support), and is the reverse, that is, ‘place and train’, so that clients are placed in real jobs and then offered variable amounts of direct personal support by an experienced employment consultant to enable them to retain their work positions. Studies of IPS programmes in North America have been encouraging in terms of increased rates of competitive employment (Drake et al, 1996, 1999; Bond et al, 1997; Marshall et al, 2001; Lehman et al, 2002).
An alternative model involves initial engagement in voluntary work and education. ‘Although these activities may yield benefits in and of themselves, it is often asserted that engagement in such activities can prepare people for entry/re-entry into employment. The continuing downward trend in employment rates indicates that this has not been the case’ (Perkins & Rinaldi, 2002). Without comparative longitudinal data we cannot make the same assertion.
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Conclusion |
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Acknowledgments |
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References |
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DRAKE, R. E., BECKER, D. R., BIESANZ, J. C., et al
(1996) Day treatment versus supported employment for persons with
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DRAKE, R. E., McHUGO, G. I., BEBOUT, R. R., et al
(1999) A randomized clinical trial of supported employment for
inner-city patients with severe mental disorders. Archives of
General Psychiatry, 56, 627
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LEHMAN, A. F., GOLDBERG, R., DIXON, L., et al
(2002) Improving employment outcomes for persons with severe
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MARSHALL, M., CROWTHER, R., ALMARAZ-SERRANO, A., et al (2001) Systematic reviews of the effectiveness of day care for people with severe mental disorders: (1) acute day hospital versus admission; (2) vocational rehabilitation; (3) day hospital versus outpatient care. Health Technology Assessment, 5, 1-75.
SOCIAL EXCLUSION UNIT (2004) Mental Health and Social Exclusion. London: Office of the Deputy Prime Minister. http://www.socialexclusion.gov.uk/downloaddoc.asp?id=134
PERKINS, R. & RINALDI, M. (2002) Unemployment
rates among patients with long-term mental health problems: A decade of rising
unemployment. Psychiatric Bulletin,
26, 295
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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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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
