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Employment as an evidencebased health intervention: Current thinking about employment for people wit


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Title: Employment as an evidencebased health intervention: Current thinking about employment for people wit

Employment as an evidence-based health
intervention Current thinking about employment
for people with mental illness
  • Geoff Waghorn PhD
  • The Queensland Centre for Mental Health Research
    (QCMHR) and The University of Queensland

Declaration of interests
  • This research is funded by Queensland Health via
    a collaboration between QCMHR and the University
    of Queensland.
  • The West Moreton MHS site is partly funded by an
    Australian Rotary Health Research Evaluation
    award in 2007 and 2008.
  • The Queensland multisite trial is funded by
    Queensland Health as a Council of Australian
    Governments (COAG) initiative for 2007-2009.
  • Development of measures and information resources
    was funded by the Australian Government
    Department of Health and Ageing in 2007-2008.
  • This visit is sponsored by Workwise Employment

  • Professor Harvey Whiteford co-director of QCMHR
  • Dr David Chant, Mathematical Statistics
  • Professor Gary Bond, Indiana - Purdue
    Universities, Indianapolis.

  • Labour force activity by people with psychiatric
  • Neither earning nor learning
  • How employment contributes to recovery
  • Traditional vocational rehabilitation
  • Evidence based practices in supported employment
  • Missing ingredients in Australia and New Zealand
  • Australian experiences with evidence-based
    supported employment
  • Advantages of integration by co-location
  • Implications for policy makers
  • Relevant reports

  • At a population level, how successful are we at
    restoring careers following onset of severe
    mental illness?

Impact on labour force activity
Neither earning nor learning by health
condition SDAC 2003, n36,088
Possible reasons for poor LFA by people with
psychiatric disorders
  • Low expectations for vocational success
  • Cause of disease remains unknown, and treatments
    only partially effective for most people
  • Insufficient places in suitable employment
  • Few vocational services target public mental
    health service clients
  • Traditional psychiatric rehabilitation concepts
    influence service delivery (e.g. work readiness
    and non-competitive employment)
  • Limited availability of evidence-based employment
  • Welfare traps
  • Employer attitudes perceived as negative
  • Past experiences of community stigma and unfair
  • Challenging and varied nature of psychiatric
  • Knowledge silos Mental health and vocational
    services do not routinely share information
  • Poor outcomes by traditional vocational
  • Poor employment outcomes by ACT services.

How competitive employment facilitates recovery
  • By reducing stigma and social marginalisation
  • By reducing disabilities secondary to the illness
  • By helping people reclaim a valued place in
  • Few other things can be done for 8 or more hours
    a day
  • By strengthening self-efficacy and self-esteem
  • By validating recovery progress through real
    measurable accomplishments
  • Increased opportunity for positive regard from
  • Greater opportunity for social inclusion and
    acceptance by the wider community

Employment can help with other problems
  • People with mental illness are nearly 3 times
    more likely to be in debt
  • Before employment ratio of expenses to income
  • After employment ratio of expenses to income 80
    (Cook, 2008)
  • Employment increases housing opportunities and
    helps prevent eviction
  • 66 of men under the age of 35 with mental
    illness who completed suicide were unemployed.
  • Deterioration in mental health can be first
    observed at work.

Psychiatric disabilities are the most challenging
for standard disability employment services
  • Australian DEEWR unpublished data 2006
  • Of the 12 disability categories assisted by the
    Disability Employment Network, psychological/psych
    iatric had the poorest job retention
  • 25 of participants with psychological/psychiatric
    disabilities accumulated 26 weeks of employment
  • 35 of all DEN participants attained this

Employment demand by people with severe mental
  • Say they want to work 55-70
  • Are currently working 21
  • Current access to evidence-based SE 0
  • Most consumers of MHS are never asked about their
    employment goals.
  • Sources Rogers, 1991 McQuilken, 2003 Mueser,
    2003 Harris 2002 Hall 2003 King et al., 2006
    West, 2005

Traditional Rehabilitation
  • Gradual stepwise process after clinical treatment
    and care is complete
  • Usually involves prevocational training (courses
    in managing mental health, general social skills,
    independent living, self-esteem)
  • Work-readiness assessments used for eligibility
  • Individual and illness characteristics are used
    to assess work readiness
  • Voluntary work, work experience, sheltered
    employment, and transitional employment are often
  • Group-based approaches often used (e.g. work
    preparation groups, Job-clubs, support groups).

EB-SE7 Evidence-based principles
  • 1. Eligibility is based on consumer choice
  • 2. Supported employment is integrated with
  • 3. Competitive employment is the goal
  • 4. Rapid job search (within 4 weeks)
  • 5. Job finding, and all assistance, is
  • 6. Follow-along supports are continuous
  • 7. Financial planning is provided.
  • 2 7 most likely to be missing in Australia
  • Others can be weak in practice
  • Evidence for each principle as well as for the
    model as a whole (Bond, 2004 Bond et al, 2008
    Psychiatric Rehabilitation Journal).

Evidence for what works best
  • Most effective approach is now known as
    evidence-based supported employment for people
    with psychiatric disabilities. Previously called
    the Drake-Becker Individual Placement and Support
    (IPS) approach.
  • Evidence includes 6 day treatment conversions and
    16 RCTs.
  • RCTs are the strongest scientific design for
    evaluating whether an intervention works.
  • 16 published and qualifying RCTs (See recent
    edition of PRJ)
  • 12 in USA
  • 1 in Hong Kong
  • 1 in Canada
  • 1 in Europe (six European countries)
  • 1 in Australia (in press with BJP).
  • 11 RCTs involve services with high fidelity to
  • This approach is most similar to the Disability
    Employment Network program in Australia.

Day treatment conversions to IPS Common study
  • Discontinue day treatment (usually group training
    in managing medication or social skills)
  • Reassign day treatment staff to new positions
  • Replace group-based programs and sheltered work
    with IPS

Mean competitive employment rates in 6 day
treatment conversions
Similar results in all 6 day treatment
  • Large increase in employment rates
  • No negative outcomes (e.g., relapses)
  • Consumers, families and staff all liked the
  • Overall, all former day treatment clients got out
    into the community more
  • Resulted in cost savings


Other employment outcomes
  • 11 of 16 RCTs compared high fidelity services to
    the best available local services (EB-SE vs.
  • More participants commenced competitive
    employment (11 studies, 62 vs. 25)
  • More participants worked 20 or more hours per
    week (4 studies, 43.6 overall, 66 vs. 14.2 at
    control sites).
  • Less days to first job (6 studies, 144.5 vs.
    214.0 days).
  • Similar accumulated employment following
    commencement of first job (11 studies, 24.5 vs.
    25.0 weeks).
  • More weeks worked at longest job (11, studies,
    22.0 vs 16.3 weeks).
  • Time to first job and job retention are major

EB-SE changed the way we think
  • Not a gradual stepwise process, goal is immediate
    competitive employment. Aim is to commence job
    searching within 4 weeks.
  • Employment service is closely coordinated with
    health treatment and care.
  • No prevocational training. All training is highly
    individualised and linked to a particular job
    Place then train, not Train then place.
  • No assessments of work-readiness. Main inclusion
    criteria are that applicants have a severe mental
    illness and are requesting assistance.
  • Assessments are ongoing once a job commences.
    Employers are provided with similar support.
  • Intensive one-one assistance is available at
    every step
  • Service characteristics rather than individual
    characteristics, predict employment outcomes
  • Individual preferences guide every aspect of
    assistance. These preferences are not modified
    and all assistance is provided on a one-one
  • Voluntary work, work experience, sheltered
    employment, transitional employment, wage
    subsidies, and temporary jobs are rarely used
  • Job tryouts at casual rates are the preferred
    method to obtain career-learning experiences.
    These are often negotiated on behalf of clients.
  • Continuing support not arbitrarily discontinued.

Missing ingredients in Australia and New Zealand
  • Integration of vocational assistance with mental
    health treatment and care.
  • Financial planning
  • to work out the cost-benefits of going to work
    and reduce the stress of financial uncertainty.
  • to clarify motivation to seek employment in those
    who have not yet volunteered.
  • Intensity, continuity, and individualised
    approach also need to be strengthened
  • With the support of a mental health team all
    volunteers can be assisted.

A key ingredient Integrating employment with
community mental health services
  • Why
  • People with psychiatric disabilities can require
    extended periods of mental health care which
    needs to be coordinated with any vocational
    services provided.
  • Employment services can facilitate engagement in
    mental health treatment and care
  • Employment outcomes can demonstrate the efficacy
    of a recovery orientated mental health service
  • Discharge plans can be linked to real world
    milestones such as stable housing and employment.

A key ingredient Integrating employment with
community mental health services
  • How
  • Co-locating by formal partnership with an
    existing employment service (e.g. Qld trial)
  • Attachment model (visiting and cross-training,
    South Auckland)
  • Rehab. staff provide enhanced inter-sectoral
    links (Newcastle)
  • MHS employs employment specialists and obtains
    MSD contract (CCDHB)
  • MHS employs employment consultant using own funds
    or research funds (ORYGEN Youth Health,

Integration by co-location
  • Employment specialists
  • Hosted by one or two clinical teams
  • Share office space with clinical team to access
    shared clients
  • Communicate informally with team members about
    progress of individual clients
  • Conduct joint interviews with clients
  • Discuss vocational progress at weekly case
  • Clinical team benefits from the input of the
    employment specialist.
  • Employment specialist benefits from knowledge and
    support of the clinical team.
  • Clients benefit from not having to coordinate
  • Clients work performance issues are more likely
    to be solved
  • Services become more effective
  • The employment service trains and supports the
    employment specialist who regularly attends the
    home vocational service.

Problems with segregated employment services
  • Breakdowns in communication
  • Referral process works poorly (delays in take-up,
    right of refusal)
  • Meetings hard to schedule
  • Clients perceived differently
  • Treatment and housing get out of step with job
  • Responsibility for follow-up unclear
  • Employment staff may get caught up in crisis work
    (care manager role).

Advantages of co-location
  • More efficient use of existing resources
  • Knowledge and expertise flow to both sectors
  • Changes in resource allocation, funding
    arrangements, or staff duties, not usually
  • Health staff implement a recognised
    evidence-based practice
  • Health staff benefit from seeing more individual
  • Health staff develop new skills and expertise in
    psychosocial rehabilitation
  • Help with risk assessment and contingency
  • Help with personal information management
  • Link treatment and care goals to
    clientsemployment goals.
  • Mental health exit strategies can be linked to
    employment milestones
  • Employment specialist can facilitate re-access to
    mental health services if needed
  • Forensic services, substance use, and acute care
    teams can participate
  • Employment specialist can assist clients most in
    need of this assistance and build more expertise
    compared to segregated services.

Employers best understand psychiatric disorders
in terms of work restrictions
Advantages of service integration
  • Mental health service accepts importance of
    return to real-world functioning as a key outcome
    indicator for MHS
  • Mental health teams refine treatment plans to
    optimise work performance
  • MHS staff (RHD students) help design add on
    programs to improve employment service
  • Work-related problem solving skills
  • Job-specific social skills
  • Motivational interviewing to delineate
  • CBT and other interventions to reduce employment
  • Integrated MH service find no downside to
    integration in the medium term.
  • Employment service assists more challenging
    clients and increases employment outcomes.

Financial planning
  • Perceptions of welfare as more stable and
    dependable. Fear of loss of income support and
    loss of fringe benefits.
  • Financial planning important to assess in advance
    the real costs and benefits of going to work
  • Identify job location and likely earnings (after
  • Identify actual value of fringe benefits
  • Identify all welfare and tax implications (income
    support, fringe benefits, taxation, housing
  • Apply for all applicable incentives
  • Clarify notification obligations
  • Calculate costs of going to work (travel, meals,
    clothing, tools)
  • Plan a budget for the first four weeks.

Australian experiences with evidence-based
supported employment
  • Queensland Multisite trial (12 sites)
  • Mental Illness Fellowship Victoria (5 of 6 sites
    similar to Qld trial)
  • Hunter Valley and New England MHS trial ( 1 site)
    2 MH staff dedicated to monitor referrals to
    local services).
  • ORYGEN Youth Health (1 site) EC employed directly
    as part of YMHS, no links to federal employment

Qld multi-site trial
Support for other sites
  • Australia
  • Launceston Choice Employment and Tasmania MHS
  • Hobart CRS Australia and Tasmania MHS
  • Rockingham MHS WA, and Ruah Workright
  • Canberra
  • Sunshine Coast Mental Health Service
  • NZ
  • Capital and Coast DHB, research support.
  • Workwise, implementation and research support.

Major challenges to integration by co-location
  • Need sufficient funded places (25 per FTE) for
  • An experienced employment specialist with a new
    case-load capacity
  • Employment service can have lower performance
    during set-up
  • Organizational culture differences need to be
  • Need for proactive change management by MHS
  • Need training for MH staff to generate referrals
    as quickly as possible and to promote acceptance
    of the EC
  • Need to accommodate the increased demand for
    employment services by other clients of the MHS.
    Need an enhanced care plan.

Minor challenges to integration by co-location
  • 3-6 months may be needed for a new co-located
    service to run smoothly
  • Most issues are practical such as IT access,
    parking, car access, confidentiality agreements,
    shared interview rooms, job search facilities for
  • It helps if a single coordinator and a small
    steering committee are appointed in the host
    service. This way all issues can be quickly

Implications for policy makers
  • Australian Disability Employment services
    characterized by
  • Segregation from mental health treatment and care
  • Difficulty with zero exclusion
  • Difficulty with rapid job search
  • Financial counselling ad hoc
  • Demand often exceeds places available
  • Otherwise a highly suitable type of service for
    people with severe mental illness
  • Another benefit to MHS is demonstrating
    successful implementation of evidence-based
  • EBP in SE much easier to implement than ACT or
    Family Psycho-education.
  • EBP in SE should have no long term costs to
    either service.
  • Approach informs inter-sectoral issues in
    education and housing.

Relevant Reports
  • Killackey, E., Waghorn, G. (2008). The
    challenge of integrating employment services with
    public mental health services in Australia
    Progress at the first demonstration site.
    Psychiatric Rehabilitation Journal, 32(1), 63-66.
  • King, R., Waghorn, G., Lloyd, C., McMah, T.,
    McCloud, P., Leong, C. (2006). Enhancing
    employment services for people with severe mental
    illness the challenge of the Australian service
    environment. Australian and New Zealand Journal
    of Psychiatry, 40, 471-477.
  • Lloyd, C., Waghorn, G. (2007). The importance
    of vocation in recovery for young people with
    psychiatric disabilities. British Journal of
    Occupational Therapy. 70(2), 50-59.
  • Porteous, N., Waghorn, G. (2007) Implementing
    evidence-based employment services in New Zealand
    for young adults with psychosis Progress during
    the first five years. British Journal of
    Occupational Therapy, 70(12), 521-526.
  • Waghorn, G., Collister, L., Killackey, E., and
    Sheering, J. (2007). Challenges to the
    implementation of evidence-based employment
    services in Australia. Journal of Vocational
    Rehabilitation, 27, 29-37.

Relevant reports continued
  • Lloyd, C., Waghorn, G., Best, M., Gemmell, S.
    (2008). Reliability of a composite measure of
    social inclusion for people with psychiatric
    disabilities. Australian Occupational Therapy
    Journal, 55(1), 47-56.
  • Lloyd, C., Waghorn, G., McHugh, C. (2008).
    Musculoskeletal disorders and comorbid
    depression Implications for practice. Australian
    Occupational Therapy Journal, 55(1), 23-29.
  • Lloyd, C., Waghorn, G, Williams, PL. (in
    press). Conceptualising recovery in mental health
    rehabilitation. British Journal of Occupational
  • Lloyd, C., Waghorn, G., Williams, PL., Harris,
    MG, Capra, C. (in press). Early psychosis
    Treatment issues and the role of occupational
    therapy. British Journal of Occupational Therapy.
  • Rampton, N., Waghorn, G., Lloyd, C., De Souza,
    T. (in press). Employment service provider
    knowledge of service user assistance needs.
    American Journal of Psychiatric Rehabilitation.
  • Waghorn, G., Lewis, S. (2002). Disclosure of
    psychiatric disabilities in vocational
    rehabilitation. Australian Journal of
    Rehabilitation Counselling, 8 (2), 67-80.
  • Waghorn, G., Lloyd, C. (2005). The employment
    of people with mental illness. Australian
    e-Journal for the Advancement of Mental Health,
    4(2) Supplement, 1-43.
  • Waghorn, G., Lloyd, C. Mackenzie-Ross, A.,
    Schembri, S. (in press). Generalizability of a
    measure of work-related subjective experiences
    for people with psychiatric disabilities. Journal
    of Rehabilitation.
  • Waghorn, G. Lloyd, C., Abraham, B., Silvester,
    D., Chant, D. (2008). Comorbid physical health
    conditions hinder employment among people with
    psychiatric disabilities. Psychiatric
    Rehabilitation Journal, 31(3), 243-246.

Contact details
  • geoff_waghorn_at_qcmhr.uq.edu.au
  • Tel. 61 07 3271 8673
  • Fax. 61 07 3271 8698
  • Postal QCMHR, The Park, Centre for Mental
    Health. Locked Bag 500, Sumner Park BC,
    Queensland 4074 Australia
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