International employment schemes for people with mental health problems.

It has been recognised that work is a positive factor for mental health since the days of Galen (2nd century CE). It was central to the theories and practice of William Tuke at the Retreat in York (founded 1796) and has continued in different forms as a therapy and/or a form of rehabilitation ever since. These forms can be usefully divided into four main categories: sheltered work, vocational training, transitional employment (or work experience) and supported employment. These broad categories have been adapted to different cultures and economic circumstances across the world. There are advantages and disadvantages to all forms, but the burgeoning research literature of the past 20 years does show that when it comes to finding people paid work in the open labour market, supported employment is markedly more successful than other methods.

The four main categories of employment schemes – sheltered work, vocational training, transitional employment (or work experience) and supported employment – have been adapted to different cultures and economic circumstances across the world, though if such schemes exist in low- and middle-income countries they tend not to appear in the literature. Paid employment is not always prioritised but increasingly this is what service users say they aspire to and in this article ‘employment’ is taken to mean work which is paid at the going rate for the job. Therefore, the extent to which these models lead to paid employment is considered a primary outcome. There are advantages and disadvantages to all forms – none is the complete answer for everyone who wants a job, but the burgeoning research literature of the past 20 years does show that when it comes to finding people paid work in the open labour market, supported employment is markedly more successful than other methods. For the purposes of this brief article I have excluded discussion of volunteering – an important and valued activity in its own right but not necessarily a methodology for employment integration.

Sheltered work

Sheltered work – work in specially constructed protected environments – is slowly (and painfully) disappearing from modern mental health services across the world, along with other forms of institutional care. The reasons for this decline are manifold: the changing aspirations of mental health service users; poor-quality, repetitive work often with little or no pay; segregation from the workaday world; very low rates of transition to the open labour market; and cost. The end of sheltered workshops is painful because, as with other institutions, those who work in them (including the staff) become dependent on them. Thus, decisions are postponed until the work dries up and the costs become so huge that they are completely unsustainable.

Newer forms of sheltered work – social firms, social cooperatives – have minimised many of the disadvantages of the sheltered workshop. Beginning with the social integration (type B) cooperatives (Thomas, 2004) formed at the time of the reforms inspired by Franco Basaglia in Italy in the 1970s, large numbers of small and medium-sized enterprises whose main aim is to create employment for people with disabilities and those who are disadvantaged have sprung up across Europe, North America (where they are called ‘affirmative enterprises’) and elsewhere (Warner & Mandiberg, 2006). Ideally, these enterprises compete for business with other firms in the open market, pay workers the rate for the job, provide good working conditions and achieve high levels of worker participation. They are popular in places with unemployment problems and high levels of stigma against people with mental illness. Greece, for instance, has made social cooperatives a key part of the structural reform of mental health services. Apart from Italy, the largest, most numerous and most economically successful social firms are in Germany. Elsewhere, the numbers are small, although there are some outstanding examples in the UK and North America. The disadvantages are mostly to do with the difficulties of running any kind of business, scalability and poor permeability with the open labour market.

Vocational training

The idea of preparing people for work by providing them with vocational skills (train, then place) sounds like common sense. However, in practice the way such training is usually organised gives poor results when it comes to finding paid work. The reasons are not hard to find and with today’s fast-changing labour market there is arguably even less justification for basic, generic training schemes. The problems begin with deciding what people should be trained for. Unless specifically commissioned by an employer, basic training schemes tend to opt for work that is no longer available or is now being carried out to a level which can only be achieved through industry standard training. Basic, generic training in information technology skills, woodworking, catering and so on have never been sufficient as a basis on which to offer jobs and nowadays the technological requirements of most workplaces have made specialised training essential. This means that, to be accepted, would-be workers have to compete for places on courses from which only the most accomplished will actually be employed. This does not, or at least should not, rule out people with mental health problems but the route to such a job would require the kind of intensive support that only individual supported employment services could provide. The unfortunate consequence is that people get stuck on a training roundabout, accumulating certificates in basic skills – which many enjoy and value – but never getting actual jobs.

One way out of the training trap may be to design modern forms of flexible, supported apprenticeship which have jobs at the end for all who can stay the course. However, it is important to note that schemes for people with mental health problems must fit with the ways in which entry into employment is organised at local and national levels. Only 5% of employers in the UK offer apprenticeships of any kind, compared with around a quarter of employers in Germany, Austria and Australia. In Germany, two-thirds of people under 25 have completed an apprenticeship qualification and there is a subsidy for employers who provide extra support for people with disabilities.

Transitional employment (or work experience)

Transitional employment is a way of working which is specific to the International Clubhouse Movement. It is based on the idea that people can prepare psychologically and socially for paid work by taking on a temporary job, which if successful gives them the confidence and discipline to apply for more permanent jobs. Nowadays the International Clubhouse standards specify supported, individually designed employment opportunities as a part of what is on offer, which arguably fall under the same broad heading as other forms of supported employment. In their pure form, placements in transitional employment are found and owned by the local clubhouse, which enters into a relationship with a local employer in which the clubhouse guarantees to get the work done, no matter who does it. The clubhouse then offers the job to a member for a limited period (6–9 months at most), who will be paid the rate for the job. If the post-holder becomes unwell, then another member (or a member of staff) will step in to fulfil the contract. Jobs are usually part-time and entry-level.

The theory of transitional employment as a bridge to permanent employment holds good as long as the member is able to cope with the loss of a job to which he or she has become attached and then plucks up the courage to take on a new job and new set of work relationships. Advocates of supported employment (discussed below) would argue that if the individual wants a job, it is probably best to go for it directly, thus obviating the need for a difficult transition. Clubhouse advocates argue that for some people this relatively risk-free form of employment commitment is a necessary stepping stone to the open labour market. There are over 300 clubhouses worldwide in 28 countries, with most situated in the USA. Numbers reach double figures in Canada, Korea, China and Finland, with other significant clusters in Sweden, Denmark and Japan.

In one randomised controlled trial (RCT) involving 120 participants, directly comparing clubhouse-supported employment with that practised in ACT (assertive community treatment) the clubhouse version performed as well or better in terms of employment outcomes (Macias et al, 2006).

Supported employment

Supported employment reverses the proposition behind vocational training – it is place then train not train then place. Adapted originally from the ‘job coach’ model of supported employment for people with intellectual disabilities, the form of supported employment known as individual placement and support (IPS) is the most researched model of employment scheme in the mental health field. Much of the research has been undertaken in the USA, where the methodology was developed (Bond et al, 2008), but there have been trials in Europe and Australia, including a multicentre study (EQOLISE) across six European countries (Burns et al, 2008) and a Cochrane review (Crowther et al, 2001). With one exception (Heslin et al, 2011) almost 20 RCTs have shown IPS to be superior to a range of alternative methods (including all those discussed above) in terms of employment outcomes, however these are measured. The EQOLISE study used as controls the best available alternative methods and showed IPS to be superior in each country. It also showed that the intervention group had a lower dropout rate and fewer hospital admissions than the controls, thus countering the suggestion that the rigours of open employment might be harmful to health.

International comparisons show that the advantages of IPS in terms of employment outcomes (Bond et al, 2012) and cost-effectiveness (Knapp et al, 2013) are maintained across different countries. However, absolute rates of employment do not match those achieved in the USA, and despite the strength of the evidence base IPS is still not widely implemented. This has been attributed to differing client and clinician attitudes, different organisational contexts and low-fidelity implementation (Boardman & Rinaldi, 2013).

Individual placement and support is a manualised methodology using a fidelity scale with 24 items based on eight basic principles:

It aims to get people into competitive employment.

It is open to all those who want to work.

It tries to find jobs consistent with people’s preferences.

It works quickly.

It brings employment specialists into clinical teams.

Employment specialists develop relationships with employers, based upon a person’s work preferences.

It provides time-unlimited, individualised support for the person and the employer.

Benefits counselling is included.

The higher the fidelity, the better are the outcomes, but it is highly skilled work and both individual employment specialists and employment support teams operate in a culture of continuous review and learning. Having said all of which, IPS does not work for everyone entering the programme. Employment rates range from 40% to 80%, depending on local conditions, the skills of the practitioners and the degree of fidelity to the model. However, it is clearly the best model the mental health field has to offer thus far to service users who want paid, competitive employment and it is increasingly recognised, even in countries where other methods are deeply embedded, that it should be one of the options available.

Conclusion

There is sufficient evidence to say that IPS is the most effective technology so far devised for enabling people with mental health problems to gain competitive employment and it should be available to everyone with this aspiration, no matter where they live.