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1 The aim and parameters of the literature review 3
2 Some understandings of mental illness 5
3 Employment 9
3.1 Definition of employment 9
4 People with mental illness and the world of work 12
4.1 Participation and recovery 12
4.2 The benefits of work 13
4.3 Barriers to employment success 14
4.3.1 Characteristics pertaining to mental illness and its treatment 14
4.3.2 Psychosocial stressors 15
4.3.3 Access to care, service use and treatment 16
4.3.4 Characteristics of labour markets, work and employer attitudes 17
4.4 Predictors of occupational outcomes 17
4.4.1 Level of functioning before the onset of mental illness 18
4.4.2 Psychiatric symptoms and diagnoses 18
4.4.3 Assessment of work behaviours 18
4.4.4 Social skills and social networks 19
4.4.5 Cognitive functioning 19
4.4.6 On site support and accommodations 20
4.4.7 Training in critical vocational skills 20
4.4.8 Job satisfaction 20
5 Employment assistance for people with mental illness 21
5.1 Employment assistance within the context of psychiatric rehabilitation 21
5.2 Vocational services 22
5.2.1 Vocational assessment and evaluation 22
5.2.2 Vocational treatment planning and career counselling 23
5.2.3 Job development 24
5.2.4 On site job support targeted at the individual employee 24
5.2.5 On site organisational interventions 26
5.2.6 Strengthening the informal support provided by family and friends 26
5.2.7 Off site job skills training and education 27
5.2.8 Off site vocational counselling, mentoring and support 28
5.2.9 Job related transportation 28
5.3 A recommended typology of employment assistance models 28
5.4 Identification of best practice principles when competitive employment
is the goal 32
6 Evaluation of the effectiveness of employment assistance models 33
6.1 Methods of evaluation 33
6.2 Key findings of some reviewed evaluation studies 36
6.3 Areas requiring further research 40
6.4 Methodological issues in relation to the evaluation of employment
assistance for people with mental illness 41
6.4.1 Research design issues 41
6.4.2 Implementation issues 42
7 Summary of key issues 44
Appendix A 45 1 The aim and parameters of the literature review
The key aim of the literature review is to locate relevant research that can describe models of employment assistance for people with mental illness and identify good practice and ‘what works’ in relation to assisting people with mental illness into employment. In determining the scope of the literature to be reviewed, it was decided to focus on the following:
literature that describes service models and approaches to employment assistance for people with mental illness
research that has sought to identify best (or good) practice principles and practices associated with these models
research that has evaluated the effectiveness of relevant service models
literature that discusses methodological issues in relation to the evaluation of employment assistance for people with mental illness.
The review has focused on literature published since January 2000. Several key studies were undertaken in the early 2000s and most of the literature from the last seven years can be accessed electronically.
The review has searched for all relevant material published in Australia and key international literature from the following countries where available in English: New Zealand; United Kingdom; United States of America; Canada; Sweden; Holland; Germany; Hong Kong; and any other country where relevant material is published in international journals.
The literature search methods included the following:
electronic searches of relevant data bases including:
A list of the references located is attached at Appendix A.
This review describes definitions of mental illness, and provides an overview of the policy landscape in the Australian context. It then outlines research in relation to people with mental illness and the world of work, and the nature of employment assistance for people with mental illness, before presenting some emerging findings in relation to the effectiveness of employment assistance models.
2 Some understandings of mental illness
In a research paper focusing on the importance of considering mental health in the context of welfare reform, the former Department of Family and Community Services (FaCS, 2004) refers to mental health as a person’s ability to function and undertake productive activities, to develop and maintain meaningful relationships and to adapt to change and cope with adversity.
Mental health problems and disorders refer to the negative end of the continuum of mental health, and are characterised by alterations in thinking, mood or behaviour associated with distress or impaired functioning. Each condition is unique in terms of its symptoms and effects, its causal factors and treatments. The paper makes the point that it is important to recognise that mental disorders affect people differently.
The constitution of the World Health Organisation (WHO) mandates the production of international classifications on health so that there is a consensual, meaningful and useful framework which governments, providers and consumers can use as a common language (see www.who.int/classifi cations/en).
The WHO has developed a framework for measuring health and disability at both individual and population levels. The earlier version of this framework, known as the International Classification of Impairments, Disabilities and Handicaps, went through an extensive period of revision in order to put the notions of ‘health’ and ‘disability’ in a new light.
In 2001, the 191 WHO member states endorsed a new framework, now known as the International Classification of Functioning, Disability and Health (ICF). It acknowledges that every human being can experience a decrement in health and thereby experience some degree of disability. By shifting the ‘focus from cause to impact it places all health conditions on an equal footing allowing them to be compared using a common metric—the ruler of health and disability’ (WHO, 2001).
In a review of literature from around the world since the endorsement of the ICF, Bruyere et al (2005) affirm that the ICF is increasingly affecting the practice of particular professions more broadly and they write about the conceptual utility of this classification framework for the fields of rehabilitation, health and other clinical disciplines. They refer to the introduction of the ICF into Australian data dictionaries and its use as a framework to inform and
structure questions in the Australian National Disability Survey.
The Australian Institute of Health and Welfare (AIHW) notes that the value of
using the ICF in Australia is that it combines the major models of disability,
and recognises the role of environmental factors in the creation of disability and the importance of participation as a desired outcome. In addition, it provides a framework within which a wide variety of information relevant to disability and functioning can be developed, assembled and related (AIHW, 2003: 5).
The ICF makes no use of the concept ‘handicap’ and instead provides a classification of:
body function and impairments of body functions as a significant deviation or
body structures and impairments i.e. problems in structure as a significant deviation or loss
activities (execution of tasks or actions by an individual) and participation
(involvement in a life situation), with associated activity limitations and
environmental factors, which make up the physical, social and attitudinal
environment in which people live and conduct their lives.
employment, can be found in the ICF in respect of:
body function and impairments—global mental functions
(b110b139) and specific mental functions (b140–b179)
activity limitations and participation restrictions—major life areas (sub-category ‘work and employment’, d840–d859).
The AIHW (AIHW, 2006) notes that disability can be measured along a continuum and that estimates of people with disability vary with the particular
definition used. In 2003, there were an estimated 3 946 400 people with disability in Australia, representing about 20 per cent of the total population.
In 432 200 people (2.2 per cent of the total population) psychiatric disability is
reported as being the main disability (AIHW, 2005: 213). The number of adult
Australians (aged between 20 and 64) with a psychiatric disability is approximately one per cent of that age group and exceeds the numbers with intellectual disability or acquired brain injury alone (SANE Australia, 2003: 3).
The definition of psychiatric disability provided by the AIHW is the following:
Psychiatric disability is associated with clinically recognisable symptoms and behaviour patterns frequently associated with distress that may impair personal functioning in normal social activity. Impairments of global or specific mental functions may be experienced, with associated activity limitations and participation restrictions in various areas. Support needed may vary in range, and may be required with intermittent intensity during the course of the condition. Changes in level of support tend to be related to changes in the extent of the impairment, or in the environment. Psychiatric disability may be associated with schizophrenia, affective disorders, anxiety disorders, addictive behaviours, personality disorders, stress, psychosis, depression and adjustment disorders. (AIHW, 2006: 5)
Mental illness is the leading cause of the non fatal burden of disease and injury in Australia, estimated to have caused about one eighth of the total Australian disease burden in 2003, exceeded only by cancer and cardiovascular disease. An estimated one in five Australians will have mental
illness at some time in their lives (AIHW, 2006: xii).
Internationally, two major classification systems are in use to describe and diagnose psychiatric conditions/mental illnesses. These are now briefly described.
The World Health Organisation’s International Classification of
The International Classification of Diseases (ICD) is one of the WHO family of
international classifications. The ICD is a structured classification of diseases with associated codes, the purpose of which is to allow morbidity and mortality data to be systematically collected from different countries and statistically analysed.
It is currently in its tenth revision (hence ICD–10) and was published in a revised second edition in 2005.
The ICD–10 uses as its core a single list of three alphanumeric codes from A00 to Z99, and is structured in 21 chapters. Chapter Five focuses on ‘mental and behavioural disorders’, which are classified with the codes F00 to F99 (access via www.who.int/classification/en).
The DSM-IV of the American Psychiatric Association
The Diagnostic and Statistical Manual of Mental Disorders is published by the
American Psychiatric Association and covers all mental health disorders for both children and adults. It is currently in its fourth edition and known as
DSM-IV. The DSM uses a multi axial or multi dimensional approach to the diagnosis of psychiatric conditions in the acceptance that other factors in a person’s life have an impact on their mental health. The five dimensions are:
Axis I—clinical syndromes, i.e. ‘the diagnosis’ in the currently accepted
terminology, such as ‘dementia of the Alzheimer’s type’, ‘obsessive compulsive disorder’ or ‘schizophrenia’
Axis II—developmental disorders (such as autism and intellectual disability, typically first evident in childhood) and personality disorders (clinical syndromes which have more long lasting symptoms and encompass the individual’s way of interacting with the world)
Axis III—physical conditions which play a role in the development, continuance or exacerbation of Axis I and II disorders
Axis IV—severity of psychosocial stressors (events that can impact on the
disorders listed in Axis I and II)
Axis V—highest level of functioning, where the clinician rates the person’s level of functioning both at the time of assessment and the highest level within
the previous year. This helps to understand how the above four axes are affecting the person and what type of change could be expected (for further detail see www.allpsych.com/disorders/dsm.html).
One of the types of psychiatric illness, namely schizophrenia, will be described in brief as an example. The discussion is based on material in the Royal Australian and New Zealand College of Psychiatrists’ treatment guide for consumers and carers (see RANZCP, 2005).
Schizophrenia is one of a group of mental disorders known as the psychoses. The condition affects around one in 100 people across all countries, social classes and cultures. Symptoms usually begin to show when people are aged between 15 and 25, and men and women are affected equally. Individuals with a parent or sibling with psychosis have more risk of developing schizophrenia.
There are two main types of symptoms in relation to schizophrenia that is, positive symptoms (experiences that happen in addition to normal experience, for example having hallucinations) and negative symptoms (incorporating a loss or decrease in normal functioning, such as feeling apathetic, depressed or suicidal).
There is currently no cure, although many treatments that aid recovery have been developed. Treatment includes the administering of antipsychotic medications (older agents, first generation antipsychotics such as Chlorpromazine, and newer agents, second generation anti psychotics such as Clozapine), and psychosocial treatment (for example, psycho-education, family therapy and cognitive behavioural therapy). The RANZCP notes that ‘the combination of treatments is crucial’ in a comprehensive program of therapy (2005:15).
An important aspect with schizophrenia is what is known as a ‘prodrome’, the period before an acute episode of psychosis, indicating that a psychotic episode may be about to occur. Prodromal symptoms include changes from normal behaviour such as worsening of usual work or school performance, social withdrawal, emerging unusual beliefs and changes in perception
such as experiencing brief instances of hearing sounds not heard by others.
People with prodromal symptoms are strongly encouraged to be thoroughly
assessed and monitored so that, if clear psychotic symptoms emerge, early specific treatment can be made readily available thus avoiding the need for hospitalisation and minimising the impact of a potential psychotic episode (RANZCP, 2005: 7-11).
3.1 Definition of employment
The definition of employment used in the Australian Bureau of Statistics’ Labour Force Survey, the official source for Australian employment and unemployment statistics, aligns closely with international
worked for one hour or more for pay, profit, commission or payment in kind, in a job or business or on a farm (comprising employees, employers and own account workers) or
worked for one hour or more without pay in a family business or on a farm (i.e. contributing family workers) or
were employees who had a job but were not at work and were:
— away from work for less than four weeks up to the end of the reference week or
— away from work for more than four weeks up to the end of the reference week and received pay for some or all of the four week period to the end of the reference week or
— away from work as a standard work or shift arrangement or
— on strike or locked out or
— on workers’ compensation and expected to be returning to their job or
were employers or own-account workers, who had a job, business or farm, but were not at work.’ (Australian Bureau of Statistics, 2006: 3)
Kravetz et al (2003: 279) provide a model of employment which makes use of the construct ‘the work life domain’. This domain refers to ‘a set of socially defined roles and associated obligations concerning activities that an individual has to perform to benefit and be benefited by society’. It contains:
boundaries that set it apart from other domains
gates and gatekeepers by means of which persons can enter and leave the work domain
work paths or careers that can lead to quantitatively and qualitatively different obligations and benefits.
The authors extend the model by describing ‘adult work phases’ as ‘partially
ordered components of the developmental process of assimilating the skills, values and roles of the work life domain and adapting to its demands’. The authors describe these phases as:
Entry/re-entry—finding employment for the first time or finding new employment due to dissatisfaction with previous employment or after a period of unemployment or education and training.
Sustention/mastery—adaptation to and maintenance of a new employment position, including learning the roles and regulations of the workplace and making the accommodations with other personal, familial and social domains of life that the employment requires.
Career development/building—horizontal or vertical changes in the work
position, usually made to increase the intrapersonal and interpersonal
benefits provided by participation in the work life domain.
The authors point out that engagement in work activities cannot be evaluated
solely in terms of the adult work phases. They extend their model by providing a list of levels of person-environment interaction, which they describe as
‘the sets of activities by means of which an individual can take advantage of
personal and environmental resources to participate in the different adult work
phases’ (Kravetz et al, 2003: 280). These levels are:
personal resources and deficits—psychosocial and demographic characteristics, skills, attitudes towards self and others, and coping strategies that could facilitate or hinder an individual’s participation in the various adult work phases
work situation—the nature of the work demands and career opportunities of a particular employment position and the situational and interpersonal characteristics of the work setting associated with that position
support systems—public and private agencies that are sources of resources and interventions such as legislation, insurance, social skill training and supported employment
cultural and economic factors—aspects of the social context such as family and friends and aspects of the economic context such as level of employment, that can be brought to bear or taken into consideration when helping a person sustain and gain mastery over and develop an employment position.
This is a useful model that can provide a framework for better conceptualising the ‘factors that impact upon the participation of persons with a psychiatric disability in the work life domain’ (Kravetz et al, 2003: 280). The report will discuss these issues in greater depth further on.
When considering the concept of employment in the context of people with
disability, two main types of employment can be distinguished:
Supported employment/employment operated by disability business
services is characterised by pay at productivity and/or competency based wages, segregated work settings, jobs reserved exclusively for people with disability and supervision provided by mental health staff or by other staff external to the workplace. The Disability Services Act 1986 uses the term supported employment to refer to group based assistance provided by business services, offering sheltered work in modified, not fully competitive work settings.
Competitive/open employmentis defined as part time or full time work in the competitive labour market at or above minimum wages with supervision provided by personnel regularly employed by the business. The work is performed alongside people without disability in integrated settings and the job can be filled by people without disability (Bond, 2004: 346; Waghorn & Lloyd, 2005). Leff et al (2005: 1238) include four components as criteria for competitive employment, namely pay at minimum wage or higher, a job located in a mainstream integrated setting, a job that is not set aside for
mental health consumers, and a job that is held independently, i.e. not controlled by a service agency. It should be pointed out that in the American literature, the term ‘supported employment’ refers not to sheltered employment as defined above, but to an approach to vocational rehabilitation, which will be described further on.
4 People with mental illness and the world of work