Research on the job and training help mental health service users want

The Research

Title: Still Dreaming: Service Users’ Employment, Education and Training Goals
Authors: The South East Essex Service User Research Group (SE-SURG), Jenny Secker and Leslie Gelling
Affiliations: SE-SURG has an administrative base at Anglia Ruskin University where Jenny Secker holds a post part-funded by the South Essex Partnership NHS Trust Leslie Gelling works for the trust

Objectives

The aim of this research was to explore what mental health service users are looking for in terms of employment, training and education. It was conducted for a very practical purpose, to inform the development of vocational services in South Essex.

An earlier exercise in 2002 had suggested that vocational services were provided primarily by the voluntary rather than statutory sector, with doubts among staff from both sectors as to whether there was enough interest among service users to justify further development.

This subsequent survey undertaken by service user researchers comprised face-to-face interviews with 82 people on the enhanced care programme approach and a postal questionnaire returned by a further 159 individuals.

Findings

Through comparison with data for the NHS trust as a whole, the 241 individuals responding to the survey were found to be typical in terms of gender (just over half female) and geographical spread. Ages ranged from 19 to 65-plus.

Asked to select from a list of daytime activities, more than two-fifths of respondents (42%) said they had no regular daytime activity of any type. Only 15% were in any form of paid work – full or part time, self-employed or supported. A further 15% undertook voluntary work and 12% were involved in formal education or training. The proportion of women in paid work was higher at 18% than the 12% for men, and was also higher for voluntary work.

The study was interested in exploring people’s preferences and aspirations in respect of work those not in employment were therefore asked about their interest in paid work. Nearly two-thirds (61%) declared an immediate interest in work, with a further 10% expressing an interest for the future. Less than a quarter of those interviewed face-to-face who were interested in paid work were receiving any help with getting into work. Asked the sort of help they wanted, people favoured ongoing support once they were in work, help to deal with mental health problems, advice on benefits, and education and training. Those interviewed were also asked what they considered to be the barriers to employment. Employers’ attitudes and threats to benefits were most commonly mentioned. People also highlighted a range of other factors, including lack of skills and qualifications, health issues, lack of work experience, having too little support and stigma.

Compared with other surveys exploring the extent to which mental health service users want to work and the barriers they perceive, the results of this study are similar, despite other studies being based in larger cities.

The proportion in employment in the study area was lower at 15% than the national figure of 21% cited by the Disability Rights Commission. The authors suggest that the findings indicated a clear need for further development of vocational services in the area.

A postscript details the progress that had been made following the survey to respond to this need. The NHS trust board approved what is termed an evidence-based strategy and established an employment strategy implementation group and a post of vocational services manager at assistant director level. A vocational services unit was being created, with vocational specialist posts to be located in each of the five community mental health teams. Liaising with local employers and accessing impartial benefits advice were considered key tasks, and particular attention was being paid to monitoring outcomes and identifying areas of unmet need.

Analysis

This modest piece of research is of interest for two reasons. First is its focus on the key issue of employment for people with mental health issues and the confirmation, often still doubted, that most mental health service users wish to work. Second is the involvement of service users as researchers.

The authors suggest that the barriers respondents perceived in accessing work and the vocational support they would value are consistent with what has been identified as the individual placement and support (IPS) approach to employment for mental health service users. Traditionally it was assumed that a gradual introduction to work through an often extended period of vocational training was the best route for mental health service users. Perhaps counter-intuitively, there is now strong evidence (see Resources) to show that it is more effective to move directly to supported employment under an IPS model. The model has several key features: a rapid job search in competitive employment to find a post that matches the user’s preferences and choices, the provision of time-unlimited and individualised support for the individual and the employer, and close collaboration between the employment programme and the treatment services. Individuals experiencing supported employment through IPS are more likely to remain in competitive employment over time, to work longer hours and earn more.

The success of this study in involving service users as researchers is the second reason for highlighting this study. In the past few years there has been an emphasis on the principles for such a strategy, but less on the details of how it can be done and on the implications of such involvement. Are there different models of involving users at different stages of the research process and in different ways. Is the potential for involvement likely to differ across different users and different user groups? To what extent should individuals be trained for the role? And is the question of whether the findings from research conducted by service users is different – and if so, in what ways – from that carried out by the traditional researcher. An early study in the mental health field (see Resources) suggested that service users interviewed by other users could be more forthcoming in respect of more negative aspects of services. Shared understanding and ensuring a focus on the issues of relevance are most often put forward as the benefits to be gained from users being involved in the research process.

The 11 user researchers in South Essex were recruited from among individuals completing a local “pathways to empowerment” course and from two voluntary sector employment projects. The study used a schedule which had already been developed for a previous study but with modifications in response to suggestions from the group. The key involvement of the group was in interviewing, survey administration and data entry. At the end of the study the user researchers provided anonymous comments on their experience of being involved. The benefits cited included increased confidence, financial reward, and experience they could cite on a CV. A longer-term outcome has been the expansion of the original survey group into the South Essex User Research Group, funded by the NHS trust.

PRACTICE IMPLICATIONS

Social Inclusion
Promoting social inclusion for those with mental ill-health has been a key theme of recent government reports, including Mental Health and Social Exclusion (2004) and Reaching Out: An Action Plan on Social Exclusion (2006), the report from the Social Exclusion Task Force. The latter gives a clear steer on the IPS approach and promotes the development of regional teams to support the development of good employment practices. The Care Services Improvement Partnership last year issued commissioning guidance for people with severe and enduring mental health problems. The challenge is to translate these policies into practice.

Changing Assumptions
Employment is not yet routinely considered for mental health service users, although most wish to work. It is often assumed that individuals are not ready for employment or that pre-vocational training should precede a move into work. Yet there is a wealth of evidence showing the beneficial impact of work on mental health and that the IPS model of supported employment is most effective. This strong evidence base needs to be promoted throughout the practice communities.

Multi-Disciplinary Working
Mental health service users often come into contact with a range of professionals in social care, health, benefits agencies and the voluntary sector. Davis and Rinaldi, for example (see Links, main story), detail a key partnership with occupational therapists. In the development of employment opportunities, good communication and collaboration across these professionals is essential. The development of a vocational services unit as in the study site is to be commended.

Evidence for Practice
This study provides a rare example of service development proceeding on the basis of an exploration of the evidence base. A survey was commissioned in order to find out what were the aspirations of service users in respect of work. Vocational services were then developed to meet these aspirations. Pooling and dissemination of available evidence should assist with the promotion of evidence-informed practice.

User Involvement
Service users, as in this study, can both play a key role in carrying out research and can benefit from the involvement. The process of involvement needs to be planned carefully and with clarity.

RESOURCES (back to analysis)

The research outlined above was published in the Journal of Mental Health, 2006, 15(1), 103-111. Further exploration of the IPS approach to employment can be found in the following sources:

● Bond G (2004), “Supported employment: evidence for an evidence-based practice”, Psychiatric Rehabilitation Journal, 27(4), 345-359

● Secker J, Grove B and Seebohm P (2001), “Challenging barriers to employment, training and education for mental health service users: the service user’s perspective”, Journal of Mental Health, 10(4), 395-404

● Crowther R, Marshall M, Bond G and Huxley P (2001), “Vocational rehabilitation for people with severe mental illness”, Cochrane Review, updated 2006

● Davis M and Rinaldi M (2004), “Using an evidence-based approach to enable people with mental health problems to gain and retain employment, education and voluntary work”, British Journal of Occupational Therapy, 67(7), 319-322

● Grove B, Secker J and Seebohm P (eds) (2005), New Thinking about Mental Health and Employment, Oxford: Radcliffe Press

● An evidence cluster focusing on “employment for people with long-term mental health problems” can be found on the website for research in practice for adults at www.ripfa.org.uk

Further discussion on user research can be found in the following articles. The second includes 10 key questions to consider in planning joint research.

● Clark C, Scott E, Boydell K, Goering P (1999), “Effects of client interviewers on client-reported satisfaction with mental health services”, Psychiatric Services, 50(7), 961-963

● Trivedi P and Wykes T (2002), “From passive subjects to equal partners: qualitative review of user involvement in research”, British Journal of Psychiatry, 181, 468-472

Alison Petch is director of Research in Practice for Adults. Ripfa promotes the use of evidence-informed practice in the delivery of adult social care services.

This article appeared in the 7 June issue under the headline “Service user vocations “