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Keywords:

  • IPS;
  • psychosis;
  • vocation

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Aim

People with psychotic symptoms have poor social and occupational functioning. The aim of this research was to improve the engagement in meaningful education, training or employment for young people with psychosis. This was undertaken by introducing a vocational specialist into the early intervention service to implement the individual placement and support (IPS) model.

Methods

Two early intervention services provided information about the vocational status of their service users 6 and 1 months prior to the introduction of the vocational specialist into one of the services. Data were collected again 12 months following the intervention and then 6 months following the end of the intervention.

Results

Unemployment was high in both services during the baseline period (approximately 75% in both), but in the service receiving the intervention this reduced to 62% whereas it remained high in the service that did not introduce the vocational specialist. Following the withdrawal of the vocational specialist the improvement was lost.

Conclusions

To enable people in first-episode services to live meaningful and valued lives occupational functioning needs to be considered a key performance indicator. Services can improve outcome by implementing and maintaining the IPS model.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Early Intervention in Psychosis (EIP) services work to improve the outcome of people with psychosis. The services are effective in reducing symptoms,[1] the number and length of admission into hospital,[2] and are consequently cost-effective primarily through reducing inpatient stays.[3] While the success of the initiative should be applauded, the question remains as to whether the services have done all they can to promote long-term resilience that will allow people to achieve meaningful recovery once services are no longer involved.[4]

In considering the effectiveness of EIP services, it is noticeable and understandable that there has been an emphasis on symptoms and relapses as the key outcome variables. However, social, interpersonal and vocational outcomes are also important to consider. Many people with psychosis do not have meaningful and rewarding educational or vocational activities.[5, 6] This may help us understand the high risk of relapse of psychosis as meaningful activity such as work, education or training is important in helping to provide structure to each day, positive social interaction with others, as well as a sense of being valued and fulfilled.[7]

Of course, when we consider the age of onset of people who develop psychosis, it is evident that psychosis can prevent people from completing education or disrupt a person's early work opportunities. Consequently, young people with psychosis may find it hard to be considered employable owing to poor educational achievement and/or limited employment history.

Interventions to improve vocational outcomes for people with severe mental health problems such as schizophrenia have commonly used the individual placement and support (IPS) model. IPS has been shown to be effective in helping people with serious mental health problems to gain and maintain open employment.[8] IPS involves integrating employment specialists into community mental health teams and ensuring vocational issues are a key component of the care planning process. The approach helps people to gain jobs in open employment, in line with their preferences usually without additional pre-vocational training. Importantly, help and support is provided to anyone who wishes to work. The IPS worker can provide advice on welfare benefits, help with job searches, preparation for interview and other support to help people enter the job market, and is able to provide ongoing support to enable people to maintain employment. Within some services, support may be provided to enable people to access, and remain in education.

The focus in the IPS model has tended to be on enabling people to gain jobs once they have lost them; however, in the case of EIP it is important to work to help the person become employable. Poor educational achievement may well limit access to the work place. Hence, an important outcome for vocational intervention in an EIP service is to improve a person's employability, which for many may help them engage in appropriate education or training courses to enable them to seek appropriate work when suitably qualified. A recent study[9] reported that 69% of young people who received IPS returned to work or study compared to 35% where no such help was available.

Given the value of these interventions, we undertook a review of the vocational functioning of the service users in an early intervention service to determine if there was need for specific vocational support. The audit indicated only 19/76 (25%) were in education, employment or training (EET). Three quarters of our service users were unemployed (not in education, employment or training (NEET)). This was substantially lower than the best performing EIP services in the UK where 60% of service users had EET status, and the EIP average for eight services in the UK was around 45% in EET.[10] Hence, there was a clearly identified need to improve the employability and employment of our service users.

This paper reports an evaluation of the impact of introducing IPS in an EIP service in the North East of England.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Design

This was a naturalistic comparison of EIP services. There were effectively two second services that shared the same entry criteria, staffing composition, and working practices, and shared some resources, that is, psychology and psychiatry that worked across both teams. Both services were developed in line with the national guidelines on EIP services. The services cover urban localities that are similar in levels of socioeconomic deprivation. The gender ratio, age, ethnic diversity, average number of admissions into hospital, average length of stay, and proportion of service users discharged back to primary care at the end of 3 years were no different between the services. An audit of EET status was undertaken in the two EIP services 6 months before the introduction of an IPS worker into one of the services. The audit was repeated 1 month before the introduction and then again after approximately 12 months following the introduction of the worker. The audit was undertaken again 6 months after the end of the vocational worker's input into one of the services. Hence, the naturalistic aspect of the design is strengthened by the recording of EET status at two time points prior to the introduction of the IPS model, and the absence of its introduction in a second EIP service in a neighbouring borough. In addition, the follow-up data allow consideration of the durability of the intervention.

Participants

Both EIP services work with people aged 14–35 who met the entry criteria, which is the presence of distressing and/or disabling psychotic symptoms for a period of 7 or more days. At the baseline phase, the mean age of the service users for the service that received the IPS intervention (service 1) was 24.2 (SD = 5.1) and the group was mainly male (75%). The service (service 2) was similar in its composition (mean age = 25.3, SD = 5.3, with 72% being male). Service 2 did not receive vocational worker input. In service 1, an audit revealed a generally low level of educational achievement. A considerable number (37/76) of service users had qualifications below the national expectation (General Certificate of Secondary Education (GCSE) that is usually taken at 16 years of age; grades G–D), 25/76 had basic qualifications (GCSE grades A–C), 4/76 had advanced levels (taken at 18 years of age), and a few had vocational qualifications, and only one person was educated to degree level. Overall, then, the educational status of the participants presents a challenge to their employment prospects. The educational status of those people in the service 2 was very similar.

Service setting

Both of the services aim to help the person experience less distressing symptoms, stay well, and achieve personally defined meaningful recovery. In both services, care coordinators work with a small case load (up to 15 service users) for a period of up to 3 years, and routinely involve families and carers. Service users are offered medication, psychological therapies, family interventions and social support. The local population has particularly high levels of deprivation. Across both services, unemployment rates especially among young people are higher (21%) than the national average.[11]

Procedure

A researcher (MN) met with Care coordinators individually at the three time points (6 months pre-intervention, 1 month pre-intervention and 12 months post-intervention) in order to complete an audit tool that enquired about the work and educational status of their current clients. The Care coordinator had been made aware in advance of the purpose of the meeting and was encouraged to ask of their service users about vocational and educational status in case this was not known. At the final follow-up time point (time point 4, 6 months following the intervention was ended) the audit was repeated by another of the research team (RD).

Intervention

Money was made available to employ a vocational specialist for a fixed term of 12 months. The person was recruited on a secondment from a local job centre plus and hence was very familiar with aspects of the benefits system, job finding, etc. The vocational specialist worked with one of the EIP teams 4 days a week for a period of 1 year. Service users gave informed consent to work with the vocational specialist. The role was designed around the IPS worker model and a measure of IPS fidelity[12] (see Table 1) indicated good compliance with the IPS framework. Even though there was only one worker in service 1, she was linked to a broader group of vocational specialists working in other mental health settings and hence was able to participate in weekly supervision and work as part of a broader vocational unit.

Table 1. Fidelity to the IPS model
SubscaleItem labelDescriptorGood or not?
  1. IPS, individual placement and support.

StaffingCaseload sizeEmployments specialist has a caseload not >25
Exclusively vocationalOnly provide vocational duties, not added to other staff duties
Generalist vocational roleSpecialist delivers all phases of vocational services
OrganizationIntegration with teamAccepted as part of team, and routinely share decision-making
Vocational unitWork as part of vocational unit with group supervision and backup arrangements
Zero exclusionNo additional screening such as job readiness assessments
ServicesOngoing. work-based vocational assessmentVocational assessment is an ongoing process based on work experiences in competitive jobs
Rapid job searchWithin 4 weeks
Individualized job searchEmployer contacts are based on clients’ job preferences rather than job market
Diversity of jobs developedEmployment specialists provide job options that are diverse and are in different settings.
Permanence of jobs developedEmployment specialists provide competitive job options that have permanent status
Jobs as transitionsAll jobs are viewed as positive experiences on the path of vocational growth and development
Follow-along supportsIndividualized follow-along supports are provided to employer and client on a time-unlimited basis.
Community-based servicesVocational services such as engagement, job finding and follow-along supports are provided in natural community settings
Assertive engagement and outreachAssertive engagement and outreach (telephone, mail, community visit) are conducted as needed

Data analytic strategy

The proportion of people who were in NEET status at time 1 (6 months pre-intervention), time 2 (1 month before intervention), time 3 (12 months following intervention) and time 4 (6 months following the withdrawal of the vocational worker) was compared between services. Comparison of time 1 and time 2 allowed consideration as to whether there was a stable baseline prior to the introduction of the intervention. Such stability helps draw inferences about the value of the intervention.[13] We recorded the outcome of individuals who worked with the IPS worker; however, new people had entered the services and many left over the duration of the intervention accounting for the different sample sizes at each time point. Therefore, the main aim of this work was to consider the impact at a service level of introducing an IPS worker and to establish this, the proportions of people in EET or NEET status between the services were examined.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The vocational worker worked with 47 service users during the year. The work varied from advice on benefits to support into paid employment. Ten people were supported into employment. Others were aided into voluntary work or education. As can be seen in Table 2, there was little difference in the NEET rate in service 1 between time 1 and time 2 with NEET status remaining high at about 75%. This figure is similar to that reported in a similar EIP service (service 2). However, following the introduction of the IPS worker the NEET status is reduced to 62% whereas it remains the same in service 2. Six months following the end of the IPS workers involvement the unemployment rate increases to a figure of 73%.

Table 2. Employment and education status for the two EIP services
ServiceBaselineOne month before IPS implementedTwelve months following IPSSix months post end of IPS
Service 1N = 76N = 81N = 104N = 101
  1. a

    Regional NEET status for people aged 16–24 years of age is 20.9% (Labour Force survey, Office for National Statistics).

  2. EIP, Early Intervention in Psychosis; IPS, individual placement and support.

Unemployed57 (75%)a61 (75%)65 (62%)73 (73%)
Part-time employment3 (4%)2 (3%)5 (5%)7 (7%)
Full-time employment6 (8%)7 (9%)13 (13%)7 (7%)
Part-time education2 (3%)3 (4%)0 (0%)7 (7%)
Full-time education7 (9%)6 (7%)18 (17%)4 (4%)
Voluntary work1 (1%)2 (3%)3 (3%)1 (1%)
Service 2N = 79 N = 80 N = 90 N = 101
Unemployed60 (76%)58 (73%)70 (78%)72 (72%)
Part-time employment2 (3%)2 (2.5%)1 (1%)5 (5%)
Full-time employment3 (4%)4 (5%)11 (12%)9 (9%)
Part-time education2 (3%)3 (3%)0 (0%)3 (3%)
Full-time education12 (15%)11 (14%)8 (9%)10 (10%)
Voluntary work0 (0%)2 (2.5%)0 (0%)2 (2%)

Over the period in which the IPS worker was in the service it was evident that there was an increase in the proportion of service users who were engaged in work, education or training. Much of the improvement was a result of helping people back into full-time education. χ2 analyses were undertaken to examine the proportion of service users in EET at each time point in the two services. Two scores were created for each time point, those in EET and those who were not. No differences were revealed at time 1 (χ2 (1) = 0.29, P = 0.36) or time 2 (χ2 (1) = 0.02, P = 0.52) between the two services. However, at time 3 the proportions of EET in service 1 (39/104) were significantly different (χ2 (1) = 5.32, P = 0.02) to that in service 2 (20/90). So there was a difference in unemployment rates at this time. At the end of 12 months involvement from a vocational specialist in comparison to a service that had no such involvement the odds ratio was 2.10, indicating those in a service with IPS involvement were twice as likely to be involved in meaningful activities. However, 6 months following the end of the IPS worker involvement there was no difference between the services in the EET proportions (χ2 (1) = 0.15, P = 0.69) indicating the benefits did not endure.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Following the introduction of IPS the rate of unemployment decreased. More service users were employed or in full-time education than in a service that had not had the vocational specialist input.

We consider that vocational outcomes should be a key metric for early intervention services. Having a meaningful activity that provides social opportunities, structure to the day and financial rewards is important in helping people remain well and prevent relapse. However, many young people with psychosis lack the necessary skills and qualifications to allow them to compete for work. Moreover, combined with the gap in their employment or educational progress perhaps caused by a hospital admission it may lead to problems in accessing and securing employment. Hence, additional help and support is needed to help people optimize their educational, training and employment opportunities. While employment services do exist for people with mental health problems and staff at the local job centres are aware of the impact of mental health problems on work it is evident that even where these services exist there was a high rate of NEET status in the EIP service. However, where an employment or vocational specialist works with a team to establish vocational outcomes as important in a service, and works with individuals, and their carers and employers to help support work and education we have evidence that the intervention can be helpful in supporting people into work and education.

The work reported here has obvious limitations in being a naturalistic comparison. The findings rest on the assumption that the only difference between the services was the presence of the vocational worker. The comparison of the second service (service 2) and the stability in NEET status over a 6-month baseline period provides some reason to be confident in the findings. Unfortunately, the lack of a long-term benefit indicates a lack of durability of the intervention. In addition, the success of getting people into employment of those who were offered direct help by the vocational worker (10/47) was lower than that reported by studies,[9] so while beneficial for the service as a whole, for the specific individuals receiving the support the gains were modest. Much of the differences in NEET status were owing to changes in educational status, which is appropriate for the EIP service users but may make it harder to demonstrate the economic benefits of vocational support.

In conclusion, early intervention services seem ideally placed to help people improve their vocational outcomes. The sustained help offered to people provides the opportunity to not only help with symptoms but also to help people engage in socially valued roles and activities such as work or education. Moreover, it seems obvious that it is easier to get someone into work for the first time at 20 rather than 35 years of age and particularly so if we expect the benefits to endure.[8]

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

We would like to thank the staff of the South of Tyne EIP services who were generous with their time. We would also like to thank Thomas Christodoulides, Eileen Colqhoun, Brian Martindale and John Moiser who were all supportive of the project. We received financial support from Sunderland Local Authority and from the NIHR.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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