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Barriers to employment in severe mental illness

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People with mental health difficulties are some of the most disadvantaged in the labour market (Learning and Skills…


VOL: 103, ISSUE: 22, PAGE NO: 32

Donna Gannon, BSc, RMN, is community mental health nurse

Nathan Gregory, BSc, MSc, RMN, is team manager, Gloucestershire recovery in psychosis team, both at Gloucestershire Partnership NHS Trust

People with mental health difficulties are some of the most disadvantaged in the labour market (Learning and Skills Council, 2006). Clients who experience severe mental illness express a clear need for access to employment and education, and research suggests that work improves self-esteem and well-being.



Studies report a strong link between suicide and unemployment, yet high unemployment rates continue among people with long-term mental health problems. For example, the Labour Force Survey revealed that 24% of all people with mental health problems are employed, whereas only 8% of those who have experienced severe mental illness are in work (Department for Education and Skills, 2003). People with a diagnosis of schizophrenia experience the most serious levels of employment discrimination.



Critical review


To examine the evidence base, an electronic database search of Cinahl, Medline, PsycINFO, BNI and the gateway access OVID was conducted. Keywords were ‘vocation’, ‘employment’, ‘inclusion’ and ‘exclusion’, with the addition of ‘mental illness’ to define the subject area. Additional information was gathered from websites including those of the Department of Health, Sainsbury Centre for Mental Health and NICE. The reference sections of the papers collected were searched for other sources.



The year range searched was from 2001-2006. Six studies were then selected for critical review.



Service users’ perspective


The limited amount of research on what service users perceive to be barriers to employment is highlighted by Marwaha and Johnson (2005). In their study the authors aimed to encapsulate the issues that affect employment, including views on service provision. However, the sample of 15 participants arguably limited its power.



In comparison, the factors associated with job retention were investigated by Secker and Membrey (2003) from the perspective of employment project clients. This qualitative study focused on participants with severe mental illness and was concerned specifically with experiences of maintaining open employment or aspects that caused employment to discontinue. However, there are reservations about the reliability and validity of this study as the authors did not refer to socio-demographic details, and this raises the question of whether the sample fairly represents the target population.



An earlier qualitative investigation by Secker et al (2001) similarly focused on participants’ views of employment, training and education. Although the study is limited due to a focus on one inner-city area, it does provide a clear geographic setting for the interpretation of data. Compared with similar studies, the authors dealt with a much larger sample with 156 people seen individually and a further 120 involved in focus groups. In addition, interviews were carried out by other service users, who were paid by the hour.



Despite their shortcomings, these three studies present marked similarities between individual participant accounts in areas such as stigma, loss of confidence and lack of priority given to employment by mental health workers.



Community mental health staff


How effective are community mental health nurses and community mental health teams (CMHTs) at facilitating employment for people with severe mental illness?



Seebohm and Secker (2003) explored the factors that promote team commitment to vocational work and aspects that create barriers. The authors used a qualitative approach to explore participant experience, with the target population consisting of care coordinators, vocational specialists and other staff involved in the provision of employment resources.



While the paper includes comprehensive descriptors of socio-demographic aspects and the variations in vocational approaches, the multifaceted nature of this study mean caution should be exercised regarding the conclusions drawn. Furthermore, the inclusion of assertive outreach teams, although improving external validity, changes the focus from CMHTs, so care is required in the interpretation of data.



O’Brien et al (2003) examined CMHTs’ approaches to vocational services in their randomised controlled trial. The authors aimed to test whether changes in their approach to vocational rehabilitation alone would improve employment outcomes without the introduction of staff specifically trained to offer support in this area. There are concerns regarding power analysis in this study and the 12-month period of the investigation may limit the findings’ validity. It takes into account outcomes from employment models in the US, yet acknowledges the financial burden that would result from this model being adopted in the UK.



In contrast, Bertram and Stickley (2005) produced a study that does not directly address employment issues but offers valuable insight into mental health staff attitudes towards social inclusion and consequent barriers. However, as the researchers were employed within the setting in which the research took place, concerns could be raised regarding observer bias.



Although there were marked variations in approach between the studies, each offered the potential to examine the efficacy of mental health staff and teams in relation to issues of employment. For example, O’Brien et al (2003) stated that their results indicate staff training alone cannot improve employment status for individuals with severe mental illness, while Seebohm and Secker (2003) identified interprofessional relationships and vocational specialists as key to improving employment opportunities.



Seebohm and Secker (2003) found that mental health workers who have a medical model perspective are more likely to have negative attitudes to employment strategies. A particular strength of Seebohm and Secker’s (2003) investigation is that it provides an insight into the number of professionals and agencies involved in vocational services.



O’Brien et al (2003) recommended that vocational services offer time-unlimited support with specialist input. This is supported by Bertram and Stickley (2005), who believe that an increase in socially inclusive policies may shift focus from principles that seek to protect the public. Seebohm and Secker (2003) recommended changes in the attitudes of mental health and the provision of resources to improve vocational opportunities for clients.





Although this review has increased awareness of the two research questions identified, it highlights the complexities that need to be considered when implementing vocational policies in the UK.



Current vocational services vary in style with no overall responsibility for provision. In addition, styles of interprofessional and multi-agency liaison vary from one area to another. When these factors are considered in conjunction with workplace stress, the effect of employment on benefits and employers who are fearful of mental illness, the barriers can appear immense.



This review adds to previous conclusions that indicate the importance of work. It is encouraging that research into vocational approaches seems to be gaining momentum.





There can be no doubt that a focus on employment issues will present challenges to individual practitioners who not only need to maintain a responsibility to include employment in care planning but also wish to improve social inclusion by promoting hope among their clients. Furthermore, attention to interprofessional and multi-agency collaboration is vital to realise service users’ potential.



The continuing interest in vocational issues coupled with reliable research may well assist practitioners in offering evidence-based approaches to tackle stigma and discrimination, promoting the social inclusion of people with mental health difficulties.



Implications for practice


- Studies from the service users’ perspective highlighted barriers to employment as stigma, loss of confidence and lack of priority given to employment by mental health workers.



- Studies on community mental health nurses and teams also highlighted some potential barriers: the limitations of staff training on its own as a means to improve opportunities for clients; and negative attitudes linked to workers who have a medical model perspective.



- Ways of improving employment opportunities through nurses and teams were identified as: interprofessional relationships and vocational specialists; vocational services offering time-unlimited support with specialist input; an increase in socially inclusive policies; and changes in mental health staff attitudes and provision of resources.



- Two factors are key to removing barriers: a change in attitudes and practice, and further research.



This article has been double-blind peer-reviewed

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