Section of Occupational Medicine
condition. We will also hope to cooperate with the Employment Rehabilitation Research Centre in some aspects of its work.
653
between patients with high and low work performance. Other workers have had similar results using tests of intelligence and personality profiles. The results of these and other studies show that vocational or occupational adjustment is not necessarily highly correlated with interpersonal or social adjustment. At present all that can be said of psychological tests is that they do not provide a reliable tool and will require considerable further Dr W B Spry development before they are useful. (Employment Medical Advisory Service, Dresden House, The Strand, Longton, Group or panel methods of selection have not Stoke-on-Trent, Staffordshire) been very much better. In one case (Stotsky 1957), after extensive evaluation by a medical reProblems in the Rehabilitation habilitation board, it was found that from those of Psychiatric Patients specially selected as suitable for employment, 33 % were failures. Plag & Arthur (1965.), in a study of Treatment of mental illness has undergone dra- 134 naval recruits at San Diego Naval Training matic changes in the last few years, with the Centre, all of whom had been classified as unfit by development of community-based systems of care. both psychiatrists and recruiting officers, found These changes are associated with the conviction that they performed remarkably well. They had that the degree of recovery will be enhanced by been allowed to serve, and 72 % completed their maintaining the patients' ties to the everyday engagement and performed as well as a group of realities of life. matched controls. There has been increasing recognition of the There is therefore no easy, reliable method of importance of work and vocational adjustment. determining work readiness. The single useful Vocational rehabilitation is an important aspect of indicator we have is that of work simulation. the total care and warrants more attention than it Whilst industrial therapy departments in hospitals receives. Studies going back as far as Steckel (1922) can fulfil some aspects of work simulation, a more have recognized that employment of the psychi- comprehensive and realistic assessment can be atric patient is associated with a lower relapse rate made at the employment rehabilitation centres. and improved quality of recovery. These centres, in this respect, offer an assessment I would like to discuss three areas where prob- of work readiness that cannot otherwise be oblems may arise in rehabilitation. tained except by sending the person into open employment with possible disastrous results. In (1) How may one determine when the psychiatric this connexion I would mention the possible use of patient is ready for employment? The psychiatrist, part-time attendance at the employment rein making his assessment, must adopt fresh para- habilitation centre over a short period in suitable meters. Rather than considering diagnostic fea- cases. tures, factors such as stability of the mental state, motivation towards employment and behavioural (2) The problem of liaison between those concerned abnormalities need to be considered. However, with health care and those offering employment: In even careful assessment is fraught with difficulty. this area the disablement resettlement officer We can all recall instances of those who failed to (DRO) service has developed and is still developadapt to work despite many factors in their favour ing. I believe that nearly all psychiatric units now and others who succeeded against all expectations. have regular visits from a DRO, but it is of interest In America considerable time and energy have to note that in those hospitals which have had a been devoted to psychological tests to measure full-time service from a DRO, not only have the vocational readiness (Gillman 1953, Stotsky & referrals to him been proportionately higher, but Weinberg 1956). Peterson (1960) has compared the the percentage placed in employment has remained Lorr Multidimensional Scale for rating psychiatric consistent and has not fallen. There is therefore a patients and the L-M Fergus Falls behaviour rating case for the psychiatric services to make fuller use sheet, and concluded that the clinical status of the of the DRO service than at present; unfortunately, patient is not necessarily an indicator of vocational in the present economic situation this is unlikely to employment potential. Stotsky (1956) analysed the occur. Kuder Preference Record, California Occupational Interest Inventory, Brainard Occupational Pref- (3) The employers' attitude to those who have been erence Inventory, Bennett Mechanical Compre- mentally ill: One cannot and should not expect hension Test and O'Rourke Mechanical Aptitude employers to offer work to people who are not Test and found that they did not differentiate capable of performing their work adequately, but
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Proc. roy. Soc. Med. Volume 70 September 1977
many who might perform satisfactorily are rejected out of hand because of employers' ignorance about mental illness. This has led to considerable unwillingness on the part of applicants to disclose their psychiatric history. An American employment service (Daniels 1966) has found that after the initial period of adjustment, which may be somewhat troublesome for all concerned, many of the formerly mentally ill do become better than average employees, with greater loyalty and greater motivation. This agency stresses the need for industry to develop a social conscience and to be aware of the potential benefits, not only to the individuals taken on, but to the company as well. They consider that the 'poor risk' employee should be given the benefit of evaluation in a real work situation. In assisting management in the potential employment of these people, occupational health services in industry have an important function. The advice of the company medical officer will normally be accepted in those firms large enough to employ one. In smaller companies more informal methods may apply that can be equally effective if properly developed. The American Medical Association's Joint Committee on Mental Health in Industry (1962) has published a guide for occupational physicians concerned with the employment or re-employment of the recovered mental patient. They have identified twelve factors requiring assessment and each of these may be graded as favourable, unfavourable or borderline. Scoring is not recommended; each case is weighed separately according to the nature of the work. The twelve factors, which are discussed in some detail, are: pre-illness personality, somatic disorder, off-the-job stress, on-thejob stress, diagnosis, treatment and rehabilitation, course and duration, after-effects, attitudes and insight, placement and transfer, interpersonal relations and follow up. In summary, the technique of work simulation, coupled with a higher level of expectation on the part of the medical profession and management, will help to maximize the potential of patients' recovery from mental illness. REFERENCES Daniels D N (1966) Community Mental Health Journal 2, 197-201 Gillman W (1953) Personnel and Guidance Journal 31, 536-539 Joint Committe on Mental Health in Industry (1962) Journal of the American Medical Association 181, 10861089 (1962) 181, 1086-1089 Peterson F A (1960) Thesis, Southern Illinois University Plag J A & Arthur R J (1965) American Journal of Psychiatry 122, 534-541 Steckel H A (1922) Mental Hygiene 6, 798-814
Stotsky B A (1956) Journal of Clinical Psychology 12, 236-242 (1957) In: Member-Employee Program - a new approach to the rehabilitation of the chronic mental patient. Ed. A A Peffer. Brockton, Massachusetts; pp 38-47 Stotsky B A & Weinberg H (1956) Journal of Counselling Psychology 3, 3-7
Mr M W J Green (Employment Rehabilitation Centre, Queen Elizabeth Medical Centre, Edgbaston, Birmingham)
The Birmingham Employment Rehabilitation Centre
The need for closer cooperation between the rehabilitation services of DHSS-financed establishments and those of Employment Service Agency (ESA; formerly Department of Employment) centres has been recognized and amplified by numerous government-sponsored reports. Such cooperation is particularly desirable in areas where hospital patients may be discharged and, after a considerable delay, find themselves beginning employment rehabilitation courses. Much of the lack of continuity has been highlighted by pioneers in the field of rehabilitation - by none more than by Mr M Porter, consultant surgeon at the Birmingham Accident Hospital. Following discussions eight or ten years ago, a policy was agreed between the DHSS and the Department of Employment. This stated that the old and by then unsuitable premises of the employment rehabilitation centre, to the n6rthwest of the city of Birmingham, should be rebuilt alongside the proposed new accident hospital at the Queen Elizabeth Medical Centre. The employment rehabilitation centre (ERC) has now been built, but limitation of resources has prevented the accident hospital from being relocated at the Queen Elizabeth Medical Centre. Despite this serious drawback to the scheme of total rehabilitation, some progress has been made towards the goal of closer identification and cooperation between medical and employment services for the handicapped. Sixty part-time places for hospital inpatients and outpatients have been made available at the new ERC; these are in addition to the 120 full-time places normally occupied by those who have completed medical treatment. The 60 patients, still receiving DHSS sickness benefit, will be able to begin their rehabilitation activities at the ERC and use its services (workshops, staff, &c.) for up to 20 working hours per week. Thus hospital patients
condition. We will also hope to cooperate with the Employment Rehabilitation Research Centre in some aspects of its work.
653
between patients with high and low work performance. Other workers have had similar results using tests of intelligence and personality profiles. The results of these and other studies show that vocational or occupational adjustment is not necessarily highly correlated with interpersonal or social adjustment. At present all that can be said of psychological tests is that they do not provide a reliable tool and will require considerable further Dr W B Spry development before they are useful. (Employment Medical Advisory Service, Dresden House, The Strand, Longton, Group or panel methods of selection have not Stoke-on-Trent, Staffordshire) been very much better. In one case (Stotsky 1957), after extensive evaluation by a medical reProblems in the Rehabilitation habilitation board, it was found that from those of Psychiatric Patients specially selected as suitable for employment, 33 % were failures. Plag & Arthur (1965.), in a study of Treatment of mental illness has undergone dra- 134 naval recruits at San Diego Naval Training matic changes in the last few years, with the Centre, all of whom had been classified as unfit by development of community-based systems of care. both psychiatrists and recruiting officers, found These changes are associated with the conviction that they performed remarkably well. They had that the degree of recovery will be enhanced by been allowed to serve, and 72 % completed their maintaining the patients' ties to the everyday engagement and performed as well as a group of realities of life. matched controls. There has been increasing recognition of the There is therefore no easy, reliable method of importance of work and vocational adjustment. determining work readiness. The single useful Vocational rehabilitation is an important aspect of indicator we have is that of work simulation. the total care and warrants more attention than it Whilst industrial therapy departments in hospitals receives. Studies going back as far as Steckel (1922) can fulfil some aspects of work simulation, a more have recognized that employment of the psychi- comprehensive and realistic assessment can be atric patient is associated with a lower relapse rate made at the employment rehabilitation centres. and improved quality of recovery. These centres, in this respect, offer an assessment I would like to discuss three areas where prob- of work readiness that cannot otherwise be oblems may arise in rehabilitation. tained except by sending the person into open employment with possible disastrous results. In (1) How may one determine when the psychiatric this connexion I would mention the possible use of patient is ready for employment? The psychiatrist, part-time attendance at the employment rein making his assessment, must adopt fresh para- habilitation centre over a short period in suitable meters. Rather than considering diagnostic fea- cases. tures, factors such as stability of the mental state, motivation towards employment and behavioural (2) The problem of liaison between those concerned abnormalities need to be considered. However, with health care and those offering employment: In even careful assessment is fraught with difficulty. this area the disablement resettlement officer We can all recall instances of those who failed to (DRO) service has developed and is still developadapt to work despite many factors in their favour ing. I believe that nearly all psychiatric units now and others who succeeded against all expectations. have regular visits from a DRO, but it is of interest In America considerable time and energy have to note that in those hospitals which have had a been devoted to psychological tests to measure full-time service from a DRO, not only have the vocational readiness (Gillman 1953, Stotsky & referrals to him been proportionately higher, but Weinberg 1956). Peterson (1960) has compared the the percentage placed in employment has remained Lorr Multidimensional Scale for rating psychiatric consistent and has not fallen. There is therefore a patients and the L-M Fergus Falls behaviour rating case for the psychiatric services to make fuller use sheet, and concluded that the clinical status of the of the DRO service than at present; unfortunately, patient is not necessarily an indicator of vocational in the present economic situation this is unlikely to employment potential. Stotsky (1956) analysed the occur. Kuder Preference Record, California Occupational Interest Inventory, Brainard Occupational Pref- (3) The employers' attitude to those who have been erence Inventory, Bennett Mechanical Compre- mentally ill: One cannot and should not expect hension Test and O'Rourke Mechanical Aptitude employers to offer work to people who are not Test and found that they did not differentiate capable of performing their work adequately, but
654
Proc. roy. Soc. Med. Volume 70 September 1977
many who might perform satisfactorily are rejected out of hand because of employers' ignorance about mental illness. This has led to considerable unwillingness on the part of applicants to disclose their psychiatric history. An American employment service (Daniels 1966) has found that after the initial period of adjustment, which may be somewhat troublesome for all concerned, many of the formerly mentally ill do become better than average employees, with greater loyalty and greater motivation. This agency stresses the need for industry to develop a social conscience and to be aware of the potential benefits, not only to the individuals taken on, but to the company as well. They consider that the 'poor risk' employee should be given the benefit of evaluation in a real work situation. In assisting management in the potential employment of these people, occupational health services in industry have an important function. The advice of the company medical officer will normally be accepted in those firms large enough to employ one. In smaller companies more informal methods may apply that can be equally effective if properly developed. The American Medical Association's Joint Committee on Mental Health in Industry (1962) has published a guide for occupational physicians concerned with the employment or re-employment of the recovered mental patient. They have identified twelve factors requiring assessment and each of these may be graded as favourable, unfavourable or borderline. Scoring is not recommended; each case is weighed separately according to the nature of the work. The twelve factors, which are discussed in some detail, are: pre-illness personality, somatic disorder, off-the-job stress, on-thejob stress, diagnosis, treatment and rehabilitation, course and duration, after-effects, attitudes and insight, placement and transfer, interpersonal relations and follow up. In summary, the technique of work simulation, coupled with a higher level of expectation on the part of the medical profession and management, will help to maximize the potential of patients' recovery from mental illness. REFERENCES Daniels D N (1966) Community Mental Health Journal 2, 197-201 Gillman W (1953) Personnel and Guidance Journal 31, 536-539 Joint Committe on Mental Health in Industry (1962) Journal of the American Medical Association 181, 10861089 (1962) 181, 1086-1089 Peterson F A (1960) Thesis, Southern Illinois University Plag J A & Arthur R J (1965) American Journal of Psychiatry 122, 534-541 Steckel H A (1922) Mental Hygiene 6, 798-814
Stotsky B A (1956) Journal of Clinical Psychology 12, 236-242 (1957) In: Member-Employee Program - a new approach to the rehabilitation of the chronic mental patient. Ed. A A Peffer. Brockton, Massachusetts; pp 38-47 Stotsky B A & Weinberg H (1956) Journal of Counselling Psychology 3, 3-7
Mr M W J Green (Employment Rehabilitation Centre, Queen Elizabeth Medical Centre, Edgbaston, Birmingham)
The Birmingham Employment Rehabilitation Centre
The need for closer cooperation between the rehabilitation services of DHSS-financed establishments and those of Employment Service Agency (ESA; formerly Department of Employment) centres has been recognized and amplified by numerous government-sponsored reports. Such cooperation is particularly desirable in areas where hospital patients may be discharged and, after a considerable delay, find themselves beginning employment rehabilitation courses. Much of the lack of continuity has been highlighted by pioneers in the field of rehabilitation - by none more than by Mr M Porter, consultant surgeon at the Birmingham Accident Hospital. Following discussions eight or ten years ago, a policy was agreed between the DHSS and the Department of Employment. This stated that the old and by then unsuitable premises of the employment rehabilitation centre, to the n6rthwest of the city of Birmingham, should be rebuilt alongside the proposed new accident hospital at the Queen Elizabeth Medical Centre. The employment rehabilitation centre (ERC) has now been built, but limitation of resources has prevented the accident hospital from being relocated at the Queen Elizabeth Medical Centre. Despite this serious drawback to the scheme of total rehabilitation, some progress has been made towards the goal of closer identification and cooperation between medical and employment services for the handicapped. Sixty part-time places for hospital inpatients and outpatients have been made available at the new ERC; these are in addition to the 120 full-time places normally occupied by those who have completed medical treatment. The 60 patients, still receiving DHSS sickness benefit, will be able to begin their rehabilitation activities at the ERC and use its services (workshops, staff, &c.) for up to 20 working hours per week. Thus hospital patients
