Australian Occupational Therapy Journal (2015) 62, 141–144
doi: 10.1111/1440-1630.12162
Viewpoint
The availability of evidence-based practices in supported employment for Australians with severe and persistent mental illness Geoffrey Waghorn1,2,3 and Emily Hielscher1 1 Queensland Centre for Mental Health Research (QCMHR), The Park Centre for Mental Health, 2Behavioural Basis of Health, Griffith University, Mount Gravatt, and 3The School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
KEY WORDS evidence-based practices, psychiatric disability, psychotic disorders, severe and persistent mental illness, supported employment.
Introduction Evidence-based practices in supported employment and vocational rehabilitation for people with severe and persistent mental illness (SPMI) are not yet widely available in Australia. SPMI includes schizophrenia, bipolar affective disorder, and other psychotic disorders, along with severe forms of other psychiatric conditions. Much is known about the most effective practices in helping people with SPMI to obtain and retain competitive employment (Bond, Drake & Becker, 2012), yet these effective practices continue to be ignored by existing policies and programmes (Carr & Waghorn, 2013). A change of Australian Government in 2013, and subsequent changes to departmental responsibilities provides a unique opportunity to revisit this problem. The purpose of this viewpoint is to inform Occupational Therapists about what can be done to make evidence-based practices more widely available to people with SPMI. This is important because Occupational Therapists working in this field have the qualifications to lead the implementation of evidence-based supported employment programmes.
Geoffrey Waghorn PhD, PG Dip Psych, BSocSci; First Author. Emily Hielscher BPsycSc (Hons); BAppSc; Second Author. Correspondence: Emily Hielscher, Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Locked Bag 500, Sumner Park BC, via Brisbane, Qld 4074, Australia. Email: [email protected] Accepted for publication 26 August 2014. © 2014 Occupational Therapy Australia
Background Most working age adults with SPMI want to be employed. Macias, DeCarlo, Wang, Frey and Barreira (2001) found that 70% of consumers of mental health services (n = 177) were interested in employment. A longitudinal study found that 61% of participants with schizophrenia were interested in employment at baseline (n = 137), and nearly half of those interested had actively tried to find employment (Mueser, Salyers & Mueser, 2001). Employment and labour force participation are low among Australians with SPMI. Australians with mental health disorders have lower employment rates than other disability groups (Killackey, Jackson & McGorry, 2008). Within the mental disorder group, those with psychotic disorders are the least employed. The second national survey of psychotic disorders in Australia found that 22% of community residents with psychotic disorders were employed in the past month (Waghorn, Saha & McGrath, 2014). This proportion had not substantially changed from the previous survey conducted in 1998. The difference between the proportion of those with SPMI interested in employment and the proportion currently employed represents an unmet vocational need.
The main problems Disability Employment Services (DES) are difficult to access. With the introduction of DES in March 2010 as the reformed national employment programme for people with disabilities, there were immediate improvements, including the removal of limits to the number of places available. This was reflected in increased programme participation (Department of Education, Employment and Workplace Relations [DEEWR], 2012), but it did not mean easier access for people with SPMI. The access rules required eligibility assessments for four programme types: (i) mainstream unemployment programmes at four intensity levels; (ii) disability employment services for people with disabilities and post-employment support needs of 6 months or less;
142 (iii) disability employment services for people with disabilities and post-employment support needs of greater than 6 months; and (iv) Business Services where jobs were reserved for people with disabilities, with wages often limited to productivity based wages. These four programmes are now administered separately by three Australian Government departments. Few employment service providers have contracts to deliver all of the competitive employment programmes (1–3). Hence, eligibility assessments can disconnect a person from their current or preferred provider (Waghorn et al., 2012). Due to a lack of a specific tool to assess psychiatric disability, and with the onus on the person to provide information justifying more intensive assistance, people with SPMI can be easily misclassified as only needing mainstream unemployment services, or as needing non-competitive employment. People with psychiatric disabilities may also be misclassified by funding level within programme types. Programmes for the mainstream unemployed are neither intended nor suitable for people with SPMI (Waghorn et al., 2012). Similarly, sheltered employment is inappropriate for a person with a competitive employment goal. Although getting people reclassified is possible, this is time consuming and requires an advocate such as an Occupational Therapist to gather and present new evidence (Waghorn, Collister, Killackey & Sherring, 2007). Usual Disability Employment Services (DES) are not effective. In terms of commencing competitive employment, DES is effective for one in four people with a primary disability of a psychological or psychiatric nature. Its effectiveness has not improved over the previous national system, with a decreasing proportion commencing employment, from 27.9% to 24.5% (DEEWR, 2012). This in turn may lead to low community expectations that competitive employment is not feasible for people with SPMI. Signs of such low expectations have emerged in a large national survey of psychotic disorders, which found that adult community residents who used a DES were more likely to end up in non-competitive employment, compared to those that used their own resources to find employment (Waghorn et al., 2014).
Possible solutions One solution to this problem involves encouraging service providers to adopt evidence-based practices in supported employment. This requires adjusting the many policy and contractual factors that discourage evidence-based practices, including those that deter close collaboration between mental health services and DES providers. Close collaboration can be achieved within the existing service delivery system by co-locating an employment specialist into a public funded community mental health team (King et al., 2006; Waghorn et al., 2012). © 2014 Occupational Therapy Australia
G. WAGHORN AND E. HIELSCHER
In a recent international review of evidence-based supported employment, nine randomised controlled trials (RCTs) from the US and six outside the US (Australia, Hong Kong, UK, Netherlands, Canada) demonstrated that 60% or more clients obtained competitive jobs, compared to 25% of those who received other forms of vocational assistance (Bond et al., 2012). A systematic review of 14 RCTs found that evidencebased supported employment, delivered at high fidelity, increases job tenure in competitive employment (Kinoshita et al., 2013). In addition, several studies have found that high integration between mental health services and supported employment produces better employment outcomes than low service integration (Gowdy, Carlson & Rapp, 2004). In Australia, integrated employment services have been particularly effective for young people with first episode psychosis (Killackey et al., 2008). Better employment outcomes were obtained for the integrated employment services compared to mental health treatment as usual, with a greater number of employment commencements (13 vs. 2, P < 0.001), hours worked per week (median 38 vs. 22.5), and total new jobs acquired (23 vs. 3). Integrated employment services were welcomed by young consumers of mental health services. This was also indicated by positive anecdotal reports and by lower attrition among those in the intervention group. Integrated services are also effective for Australian adults with SPMI. A Hunter-New England Supported Employment programme (Morris, Waghorn, Robson, Moore & Edwards, 2014) measured the impact of integrated employment services. This programme included four sites (Peel, Lake Macquarie, Newcastle, Hunter Valley) which established formal partnerships with local mental health services and co-located an employment specialist into each team. Participants (n = 95) were working age adults with SPMI (mostly psychotic disorders) who were referred to the programme by mental health service staff. Over nine months, 47.4% (45 of 95) commenced employment, which was significantly better than the national benchmark of 24.5% (employment commencement for usual DES) over the same period (P < 0.001). A multi-site trial of evidence-based supported employment services (Waghorn et al., 2012) found that a high degree of integration can be achieved in the complex Australian service delivery context. Anecdotal reports from stakeholders indicated that formal partnerships can be the main method to develop service integration. However, these partnerships require some ongoing external assistance to prevent regression back to segregated services. This partnership also requires a full-time co-located employment specialist, high commitment from each partner organisation, ongoing joint management of the new service, and routine and unbiased reporting of practice fidelity and client employment outcomes (Waghorn et al., 2012).
143
EVIDENCE-BASED PRACTICES IN SUPPORTED EMPLOYMENT
Structural barriers to evidence-based supported employment One barrier to implementing evidence-based practices in supported employment in Australia is the segregation of health services (funded by Federal-State agreements and administered by the State Government) from employment services (contracted by the Australian Government) (King et al., 2006; Waghorn et al., 2007). Current policy settings provide no incentives for employment services to formally partner with mental health services. The prevailing service segregation results in limited access by consumers of mental health services. Two solutions are suggested. The first utilises existing service systems. For this solution, funding methods, performance evaluation frameworks, eligibility assessments, and contracts with existing DES services, need to be amended to encourage, rather than hinder the delivery of integrated services and to encourage the adoption of other evidence-based practices, such as more individualised and intensive services. Employment service delivery could be further enhanced by improving the DES eligibility classification system. The current process causes delays for clients and leads to a high proportion of misclassifications which are incompatible with targeted and timely services. Several steps could immediately make a difference. Firstly, all those that do not need assessments could be exempted. This could include all those currently eligible for the Disability Support Pension or Sickness Allowance. This is appropriate because those on disability or sickness payments are already a priority for DES, and they could be given rapid access without any further assessment. Any subsequent assessments needed to determine the funding level, or programme subtype, could seek input from clinical teams, previous employment service providers, and from clients’ employment history. Current assessments do not optimally utilise these sources. In addition, the DES eligibility classification system could be enhanced by providing assessors with specialised training in mental health, particularly psychosis. This could include developing a new assessment tool to classify the overall employment-related severity of psychiatric disability. Promising components of such a tool include the Personal and Social Performance (PSP) scale, as well as measures of duration of illness and course pattern of illness. The last two in particular are brief and can be assessed from treatment history, and all three are correlated with employment status in the second national survey of psychosis (Waghorn et al., 2014). Such a tool could be developed by policy makers. If found reliable and valid, it could prevent much of the misclassification of people with psychiatric disorders that is so often reported by those involved with job capacity assessments (Killackey & Waghorn, 2008).
The second solution is to enable mental health services to directly employ an employment specialist. This direct employment method has worked well in Australia (Killackey et al., 2008) although the main limitation of this approach is financial sustainability (Killackey & Waghorn, 2008). This could be addressed by allowing mental health teams to access the same employment milestone payments paid for eligible clients of the DES programme (DEEWR, 2012). Costs of the programme would be limited to a single salary of the employment specialist, as supervision and other indirect programme costs could be met by the mental health team. Another potential limitation is the culture of some mental health services that do not consider employment as part of their core business. This could be addressed by conducting mandatory health staff training and by having the employment specialist attend weekly clinical meetings (Killackey & Waghorn, 2008). Occupational Therapists could lead both solutions. Those working in the DES sector could help design and implement training in more client-centred, intensive and evidence-based practices. Those working in public mental health could contribute by leading the implementation of integrated services, and provide ongoing training for clinical staff, inter-service coordination, practice fidelity assessments and support programme outcome evaluation integrated with joint service delivery. Other opportunities include developing add-on interventions that further enhance employment outcomes, recovery and social inclusion.
Conclusions Australians with SPMI do not yet have access to evidence-based forms of supported employment. There is an unmet need for more effective forms of vocational rehabilitation and supported employment. The current DES programme in Australia has not sufficiently addressed this need and is unlikely to do so because it is relatively ineffective for this population. However, important opportunities remain to implement more evidence-based practices in supported employment for people with psychiatric disabilities. Two ways this can be achieved in the Australian context are discussed. Occupational Therapists working in both public mental health services and in the DES programme are well qualified to become involved and to lead the implementation of the evidence-based practices needed. Although systems change is challenging, there is nothing to be gained by continuing to support the status quo.
References Bond, G. R., Drake, R. E. & Becker, D. R. (2012). Generalizability of the Individual Placement and Support (IPS) model of supported employment outside the US. World Psychiatry, 11, 32–39.
© 2014 Occupational Therapy Australia
144 Carr, V. J. & Waghorn, G. (2013). To love and to work: The next major mental health reform goals. Australian and New Zealand Journal of Psychiatry, 47, 696–698. Department of Education, Employment and Workplace Relations. (2012). Evaluation of disability employment services interim report: Reissue March 2012. Retrieved March 11, 2014, from http://docs.employment.gov.au/ system/files/doc/other/evaluation_of_disability_employment_services_interim_report_reissue_march_2012.pdf Gowdy, E. A., Carlson, L. S. & Rapp, C. A. (2004). Organizational factors differentiating high performing from low performing supported employment programs. Psychiatric Rehabilitation Journal, 28, 150–156. Killackey, E. & Waghorn, G. (2008). The challenge of integrating employment services with public mental health services in Australia: Progress at the first demonstration site. Psychiatric Rehabilitation Journal, 32, 63–66. Killackey, E., Jackson, H. J. & McGorry, P. D. (2008). Vocational intervention in first-episode psychosis: Individual placement and support v. treatment as usual. British Journal of Psychiatry, 193, 114–120. King, R., Waghorn, G., Lloyd, C., McLeod, P., McMah, T. & Leong, C. (2006). Enhancing employment services for people with severe mental illness: The challenge of the Australian service environment. Australian and New Zealand Journal of Psychiatry, 40, 471–477. Kinoshita, Y., Furukawa, T. A., Kinoshita, K., Honyashiki, M., Omori, I. M., Marshall, M. et al. (2013). Supported
© 2014 Occupational Therapy Australia
G. WAGHORN AND E. HIELSCHER
employment for adults with severe mental illness. Cochrane Database of Systematic Review, 2013, 9. Macias, C., DeCarlo, L. T., Wang, Q., Frey, J. & Barreira, P. (2001). Work interest as a predictor of competitive employment: Policy implications for psychiatric rehabilitation. Administration and Policy in Mental Health, 28, 279– 297. Morris, A., Waghorn, G., Robson, R., Moore, L. & Edwards, E. (2014). Implementation of evidence-based supported employment in regional Australia. Psychiatric Rehabilitation Journal, 37(2), 144–147. Mueser, K. T., Salyers, M. P. & Mueser, P. R. (2001). A prospective analysis of work in schizophrenia. Schizophrenia Bulletin, 27, 281–296. Waghorn, G., Collister, L., Killackey, E. & Sherring, J. (2007). Challenges to implementing evidence-based supported employment in Australia. Journal of Vocational Rehabilitation, 27, 29–37. Waghorn, G., Childs, S., Hampton, E., Gladman, B., Greaves, A. & Bowman, D. (2012). Enhancing community mental health services through formal partnerships with supported employment providers. American Journal of Psychiatric Rehabilitation, 15, 157–180. Waghorn, G., Saha, S. & McGrath, J. J. (2014). Correlates of competitive versus noncompetitive employment among adults with psychotic disorders. Psychiatric Services, doi: 10.1176/appi.ps.201300096. Advanced online publication.
Copyright of Australian Occupational Therapy Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
doi: 10.1111/1440-1630.12162
Viewpoint
The availability of evidence-based practices in supported employment for Australians with severe and persistent mental illness Geoffrey Waghorn1,2,3 and Emily Hielscher1 1 Queensland Centre for Mental Health Research (QCMHR), The Park Centre for Mental Health, 2Behavioural Basis of Health, Griffith University, Mount Gravatt, and 3The School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
KEY WORDS evidence-based practices, psychiatric disability, psychotic disorders, severe and persistent mental illness, supported employment.
Introduction Evidence-based practices in supported employment and vocational rehabilitation for people with severe and persistent mental illness (SPMI) are not yet widely available in Australia. SPMI includes schizophrenia, bipolar affective disorder, and other psychotic disorders, along with severe forms of other psychiatric conditions. Much is known about the most effective practices in helping people with SPMI to obtain and retain competitive employment (Bond, Drake & Becker, 2012), yet these effective practices continue to be ignored by existing policies and programmes (Carr & Waghorn, 2013). A change of Australian Government in 2013, and subsequent changes to departmental responsibilities provides a unique opportunity to revisit this problem. The purpose of this viewpoint is to inform Occupational Therapists about what can be done to make evidence-based practices more widely available to people with SPMI. This is important because Occupational Therapists working in this field have the qualifications to lead the implementation of evidence-based supported employment programmes.
Geoffrey Waghorn PhD, PG Dip Psych, BSocSci; First Author. Emily Hielscher BPsycSc (Hons); BAppSc; Second Author. Correspondence: Emily Hielscher, Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Locked Bag 500, Sumner Park BC, via Brisbane, Qld 4074, Australia. Email: [email protected] Accepted for publication 26 August 2014. © 2014 Occupational Therapy Australia
Background Most working age adults with SPMI want to be employed. Macias, DeCarlo, Wang, Frey and Barreira (2001) found that 70% of consumers of mental health services (n = 177) were interested in employment. A longitudinal study found that 61% of participants with schizophrenia were interested in employment at baseline (n = 137), and nearly half of those interested had actively tried to find employment (Mueser, Salyers & Mueser, 2001). Employment and labour force participation are low among Australians with SPMI. Australians with mental health disorders have lower employment rates than other disability groups (Killackey, Jackson & McGorry, 2008). Within the mental disorder group, those with psychotic disorders are the least employed. The second national survey of psychotic disorders in Australia found that 22% of community residents with psychotic disorders were employed in the past month (Waghorn, Saha & McGrath, 2014). This proportion had not substantially changed from the previous survey conducted in 1998. The difference between the proportion of those with SPMI interested in employment and the proportion currently employed represents an unmet vocational need.
The main problems Disability Employment Services (DES) are difficult to access. With the introduction of DES in March 2010 as the reformed national employment programme for people with disabilities, there were immediate improvements, including the removal of limits to the number of places available. This was reflected in increased programme participation (Department of Education, Employment and Workplace Relations [DEEWR], 2012), but it did not mean easier access for people with SPMI. The access rules required eligibility assessments for four programme types: (i) mainstream unemployment programmes at four intensity levels; (ii) disability employment services for people with disabilities and post-employment support needs of 6 months or less;
142 (iii) disability employment services for people with disabilities and post-employment support needs of greater than 6 months; and (iv) Business Services where jobs were reserved for people with disabilities, with wages often limited to productivity based wages. These four programmes are now administered separately by three Australian Government departments. Few employment service providers have contracts to deliver all of the competitive employment programmes (1–3). Hence, eligibility assessments can disconnect a person from their current or preferred provider (Waghorn et al., 2012). Due to a lack of a specific tool to assess psychiatric disability, and with the onus on the person to provide information justifying more intensive assistance, people with SPMI can be easily misclassified as only needing mainstream unemployment services, or as needing non-competitive employment. People with psychiatric disabilities may also be misclassified by funding level within programme types. Programmes for the mainstream unemployed are neither intended nor suitable for people with SPMI (Waghorn et al., 2012). Similarly, sheltered employment is inappropriate for a person with a competitive employment goal. Although getting people reclassified is possible, this is time consuming and requires an advocate such as an Occupational Therapist to gather and present new evidence (Waghorn, Collister, Killackey & Sherring, 2007). Usual Disability Employment Services (DES) are not effective. In terms of commencing competitive employment, DES is effective for one in four people with a primary disability of a psychological or psychiatric nature. Its effectiveness has not improved over the previous national system, with a decreasing proportion commencing employment, from 27.9% to 24.5% (DEEWR, 2012). This in turn may lead to low community expectations that competitive employment is not feasible for people with SPMI. Signs of such low expectations have emerged in a large national survey of psychotic disorders, which found that adult community residents who used a DES were more likely to end up in non-competitive employment, compared to those that used their own resources to find employment (Waghorn et al., 2014).
Possible solutions One solution to this problem involves encouraging service providers to adopt evidence-based practices in supported employment. This requires adjusting the many policy and contractual factors that discourage evidence-based practices, including those that deter close collaboration between mental health services and DES providers. Close collaboration can be achieved within the existing service delivery system by co-locating an employment specialist into a public funded community mental health team (King et al., 2006; Waghorn et al., 2012). © 2014 Occupational Therapy Australia
G. WAGHORN AND E. HIELSCHER
In a recent international review of evidence-based supported employment, nine randomised controlled trials (RCTs) from the US and six outside the US (Australia, Hong Kong, UK, Netherlands, Canada) demonstrated that 60% or more clients obtained competitive jobs, compared to 25% of those who received other forms of vocational assistance (Bond et al., 2012). A systematic review of 14 RCTs found that evidencebased supported employment, delivered at high fidelity, increases job tenure in competitive employment (Kinoshita et al., 2013). In addition, several studies have found that high integration between mental health services and supported employment produces better employment outcomes than low service integration (Gowdy, Carlson & Rapp, 2004). In Australia, integrated employment services have been particularly effective for young people with first episode psychosis (Killackey et al., 2008). Better employment outcomes were obtained for the integrated employment services compared to mental health treatment as usual, with a greater number of employment commencements (13 vs. 2, P < 0.001), hours worked per week (median 38 vs. 22.5), and total new jobs acquired (23 vs. 3). Integrated employment services were welcomed by young consumers of mental health services. This was also indicated by positive anecdotal reports and by lower attrition among those in the intervention group. Integrated services are also effective for Australian adults with SPMI. A Hunter-New England Supported Employment programme (Morris, Waghorn, Robson, Moore & Edwards, 2014) measured the impact of integrated employment services. This programme included four sites (Peel, Lake Macquarie, Newcastle, Hunter Valley) which established formal partnerships with local mental health services and co-located an employment specialist into each team. Participants (n = 95) were working age adults with SPMI (mostly psychotic disorders) who were referred to the programme by mental health service staff. Over nine months, 47.4% (45 of 95) commenced employment, which was significantly better than the national benchmark of 24.5% (employment commencement for usual DES) over the same period (P < 0.001). A multi-site trial of evidence-based supported employment services (Waghorn et al., 2012) found that a high degree of integration can be achieved in the complex Australian service delivery context. Anecdotal reports from stakeholders indicated that formal partnerships can be the main method to develop service integration. However, these partnerships require some ongoing external assistance to prevent regression back to segregated services. This partnership also requires a full-time co-located employment specialist, high commitment from each partner organisation, ongoing joint management of the new service, and routine and unbiased reporting of practice fidelity and client employment outcomes (Waghorn et al., 2012).
143
EVIDENCE-BASED PRACTICES IN SUPPORTED EMPLOYMENT
Structural barriers to evidence-based supported employment One barrier to implementing evidence-based practices in supported employment in Australia is the segregation of health services (funded by Federal-State agreements and administered by the State Government) from employment services (contracted by the Australian Government) (King et al., 2006; Waghorn et al., 2007). Current policy settings provide no incentives for employment services to formally partner with mental health services. The prevailing service segregation results in limited access by consumers of mental health services. Two solutions are suggested. The first utilises existing service systems. For this solution, funding methods, performance evaluation frameworks, eligibility assessments, and contracts with existing DES services, need to be amended to encourage, rather than hinder the delivery of integrated services and to encourage the adoption of other evidence-based practices, such as more individualised and intensive services. Employment service delivery could be further enhanced by improving the DES eligibility classification system. The current process causes delays for clients and leads to a high proportion of misclassifications which are incompatible with targeted and timely services. Several steps could immediately make a difference. Firstly, all those that do not need assessments could be exempted. This could include all those currently eligible for the Disability Support Pension or Sickness Allowance. This is appropriate because those on disability or sickness payments are already a priority for DES, and they could be given rapid access without any further assessment. Any subsequent assessments needed to determine the funding level, or programme subtype, could seek input from clinical teams, previous employment service providers, and from clients’ employment history. Current assessments do not optimally utilise these sources. In addition, the DES eligibility classification system could be enhanced by providing assessors with specialised training in mental health, particularly psychosis. This could include developing a new assessment tool to classify the overall employment-related severity of psychiatric disability. Promising components of such a tool include the Personal and Social Performance (PSP) scale, as well as measures of duration of illness and course pattern of illness. The last two in particular are brief and can be assessed from treatment history, and all three are correlated with employment status in the second national survey of psychosis (Waghorn et al., 2014). Such a tool could be developed by policy makers. If found reliable and valid, it could prevent much of the misclassification of people with psychiatric disorders that is so often reported by those involved with job capacity assessments (Killackey & Waghorn, 2008).
The second solution is to enable mental health services to directly employ an employment specialist. This direct employment method has worked well in Australia (Killackey et al., 2008) although the main limitation of this approach is financial sustainability (Killackey & Waghorn, 2008). This could be addressed by allowing mental health teams to access the same employment milestone payments paid for eligible clients of the DES programme (DEEWR, 2012). Costs of the programme would be limited to a single salary of the employment specialist, as supervision and other indirect programme costs could be met by the mental health team. Another potential limitation is the culture of some mental health services that do not consider employment as part of their core business. This could be addressed by conducting mandatory health staff training and by having the employment specialist attend weekly clinical meetings (Killackey & Waghorn, 2008). Occupational Therapists could lead both solutions. Those working in the DES sector could help design and implement training in more client-centred, intensive and evidence-based practices. Those working in public mental health could contribute by leading the implementation of integrated services, and provide ongoing training for clinical staff, inter-service coordination, practice fidelity assessments and support programme outcome evaluation integrated with joint service delivery. Other opportunities include developing add-on interventions that further enhance employment outcomes, recovery and social inclusion.
Conclusions Australians with SPMI do not yet have access to evidence-based forms of supported employment. There is an unmet need for more effective forms of vocational rehabilitation and supported employment. The current DES programme in Australia has not sufficiently addressed this need and is unlikely to do so because it is relatively ineffective for this population. However, important opportunities remain to implement more evidence-based practices in supported employment for people with psychiatric disabilities. Two ways this can be achieved in the Australian context are discussed. Occupational Therapists working in both public mental health services and in the DES programme are well qualified to become involved and to lead the implementation of the evidence-based practices needed. Although systems change is challenging, there is nothing to be gained by continuing to support the status quo.
References Bond, G. R., Drake, R. E. & Becker, D. R. (2012). Generalizability of the Individual Placement and Support (IPS) model of supported employment outside the US. World Psychiatry, 11, 32–39.
© 2014 Occupational Therapy Australia
144 Carr, V. J. & Waghorn, G. (2013). To love and to work: The next major mental health reform goals. Australian and New Zealand Journal of Psychiatry, 47, 696–698. Department of Education, Employment and Workplace Relations. (2012). Evaluation of disability employment services interim report: Reissue March 2012. Retrieved March 11, 2014, from http://docs.employment.gov.au/ system/files/doc/other/evaluation_of_disability_employment_services_interim_report_reissue_march_2012.pdf Gowdy, E. A., Carlson, L. S. & Rapp, C. A. (2004). Organizational factors differentiating high performing from low performing supported employment programs. Psychiatric Rehabilitation Journal, 28, 150–156. Killackey, E. & Waghorn, G. (2008). The challenge of integrating employment services with public mental health services in Australia: Progress at the first demonstration site. Psychiatric Rehabilitation Journal, 32, 63–66. Killackey, E., Jackson, H. J. & McGorry, P. D. (2008). Vocational intervention in first-episode psychosis: Individual placement and support v. treatment as usual. British Journal of Psychiatry, 193, 114–120. King, R., Waghorn, G., Lloyd, C., McLeod, P., McMah, T. & Leong, C. (2006). Enhancing employment services for people with severe mental illness: The challenge of the Australian service environment. Australian and New Zealand Journal of Psychiatry, 40, 471–477. Kinoshita, Y., Furukawa, T. A., Kinoshita, K., Honyashiki, M., Omori, I. M., Marshall, M. et al. (2013). Supported
© 2014 Occupational Therapy Australia
G. WAGHORN AND E. HIELSCHER
employment for adults with severe mental illness. Cochrane Database of Systematic Review, 2013, 9. Macias, C., DeCarlo, L. T., Wang, Q., Frey, J. & Barreira, P. (2001). Work interest as a predictor of competitive employment: Policy implications for psychiatric rehabilitation. Administration and Policy in Mental Health, 28, 279– 297. Morris, A., Waghorn, G., Robson, R., Moore, L. & Edwards, E. (2014). Implementation of evidence-based supported employment in regional Australia. Psychiatric Rehabilitation Journal, 37(2), 144–147. Mueser, K. T., Salyers, M. P. & Mueser, P. R. (2001). A prospective analysis of work in schizophrenia. Schizophrenia Bulletin, 27, 281–296. Waghorn, G., Collister, L., Killackey, E. & Sherring, J. (2007). Challenges to implementing evidence-based supported employment in Australia. Journal of Vocational Rehabilitation, 27, 29–37. Waghorn, G., Childs, S., Hampton, E., Gladman, B., Greaves, A. & Bowman, D. (2012). Enhancing community mental health services through formal partnerships with supported employment providers. American Journal of Psychiatric Rehabilitation, 15, 157–180. Waghorn, G., Saha, S. & McGrath, J. J. (2014). Correlates of competitive versus noncompetitive employment among adults with psychotic disorders. Psychiatric Services, doi: 10.1176/appi.ps.201300096. Advanced online publication.
Copyright of Australian Occupational Therapy Journal is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
