Utilising Individual Placement and Support to address unemployment and low education rates among individuals with psychotic disorders

Unemployment is a near-universal functional disability associated with psychotic illnesses such as schizophrenia. There exist a number of ways of addressing unemployment in this population. These include transitional employment, social firms and supported employment, with the latter utilising a place-(in competitive employment)-and-support model (Killackey et al., 2006). While all three methods have pros and cons, and no single method is right for all people with schizophrenia, the research evidence indicates that supported employment is far and away the most successful approach to helping people with psychotic illnesses find a job in the mainstream competitive labour market (Bond et al., 2008). The most defined form of supported employment is Individual Placement and Support (IPS). This article will argue the case for the inclusion of IPS as a standard practice in any recovery-focused mental health setting. It will do this through establishing that there is a need for an employment intervention in psychotic illness, defining what IPS is, briefly surveying the evidence for IPS, and highlighting where IPS might be further augmented and developed. Finally, it will identify some barriers that have acted against its wide implementation and suggest how these may be overcome.

Is there a need for an employment intervention?

Unemployment is the near-universal experience of people with psychotic illness. At the outset of illness approximately 50% are unemployed and this quickly increases to between 70% and 95% in chronic stages (Killackey et al., 2006). This is significantly more than the community level of unemployment either generally or, in the case of first-episode psychosis, at the level of youth unemployment.

Unemployment among people with schizophrenia is enormously expensive for the community as well as devastating to the economic and social participation prospects of the individual. The cost of unemployment among people with schizophrenia is estimated at more than 50% of the total cost of illness (Wu et al., 2005).

Finally, despite such high unemployment rates, despite people with mental illness being the largest disability group accessing the disability support pension in Australia (VICSERV, 2008), despite people with mental illness being the group who benefits the least from disability employment services in Australia (VICSERV, 2008), and despite a prevailing lay and clinical myth that people with psychotic illnesses are not able to or should not work, study after study shows that employment is either the number one or a highly ranked goal of people with psychotic illness (e.g. Ramsay et al., 2011).

Given the cost of unemployment at a personal and societal level, the desire of people with psychotic illness to work, and the disparity between unemployment rates in the general community and among people with psychosis, very little has been done to address this problem. After all, for most adults in most developed countries, a job appropriate to their capacity to work is a normal expectation of life. As stated above, there is a diversity of approaches to employment for people with psychosis. However, the intervention with the most supporting evidence is supported employment, of which the most defined form is IPS.

What is Individual Placement and Support?

Individual Placement and Support (IPS) is a method of vocational intervention for people with severe mental illness. IPS has eight fundamental principles (Drake et al., 2012), which are as follows:

1. IPS is open to any person with mental illness who wants to look for work.

2. IPS is integrated with the mental health treatment team.

3. IPS is focused on competitive employment as an outcome.

4. Personalised benefits planning/counselling is provided in IPS.

5. Job searching commences directly on entry into the IPS program and is not determined by measures of work-readiness or illness variables.

6. The IPS worker develops relationships with employers based upon client interests.

7. Potential jobs are chosen based on consumer preference.

8. Support provided in the program is time-unlimited, continuing after employment is obtained, and is adapted to individual needs.

IPS has been assessed in 15 randomised controlled trials (RCTs) in North America, Europe, Asia and Australia, in both established and first-episode psychotic illness. In every trial, IPS was found to be superior to all control conditions in rate of competitive employment (Drake and Bond, 2011). Notably, these results have occurred in a number of countries with different labour markets, different prevailing economic conditions, and different attitudes towards mental illness. With respect to IPS in first-episode psychotic illness, there have been two published RCTs (Killackey et al., 2008; Nuechterlein et al., 2008). These were different to those conducted in populations with established illness in that they included educational placement as a successful outcome because of the younger age of the participants involved. Including education and employment as an outcome led to 85% (Killackey et al., 2008) and 83% (Nuechterlein et al., 2008) of participants in IPS conditions in these trials enjoying a successful vocational outcome. These results also indicate the importance of starting vocational rehabilitation early in the course of illness. The necessity of addressing such vocational recovery early in the course of illness is highlighted by studies that show early (1-year) functional rather than symptomatic recovery is indicative of long-term (7-year) functional recovery (Alvarez-Jimenez et al., 2012).

Collectively, these findings provide ample evidence to support the proposition that IPS is an effective way for people to obtain work or enrol in education. However, a key goal remaining is to ensure that employment, or educational placement, is maintained. A range of barriers to maintaining employment for people with psychosis have been identified, including stigma, low self-esteem/self-efficacy, motivation, and the disincentive associated with receiving disability benefits. Two illness-related barriers consistently associated with vocational outcomes, including durability, are neurocognitive and social cognitive difficulties.

Enhancements to IPS

While IPS itself is well established, there are a number of potential enhancements addressing neurocognition and social cognition that are at an earlier stage of research.

Neurocognitive interventions: Three RCTs conducted in chronic schizophrenia have examined whether the addition of neurocognitive remediation enhances vocational outcomes for people participating in supported employment. Outcomes for the group that received neurocognitive remediation plus supported employment were found to be superior with respect to successful job placement (Bell et al., 2008; McGurk et al., 2007; Vauth et al., 2005), wages earned (McGurk et al., 2007) and hours/weeks worked (Bell et al., 2008; McGurk et al., 2007).

Social cognition: Research suggests that social cognition may have even stronger effects on vocational outcomes than neurocognition (Fett et al., 2011). This is because social cognition is believed to be more ‘proximal’ to real-world behaviour than neurocognition. Indeed, social cognition has been found to mediate the relationship between neurocognition and vocational outcomes (Bell et al., 2009). Accordingly, it is speculated that IPS combined with social cognition training may lead to enhanced vocational outcomes. However, this question is yet to be examined.

Neurocognitive and social cognitive deficits and peak levels of disability develop in the early years of psychotic illness. This period also represents a significant phase of neurodevelopment when higher-order neurocognitive and social cognitive processes are still developing. Thus, it is argued that there may be greater scope for significant functional improvement and the prevention of functional decline due to the greater brain plasticity associated with ongoing neurodevelopment in this phase of life (Blakemore, 2008). Indeed, recent research has shown that younger patients with psychosis respond better to interventions targeting cognitive processes than older patients (Wykes et al., 2009). However, to date, no study has examined whether neurocognitive or social cognitive remediation enhances IPS outcomes in people with first-episode psychosis.

Implementation

There are a number of barriers to the implementation of IPS as a standard part of the mental health service offerings. These include the existing disability and regular employment systems; cultural attitudes among clinicians, carers and consumers about the appropriateness of employment; the lack of workers with specialist skills for working in IPS in Australia; and a closed mindedness on the part of disciplines traditionally involved in mental health care to accept people from other backgrounds as part of the direct care team. None of these barriers is insurmountable. As well as having IPS workers in place, as at the EPPIC (Early Psychosis Prevention and Intervention Centre) in Melbourne (Killackey and Waghorn, 2008), other IPS-based models of collaboration between mental health and employment services are being tested (Waghorn et al., 2012). Guidance for establishing IPS services can be found in both manuals (Becker and Drake, 2003; Drake et al., 2012) and, in parti­cular, from the website of the Dart­mouth IPS Center (www.dartmouth.edu/~ips/).

A key requirement to implementation is a change in attitude and focus. There is no reason for the participation rates and the employment rates of people with mental illness to lag so far behind those of people with physical disabilities and those of the general population (VICSERV, 2008). If mental health care is to be rehabilitative and recovery focused, and if people with illness overwhelmingly want to work, it is incumbent on the mental health system to use the evidence-based psychosocial treatments available to make this happen.