Mental health occupational therapy and supported employment

Purpose – The individual placement and support (IPS) model is an evidence-based approach to employment support for people with severe mental illness that functions by co-locating an employment consultant from the local disability employment service within a community mental health team to assist service users to find work. This paper aims to examine the unintended impacts of implementing IPS on occupational therapy practice and offer some suggestions. Design/methodology/approach – The authors performed a narrative literature review on the IPS model, employment and occupational therapy. Authors then analysed and discussed impact on occupational therapy practice and concluded bymaking suggestions based on current evidence and practice. Findings – The authors concluded that implementation of IPS has resulted in some unintended changes of practice in mental health with occupational therapists taking a less active role in enabling employment outcomes than previously. This paper concludes by calling upon occupational therapists to re-establish their role of enabling employment. Originality/value – This paper offers an original viewpoint on employment and occupational therapy based on current evidence and authors’ expertise.


Occupational therapy and employment
Meaningful employment has been shown to improve self-esteem, increase personal empowerment and social contact, social identity and status (Marwaha et al., 2014).Reduced clinical symptoms, the development of personal wellbeing and higher levels of functioning have also been associated with employment (Dunn et al., 2008;Siu et al., 2010).However, despite the value that work has for people with a mental illness, competitive job tenure remains relatively brief.Williams and Lloyd (2016) looked at the job tenure of young people with psychosis and found that receiving support from a specialist disability support provider did not protect the person from losing his or her job.Waghorn et al. (2015) suggested that post-employment support was the most important phase of supported employment when the focus shifts to job retention and career development.In a further publication, Waghorn and Hielscher (2015) suggested that occupational therapists working in public mental health services and supported employment programmes are well-qualified to become involved and lead the implementation of such evidence-based practices.
Occupational therapy has a long history of recognising the value of work and other productive activities to maintain and enhance health (Arbesman and Logston, 2011).Kirsh et al. (2005) stated that occupational therapists have been advocates for people with a mental illness who are entering or re-entering the workforce.Based upon their knowledge and understanding of the person-occupation-environment, occupational therapists are able to provide job matching, individualised environmental supports, skill development and on-the-job training (Kirsh et al., 2005).Occupational therapists have expertise in designing compensatory strategies and accommodation based on individual need, use activity analysis to break down skills so that they can be gradually mastered and help people resume past roles or assume new ones (Arbesman and Logston, 2011).Woodside et al. (2006) suggested that occupational therapists should continue to focus their attention on listening to their clients to understand where they are on their recovery journey.Clinicians need to encourage hope for recovery by being aware of the potentially damaging implications of one's own lack of hope for the service user's recovery, being someone who believes in recovery, facilitating access to narratives of recovery and providing new ways of understanding difficulties (Hobbs and Baker, 2012).This is particularly important in the area of employment where traditionally many people with a mental illness were not supported in the area of finding work.Winstead (2009) explored the ways in which occupational therapists are able to provide a range of different vocational services to people with a mental illness.She discusses issues such as disclosure and various accommodation options that could be implemented, for example social skills training, stress management and time management skills.Further work has been conducted in the area of disclosure, and McGahey et al. (2016) conducted a research project which looked at the usefulness of the Personal Management Plan which gives people with a mental illness the opportunity to talk in detail about their abilities in the workplace, regardless of their insight into diagnosis.This plan enables service users to maintain a sense of control over their own information and labelling of their experience.It was found that those who had completed a plan to manage their personal information had 4.9 times greater odds of employment at six weeks than those who preferred not to disclose any personal information.
In New Zealand, Liu and Wilson (2009) suggested that occupational therapists have a significant role to play in providing vocational rehabilitation services.They considered that this was due to the expertise of occupational therapists in enabling occupation, including work-related activities, which are a key occupational area.In the UK, (Martin et al., 2011) explored occupational therapists' perceptions about their role within mental health, vocational rehabilitation, individual placement and support (IPS).They suggested that occupational therapists offer a unique professional understanding of the individual's performance and participation in current or future worker roles.Occupational therapists have developed standardised assessment tools which may be useful in the provision of IPS services to better understand individual clients' perspectives of psychosocial and environmental impacts on work (Martin et al., 2011).

Current trends in employment and occupational therapy
While occupational therapists are regarded to have a professional and ethical responsibility to consider work-related issues for all clients (Occupational Therapy Australia, 2013), there has been a tendency to leave this to supported employment consultants.In many cases, this has come about with advances in supported employment in which an employment specialist shares office space with mental health clinical staff and attends case reviews (King et al., 2006).Mental health staff have been quick to refer people to employment specialists for all their vocational needs without taking into account the valuable role that occupational therapists could potentially play in this area.Employment specialists are not clinically trained to identify or deal with the illness-related barriers to employment that people with mental illness present (Waghorn et al., 2007).While identification remains a role of clinical staff, particularly occupational therapists, the practice among mental health staff suggests that this is left to employment specialists.This practice has disadvantaged mental health service users, delays recovery and also devalues the role of occupational therapists.Despite the introduction of evidence-based supported employment interventions such as the IPS, workforce participation rates among people with a mental illness in many countries such as Australia still remain significantly lower than that for people with other types of disabilities and those with no disabilities (Australian Bureau of Statistics, 2012).Occupational therapy has real potential for improving workforce participation rates of people with a mental illness.Occupational therapists should continue to work with service users who are interested in finding work and address the barriers to employment that they might be experiencing.
The case for occupational therapy role in employment Occupational therapists have expertise in the employment service area because occupation is central to the frame of reference of occupational therapy, and this includes employment (World Federation of Occupational Therapy, 2012).Therefore, occupational therapists have the expertise to holistically consider the persons physical, behavioural, cognitive, social and emotional capacity in relation to employment.Task analysis is a core skill of occupational therapy and allows the identification of barriers and enablers to work.Consequently, occupational therapists are able to determine the necessary interventions to enhance the jobperson fit.
Occupational therapists have many assessment tools such as the occupational performance history interview (Kielhofner et al., 2001), the occupational self-assessment (Kielhofner et al., 2010), the volitional questionnaire (Chern et al., 1996), the worker role interview (Fenger and Kramer, 2007) and the work environment impact scale (Ekbladh et al., 2014) that they are trained to use to accurately identify strengths and barriers to employment.Occupational therapists possess the knowledge and skills to adapt the job environment together with the person to achieve their maximum capacity for work (World Federation of Occupational Therapy, 2012).When service users are not seen by occupational therapists, then there is a risk that consumers' skills and barriers may not be adequately identified, and job person-fit may not be fully realised.The recommended role of occupational therapists is summarised in Table I.
Occupational therapists should continue to support individuals who want to work to choose, get and keep a job in the open labour market, working alongside employment consultants and using occupational therapy skills to perform job assessment, task analysis and job matching to make recommendations and improve the potential of successful and safe re-engagement in the workforce.It is also recommended that occupational therapists should support employers to help consumers stay at work or return to work using a range of employment and rehabilitation approaches in accordance with individual needs or preferences (Occupational Therapy Australia, 2013).-promote choice "autonomy" of type of job and need to work -personal closeness with helping staff "Relatedness" -personal causation or belief in skill "competence" Motivate job seeker using motivational interviewing Advocate for people with a mental illness Follow-along supports Provide individualised environmental supports, skill development and on-the-job training (Kirsh et al., 2005) -improve occupational performance in the area of finances/ budgeting (Chan et al., 2009) Mental health occupational therapy

Conclusion
The occupational therapy profession needs to re-affirm the rights of people, regardless of their ability to participate in productive occupations such as paid work and to affirm that occupational therapists have the expertise in the employment service area to enable this participation.