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Personal experiences of people with serious mental illness when seeking, obtaining and maintaining competitive employment in Queensland, Australia.pdf

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  Work 53 (2016) 835–843DOI:10.3233/WOR-162252IOS Press 835 Personal experiences of people with seriousmental illness when seeking, obtaining andmaintaining competitive employment inQueensland, Australia Beverley Gladman a , c , ∗ and Geoff Waghorn a , b a Queensland Centre for Mental Health Research (QCMHR), The Park Centre for Mental Health, Brisbane,QLD, Australia b School of Applied Psychology, Griffith University, Mount Gravatt, Brisbane, QLD, Australia c The School of Medicine, The University of Queensland, Brisbane, QLD, Australia Received 19 March 2014Accepted 12 May 2015 Abstract . BACKGROUND:  High non-participation in the labour force and unemployment remain challenging for adults with seriousmental illness. OBJECTIVES: Thisstudyexaminedthepersonalexperiencesofpeoplewithseriousmentalillnesswhenseeking,obtainingand maintaining competitive employment. The aim was to increase understanding of personal experiences of employmentandhowtheseexperiencescanbeusedtoinformtheassistanceprovidedinsupportofclients’competitiveemploymentgoals. METHODS:  Qualitative data from a two-year period were thematically analysed from one participating site in a multi-sitetrial of employment services integrated with public funded community mental health treatment and care. RESULTS: Bothpositiveandnegativethemesarose.Positivethemesincluded:Aspirationsforabetterlife,receivingfeedback on good job performance, employment displacing preoccupation with illness, and employment improving self-esteem andreducing financial stress. Negative themes included stigma experiences, stress, and health difficulties. Both positive andnegative experiences did not depend on type of employment service assistance nor key client characteristics such as age, sex,and diagnostic category. CONCLUSIONS: Despite its many benefits, employment can also increase the risk of negative personal experiences. Thesefindings suggest that employment service providers could do more to assist people who commence employment, to reducethe risk of negative personal experiences and to enhance the benefits of competitive employment.Keywords: Employment, psychiatric disability, personal experiences, stigma, disclosure 1. Introduction High non-participation in the labour force andunemployment remain problematic for adults with ∗ Address for correspondence: Beverley Gladman, QueenslandCentre for Mental Health Research, The Park Centre for MentalHealth, Locked Bag 500, Archerfield, via Brisbane, QLD 4108,Australia. Tel.: +07 3271 8671; Fax: +07 3271 8698; E-mail:beverley gladman@qcmhr.uq.edu.au. severe and persistent mental illness with mostresearch focussing on labour force activity, unem-ployment,barrierstoemployment,theexperiencesof unemployment, or employment outcomes obtainedby specific employment programs. However, rel-atively few studies have explored the personalexperiences associated with obtaining competitiveemployment. Clients’ personal experiences and neg-ative experiences in particular, may be important for 1051-9815/16/$35.00 © 2016 – IOS Press and the authors. All rights reserved  836  B. Gladman and G. Waghorn / Personal experiences of people with serious mental illness understanding the relatively short mean job-durationamong people with severe mental illness. Job reten-tion is an ongoing issue for service delivery to thispopulation by Disability Support Service providers,even if a relatively high proportion of clients com-mence competitive employment. In recent reviewsof the most effective forms of supported employ-ment for this group, the mean job duration of thelongest job held was 22 weeks [3, 4]. This high-lights job retention as an important ongoing issuefor service delivery even if a relatively high propor-tion of clients commence competitive employment.Improving the quality of support, once employmenthas commenced, therefore appears urgently neededfor people with severe mental illness, because alarge proportion of jobs end suddenly or unsatis-factorily. Several reasons for sudden job-loss havebeen suggested, including a need for help with socialinteractions at work and with managing psychiatricproblems while working [1, 27].In a study focusing on the job search phase, it wasfound that the quality of employment support wasimportant, particularly advice and counselling dur-ing the job search phase to enable informed choiceabout disclosure and to prepare for ongoing supportonce employment commences [5]. Koletsi et al. [19]explored clients’ views of the difficulties involved inobtaining and maintaining employment, their expe-riences of the support received from their supportworkers, and the perceived impact of employment onclients’ lives. They found that workers with severemental illness associated employment with financialstability,improvedsocialparticipation,increasedself-esteem, greater integration into society, and reducedfeelings of boredom and isolation. They also foundsome unintended negative consequences of employ-ment such as increased levels of stress, conflict withcolleagues, and having less personal time. Someclients wanted their support workers to have moreknowledge of their industry and some wanted morefrequentcontactandsupportwhileatwork.Althoughseveral studies have explored personal experiencesofobtainingcompetitiveemploymentfromanopera-tionalperspective[9,19,21,25],relativelyfewstudieshaveexplorednotonlythepositivebutalsothenegativepersonal experiences associated with first obtaining,thenmaintainingcompetitiveemployment.Inaqual-itative study by Becker et al. [2] of employmentexperiences, three overlapping themes of manage-mentofsymptoms,copingskillsandadequatesupportserviceswereidentifiedthatwereperceivedbypartic-ipantstoinfluencetheirworkbehaviour.The successful management of symptoms and thedevelopment of appropriate coping skills appearedto play an important role in finding, obtaining andmaintaining employment. Participants indicated theygenerally preferred part-time employment becauseof the reduced demands and because part-time work was perceived as being compatible with continuinghealth and welfare benefits. In a survey developedandadministeredbyaconsumer-ledresearchteamto389 persons receiving case management and outpa-tient services at an urban mental health centre withinthe United States, concern about losing health andwelfare benefits was identified as the most signif-icant barrier to employment [22]. Consumers whosaid they were not interested in looking for work,would be interested if they were better informedabout how employment can be managed withoutlosing their health and welfare benefits. Anotherbarrier to employment was low pay. The authors sug-gested that this be addressed by vocational programshelping consumers to develop skills and qualifica-tions that lead to better paid jobs. Participants alsorecognized the importance of support services inmakingsuccessfultransitionsfromunemploymenttoemployment and between jobs however, even takinginto consideration reported difficulties with gainingand maintaining employment, Becker et al. [2] con-cluded that the long-term trajectories of participantsin supported employment programs were positiveoverall.Irrespective of the reported difficulties with gain-ing and maintaining employment, many individualsin this population express the desire to work anddescribe positive benefits associated with having a job. Using a grounded theory approach in their study,Liu et al. [21] suggested that experiences of partici-pants in effective supported employment programs[see 4] highlight the importance of participationin meaningful occupations as both a therapeuticprocess and a desired rehabilitation outcome. Ina recent international study conducted across twocommunity-based mental health settings, employedparticipants in the Individual Placement and Support(IPS) group reported improved personal well-beingand increased self-efficacy after three months of employment [26]. Positive comments included beingmorefinanciallyindependent,higherself-confidence,a sense of accomplishment, and feeling better able tohandleobstacles.However,somenegativecommentswere also reported. These included deterioration inphysical health because of long working hours ormanual labour, increased anxiety, and not having   B. Gladman and G. Waghorn / Personal experiences of people with serious mental illness  837 enough personal leisure time. Among those whoremainedunemployed,theresponsesweredominatedby negative comments. Participants reported doubt-ing their own abilities or reported feeling uselessthrough not being able to gain employment. Othernegative experiences reported were reduced self-worth, poor self-esteem, and feeling worried aboutever being able to earn a living by themselves.Consumers who said they were not interested inlooking for work, would be interested if they werebetter informed about how employment can be man-aged without losing their health and welfare benefits.Another barrier to employment was low pay. Theauthors suggested that this be addressed by voca-tional programs helping consumers to develop skillsand qualifications that lead to better paid jobs. Cun-ningham et al. [9] compared experiences of thosewho had been successful in gaining and maintain-ingemployment,withthosewhohadbeensuccessfulgainingbutnotmaintainingwork,andthosewhohavebeenunsuccessfulgainingemployment.Theindivid-uals appeared to differ in three significant ways i.e.,the way they talked about their illness, the way theytalked about work, and the strategies they describedfor coping with bad days. It appeared that peoplewere aware of the pressures of work and the needfor better management of their illness when at work.Therefore, having a clear perspective on their illnessseemed to be a significant factor in being able to gainemployment. Perceiving the mental illness as only apart of who they are, emerged as a significant factorin maintaining employment. Similarly, Honey [16]interviewed41consumersabouttheirperspectivesonemployment.Participantsdescribedarangeofobjec-tive issues relating to the need to maintain mentalhealth, work goals, work confidence, and managingdifficulties with work performance. It has been sug-gested that the relationship between objective andsubjective measures of recovery can be blurred byidiosyncratic differences therefore to define the per-son as an individual and not as an illness, suggest amore subjective, personal measure of recovery needsto be applied when investigating best practice forassistingpeoplewithmentalillnessgainandmaintainemployment [7, 10, 11].The aim of the study was to increase our under-standing of the personal experiences of employmentand how these experiences can be used to informthe assistance provided in support of clients’ com-petitive employment goals. The implication is thatbetterunderstandingoftheseexperienceswillleadtomore individualized and tailored support, to reducetheincidenceofpreventablejob-lossandincreasejobretention in jobs that clients wish to retain. Hence,we were particularly interested in the personal expe-riences that had practical implementations for thedelivery of intensive supported employment servicesto people with severe mental illness. Although therehas been some valuable research in this area previ-ously,fewstudiesofsupportedemploymentprogramoutcomes have also examined personal experiencesin sufficient detail to inform service development. 2. Methods EthicalapprovalwasobtainedfromtheWestMore-ton and Darling Downs Human Research EthicsCommittee. All participants provided informed con-sent. Participants consisted of 23 males and 16females that ranged in age from 22 to 45 years(M=33.13, SD=8.11). All participants were diag-nosed with a psychotic disorder. The majority of participants were of Australian or New Zealanddecent. No significant differences between the inter-vention and comparison groups in terms of basiccharacteristicsandspecificresponseswereidentified. 2.1. Recruitment  Three public funded mental health case manage-ment teams in West Moreton (The Park, Goodna,andIpswich)wereinformedaboutthenewintegratedemploymentprojectinwhichanemploymentspecial-ist was made available to clients of the three mentalhealth teams. Each team received a formal presen-tation on the project and was invited to refer clientswho met eligibility criteria. Project inclusion criteriawere:Expressedinterestincompetitiveemployment,available to work for eight hours or more per week,disability employment services in the local area [30].Clientsallocatedtotheactiveinterventiongroupwerereferred to one of two employment specialists co-located within two of the three mental health teams.Each employment specialist assisting interventiongroup clients followed practices recommended forhigh fidelity IPS services. Comprehensive clientinterviews were conducted by trained research offi-cerswhohadprofessionalmentalhealthbackgroundsat baseline ( n =81), six months ( n =63), 12 months( n =53), and 24 months ( n =33). A good rapportwas developed between the researcher and partici-pant enabling the participant to fully express theirresponsetoeachquestion.Participantresponseswere  838  B. Gladman and G. Waghorn / Personal experiences of people with serious mental illness hand written by the researcher. Average interviewtime was 45 minutes. The research was conductedduring the period February 2007 and June 2010.Duringeachinterviewparticipantsfromboththecon-trol and intervention groups were asked a number of openendedquestionsdirectlyrelevanttotheirexperi-ences of employment. Other questions were directedtowards their related experiences of stigma, disclo-sure and social inclusion. The questions analysed forthis report were:1) Please comment on how your most importantrole gives you a sense of being a valued memberof the community (included in this study if theirchosen role was employment).2) Can you provide examples to illustrate why youthink your employment performance is at a par-ticular standard?3) In the past month, has any person treated youmore differently than you want to be treatedbecause you are a mental health consumer?Please give an example of how you have beentreated differently.4) Inthepastsixmonths,haveyoueverbeentreateddifferently because you are a mental health con-sumer to the extent that this has had an effect onyou today?5) Pleasegiveanexampleofadisclosureyourecallmaking in the past month.6) If no longer in this job, what was the reason forthe job ending? 2.2. Analysis The randomised control trial data used for thisstudy srcinally captured participant information atfour intervals: Baseline, 6, 12 and 24 month. How-ever, in this study, data covering a period of 12monthswasutilisedasthistimeframehasbeenfoundto be a sufficient period to reflect personal experi-ences of employment in a competitive environment[2, 5, 9]. Given its combination of grounded the-ory, positivism, interpretivism and phenomenologyan Applied Thematic Analysis (ATA) [31, 32, 35]approach was applied. Applied Thematic Analysis(ATA) is an inductive analysis method for qualitativedata involving multiple analytic techniques suitableto identify both implicit and explicit ideas withinthe data set i.e., themes that revealed attitudes toemployment and the personal experiences of obtain-ing and maintaining employment. Because we useda thematic approach, a robust three-way classifica-tion system was also applied to elucidate themes andfurther enhance data interpretation.With the purpose of retaining a focus on per-sonal experiences with practical implications fordelivery of employment services, only commentswith positive or negatives themes were gathered.Thoseresponsesthatappearedneutralorwhichcouldnot be clearly interpreted as positive or negative,were excluded from further analysis. The commentswere classified according to type of theme, (posi-tive or negative), type of intervention i.e., ControlGroup(CG)orActiveInterventionGroup(AIG),andthe experience phase i.e., previously employed (butnot employed at time of interview); past employ-ment (was recently employed but employment hadceased at time of interview) and those still currentlyemployed.Credibility of responses in relation to employ-ment was determined via use of questions PEx8,PEx9, PEx13, NEx3, NEx5, NEx6 and NEx8. Thesequestions were best thought to capture credibleexperiencesthephenomenoninquestion[35,36]par-ticularly PEx8 and NEx8, responses from the sameparticipant recorded at different intervals. Trans-ferability of results was assessed via checking forpatterns of positive or negative experiences related toanyparticularemploymenttype,acrossallresponses.It is suggested that if a pattern is found indicat-ing a particular type of phenomenon, in this caseemployment, had produced overly positive or neg-ative experiences then transferability of results to adifferent type of employment may not be possible[31,32,35,36].ExamplesPEx1-PEx3,PEx9,PEx10,PEx11,NEx3andNEx14wereusedtoidentifyexpe-riences thought to be easily transferable to otheremployment settings. Consistency and conformabil-ity were achieved via use of two trained researcherswhoconductedblinded,crossreferencedanalysisandinterpretation of responses, hence also maintainingrigor, enhancing inter-coder agreement and strength-ening reliability. 3. Results Of the 39 experiences of employment anal-ysed across three time points (Baseline, 6 monthsand 12 months), 14/39 (36%) experiences wererecorded from the control group (CG: M=8/14,57%; F=6/14, 43%) and 25/39 (64%) experienceswere recorded from the active intervention group(AIG: M=15/25, 60%; F=10/25, 40%). Of the 14

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