Posted: July 19, 2005

'Not for service' - Part 2

In Part 1 of this blog (posted on July 7) I discussed the evidence presented by the Human Rights Commissioner and the Mental Health Council of Australia (MHCA) on the first day of public hearings by the Senate Select Committee on Mental Health. The transcript can be accessed by clicking on the link for the Canberra hearing of May 19. Part 1 made for grim reading. It documented a systemic failure to provide for the basic care needs of people with mental illness and the wilful neglect of human rights. The motherhood statements, which presume to define goals for the National Mental Health Strategy, are not supported by real resources. Data collection and outcome targets - to determine whether we are making progress or sinking to new depths – are notable for their absence.

The May 19 hearing also exposed the acute disadvantage experienced by people affected by mental illness who wish to engage in paid work. This was the focus of CofFEE’s Submission (No. 228) to the Inquiry and was a point noted by the Human Rights Commissioner. Dr Ozdowski observed that the past decade had seen no advancement in the area of employment for people with disabilities and that “people with mental illness have the highest rate of unemployment”. The MHCA also stressed the need to make systemic connections between vocational areas, employment service providers and the health sector to address workforce participation rates, which are low by international standards.

In the CofFEE paper we argue that the realisation of full equality and participation for people with mental illness (covenants to which Australia has made a commitment) will remain shackled by the operation of restrictive macroeconomic policy. In the absence of a prescribed right to work, and a state commitment to effective full employment policy, the job prospects of those affected by mental illness will remain remote. We establish how the current raft of disability employment policies - which aim to make people with disability more ‘employable’ - have been particularly ineffective for those with mental and/or episodic illness. We argue instead for a new policy paradigm in the form of a Job Guarantee (JG), which could synthesise the right to work with a full employment policy. Under this model, the role of the state will be two-fold. First, the state must provide the quantum of JG jobs required. Second, the state must ensure that the design of jobs is flexible enough to meet the heterogeneous and variable support needs of workers. This will require effective integration of the JG scheme with mental health, rehabilitation and employment support services in order to maintain continuity of care.

When it comes to the integration and coordination of services that people affected by mental illness will need in order to maintain employment Australia’s performance beggars belief. Appearing at the Senate hearing, Geoff Waghorn from the Queensland Centre for Mental Health Research said: “We have an award winning level of sectorisation and fragmentation of services”. He explained that there were five types of services unevenly distributed across four different sectors, and that while the money going into acute and continuing care had increased 65 per cent in the last decade, employment rates for Australians with mental illness had not increased in that time. Trying to sort out a new system of integrated employment, rehabilitation and care services will be the subject of CofFEE’s new ARC grant with Hunter Mental Health on creating effective employment solutions for young people with psychosis. Research on supported employment programs in the United States will be one of our first ports of call.

This brings me to the final witness on Day 1 of the Senate hearing – Professor Gary Bond of Indiana University who was visiting Australia as a guest speaker for Schizophrenia Awareness Week. Professor Bond’s area of expertise is on the use of the supported employment approach to enable people with severe mental illness to work in mainstream employment. His message for the Committee was straight-forward: “Firstly, people with severe and persistent mental illness want to work; secondly, they have the capacity to work; and, thirdly, in order to achieve this goal, they need the help of particular types of services”. He stressed the importance of work to a person’s sense of self and how one of the things we all need to have a satisfying and meaningful life is to be part of a community and to be productive. For many people with mental illness a lot of time is spent in isolation, watching television, going through repeat cooking classes in day treatment, leading a pretty empty life. Employment is one of the things that can change that picture and, importantly, supported employment is an evidence-based practice.

In his evidence, Bond referred to the lessons from 12 randomised control trials (“the gold standard in science”) comparing supported employment to a variety of vocational programs. Across the trials, 60 per cent of participants achieved competitive employment after involvement in a supported employment program compared to around 20 per cent for vocational programs. In all twelve trials supported employment participants achieved significantly better employment outcomes with respect to earnings, job tenure, time of first job, full-time employment and employment rate. These results leave those from Australia's Disability Employment Service programs for dead so what can we learn from these studies? Bond set out six key lessons from the randomised control trials:

1. The only precondition for acceptance into a supported employment program should be a desire for work. In particular, people with mental illness should not be excluded if they also have a drinking or substance abuse problem.

2. Supported employment must be integrated with mental health treatment.

3. The focus should be on mainstream employment without providing ‘stepping stones’ like day treatment or sheltered employment.

4. For an employment program to be successful, the supportive resources must be mobilised as soon as the person enrols in the program.

5. Jobs should be matched with the individuals preferences and interests; and

6. Given that mental illness is often episodic, supports need to be available over the long-term.

Blog entry posted by Sally