Place-then-train models

«Tur-retur til arbeidslivet»
Kvalitative studier av hvordan personer med
alvorlige psykiske helseproblemer
har erfart arbeidsintegrering
Innlegg 29.10.2014
NOA høstkonferanse
Liv Grethe Kinn
[email protected].
Førsteamanuensis
Høgskolen i Bergen, AHS
Institutt for ergoterapi, fysioterapi og radiografi
Agenda
Mål, bakgrunn,
forskningsspørsmål,
metoder og funn i mitt
PhDprosjekt
Implikasjoner for praksis
PhD - prosjektets
hovedmålsetting
Å utvikle forståelse for hvilke
forhold personer med
alvorlige psykiske
helseproblemer selv vektlegger
som fremmende og
hemmende faktorer for
arbeidsintegrering, og hvordan
kunnskap om dette fenomenet
kan konstrueres
Bakgrunn
Bare ca. 15 % av de med
alvorlige psykiske
lidelser er yrkesaktive
Flertallet
ønsker
lønnet
arbeid
«Those who are working tend to be
underemployed and have poor job retention»
(Dunn, Wewiorski&Rogers,2010:185)
(WHO,2000;OECD,2012;McQuilken,Zahniser,Novak, Starks, Olmos& Bond,2003;Marwaha
et al., 2004,2007;Mykletun&Knudsen2009,Knudsen, Øverland, Hotopf&Mykletun2012)
Facilitators of work
participation
Konkurrerende paradigmer
innen det psykiske helsefeltet
Sykdomsorienterte modeller
«Recovery- from»=
Å være "symptomfri"
Patologi
Sykdomshistorie
Behandlingstiltak
Lege - pasient
«Stress og sårbarhet»
Akontekstuell
«Train-then-place models»
Bedringsorienterte modeller
«Being-in-recovery»=å
leve et aktivt liv på tross av
psykiske helseproblemer
Hverdagslivsfokus
Livshistorie
Ressurser
Erfaringskompetanse
Håp
Sosial kontekst
«Place-then-train
models»
(Anthony, 1993; Borg&Kristiansen,2004; Borg,Karlsson&Kim,2009; Boutillier et al, 2011; Corrigan & McCracken,
2005; Davidson, 2003; Davidson, Tondora, & Ridgway, 2010; Deegan, 2005; Topor,2011;Karlsson&Borg,2013)
«Train-then-place models»
Brukeren må tilpasse seg
samfunnets- og arbeidslivets
krav
Lære ferdigheter i trygge,
skjermede omgivelser
«Noen kan jobbe,
andre kan ikke»
(Rinaldi et al ,2008; Corbiere & Lecomte, 2009; Corrigan & McCracken,
2005; Kirsh, Krupa, Cockburn&Gewurttz,2010;Schafft;2013)
Mantra:
«Ting
tar tid»
« Place-then-train-models» -
Individual Placement and Support (IPS)
1. Focus on competitive employment; with “non-disabled”
coworkers, paying minimum wage or higher
2. Eligibility based on consumer choice
3. Rapid job search
4. Integration of mental health and employment services
5. Attention to consumer preferences in the employment
process
6. Individualized job support
7. Personalized benefits counseling (Bond et al., 2008, p. 281).
Criticism: Increased focus on rapid job
search in the IPS model resulting in….
…job offers being
concentrated at the
entry level with low
pay and few benefits
as well as decreased
attention to the career
development of
(Gewurtz, Cott, Rush, & Kirsh, 2012)
service users
To create career pathways for people with
SMI –
a challenging project
•
Both on individual and systemic levels
•
Fears on the part of the professional, individuals,
and families
•
A culture of low expectation
•
Failure to provide the support that we know works
•
A global “credit crisis” downturn
(Rinaldi, Miller, et al., 2010).
Why are certain IPS programs are more
successful than others?
(Dreher, Bond, & Becker, 2010; Rinaldi, Miller, et al., 2010)
The IPS standards:
«Employment specialists have
face-to-face contact within one
week before starting a job,
within 3 days after starting a
job, weekly for the first month,
and at least monthly for a year
or more, on average, after
working steadily, and desired
by clients»
The IPS model assumes
that most service users
do not require
intensive on-site job
coaching….
(Becker et al., 2008,ref; Bond & Kukla, 2011, p. 150)
?
Little is known about the
employment specialists actual
support strategies (Whitley et al.,
2010), but shortages in the followup support have been found (Bond &
Kukla, 2011)
Workers in the field of SMI
report shortages of on-going
support and role-specific
assistance
(Johnson et al., 2009; Koletsi et al., 2009; Waghorn & Lloyd, 2005)
Manglende kunnskap
om
Hvordan «motivere» til
arbeidsdeltagelse?
Hvorfor brukere «faller» ut
av arbeidslivet?
Hva kjennetegner «god»
jobb-støtte?
(Auerbach and Richardson,2005;Shankar&Collyer,2003;Kirh,Cuckburn&Gewurtz,
2005;Kirsh, Krupa, Cockburn&Gewurttz,2010)
?
Presentasjon av artikler,
og funn i min PhD
Research question
“What is known about persons with psychiatric
disabilities` experiences of facilitators and barriers
to participation in paid and unpaid work in sheltered,
transitional, supported, and open employment
settings?”
(Kinn, Holgersen,Aas&Davidson,2014)
16 artikler inkludert og syntetisert
Publisert i perioden fra
1996 til 2009
Totalt 602 brukere
Fem studier gjennomført i
USA,
tre i Canada,
tre i Storbritannia,
to i Australia,
en i New Zealand,
og to i Sør- Afrika
Datainnsamling: Intervju
Utvalg: fra 4 til 20
informanter i alderen fra 21
til 60 år
Kontekst:
Ulike “train-then-place” og
“place-then-train” tiltak
(Kinn, Holgersen,Aas&Davidson,2014)
Balancing on Skates on the Icy Surface of Work
Helplessness
Boring Routine
Isolation
Discouragement
Overconfidence
Overstimulation
High Social Demands
Unrealistic Expectations
(Kinn, Holgersen,Aas&Davidson,2014)
Getting off the bench:
(1) “fighting inertia, (2) taking control, (3)
encouraging peers, (4) disruptions related to
illness, and (5) lack of opportunities and
supports”
Skating on the ice:
(6) “going mainstream, (7) social cohesion,
(8) clarity in roles and responsibilities, (9)
environmental factors, and (10) managing
self-disclosure”
(1) Fighting inertia
•
Several studies suggested that confidence in
being able to get off the bench was enhanced by
participants’ involvement in activities other than
work
• Exercising, socializing, baking bread or
mingling at a Clubhouse, hanging out with
‘’ordinary’’ people (i.e., people who did not have
a mental illness), and volunteering all added to
participants’ skill sets and served as important
glimpses into what a life off of the bench
(Kinn et al,2014)
(5) Lack of Opportunities and
Supports
I could not use (my supervisor)
as a support or confide in
him... I'd look at him and put
myself down immediately, just
like I'm not doing good enough
and it would cause major
anxiety» [ 48 , p. 28].
«
(Kinn et al,2014)
(8)Clarity in Role and Responsibilities
«I like to know what are my duties, tell me
every one and how you want them and
when you want them due. My boss was
wonderful at telling me each step … I’ve
been in other jobs where they kind of want
you to figure that out»
([56 , p. 176]:ref; Kinn et al,2014)
(9) Environmental Factors
«He [the manager] just said: when can you
start, there are so many hours, and I don't give
breaks.
And I thought well, he got to be joking, not
getting breaks. But he wasn't. And that was it.
That was the interview. Researcher: Was [the
employment support worker] there? Yes.
Researcher: And [the employment support
worker] heard him say he didn't give breaks?
Yes. Researcher: How many hours do you work?
Eight and a half hours a day. Researcher: Not,
without a break? Yes»
([ 2 ];ref; Kinn et al, 2014)
19
Research question
“How do persons with severe mental health
problems experience their personal
occupational history and what was it like for
them to be participants in a transitional
employment course?”
(Kinn, Holgersen, Borg&Fjær,2011)
METODE
UTVALG
Fenomenologisk 2 x kvalitative
tilnærming dybdeintervju
4 stegs analyse Intervjuguide
Inspirert av
Giogi
KONTEKST
Et av NAV sine
Oppdatering og
Yrkesplanleggingsku
rs
5 informanter i alderen 2740 år, 3 kvinner, 2 menn
17 uker:
Arbeidserfaring:
9 uker teori,
2 – 15 år, både i fast arbeid 8 uker praksis i
og i ”strøjobber”
ordinær bedrift
(Finlay1999;Malterud 2003;Giorgi 1993;Kinn et al,2011)
Article 2:
Results
4 main themes
“1. All it takes to have a life
2. Being on the right track
3. Asking for feedback
4. Candidates – for what?”
(Kinn, Holgersen, Borg&Fjær,2011)
3 av de 4 overordnede funnene i
min avhandling:
"1. For some people working is like iceskating
2. Pushes-and-pull mechanisms place
people on the sideline
3. Engagement in everyday activities is
helpful"
1. For some people, working is like
ice-skating
«I have hardly limited myself because of my problems,
but rather pushed my borders. Consequently, I often find
myself in difficult situations. … As a student: I was
periodically sneaking around in the corridors at school,
unable to socialize with my classmates… Some years
ago, I worked for a temporary employment agency –
doing boring tasks like selling sausages. In order to fulfill
the expectation, I tried to act perfect. Even so, I ended up
having several emotional outbreaks at work. So I couldn’t
meet my colleagues’ eyes and quit» (Silje, interview 1)
(Kinn, Holgersen, Borg, & Fjær, 2011)
Many of the informants struggled with
self-doubt and felt uneasy at work
«I have often felt like I wished I were a fly on the
wall in people’s offices, so I would know how
real people acted in a situation, rather than me
struggling through where I was. If I knew how
“normal” people did it, then I would be able to
copy it»
(Kirsh, 1996, p. 30: ref;Kinn et al,2014)
How can persons with SMI learn
to cope with a working life?
•
Studies 1 and 2 showed that those who managed to
succeed were assured by internal and external positives
•
The informants in both studies consistently reported
that a high degree of emotional and practical support
had assisted them in acquiring a job – a finding that is
consistent with the results of previous research
(Kinn et al,2011,2014)
•
It is known that service users who received
positive messages from at least one source were
more able to obtain and retain jobs (Killeen & O'day,
2004;Kinn,2014).
2. Pushes-and-pull mechanisms place
people on the sideline
"In the job interview I was clear that I am completely
not practical. However, now I am supposed to be a
kind of handy-man such as using the hammer, which
is a typical task that I claimed that I don't handle. I am
not the right person for this job! I am only one extraperson with unpredictable duties.This role makes me
very insecure. I don't know how to present myself
towards my colleges. When I come home after work, I
am completely exhausted and even I haven't used my
know-how and skills"(Knut, interview 2)
(Kinn, Holgersen, Borg, & Fjær, 2011:442)
3. Engagement in everyday activities
is helpful to grow into a worker role
•
Many of the participants in studies 1 and 2 reported that
meaningful activities, such as homemaking, baking bread,
taking care of pets, data, painting, knitting, writing poems,
playing an instrument, singing in a choir, playing sports,
staying informed, or mingling with “ordinary” people in
public, positively influenced their recovery processes and
work ability
•
The health benefits of “balanced” occupations may not be
an unexpected finding, although it actualizes the notion that
recovery is coupled with a person’s growing self-realization
(Kinn et al, 2014)
Doing-being-becoming
Personal experience with
doing, as well as being
and belonging in the
atmosphere of doing,
enables people to foresee
new possible roles to be
filled, beyond being “sick”
(Davidson, 2003; Wilcock, 1999;Kinn et al,2014)
Occupational Engagement
«First and foremost, I like sitting on a bus
early in the day, being part of the so-called
usual life. I am one of those who are busy, on
my way to a setting, which is important for
me. Now I can define myself as a contributor,
not as a person standing on the sideline,
who doesn’t manage to be a part of society»
(Silje)
(Kinn et al., 2011, p. 440)
Implications
•
To facilitate work integration, employment
specialts should analyse and value service
users occupational narratives, interest and
needs - not only those related to the work
place
•
To focus on activities that makes a
person feel good (Kinn,2014)
Implications
•
Professionals such as providers, employment
specialists, and job coaches must analyze
and redefine several aspects of the quality of
employment support
•
Listen carefully to and draw on the
experiences and preferences of service
users in the collaborative process of work
integration
Takk for oppmerksomheten!