«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 liv.kinn@hib.no. 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 service users (Gewurtz, Cott, Rush, & Kirsh, 2012)
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» (Becker et al., 2008,ref; Bond & Kukla, 2011, p. 150) The IPS model assumes that most service users do not require intensive on-site job coaching.?
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)
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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 KONTEKST Fenomenologisk tilnærming 4 stegs analyse Inspirert av Giogi 2 x kvalitative dybdeintervju Intervjuguide 5 informanter i alderen 27-40 år, 3 kvinner, 2 menn Arbeidserfaring: 2 15 år, både i fast arbeid og i strøjobber Et av NAV sine Oppdatering og Yrkesplanleggingsku rs 17 uker: 9 uker teori, 8 uker praksis i 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!