Supporting Clients with
Mental Health Problems:
The Career Practitioner’s Role
Neasa Martin & Kathy McKee
Cannexus Confere...
Project’s Roots
Project context
MH work-related costs


Fastest growing occupational disability



Cost to Canadian economy





$14.4 B lost product...
Understanding stigma & discrimination:
What is stigma & why does it exist?
Stigma Attribution Model
1.

Labeling: Characteristics
signal important difference.

2.

Stereotyping: Differences
linked ...
Decade of the ‘Broken Brain’
Self-stigma is common
What works to reduce stigma?
Contact is most effective…
Contact is common - disclosure is not - creates a distorted image





Relationship of equa...
Social inclusion is the journey towards greater
participation and citizenship…
Survey Findings:
Project Approach

May 2011

Sept. 2011

May 2012
Survey tool
Who participated?
266 survey participants in total (81.5% completion)


176 Career practitioners




46% report having ...
Contact is common - 1 in 5
“Only those close to the person would ever know they
are experiencing a mental health problem” Client

Career Practitioner...
Disclosure is not…
Disclosure
People disclose when they feel safe
LIKELY to DISCLOSE

LIKELY to be ACCEPTING

Spouse

92%

90%

Family

90%

...
To help clients Career Practitioners
need to know… Impact of stigma on work (99%)


over
90%
agree

mental illness (99%)
...
Clients rating vs Career Practitioners







Knowledge of mental health
Making right referrals
Recommend peer suppo...
Client rating cont…
Strongly/Agrees

Career Practitioners:
 Share tools for coping with work
 Good support & access work...
Satisfaction working with clients
“Same as with all clients”
Seeing progress… Supporting change… Gaining trust… Helping
cl...
Frustrations working with clients
Barriers to employment
“Sometimes (stigma and discrimination) is very apparent and other times it is hidden but
lurking be...
Impact of mental health
problems?
Client rating








Self-confidence
Finances
Employment
Community involvement
Fa...
Have you seen workplace discrimination?
Clients:

90% - Yes “Happens all the time…”

Career Practitioners:

48% - Yes “Qui...
Clients agree…


Agree discrimination is common

(96% vs 76%)



Few feel fairly treated by employers

(< 7%)



Agree ...
In client / counselor relationship very/important…

choices



90%

CLIENTS

agree

Given



Believes my capacity to rec...
Strong agreement on how to help
“Treat People Like People… Not a Disorder”
“Include us as partners in planning”
Where would clients prefer to
receive career planning service?

43%

23%

18%

16%
Career Practitioner Training Needs
Take away messages…
Last Words…
“Have your people not be therapists...but be knowledgeable about the
clients they are trying to help integrate...
http://chartingthecourse.nscda.ca/index.php/workplace
Stigma & Discrimination Related readings
Bio-medical framing

Angermeyer M, Matschinger H. Causal beliefs and attitudes t...
Education & changing attitudes

Spagnolo, A. B. Murphy A. A. and Librera L. A.. (2008) Reducing stigma by meeting and lea...
Charting the course project overview Cannexus 2012
Charting the course project overview Cannexus 2012
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Charting the course project overview Cannexus 2012

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CERIC funded a province wide research study focused on understanding the barriers people with mental health problems face when accessing employment counselling services. Sponsored by the NSCDA.

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  • INTRODUCTION BY KATHY
    Neasa as project researcher
    Kathy as a career practitioner, Manager of a rural NS career resource centre, board of the NSCDA
  • Project Roots
    Over the course of many years – discussions about mental health and the social inclusion movement – can’t help but do it when someone is so passionate about their work
    Interestingly enough – parallel to these discussions the issue was popping up around me
    Was I just being sensitized to the topic of mental health or was there an actual increase of incidence in our work?
    In analyzing our work, we saw clearly that it was a trend that was increasing, in step with economic difficulties, mass exodus of labour to the west and beyond and coupled with the difficulties inherent in the economies of rural communities in Nova Scotia – decreased production, demographic change, loss of hope
    Discussion ensued – what do we do with the crazy people, do they belong here, how can we provide help, why aren’t they moving forward faster, not dependable, frustrating
    Realization that we didn’t know enough – worried that we were doing harm and at times embarrassed that we really didn’t want to deal with ‘them’.
    Neasa invited to present to my staff – we realized that problem was us – our beliefs and attitudes needed to be examined.
    Not to say that we lack compassion or desire to do the right thing, only that a light bulb went off for staff when we realized that our systems, beliefs and experiences may have been contributing to the problem.
    I also am the Chair of the CRC Managers Group in NS and have had province wide discussions with other stakeholders about this issue – the comments were the same. Mental health was seen as an increasingly important issue in our work.
    CERIC was approached:
    Could we get a handle on this issue academically? How can we confirm what is going on and how could we tease out what importance this issue played in the work of NS Career Practitioners?
    NSCDA – sponsor, well developed CP leadership team, small province, well connected
    CERIC – funder – priority issue for members - Funding fast tracked - Right issue… partners… approach. Right time!
    NEASA – researcher knowledge and experience with employment, recovery, stigma and discrimination
    KATHY– project enabler – make connections
    This project is all about planting seeds and hoping something takes root!
  • EMPLOYMENT &amp; Mental Health Problems /Mental illness
    Work is a cornerstone of QOL &amp; social inclusion. It provides us with our sense of identity, purpose and worth.
    Work connects us to community and is a source of friendships.
    Conversely unemployment leads to poverty, isolation and lessened self esteem.
    Unemployment for people identified with MHP/MI much greater than can be explained by the impact of illness.
    Significantly higher than any other disability group.
    Stigma &amp; discrimination are seen as BIG barriers. Addressing this issue an important first step.
    Career counselors serve as critical gatekeeper &amp; enablers of training and employment.
    Indications that there is increasing disclosure within career counseling. practice
    Staff attitudes influence client work/training. “do they belong?”
    Currently there is no systematic training for career practitioners.
    Uncertainty regarding ‘best practices’.
    NSCDA willingness to lead but this is a national issue.
    Project intended to test assumptions, Identify needs - create an action plan
    Project Goals: Improved employment opportunities &amp; enhance social inclusion people with MHP/MI
  • Work Place Mental Health is an issue gaining high visibility.
    Presenting an opportunity for meaningful change.
    Single-biggest cause of work-related disability.
    MHP Fastest growing occupational disability.
    60% work-days lost due to depression.
    1/20 workers diagnosed with MHP/MI.
    Recognition that workplaces can cause MHP/MI - Many employers handle them poorly.
    Leading to increased time off, reduced successful return
    Increasing focus placed on workplace mental health
    Healthy, engaged employees, increases profits (by an estimated 43%)
    Focus on prevention &amp; early intervention.
    Legal context: Bill C- 45 - ‘Do no harm’, duty of care,  litigation,
    Bill 168 Ontario - Preventing Workplace Violence And Workplace Harassment
    Motivating employers to take action
    Improving workplace mental health benefits all employees
    A rising tide raises all boats. Supports accommodations for people with MHP/MI
  • Thirty years working in mental health working across the mental health system
    The last ten years as an independent mental health consultant with stigma, discrimination &amp; social inclusion as particular focus.
    I have undertaken extensive reviews of the research, consulted with international experts and conducted broad stakeholder consultations on this issue working with diverse clients including the MHCC, Canadian Medical, and Psychiatric Associations, general and provincial psychiatric hospitals, NNMH, SSC and the internationally Queensland Alliance.
    What I have learned through these reviews has dramatically changed my thinking.
    All stakeholder groups, see stigma and discrimination as a priority concern in mental health.
    The research literature confirms a litany of misery that it causes.
    People living with mental illness describe discrimination as pernicious and pervasive.
    What is the impact of stigma?
    Self image, self-esteem and affect - stigma can be deadly an is identified as a factor in suicide
    Help seeking, treatment (engagement, &amp; outcomes)
    It effects employment - not hired, not promoted, fired or for some people give up believing in their capacity to contribute.
    Poorer health care, more chronic illness, shortened life span - 10 years
    Social roles - multiple losses - loss of friends, withdrawal of family, marriage breakdown, rejection by neighbours
    Reduced access to resources and denial of services such as life insurance, mortgages,
    Social policy - government neglect, systemic under funding research, services and supports.
    Human rights - routinely violated, victimization, criminalization, unable to cross the border.
    Stigma enables discrimination
    The research has primarily focused on the individual impact of stigma - framing the issue primarily as an illness-based phenomena.
    Less attention has paid to exploring what helps stop discrimination, protects people from stigma or in minimizing its sting.
    National anti-stigma campaigns are underway around the world, are being carefully evaluated and bringing new insights.
    The emerging trend internationally is to understand this NOT as a health issue but one of social justice, human rights and ultimately social inclusion.
  • What is stigma?
    Stigma is defines as a “mark of shame, disgrace or disapproval”
    It is the negative, internal ‘feelings &amp; beliefs’ we hold about stigmatized groups
    It is important because it limits opportunities, options &amp; influences identity.
    It is culturally defined and socially imposed - and differs across cultures - and is not immutable to change.
    Research describes a number interconnected FORMS of stigma:
    1) Health-related stigma - You are not worthy
    2) Self Stigma - I am not able
    3) Courtesy Stigma - You must be crazy
    4) Label avoidance - I won’t let people know - avoid treatment
    Discrimination is the external ‘behaviour’ resulting from prejudice including laws, institutional policies, practices &amp; denial of rights.
    Corrigan describes three related problems:
    1)Lack of knowledge (ignorance)
    2)Negative attitudes (prejudice)
    3) Excluding/avoiding behaviours (discrimination)
    It is built on repeated exposure to misinformation - media
    Which reinforce negative perceptions
    False beliefs are intensely held and enduring
    Results from fear and mistrust of differences
  • Phelan &amp; Link’ Attribution Model
    How do people acquire a ‘spoiled identify’.
    Labeling people as different: Key characteristics are identified which signal to others important difference.
    Stereotyping: Differences are linked to undesirable characteristics. (most common for mental illness are violent, incompetent, impulsivity, unreliable, incapacitated)
    Separating: Distinction made between ‘normal’ &amp; labeled groups creating ‘them &amp; us’.
    Status loss: leading to devaluing, rejecting, discriminating &amp; excluding.
    Discrimination depends on social, economic &amp; political power.
    Decreasing discrimination requires changing attitudes &amp; beliefs of powerful groups that lead to labeling or by limiting their power.
    Career practitioners can facilitate access to resources - powerful group
  • Work by Bruce Link, Phelan, Augermyer, Corrigan, Wahl decades of tracking public opinion.
    Despite considerable public education efforts - stigma and discrimination is increasing
    Why are things not improving?
    Mental health literacy / promotion has been a dominant approach to addressing stigma.
    Professions the dominant ‘expert’ voice.
    Goals is to bring public thinking into alignment with medical model of mental illness.
    Raise awareness, teach signs &amp; symptoms, emphasize potential risk of morbidity, disability &amp; mortality
    Our understanding of mental illness is rooted in Western bio-medical disease model,
    Neuro-scientific attribution of illness, genetically-based, chemically mediated - ‘broken brain’
    Intention is to emphasize it is NOT a character weakness - not your fault - Illness like any other.
    Encourage help seeking - see your doctor - treatment (medications) helps.
    Goal is to build compassion.
    This approach is thought to increase - not reduce stigma
    GOOD NEWS
    Public is now more accepting of biological, genetic basis of mental illness
    Better able to recognize mental illness &amp; more supportive of funding for treatment
    BAD NEWS
    Unanticipated consequence is the public holds more stigmatizing attitudes
    Increased tolerance of discrimination and desire for greater social distance
    Increased perception of dangerousness, incompetence, untrustworthy
    Decreased belief in potential for recovery - particularly for schizophrenia, psychosis, &amp; bipolar disorders
    If knowledge of mental illness and its treatment is not the solution alone.
    Research also tells us that there is more stigma and discrimination amongst health care providers.
    Many people highly value support they receive. In QOL survey 93% acknowledge that mediations are critical to their QOL.
    Yet stigma in HC is a top priority - people seeking systemic change.
    In multiple surveys people report experiencing high levels of stigma - often 1st exposure is in health care - sows the seeds self doubt.
    Painful experience - people feel confused, hurt, sad &amp; angry.
    Research reveals that health care providers DO hold more stigmatizing attitudes than general public.
    More pessimism of recovery - well beyond research evidence.
    Encourage lowering expectation: work, school, risk taking, parenting, marriage, use of peer support, social activity.
    Pessimism results in greater focus on symptoms management &amp; avoidance of adverse incidents.
    Less investment in recovery-oriented services.
    Focus primarily of treatment is on medications and compliance - not social context within which the illness occurs.
    Staff tend to be more directive, authoritarian, ê treatment choices.
    Greater tolerance for coercive treatment &amp; loss of rights.
    Once Dx - MI assumes “master status”
    ‘Diagnostic shadowing’ &amp; under diagnosing:
    Poorer physical health, more chronic illnesses (diabetes, heart disease, strokes, metabolic disorder…)
    Medical complaints ascribed to mental illness.
    ê investigative testing, ê interventions, poorer outcomes.
    Emergency room care - é waits times, “not real patients”, “cluttering up my waiting room”.
    Receive less health promotion &amp; preventative medicine.
    Side effects &amp; risks of medications not explained.
    Life span shortened by 5 to 10+ years.
    There is MORE stigma when:
    People are treated by psychiatrist, Psychiatric hospitalization, Use of seclusion, CTO’s, forced treatment. Emphasis on psychotropic medications.
    Impacts self-stigma . Medications have stigmatizing side effects- wt gain, restlessness, fatigue, sexual dysfunction.
    Reminds people they are different, &amp; are seen as different by others
    There is LESS stigma when…
    MI is seen as an understandable response to social stress, losses or hx of trauma or abuse
    Public more accepting of depression &amp; anxiety because they are seen as “normal with the volume turned up”
    Descriptors are used rather than dx. If treatment is perceived as successful and recovery is promoted.
    In societies where mental health services are provided - particularly funding for community-based services.
    Government policy neglect contributes to stigma and discrimination
  • More attention is being paid to addressing self-stigma
    What is self-stigma?
    People living with mental illness hold similar attitudes to broader community.
    Self-stigma is self hatred, internalization of negative beliefs - stereotypes.
    Harsh self-judgment,  doubt &amp; blame.
    Withdrawal, isolation, - negative comparisons to others. self limiting.
    Rejection of others with people with MI.
    Fear of rejection or failure:
    won’t pursue opportunities or
    challenge discrimination.
    Overcompensation  burnout.
    Hopeless, helpless,  belief in recovery.
    Anxiety, angry, despair, suicide.
    Sources of self-stigma
    Feeling ‘different’, not ‘fitting in’, being a burden.
    Neg. media portrayals of MI.
    Rejection by family, friends, employers, neigbours...
    Contact MH services.
     Identifying with diagnosis. Secrecy regarding illness.
    Gov. neglect - lack of parity &amp; equity of $ services.
    Career practitioners need to be mindful of the impact of self stigma on clients
  • Major source of health information is through the media
    Although reporting is improving - media has played a significant role in linking violence, incompetence and mental illness.
    Otto Wahl
    1 in 4 pg rated films had a character identified as mentally ill
    Children are constantly bombarded with negative messaging
    Violence and villainy most common role
    People depicted as different, dangerous and incompetent. Unlikely to recover.
    Media calls on health care professionals to speak about mental illness. Trusted and respected.
    Challenge is they may be more pessimistic, emphasize morbidity, mortality…
    Few consumer perspectives included within media - Lack a 1st person language
    Signals incapacity to speak for oneself. Inconsistent with other disability groups.
    First person voice - share the journey but emphasizing recovery not disability
    International trend is consumers/ family generating their own media
  • Best Practice Principles drawing from the research, international anti-stigma programs and advice from the experts:
    CONTACT/EDUCATION/PROTEST
    EDUCATION
    Information alone does not change attitudes:
    Increase understanding of challenges people face (including discrimination)
    How challenges are overcome
    What helps people recovery
    How others can be helpful
    Messages of equality, hope &amp; recovery
    Creative media increases impact
    Framing matters - mental health problems are best framed as part of the human condition
    Understandable response to a unique set of circumstances
    Not purely bio-medical, genetically based or a diseased state of the brain.
    Create a simple, enduring national vision which promotes human rights, social inclusion and full citizenship
    Support grass roots, local programming
    Work in partnership with government / stakeholders
    Multi-sector plan for systemic change of service system
    Legislative and policy level
    Target programs at influential groups
    Emergency response
    Health care providers
    Police
    Teachers
    Counsellors
    Friends &amp; family
    Religious leaders
    Include them in creating messages and delivery
    Assist media to play a significant positive role - depicting people as competent, capable &amp; productive
    First person narrative
    Challenge inaccuracies or discriminatory portrays
    Challenge myths of violence, incompetence…
  • Direct personal contact with people who experience mental illness is the best approach:
    Relationship of equal status
    Context of cooperation
    Opportunity for discussion
    Credible presenters - disabuse myths of dangerousness, incompetence &amp; incapacity.
    Celebrates differences, recognizes contributions and abilities
    Have lots of contact (1-5) – what we don’t have disclosure
    Emphasize positives of disclosure - with broader disclosure - problem would be solved - 1 in 5
    Reducing self-stigma
    Peer support inoculates against self stigma. Sense of accepting community
    Positively reframing mental health problems ‘strong &amp; courageous for seeking help’
    Greater tolerance and understanding
    Deeper, richer sense of self
    Sense of pride in overcoming adversity
    Strong and courageous seek help.
    Advocacy enhances empowerment
    Helping others gives purpose and meaning to illness
    Support people living with mental illness in active leadership
    Consumers included in setting priorities, designing programs, doing research
    Protest, disclosure and group identification are cornerstone
  • Many people living with mental illness will tell you that managing their illness alone is insufficient to achieving full citizenship and that they face real structural barriers to inclusion.
    Social Inclusion is a journey towards greater participation &amp; citizenship.
    The indicators of inclusion are:
    Employment
    Secure housing
    Friendships
    Supportive family
    Intimate relationships
    Meaningful roles in community
    Active civic engagement
    Equal access to health &amp; social services.
    Social inclusion places stigma and discrimination within a larger social context.
    Emerging from Europe - there is recognition that not all groups are benefiting equally economically and some face structural exclusion:
    people with ill health, disabilities, immigrants, ethno-racial communities, sexual orientation, gender or age. Intensify with multiple membership.
    The process of exclusion is complex and multi-facetted.
    It includes the denial of goods and services, inability to participate in ‘normal’ relationships, and exclusion from activities enjoyed by majority of the population.
    It has economic, cultural, political dimensions.
    Stigma &amp; discrimination play a fundamental role in the exclusion process.
    Results in decreased quality of life, inequality, and a loss of social cohesion - for ALL members of society.
    Unless addressed exclusion becomes chronic &amp; intractable - unsolvable at the individual level.
    Adopting this model requires a whole of government approach and the collaborative efforts of all stakeholders to work together.
    UK, Scotland, Ireland, Australia have each adopted this approach with Sr. Government Support.
    Strategic planning across ministries and involving broad stakeholder groups.
    Stressing equity and parity in resource allocation.
    Health and social service transformation - recovery.
    Focus on individual economic inclusion.
    “If you don&amp;apos;t know where you are going, any road will take you there”.
    Social Inclusion: journey towards greater participation &amp; citizenship:
    Proactive approach by gov’n, pubic service, NGO’s to remove access barriers.
    Disability is imposed - Tx can’t solve.
    From separated to mainstream services.
    Job placement vs vocational training.
     number of people working.
     partic. in education &amp; training.
    Remove barriers that limit employment:
    Punitive disability pensions;
    Adopt client-centred approach - offer practical assistance;
    Job placement, workplace support;
    &amp; education (employers/workmates).
    Community development and health promotion.
    Social Inclusion Theory draws together three intersecting models
    Disability Model:
    Disability not just a health issue.
    Treatment alone can not solve.
    Disability imposed from outside as a result of prejudicial attitudes &amp; structural barriers
    Social Determinants of Health:
    Illness, disability and exclusion result when social determinants of health are not in place.
    Their absence is a cause, contributes to is the consequence of illness/disability.
    Mental Health Promotion
    Creating mentally healthy and inclusive societies for all.
    Includes anti-violence, anti-discrimination, building resilience/coping, civic infrastructure, and supporting, individuals, families and communities.
  • Action oriented research - transformative change
    Focus: Career stakeholders, policy makers &amp; service users.
    Applying a stigma and discrimination filter to project development
    Finding a new course in uncharted waters - identify learning&amp;apos;s as we progress
    Approach: Surveys, regional workshops, identify barriers &amp; enablers, share resources, undertake provincial planning &amp; foster national engagement.
  • Engaged ‘end-user’ in survey design - on-line and hard copy
    Building on stigma research and MHCC/Stats Canada survey we asked about:
    Work experience
    Attitudes and belief re working with clients with MHP/MI
    Employment barriers and enablers
    Contact and disclosure
    Stigma and discrimination
    Training and education needs
    Best advice for NSCDA
    Qualitative and quantitative questions…
    Promoted through NSCDA network, mental health consumer, family, mh rehabilitation, health service, &amp; networks. Multiple prompts.
    Used Survey Monkey - cautions
    Thematic analysis of data
    Regional meetings - preliminary ‘test’ findings - timelines extended.
    Cannexus 2012
  • Avoided using ‘clinical’ definitions of mental illness because of the research on how diagnostic labeling increases stigma. Used definition from MHCC/Stats Canada
    People have differing opinions on what constitutes a mental illness ie depression and anxiety are not seen by many as a mental illness
    Definition: “an emotional or mental health condition that may need treatment from a health professional. This includes any mental disorder that significantly interferes with a person&amp;apos;s functioning (mood &amp; anxiety disorders, psychotic disorders, excessive stress, substance abuse, gambling disorder etc.)”
    266 survey participants
    176 Career Practitioners
    Over half working as career practitioners, 8% counselors at Masters level, 1/3 employed in job resource centres, 14% were mental health professionals
    91% report they are working with people with mhp/mi
    57% feel number of clients disclosing mhp/mi is increasing (27% don’t know)
    85% provide individual counselling, majority work as part of a team, working with clients in groups
    40% respondents working less than 5 years in employment field, 31% over 11 years experience
    CP working across the spectrum of population and age groups
    90 service users - 62% female, 38% male - 41% under 40 years old, 39% over 40 years old
    Across the province, 46% live in Halifax
    Education of mhp/mi: 47% college/trade, 20% university &amp; 6% grad. degree, 14% high school
    Employment: 34% unemployed, Less than 1 year = 30%, 1 - 5 yrs = 56% &amp;lt; 1 yr, 11% &amp;gt; 6 yrs, 4% no paid work history
    Income: 43% employment, 40% prov. &amp; 11% fed. assistance, 17% training, student loans, Relying on $$ friends, family, savings.
    Service users without mhp/mi
    Slightly younger, less educated, slight increase in full time employment, student or in training
    SU MHP/MI:  full-time employment,  under/ unemployment,
     training,  disabled/unable to work,  student /caregiver
    SU MHP: unemployed  1 yr = 39%; 1- 5 yrs = 54%;  6 yrs 5%.
  • Contact is much more common than people think - people with mental health problems/illness are not the black sheep.
  • MHP - people seen as somehow different and other - yet mhp are common.
    “Only those close to the person would ever know they are experiencing a mental health problem”
    Research tells us contact is critical for shifting attitudes and behaviour.
    It has been said stigma is a problem which could be solved if everyone who was impacted shared their experience with others.
    Contact is common but disclosure is not! So we have a distorted vision of mental illness.
    People choose to suffer alone rather than risk discrimination.
    46% of Career practitioners report having experienced a mi.
    Career practitioners identify mhp/mi in co-workers at twice the rate.
    Contact is increased due to participation in treatment, peer support groups.
    Greater degree of acceptance of others with MI when this is a shared experience
    Rates of contact for clients who do not identify as having a mental illness are significantly lower
  • Would you tell your boss?
    No - I would loose all credibility!
    Service Users 62%
    Career Practitioners 37%
    Yes - I have nothing to hide!
    Service Users 21%
    Career Practitioners 37%
    Depends - Only if I had to!
    Both - 30%
    72% of CP feel their employer would be very/supportive.
  • Meaning:
    People disclose when they feel safe
    Many clients won’t disclose - for fear loosing benefits - being denied access to resources
    Clients disclose to career counselors but they aren’t always accepting
    Disclosing to workmates is risky - not always seen as supportive
    Teachers are not seen as overly supportive
    Close connections (spouse/family/friends) are trusted and as supportive
    More likely to disclose to employers but not seen as supportive
    Neighbours (public) are not seen as accepting
    Both career practitioners and their clients expressed ambivalence and uncertainty about disclosure
    Recognition of the risks - discrimination &amp; reject but also the right and potential for accommodations
  • There is a high level of agreement on what CP need to know to be helpful in supporting clients with mhp/mi
  • Career practitioners rate themselves highly on a number of key areas
    Clients giving them a failing grade
    Understanding of mental health problems (58% vs 81%)
    Comfortable discussing mental health problems (51% vs 57%)
    Confident refering clients to service (CP 86%)
    Makes right referrals for resources (51% vs 81%)
    Discusses +/- disclosure (41% vs 66%)
    Recommend peer support (40% vs 88%)
    Explains rights &amp; entitlements (36% vs 55%)
    Comfortable working with MHP/MI clients (33% vs 57%)
    Understands legal rights (33% vs 55%)
    Address clients mental health - all clients! CP 96%
    Stigma an issue in career counseling. CP 77%
  • Inadequate CP training, confidence
    discomfort working with MHP/MI.
    Some CP felt that people who lacked knowledge of mental illness risk doing more harm than good &amp; those who disclose or are identified should be redirected to specialized services
    In some career centres this is a formalized policy - in others CP will refer to specialized services depending on their comfort and confidence in working with mental health clients and availability of alternative services.
    Inadequate health-care supports, wait times, systemic issues.
    Complex needs, limited time to support, role / mandate limits.
    Having to ‘pass off’ clients - policy.
    Feeling lost, hopeless, powerless, little to offer.
    Difficult clients, lack insight &amp; motivation, cyclic illness, unrealistic goals, not ‘job ready’.
    FRUSTRATIONS WITH HEALTH CARE SYSTEM
    Difficulties regarding treatment
    Difficult to access, long waiting lists
    Access particularly challenging in rural areas.
    Too focused on medications, no support, pessimistic about work - discouraging clients - limits options, illness rather than wellness focused
    Too often people are not being connected to mental health services.
    Most career practitioners want closer working relationship with mental health services.
    When mental health resources are available and there is connection between career counseling and treatment then people report better quality of service and success in returning to work/training.
    The lack of community knowledge about mental illness plays a significant role in stigma and social exclusion.
  • Both Clients and Career Practitioners identified similar barriers:
    External barriers
    # 1 barrier is stigma, followed by discrimination &amp; fear.
    Fear of people with mental illnesses, rejection of differences
    Employers - won’t hire, lack of support, motivation, have limited knowledge of MI. Unsure how to accommodate
    Service users are more likely to report pessimism - by all professionals, limited knowledge of mi &amp; recovery,
    Lack mental health counseling skills, feelings of being judged and a lack of empathy.
    Co-workers attitudes -  competent,  burden,  ostracized,
    People face multiple challenges as both a cause and a consequence of mental illness such as:
    poverty, instability in housing, childcare, health, legal, transportation.
    Particularly true in rural NS - lack of career planning and mental health service &amp; barriers of transportation.
    Limited supports - mental health services, medical care  too narrow a focus,  job coaching, loss of family, friends, social exclusion and isolation
    Structural barriers, limiting policies, benefit loss ($$, meds).
    Internal Barriers: Client limitations - work gaps, concentration, communications, loss of self-confidence, decreased self-esteem, lost dreams,  risk-taking - $$ fears, stress of hiding MI.
    Unique barriers identified by career practitioners:
    Lack of insight, motivation, symptoms of illness, denial of illness, unrealistic goals, not employment ‘ready’,
    Fear of violence (CP).
  • Clients rating sever/ moderate impact:
    The impact of mhp/mi is global and profound. Addressing only employment issues without looking at other life domains will impede efficacy of career counseling process.
    Traditional siloed approach is not working for people with mental health problems/illness .
    Career Practitioner don’t need to deal with everything but consider if and how other factors are being addressed.
    Global assessment - learn about resources - refer clients - advocate for supports
  • Impact - stigma &amp; discrimination -
    Examples of discrimination?
    Career practitioners and clients both report:
    Jokes, gossip, not hired/ promoted/ fired, exclusion, name calling, bullying. é expectation / workload, not taken seriously. Refused service or referred on. More discrimination by staff with MHP/MI.
    Clients also reported:
    Being shunned, isolated, verbal &amp; emotional abuse, negative judgments, denial of sick days/ benefits, segregation, poor workplace supports, loss of support, low expectations…
    Negative Impact: Life-long experience, hiding illness, suffer in silence, withdrawal, social isolation, é stress, sickness, giving up, reduced self confidence.
    Positive Impact: Defiance in face of discrimination: empowering - advocating for change - refusing to give up - relief at getting help - better self care…
    Some CP report presence of positive policies of inclusion &amp; protection of rights.
  • Good news is CP strongly agree that you do not need to be symptom free to pursue work, that people with mhp are not less reliable and that work improves mental health
    Less confident about recovery
    The vast majority of people do not feel they are being treated fairly, that they face considerable discrimination
    BUT they have not given up hope - 1/2 recognize that work is stressful and this can cause fearfulness
  • It is critical to note that these are not knowledge-based issues but reflect attitudes, beliefs and behaviours.
  • There is a high level of agreement between clients and Career Practitioners on how to help
    Work with employers - opportunities, accommodations
    Learn about mental health resources &amp; how to refer.
    Partner with resources - collaborate to build network.
    Help clients to access support.
    Treat them as partners in planning.
    Don’t wait for  symptoms - support training &amp; employment.
    Focus on work needs NOT on mental illness.
    Build hope, insight, positive vision, confidence, self esteem.
    Get training (mental illness/treatment/recovery/rights).
    Know your limits - refer when beneficial.
    Improve skills in motivation, coaching, mentoring...
    See the big picture, advocate for funding parity.
  • TRAINING NEEDS
    Understanding stigma.
    Local MH resources:
    Access, availability, networks
    Supporting employers:
    Support, accommodation, coaching, labour market trends.
    Mentally healthy workplaces.
    Assessment tools, adult learning/coaching/recovery.
    Legal rights &amp; obligations.
    Managing disclosure.
    Recognize/treatment of MI (with focus on employment).
    APPROACH
    Mental Health First Aid.
    Joint training with MH professionals, partners.
    Case studies.
    Workplace seminars.
    Prof. development workshops.
    Consumer-led workshops
    Web/print materials for clients.
  • SHARE ADVICE FOR NSCDA
    If working with MHP/MI clients &amp; everyone is - get training.
    Develop (mandatory) education tools.
    Work with employers - build insight, opportunity &amp; support.
    Host a NSCDA conference focused specifically on MH/MI.
    Make training accessible (access/cost). Create discussion forums.
    Include people living with mental illness in training.
    Focus on enhancing skills re: career planning services.
    Identify &amp; share global ‘best practices’.
    Know when and how to refer to community supports.
    Partner with MH experts. Link clients to mental health services.
    Work with the media. Promote positive profiles - emphasize recovery.
    Advocate for better funding for MH services - shared concern.
  • Findings are consistent with research
    MHP/MI is common – disclosure is not.
    Clients are identifying mental health problems are a job factor.
    Career practitioners are critical bridge to inclusion
    Career practitioners are not always confident/ comfortable/ skilled. Clients agree.
    Specialized service have an important role - mainstream access is a right.
    See the person - work collaboratively across disciplines / sectors
    Stigma and discrimination is a critical barrier to work.
    Start with own attitudes, beliefs &amp; actions.
    People want and NSCDA can play a leadership role in education.
    Include consumers from day one.
    Use contact, education &amp; protest - stress voice and choice.
    Social inclusion and full citizenship to the goal
  • Charting the course project overview Cannexus 2012

    1. 1. Supporting Clients with Mental Health Problems: The Career Practitioner’s Role Neasa Martin & Kathy McKee Cannexus Conference, January 24th 2012, Ottawa, ON
    2. 2. Project’s Roots
    3. 3. Project context
    4. 4. MH work-related costs  Fastest growing occupational disability  Cost to Canadian economy    $14.4 B lost productivity $18.6 B substance abuse Focus is on workplace mental health
    5. 5. Understanding stigma & discrimination:
    6. 6. What is stigma & why does it exist?
    7. 7. Stigma Attribution Model 1. Labeling: Characteristics signal important difference. 2. Stereotyping: Differences linked to undesirable characteristics. 3. Separating: Distinction between ‘normal’ & labeled group creating ‘them & us’. 4. Status loss: Devaluing, rejecting, discriminating & excluding.
    8. 8. Decade of the ‘Broken Brain’
    9. 9. Self-stigma is common
    10. 10. What works to reduce stigma?
    11. 11. Contact is most effective… Contact is common - disclosure is not - creates a distorted image     Relationship of equal status Context of cooperation Opportunity for discussion Credible presenters - disabuse common myths
    12. 12. Social inclusion is the journey towards greater participation and citizenship…
    13. 13. Survey Findings:
    14. 14. Project Approach May 2011 Sept. 2011 May 2012
    15. 15. Survey tool
    16. 16. Who participated? 266 survey participants in total (81.5% completion)  176 Career practitioners   46% report having mental health problems/illness (65) 90 Clients  62% report having mental health problems/illness (56)  100 stakeholders participated in 5 regional meetings  Meeting of 25 Career Resource Centre Managers
    17. 17. Contact is common - 1 in 5
    18. 18. “Only those close to the person would ever know they are experiencing a mental health problem” Client Career Practitioner contact with MHP/MI % Yes Co-worker 86% Close family/friends member 78% Personal experience 46% Client contact with MHP/MI % Yes Co-worker 78% Close friend 77% Close family member 71% Contact is common
    19. 19. Disclosure is not…
    20. 20. Disclosure People disclose when they feel safe LIKELY to DISCLOSE LIKELY to be ACCEPTING Spouse 92% 90% Family 90% 80% Friend 88% 82% Guidance/Career 80% 68% Teachers 50% 46% Work-mates 31% 24% Employers 28% 22% Neighbours 21% 18%
    21. 21. To help clients Career Practitioners need to know… Impact of stigma on work (99%)  over 90% agree mental illness (99%)  About  Mental health  About  Skills in  Work-related  How to support  About  About resources (98%) peer support (97%) motivating clients (96%) coaching (95%) employers recovery (94%) practices (89%) treatment for MI (79%)
    22. 22. Clients rating vs Career Practitioners       Knowledge of mental health Making right referrals Recommend peer support Comfort working with clients Discussing +/- disclosure Understanding & explaining rights Across all categories Career Practitioners rate themselves higher than Clients
    23. 23. Client rating cont… Strongly/Agrees Career Practitioners:  Share tools for coping with work  Good support & access work/training  Have knowledge to help me re: work  LESS likely to refer clients for training 50% 35% 33% 28%
    24. 24. Satisfaction working with clients “Same as with all clients” Seeing progress… Supporting change… Gaining trust… Helping clients get / maintain job… Support people to reach their goals… Improving self-esteem… Supporting greater social inclusion
    25. 25. Frustrations working with clients
    26. 26. Barriers to employment “Sometimes (stigma and discrimination) is very apparent and other times it is hidden but lurking below the surface. I was once told at a workplace that I would advance no further in my career because of my mental illness.” “When I was first diagnosed with schizophrenia in my early 20's, I went to what was then called the Manpower Office and asked for training. The counselor told me there were no training opportunities for me because I was chronically ill with schizophrenia.”
    27. 27. Impact of mental health problems? Client rating       Self-confidence Finances Employment Community involvement Family relationship Friendships 98% 96% 91% 91% 81% 78%
    28. 28. Have you seen workplace discrimination? Clients: 90% - Yes “Happens all the time…” Career Practitioners: 48% - Yes “Quit being paranoid”
    29. 29. Clients agree…  Agree discrimination is common (96% vs 76%)  Few feel fairly treated by employers (< 7%)  Agree work improves mental health (89% vs 80%)  Agree recovery is possible (87% vs 76%)  Have hope they will work (79%)  Don’t need to be symptom free to work (76% vs 86%)  Agree mental health problems make work stressful (52%)  Career Practitioners disagree less reliable employees (86%)
    30. 30. In client / counselor relationship very/important… choices  90% CLIENTS agree Given  Believes my capacity to recover  Can trust my counselor (91%)  Feel respected  Treated  My • Listen  Inspires  Feel care & fairly (91%) (94%) (94%) privacy is respected (93%) without judgment (91%) hope (91%) compassion (84%) (91%)
    31. 31. Strong agreement on how to help “Treat People Like People… Not a Disorder” “Include us as partners in planning”
    32. 32. Where would clients prefer to receive career planning service? 43% 23% 18% 16%
    33. 33. Career Practitioner Training Needs
    34. 34. Take away messages…
    35. 35. Last Words… “Have your people not be therapists...but be knowledgeable about the clients they are trying to help integrate back into society. We want to be part of the workforce but may only dip our toes in and then back away, come back and test the water again...several times before we are really ready. HAVE PATIENCE....we will jump in when we are ready, just offer the tools and services so that we can make an informed decision. Do not force us. We have enough struggles already, this has to be something that we do for ourselves...and we will...trust me! :0)” http://Chartingthecourse.nscda.ca
    36. 36. http://chartingthecourse.nscda.ca/index.php/workplace
    37. 37. Stigma & Discrimination Related readings Bio-medical framing  Angermeyer M, Matschinger H. Causal beliefs and attitudes to people with schizophrenia: trend analysis based on data from two population surveys in Germany. Br J Psychiatry 2005;186:331–334.  B. Schulze. (2007) Stigma And Mental Health Professionals: A Review Of The Evidence On An Intricate Relationship; International Review Of Psychiatry; 19 2 ;137-155  Arthur Crisp, Liz Cowan and Deborah Hart. (2004) The College's Anti-Stigma Campaign, 1998-2003: A shortened version of the concluding report; Psychiatric Bulletin; 28 4 ;133-136  Read, J. & Harre, N. (2001). The role of biological and genetic causal beliefs in the stigmatization of ‘mental patients’. Journal of Mental Health, 10, 223-235.  Stigma – Related Attitudes and Beliefs in the United States 1950 - 2006" Presented by Bruce G. Link, Stigma in Mental Health and Addiction, delivered in Calgary, June 3, 2008. Schnittker, J. (2008) An uncertain revolution: Why the rise of a genetic model of mental illness has not increased tolerance. Social Science & Medicine, 67(9), 1370-1381.   http://www.camhcrosscurrents.net/thelastword/2010/03/psychiatrists-fighting-stigma.html    Read J, Haslam N, Sayce L, Davies E. (2006) Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatr Scand: 114: 303–318  Phelan, J., Cruz-Rojas, R. and Reiff, M. (2002) Genes and stigma: the connection between perceived genetic etiology and attitudes and beliefs about mental illness, Psychiatric Rehabilitation Skills, 6(2): 159–85.  Ross M. G. Norman, Richard M. Sorrentino, Deborah Windell, Rahul Manchanda. (2008) The role of perceived norms in the stigmatization of mental illness. Social Psychiatry and Psychiatric Epidemiology Online publication date: 23-Jul-2008.  Walker I. And Read J. (2002) The differential effectiveness of psychosocial and biogenetic causal explanations in reducing negative attitudes toward "mental illness"; Psychiatry-Interpersonal And Biological Processes; 65 4 ;313-325  Bernice Pescosolido, Stigma in Global Context: Fourth International Conference on Stigma (Jan. 2009) London, England  Corrigan PW. How clinical diagnosis might exacerbate the stigma of mental illness. Soc Work. 2007 Jan;52(1):31-9.  LAM Danny C. K., SALKOVSKIS Paul M.; An experimental investigation of the impact of biological and psychological causal explanations on anxious and depressed patients’ perception of a person with panic disorder, Behaviour Research and Therapy Volume 45, Issue 2, February 2007, Pages 405-411
    38. 38. Education & changing attitudes  Spagnolo, A. B. Murphy A. A. and Librera L. A.. (2008) Reducing stigma by meeting and learning from people with mental illness; Psychiatr.Rehabil.J.; 31 3 ;186-193  Nagel, T, Thompson, C, (2007) AIMHI NT ‘Mental Health Story Teller Mob’: Developing stories in mental health, Australian e-Journal for the Advancement of Mental Health, vol 6, issue 2  Chang, C, Increasing Mental Health Literacy via Narrative Advertising, (2008) Journal of Health Communication, 13:37-55  Angermeyer, M. C., & Schulze, B. (2001). Reducing the stigma of schizophrenia: Understanding the process and options for interventions. Epidemiologia e Psichiatria Sociale, 10(1), 1-7.  T. M. Lincoln, E. Arens, C. Berger and W. Rief. (2008) Can anti-stigma campaigns be improved? A test of the impact of biogenetic vs psychosocial causal explanations on implicit and explicit attitudes to schizophrenia; Schizophr.Bull.; 34 5 ;984-994 Self-stigma  Lauber, C. Anthony, M. Ajdacic-Gross, V., Rössler, W. (2004) What about psychiatrists' attitude to mentally ill people? European Psychiatry. Volume 19, Issue 7, November, Pages 423-427  Link, B. Mirotznik, J & Cullen, F. (1991). The effectiveness of stigma coping orientations: Can negative consequences of mental illness labelling be avoided. Journal of Health and Social Behavior. 32(3), p. 302 – 320.  Hyman, I. (2008) Self-Disclosure and Its Impact on Individuals Who Receive Mental Health Services. Substance Abuse and Mental Health Services Administration.  Otto F. Wahl, Ph.D. Mental Health Consumers' Experience of Stigma Schizophrenia Bulletin 1999 25(3):467-478;  Fighting Shadows: Self-Stigma And Mental Illness: Whawhai Atu te Whakamâ Hihira. 2008 http://www.likeminds.org.nz/assets/docs/FS%20Brochure_FINAL_SCREEN.pdf  Corrigan, P. (2001). Don’t call me nuts: Coping with stigma and mental illness. Tinley Park, Ill: Recovery Press.  Corrigan, P.W., Larson, J.E., Nicolas Rusch, N. (2009) Self-stigma and the “why try” effect: impact on life goals and evidence-based practices. (World Psychiatry 2009;8:75-81)

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