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Vocational rehabilitation in early psychosis: cluster randomised trial

  • Tom Craig, Geoff Shepherd, Miles Rinaldi, Jo Smith, Sarah Carr, Fay Preston and Swaran Singh...

Individual placement and support (IPS) is effective in helping patients return to work but is poorly implemented because of clinical ambivalence and fears of relapse.


To assess whether a motivational intervention (motivational interviewing) directed at clinical staff to address ambivalence about employment improved patients' occupational outcomes.


Two of four early intervention teams that already provided IPS were randomised to receive motivational interviewing training for clinicians, focused on attitudinal barriers to employment. The trial was registered with the International Standard Randomised Controlled Trial Register (ISRCTN71943786).


Of 300 eligible participants, 159 consented to the research. Occupational outcomes were obtained for 134 patients (85%) at 12-month follow-up. More patients in the intervention teams than in the IPS-only teams achieved employment by 12 months (29/68 v. 12/66). A random effects logistic regression accounting for clustering by care coordinator, and adjusted for participants' gender, ethnicity, educational and employment history and clinical status scores, confirmed superiority of the intervention (odds ratio = 4.3, 95% CI 1.5–16.6).


Employment outcomes were enhanced by addressing clinicians' ambivalence about their patients returning to work.

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Corresponding author
Professor Tom K. J. Craig, HSPRD, King's College London, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Email:
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The study was funded by a grant from the National Institute for Health Research (NIHR) under its Research for Patient Benefit programme. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.

Declaration of interest

J.S. and M.R. are independent consultants to the Catalyst IPS programme with Jannsen Cilag, UK. T.C. has spoken about employment at an educational event organised by Roche.

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Vocational rehabilitation in early psychosis: cluster randomised trial

  • Tom Craig, Geoff Shepherd, Miles Rinaldi, Jo Smith, Sarah Carr, Fay Preston and Swaran Singh...
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Vocational rehabilitation: attitudinal barriers and developing country perspective

Thanapal Sivakumar
26 November 2014

Dear Editor,We read the article ???Vocational rehabilitation in early psychosis: cluster randomized trial??? by Craig et al 2014 with interest. We would like to raise some issues and discuss developing country perspective of vocational rehabilitation. The authors have stated that participants expressed a desire a wish to work (mean score 7.8, s.d.=2.1) while most thought that they would be unlikely to achieve this ambition in the near future (mean 3.9, s.d.=2.0).This corresponds to first two factors highlighted in rehabilitation readiness technology: need for change and commitment to change (Farkas et al 2000). It would be interesting to know the effect of motivational interviewing in improving rehabilitation readiness of clients and its subsequent impact on effectiveness of IPS (Individual placement and support). It was not clear from the article about nature of motivational interviewing interventions offered to clients and issues which were dealt with. In developing countries like India, schizophrenia is considered to have a better prognosis due to various factors including absence of social security benefits which may motivate a person disabled with schizophrenia to seek work (Thara 2004). We feel that due to absence of strong social security schemes in resource constrained settings like India, IPS is likely to have better employment outcomes in terms of job retention and length of employment. When work is a disincentive to receive disability pension (Priebe et al 1998), people may look forward to voluntary jobs fora sense of purpose and improved quality of life rather than regular competitive paid employment. This may also partly explain why contrary to expectation, voluntary posts do not serve as stepping stones to paid employment. Impoverishment may be a motivating factor for an individual with mental illness to seek work. It would be interesting to know if this could have partly accounted for better outcomes in the intervention team which were more impoverished vis a vis the control team.A general perception among psychiatrists that psychosocial interventions are in the realm of social workers, occupational therapists, recreational therapists and activity therapists (Dhillon & Dollieslager, 2000) is an important barrier to rehabilitation. The authors have subtly highlighted this issue by the attendance of psychiatrists and psychologists in motivational training sessions. It is worrying that some mental health professionals hold a negative attitude like general public, ignorant about psychiatric disorders (Nemec 2007). While interacting with a person diagnosed with mental illness, mental health professionals may inadvertently convey their lowered expectations about the person???s abilities which has a cascading effect on the person???s self-image, motivation, efforts, opportunities and achievement. The other barriers are an incrementalistic attitude of considering employment only after symptomatic recovery and offering rehabilitation interventions to a disabled person rather than preventing potential predictable disability inhigh risk individuals. This point is aptly emphasized by the US President???s new freedom commission on mental health which states that current scheme of things ???manages symptoms and accepts long term disability??? (DHHS, 2003). It is important to sensitize trainees in mental health disciplines about multidisciplinary nature of the rehabilitation process where every stakeholder is equally or perhaps more important than the mental health professionals. As a part of their training, opportunities should be provided to convince them about the need and effectiveness of rehabilitation interventions. Training mental health professionals with necessary skills to see the person in every patient, offer tailor-made rehabilitation interventions and coordinate with different stakeholders isquintessential to ensure that ???recovery??? is a reality. References1.Craig T, Shepherd G, Rinaldi M, Smith J, Carr S, Preston F, Singh S. Vocational rehabilitation in early psychosis: cluster randomized trial. British J Psychiatry 2014;205:145-150. 2.Farkas M, Cohen M, McNamara S, Nemec R, Cohen B. Psychiatric Rehabilitation training technology. Assessing readiness for rehabilitation. Boston University, Centre for Psychiatric Rehabilitation. 2000. 3.Thara R. Twenty-Year Course of Schizophrenia: The Madras Longitudinal Study. Can J Psychiatry 2004:49;564???5694.Priebe S, Warner R, Hubschmid T, Eckle I. Employment, attitudes toward work, and quality of life among people with schizophrenia in three countries. Schizophrenia Bulletin 1998;24(3:469-477. 5.Dhillon AS, Dollieslager LP. Overcoming barriers to individualized psychosocial rehabilitation in an acute treatment unit of a state hospital. Psychiatric services. 2000;51(3): 313-317. 6.Nemec P. Foreward. In Pratt CW, Gill KJ, Barrett NM, Roberts MM. Psychiatric Rehabilitation. Second Edition. 2007. Elsevier. 7.Department of health and human services. Achieving the promise: transforming mental health care in America. President???s new freedom commission on mental health. Final report. Rockville, MD. 2003.

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