Intensive assessment for "Intensive Assistance": unemployment, mental health and the need for holistic assessment of long-term unemployed people.
Since May 1998, when the main responsibilities and functions of the former CES were delegated to the private sector, unemployed clients seeking the Newstart allowance have been required to complete a self-report questionnaire called the Job Seeker Classification Index (JSCI). The purpose of this screening device is to gather critical information on the client with a view to determining the level of government assistance to be provided. Factors including residential location, distance to population centres, age and qualifications are each given weightings which together result in an overall score indexing risk of long-term unemployment and used for streaming the client to appropriate assistance. Included on this questionnaire are sections where medical conditions or personal factors affecting workability can be noted by the job-seeker.
Clients who appear at risk of long-term unemployment have been streamed into a scheme designed to provide "intensive assistance" (IA). Clients in this stream choose an employment organisation contracted to provide one-to-one assistance in a "case-management" framework. Each client attracts a set amount of money to the employment organisation depending on the JSCI scores; clients who report the most difficult circumstances and factors attract the largest fees because relatively more resources will need to be spent gaining employment for them than for other clients. The system of referral to employment agencies offering IA (and other employment services) has been promoted by the government as the "job network" although such agencies are in competition with one another to place unemployed people in jobs. Thus employment organisations have a very strong interest in the early identification of significant factors affecting employment, as they are in a competitive environment and need appropriate resources to be allocated to the most challenging clients. Once placed in intensive assistance, the client sees an employment consultant who they will work with for up to a year (in most cases) or until stable employment is secured. It is through the IA process that it is hoped many of the client's barriers to work will be overcome.
Newstart clients with certain documented conditions and special needs may be eligible for a variety of schemes better suited to their particular needs than IA. These schemes include the Disability Support Pension (DSP), assistance from employment agencies specialising in clients with disabilities and the Community Support Program (CSP).
The CSP has been an attempt to meet the special needs of Newstart recipients who have difficult personal, mental-health, family or other similar related barriers to employment effectively preventing them from holding full-time work. CSP clients have participated voluntarily in community based programs for up to two years. The emphasis of the CSP has not been to assist the client to obtain work per se, but to attain a state of mental and physical health sufficiently robust to re-enter the hunt for full-time work. The kinds of clients that are placed on the CSP include those needing drug rehabilitation, psychological help, and assistance with housing and other forms of assistance aimed at stabilising circumstances and functioning.
The argument of this article is that there are a considerable number of people with mental-health and disability issues who have remained "hidden" in the unemployment system, with their issues unaddressed, because they have not been adequately assessed by processes of either the government or private-sector systems that engage with them. Recently announced changes to IA and CSP programs should significantly improve this situation.
Unemployment and Mental-health Issues.
Both the published literature and our own experience inform us that we should expect to find high incidence of mental health morbidity in the long-term unemployed populations found in IA.
1. The published literature
It is beyond both the scope of the present author's expertise and the bounds of this article to attempt any kind of comprehensive review of the considerable literature on mental health and unemployment. Nevertheless, a few key points from this literature are worth a brief discussion.
There is an established and extensive international literature documenting considerably higher incidence of mental and physical health problems in unemployed people compared with what is found in the employed and general population. This relationship was first documented during the years of the great depression in the 1930s by researchers including Bakke (1934) and Komarovsky (1940). More recent epidemiological and hospital admission studies have identified unemployment as a key risk factor for developing clinical anxiety disorders (Bell et al., 1991; Leon, 1995; Wittchen et al., 1994; Huppert et al., 1992) and depressive disorders (Bell et al., 1991; Claussen et al., 1993).
The correlation between poor mental health and unemployment is clear. However, correlation and causality is an old statistical chestnut and it has been a key question in the literature on mental health and unemployment. The debate concerns whether poor health documented amongst unemployed people is caused by negative personal impacts of unemployment (the "exposure" or "social causation" hypothesis) or is caused by tendencies for physically and psychologically unwell people to drift out of work (the "selection" or "drift" hypothesis) (Winefield, 1997). Finding methodological techniques by which to tease out these effects is difficult, but many reviewers of the literature conclude that the negative psychological effects associated with unemployment contribute directly to the increased mental health morbidity found in unemployed populations over and above effects due to pre-existing mental health (eg. Ezzy, 1993, Poikolainen, 1996, Winefield et al 2000).
Although unemployment appears to play a causative role in associated reductions in mental health, research indicates the relationship between unemployment and mental health is not simple; not all unemployed people suffer reductions in mental health and wellbeing, and full-time employment is not always positive for workers. Nordenmark and Strandh (1999) point out that the adverse effects of unemployment on mental health appear to be mediated by factors including the person's economic situation, gender, social class, age, marital status, duration of unemployment, previous unemployment experience and degree of psychological investment in work.
Theorists trying to explain the relationships between unemployment and mental health have emphasised the degree to which unemployment thwarts important financial, psychological and social needs usually met by employment. For instance, one theory argues that unemployment has deleterious effects on mental health because it provides fewer opportunities for structured time, social contact, participation in collective purposes, status and identity and regular activity (Jahoda, 1981, 1982). The details of this literature are beyond the scope of the present article but Ezzy (1993) provides a good review.
In 1997 the Australian Bureau of Statistics conducted a nationwide survey indexing prevalence and treatment of mental health problems in Australia. Contained among a number of social and demographic research variables was "employment status" in which participants were categorised as full-time (FT) employed, part-time (PT) employed, unemployed or out of the labour force. The findings were consistent with other literature indicating elevated incidence of mental health problems in unemployed populations compared with both FT employed populations and PT employed populations. Age standardised figures for men and women combined showed anxiety disorders (including panic, agoraphobia, post traumatic stress disorder and social phobia) in 7.1% of FT employed people compared with 14.9% of unemployed people, affective disorders (including major depression, bipolar disorder, dysthymia and cyclothymia) in 3.8% of FT employed people compared with 10.1% of unemployed people and substance abuse in 15% of FT employed people compared with 26.7% of unemployed people (Mental health and wellbeing: profile of Australian adults. Australian bureau of statistics. Catalogue 4326.0, 1997). Thus prevalence rates for these broad mental health categories were 2-3 times higher in the unemployed population than in the FT employed population. Non age standardised figures indicated a mental disorder of some sort in 16.9% of FT employed people compared with 34.1% of unemployed people. Thus less than one in five FT employed people had a mental health problem while over one in three unemployed people had diagnosable, recognised condition or disorder.
The Australian Psychological Society have recently released a position paper on employment and unemployment headed by Professor Tony Winefield who has conducted some of the largest and most influential studies of unemployment impact in Australia. This paper argues for a causal link between youth unemployment and poor mental health on the basis of longitudinal studies of school leavers. It also points out that job loss in middle age appears to be more damaging to mental health that in the young on the basis of two Australian studies. The authors of the paper suggest that unemployment may be considered as analogous to highly stressful employment: "unemployed people can ... be regarded as involuntary, poorly paid, low status, insecure, public service workers with virtually no negotiating rights, whose work (persistent hopeless search for nonexistent jobs, managing households on inadequate resources and participating in humiliating bureaucratic rituals) carries massive risk of occupational strain".
Finally, a recent qualitative study of 40 long-term unemployed Melbournians helps flesh out the kinds of statistics discussed above in human form (Surviving not living: Disadvantage in Melbourne, Catholic Social Services, 2001). Twenty-two of the 40 people studied came from severely disadvantaged family backgrounds. For instance, 7 had backgrounds of homelessness, 2 had been orphaned as children and 7 had come from sole parent homes. Eight of the 40 had lived on the streets at some time and 2 of the men were in shelters at the time of the study. Some of the participants were placed in foster homes or made wards of the state as children.
It is notable that the section of the report dealing with health actually begins by discussing some of the mental health problems rife in the sample. Of the forty people in the study 12 women and 3 men were being treated for depression and another 7 were being treated for other mental health issues including bipolar disorder. The report indicates that one woman's depression was so severe that her hair had fallen out. Past drug use, current drug use and detoxification programs were reported to affect 9 of the 40 people directly. Four of the sample had ongoing gambling problems and two were trying to adjust from release from prison.
2. Our experience
Consistent with this literature, our experience over the last three years is that many IA clients have unrecognised mental health needs and issues that greatly impact on work-ability coming into our agency. Centacare Australia is a nationwide welfare agency attached to the Australian Catholic Church. Centacare have been providing employment services via the Centapact Employment Agency in Tasmania since 1997. In anticipation of the needs of job-seekers, Centapact Tasmania has utilised a team of professionals including a psychologist, social workers and welfare workers to assist clients with many issues affecting their employability. Our team's experience is that many clients have significant barriers to employment that were not disclosed or identified on the Job Seeker Classification Instrument, and that have merited transferral to the kinds of schemes discussed above. Excluding those clients transferred to the DSP on the basis of physical conditions, we have still identified and documented around one client every ten days whose condition or circumstances renders them eligible for support via the DSP, CSP or specialist agency.
In our experience the most common mental health issues to warrant careful attention have been related to depression, anxiety disorders, substance abuse and trauma/ abuse. Less frequently IA clients have been referred to other schemes because of psychotic episodes sometimes related to drug use and at other times related to schizophrenia and bipolar disorder.
Depression and related--we have come across many IA clients debilitated by ongoing depression. Some of our IA clients have threatened suicide, taken overdoses or cut themselves and required hospital admissions. On one occasion we arranged an ambulance because a young woman threatened to suicide on our office premises. Other clients have been depressed following relationship break-ups or deaths of loved ones. Many other clients have received counselling and referral to GPs for assistance with depression. Many clients have been transferred to the CSP and some have gone to the DSP.
Panic attack and related disorders--we have identified and assisted a number of clients with panic and agoraphobic difficulties who had great difficulty leaving their homes. One client failed to attend her local hospital for an appointment with a psychiatrist because of her difficulty leaving the house and we were able to assess her issues via a home visit. Another client would only come to our offices early in the morning, would avoid town and highways fearing panic attacks at the wheel. A client recently phoned just prior to his initial IA consultation explaining his agoraphobic condition. With his permission we arranged liaison with a Centrelink psychologist and the man is now on the CSP program. A young man just out of a youth detention centre was most concerned about what he thought were heart attacks but which were actually anxiety attacks associated with heavy cannabis use. Most recently a man just released from jail could not travel in a crowded bus to participate in farm work for panic and agoraphobic difficulties.
Substance abuse--Many of our IA clients no doubt use recreational drugs regularly without seriously affecting their work-abilities. However, we have had many clients whose substance abuse has been a major barrier to employment. We have had IA clients needing extended live-in drug rehabilitation programs, other spending literally hundreds of dollars every week on cannabis, clients going "cold turkey" from opiate dependence with minimal medical supervision and many clients on the methadone program. Other IA clients include those whose drug use has resulted in psychotic episodes, whose drug use is related to prison history, sexual abuse or domestic violence. We have also seen clients whose long history of alcoholism has resulted in permanent cognitive impairment sufficient for the DSP.
Trauma related issues--Some IA clients have arrived at our agency with current problems associated with trauma as a barrier to work. We have had IA clients with trauma related to work as a bodyguard, home invasion, domestic violence, sexual assault and motor vehicle accidents. Other IA clients have been migrants with very significant war and refugee experiences. Many of these clients meet the current formal requirements of Post Traumatic Stress Disorder and have trouble sleeping, have "flashbacks", have medical problems associated with anxiety and have other concurrent difficulties including depression. In many cases these issues make sustaining full-time work very difficult and they have been transferred to the CSP.
Psychotic disorders--Some of our IA clients have had psychotic disorders as a barrier to work. One of these clients, whose history of bipolar disorder was unknown to us, commenced work at a factory where work-stress quickly precipitated an episode of mania and he was hospitalised and had to give up his work. In recent months we have come across another eight clients with current difficulties associated with schizophrenia and related psychotic illnesses. One of these clients has been recently hospitalised again and is seeking the Disability Support Pension with help from his psychiatrist.
In addition to these mental-health issues, we have had a considerable number of clients transferred to the DSP and specialist employment agencies following documentation of intellectual and learning disabilities.
Intellectual disability--From January 2000 to September 2001 we have identified 16 clients having a mild intellectual disability (in the "Borderline" range) and a further 13 with clear intellectual disabilities (having full-scale IQ scores in the "Extremely Low" range and experiencing independent living difficulties). Clients in the latter category are immediately eligible for the DSP under current social-security regulations and clients in both the former and latter ranges may also be helped to access specialist employment programs and agencies. All together we have had 20 clients transferred to other schemes (mostly the DSP) since January 2000 following documentation of intellectual and learning disabilities. The vast majority of these clients had never been formally assessed before coming to our agency. Many had done numerous vocational training courses in reputable agencies (with very mixed success) yet never been identified formally as having these disabilities. None bar one of these clients to our knowledge disclosed their issues on the JSCI.
Acquired learning/memory difficulties--we have also had a number of clients with learning/memory difficulties associated with an acquired brain injury or traumatic brain injury. IA clients never before identified with these difficulties have included those with histories of major neurosurgury, birth trauma resulting in cerebral hypoxia and closed head injuries resulting from motor vehicle, sporting or industrial accidents.
Why are such Clients not Identified on the JSCI, or how do they end up in IA?
There seem to be a number of possible, usually common sense, reasons that Newstart recipients with significant mental health issues may go on to IA without such issues being properly understood by Centrelink.
One reason is that until recently the weightings attributed to such issues on the JSCI have been quite modest. Until recently disclosure of a mental illness (presumably under the disability/medical condition section) attracted only 2 points on the JSCI. This should be a sobering figure for male baby boomers who can expect to be awarded 10 JSCI points (male aged 50-54) in comparison! Failure to complete grade 10 (6 points) has also been considered a more noteworthy handicap to employment until recently. Fortunately one of the outcomes of a recent JSCI review process has been to increase the weightings that medical/psychiatric conditions attract. There has also been an expansion in the number of conditions that, once disclosed, will automatically trigger further careful assessment by Centrelink. Disclosures now of psychiatric, psychological and other similar problems will automatically result in further classification and examination. These alterations in JSCI weightings and procedures may help identify these issues more clearly.
Another related reason contributing to non-identification of mental health issues in Newstart recipients may be that the JSCI section on "Personal Factors" and "illnesses/Disabilities" has not listed any mental health factors as examples for recipients. Instead only medical conditions such as epilepsy have been given as legitimate examples of relevant conditions for disclosure. It may be that inclusion of factors such as depression and substance abuse would prompt clients to disclose more freely.
A third set of reasons for non-identification of such issues relates to client willingness to disclose and insight into their own functioning. Our discussions with IA clients suggest that they almost never disclose mental health and related conditions on the JSCI. There appear to be a number of main reasons for this.
i) First, some clients appear to choose not to disclose a known condition because they fear the consequences of such a disclosure. Many of our clients with anxiety disorders have indicated they did not document their limitations because they feared having to see a government psychologist or psychiatrist. They may wish to ignore their conditions and feel unwilling to seek treatment or discuss it with anyone. Some clients also appear to fear that disclosure of a condition will penalise them in some way as regards the social security system. Others simply appear to want such information off official government records, perhaps fearing stigma associated with mental illness. To Centrelink's credit they have gone to some trouble on the JSCI to inform job-seekers that any personal information they disclose "will be used to help" them and will be treated confidentially. Despite these genuine efforts our anecdotal experience is that clients do not like disclosing personal, mental health or disability issues on the JSCI.
ii) Second, some clients appear ignorant of their condition and appear not to have realised that the difficulties they have are documentable "conditions" that are highly relevant to their work-ability and should be noted somewhere on the JSCI. Ignorance of the presence of a medical condition or personal factor may seem unlikely at first, but in many cases our assessment work with clients brings a genuine condition to their attention for the first time. For instance, many of the IA clients we have assessed as having an intellectual disability knew very well that they had a variety of everyday difficulties and limitations (such as trouble with memory, difficulty at school, slowness at working, trouble reading etc) yet only a single client knew they had a quantifiable intellectual disability. Another excellent outcome of the JSCI review process has been that disclosure of an intellectual disability on the JSCI will now prompt an automatic assessment of their work ability using Centrelink's Work Ability Tables. This seems an excellent idea and should help properly assess and stream such clients. As indicated above though, we have come across a large number of IA clients with significant intellectual disabilities who did not disclose them because they were unaware of their disability.
iii) A third reason for lack of disclosure of relevant conditions on the JSCI may relate to the fashion and environment in which the JSCI is administered. It would be surprising if careful attention to over 20 JSCI questions was given by Centrelink staff who are required to work quickly with a large volume of customers everyday, and by Centrelink customers who may well be intimidated by paperwork and wish to complete the form in as little time as possible. Many clients we have spoken to do not remember filling out the JSCI at all.
iv) A final common sense factor is that human nature is usually to disclose difficult personal issues within the context of an ongoing, confidential relationship based on trust, rather than in a fleeting encounter with a stranger or official (Centrelink officer). Centrelink cannot, of course, hope generally to foster ongoing trust-based relationships with their clients. This may well contribute to what we think is an under reporting of mental health and related issues on the JSCI.
What are the Current Chances of these Issues being Identified once the Client is in IA?
Access to JSCI information
The first opportunity for identification of such issues once in IA might be directly from the JSCI information. Assuming that the client has completed the JSCI in an accurate and insightful way, an interested employment consultant may be able to look up JSCI details to better understand their client in the early stages of their working relationship. Employment consultants, however, may only gain access to client JSCI details in cases where the client has signed a statement allowing release of such information. While there seems no a priori reason to suspect clients not to do this, the experience of many of our employment consultants is that they often do not have access to JSCI details. The two employment consultants in the office where I am based estimated that they only get automatic access to around one in five client JSCIs. While it is possible, of course, to gain client permission for release of this information they reported rarely doing this. Other employment consultants in our state organisation have reported similar difficulties getting access to JSCI details.
"Low resolution" JSCI information
Even in cases where employment consultants do get ready, quick access to JSCI details, the quality of the information contained on the JSCI screen may not be sufficient to provide meaningful clarification of an issue. Mental health issues may be listed under either the "disability/medical condition" section or the "personal factors" section, in either case the only details that are listed on the JSCI screen are the JSCI points attributed to the issue disclosed; there are no details or descriptions of the actual issues, conditions or personal factors nominated by the client. Thus a client may disclose at Centrelink that that they have bipolar disorder, are grieving, sometimes have anxiety attacks, are on the methadone program or are recovering from a trauma of some sort, but none of these details will be available to the employment consultant on the JSCI screen. The only indication that the client has any of these issues will be the inclusion of the point weightings next to the terms "disability/medical condition" or "personal factors". Some similarly brief but vague description may also, if fortunate, be available on another JSCI page dealing with activity agreements. It may also be possible to access a total of three lines of text on a screen relating to psychological or personal factors but our anecdotal experience is that this screen is rarely used. This is not a criticism of the JSCI per se; the JSCI is not designed to provide a rich seam of information but a broad categorical weighting to factors relevant to employability. It provides a "low resolution" picture of a broad landscape of factors relevant to employment probability. The JSCI appears in many ways to perform very well in this function. However, such "low resolution" assessment does not, by definition or purpose, inform in a detailed or meaningful way about any single factor.
Identification of mental health issues by employment consultants
Given patchy access to the categorical, "low-resolution" information provided by the JSCI, it will often be entirely up to the employment consultant to both identify a medical/personal or mental health issue, and judge its potential or actual impact on work ability.
Intuitively it might seem obvious that any client with mental-health and related problems representing significant barriers to work ought to stand out and be apparent to employment consultants, not just mental health professionals. In our experience some employment consultants have indeed successfully and accurately identified the extent and nature of mental-health and disability issues. Such identifications usually occur in cases where the difficulties are obvious or in cases where the client freely discloses their difficulties.
However, in many cases discovery of significant mental-health issues has happened following professional assessment based on employment consultants having only hunches, a sense that "something is wrong", or following referral for side issues. For instance, we have had clients with significant intellectual disabilities (who were immediately eligible for the DSP) referred because they seemed "unmotivated". Conversely, we have had a client need hospitalising for major depression shortly after being referred because he seemed not to comprehend instructions.
A group of around 9 clients referred for a "job-seek/motivation" group turned out to contain a client in treatment for an anxiety disorder, a client who disclosed sexual abuse as a child, a client who was later transferred to the CSP for depression, another who was admitted to the DSP later for depression, a client with bi-polar disorder who later had a psychotic episode and was transferred to another scheme, a client with what was almost certainly Asperger's disorder and a client with an intellectual disability who was transferred to the DSP. The employment consultants had knowledge of these conditions in only two of the seven cases.
It is true that some of these issues may have come to light without the intervention of professional assessment. It is also true, as indicated above, that employment consultants may sometimes be totally accurate in their identification of issues.
At the very least, in the cases discussed above, they have been astute enough recognise "something" was wrong even if the "something" was quite mysterious. Nevertheless, the likelihood that many or most of these issues would have been identified and understood without follow-up professional assessment seems very low. It seems a higher probability that these sorts of mental health/disability issues would be noted in a vague way by the employment consultant who would continue to focus exclusively on issues of job-hunting/training without a full understanding of the impact of the former on the latter.
How Accessible is Professional Assessment to IA Agencies?
Assuming that an astute IA provider has identified a potential mental-health issue significantly affecting job readiness, how easily may they get professional assessment to investigate and document their suspicions? Currently IA providers may get access to mental-health and disability expertise in a number of ways: by providing such expertise in-house, by paying for such services external to their agency and/or by purchasing such services from Centrelink.
The Job Network is largely made up of organisations with consistent expertise in employment and recruitment, but with very varying degrees of expertise in mental health and disability. The recent Job Network Evaluation Report carried out by DEWRSB reported that the most common forms of support within the IA network were "personal support, such as meetings between job seekers and case-managers and other provider staff" such that "72% (of job seekers reviewed) agreed their provider helped them stay motivated and 58% said their provider improved their self-confidence" (pg 79).
However, further into the report it is explained that "when probed on the services they offered to IA clients ... very few providers reported that they were offering services which would address underlying barriers to employment such as language classes, counselling or assistance with vocational training. The basic services that were described were regular meetings with a case manager, resume preparation, job search and interview skills. Service providers said they offered access to other services as needed. In most cases the availability of these `extra' services was at the discretion of the case manager or office manager" (pg 80, my italics). It appears, therefore, that very few IA providers have expertise or resources sufficient to provide counselling, psychological assessment or other related services in-house.
The extent to which these "extra" services have actually been out-sourced by IA providers is unknown, but consideration will be given in the following section to a number of financial reasons which might disincline providers to out-source such services.
Purchasing professional expertise external to the IA agency
In many cases IA consultants wishing to follow-up with professional assessment of mental-health issues have no choice but to purchase these services externally. This may be a significant factor contributing to many genuine mental-health issues remaining "hidden" in the IA system. Where mental-health and related issues are suspected many such workers may choose not to investigate their suspicions given the relatively high cost of assessment and low guarantee of financial return in what is a competitive private sector industry.
In the current system employment agencies managing IA clients are required to purchase psychological assessments external to their agency in many cases where they request Centrelink to review client's social-security and IA level status. Testing eligibility for DSP, specialist employment agency services and CSP all involve substantial outlay of money.
In cases where intellectual/learning barriers are suspected the appropriate alternative schemes include the DSP and help through a specialist employment agency. Investigation and documentation of intellectual and learning abilities requires purchase of psychological assessment services and it is quite conceivable that fees attached to such services might cost $500-800; a fee accounting for up to 70% of the up-front payment the client attracts to the agency. This is a high cost to pay if assessment indicates no disability sufficient to warrant altering the client's social security scheme or status.
In cases where mental-health related issues are suspected employment agencies may choose either to continue working with the client, but seek additional funds from Centrelink in recognition of the barrier (via an upgrade of their JSCI score), or they may seek to exit the client altogether from their agency with a view to the client being transferred to a more suitable social-security scheme. Both options require substantial outlays of money.
In the first case in which a simple review of the client's rating is requested, agencies are required to purchase psychological assessment external to their agency. As indicated, this may easily cost $500; a fee which is barely recovered even if the outcome of the new evidence and review by Centrelink is favourable. It is notable that Centrelink were surprised at the low numbers of requests for review from employment agencies in the first year of the Job Network's operation. If requests for review on any basis were low it is reasonable to think that requests for review on the basis of assessment evidence purchased external to the agency were very few indeed.
Purchasing a "Special Needs Assessment"
In cases where agencies request Centrelink's consideration of schemes like the CSP the agency must pay a $536 fee to Centrelink to have their own psychologist perform a Special Needs Assessment (SNA). One possible justification for this fee is that it may act as a deterrent to agencies attempting to indiscriminately exit any client who appears to have a difficulty and who would be hard to gain employment for. Unfortunately it may also act as a deterrent to agencies who would prefer to simply save the money, work with their "job ready" clients and put their challenging cases desperately in need of assessment to the "back of the filing cabinet".
When asked about referral rates to the CSP nationwide over the first CSP contract, Centrelink's office in Melbourne indicated that there had been proportionally very few clients referred from IA agencies, based on the very few recorded instances of fees paid for SNAs (personal communication August 2000). The only explanations for this appear to be i) that there are extremely few clients in need of re-assessment in IA, ii) IA agencies are poor at identifying important mental-health barriers without professional assessment and iii) IA agencies are reluctant to spend money on such assessment. Our experience tells us that the latter two possibilities are far more likely than the first.
A paradox in the current system is that the $536 fee has been required in all cases, even when all parties are in agreement that the client was unsuitable for IA. Thus even in cases where Centrelink agree that their own tool, the JSCI, failed and a client with unidentified barriers to work was inappropriately referred to IA, the employment-agency is required to pay the $536 SNA fee in order that Centrelink perform the job it should have done initially. If the $536 fee is intended to act as a deterrent to indiscriminate requests for SNAs it is suggested that it only be applied where Centrelink deem the client fit for IA following their SNA. In the current system agencies that spend time and resources on making sure they identify barriers accurately and request SNAs appropriately are perhaps being penalised for the sins of other, less ethical and professional organisations for whom the fee is designed to act as a deterrent.
It may be objected by some that the arguments above are void on the basis that IA agencies are funded by the government to case-manage IA clients and considerable expenditure on this process is something to be rejoiced in not complained about. This would be true if the funds under consideration were being spent on employment related issues such as training, accreditation, clothes for work and other similar vocational needs. However, the funds under consideration are not being spent on employment related matters, but on attaining information and understanding of a basic, pre-vocational nature. The questions being addressed are not "what kind of work is this person suited to?" and "how can I get their foot in the workplace door?", but "is this person able to do any work?" and "are they on the right social security scheme?". These are basic questions Centrelink should already have understood properly prior to referral to IA. Every dollar spent by IA organisations sorting these issues out is a dollar not spent on employment of suitable IA clients. It would be a surprise if the government and taxpayer were content that Job Network agencies spend money assigned for employment purposes on other matters that should have been resolved by Centrelink.
This section has presented arguments that under the current system IA agencies may fail to identify many clients with significant mental-health and disability issues and fail to seek appropriate assessment and referral of them if identified. Our experience is that non-expert employment-consultants correctly identify obvious mental-health barriers, but discovery of the many "hidden" barriers is more a matter of lucky referral to a mental-health expert or through referral to mental-health expertise on the basis of a vague sense on their part that "something is wrong". Once identified, there appear to be a number of financial reasons why, in the current system, employment agencies might be disinclined to pursue professional assessment of any sort either through a psychologist external to their agency or through Centrelink's SNA.
Recently Announced Changes to the Job Network
Holistic assessment: a new role for Intensive Assistance providers
It has been argued in this article that mental health issues preventing or obstructing a client from work may not be identified on the JSCI in considerable numbers of cases for understandable reasons. In these cases the Onus for appropriate assessment of client needs is falling to private-sector employment agencies. However, they have little or no in-house expertise in mental health, they may have little insight or incentive to identify such barriers and the cost of purchasing such assessment either externally or via Centrelink may well be prohibitive and a disincentive.
A recent government announcement has been that from July this year Intensive Assistance organisations will be contractually required to make an assessment of personal barriers, motivational barriers, skills barriers and other barriers that make work especially difficult, within the first four weeks of seeing a new IA client. The government has recognised the importance of assessing clients for such barriers and delegated this task to the private sector job network agencies as a new contractual requirement termed the "Intensive Support Assessment". We applaud this move, as such barriers often only come to light in the context of an ongoing client-worker relationship as is found in IA.
The government has also addressed some of the problems associated with financing such assessments discussed in the previous section. Recent announcements are that IA organisations will be given a $536 fee up front as a sort of deposit or downpayment for accepting and assessing the client. If they deem the client unsuitable for IA within the four week assessment period they may refer the client back to Centrelink for streaming to another program free of charge and retain the $536. If they deem the client for IA they receive a second payment making up the full amount of monies that would normally be paid "up front" to such organisations for taking on an IA client. If, however, the organisation later discover some barrier that effectively prevents progress in IA they will have to return the $536 as a payment to Centrelink to have the client exited from IA into an more useful scheme as is currently the case. There is, thus, a financial incentive for IA organisations to perform quick, accurate, valid and reliable assessments of holistic functioning at the start of IA.
As IA providers will have an interest in quickly identifying all factors relevant to success it makes sense that they may wish to conduct some formalised checks on basic functioning and work-readiness rather than rely solely on informal interview, gut instinct or Centrelink's JSCI. There is no reason why such agencies cannot do their own checks on basic emotional coping and physical functioning using one of the published tools available to training and personnel organisations. In fact, since February 2000 Centacare in Tasmania (through its arm Centapact) have been inviting IA clients to complete a formalised self-report style assessment giving indications of factors like anxiety, depression, coping, literacy, numeracy and problem solving. The result on numerous occasions has been the early identification of mental health and disability issues that would otherwise have remained a mystery or guesswork. Our clients who obtain unusually low scores on measures of anxiety, depression, problem solving and similar have these issues explored sensitively by the IA consultant who may invite the client to seek professional assessment and intervention if the issue is deemed a barrier to employment.
These kinds of assessments fit extremely well with the government's new requirement for IA agencies to conduct an "Intensive Suppoort Assessment. It will be far more financially viable for IA agencies to spend resources on these kinds of assessments both in-house and with follow-up by external professionals following July 2002 with the government's recognition of these needs and appropriate funding.
The Personal Support Program: A growing recognition of the mental health needs of some unemployed people
A second welcome announcement by the government has been significant expansions to the CSP which will be renamed the Personal Support Program (PSP). The government intends to increase funding per client by 50% of current levels and triple the total number of clients placed on the incrementally from July 2002 to 2004. Thus the government are investing resources in addressing the needs of the large number of long term unemployed people with especially complex barriers to work.
These increases in both funding and numbers of participants are to be applauded. It has generally been regarded that the current funding for case-management of CSP clients has been woefully inadequate. We welcome the increases in funding. It is also to be applauded that the government intend to triple the numbers of jobseekers eligible for the PSP in long overdue recognition of the need to address the mental health and related needs of so many unemployed people who are so easily overlooked.
We view these changes as a very positive step that will work in a complementary fashion to the increasing numbers of IA clients who, with adequately funded professional assessment, will probably be referred to the PSP.
The argument in this article has been that Newstart recipients receiving Intensive Assistance who have significant mental health or disability issues may still remain "hidden" in the current employment services system. The literature is clear that incidence of mental health problems is much higher in long-term unemployed populations that in the general population. Our experience in IA is that many clients with significant mental health and disability issues have remained undetected for years and have not disclosed their issues on the current JSCI screening tool. Some of the factors that may have contributed to this may include the relatively low weightings that mental health issues are given on the JSCI, the kinds of medical /disability conditions that are given as valid examples on the JSCI form and lack of willingness on the part of clients to disclose such issues for various understandable reasons. Once in IA these issues may remain misunderstood or hidden because of JSCI access issues and the relatively "low resolution" information contained on the JSCI, the difficulties associated with non-professional identification of mental health/disability issues and the high costs of purchasing professional assessment. Recent changes to both Intensive Assistance and the Community Support Program (to be come the Personal Support Program) appear to us to be very positive steps in addressing these important issues.
Table 1. Numbers of clients seen by our psychologist with significant mental-health and disability barriers to work Jan 2000 to Sept 2001. Primary issue, condition IA clients IA clients or disorder identified and/ transferred or or helped for awaiting this issue by transfer to Centapact other schemes. psychologist Depression 28 15 Panic/agoraphobia 5 3 Other anxiety issue 5 4 Post Traumatic Stress 11 5 Substance abuse 23 14 Psychotic disorders 10 10 Miscellaneous 10 6 Mild intellectual disability 16 9 Significant intellectual disability 13 11 Specific learning/memory issue 15 11 Total 146 88 * these are just the clients we have successfully identified--we expect there may well be more that remain unidentified. These figures do not include clients seen for other issues like relationship problems, medical conditions and self esteem.
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Dr Toby Croft is a Clinical Psychologist with Centacare Tasmania and Honorary Lecturer in the School of Psychology, University of Tasmania.
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|Publication:||Australian Journal of Social Issues|
|Date:||May 1, 2002|
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