Title: EMPOWER: Enabling and Motivating People (with a Personality Disorder) in Occupation, Wellbeing, Education and Responsibility
Funder: Department of Health and Social Care

Abstract: Background: 38% of those on incapacity benefit have a mental disorder (Layard, 2006), of these at least 10% will have a personality disorder (PD). PD is characterised by difficulties with emotional regulation, interpersonal difficulties and poor self management (including impulsivity and substance abuse), all of which affect employment. In standard treatment for PD, vocational status remains poor even after symptom reduction. Two pilot studies in the USA have indicated that Dialectical Behavioural Therapy (DBT) is effective for increasing employment and wellbeing (Koons et al., 2006; Comtois et al., 2010). Aims: The aim of this research programme is to evaluate Dialectical Behavioural Therapy Skills for Employment (DBT-SE) for individuals with a PD in the UK employment context. Objectives: To increase understanding of the specific challenges which face individuals with a PD in obtaining and retaining employment (WP1) and finalise the treatment manual. To develop and evaluate a Preparedness for Employment Scale for individuals with PD (PES-PD), for use in treatment planning and outcome measurement (WP2). To evaluate the effectiveness of DBT-SE with a feasibility study (WP3) followed by a full Randomised Control Trial (WP4). To identify if DBT-SE is cost effective compared to existing interventions (WP4). To develop an implementation plan to facilitate the dissemination DBT-SE (WP5). Hypotheses: It is predicted that at 16 month follow up the results of the RCT of DBT-SE, as compared to usual care, will show (compared to the 16 months prior to treatment): an increase in hours of employment. improvements in wellbeing as measured by the mood and social functioning measures. a reduction in use of physical health, mental health, criminal justice, and social services. Following the development and psychometric evaluation of the PES-PD it is predicted that: those in DBT-SE will show a significant improvement on the Preparedness for Employment Scale (PES-PD) by end of treatment. Improvement on the PES-PD will be associated with an increase in employment seeking activity. Methods: The first step (WP1) will be to further elucidate the barriers and challenges for individuals with PD in negotiating employment through additional focus groups and qualitative interviews across the stakeholders (clients, families, employers, and employment services). An initial consensus meeting of experts in DBT, employment, and the PPI committee will then finalise the draft treatment manual. This manual will then be distributed to a wider group of clinicians (NHS and non-NHS), service users, families, managers, and commissioners to broaden the consensus process. Using the existing literature on readiness for employment and data from WP1, we will draft the Preparedness for Employment Scale for PD (PES-PD) (WP2). The development and psychometric evaluation will include: systematic literature review of existing scales and the literature on PD and employment to identify domains and items; piloting of the scale for readability, completeness, and applicability; a small pilot a preliminary factor analysis to identify items to be removed; a formal reliability study for the identification of means and standard deviations, internal consistency, and factor structure; validation of the measure through comparison with scales related to the concepts (e.g. well being, activity, beliefs); test-retest reliability; and evaluation of sensitivity to change after treatment. The scale will be evaluated to consider movement on the path to employment. We will commence with a non-randomised feasibility study (WP3) to consider: acceptability of the intervention (good attendance, low drop out rate, qualitative feedback); rates of recruitment (from clinicians, GPs, and self referral), retention rates (both non-starters and drop outs); ability of staff deliver the treatment (adherence ratings of tapes; practice logs); acceptability of the measures (completion rates, qualitative feedback); an estimate of effect sizes; and willingness to be randomised. From this accumulated data, a better estimate of required sample size for the RCT can be identified and the statistical analyses and health economics plans finalised. Following the feasibility study, the single blind RCT will commence (WP4). The full RCT will be comprised of 432 individuals randomised to one of two conditions: DBT-SE or local services for mental health and employment. The study will be conducted across six sites across England and Wales to allow for consideration of differences in socio-economic factors and staff expertise. Consideration of factors relevant to implementation (WP5), will commence with the development phase and continue throughout the programme. Issues relevant to implementation will be gather through qualitative feedback in the form of interviews with clients/families/employers at each stage of the evaluation of DBT-SE, therapists practice logs after each session of the intervention, and interviews with relevant stakeholders including service managers and commissioners. The main outputs will be an implementation plan, training package, and website.

Lay abstract: In January 2013, 1.43 million people in the UK were in receipt of incapacity benefit, many with mental health difficulties. There is a complex relationship between employment and mental health; poor mental health predicts unemployment, while employment leads to improvements in mental health (wellbeing). Assisting those with mental health difficulties to obtain and retain employment is a priority for the NHS and social care organizations. Personality disorder (PD) is a mental illness characterised by intense emotional responses and impulsive high risk behaviours. These individuals have difficulties developing and sustaining interpersonal relationships, necessary for both wellbeing and employment. Both symptoms of PD and unemployment negatively affect families. Thus improvements in mental health and employment status will have a wider effect on families and communities. Dialectical Behavioural Therapy (DBT) is an evidence based treatment for PD, recommended by the National Institute of Clinical Excellence (NICE). Two pilot studies conducted in the USA suggests that DBT may be effective in assisting those with a PD into employment. This research will develop and evaluate a 16 week group treatment (DBT skills for Employment; DBT-SE), to prepare for people for employment, through learning to manage intense emotions, improve interpersonal relationships, reduce the impact of self criticism, and improve self management. Active participation of patients, families, employers, and employment services in the development of the treatment (workpage 1) is essential for greater understanding of the barriers to employment and the generation of effective solutions. Preparedness for employment involves undertaking the challenging prospect of applying for and commencing employment, or returning to employment after extended sick leave. Hence we will design and evaluate the Preparedness for Employment Scale for PD (PES-PD). This scale is expected to be helpful in the planning of support for individuals considering employment, and for measuring the outcome of treatments across mental health and non-NHS providers (workpackage 2). Following a feasibility study designed to consider acceptability of DBT-SE and practicality of aspects of the research plan, we will conduct a randomised control trial (RCT) comparing DBT-SE to existing local usual care for mental health and employment (workpackages 3 & 4). The RCT will be carried out across six sites in England and Wales to allow for consideration of factors which may be important for widespread roll out if DBT-SE is proven effective. The predicted outcomes are increased employment and increased wellbeing. If found to be both effective and cost-effective, the manual for the delivery of DBT-SE and the training package will be made widely available across the NHS and non-NHS employment and mental health providers (e.g. MIND, Richmond Fellowship, etc) (workpage 5). To reduce stigma and improve the workplace environment, we will produce a booklet on PD and provide phone/email support for employers.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH