Supported employment interventions for workplace mental health of persons with mental disabilities in low-to-middle income countries: A scoping review

OBJECTIVE

To review the evidence of supported employment interventions in low-to-middle income countries, documents their impact for persons with mental disorders in the open labour market and well as support decision making for its wider implementation in the workplace.

DESIGN

The scoping review is conducted following guidelines in the Arksey and O'Malley (2005) Framework.

DATA SOURCES AND ELIGIBILITY

Eleven databases which are PubMed, Scopus, Academic Search Premier, the Cumulative Index to Nursing and Allied Health Literature, Africa-Wide Information, Humanities International Complete, Web of Science, PsychInfo, SocINDEX, Open Grey and Sabinet were searched for articles published between January 2006 and January 2022. Both peer-reviewed articles and grey literature were eligible if they were on supported employment interventions in low-to-middle income countries. Only articles published in English were included.

STUDY APPRAISAL AND SYNTHESIS

Articles were screened at title, abstract and full article levels by two independent teams with the use of Rayyan software. Deductive thematic analysis was used to synthesize evidence on the supported employment interventions implemented in LMICs, capturing evidence of their outcomes for persons with mental disabilities securing competitive work.

RESULTS

The search yielded 7347 records and after screening by title and abstract, 188 studies were eligible for full article screening. Eight studies were included in this scoping review. Thematic descriptions of the findings were based on the availability of supported employment interventions within the context, the type of supported employment interventions as well as mental health and vocational outcomes in the workplace.

CONCLUSIONS

There is limited evidence of supported employment interventions in low-to-middle income countries despite the promising potential it has as an intervention to address mental health problems in the workplace and facilitate work participation by persons with mental disabilities.

Proactive Community Occupational Therapy Service for Social Participation Development of Thai Adults with Depression: A Grounded Theory Study from Occupational Therapists' Perspective

Introduction

Depression in adulthood decreases social participation in the workplace, family, and community, which further results in decreased work performance and cessation and social isolation. There is a high statistic of outpatient consultation and readmission of Thais with depression, yet the mental health support for remission in community life and social participation remains limited and unclear. Further, due to the lack of mental health professional resources, particularly occupational therapists, there is much to be known regarding how such therapists work to support the development of social participation in Thai adults with depression.

Objective

This research was aimed at understanding the process of how occupational therapists work to redevelop the social participation of community-dwelling Thai adults with depression.

Method

The grounded theory methodology was used in this study. Data were collected through interviews and nonparticipatory observations of 14 participants who had experience providing mental health care in community services. The constant comparative analysis method was employed.

Result

Three concepts illustrated a proactive community occupational therapy service for depression (PCOTS-D), namely, integrating depression care in community occupational therapy service (COTS), supporting meaningful participation, and forming collaborative networks. The PCOTS-D supported the reconnection of social participation by leading from proactive depression care service to COTS and then working to support meaningful participation toward the patient's self-management and building collaborative networks with inter- and intraprofessional teams simultaneously.

Conclusion

The PCOTS-D presented a holistic view of working with community-dwelling Thai adults with depression by considering the importance of the community and researchers' network to redevelop social participation, promote health and recovery, build teams in depression care, and encourage research evidence to enhance the supportive advocacy policy for Thai people with depression.

Understanding retirement for ageing adults with a disability in supported employment

Introduction

Employees with disabilities in supported employment are ageing and, as their retirement from work approaches, it is critical to consider how they perceive their occupational roles might change. They need to consider what activities they choose to engage in, and what service or supports might be necessary to make a successful transition to retirement. The aim of this study was to understand how ageing employees with disabilities perceive retirement, and how their occupational roles might change.

Method

A qualitative study was conducted with 10 participants working in a supported employment service, for whom transitioning from work to retirement was imminent.

Findings

Participants perceived retirement to be boring, full of meaningless activities and lonely. It also meant a reduced income that would result in hardship, and a loss of self-esteem at losing their employee role. They had limited knowledge about alternative activities in retirement.

Conclusion

Participants perceived significant barriers to making the transition from employee to retiree. Occupational therapy can provide support with pre-retirement planning and evidence-based strategies such as a client-centred approach, mapping new routines, and training staff and mentors. They could also advocate for changes in service delivery to improve practices that will encourage active ageing for people with disabilities in retirement.

Characteristics of Norwegian clubhouse members and factors associated with their participation in work and education

Introduction

People with mental illness, in particular those with psychosis, have more problems related to getting and keeping a job than people in the general population. Clubhouses for people with mental illness are becoming increasingly common, but little is known about clubhouse members and their participation in work and education. The aim of this study was to explore these issues.

Method

A member survey was conducted at one clubhouse in Oslo during February 2015. The data were analyzed with descriptive statistics and logistic regression analysis.

Results

Eighty-nine clubhouse members completed the survey (response rate 55.6%). More than half of the sample had a desire to work, but only 14% participated in ordinary work. Sixty-seven percent of the participants were more than 50 years old, and they were frequent users and long-time members of the clubhouse. Higher age among the participants decreased their chances for participating in work and/or education.

Conclusion

The study indicates that the clubhouse is of importance to its members, and that older members who have a desire to participate in work and/or education may be particularly challenged in their work towards such goals.

Implementation of the enhanced intersectoral links approach to support increased employment outcomes for consumers of a large metropolitan mental health service

Introduction

The purpose of this article is to describe the outcomes of the enhanced intersectoral links (EIL) approach to supporting employment outcomes for individuals accessing a large mental health service.

Method

Based on individual placement and support (IPS) principles, features of EIL included: strong service-level relationships between mental health and local disability employment services; monthly joint meetings to share information; resources to assist mental health clinicians in supporting consumers to access employment services; and provision of training. Programme fidelity was evaluated against IPS principles. Outcome measures included: time from referral to commencement; time to first employment placement; employment placement rate; and duration of employment.

Results

Seventy-nine consumers were referred to the programme. At the close of data collection, 60 participants remained in the programme and 38 of these (63%) had gained at least one employment placement. Average duration of employment was 10.9 weeks. As expected, the EIL programme demonstrated ‘fair’ fidelity against IPS principles. The average time from referral to commencement was 47 days and from commencement to first placement was 81 days.

Conclusion

This project demonstrated how EIL can be implemented in a large mental health service. Further development is required to avoid delays in consumers’ commencement with employment services and support better job tenure.

Supported employment for people with severe mental illness: systematic review and meta-analysis of the international evidence

BACKGROUND

Individual placement and support (IPS) is a vocational rehabilitation programme that was developed in the USA to improve employment outcomes for people with severe mental illness. Its ability to be generalised to other countries and its effectiveness in varying economic conditions remains to be ascertained.

AIMS

To investigate whether IPS is effective across international settings and in different economic conditions.

METHOD

A systematic review and meta-analysis of randomised controlled trials comparing IPS with traditional vocational services was undertaken; 17 studies, as well as 2 follow-up studies, were included. Meta-regressions were carried out to examine whether IPS effectiveness varied according to geographic location, unemployment rates or gross domestic product (GDP) growth.

RESULTS

The overall pooled risk ratio for competitive employment using IPS compared with traditional vocational rehabilitation was 2.40 (95% CI 1.99-2.90). Meta-regressions indicated that neither geographic area nor unemployment rates affected the overall effectiveness of IPS. Even when a country's GDP growth was less than 2% IPS was significantly more effective than traditional vocational training, and its benefits remained evident over 2 years.

CONCLUSIONS

Individual placement and support is an effective intervention across a variety of settings and economic conditions and is more than twice as likely to lead to competitive employment when compared with traditional vocational rehabilitation.

Individual placement and support versus individual placement and support enhanced with work-focused cognitive behaviour therapy: Feasibility study for a randomised controlled trial

Introduction

Employment is a key goal for many people with long-term mental health issues. Evidence-based individual placement and support is a widely advocated approach. This study explored whether individual placement and support outcomes could be enhanced with work-focused counselling.

Method

The study was designed as a pragmatic randomised controlled trial comparing the cost-effectiveness, in severe mental illness, of work-focused intervention (intervention) as an adjunct to individual placement and support compared to individual placement and support alone (control).

Results

The original sample (330) proved impossible to attain so the design was revised to a pilot study from which information on feasibility of a full trial could be drawn. Twenty-five individuals out of 74 found paid work but no difference was found in the mean number of hours in paid employment between the intervention and control groups.

Conclusion

Results demonstrate that delivering work-focused counselling in tandem with individual placement and support is feasible and acceptable to service users. The study observed that, even during a period of recession (2010–13), individuals with mental health problems succeeded in obtaining paid employment. Any additional benefit of counselling over individual placement and support alone could not be ascertained, due mainly to the high drop-out rate from this study.

Supporting Recovery Orientated Services for People With Severe Mental Illness

There is now wide agreement that people with severe mental illness can be adequately treated and cared for in the community, provided back-up hospital care is available when needed. Another important development has been the recognition that clinical treatment and care is insufficient for recovery and restoration of role functioning following illness onset, and must be supplemented by evidence-based practices in psychiatric rehabilitation. This article describes how allied health professionals can lead recovery oriented approaches that incorporate evidence-based forms of psychiatric rehabilitation. Family psychoeducation and supported employment are provided as examples of such evidence-based practices that require wider implementation.

Implementing evidence-based supported employment in Sussex for people with severe mental illness

Introduction

The aim of this research was to evaluate a large-scale implementation of evidence-based supported employment for people with severe mental illness, at 17 locations throughout Sussex, England.

Method

A parallel group observational design was used to evaluate an implementation of the individual placement and support approach to supported employment. Three sites provided both a comparison pre-individual placement and support cohort ( n = 140), and a new post-individual placement and support cohort ( n = 107) as part of the individual placement and support implementation ( n = 446). All individual placement and support sites involved community mental health teams forming partnerships with Southdown Supported Employment to co-locate an employment specialist into each mental health team. The primary outcome was the proportion of participants commencing competitive employment during the follow-up period.

Results

The new individual placement and support sites attained higher fidelity with respect to individual placement and support principles and practices (mean 97 of 125) than the pre-individual placement and support sites (mean 77 of 125). Significantly more individual placement and support participants commenced competitive employment than pre-individual placement and support participants (24.9% vs 14.3%). Individual placement and support participants experienced less delay before commencing their first job (153 vs 371 days), and when employed, worked more hours per week (24.3 vs 15.4 hours).

Conclusion

This implementation of individual placement and support in Sussex improved on the previous vocational services. Although progress is encouraging there is much room for improvement. More resources appear needed to support programme development, specifically to strengthen site-level management, training, technical support, fidelity assessment, programme monitoring, and outcome evaluation.

Identifying educational priorities for occupational therapy students to prepare for mental health practice in Australia and New Zealand: Opinions of practising occupational therapists

BACKGROUND

The effective preparation of occupational therapy students for mental health practice is critical to facilitate positive consumer outcomes, underpin optimal practice and support new graduates' professional identity. This project was established to determine a set of 'educational priorities' for occupational therapy students to prepare them for current (and future) entry-level practice in mental health, from the perspective of mental health occupational therapists in Australia and New Zealand.

METHODS

The study included two phases. In Phase One, participants identified what they considered to be important educational priorities for occupational therapy students to prepare them for practice in mental health. For Phase Two, an 'expert panel' was assembled to review and rank these using a Policy Delphi approach.

RESULTS

Eighty-five participants provided educational priorities in Phase One. These were grouped into a total of 149 educational themes. In Phase Two, the expert panel (consisting of 37 occupational therapists from diverse locations and practice settings) prioritised these themes across three Delphi rounds. A final priority list was generated dividing educational themes into three prioritised categories: 29 'Essential', 25 'Important' and 44 'Optional' priorities. Highest-ranked priorities were: clinical reasoning, client-centred practice, therapeutic use of self, functional implications of mental illness, therapeutic use of occupation and mental health fieldwork experience.

CONCLUSION

The priority list developed as part of this project provides additional information to support the review of occupational therapy curricula across Australia and New Zealand to ensure that new graduates are optimally prepared for mental health practice.

Exploring emerging occupational therapy identity and the development of graduate attributes among occupational therapy students

Introduction

Strong professional identity allows for appropriate representation and promotion of occupational therapy. Academic education assists in the development of occupational therapy identity. This study aims to explore the development of occupational therapy identity and graduate attributes in occupational therapy students after the first year of a revised curriculum.

Method

Occupational therapy students ( n = 58) were surveyed at the commencement of the second year. Data analysis used descriptive statistics and inferential statistics (χ2 for trend).

Results

A total of 54 students (93.1%) completed the survey. Students progressively developed occupational therapy identity over time. There were no significant associations between main factors influencing the original decision to study occupational therapy and when occupational therapy identity developed. However, there were significant associations between main factors influencing students' decision to continue studying and when identity developed. Most students agreed the curriculum equipped them to develop graduate attributes, although this was not significantly associated with factors that either influenced students to study, or continue studying, occupational therapy. There was significant association between development of graduate attributes and occupational therapy identity over time.

Conclusion

This study showed an emergence of occupational therapy identity and graduate attributes in students, demonstrating the importance of first year curriculum in the development of these factors.

"Balancing on Skates on the Icy Surface of Work": a metasynthesis of work participation for persons with psychiatric disabilities

PURPOSE

To explore how persons with psychiatric disabilities experience facilitators of and barriers to participation in paid work in transitional, supported, and open employment settings, in order to provide guidance for efforts to attract and retain these persons in gainful employment as a key dimension of recovery and community life.

METHODS

A metasynthesis was conducted using 16 qualitative studies published between 1990 and 2011.

RESULTS

Ten themes, two phases, and an overarching metaphor were identified. The first five themes describe facilitators of and impediments to getting a job (getting off the bench): (1) fighting inertia; (2) taking control; (3) encouraging peers; (4) disruptions related to the illness; (5) lack of opportunities and supports. The next five themes represent facilitators of and impediments to working (skating on the ice); (6) going mainstream; (7) social cohesion; (8) clarity in role and responsibilities; (9) environmental factors; (10) managing self-disclosure. We chose as our overarching metaphor "Balancing on Skates on the Icy Surface of Work," as we view both iceskaters and workers with psychiatric disabilities as needing to achieve and maintain their balance while being "on the edge" between various extremities.

CONCLUSION

We have shown that, for persons with psychiatric disabilities to "get off the bench" and "onto the ice" of employment, they may need to be supported in finding and maintaining their balance in new situations through a combination of learning new skills and competencies (learning how to skate) while receiving in vivo assistance from empathic and knowledgeable supporters (being coached while on the ice).

Readiness for employment: perceptions of mental health service users

Work is good for both physical and mental health, and access to work is a basic human right. People with mental health conditions want to work and with the right support can work but are often excluded from the workplace. We explored factors influencing individual's perceptions of their readiness for employment. Participants' narratives focused particularly on personal causation and it's inter-reactions with other aspects of volition, habituation and the environment and highlight a number of key areas, which are discussed in relation to service provision. Sheltered workshops offer support and some structure and routine but may limit an individual's readiness for employment. Services should be evidence based and focused on real work opportunities which fit with individual's interests and values. Occupational therapy theory offers a unique and valuable perspective in understanding perceptions of readiness for employment and occupational therapists offer valid and useful assessments and interventions for vocational rehabilitation.

'Earning and learning' in those with psychotic disorders: the second Australian national survey of psychosis

OBJECTIVE

Participation in mainstream education and employment facilitates both the recovery and the social inclusion of people with psychotic disorders. As part of the second Australian survey of psychosis, we assessed labour force activity and participation in formal education among working age adults with psychotic disorders.

METHOD

Data were drawn from a large national community prevalence survey of adults with psychotic disorders. Known as the Survey of High Impact Psychosis (SHIP), it was conducted in seven Australian catchment areas during March to December 2010. Current and past year labour force activity, current employment, past year participation in formal education and vocational training, and key clinical and demographic characteristics were examined in a sample of 1825 participants.

RESULTS

Only 22.4% of people with psychotic disorders were found to be employed (either full-time or part-time) in the month prior to the survey. In the previous 12 months, 32.7% were employed at some time. Of those in competitive employment, the majority worked part-time (63.9%), while a quarter worked 38 or more hours per week (23.4%). In terms of educational attainment, 18.4% reported difficulties with reading or writing, while 31.9% completed high school, which represents 12 years of formal education.

CONCLUSIONS

The proportion currently employed has remained stable at 22% since the last national survey in 1997. Policy makers and service providers could do more to ensure people with psychotic disorders obtain access to more effective forms of assistance with respect to both their continuing education and employment. More effective vocational and educational interventions for people with psychotic disorders appear to be urgently needed.

The impact of Vocational, Education, Training and Employment Coordinator positions on attitudes and practices in a NSW mental health service

OBJECTIVE

To determine attitudes and practices of community mental health clinicians in relation to employment and education for consumers and to assess the impact of the establishment of Vocational, Education, Training and Employment (VETE) Coordinator positions.

METHOD

A snapshot was conducted by surveying community mental health clinicians regarding every consumer on their caseload in 2007. This was repeated in 2010 and the results were compared.

RESULTS

From 2007 to 2010, the overall rates of VETE interventions increased, including a doubling of the rate of linkage to employment agencies for job seekers. Services with the consistent presence of a VETE Coordinator showed a greater impact on a number of factors, highlighted by a positive shift in clinician attitudes regarding their consumers' capacity to work.

CONCLUSION

The establishment of VETE Coordination positions in the mental health service appears to be an effective way of raising awareness of VETE issues and improving VETE service provision. An important role has been assisting clinicians to begin implementing the principles of the Individual Placement and Support model of Supported Employment and to incorporate support for employment and education as a routine part of practice.

The Importance of Service Integration in Developing Effective Employment Services for People with Severe Mental Health Conditions

Introduction:

This report examines the importance of integrating mental health services with supported employment services for people with severe mental health conditions and psychiatric disabilities. Integrated mental health and employment services are considered a key principle of evidence-based practices in supported employment for this group.

Method:

The importance of this principle was tested by examining both the service practices and the employment outcomes attained by 270 clients of a segregated employment service in Christchurch, New Zealand. Service practices were examined using an established scale to assess the fidelity of evidence-based practices in supported employment. Employment outcomes were benchmarked to a range of employment outcome variables reported in national and international studies of specialised supported employment services.

Results:

Despite only a fair overall fidelity score of 64/75, 73.7% of clients commenced competitive employment within a mean of 86 days from programme entry. The mean hours worked by those employed was 22 hours per week, and 41.5% of those who commenced employment worked for 26 weeks or more.

Conclusion:

These promising results confirm that very good implementation of evidence-based practices other than service integration practices can compensate for the disadvantages of service segregation.

Mental Health Service Users' Perspectives of Work: A Review of the Literature

Purpose:

Much of the literature about the meaning and experience of work for people with mental health problems is limited in the extent to which individual perspectives are represented, because the evidence derives from studies that are mainly quantitative in design. This literature review focused on qualitative studies, which sought to elicit the experiences of returning to work with a mental health problem.

Method:

An electronic search of the databases SCOPUS, CINAHL and PsycINFO was carried out. Papers with a publication date between December 1989 and December 2009 were sought. This time period was chosen to reflect the developments in approaches to vocational rehabilitation that have developed during the last 20 years.

Findings:

The findings indicate that work holds multiple meanings for people with mental health problems, that there are advantages and disadvantages to working, and that many barriers to work exist. The crucial nature of support for the individual in accessing employment is emphasised, and what users want from supportive relationships is detailed. The findings suggest that barriers can be overcome if the right support is available.

Conclusion:

The findings provide support for the involvement of occupational therapists working in vocational services, and offer some pointers for developing relationships with clients. The findings highlight the importance of exploring clients' feelings about work, including perceived barriers and benefits to working, and provide a deeper understanding of the type of supportive relationship required by a person with a mental health problem who wishes to access employment.

Examining the Validity of the Model of Human Occupation Screening Tool: Using Classical Test Theory and Item Response Theory

Introduction:

This study examined the psychometric properties of the Model of Human Occupation Screening Tool, using both item response theory and classical test theory.

Method:

One hundred and one people with mental health problems, aged 18–65 years, were recruited. The Chinese version of the Model of Human Occupation Screening Tool, the National Taiwan University Hospital Symptom Checklist, the Volitional Questionnaire, the Assessment of Communication and Interaction Skills, and the Mini Mental State Examination were administered. Rasch analysis and correlational analysis were used to examine the construct, convergent, divergent validity and known group validity.

Results:

Rasch analysis confirmed that there were six subscales within the Chinese version of Model of Human Occupation Screening Tool. The Volitional Questionnaire strongly correlated with the volition subscale (r = 0.583). The Assessment of Communication and Interaction Skills strongly correlated with the communication and interaction subscale (r = 0.815). The Mini Mental State Examination was moderately correlated with the process subscale (ρ = 0.334) and the symptomatology was not associated with any of the subscales as expected. There were significant differences on selected subscale scores across four known groups of participants.

Conclusion:

The Chinese version of the Model of Human Occupation Screening Tool was valid when applied to people with mental health problems.

Sustaining Employment in a Social Firm: Use of the Work Environment Impact Scale V2.0 to Explore Views of Employees with Psychiatric Disabilities

Evidence suggests that people with psychiatric disabilities find it difficult to get and keep jobs, with workplace characteristics contributing to difficulties staying in employment. This qualitative study aimed to understand the views of employees with a psychiatric disability about working in an Australian social firm designed to provide an inclusive and supportive work environment.

Method:

Seven participants who had sustained jobs for 6 months or longer in the social firm, a contract cleaning business, were interviewed using the Work Environment Impact Scale (Version 2.0). Interviews were audiotaped, transcribed and analysed inductively using thematic and narrative analysis.

Findings:

Participants' views of the work environment included that the regular structure and achievable tasks, the supportive and cooperative team and the benefits of the job made working in the social firm enjoyable and the right job for now. The findings suggest that participants' decisions to stay in their jobs were influenced by the social firm environment, which supported their wellbeing, and by their individual illness and occupational narratives.

Conclusion:

The WEISv2.0 was effective in gaining participants' views on wide-ranging features of their workplaces. Further research is recommended to expand the evidence base concerning workplace features that support employees with psychiatric disabilities to sustain their jobs.