IPS Support Employment: A 20-Year Update

Addressing social determinants of health in individuals with mental disorders in clinical practice: review and recommendations

Social determinants of health have been shown to have a greater impact on overall health than traditionally considered medical risk factors, especially in people with mental disorders. It is the primary responsibility of healthcare providers to ensure that persons with psychiatric disorders are actively helped in reducing the adverse effects of SDoMH on their health and healthcare. Yet, the current clinical psychiatric practice in the U.S. does not have any standardized guidelines for evaluating or addressing these critical factors even among individuals who are receiving psychiatric and other medical treatment. Although there are several barriers to implementing such interventions, there are also practical approaches to address selected social determinants of mental health and improve the well-being of our patients. In this article, we review the literature on the assessment of relevant social factors and pragmatic psychosocial strategies at the individual, family, and community levels to help reduce their adverse impact. We offer guidelines for psychiatric clinicians and case managers to improve the health and quality of life of persons with mental disorders, using sustained inter-professional collaborative efforts.

Supported employment coaches' difficulties and facilitators with clients diagnosed with personality versus other disorders: A qualitative study

Aim

People with severe mental illnesses (SMI) face different occupational challenges than those diagnosed with personality disorders (PD). Supported employment (SE) has been validated for SMI patients but its effectiveness for individuals with PD remains unclear, and the reasons for this potential difference have not been explored. This study aimed to identify differences in SE practice for clients with SMI and those with PD.

Methods

Six SE job coaches were interviewed about their experiences. A thematic analysis was run.

Results

More difficulties and facilitators were mentioned regarding clients with PD than regarding clients with other SMI. For both, patients' symptoms were reported to negatively affect their (re)integration into the job market. However, in contrast to that of clients with SMI, the relation between symptoms and SE success for clients with PD involved difficult behaviors and their negative impact on the therapeutic relationship.

Conclusion

In summary, SE practice seems to be undermined by PD and could benefit from adaptations, such as specific training for SE teams to help them in managing clients with this disorder.

Intervention outcome preferences for youth who are out of work and out of school: a qualitative study

Background

While interventions have been developed and tested to help youth who have become disconnected from work and school, there is a paucity of research on young people’s intervention preferences. This study aims to understand young people’s preferred intervention outcomes and approaches for youth who are out of work and school.

Methods

Thirty youth participated in virtual focus groups. Transcripts were analyzed using thematic analysis.

Results

Youth want interventions and approaches that support them in (1) vocational readiness, (2) securing a job, and (3) mental health and well-being, while providing them with (4) high-contact, individualized, and integrated support.

Conclusions

Young people want interventions to be individualized and integrated, providing a high level of support for their educational and employment pursuits as well as their mental health and well-being. Incorporating youth's perspectives when designing interventions can increase intervention relevance and potentially service uptake, helping youth continue to pursue their educational and vocational goals.

"These are people just like us who can work": Overcoming clinical resistance and shifting views in the implementation of Individual Placement and Support (IPS)

Purpose

Individual Placement and Support (IPS) is a recovery-based approach to support people with mental health difficulties back into employment. Embedding of IPS within the mental health Multi-Disciplinary Team (MDT) is a key component of IPS fidelity; however, few studies have examined how those involved with IPS implementation navigate this process. This article explores how IPS Employment Specialists (ES) and Occupational Therapist (OT) Managers integrated and embedded IPS within traditionally-oriented MDTs as part of a national reform program in the Republic of Ireland.

Methods

The study design was qualitative, descriptive with data collected through three focus groups with 17 IPS ESs and 11 OT Managers. Data were analyzed using thematic synthesis.

Results

Three key themes emerged from analysis. The first characterizes the context into which IPS landed, described as one marked by clinical resistance, doubt, and fear of risk. The second explores the strategies and factors that helped with the introduction of IPS into Irish mental health services. These included strategies, such as providing education and information about IPS and reassuring the MDT about IPS governance and IPS ES’ competencies. The evidenced-based nature of IPS and its attached accountabilities through IPS fidelity measures were perceived to be an important factor in its acceptance. The final theme encapsulates perceptions of how IPS impacted on the MDTs’ views of people with mental health difficulties. Findings suggest a shift in the ways in which MDTs view their clients. Initial fears about work capacity and risk shifted towards seeing people beyond the label of ‘service user’ and their diagnosis.

Conclusions

It is contended that IPS is an approach that allows practitioners to engage with real recovery-practice and may be one key to unlocking how a recovery approach can truly trickle down and embed itself within mental health service provision and support mental health system reform.

Individual placement and support and employment in personality disorders: a registry based cohort study

BACKGROUND

To explore the relative impact of Individual Placement and Support (IPS) in patients with personality disorders (PDs) as compared to patients with other mental disorders.

METHODS

Data from the Dutch Employee Insurance Agency of participants enrolled in a national IPS trajectory between 2008 and 2018 were linked to corresponding data on employment outcomes, diagnostic and sociodemographic information from Statistics Netherlands. This resulted in a sample of 335 participants with PDs who could be compared with 1073 participants with other mental disorders.

RESULTS

Participants with PD just as often found competitive employment as participants with other mental disorders (37.6% vs. 38.0%, OR_adjusted = 0.97, 95% confidence interval (CI) 0.74 to 1.27). The median time to gaining employment for those gaining employment (37.9%) was 195.5 days (mean number of days 252.5) in the PD group and 178.5 days (mean number of days 234.6) in the other mental disorders group (HR_adjusted = 0.95, 95% CI 0.77 to 1.18). Also, total number of hours paid for competitive employment did not differ significantly between groups (median hours 686.5 vs 781.5, IRR_adjusted = 0.85 95% CI 0.69 to 1.05).

CONCLUSIONS

Based on this study, which includes the largest sample of patients with PDs in any published IPS study, IPS seems to result in an equal percentage of patients with PDs and other mental disorders, gaining and maintaining employment. Although future studies should determine whether PD-specific adaptations to IPS are useful, our findings indicate that IPS could be an effective way to increase employment outcomes in PDs. This is important because the enormous societal costs of PDs are largely driven by loss of economic productivity, and because clinical recovery in PDs is suggested to be enhanced when patients are employed.

"Navigating Between Unpredictable Icebergs": A Meta-Ethnographic Study of Employment Specialists' Contributions in Providing Job Support for People with Mental Illness

Purpose To explore and synthesize the views of Supported Employment clients, employment specialists and their supervisors on the core contributions of employment specialists to job support within the mental health field. Methods We systematically searched four databases with no time limitations and identified 16 qualitative studies published between 2006 and 2018 to be included in this meta-ethnographic study. Results The overarching metaphor of "Navigating an Unpredictable Iceberg-laden Sea" (a workplace) and seven themes were revealed: (1) "It's you and me looking," which represented the relationship between the client and ES, and (2) taking job seekers' ambitions and needs seriously, (3) mapping the route, (4) exploring the hidden, (5) being on tap, (6) avoiding crashes, and (7) bridging, which embodied the work of employments specialists. Conclusion. Our iceberg metaphor illustrates the importance of employment specialists being competent in addressing clients' work performance difficulties related not only to the individual's illness, age, gender, and cultural-related challenges, but also to psychosocial, behavioral, and environmental workplace factors. Given the effects of the specific characteristics of the working alliance developed in supported employment, we suggest that employment specialists' training and supervision be enriched by paying more attention to these important relational processes.

Employment in Personality Disorders and the Effectiveness of Individual Placement and Support: Outcomes from a Secondary Data Analysis

Purpose Personality disorders (PDs) are associated with severe functional impairment and subsequent high societal costs, increasing the need to improve occupational functioning in PD. Individual placement and support (IPS) is an effective, evidence-based method of supported employment, which so far has been tested in various mixed patient populations with severe mental illness (SMI, including PDs). However, the effectiveness of IPS for PDs per se remains uninvestigated. Methods Data from the SCION trial were used, including 31 SMI patients with PDs and 115 SMI patients with other primary diagnoses (primarily psychotic disorders). First, the interaction effect of diagnosis (PD vs other SMI) and intervention (IPS vs traditional vocational rehabilitation) was studied. Second, in the IPS condition, difference between diagnostic groups in time to first job was studied. Results We did not find evidence of a moderating effect of PD diagnosis on the primary effect of IPS (proportion who started in regular employment) (OR = 0.592, 95% CI 0.80-4.350, p = 0.606) after 30 months. Also, PD diagnosis did not moderate the effect of time until first job in IPS. Conclusions From the present explorative analysis we did not find evidence for a moderating effect of PD diagnosis on the effectiveness of IPS among PD participants. This indicates that IPS could be as effective in gaining employment in participants with PD as it is in participants with other SMI. Future studies, implementing larger numbers, should confirm whether IPS is equally effective in PDs and study whether augmentations or alterations to the standard IPS model might be beneficiary for PD.

Consumer, health professional and employment specialist experiences of an individual placement and support programme

BACKGROUND

Individuals with severe mental illness (SMI) are under-represented in the workforce. The Individual Placement and Support (IPS) programme is an evidence-based intervention that co-locates an Employment Specialist in a community mental health team to support individuals with a SMI with their goal of finding work. Previous research predominantly explored IPS programme outcomes rather than stakeholder experiences.

AIM

To explore programme stakeholder perspectives and experiences during the early stages of IPS programme implementation.

METHODS

Qualitative descriptive methodology explored consumers (n = 11), health professionals and employment specialist (n = 11) perceptions and experiences of the IPS programme. Semi-structured interviews were conducted and thematically analysed.

RESULTS

Three main themes emerged: enacting core care philosophies, IPS programme process and catalyst for supportive environments and relationships. The combination of IPS programme relationships, enactment of core care philosophies, and programme process promoted development of supportive environments and relationships for consumers participating in the programme.

CONCLUSION

Findings suggest IPS processes promoted the enactment of person-centred and recovery-oriented care approaches and positively influenced care planning practices and service culture.

SIGNIFICANCE

IPS directly tackles the compounding disadvantage resulting from unemployment for people with a SMI. At a service level, IPS can foster positive changes to care practices and service culture.

Toward an Experimental Therapeutics Approach in Human Services Research

Over the past decade, the experimental therapeutics approach has gained currency as an organizing framework for research in mental health. However, examples of this approach outside of person-directed therapeutic and preventive interventions have been relatively uncommon. This article describes an experimental therapeutics approach to mental health and human services research that considers the role of social and ecological determinants in a person's recovery from mental disorder. To illustrate this approach, this article decomposes an employment intervention to show three of its components and identifies the targets for two components: social relationships and health insurance. These targets can be engaged by provider-, community-, or policy-level interventions. Such applications of an experimental therapeutics approach to research on mental health services can enhance the rigor of studies and thereby contribute to the well-being of persons living with mental disorders in the United States.

Barriers and facilitators to employment in borderline personality disorder: A qualitative study among patients, mental health practitioners and insurance physicians

Background

Borderline personality disorder (BPD) is associated with unemployment and impaired functioning. However, a comprehensive understanding of barriers and facilitators to employment from a multidisciplinary perspective is currently lacking. Therefore, the aim of this qualitative study was to explore barriers and facilitators in gaining and maintaining employment in BPD from the perspectives of patients, mental health practitioners (MHPs) and insurance physicians (IPs).

Methods

Fifteen semi-structured interviews were conducted in patients with BPD and two focus groups were carried out among MHPs (n = 7) and IPs (n = 6) following a thematic content analysis approach.

Results

All participants described barriers and facilitators relating to three overall themes: characteristics of BPD, stigma, and support to employment. Barriers to employment mainly related to characteristics of BPD, such as low self-image, difficulty posing personal boundaries, difficulty regulating emotions, and lack of structure. MHPs and IPs additionally mentioned externalization and overestimation of competencies on the part of patients. Enhancing emotion regulation and self-reflection by successful treatment was suggested as a facilitator to enhance employment. Increasing collaboration between mental health and vocational rehabilitation services, and increasing knowledge about BPD, were suggested to increase sustainable employment and decrease stigma.

Conclusions

The present findings revealed that both facilitators and barriers are important in gaining and maintaining employment in BPD in which diminishing symptoms, examining stigma and increasing support to employment are key. As a next step, supported employment strategies that follow patient preferences and integrate employment and mental health services, should be studied in the context of BPD.

Feasibility of Family Group Conference to promote return-to-work of persons receiving work disability benefit

Purpose: To investigate the feasibility of Family Group Conference for promoting return to work by clients receiving work disability benefits from the Social Security Institute in the Netherlands.Methods: We conducted a mixed-method pre- post-intervention feasibility study, using questionnaires, semi-structured interviews and return to work plans drafted in Family Group Conferences. A convenient sample of Labour experts, Clients, and Facilitators was followed for a period of six months. Feasibility outcomes were demand, acceptability, implementation and limited efficacy of perceived mental health and level of participation.Results: Fourteen labour experts and sixteen facilitators enrolled in the study. Of 28 eligible clients, nine (32%) participated in a Family Group Conference. About 78% of the Family Group Conferences were implemented as planned. Participant satisfaction about Family Group Conference was good (mean score 7). Perceived mental health and level of participation improved slightly during follow-up. Most actions in the return to work plans were work related. Most frequently chosen to take action was the participating client himself, supported by significant others in his or her social network. Six months after the Family Group Conference five participating clients returned to paid or voluntary work.Conclusions: Family Group Conference seems a feasible intervention to promote return to work by clients on work disability benefit. Involvement of the social network may have added value to support the clients in this process. An effectiveness study to further develop and test Family Group Conferences is recommended.Implications for rehabilitationFamily Group Conference may represent a promising approach to be used in activation strategies to enhance social inclusion and return to work of persons receiving disability benefits.Conventional supply-oriented activation services could be improved by providing the Family Group Conference to unemployed persons on disability benefit.Involvement of the social network may have added value for return to work of clients receiving work disability benefits.

Subjective Experiences of the Benefits and Key Elements of a Cognitive Behavioral Intervention Focused on Community Work Outcomes in Persons With Mental Illness

New research suggests that group-based cognitive behavioral therapy (CBT) may help improve employment outcomes in persons with mental illness, yet the effects and potential key elements facilitating change in such interventions are unclear. Using a mixed methods approach, this study examined the perspectives of persons with mental illness after participating in a pilot study of the "CBT for Work Success" intervention. Findings demonstrate that participants valued the intervention and perceived that it assisted them in achieving work goals. Therapeutic effects included improved self-efficacy, work motivation, enhanced sense of self as workers, and increased beliefs that work success is attainable. CBT for Work Success elements perceived to be important in facilitating work goals included cognitive restructuring, behavioral coping strategies, problem solving work barriers, meaningful reflection on oneself as a worker, and important factors associated with the group process. The authors discuss the implications of these findings and future research directions.

"What's Wrong with the Seed?" A Comparative Examination of an Empowering Community-Centered Approach to Recovery in Community Mental Health

This cross-sectional group comparison aimed to examine whether personal empowerment, recovery and community integration were associated with the individual's participation in an empowering community-centered model of intervention. Ninety-three participants from an empowering community-centered community mental health organization were compared with a matched group of individuals from standard interventions of four equivalent organizations. Results showed that participants taking advantage of the empowering community-centered approach were more involved in high recovery-oriented programs; and attained higher levels of personal goals and hope, empowerment, and of community integration. An involvement in high recovery-oriented programs (supported employment or independent housing) revealed improved outcomes for the individual. In conclusion, the findings suggested a transformative impact of the empowering community-centered model both at the individual and the program level by altering the resource accessibility and social conditions for people who experience mental illness. The implications of findings for transforming community mental health practice are discussed in detail.

Virtual Reality Job Interview Training and 6-Month Employment Outcomes for Individuals with Substance Use Disorders Seeking Employment

BACKGROUND

Individuals with substance use disorders (SUDs) have low employment rates and job interviewing is a critical barrier to employment for them. Virtual reality training is efficacious at improving interview skills and vocational outcomes for several clinical populations.

OBJECTIVE

This study evaluated the acceptability and efficacy of virtual reality job interview training (VR-JIT) at improving interview skills and vocational outcomes among individuals with SUDs via a small randomized controlled trial (n=14 VR-JIT trainees, n=11 treatment-as-usual (TAU) controls).

METHODS

Trainees completed up to 10 hours of virtual interviews, while controls received services as usual. Primary outcome measures included two pre-test and two post-test video-recorded role-play interviews and vocational outcomes at six-month follow-up.

RESULTS

Trainees reported that the intervention was easy-to-use and helped prepared them for future interviews. While co-varying for pre-test role-play performance, trainees had higher post-test role-play scores than controls at the trend level (p<0.10). At 6-month follow-up, trainees were more likely than controls to attain a competitive position (78.6% vs. 44.4%, p<0.05, respectively). Trainees had greater odds of attaining a competitive position by 6 month follow-up compared to controls (OR: 5.67, p<0.05). VR-JIT participation was associated with fewer weeks searching for a position (r= -0.36, p<0.05).

CONCLUSIONS

There is preliminary evidence that VR-JIT is acceptable to trainees. Moreover, VR-JIT led to better vocational outcomes with trainees having greater odds of attaining a competitive position by 6-month follow-up. Future studies could evaluate the effectiveness of VR-JIT within community-based services.

Virtual reality job interview training and 6-month employment outcomes for individuals with schizophrenia seeking employment

BACKGROUND

Individuals with schizophrenia have low employment rates and the job interview presents a critical barrier for them to obtain employment. Virtual reality training has demonstrated efficacy at improving interview skills and employment outcomes among multiple clinical populations. However, the effects of this training on individuals with schizophrenia are unknown. This study evaluated the efficacy of virtual reality job interview training (VR-JIT) at improving job interview skills and employment outcomes among individuals with schizophrenia in a small randomized controlled trial (n=21 VR-JIT trainees, n=11 waitlist controls).

METHODS

Trainees completed up to 10h of virtual interviews using VR-JIT, while controls received services as usual. Primary outcome measures included two pre-test and two post-test video-recorded role-play interviews scored by blinded raters with expertise in human resources and self-reported interviewing self-confidence. Six-month follow-up data on employment outcomes were collected.

RESULTS

Trainees reported that the intervention was easy-to-use, helpful, and prepared them for future interviews. Trainees demonstrated increased role-play scores between pre-test and post-test while controls did not (p=0.001). After accounting for neurocognition and months since prior employment, trainees had greater odds of receiving a job offer by 6month follow-up compared to controls (OR: 8.73, p=0.04) and more training was associated with fewer weeks until receiving a job offer (r=-0.63, p<0.001).

CONCLUSIONS

Results suggest that VR-JIT is acceptable to trainees and may be efficacious for improving job interview skills in individuals with schizophrenia. Moreover, trainees had greater odds of receiving a job offer by 6-month follow-up. Future studies could evaluate the effectiveness of VR-JIT within community-based services.

Mental health services for individuals with high functioning autism spectrum disorder

Adolescents and adults with an autism spectrum disorder (ASD) who do not have an intellectual impairment or disability (ID), described here as individuals with high-functioning autism spectrum disorder (HFASD), represent a complex and underserved psychiatric population. While there is an emerging literature on the mental health needs of children with ASD with normal intelligence, we know less about these issues in adults. Of the few studies of adolescents and adults with HFASD completed to date, findings suggest that they face a multitude of cooccurring psychiatric (e.g., anxiety, depression), psychosocial, and functional issues, all of which occur in addition to their ASD symptomatology. Despite this, traditional mental health services and supports are falling short of meeting the needs of these adults. This review highlights the service needs and the corresponding gaps in care for this population. It also provides an overview of the literature on psychiatric risk factors, identifies areas requiring further study, and makes recommendations for how existing mental health services could include adults with HFASD.

Beyond cognition: a longitudinal investigation of the role of motivation during a vocational rehabilitation program

Studies that have specifically examined the effects of motivation on work have been limited to evaluations of baseline motivation and have not accounted for cognition. These have also not examined whether motivation changes over time. In the current analyses, we examined how baseline motivation and longitudinal changes in motivation, along with the effects of baseline cognition, related to work function in a sample of 123 individuals with schizophrenia or schizoaffective disorder participating in a 26-week vocational rehabilitation program. Our results indicate that cognition at baseline was a significant predictor of work outcomes over time. Baseline motivation and changes in motivation were significantly linked to work outcomes. The impact of motivation remained significant even after accounting for baseline cognition. These findings provide evidence that motivation is malleable during vocational rehabilitation and has an important impact on vocational function above and beyond the impact of cognition.

'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.