Background
Aims
Methods
Study design
Participants
IPS clients
IPS employment specialists
Procedures
Interviews
Focus groups
Ethical considerations
Data analysis
Results
IPS clients (n = 10) | |
Sex female (n) | 4 |
Median age in years (range) | 40 (27–55) |
Psychotic disorder (n) | 7 |
Low and medium level of education (n) | 7 |
Receiving benefits (n) | 8 |
Competitively employed in the past 5 years (n) | 7 |
Currently employed (n) | 6 |
Median working hours/ week (range) | 20 (14–40) |
IPS employment specialists (n = 15) | |
Sex female (n) | 13 |
Median age in years (range) | 42 (23–62) |
Median number of years of experience as employment specialist (range) | 2.5 (1–11) |
1. Experiences with IPS | |
1.1 Importance of discussing client’s motivation and motives to work | Requires attention regularly Various motives to work |
1.2 Facilitators to obtaining employment | IPS employment specialist’s crucial role Employers’ inclusiveness Client’s relevant work experience, competences and/ or skillsa |
1.3 Barriers to obtaining employment | Financial factors related to client (e.g. fear of financial decline) Disclosure of client’s mental illness to employer Client’s lack of self-confidence and/ or self-esteema |
1.4 Facilitators to maintaining employment | Disclosure of client’s impairments and needs towards employer Positive atmosphere and culture within company |
1.5 Barriers to maintaining employment | Client’s mental health problems and susceptibility to stress Financial factors related to employer (e.g. low wage) |
2. Experiences with multifaceted implementation strategy | |
2.1 Facilitators to collaboration between stakeholders | Regular meetingsb Committed contact persons within benefits agenciesb |
2.2 Barriers to benefits counselling | Employment specialist’s limited knowledge regarding benefits Long response time of professionals within benefits agencies Complex laws and legislation regarding social security |
2.3 Organizational barriers to IPS execution and collaboration between stakeholders | Lack of continuityb |
2.4 Financial barriers to IPS execution | Inadequate IPS fundingb Variation in follow-up support depending on psychiatristb |
2.5 Experiences with pay for performance element | Not aware of pay for performance element Not an appropriate incentive Logical that mental health agency receives extra paymentsa Does not influence employment specialistb |
Experiences with IPS
Importance of discussing client’s motivation and motives to work
Various client’s motives to work were mentioned by both clients and employment specialists. According to the employment specialists and several clients, financial factors, such as low pay and fear of losing benefits, were important for the client and influenced their motivation, choices regarding work and (mental) health.ES14: “[ … ] I explain that motivation is the only thing that counts for participation in IPS. I had another client yesterday and he said: [ … ] ‘so if I don't want to, then I don’t have to?’ And then I thought [ … ]: you are in control. I explain and make this clear right from the start so that they also know that if they are not motivated, they can express that and that they don’t have to think: I am now obliged to participate.”
Being occupied (with something meaningful) and a sense of belonging and participation were mentioned as the most important motives to work by most clients.Man, employed 24h/w: “It isn’t anything more than benefits, so in that sense, I wouldn’t notice much financially. But yes, if you worked there for five days, you’d have the feeling that you didn’t earn much, and then receiving benefits would almost be more interesting [ … ]. Yes, that might be a reason to leave in the long run, but then of course I’d have to find something that really pays well and suits better.”
Facilitators to obtaining employment
Other important facilitators mentioned by both clients and employment specialists, were the employment specialist’s network, and activating and motivating the client by the employment specialist.Man, employed 26h/w: “[ … ] what do you want yourself? What do you want to achieve? What are your ambitions? She [his IPS employment specialist] started to ask those questions and that is how we came up with what I wanted. [ … ] I am very satisfied with my IPS employment specialist. She did a good job. I'm pretty much where I should be now, and yes, she listened to me and understood my ambitions correctly.”
Several employment specialists also pointed out that they have an important task in challenging stigmatizing attitudes among employers and the mental health care providers within their own team, who often underestimate the client’s capabilities to work.Woman, employed 18h/w: “[ … ] I wasn’t that motivated to start working again. [ … ] Here you were encouraged, like: try it and look how it goes [ … ]. But also: just come every week to our appointment, then we are going to search for a job together. I was just anxious to start working again. [ … ] And here I was told: ‘you can do it, it is going to be alright.’”
Most clients and employment specialists also stated that the employer’s inclusiveness (i.e., a positive attitude towards providing opportunities to people with a mental illness and hiring them) was an important facilitator; according to these employment specialists, inclusive employers often represent small companies that have affinity with people with mental health issues.ES14: “They [her multidisciplinary treatment team] gave me the feedback that they expected me to focus on destigmatization. So, for example, if choices were made about daytime activities or IPS, with new clients, that I would think about those kinds of decisions together with them [her multidisciplinary treatment team] [ … ].”
Barriers to obtaining employment
In addition, disclosure of the client’s mental illness towards the employer was considered a barrier. According to several clients and employment specialists, disclosure of the diagnosis can lead to stigma and discrimination, resulting in not being hired. Most of these employment specialists recommended to disclose only relevant information, such as the client’s needs in order to function optimally at work.Woman, unemployed: “[ … ] I thought [ … ] that I would earn less in terms of salary for a job than my benefits. And yes, I thought: well … I’ve already completed my studies and I do want to be rewarded for that.”
Other important barriers mentioned by several clients were the client’s lack of self-confidence and/ or self-esteem, due to a lack of societal participation and a significant distance from the labour market.ES9: “In this, I am sometimes directing, well I mean: not directing but more advising. If people do want to disclose and simply say: ‘I have schizophrenia and I have experienced psychoses’, I will say: do you understand that statements like that can evoke certain ideas in a person? Does it serve you to use those terms or can you perhaps use a different way to describe the situation? It often just doesn’t have a positive effect, because people have certain ideas about those terms.”
Facilitators to maintaining employment
The other facilitators mentioned were mainly related to the employer and work environment. A positive atmosphere and culture within the company, characterized by a supportive and flexible environment, and opportunities for self-development, were seen as one of the most important facilitators by both clients and employment specialists.Woman, employed 18h/w: “I am very sensitive to stress and I don't mind my employer knowing that. When my employer knows what kind of person I am and how I should be treated, it gives me a certain reassurance. It also takes some sort of pressure off [ … ].”
In addition, the presence of an in-company job coach or another supporting professional (e.g. team leader) within the company, was experienced as another important facilitator by several employed clients.Woman, employed 20h/w: “I can just be myself with all the things I blurt out [...]. It feels familiar, they [her colleagues] are my type of people [ … ] and it is not much of a business world, [ … ] they are very gentle people and everything just goes the way it goes [ … ]. It is not all very tight, because then I wouldn’t have been able to cope with it [ … ]. I also dare to say what is and what is not going well. I also feel comfortable to say if I have not got around to doing something, I also dare to say what I am unsure about [ … ]; I dare to say all that, to everyone who works there."
Barriers to maintaining employment
Several clients and employment specialists also reported that financial factors, such as a low wage, were an important barrier. In addition, financial motives of employers to hire the client were considered a barrier by several employment specialists. They believed that hiring the client because of financial incentives lowers the chance of successfully maintaining a job, as some employers end the client’s contract as soon as they stop meeting the conditions for the financial compensation.Man, unemployed: “I’m quitting [the job] because I don’t think it is worth being admitted in the clinic for the third time.”
ES13: “I think that it is important to really check, at an earlier phase, whether an employer is motivated to deal with any difficulties that might exist. If there is only a financial incentive, the chances are that it will fail.”
Experiences with multifaceted implementation strategy
Facilitators to collaboration between stakeholders
Barriers to improving benefits counselling
Woman, employed 20h/w: “[ … ] I was very scared of the financial consequences, because I thought I would really be worse off, financially. That is entirely possible, you could just lose hundreds of euros if you were to start working more. And, no one could tell me where I could find that information; not on the internet, nobody. I called UWV, nobody could tell me … those IPS employment specialists couldn't do that either. I was really worried about that, I was completely stressed.”
Organizational barriers to IPS execution and collaboration between stakeholders
In addition, the employment specialists reported that many colleagues felt they were underpaid for their job compared to other mental health care professionals and that this was an important reason for many employment specialists to search for another, better paid job, resulting in a high turnover of employment specialists.R9: “What affects our results and the way we work with IPS is that for the last three or four years, we’ve had an outflow of IPS employment specialists and then a new inflow and sometimes, for months, no IPS employment specialist in the team, and then once again, someone new that has no experience. [...] You really have to work two years or three years to really improve results and get more people [clients] to work. Plus the number of agreements and contracts that are there, with the municipality, with UWV, that are not always [ … ] transferred properly because there is such an amount of information that people [employment specialists] already have to absorb.”
Financial barriers to IPS execution
The employment specialists stated that they did try to provide follow-up support, despite the lack of IPS funding. Several employment specialists claimed expenses from the health insurance company for the provided follow-up support, after the ending of the trajectory. To claim these expenses, they needed permission from the psychiatrist. According to the employment specialists, this can result in variation of the support offered depending on the psychiatrist, as some psychiatrists experienced pressure from the health insurer and did not allow this funding to be used for IPS, while other psychiatrists perceived IPS as a part of the mental health treatment and gave permission to claim expenses.R13: “[ … ] I now have the first people for whom the IPS trajectory has ended and for whom it’s gone wrong afterwards, and I think it would be very good if there were some kind of fallback possibility. So that in principle, the trajectory does stop, but if it is necessary that you can jump in quickly for a short period.”
Experiences with pay for performance element
The employment specialists did not feel a financial incentive, extra motivation or pressure due to the pay for performance element. In addition, they were not aware of the criteria for the extra payments. Some employment specialists thought a financial incentive was not appropriate considering the risk of selection of promising clients; others felt more appreciation and less workload for the employment specialist would be preferable and more motivating for the employment specialist than the pay for performance element.Woman, employed 20h/w: “Isn't the IPS employment specialist getting his salary paid [ … ]? So why should the mental health agency still receive a bonus? I do not really find it necessary [ … ].”