Facilitating the employment of people with mental health difficulties in Ireland

The therapeutic importance of suitable employment and its ability to enhance a person's health and wellbeing is widely noted in research (Drake, et al., 2012; Khalema and Shankar, 2014; Prior, et al., 2013). Jahoda's latent deprivation theory (1982) posits that employment provides people with structure, purpose, social connectedness, identity and activity, with these latent benefits of employment contributing to psychological wellbeing (Batinic, et al., 2010).

Suitable employment has many advantages for individuals with mental health difficulties, including its well-documented association with reductions in outpatient psychiatric appointments and improved quality of life (Amnesty International, 2013; Luciano, et al., 2014). The importance of engaging in a meaningful occupation is central to promoting social inclusion, increasing a person's self-esteem and improving income levels of those with a mental health disability (Drake and Bond, 2011; Knapp, et al., 2014; Luciano, et al., 2014; Meuser, et al., 2016) with returning to employment cited as a key factor for a person with a mental health disability in their recovery journey (Cullen, et al., 2017; Prior, et al., 2013).

In Ireland, a person attending a secondary or specialist mental health service is deemed to have a severe and enduring mental illness (Mental Health Reform, 2018). Symptoms may begin early in a persons’ life and persist for decades, affecting cognitive and social functioning, which in turn impacts negatively on educational status, housing, physical health and of course employment options (Hodgson, et al., 2011). Early onset of mental health disability can act as a barrier to school completion and can therefore limit a person's ability to obtain suitable employment, gain financial security and reduce dependence on welfare (Leach and Butterworth, 2012; Mojtabai, et al., 2015). Clients with a mental health disability often rely on positions in gardening, or in food or janitorial services. These positions often provide fewer opportunities for career advancement and financial security (Krupa, et al., 2009). For those with existing qualification or skills, or for those who simply want more permanent work, this can represent a form of underemployment, which in itself is expected to contribute to negative consequences for the health and wellbeing of individuals (Cassidy and Wright 2008). After re-employment, workers also tend to find jobs of lower quality than those previously held (McKee and Harvey 2011).

Mental illness can have a severe and negative impact on many life domains, leading to the need for multiple supports from the mental health treatment teams (Drake, et al., 2012). Cognitive functioning may be affected by a mental health illness, particularly in the areas of memory, concentration, regulation of emotions and perceptions of reality. The side-effects of medication, such as fatigue, drowsiness and weight gain, can compound this, making it difficult for those affected to function effectively in the work environment (Khalema and Shankar, 2014). These illnesses produce severe and debilitating symptoms for clients, often requiring admissions to psychiatric hospitals and the need for long-term care with mental health treatment teams (Hodgson, et al., 2011). Another important concern for clients who are returning to employment is the effect this may have on a person's social welfare entitlement and other secondary benefits they may be receiving (O’Day, et al., 2017). A fear of losing a social welfare payment can act as a disincentive to returning to employment for those with a mental health illness or may act as a constraint to them returning to full-time employment, causing them to seek part-time hours as a way of retaining welfare payments (Krupa, et al., 2009; O’Day, et al., 2017). Research suggests that earnings from supported employment are typically low and that this is strongly associated with disincentives in the welfare payment system for those with a disability to return to employment (Campbell, et al., 2011). Difficulties encountered by clients when returning to a welfare payment if a job placement does not work out can also act as a constraint to returning to employment (Bond and Drake, 2014), leading to a ‘benefit trap’ situation (Boardman and Rinaldi, 2013).

The A Vision for Change (2006) strategy document provides a framework for the delivery of mental health services in Ireland. It recommended that services should be put in place to facilitate meaningful employment with the development of support services and coordination between training and vocational agencies (Health Service Executive, 2006). In response, a pilot project entitled Integrating Employment and Mental Health Supports (IEMHS) was trialled from 2015–2017. As part of this, the Health Service Executive (HSE), Department of Employment Affairs and Social Protection, and Mental Health Reform worked together in implementing the individual placement and support (IPS) model of supported employment. This pilot involved supporting those with severe and enduring mental health difficulties to return to paid competitive employment in the West, South, North-East and Northern regions. Findings published by Mental Health Reform, following completion of the project, revealed that a third of participants were successful in obtaining paid work, while almost a fifth of participants went on to further education or training. Five per cent moved from supported accommodation to independent living during the timeline of the project, highlighting the positive social outcomes, even where clients where not successful in obtaining paid, competitive employment (Mental Health Reform, 2018).

The IPS model is currently the most empirically researched and successful supported employment model internationally developed for specifically supporting people with severe and enduring mental health difficulties and their employers or potential employers (Meuser, et al., 2016; O’Day, et al., 2017). The IPS model emphasises a ‘place and then train’ approach, rather than the traditional model of vocational rehabilitation that favours a ‘train and then place’ approach (Drake, 1998). A key feature of IPS supported employment is that it emphasises open competitive employment as a primary goal. This is in contrast with other vocational rehabilitation services that aim to employ people in sheltered workshops. McAnaney and Wynne (2017) argue that such methods do not serve the varying and complex needs that a person may have at their different life stages. The IPS model's ‘place and train’ approach is to help people secure a job in line with the individual's preferences, as quickly as possible, and then support them in it, in contrast with the lengthy pre-employment training/preparation and prerequisite for the person to be ‘job ready’ to which other supported employment approaches adhere. A policy of zero exclusion is applied in considering factors such as job readiness, education/training and current physical health (Campbell, et al., 2010). If a client states that they want to return to employment, an employment specialist who is a member of the MDT assists them in this. Individualised support is provided to both the employer and client, as required, once a job placement is secured.

The concerns of employers regarding employing a person with a mental health illness include issues pertaining to trust, lack of practical capabilities and frequent absenteeism (Essen, 2012; Drake, et al., 2012; 2014). Research suggests that employers may view employing a person with a mental health disability as an ‘act of charity’ and not see the potential the person has to offer in the workplace (Krupa, et al., 2009). Research also suggests that the way in which mental health illness is reported in the media also has a significant negative impact on employers’ attitudes to employing a person with a mental health difficulty (McClelland, et al., 2000), since they are concerned about potential violence and other undesirable traits and behaviours associated with the illness (Gaffey and Evans, 2016). This can be improved by creating better awareness through education and by supporting inclusion and diversity in the workplace (Biggs, et al., 2010; Krupa, et al., 2009). In Ireland, programmes such as the See Change Programme have been introduced to address the stigma of mental health in the workplace. Research by See Change in Ireland revealed that 46% of people under the age of 35 would conceal a mental health difficulty, with while only 66% of people were found to be willing to work with someone with a mental health difficulty (See Change, 2017).

Employers frequently state the need to able to access timely and appropriate advice when employing a person with a mental health difficulty (Biggs, et al., 2010), since guidance regarding employing a person with a mental health disability is lacking in comparison to employing a person with a physical disability (Krupa, et al., 2009). Irish equality legislation places the responsibility not to discriminate against people with a mental health disability under disability grounds firmly on the employer. This legislation also includes the responsibility of the employer to provide reasonable accommodations to the person, where appropriate. However, the legislation poses a challenge for employers, given its limited description of a reasonable workplace adaption for those with a mental health difficulty, combined with little empirical data available pertaining to suitable adaptions (Villotti, et al., 2017). Most workplace accommodations for the mental health client, while being unique to the individual, are actually low in cost, although with limited knowledge, a perception can exist that the costs are greater.

Research suggests that those with a mental health illness are highly disinclined to disclose this to an employer when seeking employment at either the written application stage or the interview stage, citing fears of stigmatisation and/or discrimination (Donnelly, 2017). Disclosing a mental health illness to an employer carries with it both risks and benefits. Benefits may include help and support from colleagues and reasonable accommodations such as flexible working hours and job-sharing possibilities (Biggs, et al., 2010; Rusch, et al., 2017).

Mental health tends to be an ‘invisible’ disability (Shefer, et al., 2016; Drake, et al., 2012). A physical illness or disability is usually more observable to others. This ‘invisibility’ can raise questions regarding the legitimacy of the mental health illness. Employees with a mental health illness may be viewed by colleagues as receiving special treatment and shirking responsibility in the workplace (Krupa, et al., 2009). Supervisors and line mangers provide feedback to employees regarding performance and addressing matters such as poor time keeping, poor job performance and personal appearance. However, research suggests that supervisors and line managers may be uncomfortable addressing such matters with employees who have disclosed a mental health difficulty, feeling that it may be inappropriate or best not to do so, as they can see no clear way how these matters may be resolved (Bell, et al., 2007).

Validity in qualitative research is achieved through the appropriate selection and questioning of participants, and through scrupulous data analysis and reporting on the findings (Fischer, 2006). A total of 22 interviews were conducted during this research project, comprising both structured and semi-structured interviews. Structured interviews were conducted with service users and MDT members, to prevent data from being compromised by the corresponding author's position as an employment specialist in the rehab and recovery unit (Schultze and Avital, 2011). The decision to use structured interviews was justified by research to be the most appropriate method of data collection, to reduce interviewer bias and to yield the most appropriate and actionable results (Wilson, 2014). Research also suggests that structured interviews may also be more suited to individuals who have severe and enduring mental health difficulties, as they may not be able to interpret abstract questions (McCann and Clark, 2005).

Semi-structured interviews were conducted with local employers, who provided vocational opportunities for service users who engaged with the IEMHS project. Semi-structured interviews were adopted to gain an understanding of employing a person with a mental health difficulty from the employer's perspective. Research suggests this to be a suitable data collection tool when behaviours cannot be observed directly (Wilson, 2014). Semi-structured interviews were chosen for this cohort of research participants due to the variety of business involved, the variety of roles in which participants engaged in, the varying lengths of time in which the service user and employer engaged with the project, and the different issues that may or may not have proved problematic.

Four themes identified in the literature (Table 2) were used to inform the interview questions. These themes related to the suitability of the IPS model of supported employment, cognitive and social functioning of clients, employment/vocational related issues and stigma surrounding mental health. The findings are also presented around these themes.

Questions relevant to these themes were formulated to gather data on similar topics, to provide a more coherent and thoughtful response from interviewees (Easterby-Smith, et al., 2015). Principles of good design in structured interviews was adhered to, in that one item was asked per question. All jargon was avoided, with simple expressions used, and leading questions were avoided (Easterby-Smith, et al., 2015). In the interviews with service users and MDT members, meaningful responses were encouraged with the use of open-ended questions such as, ‘Can you describe any concerns that you may have regarding disclosure to employers that you have a mental health difficulty?’ Some closed questions were also included in both the structured and semi-structured interviews. This was to allow for specific answers to be given to a limited range of responses. These questions related specifically to the suitability of the IPS model of supported employment in the Irish Mental Health Services. A thematic analysis technique was employed to disseminate the data obtained from the participants, using a systematic, rigorous, and auditable process, in line with best practice (Braun and Clarke, 2006).

The questions asked in this section focused on both the possibility and suitability of service users going straight into paid competitive employment, in line within the core IPS principle of adopting a ‘place and then train’ ethos for service users. Employer questions related to the capability of service users to return to paid competitive employment within their organisation or a similar organisation. The employers who were interviewed stated that of the nine service users collectively who had availed of vocational opportunities within their organisation or business, only three were capable of paid competitive employment. Employers stated that a further two service users were capable of some sort of employment but ‘would need extra assistance and support’. The employers stated that in their opinion, four service users who availed of vocational opportunities within their organisations ‘were not capable of any employment at that time’.

No MDT member suggested that service users should go straight back into paid employment, stating that work trial/work experience opportunities or education/retraining opportunities were preferable first options, with one participant stating: ‘Most people who have been out of the workforce need to re-train or upskill not just those with a mental health issue”(MDT4).

Of the six service users interviewed, only two (SU1, SU2) stated that they wished to avail of paid competitive employment as a first step back into the workforce, with (SU2) stating: ‘I would like to go back to work full time to be more independent’ (SU2).

Availing of work experiences/work trial opportunities was the preferred choice for almost half of service users interviewed, as a first step back into the workforce, with one (SU6) stating, ‘I wouldn’t be fit to do that now,’ referring to paid competitive employment, and another (SU3) stating, ‘Competitive work would be difficult.’

Employers were asked for their opinions on how the service users functioned in the workplace in comparison to other employees. Four employers highlighted the lack of training and current skillset as a major difficulty for service users in the workplace, with one stating: ‘I do not have the time or manpower to sit beside them [service users] and guide them through every little aspect of the job’ (EMP3).

Two employers highlighted the Service Users lack of energy in the workplace with comments such as: ‘She is tired, exhausted and just not with it’ (EMP7); ‘very tired but I put that down to medication’ (EMP1); and ‘Four hours was the maximum possible’, stating that the service user was ‘at his limit’ (EM 2).

A further three employers highlighted the need for service users to increase their levels of physical fitness to improve their chances of obtaining paid, competitive employment.

When asked how their mental health affected them on a day-to-day basis, service users’ responses varied, with stating that it was a ‘burden; and’ ‘stressful’ (SU 3), and with others unable to describe how their mental health difficulty affected them on a day-to-day basis, responding to this question by stating their diagnosis.

Four MDT members stated that they believed that all service users could return to the workforce ‘with support’; and one MDT member stated: ‘It is difficult to go from doing nothing to paid employment’ (MDT8).

The remaining MDT members answered this question very differently, stating that they did not think that all service users could return to the workforce, with one member saying: ‘I would love to say yes but some just can’t’ (MDT4). Another member answered this question with an emphatic ‘No’, stating: ‘With symptom severity and a long time out of the workforce some service users will never return to employment’ (MDT5).

Employers and MDT members were asked questions regarding their knowledge of the supports available in the community and from the Department of Employment Affairs and Social Protection to assist service users in returning to the workforce. Service users were asked questions relating to their current vocational activities and any concerns they might have regarding social welfare payments and benefits.

Employers were asked about their knowledge of supports available for people with a mental health difficulty to return to the workplace. Two employers (EMP1, EMP 3) stated that they were aware of supports, as directories of these services were available in their organisations.

EMP 5 stated that they had no knowledge of any supports available, apart from one employment specialist service in the west of the country. The remaining employers stated that they had no knowledge of supports available for people with a mental health difficulty to return to the workplace.

A specific question was asked regarding employers’ knowledge of wage subsidy schemes which operate from the Department of Employment Affairs and Social Protection. Four employers stated that they had no knowledge of the Wage Subsidy Scheme, another employer claiming that they had heard of it in a previous role but had understood that this support was only for those with a physical disability.

Employers were also asked about their knowledge of the legislation regarding employing a person with a disability. Six employers responded that they had no knowledge regarding this legislation. EMP 8 responded ‘probably we could know more’, going on to state that they have much more knowledge regarding employing a person with a physical disability than a mental health disability and confirming that there is much more awareness of supports available for people with physical disabilities.

Service users voiced a variety of concerns about returning to the workforce ranging from ‘not fit enough’ (SU1) and ‘not being able to cope’ (SU2) to ‘not fitting in’ and ‘letting people down (SU3).

SU 4 stated that they had concerns about not having ‘enough experience’, going on to say: ‘You would need a good CV and education’ (SU4).

Without any prompting, no service user identified any concerns or worries regarding social welfare payments/benefits. With prompting, three service users (SU1, SU4, SU6) stated that they had concerns regarding their social welfare payments, saying: ‘You might lose them then lose your job and your benefits cut’ (SU4). SU6 stated that they would not like to lose their social welfare payment, as they ‘mightn’t get it back again’.

When asked for suggestions or changes that MDT members would implement in the Mental Health Services, to increase the opportunities for service users to return to the workforce, five MDT members recommended introducing more dedicated employment specialist roles, with MDT 6 stating: ‘What is necessary is a core team solely to deal with that [returning to employment] and working with the IPS person’ (MDT6).

MDT 4 cited the importance of early intervention with service users stating: ‘That's the time to get them [service users] when they appear on the Unit (Adult Mental Health Unit) and not slip into the net of not going to work’ (MDT4).

With regard to stigma and mental health, respondents were asked whether they had any concerns disclosing to an employer that they had a mental health difficulty. The results found that three service users had no concern disclosing that they had a mental health difficulty, with one service user stating: ‘It is important to talk to an employer about your depression and explain so that they can understand where you are coming from’ (SU4).

However, remaining participants stated that they would not be happy to disclose to an employer that they had a mental health difficulty, all citing a fear of not getting the job. Their concerns regarded being ‘treated differently’ (SU2), or a fear that the employer may ‘not treat [them] fairly, side-line [them] or let [them] go’ (SU3).

All MDT members interviewed stated that, in their opinion, a stigma surrounding mental health difficulties was still present today:’ Absolutely, very much so’ (MDT5).

MDT respondents also highlighted the stereotypical portrayal of the person with a mental health difficulty in the media as an issue that needs to be addressed in overcoming this stigma.

Another recommended empowering service users to feel confident going out into the workforce making them aware that ‘They are entitled to work like any other person and cannot be discriminated against’ (MDT2).

Responses from employers highlighted an understanding of that sense of stigma and a necessity to provide extra support for individuals. Three employers highlighted the support provided by an employment specialist as important in this regard: ‘Just a person to contact … a person to speak to in case something happened, and we didn’t know how to deal with it’ (EMP 2).