A thorny road towards a wellbeing-oriented mental healthcare

According to the Universal declaration of Human Rights, everyone has the right to work and protection against unemployment ⁽¹⁾Article 23, The Universal Declaration of Human Rights (UDHR. Nevertheless, employment rates of people with severe mental disorders are extremely low ⁽²⁾OECD. (2021). Fitter Minds, Fitter Jobs: From Awareness to Change in Integrated Mental Health, Skills and Work Policies. OECD Publishing. https://doi.org/doi:https://doi.org/10.1787/a0815d0f-en, ⁽³⁾Luciano, A., & Meara, E. (2014). Employment status of people with mental illness: national survey data from 2009 and 2010. Psychiatric services (Washington, D.C.), 65(10), 1201–1209. https://doi.org/10.1176/appi.ps.201300335, ⁽⁴⁾Diby, A. S., Lengagne, P., & Regaert, C. (2021). Employment Vulnerability of People With Severe Mental Illness. Health policy (Amsterdam, Netherlands), 125(2), 269–275. https://doi.org/10.1016/j.healthpol.2020.10.008, despite them wanting to be employed ⁽⁵⁾Iyer, S. N., Mangala, R., Anitha, J., Thara, R., & Malla, A. K. (2011). An examination of patient-identified goals for treatment in a first-episode programme in Chennai, India. Early intervention in psychiatry, 5(4), 360–365. https://doi.org/10.1111/j.1751-7893.2011.00289.x, ⁽⁶⁾Ramsay, C. E., Broussard, B., Goulding, S. M., Cristofaro, S., Hall, D., Kaslow, N. J., Killackey, E., Penn, D., & Compton, M. T. (2011). Life and treatment goals of individuals hospitalized for first-episode nonaffective psychosis. Psychiatry research, 189(3), 344–348. https://doi.org/10.1016/j.psychres.2011.05.039, . A vocational rehabilitation model ‘Individual Placement and Support’ shows promising results, but high turnover among its service providers is concerning.

In 1994, a method of vocational rehabilitation was developed by Deborah R. Becker and Robert E. Drake to combat the injustice of the situation ⁽⁷⁾Becker, D. R., & Drake, R. E. (1994). Individual Placement and Support: a community mental health center approach to vocational rehabilitation. Community mental health journal, 30(2), 193–212. https://doi.org/10.1007/BF02188630. The model is called Individual Placement and Support’ (IPS) and aims to help those with severe mental disorders wanting a paid employment. IPS, as a model of supported employment, is anchored in the idea that paid employment in a competitive job market is both means for and the goal of recovery from a severe mental disorder.

It is based on eight principles ⁽⁸⁾Drake, Robert E., Gary R. Bond, and Deborah R. Becker, Individual Placement and Support: An Evidence-Based Approach to Supported Employment, Evidence-Based Practice (2012; online edn, Oxford Academic, 24 Jan. 2013), https://doi.org/10.1093/acprof:oso/9780199734016.001.0001: 1) paid employment in competitive job market is a goal; 2) zero exclusion – anyone wanting to get a competitive employment is eligible for IPS; 3) IPS is integrated in mental health treatment teams; 4) provision of the services is based on user preferences; 5) IPS providers help users with understanding social benefits reception; 6) job search and application start as soon as possible; 7) IPS providers develop trusting relationships with local employers based on user preferences; 8) IPS users receive time-unlimited individualized support to maintain employment.

The key figure in IPS is the service provider – the employment specialist, whose job is to help people with severe mental disorders to obtain and maintain competitive employment. Efficacy of IPS in terms of paid employment for people with severe mental disorders has been demonstrated across different countries, including Norway ⁽⁹⁾Reme, S. E., Monstad, K., Fyhn, T., Sveinsdottir, V., Løvvik, C., Lie, S. A. & Øverland, S. (2019). A randomized controlled multicenter trial of individual placement and support for patients with moderate-to-severe mental illness. Scandinavian Journal of Work, Environment & Health(1), 33-41. https://doi.org/10.5271/sjweh.3753. A meta-regression by Brinchmann et al. (2019) concluded that users of IPS were twice as likely to find competitive employment, compared to other vocational rehabilitation methods ⁽¹⁰⁾Brinchmann, B., Widding-Havneraas, T., Modini, M., Rinaldi, M., Moe, C. F., McDaid, D., Park, A. L., Killackey, E., Harvey, S. B., & Mykletun, A. (2020). A meta-regression of the impact of policy on the efficacy of individual placement and support. Acta psychiatrica Scandinavica, 141(3), 206–220. https://doi.org/10.1111/acps.13129. Therefore, in consideration of efficacy perspectives, IPS is an evidence-based practice that has merit to contribute to protecting people with severe mental disorders from unemployment.

High turnover among employment specialists is concerning

Considering the person-centered, empowering nature of IPS and its efficacy on one side and ‘Arbeidslinja’ mentality on the other, it seems natural that the Norwegian society gained interest in implementing IPS permanently on a national scale. Various research projects followed, aiming to evaluate the effectiveness of IPS implementation. One barrier that was identified in the implementation studies was a high turnover of IPS employment specialists. The question is, how can high turnover be a barrier for the implementation of IPS?

The answer lies on the surface – for IPS to function, there is a need for employment specialists who are well-trained, motivated and have an established network of local employers. It is also especially important that they are well-integrated in mental healthcare treatment teams. When an employment specialist quits, the organizational loss is not limited to their knowledge and skills – their working alliance with users is also lost. The latter is highly problematic, as working alliance was shown by Corbeière’s et. al. (2017), to be a predictor of better employment outcomes for IPS users ⁽¹¹⁾Corbière, M., Lecomte, T., Reinharz, D., Kirsh, B., Goering, P., Menear, M., Berbiche, D., Genest, K., & Goldner, E. M. (2017). Predictors of Acquisition of Competitive Employment for People Enrolled in Supported Employment Programs. The Journal of nervous and mental disease, 205(4), 275–282. https://doi.org/10.1097/NMD.0000000000000612. In the short-term perspective, these losses could jeopardize the acceptance and adoption of the service. In the long-term, they can increase costs and make the service unsustainable.

Interdisciplinary collaboration is challenging

When it comes to research on turnover of IPS employment specialists, not much is actually known. Recent findings from a Norwegian survey-based study, conducted by the IPSNOR project, show that turnover of IPS employment specialists is more than twice as high compared to other public sector jobs ⁽¹²⁾Butenko, D., Rinaldi, M., Brinchmann, B., Killackey, E., Johnsen, E., & Mykletun, A. (2022). Turnover of IPS employment specialists: Rates and predictors. Journal of Vocational Rehabilitation. 23 – 32. https://doi.org/10.3233/JVR-221195. The study showed that turnover ideation is strongly associated with several subjective job-related attitudes: job satisfaction, current work supervision, and work meaningfulness.

A qualitative study that is soon to be published, elaborates further on previous survey-based findings. The study is based on semi-structured interviews with those IPS providers who quit. It suggests that poor work environment conditions gradually vaporize initial motivation and personal meaning of the job. This in turn leads to decreasing job satisfaction and increasing quitting ideation, eventually resulting in a decision to resign. It is troubling that one of the key factors in their decision to quit is negative experience of interaction with mental healthcare specialists and the system in general.

The interviews illustrate that quite often, clinical workers see employment of people with severe mental disorders as a task outside of healthcare and consequently of IPS. It is viewed not as a healthcare intervention, but a task for NAV. This view found a positive response in the state policy. First, the Ministry of Labour and Inclusion declared IPS to be a NAV employment scheme in 2019 ⁽¹³⁾Ministry of Labour and Inclusion, (2019). Regulation. Forskrift om oppfølgingstjenester i Arbeids- og Velferdsetatens egen regi.. Then, in 2022, the Directorate of Health stated that IPS provided by NAV should not be seen as a healthcare intervention ⁽¹⁴⁾Directorate of Health (2022). Samarbeid mellom helse- og omsorgstjenesten og NAV om individuell jobbstøtte (IPS) – rettslig grunnlag for tverrsektorielt samarbeid.. Problematically, these decisions are in conflict with one of the core principles of IPS – close integration of the service into mental health treatment teams. Therefore, it is plausible to assume that the high turnover and work environment problems are a consequence of maladaptive integration of IPS in the Norwegian healthcare-welfare system.

What is mental healthcare?

It is disconcerting to see, how rigid bureaucratic systems shape political decisions, which have a negative impact on the work environment of IPS employment specialists that eventually makes some of them quit. It is even more worrying as high turnover in its own turn has a merit to limit accessibility and effectiveness of the service that the system is clearly lacking.

In my view, the purpose of mental healthcare is to help an individual to achieve a functional state of self-sufficient wellbeing. In the current socio-economic system we live in, employment often becomes a source of meaning in life, feeling of social unity and income needed to exist. So if employment is outside of the scope of a mental healthcare system, then what is within its scope? Is it still just symptom reduction?