The «individual placement and support» method to promote the socio-occupational integration of people with severe psychiatric disorders

Patrizia Russo

Azienda Sanitaria Regione Molise, Campobasso, Italy

Elita Santone

Azienda Sanitaria Regione Molise, Campobasso, Italy

CORRESPONDENCE:

Elita Santone

e-mail: elitasantone90@gmail.com

Abstract

The Individual Placement and Support (IPS) method is an intervention model to support the job placement of people with mental disorders in active job search policies. This pathway is aimed at obtaining a competitive job in the open market. The Agreement Protocol signed between the Mental Health Centre and the «LaboratorioAperto» Non-profit organization has enabled this practice to be implemented since 2013, through Recovery-oriented paths: a productive and satisfying life condition despite the limitations of the illness. This work aims at: describing the phases through which the IPS Method is implemented, outlining the projects activated so far, highlighting the critical elements identified and addressed, presenting the most effective standardised assessment tools. The work placement of people with psychiatric vulnerability fosters social cohesion and desensitisation to prejudices, through work man satisfies not only his material needs, but also other more intimate and profound needs, which involve him both as an individual and as a social being, allowing greater psychophysical well-being. Current Evidence-Based tools allow only partial evidence of the improvements obtained through work activity, and this lack has prompted the team of professionals to create a specific form: the Individual Evaluation Grid.

Keywords

Work placement, psychosocial rehabilitation, psychiatric disorders, non-profit organization.

Introduction

Work is a right sanctioned by Italian Constitution and as such has a primary role in the life of every person. It not only guarantees an income, but also promotes the construction and acknowledgement of a personal and professional identity, essential for being an integral part of society. Sometimes there are people who, for various reasons, are living on the fringes of the labour market, as they struggle to join or re-join it and for this reason they are disadvantaged. In recent decades, non-profit organizations have actively contributed to the implementation of services aimed at supporting the employment of disadvantaged people, including people with psychiatric disorders.

This perspective finds its foundation in the national legislative panorama, where the issue of the right to work for persons with disabilities was first dealt with in Italy with Law 482/1968, General regulation of compulsory employment in public administrations and private companies; it outlined a strongly welfare-oriented approach, paying little attention to the skills and abilities of the disabled person as a person. It was only with Law 104/1992 (Framework Law) that the principle of assessing the working and relational abilities of the disabled person in relation to the characteristics of the workplace was introduced; this principle only found concrete expression with Law 68/1999, Rules for the right to work of the disabled, this legislation allowed the concept of targeted employment to be disseminated throughout Italy.

Law 68/1999 provides: that disabled persons with a degree of disability greater than 45%, of working age, registered in the targeted employment lists (subject to a functional diagnosis with a positive opinion on the implementation of work activities) may be placed at work; that companies are obliged to employ a percentage of disabled persons; and that public or private companies may use apprenticeships as a form of job placement. Article 12 bis of Law 247/2007 outlines and encourages the hiring of persons with disabilities through agreements between companies and non-profit organizations. The mechanism is quite simple: the non-profit organization recruits the worker instead of a for-profit company, which in return assigns the non-profit organization work orders proportionate to the cost of the personnel recruited.

In line with national legislation, also the Molise Region, starting with Regional Law 30/2002, has favoured the implementation of integrated pathways for the socio-occupational integration of persons with mental disorders, in conformity with the indications of the Ministero del lavoro e delle Politiche Sociali (Ministry of Labour, Health and Social Policies).

It is undeniable that in the current characterisation of our welfare systems, productive and competitive work represents, even for people with mental disorders, an essential level of assistance. Studies on the subject, show a marked contribution to the achievement of good levels of Recovery by focusing on patients’ needs and aspirations, thus favouring the ability to recognise and accept their disorder, shifting the focus of traditional psychiatric rehabilitation to assisted self-rehabilitation.

As mentioned before, today non-profit organizations play an important role (Law 247/2007) since the widespread interest in the employment of persons with psychic distress stems from the idea that work is a form of «cure»: it allows one to achieve greater economic solidity, facilitates the construction and maintenance of a social network, reduces isolation, and enhances autonomy and self-esteem.

Individual Placement and Support method

The Individual Placement and Support (IPS) methodology is an intervention model for the job placement of people suffering from mental disorders, which aims to support them throughout their entire pathway so that they can obtain competitive employment in the open market. This model was developed in the 1990s by Dr. Deborah Becker and Dr. Robert Drake in America; the American researchers studied and produced a manual for the training of practitioners, given the scarcity of information in this field. Today, IPS is the Gold Standard for the employment of people with severe mental disorders such as Schizophrenia and Bipolar Disorder. Having a job is a particularly heartfelt goal for most people with mental disorders who, through achieving it, aspire to economic independence, recognition of a social role, greater self-esteem and thus fuller social inclusion.

The introduction of IPS in Italy came through the EQOLISE multicentre study financed by the European community in 2003; it replicated the results of previous American research (rif. Bibl.), demonstrating the transferability of the model also in the European and Italian context. An Italian peculiarity is represented by the experience of non-profit organizations, which emerged precisely in the years of deinstitutionalisation. These non-profit organizations can be considered the «Instrument of care and production» that has allowed access to the world of work for many people in the mental health service.

Several studies (rif. Bibl.) have found that the IPS method is more effective, compared to other practices used in the same field, in terms of employment outcomes. In fact, 55% of IPS users obtain competitive employment compared to 23% of users in other projects. Moreover, users followed with the IPS method find work faster, work longer hours (Bond et al., 2016) and earn higher wages than users followed with other programmes (Marshall et al., 2014).

Two long-term follow-up studies also suggested that more than half of those who were involved in IPS-based interventions became stable workers, employed at least 50 per cent of the time over a 10-year period after IPS enrolment (Campbel, Bond & Drake, 2011), regardless of severity of diagnosis, educational level, socio-cultural and ethnic background and work history, according to the principle of zero exclusion (Campbell et al., 2011).

The IPS method is based on eight principles to which operators must adhere (Fiorilli & Berardi, 2017):

1. Competitive employment. The team specialists help patients to obtain competitive employment on the labour market, i.e. employment paid at least the minimum wage, with a salary equal to that received by others doing the same job, based in non-discriminatory settings, alongside workers without disabilities, with a position not reserved for people with disabilities.
2. Employment support is integrated with the treatment of the disorder. IPS employment support services are closely integrated with the treatment work of mental health services. Employment specialists are members of multi-disciplinary teams that meet regularly to review the development of the situation of those placed in employment, sharing information and structuring support programmes to help them recover their social functioning.
3. Zero exclusion. Eligibility is based on the client’s choice. Any person with severe mental illness who wants to work is eligible for IPS employment support, regardless of psychiatric diagnosis, symptoms, or other problems. The core of the IPS employment philosophy is that all persons with disabilities can work by accessing competitive jobs in the community, without any specific preparatory training, and that no one should be excluded from this opportunity.
4. Attention to customers’ preferences. Services are based on customers’ preferences and choices, rather than on tutors’ judgements.
5. The importance of counselling on economic agreements. Employment specialists help clients access and maintain ongoing guidance regarding social security, medical care, and other economic and pension benefits. Fear of losing benefits is one of the main reasons why clients decide not to look for work.
6. Quick job search. Employment specialists help clients look for work directly, rather than offering a choice between the wide range of pre-employment assessment and training activities or «sheltered» work experience. Starting the job search process early (i.e. within 30 days of starting) shows clients that their wish to work is taken seriously, and conveys optimism about the many opportunities the local community provides to achieve their professional goals.
7. Systematic professional development work. Employment specialists develop relationships with employers, based on their clients’ professional preferences, face-to-face meetings or through on-site visits. Employment specialists know the work environment and the professional needs of employers. They find job functions suitable for their clients in the job sites visited, which may not yet be known to the employers. They gather information on the nature of job opportunities and check whether they are suitable for a good job for their client. Employment specialists continue to make regular visits to curate the network that connects people who want to find work.
8. Support is unlimited. Duration and support are individualised and based on the client’s demands and needs. Employment specialists and members of the multi-professional team not only provide employment support but also seek other available natural supports (e.g. family, friends, colleagues). The aim is to help the client become as independent as possible in his/her professional role by providing support and, if necessary, direct assistance. After an appropriate period of time from the start of a competitive job, the possibility of leaving the IPS employment support programme for entry into the competitive market is discussed.

The project

In the Molise Region, since 2013 the non-profit organization «Laboratorio Aperto» has signed an Agreement Protocol with the Campobasso Mental Health Centre (CSM) for the implementation of innovative socio-work integration paths for serious psychiatric patients aimed at achieving/consolidating the social and work functioning skills of users belonging to the CSM (Mental Health Centre) in the territory. Frequently, people with severe mental disorders present marked difficulties both in the active search for a job in the competitive market and in maintaining the same, therefore, it is auspicious, through the Individual Placement and Support (IPS) method, to contribute to the re-appropriation of the sense of active participation in the search for and maintenance of work activities. This approach allows for the abandonment of the role of psychiatric patient in favour of that of Person/worker citizen.

The structured paths between the Campobasso CSM and the «Laboratorio Aperto» non-profit organization have the purpose of defining a multidisciplinary and network working modality, not only aimed at identifying the grant holders who are candidates for insertion, made suitable also by means of a possible training course with recourse to the accredited territorial bodies, but also to guarantee a path of accompaniment and support for the entire duration of the profiled experience.

It is essential to emphasise that the project also represents an innovative pathway from a social policy point of view since it was implemented by channelling funds from the health and social sectors. This rationalisation made it possible to obtain a larger budget to support these pathways, but also to avoid spot and short-term interventions, which are ill-suited to the rehabilitation needs of persons suffering from these disorders. Moreover, the aspect of integration and the reduction of prejudice and stigma against psychiatric patients is also to be highlighted, as a result of the experimentation of integrated pathways with public and private partnerships. More specifically, the project envisages:

• theoretical and professional training by an accredited training society for the acquisition of a regional professional qualification as green worker;
• entrusting by public notice of the management of the city’s symbolic monument, the Monforte Castle, and its surrounding green spaces and the city centre;
• partnership with a local restaurant business for the promotion of Molise’s traditional culinary heritage;
• organisation and management of historical and cultural events within the monument in cooperation with the municipal administration, ProLoco (Local Promotion Association) and other local non-profit organizations;
• management of the RSM «Mental Health Network» site;
• work placement at the regional «Equal Opportunities» office.

The indications drawn up in the Agreement Protocol detail the operating methods relating to the selection and in itinere monitoring phase with particular attention to the area of socialisation, acquisition of the work dimension, learning of tasks, motivation, as well as cognitive and behavioural aspects, professionalism, evaluation of results (productivity and quality), autonomy and organisation of work, attributing a score to the various areas.

This complexity of pathways can only be guaranteed through the construction of an integrated multi-professional team that includes: a Psychiatric Rehabilitation Technician, a Social Worker with expertise in social and work reintegration, Expert Tutors and Peer Tutors as far as the Non-profit organization is concerned and, as far as the CSM is concerned, Psychiatrists, Psychologists, Social Workers and Psychiatric Rehabilitation Technicians who are in charge of the users. By means of periodic structured meetings, initial, intermediate and final assessments are carried out to verify interests, work experience, work skills, adherence to work (attendance/absence), productivity. Work integration takes place in the following phases.

Preliminary Phase: the first step consists in the pre-selection of the CSM users, first of all through the assessment of personal and social functioning (VADO interview), and only if the user is not seriously compromised in the area of socially useful activities, it continues with the administration of the Orientation Form (SdO) thanks to which the following emerge: strengths, weaknesses, previous work activities, study path, other useful information for profiling. The SdO allows the CSM to respond effectively to the needs of the Co-operative, which may require users with various and particular work skills. The VADO and the SdO allow the user to be entered into the Database of Work Insertion Requests (DIL).

Initial phase: when the non-profit organization needs to insert a worker, it will communicate the necessary requirements to the Social Worker and/or to the Psychiatric Rehabilitation Technician of the CSM who, on the basis of the DIL, will select all the users meeting the criteria. The referrers will communicate the possibility of job placement to their patient so that the Social Worker will only contact the patient if he/she is interested in the job offer.

Informative interview: the Psychiatric Rehabilitation Technician and the Social Worker illustrate to the worker in detail the tasks to be carried out and the steps foreseen by the Agreement Protocol, as well as the specific objectives inherent to its rehabilitation pathway. The worker will also be provided with information regarding the assessment steps envisaged in the pathway, rights and duties relating to interactions with the Mental Health Centre and the non-profit organization’s reference figures. If the user/worker accepts the job offer, he/she will sign an informed consent for inclusion in the protocol. All the documentation will be included in the Individual Folder (CI) managed according to the regulations in force for the processing of personal data.

Initial assessment (T0): The Psychiatric Rehabilitation Technician and the Social Worker, during the initial assessment, will fill in the following forms together with the new worker: anamnestic form, Life Skills Profile (LSP), Personal and Social Functioning Scale (FPS) and Individual Assessment Grid (GVI). The assessment is carried out through the objective attribution of a score for each of the assessment scales used; they are also used in the subsequent stages of job placement.

In particular:

• FPS scale: the score ranges from 0 to 100, the calculation is made following the assignment of a rating (from «Absent» to «Very Severe») in the 4 areas investigated i.e. socially useful activities, personal and social relationships, care of appearance and hygiene and disturbing and aggressive behaviour.
• LSP scale: consisting of 39 items that can be attributed to 5 different areas (self-care, non-turbulence, social contact, communicativeness and responsibility), each item can be given a score from 4 to 1.
• GVI: the minimum score attributable is 220 and the maximum is 340, the calculation is made by assigning a rating ranging from «Very deficient» to «Excellent».It should be noted that the compilation of the GVI allows five macro-areas to be monitored:
  1. socialisation: this area allows for the assessment of communication skills, cooperation and sharing of space, social relationships, degree of appropriateness of behaviour according to the context, care of self and space;
  2. organisation of the working day: this area makes it possible to analyse the pace of work, break requests, task analysis, continuity in activities (presence/absences, advance notice of absences);
  3. motivation: this area highlights the level of motivation and interest, the perceived sense of responsibility and the degree of autonomy in the task at hand;
  4. learning: this area is used to determine the recognition of roles, the achievement of objectives set for each individual task and the degree to which errors are recognised;
  5. professionalism and cognition: this area assesses the enhancement of functions such as attention, concentration, cognitive flexibility, cognitive decision making and problem solving.

Interim evaluations (T1): The number of intermediate assessments, on a monthly basis, varies according to the duration of the contract. The Psychiatric Rehabilitation Technician, in collaboration with the Social Worker, carries out assessment interviews oriented towards the implementation of Problem Solving to identify useful strategies for solving practical, interpersonal, intrapersonal and emotional problems.

During the intermediate assessments it is possible to carry out interventions or use additional Evidence Based tools (Social Skills Training, cognitive restructuring, management of early signs of crisis). During each intermediate assessment, the professional must complete the GVI and the worker must periodically complete the Self-Assessment Form (SAU). At the end of each intermediate assessment, the Psychiatric Rehabilitation Technician enters the following information/report in the IC: the interview and test results (LSP, SAU), the result of the monitoring carried out by the Expert Tutor and/or Peer Tutor and the summary of the report carried out by the Social Worker.

Final Evaluation (T2): In this phase, in addition to the forms filled in during the intermediate phases, the Final Evaluation Form (VALF) is filled in. This form makes it possible to highlight the following elements: objectives achieved at T1 and T2, critical areas strengthened, critical areas found, residual deficits, further observations and the final outcome. The Final Evaluation Form allows the comparison of the results obtained from the assessments at the beginning and at the end of the work placement through the use of the FPS Scale, the LSP, the GVI.

The project also envisages meetings between the non-profit organization’s team and the treating team of the Mental Health Centre, in the presence of the user/worker, in order to share the pathway, the objectives achieved, and any improvement actions, for an integrated and synergic taking charge. The outcomes of these meetings are all shared with each referring doctor of each patient included in the pathway.

Target Population

The inclusion criteria agreed by the non-profit organization’s practitioners with the CSM team are as follows:

• age between 18 and 55;
• diagnosis of severe psychic disorder;
• stable and continuous relationship with the CSM for at least 6 months;
• good mental health for at least 6 months and show good compliance with treatment;
• possession of aptitude, ability, competence and motivation for the required task or, at the very least, to embark on a path of work integration.

It should be noted that inclusion characteristics are assessed with EBM tools including BPRS, DSM-IVR, DSM-V, as well as periodic checks with caregivers.

On the other hand, the following are considered exclusionary conditions:

• mental retardation;
• the presence of disorders caused by the use of psychoactive substances;
• the presence of organic pathologies such as to compromise the possibility of following the various stages of the pathway;
• double diagnoses.

Results and discussion

The trial refers to the period from 2013, the start date of the trial, to the end of 2021.The evaluation of the effects of the intervention focuses on the improvement of the quality of life of the patients included, which is a priority objective of the intervention. The causal hypothesis postulates that the pathway can promote the overcoming of individual limitations and external barriers as well as the active search in the competitive labour market with the consequent reduction of social stigma.

The number of beneficiaries identified in the 2013-2021 period for the activation of work grants included 34 people, with a Drop Out of 6%.

The «protected» employment and training areas within which the work bursaries were activated were as follows:

• theoretical-practical professional training by an accredited training organisation for the acquisition of a regional professional qualification;
• entrusting by public notice the management of the city’s symbolic monument, the Monforte Castle, and its surrounding green spaces and the city centre;
• organisation and management of historical and cultural events within the monument in cooperation with the municipal administration, ProLoco and other local associations;
• partnership with a local catering business for the promotion of Molise’s traditional culinary heritage;
• management of the RSM «Mental Health Network» site;
• job placement at the regional «Equal Opportunities» office;
• production of handicrafts and artistic works of street furniture.

The work placements managed by the LaboratorioAperto non-profit organization involved 55% males and 45% females of the selected users. It should also be noted that 66% of the people included in the pathways suffer from Psychotic Disorder, 28% from Mood Disorder, 6% from Personality Disorder and 13% have psychiatric comorbidity. As far as the age range is concerned, 34% of those placed are under 40 years of age, 41% are under 50 and 25% are over 50. Within the time limits of the study, no negative effects emerged from the possible prolongation of the work grant, especially for that target group of particularly compromised users who have marked difficulties in entering the free market. Finally, it should be noted that 28% of the workers included in the experiment adhered to at least 2 different projects over time (Table 1).

Females	45%
Males	55%
18-35 years	34%
36-49 years	41%
More than 50 years	25%
Mood disorders	28%
Psychotic Disorders	66%
Other Personality Disorders	6%
Psychiatric comorbidity	13%
Participation in various Projects	28%

Table 1 Characteristics of psychiatric patients in work placement projects

The evaluations carried out up to now show that the IPS method is able to produce satisfactory results in relation to the causal hypotheses and therefore, to the general objectives of the experimentation, also highlighting positive effects in relation to the chances of access to competitive work: 31% of the subjects placed, in fact, were able to obtain jobs in other companies, taking advantage of the experience gained through the work grant. Thus, the variations found between before and after work placement are in line with the hypothesis that work grants improve work skills, productivity and reduce admissions to the SPDC (Psychiatric Diagnostic and Treatment Service).

Regarding the substantial increase in Quality of Life, the detailed data on the FPS Scale, the LSP and the GVI are comforting. Specifically, there was a 9-point improvement on the Personal and Social Functioning scale, a 31-point improvement on the Life Skills Profile total score and a 62-point improvement on the Individual Assessment Grid, as shown in Figure 1 by comparing the initial and final average score on the above-mentioned EBM instruments.

It should also be considered that the experimentation allowed the observation of a general improvement in social-relational skills not only with reference to the world of work but also to the different spheres of life. This evidence enabled the subjects placed in the trial to make less frequent use of strictly clinical-rehabilitation support services and to increase their social network. Even from the point of view of their perceived self-efficacy, found in individualised interviews with the Social Worker, the margins for improvement are clear.

It is useful at this point to delve into the qualitative aspect of the analysis carried out so far, it clearly emerges that clear margins for improvement are also to be found in the sphere of social, personal and relational functioning. In fact, thanks to the acquisition of adequate competences in the correct use of communication skills, our users have seen a clear expansion of their social and friendship network, experiencing significant relationships both at work and in their free time. Inevitably, all this has also led to an increase in self-esteem and sense of self-efficacy, which has enabled the operators to work positively on the management and use of money, independent living choices, and the identification of new coping strategies for solving problems related to the management of everyday life, with a consequent increase in the patient’s perception of the level and quality of his or her well-being.

Figure 1 Average Score Pre and PostJob Placement.

The extent to which work placement has a positive impact on compliance, adherence and concordance is highlighted: the person is an active participant in the planning and implementation of his or her rehabilitation treatment pathway, recognises himself or herself as an «expert in his or her own experience», is able to maintain focus on a specific treatment regimen and adopts behaviour in accordance with the treatment team’s recommendations. These elements indicate the extent to which the IPS acts on all areas of Recovey: on the clinical level (symptoms and relapses), on the level of functioning (work, living and training) and on the personal level (capacity for choice and self-determination).

It should be noted that the EBM assessment tools adopted only partially highlight the improvements achieved through work activity, therefore, in order to allow for an accurate assessment and congruous monitoring, the team devised the Individual Assessment Grid (GVI) specifically to monitor indicators relating to socialisation, motivation, autonomy, learning and professionalism acquired.

Consistently conducting follow-up meetings 1 year after the end of each work placement pathway makes it possible to ascertain improvement, worsening or maintenance of the personal and social skills implemented through the IPS Method. Follow-up meetings are oriented towards the evaluation of the LSP and FPS Scales. Figure 2 shows graphically the results obtained from the compilation of the Social Skills: for 19 grant holders the score had remained almost unchanged, for 9 of them it had improved and for the remaining 4 it had worsened. Figure 3 shows graphically the results obtained by filling in the FPS Scale: for 11 grant holders, the score remained almost unchanged, for 16 of them it had improved and for the remaining 4 it had worsened.

Figure 2 LSP Follow-up.

Figure 3 FPS Follow-up.

An indirect effect of the experiment concerns the climate and well-being of the organisations hosting the grant holders. Considering that the general objective of the experimentation concerns the fight against stigma and the containment of prejudice with respect to mental disorders, on the basis of the reports drawn up during the coordination meetings, a significant cultural change was noted on the part of those who collaborated in the implementation of the activities and professional training in the field. What was reported is a sign of an important cultural «contamination» action aimed at fostering a full and real integration of people with psychiatric illnesses, thus overcoming the logic of welfarism and pietism.

The use of the IPS method produces further positive repercussions: reduced healthcare costs and shorter waiting times (in acute and outpatient settings). This reflection is essential to promote the Recovery Oriented work of all mental health service practitioners and also that of the governance of the health system. A further consideration concerns the academic world; the results of the IPS set out in this paper make it possible to highlight the need to disseminate and use this methodology in a homogeneous manner throughout the world.

With respect to the Italian context, it could be useful to replicate, regulate and apply work placement systems through standardised funding and accreditation systems. This could only be ensured through the involvement of health authorities, Mental Health Centres and non-profit organizations. This perspective implies the redefinition of permanent financing systems that would allow the «fragile worker» the best possible therapeutic rehabilitation project.

Conclusion

This article describes the phases through which the IPS Method is implemented, outlines the projects activated so far, highlights the critical elements encountered and addressed, and highlights the outcomes of the evaluations carried out. The expected outcome envisages the employment of the job grant holder with a regular employment contract according to the national legislation on collective agreements in favour of disadvantaged persons, since the job bursary is only an orientation, training and personal growth opportunity to increase employment probability.

In conclusion, the experimentation showed that the job placement of people with a psychiatric vulnerability favours social cohesion and desensitisation to prejudice and exclusion. Through work, people satisfy not only material needs, but also others, more intimate and profound, which involve both as an individual and as a social being for a greater psychophysical well-being, therefore work activity is for these subjects in a state of disadvantage, prodromal for recovery. Through work, the «role» of the psychiatric patient is abandoned in favour of a consistent re-appropriation of the sense of the person/citizen, who fully exploits residual abilities and builds new ones. This paper highlights that IPS is the evidence-based practice in rehabilitation, being the most effective work approach currently available in helping people with severe mental disorders to achieve their work goals.

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