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1 Introduction

The focus of this chapter is on employment support and vocational rehabilitation that assists people with serious mental illness to find, enjoy, and sustain meaningful employment in their communities. Work is considered to be fundamental both to recovery in mental illness and full citizenship, and subsequently designing effective employment services and approaches has received much attention within the field of psychiatric vocational rehabilitation.

The chapter begins by defining serious mental illness from an employment perspective and is followed by a review of key principles underlying vocational rehabilitation and employment support programs. The field has witnessed the development of a range of services and initiatives meant to create and support real work opportunities for people with serious mental illness. Three of these approaches are described. In addition, complementary interventions that have the potential to enhance vocational outcomes are presented, as well as a few of the ongoing challenges and debates that exist in the field. Finally, the chapter will discuss the relevance of the International Classification of Functioning, Disability and Health (ICF) [1] core set categories to psychiatric vocational rehabilitation and employment support services for people with serious mental illness. The potential application of the ICF core set categories for vocational rehabilitation is highlighted by its application to one vocational rehabilitation program that has a mission to enable successful and satisfying work experiences for people with serious mental illness.

2 Defining Serious Mental Illness and Employment

Rates of unemployment among people with mental illness are high, but understanding their actual employment status is complicated by the fact that people with serious mental illness are a diverse group, heterogeneous both with respect to their illness experiences and their participation in important life domains such as work. Definitions of serious mental illness typically include consideration of both mental ill health and evidence of problems in function. In this chapter, we suggest that consideration of serious mental illness in relation to employment should include reference to the high levels of marginalization and detachment from the community workforce experienced by the population.

2.1 Serious Mental Illness and Diagnosis

The concept of “serious mental illness” engenders assumptions about particular mental illness diagnoses. For example, serious mental illness is often equated with diagnoses of schizophrenia, bipolar disorder, and other major mood disorders that have a persistent quality, even when acute episodes are episodic. Although there has been much debate about the relationship between diagnosis and employment rates, research evidence has not supported that employment can be predicted by diagnosis [2]. Yet, schizophrenia and mental illnesses with psychotic components have long been regarded as serious mental illnesses with lower rates of employment than other mental illnesses. For example, analyzing US national health interview survey on disability distinguished between serious mental illness with employment rates of 37 % and severe mental illness (defined as including those with schizophrenia and related disorders), with employment rates at 22 % [3].

Estimating employment rates according to diagnosis is a complex undertaking and findings are not easily interpreted. For example, a broad review of literature reporting employment rates for people with schizophrenia demonstrated huge variations internationally [4]. It was highlighted that interpreting employment rates among this population is complicated by differences in how diagnosis is determined, what activities are actually included as employment in national statistics, and a host of social and cultural differences, including access to social welfare, expectations regarding employment, and labor market opportunities.

2.2 Serious Mental Illness and Functional Impact

Contemporary conceptualizations of serious mental illness go beyond diagnosis to consider the extent to which there are significant functional implications related to the mental health condition. In this way a broader range of diagnostic categories can be included under the label of serious mental illness if a consequence is significant functional impairment and disability [5].

Symptoms, impairments, and experiences associated with serious mental illness that have been associated with negative employment outcomes include the following:

  • Impairments of psychological and emotional health related to persistent feelings of low volition and drive and disruptions in emotional connections to activities and people have been linked to poorer employment outcomes [6].

  • A broad array of cognitive impairments are associated with serious mental illnesses, such as working memory, processing speed, sustained attention, and executive functioning, and have been associated with poorer employment outcomes and limited job tenure [7]. Disturbances in cognition can interfere with the ability to meet the demands of important job tasks and social relations on the job. In addition they can limit an individual’s improvement within rehabilitation programs designed to improve work performance [8].

  • Personal insight has been linked to employment outcomes. Insight refers to a range of mental processes, such as the ability to identify and accept particular experiences as disturbances of mental function, the capacity to identify that one is being impacted by these mental disturbances, and acceptance of the need for treatment, supports, or strategies to address these disturbances [9]. Insight is important in the context of employment, where the capacity to receive feedback, have self-awareness, understand personal strengths and weaknesses, self-monitor, and self-correct is fundamental to work performance and social relations [8, 10]. While insight is believed to be related to neurocognitive function, awareness and acceptance of illness has also been identified as an important task in the process of recovery in serious mental illness. Recovery is believed to be moderated by the meaning that people give to their illness experiences. For example, the extent to which the meanings given to the mental illness are self-stigmatizing (i.e., mental illness means incompetence, a grim future, low expectations, etc.), the less likely people are to engage in important social roles such as work [11].

  • The capacity for self-management of the functional implications of mental illness has been linked to employment. Since serious mental illnesses involve a range of significant functional consequences, the individual’s sense of agency and ability to effectively cope with these consequences will be instrumental in meeting work-related expectations [12].

    The age of onset of a serious mental illness has been linked to employment success. When experienced in adolescence and young adulthood, it can disrupt the many developmental activities associated with adult employment including: educational achievement, work experience, basic life skills that support working, the development of social networks that can provide work connections and opportunities, the evolution of a work identity and career planning, and the financial autonomy to pursue work-related ambitions [13]. The growth of early intervention for psychosis services internationally has evolved largely from an interest in preventing disability, including unemployment, labor force detachment, and social dependence among young people [14].

2.3 Serious Mental Illness as Marginalization

Perhaps a defining work-related characteristic of people with serious mental illness is the extent to which their employment status can be characterized as marginalized, or at high risk for marginalization. This position of marginalization has been identified by scholars in the field for over 30 years as an explanation for their high levels of unemployment. For example, Warner [15] described how the employment status of people with a diagnosis of schizophrenia can be understood as a social-political response in the context of broader economic conditions. Warner demonstrated how attitudes related to employability of the population, and actual employment rates, improve in market-based economies during economic booms but recede during times of economic depression. Baron and Salzer [16] added to this by arguing that the social and economic circumstances of people with serious mental illness, such as low educational achievement and poverty, needed to be added to the “usual suspects” in explaining low employment rates.

Marginalization from the workforce suggests that people with serious mental illness have weak labor market attachments demonstrated in a variety of ways, including:

  • The notion of “return to work” used in vocational rehabilitation does not apply, since they may have no employment situation awaiting or expecting their return.

  • Their social networks are often exceptionally limited, providing few opportunities to develop employment or work-related connections. Indeed, their social networks may not be expecting them to engage in employment and may even see employment as harmful if it is perceived as potentially disrupting stability in community life or undermining the financial security of disability income benefits.

  • They may have limited access to important material resources such as clothing, food, transportation, etc. that are basic to supporting employment.

  • They may not have access to quality treatment or evidence-informed employment support services. Indeed, historically mental health services were not developed from a firm belief that employment is possible (or even positive) for this group of people. An often sited publication by Marrone and Galowka [17] highlighted that while the mental health field has concerned itself with the harmful impacts of work stress, there has historically been less concern about the stress associated with chronic unemployment and ultimately the field projects an attitude of paternalism. Historically, vocational initiatives for people with serious mental illnesses were directed to creating work activities that were alternatives to the community labor force, such as sheltered workshops. These initiatives have been linked to the stigma of mental illness and in particular assumptions that providing work to people with a serious mental illness is a form of charity rather than a right of citizenship [18].

  • It is common for people with a serious mental illness to be financially supported by government disability incomes. Compared to other populations, people who receive disability benefits in the context of mental illness are less likely to leave this public assistance [19]. Receipt of disability benefits can act as a disincentive to pursue and sustain employment in a number of ways. For example, it can promote an internalized view of the self as too disabled to work and leave individuals feeling financially insecure and even compromised should they pursue employment because of complicated administrative processes or taxation policies that impact earnings [20].

  • Those who have current work experience are typically working in entry-level and part-time work, often with limited or no benefits. These types of employment conditions have been identified as a form of underemployment [16, 19] and marginalization within the workforce [21].

A closer look at the employment rates of people with mental illness suggests a high level of marginalization. Kozma and colleagues [22] analyzed the employment status of a population of individuals with a diagnosis of schizophrenia and found that among the many who were not employed, the majority were not even looking for work. Interestingly, research and personal accounts from people with serious mental illness suggest that they value employment and generally desire to be able to work [23]. It is this positive inclination to work that led the Mental Health Commission of Canada to use the label the “Aspiring Workforce” to describe the employment status of this population [24].

3 Principles Underlying Vocational Approaches

Contemporary vocational rehabilitation interventions and approaches are evolving from a set of principles. These principles address the employment marginalization experienced by this population by focusing on accessing, supporting, and creating real work opportunities as the foundation of best practice. They challenge the assumptions underlying traditional vocational rehabilitation approaches which focused primarily on understanding and addressing the work-related deficiencies (i.e., work attitudes, aptitudes, knowledge, skills, etc.) of individuals, or creating alternative work structures (such as sheltered workshops or day programs). The development of these principles was sparked by evidence indicating that traditional vocational rehabilitation approaches were not leading to employment [25].

These principles largely emerged during the development of supported employment as an evidence-based vocational rehabilitation approach [25, 26]. While the principles have largely been applied to a specific evidence-based model for practice, the individual placement and support (IPS) model, we argue here that they have broader relevance in the field, serve as a foundation for the development of a range of approaches, and contribute positively to a high-level debate within the field about the philosophy and nature of employment support and vocational rehabilitation. Kirsh and colleagues [27], for example, have examined how philosophies, principles, and practices related to vocational rehabilitation and employment support are cutting across different populations (those with brain injury, intellectual disability, or mental illness) that are vulnerable to high levels of marginalization.

What are these principles?

  1. 1.

    Creating and supporting real work opportunities is the focus of vocational rehabilitation.

  2. 2.

    Access to real work opportunities should be available to anyone who aspires to work.

  3. 3.

    Individuals with serious mental illness should be supported to consider employment as a real possibility.

  4. 4.

    Work opportunities should offer good work conditions, with health and safety, psychological well-being, and wage structures that are consistent with societal standards and expectations.

  5. 5.

    Work participation should be based on individual preferences and choice.

  6. 6.

    People with serious mental illness who engage in real work opportunities should have available to them ongoing, follow-along supports and access to a range of specific employment enabling interventions.

  7. 7.

    Treatments and services for mental illness should be delivered in an integrated fashion along with vocational rehabilitation.

  8. 8.

    Employment supports should attend to the material conditions of people’s lives that impact employment, offering, for example, assistance related to finances, transportation, housing, personal safety, etc.

  9. 9.

    Employment supports and vocational rehabilitation approaches should act to improve the social and economic status of individuals with serious mental illness. This includes, for example, attention to social inclusion within work, evidence of improved material conditions in life, opportunities for advancement, work-life balance, and maintaining a career perspective.

  10. 10.

    Evaluation of vocational rehabilitation should include a range of individual-level outcomes (e.g., satisfaction and meaning in work, work abilities, quality of life), occupation-level outcomes (nature of accommodations offered, workplace social climate, etc.), and societal-level outcomes (cost-benefit, improved attitudes and actions toward marginalized groups, etc.).

4 Vocational Rehabilitation Approaches

In this paper we focus on three contemporary approaches to addressing the employment needs of people with serious mental illnesses, all having the potential in their implementation to be consistent with the principles outlined above.

4.1 Supported Employment

The most widely disseminated, well-defined, and standardized approach in the field is supported employment, particularly in the form of Individual Placement and Support (IPS). Standardization of IPS implementation is promoted by the application of fidelity scales with good psychometric properties [28]. In this approach “real work” is defined as employment in the existing community workforce. Clients of the IPS service receive counseling to identify personal strengths and possibilities and employment preferences to match conditions of work to individual needs. Rapid job entry is offered rather than prolonged vocational assessment and preparation. Clients are assisted with finding and securing their own jobs, or jobs may be secured by IPS providers; but regardless of how a job is secured ultimately, the individual is employed by the community work site. While clients served by IPS are generally expected to fit into existing work structures and expectations, employment support can include identifying and advocating for accommodations, and increasing employer awareness, providing the workplace with training and otherwise enlisting their support in the process. Ongoing follow-along supports are meant to enable job success and stability and can address symptoms, impairments, and other mental health issues, workplace task or social demands and experiences, or broader life issues impacting employment. The model includes counseling around financial benefits to ensure that clients are well informed about their benefit plans to support related decision-making [25, 28–32].

Supported employment in the form of IPS has been the subject of much research, and randomized controlled trials have demonstrated the capacity of the model to improve vocational outcomes compared to traditional forms of vocational support or mental health treatment [26]. These findings have been repeated across different mental health care contexts, with special populations (such as those with co-occurring substance use problems) and across several countries worldwide (see, e.g., [33–35]). To date, the majority of jobs found in supported employment are entry-level and part-time jobs [36]. There have been varying results with respect to the socioeconomic outcomes of supported employment, but there has been some indication that it can lead to reduced reliance on government disability benefits [32]. A comprehensive review of the literature by Kirsh [36] indicated several positive personal level changes through involvement with supported employment, including improvements in self-concept, expansion of social networks, improved quality of life, improved financial resources, and improvements in work skills and adaptation.

In recognition of the need to address educational achievement in order to improve career prospects and job status, the components of the supported employment model have been applied to develop supported education services. Supported education focuses on assisting individuals to make choices about their studies, securing entry into educational programs, and offering ongoing support to enable educational achievement while maintaining well-being. Program models can be located off campus or can be integrated within educational settings, for example, as distinct educational programs offered within the postsecondary setting or as support services located on campus [37, 38]. Recent adaptations of the model have been linked directly to supported employment as a means to facilitate the smooth transition to work [39].

4.2 Social Entrepreneurship

Social entrepreneurial approaches use market-based strategies to create employment opportunities for people with serious mental illnesses. Unlike supported employment approaches, which seek to secure jobs for people in the existing community workforce, these entrepreneurial initiatives aim to create new employment opportunities within business structures that sell goods and services in competition within the general marketplace.

Perhaps the most common approach is the creation of employment opportunities by the development of legally registered businesses that operate within the broader economy. These businesses are often referred to as “social businesses,” “social firms,” or work integration social enterprises (WISES [40–42]). They hold dual missions; a social mission, which in this case is creating employment for a disenfranchised population; and an economic mission focusing on promoting business sustainability. As legal workplaces they are expected to meet workplace standards for payment and health and safety. The work organization itself is structured to enable the work participation of individuals who experience disabilities and participation limitations. For example, workplace operations may be structured to accommodate for differences in the ability to manage complex tasks, or rates of production, and attention may be directed to ensuring that workers are provided with the material goods they require to work. Other businesses have been developed to capitalize on specific strengths of a population. For example, businesses designed for homeless youth have attempted to translate their street skills to develop income-generating activities [43]. Similarly, opportunities for advancement through the ranks to management can be intentionally structured. Some businesses offer a mix of stable job positions, with places reserved for those in training positions. Given the implications for financial sustainability, attention directed to structural issues is considered an imperative.

Social businesses/firms have proliferated internationally with variations in business structures and models across locations. In the mental health field, the business cooperatives that were developed in Italy in response to the national move to deinstitutionalization are a good example [42]. In some jurisdictions social firms are expected to have at least 1/3 of their workforce be people without mental illness and labor disadvantage (see, e.g., [44], while in others these businesses have been completely owned, operated, and staffed by people with mental illness [45, 46]. Interactions within the community economy are expected to take place through a variety of business transactions within the broader public and even through membership within community business organizations.

While guidelines for the development of social businesses/firms do exist, the lack of clearly defined and accepted models defining key features of the approach (or approaches) hampers development, dissemination, and evidence building in the field. A recent review of the scholarship related to this approach demonstrated that most of the knowledge building has been focused on business processes and outcomes related to issues such as sustainability [47]. Literature related to individual worker experience suggested that they largely use their incomes to supplement their disability pensions, although a significant minority do appear to reduce their use of social assistance [48], and experience the businesses as promoting their recovery [49, 50]; and a significant minority have aspirations to find jobs outside of the business in the open market [51]. Individuals working within these social businesses will typically continue to receive support from mental health professionals, although the extent to which the business itself is linked to the mental health system has both advantages and disadvantages. For example, the mental health system may create market opportunities for the sale of goods and services, but businesses that are located structurally within the mental health system can find their autonomy around business decisions compromised [40]. Indeed, the focus on development of a distinct business structure is inconsistent with the focus on development of programs and services.

A second entrepreneurial approach is the development of self-employment among people with mental illnesses. In this approach, individuals with an entrepreneurial spirit are supported to develop the feasibility of their business ideas and provided with supports that can be offered in the form of business advice and mentorship, shared business resources, and small low-interest business loans [41, 52]. An example of this approach is a partnership developed between the Rotman School of Business at the University of Toronto and Toronto’s Centre for Addictions and Mental Health, which began as a local pilot and became a province-wide initiative to fund prospective entrepreneurs [53].

Conceptual foundations of the approach can be traced back to community economic aims to address the poverty and social conditions of disadvantaged groups using market rather than care strategies [54] and asset-based community development frameworks [55]. While these perspectives provide the vocational rehabilitation field access to a wide range of relevant and high profile international scholarship, they are largely outside of the health and mental health systems and subsequently have not been readily integrated into the field.

4.3 Employment Opportunities Within Health and Social Systems

A third approach to the creation of employment opportunities has been the development of jobs for people within the mental health system. This approach emerged primarily in recognition of the many benefits associated with integrating people with lived experience of mental illness actively in program development and implementation [56, 57]. The approach has disseminated rapidly, leading to transformations in hiring and employment structures across the system. The expansion of these job positions has included a variety of paid positions from peer-provider jobs, service developers and managers, research associates, and educators. The hiring of peer providers is now considered a best practice in many jurisdictions, and this suggests that a growing number of employment positions are being created. Most of the scholarship focusing on these affirmative employment positions has focused on the tasks and challenges associated with integrating new types of jobs into existing employment structures. For example, the literature includes discussions about challenges related to developing job descriptions, identifying and providing for training needs, ensuring inclusion and emotional well-being in the workplace, and the nature of the job responsibilities (see, e.g., [58–60]).

5 Complementary Interventions

Consistent with the idea of providing ongoing employment support to people with serious mental illnesses as required, several research studies have demonstrated that vocational outcomes can be improved by the implementation of specific interventions focused on improving work functioning. The studies primarily investigate these complementary interventions in the context of evidence-based supported employment, but, at least in theory, they should be applicable to the other employment approaches described above.

There is some evidence that work-focused social skills training integrated within supported employment leads to better employment outcomes [61, 62]. Cognitive remediation, when integrated with supported employment, has been shown to lead to better cognitive and employment outcomes than offering either approach alone [63]. While there appears to be some support for the integration of cognitive behavioral therapy with employment support programs for people with serious mental illnesses, research is still limited in this area [64]. Interestingly, given the high percentage of individuals with a serious mental illness who are not pursuing employment, there has been limited attention to the development and evaluation of focused motivational interventions.

6 Challenges in the Field: Tensions Related to Defining Work

In the midst of the rapid growth and development, the field of psychiatric vocational rehabilitation is facing multiple debates and challenges. The underlying differences between the employment approaches outlined in this paper are differences of philosophy with regard to what constitutes “real work.” When employment in the open, competitive workforce is considered the only real form of work, then supported employment models will be considered the ideal approach. That said, challenges to supported employment have included arguments that (1) the approach has lead largely to entry-level jobs with low pay, low skill, and few benefits; (2) the levels of job tenure within the supported employment has been troublesome; and (3) individuals receiving supported employment services remain “clients” of a service system, perhaps undermining their identity as worker [65]. Entrepreneurial approaches and jobs within the mental health system have been criticized as potentially perpetuating segregation and stigma, perceived as protected environments. Yet, they have also been viewed as important venues to develop leadership, social learning, and collective action among mental health service users [46] and to effect change in the broader employment structures within which they have historically been disenfranchised. As highlighted by Kirsh and colleagues [27], reconciling these conflicting philosophies will be important to further development in the field: “Advancing interventions that may improve work participation requires ongoing reflection on the conceptual underpinnings of selected approaches as they relate to the end goal of productive employment, in addition to consideration of the individual” (p. 400).

7 Applying the ICF Core Set Categories to Vocational Rehabilitation for People with Serious Mental Illness

Within the mental health system, psychiatric rehabilitation is the field that has directly focused on enabling the full, successful, and satisfying community lives of people with serious mental illness. Psychiatric rehabilitation has largely focused on addressing the activity and participation needs of people with a serious mental illness, given the extent to which, historically, the population has been socially and economically marginalized. Within psychiatric rehabilitation, the distinction between mental illness and disability has been clear. It is well known within psychiatric vocational rehabilitation, for example, that diagnosis does not predict participation in important life roles such as employment, that work participation is possible even while experiencing ongoing symptoms of mental illness, and that environmental factors play a large role in determining work participation. Indeed, the employment support and vocational rehabilitation models described previously in this chapter have all been designed to address the comprehensive range of illness, personal, occupational, and environmental factors that can contribute to well-being, satisfaction, and success at work. In this way, there are notable consistencies between the ICF classification system and the field of psychiatric rehabilitation (and specifically psychiatric vocational rehabilitation), with regard to how they view and conceptualize health, disability, and participation.

Applications of the ICF in psychiatric rehabilitation have included its use as a tool to frame rehabilitation education [66] and its potential in interpreting the differences in disability among individuals with serious mental illnesses across cultural contexts [67]. Another potentially useful approach is to implement the ICF, and specifically the ICF core categories that have been developed for vocational rehabilitation [68], as a means to describe the critical elements of vocational programs and employment support services. Table 15.1 summarizes the brief core set for vocational rehabilitation [68, p. 7] with a definition for each [1]. The rest of this chapter describes the application of the ICF categories for vocational rehabilitation to a specific employment support and vocational rehabilitation program.

Table 15.1 ICF core set for vocational rehabilitation – a guide with definitions
Full size table

The psychiatric vocational rehabilitation program is located in a small city center in southern Ontario, Canada. The vocational service is one service element within a multiservice community mental health agency that focuses on supporting recovery and community life for people with mental illnesses, particularly those with serious mental illnesses. The agency is committed to the philosophy and principles of psychosocial rehabilitation and implementing practices that are evidence based. The agency saw the value of applying the ICF core set categories for vocational rehabilitation to its vocational service as a means to develop clarity about the processes and nature of services offered, facilitate communication about services to a range of stakeholders and audiences, and facilitate evaluation of services and as a guide for training and education.

The employment support and vocational rehabilitation services are offered in a phased, but individualized manner, with multiple service components accessible at each phase (see Table 15.2). The core focus of the vocational program, or its central mission, is consistent with the ICF core categories for vocational rehabilitation, d845, acquiring, keeping and terminating a job, and d850, remunerative employment. This distinction is important for clearly communicating the goals of the program; it is solidly focused on connecting people to paid work opportunities. Given the large number of people with serious mental illnesses who are engaged in few or no work-related productivity activities, referrals to the program from other mental health or social service sectors often mistakenly expect that the program will address a broader range of productivity options, such as non-remunerative employment options (d855). Where the expectations of individuals who access the service and the goals of the service are not consistent, efforts are made to connect individuals to more appropriate services that focus on other vocational options. The initial phases of the program, including referral, intake/orientation, and even assessment, reflect a collaborative process to ensure that individuals are, in fact, oriented toward paid work and to begin developing an appreciation for the strengths, challenges, and preferences that individuals bring toward this goal.

Table 15.2 Employment support and psychiatric vocational rehabilitation: a case example
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Job preparation is a time-limited phase, oriented to solidifying readiness for work. A central focus is building up the capacity for sustained motivation for employment, consistent with b130 energy and drive functions. Challenges related to energy and drive are prevalent among people with serious mental illnesses and can result from biomedical factors associated with the disease process (e.g., negative, avolitional symptoms), psychological processes (e.g., the loss of self-confidence, tentative goal structures), and social processes (e.g., the experience of stigma, poverty). Job preparation is also oriented to addressing the handling of stress and other psychological demands (d240). A particular focus at this point are stress and psychological demands related to: shifting activity patterns to accommodate employment; managing self-care including illness management; beginning to identify triggers for illness experiences, possible supports, and coping strategies; developing crisis plans; and determining eligibility for special government employment resources.

The job development phase of the service focuses on successfully transitioning individuals to one of a range of paid work opportunities. Creating job opportunities is a key activity of dedicated job development staff who engage with labor-related systems, policies, and services to secure employment possibilities (e590). Once in the job, the individual is supported in meeting work-related stress and psychological demands (d240) and acquiring the range of skills associated with the specific job (d150). For many participants, the lack of recent work experience has contributed to physical deconditioning, and individualized fitness programs are offered as an additional support (b455 exercise tolerance functions). Many people experience specific cognitive impairments (e.g., attention, memory) associated with their mental illnesses (b140-b189 specific mental functions), and for these individuals complementary neurocognitive enhancement training is offered in partnership with a local university psychology program.

As service recipients continue in their work situation, issues and challenges (as well as positive experiences) unfold and job retention activities focus on sustaining commitment to work, while promoting a good job match. In this phase, in addition to handling stress and psychological demands of work (d240), an important focus of support is on meeting the challenges associated with a range of complex interpersonal interactions (d720), such as relations with coworkers and customers; people in positions of authority (e330), such as immediate supervisors, and employers; and meeting expectations that require high-level cognitive functions (b164), such as organization and planning, problem solving, and time management. Consistent with evidence-informed principles of psychiatric vocational rehabilitation, the service pays close attention to ensuring the ongoing delivery of health services to ensure the mental health and well-being fundamental to sustained employment (e580) and to labor system policies and practices to sustain motivation for employment (e590).

The exercise of applying the ICF core set categories was a useful one for the vocational service. The process engaged them in clearly defining the objectives of their work and considering how they communicate these to their community partners, potential service recipients, and other stakeholders. It also helped them to further develop the rationale underlying the specific elements of their services. The resulting framework may be applied for training and evaluation purposes.

8 Summary

This chapter focuses on employment support and vocational rehabilitation applied to those with serious mental illnesses. Current approaches to enabling employment have largely been directed to reducing the profound levels of social and economic marginalization that have historically been experienced by this population and subsequently have been directed to creating and supporting real work opportunities. The ICF core set categories for vocational rehabilitation provide a potentially useful resource for developing a shared language and understanding about the critical features of these programs applied to people with serious mental illnesses. They also provide the opportunity for cross-cultural comparisons and international programs of evaluation and research.

  • The employment status of the population of people with a serious mental illness can be described as “marginalized.”

  • Employment marginalization suggests that individuals have weak labor market attachments. This means that they have few work-related social networks and are often inactive with respect to pursuing or even expecting to work.

  • Contemporary approaches to vocational rehabilitation for people with serious mental illnesses are oriented to developing real work opportunities and providing support to ensure individual success and satisfaction.

  • Employment supports for people with a serious mental illness integrate attention to personal, illness, occupational, and environmental factors that influence work participation.

  • The ICF core set categories for vocational rehabilitation can be applied to describe the critical elements of vocational programs and employment support services for people with serious mental illnesses.

Study Questions

  1. 1.

    Why do you think that diagnosis has not been a good predictor of employment among people with serious mental illnesses?

  2. 2.

    There is considerable controversy in the vocational rehabilitation field about what constitutes “real work.” How would you define “real work”?

  3. 3.

    Explain why the term “unemployed” does not fully capture the employment status of people with serious mental illnesses?

  4. 4.

    Compare the three approaches to creating employment opportunities outlined in this chapter with regard to their potential to positively impact the inclusion of people with serious mental illnesses in broader society?

  5. 5.

    Describe why health service providers may not encourage or expect people with serious mental illnesses to consider working in paid jobs.