Introduction

Job acquisition for people with a severe mental illness is challenging due to individual and environmental factors (Bond et al. 2008; Corbière et al. 2011). Supported employment (SE) programs have been developed to facilitate the work integration of this population; these programs are now recognized as evidence-based practices, particularly the Individual Placement and Support model (IPS) (Drake et al. 2012). Until now, 20 randomized controlled trials of the IPS model showed that an average of 60% of people with severe mental illness obtained competitive employment compared to 25% of people registered in other types of vocational programs or services (Drake et al. 2012; Bond et al. 2008). However, Bond et al.’s study (2012) showed that the competitive employment rate was poorer in Canada and European countries (about 47%) compared to the USA, Australia and Asia (about 62%). Explanations for these differences included the disability policies of Canada and the European countries as well as the lack of training of employment specialists working in SE programs (Bond et al. 2012; Corbière et al. 2014a).

Traditional vocational programs (e.g., sheltered workshops) have been the standard approach in Europe for some time, and the European scientific community, particularly in France, previously viewed SE programs with skepticism, doubting the possibility of replicating them in their specific cultural contexts with the same performance as in the United States (Fioritti et al. 2014). However, thanks to extensive research demonstrating that SE programs, particularly the IPS model, can be as effective in Europe as in the United States (Burns et al. 2007), interest in implementing “place then train” practices has been growing; first in Northern Europe (e.g., United Kingdom, the Netherlands), and more recently in the Southern Europe (e.g., Italy, Spain) (Fioritti et al. 2014).

In order to promote the implementation of supported employment in France, which is only at its beginnings, the French government has expressly recognized and recommended this approach (and begins to finance it) in the recent labor law (n° 2016-1088 of 8 August 2016), but globally this type of practice is still poorly developed in our country. Structural reasons such as deeply rooted cultural values of protecting disabled people, the foundation of welfare systems, and the current economic crisis probably account for this slow uptake of SE programs (Fioritti et al. 2014). France is currently behind other European countries in terms of the work integration of people with a severe mental illness in the regular labor market, illustrated by scarce studies on vocational services for this population and no studies on “place and train practices” (Pachoud and Corbière 2014). In 2005, a French Law on Equal Rights and Opportunities was set up “to promote social inclusion for disabled people”, including people with a “psychiatric disability”. Within this French system, a person with a severe mental illness must first be recognized as having a psychiatric disability to benefit from financial supports and psychosocial services, including vocational services (Blanc 2010). The data about the employment rate of people with severe mental illness in France are missing, but it is widely agreed that this rate remains very low and the traditional vocational services are poorly effecive for work integration in the regular labor market. It might be that may be that the “psychiatric disability” label has reinforced stigma towards these persons by emphasizing their deficits rather than their capabilities (Pachoud and Plagnol 2016). Yet, in France, strong prejudice remains in particular from employers that people with severe mental illness cannot work in the regular labor market or should be prepared for a long delay before entering the regular labor market (Laberon 2014).

Thanks to recent initiatives in France, SE programs are becoming more well known to vocational counselors working in the community (Pachoud and Allemand 2013; Pachoud and Corbière 2014; De Pierrefeu and Charbonneau 2014), and some sheltered workshops or prevocational services are slowly being converted into SE programs, as occurred 10 years ago in Canada (Oldman et al. 2005). Since 2013, SE practices have started to emerge in France, though scarce public funds exist to support them. Among these structures, the Messidor Association is one of the most dynamic prevocational organizations willing to adopt and implement SE programs. Since 1975, this association located in the Rhone-Alpes region offers a particular kind of vocational program dedicated to people with a psychiatric disability, which may be seen as a hybrid form of social enterprise and SE program (De Pierrefeu and Charbonneau 2014). Unlike the sheltered workshops implemented in France, in which most people stay for many years even though they should be supported to shift to competitive employment, Messidor aims to help their workers integrate into the regular labor market. This objective is clearly stated to people wishing to be admitted to the Messidor transitional program, and is supported by a higher staff-to-client ratio than in traditional sheltered workshops. Work activities in these structures include, for example: catering, gardening, cleaning or administrative work. Most of the workers work directly in their employers’ workplaces (e.g., industrial or logistics places, headquarters of companies), i.e., under the work conditions of the regular labor market. Supervisors manage small teams of workers (5–7 persons), which allows more personalized management; each worker has professional objectives to reach every trimester, considering the worker’s capacities, needs and career goals in the regular labor market. In 2013, approximately 500 workers were working in Messidor programs (De Pierrefeu and Pachoud 2014).

One characteristic of Messidor is that people with a psychiatric disability working in these structures are supervised by two people: first, by a manager overseeing their work and everyday life and second, they are trained by a “vocational counselor” whose role is to ensure that the worker will not stay too long in the Messidor program and will obtain employment in the regular labor market as soon as possible. This role seems fairly similar to the employment specialist working in a SE program, i.e., helping people with a severe mental illness to gain and keep a competitive job in the regular market (De Pierrefeu and Charbonneau 2014). This effective practice in France provides the opportunity to evaluate vocational counselors’ competencies, and to compare them to those working in evidence-based practices, such as employment specialists working in IPS programs. The potential gap between the competencies of the French vocational counselors working in Messidor and employment specialists working in IPS programs could be addressed as needed, thus improving SE services that Messidor wants to develop for increasing vocational successes in the regular labor market. Furthermore, as many studies have shown, employment specialists’ competencies are recognized as key factors for predicting work outcomes (Corbière et al. 2014a; Drake et al. 2006; Dreher et al. 2010).

To date, two tools have been developed to investigate employment specialists’ competencies: the Individual Placement and Support Questionnaire (IPS-Q; Dreher et al. 2010) and the Behaviors, Attitudes, and Knowledge in Employment Specialists questionnaire (BAKES; Corbière et al. 2014a). The former is a 30-item multiple-choice quiz for employment specialists, covering fundamental IPS principles and key SE components (Dreher et al. 2010). This tool gathers information about the level of knowledge of SE program employment specialists, but several authors have pointed out that despite the level of knowledge being a valid criterion for assessing competencies, the attitudes and behaviors relating to skills in different fields should also be assessed to get a complete picture of employment specialist competencies, such as communication, negotiation, relationships, marketing (Corbière et al. 2007; Dreher et al. 2010). To do so, Corbière et al. (2014a) developed a more comprehensive tool for assessing employment specialist competencies in SE programs, the BAKES questionnaire. This scale measures the behaviors, attitudes and knowledge of employment specialists working in SE programs, and is significantly associated with work outcomes (obtaining and maintaining competitive employment). The BAKES seems to be an appropriate and comprehensive tool to evaluate the competencies of vocational counselors working at Messidor. Furthermore, this tool has the advantage of being validated in Canada and, in Europe, in the Netherlands (Corbière et al. 2014a). The BAKES was also validated in French since several employment specialists working in Quebec (Canada) were French Canadian. Only, a few minor changes were necessary to adapt the BAKES to the French culture of France (e.g., idioms). The main objective of this study is to evaluate Messidor’s vocational counselors competencies using the BAKES by comparing their results to those obtained by employment specialists working in IPS programs located in Canada.

Methods

A quantitative method was chosen for this study: descriptive analyses and comparison means allowed us to evaluate Messidor’s vocational counselors using the BAKES (n = 25) in order to compare these results to those of employment specialists working in IPS programs implemented in Canada (n = 49) (Corbière et al. 2014a).

Data Collection and Sample

The French version of the BAKES questionnaire (see below for a description) was administered to Messidor vocational counselors from the Rhone-Alpes region and from the Picardie and Ile-de-France regions. The single inclusion criterion was: working at Messidor for more than 6 months. A total of 25 (out of 26) vocational counselors completed the questionnaire. Almost all participants were female (88%, n = 22). The average age of the respondents was 40.25 years (SD = 7.74). Participants worked at Messidor for an average of 3.3 years (SD = 2.7). The average caseload for vocational counselors was 29 workers (SD = 12.2). All participants provided written informed consent; the study was approved by the Conseil d’Evaluation Ethique pour les Recherches en Santé (CERES) from the Cochin Hospital in Paris.

The Canadian sample was composed of 49 employment specialists working in IPS programs located in three Canadian provinces (British Columbia, Ontario, and Quebec). The average age was 41.2 years (SD = 12.76) and 83.7% (n = 41) of the sample was female. The average work history in the SE program was 3.8 years (SD = 5.1). The average caseload was 25 clients (SD = 13) for these employment specialists.

The BAKES questionnaire was used to measure the behaviors, attitudes and knowledge of employment specialists working in SE programs. A total of 90 competencies spread over 12 subscales emerged from factor analyses: (1) Outreach and work accommodations (13 items, e.g., Attend job interviews with your clients when you have their permission); (2) Job-search strategies (6 items, e.g., Teach your clients how to market themselves and how to negotiate with potential employers); (3) Support in identifying work interests and labor market (6 items, e.g., Help your clients identify their interests and preferences in terms of work); (4) Social behaviors and healthy lifestyle (6 items, e.g., Help your clients find a balance between their work and activities outside of work); (5) Adaptation to and dealing with the workplace culture (6 items, e.g., Suggest to your clients appropriate ways to behave to help them keep a job); (6) Relationships with employers and supervisors (10 items, e.g., Inform employers about work accommodation arrangements that could be implemented to help your clients); (7) Relationships with mental health professionals (10 items, e.g., Establish a working relationship with the health professionals who follow your clients); (8) Dealing with stigma and self-stigma (7 items, e.g., Discuss with your clients the consequences of internalizing stigma); (9) Support and client-centered approach (8 items, e.g., Use supportive interpersonal skills in working with your clients, such as listening and empathizing); (10) Knowledge of clinical symptoms and health/vocational services (11 items, e.g., Know the impact that labels may have on your clients); (11) Knowledge of the workplace (5 items, e.g., Have a good knowledge of various occupations and jobs); and (12) Knowledge of the laws and policies related to disability (3 items, e.g., Have a good understanding of the laws pertaining to work accommodation).

Most of these 12 BAKES subscales have been highlighted in the literature as critical ingredients in SE programs and employment specialists’ competencies (e.g., Relationships with employers and supervisors, Support in identifying work interests and labor market). This self-report questionnaire rates all 90 items on a seven-point Likert-type scale (1 = never to 7 = always, for behaviors and attitudes; 1 = not at all to 7 = perfectly, for knowledge). Construct and predictive validities as well as internal consistency (Cronbach alphas) for each subscale were satisfactory (Corbière et al. 2014a).

Descriptive analyses and a MANOVA were carried out with SPSS Statistics v.22 software on all BAKES’ subscales to compare the results for Messidor’s vocational counselors (n = 25) to those of employment specialists working in IPS programs (n = 49) located in Canada.

Results

As expected, the MANOVA (Wilk’s Lambda multivariate test) results showed that employment specialists working in Canadian IPS programs (n = 49) had higher scores for BAKES subscales than Messidor’s vocational counselors (n = 25) (F = 5.5, df = 12, p < 0.001). Canadian scores ranged from 4.6 (Relationships with employers and supervisors) to 6.4 (Support and client-centered approach) while French vocational counselors presented scores from 4.2 (Knowledge of the laws and policies related to disabilities) to 5.6 (Support and client-centered approach). In particular, Canadian employment specialists’ scores were significantly higher for 8 of the 12 BAKES scales (Fig. 1): Outreach and work accommodations (F = 5.8, df = 1, p < 0.02); Job search strategies (F = 8.0, df = 1, p < 0.01); Support in identifying work interests and labor market (F = 8.0, df = 1, p < 0.01); Adaptation to and dealing with the workplace culture (F = 8.9, df = 1, p < 0.01); Dealing with stigma and self-stigma (F = 5.73, df = 1, p < 0.02); Support and client-centered approach (F = 30.1, df = 1, p < 0.000); Knowledge of clinical symptoms and health/vocational services (F = 26.9, df = 1, p < 0.001); and Knowledge of the laws and policies related to disability (F = 7.6, df = 1, p < 0.01). No significant differences between both groups were observed for the following BAKES subscales: Social behaviors and healthy lifestyle (F = 1.4, df = 1, p = 0.23); Relationships with employers and supervisors (F = 0.007, df = 1, p = 0.94); and Relationships with mental health professionals (F = 3.1, df = 1, p = 0.06); Knowledge of the workplace (F = 0.94, df = 1, p = 0.34).

Fig. 1
figure 1

BAKES’ results of Messidor’s vocational counselors in France and IPS employment specialists in Canada

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Discussion

The efficiency of SE programs in helping people with severe mental illness to obtain a job has been proven; France is willing to develop and implement this evidence-based practice and some prevocational services, such as the Messidor Association, are also moving toward SE programs. The objective of this study was to identify the gaps between French vocational counselors at Messidor and Canadian employment specialists working in IPS programs using a validated tool to assess their competencies. These results could provide useful information to address training for Messidor vocational counselors, thus improving the implementation of SE services in France. Supported by the quantitative results of this study and data from the literature, we will first look at the similarities between employment specialists working in IPS programs and vocational counselors at Messidor. Then, we will discuss differences and peculiarities related to Messidor vocational counselors, followed by recommendations and clinical implications.

Similarities Between Vocational Counselors in France and Employment Specialists in Canada

Comparisons between vocational counselors at Messidor and employment specialists working in IPS programs using the BAKES identified some similarities in the competencies of these two populations, while the policies and sociocultural context of these two countries remain different. Even though the BAKES was conceived particularly for employment specialists, French vocational counselors’ scores for all subscales are quite high. The two BAKES subscales Support and client-centered approach and Support in identifying work interests and labor market have the highest scores compared to other subscales, highlighting the work of these vocational professionals to intervene on basic elements such as work interests and preferences, and to focus mainly on the client’s needs (Rinaldi 2014). Also, there is a very similar Mean between the two populations for the scale Relationships with employers and supervisors (Canadian = 4.64 and French = 4.67), emphasizing the proactive approach to employers taken by French vocational counselors. Interestingly, the three previous BAKES subscales have been considered as the competencies most related to the work integration of people with a severe mental disorder (Corbière et al. 2014a).

The similarities between the two populations highlighted that Messidor’s vocational counselors already have many competencies needed in an evidence-based practice such as the IPS program. Therefore, moving this prevocational program toward SE programs would mean reinforcing these elements of their practice, particularly the working alliance with their clients and relationships with different stakeholders (employers, health professionals). The differences we observed between these two vocational professionals also stressed some new skills that should be developed and the gaps that should be filled to move toward an evidence-based practice.

Differences Between Vocational Counselors in France and Employment Specialists in Canada

First, our quantitative results determined that French vocational counselors work closely with clients to plan their work reintegration but not as rapidly as employment specialists in IPS programs. Given that Messidor plays a prevocational role, this difference in time dimension is logical when compared to IPS programs. Nevertheless, it could be advantageous for this French practice to shorten the period of time their clients stay in Messidor. Indeed the IPS model demonstrated that the time dimension is key to the work integration outcome. Rapid job search is one the 8 principles of the IPS model (Mueser and McGurk 2014), which means that the sooner the client starts to search for a job, the better his chances of getting one.

Second, another difference identified by these results was stigma toward people with mental illness. The BAKES results pointed out that Messidor’s vocational counselors have lower scores on the subscale “dealing with stigma and self-stigma”. One hypothesis to interpret this result is the cultural context: mental health problems are still scarcely discussed in France. The stigma dimension remains underestimated, and therefore neglected (Castillo et al. 2008; Daumerie et al. 2012). This cultural aspect has consequences on French vocational practice and addressing it could be a way to progress on this issue. Indeed many studies have pointed out that stigmatization, especially internalized stigma, is a barrier to work integration in the regular labor market with potential isolation and work disability consequences (Stuart 2006).

Practical Implications

The practical clinical implications of this study include supervision and training of Messidor’s vocational counselors as an efficient way to reinforce and develop their skills, and filling the gaps to move toward this evidence-based practice. Some studies have defined the needed ingredients to ensure efficient implementation of SE services. One has been identified as the training of employment specialists, and that if training of employment specialists is a key ingredient to implement SE programs, it must be done with supervision to maintain its efficiency over time (Corbière 2012).

First, Messidor could follow the recommendations of other studies about the profile of the supervisor when hiring. For instance, it is important for employment specialists to be supervised by a “leader” or a “champion” of work integration for people with mental disorders (Swain et al. 2010), meaning someone with a clear vision of SE programs’ principles and procedures, and with the authority to apply them. The leader must have real faith that people with mental disorders can integrate into the regular labor market with appropriate support. This person should share some concrete examples to inspire employment specialists (Corbière 2012) and should give them some objectives to reach instead of “letting go” (Rapp et al. 2010). This supervision could help vocational counselors by reinforcing their strong competencies such as those related to “relationship with employers” or “support and client-centered approach”. For example, if the supervisor frequently emphasizes the importance of these competencies and rewards vocational counselors using them regularly, this could positively impact the approach of the vocational counselors.

Second, Messidor could develop some general training as well as some specific training for their vocational counselors. For general training, the Messidor organization could consider the approach of Marshall et al. (2008) who defined a 2-day training program for employment specialists when first implementing IPS programs. The training is completed during the first year of implementation with continuous support (e.g., job-development competency, team meetings to analyze case studies). Another general way of improving the training of vocational counselors could be self-evaluation of their competencies using tools such as the BAKES (Corbière et al. 2014a) or the IPS-Q scales (Dreher et al. 2010). This would help Messidor’s vocational counselors to identify precisely: (1) which competencies they are using well and which should continue to be reinforced; (2) which competencies they have gained since they began their training; and (3) which competencies are still to be improved since they began their training, for example, competencies related to “dealing with stigma and self-stigma”.

A more specific training program could also be developed to improve the competencies of vocational counselors for “dealing with stigma and self-stigma”. This program could provide instruction about the consequences of stigma, for example, how stigma influences employers’ attitudes and behaviors. The program could also teach vocational counselors how to elaborate strategies to fight stigma and self-stigma, such as the disclosure of mental health disorders. For example, vocational counselors could learn to work with their clients to define a decision-making process early in the job search, to determine what information is to be disclosed, how and to which persons, and to analyze the consequences of disclosure (Jones 2011; Corbière et al. 2014b). In addition, disclosure of a mental health disorder could be helpful in gaining some work accommodations related to job tenure, so this strategy could both fight stigma and improve job tenure.

Conclusion

This study compared the competencies of employment specialists in Canadian IPS programs with those of French vocational counselors working at Messidor. Even though their cultural contexts and programs were quite different, similarities existed between French and Canadian counselors, including the same importance paid to the working alliance with clients and support offered to them, the development of relationships with different stakeholders (e.g., employers, health professionals) and the knowledge of the workplace. To more closely match the methods and competencies of the IPS employment specialists, French vocational counselors could begin job searches with their clients earlier in the work process. French vocational counselors could also be trained to develop new skills for dealing with stigma from stakeholders in organizations, adopting a strategy with their clients for disclosing mental health problems in the workplace. Clinical implications are suggested to ensure the development of competencies in French vocational counselors and to inspire them to increase their performance in helping people with severe mental disorders obtain and keep competitive employment.