Stakeholders' views on vocational rehabilitation programs: a call for collaboration with Occupational Health Physicians.

BACKGROUND: The triple-dip recession taking place in Italy in 2008-2014 impacted negatively on health, mainly by increasing the rate of unemployment. This increased the prevalence of mental health disorders, while reducing the number of available places on vocational rehabilitation programs (VRPs) delivered by the psychiatric services.
OBJECTIVES: To explore the different points of views of stakeholders (namely, users and professionals) involved in VRPs developed inside an Italian Community Mental Health Center (CMHC).
METHODS: A sample of users, psychiatrists, educators and nurses of an Italian CMHC involved in VRPs took part in a focus group. Content analysis was performed with MAXQDA 12, by developing a hierarchical code system a posteriori (i.e., derived from the data). The respondent validation phase was carried out by means of a multiple-choice questionnaire, administered to all participants.
RESULTS: A total of 86 emerging issues were coded, divided into two macro-areas: Positive and Negative Reinforcements (48 contributions, 56%, and 38 contributions, 44%, respectively), further subdivided into three areas: professional (service) factors, personal (i.e, user-related) factors, and work environment features (including relationships in the workplace). Some contributions raised issues concerning occupational health protection (e.g. need of information about the rights and duties of the users-workers, as well as the risks they are exposed to in the workplace).
CONCLUSIONS: The analysis suggested to address specific issues concerning work and VRPs by means of psycho-education group interventions currently carried out at CMHCs, and pointed to the need to foster collaboration between mental health professionals and the occupational health physician of the company where the VRP is started and where the user might be employed.

Introduction

In 2008 most countries in the world faced the worst economic crisis since 1929, for this named the Great Recession (“the Recession”) (15). As a result, in 2012 124.2 million Europeans (25% of the population) were at risk of poverty and social exclusion (9), as well as mental health problems (12, 18). In Italy, after the onset of the Recession, rates of suicide and attempted suicide due to financial problems increased (6, 7). Such negative health outcomes were mainly attributed to increasing rates of unemployment; however, other work-related difficulties affecting those who remain at work in times of economic hardship should be taken into account, such as substance-use behavior, somatization and Burnout Syndrome (4, 11, 13). In addition, austerity measures implemented in response to the economic downturn may have resulted in deteriorating public health (19, 27, 29).

This was the case of Italy, where a triple-dip recession took place in 2008-2014, and austerity measures were implemented. Not surprisingly, an increased prevalence of psychiatric disorders, namely depression and substance use disorders, was reported (19, 26, 28). However, other more subtle, indirect consequences of the Recession and austerity on mental health need to be acknowledged. In fact, by reducing the number of companies and jobs, the Recession also impacted on vocational rehabilitation programs (VRPs). These are clinical projects generally promoted by Community Mental Health Centers (CMHCs), aimed at helping individuals affected by psychiatric disorders to find a job (2). The reduced number of jobs due to the Recession prompted the adoption of strategies that may improve the outcome of VRPs.

In Italy, VRPs are regulated by an extensive national legislation, based on Act 68/99, which favors employment and social integration for people with disabilities by means of support services, namely the system of “Effective Placement” (EP) [collocamento mirato]. To enter this system, CMHCs’ users need a certification quantifying their disability in terms of reduced functioning. This certification is issued after a specific assessment made by integrated medical committees, in which the presence of an occupational health physician (OHP) is required, whose aim is to assess the productive activities of the territory (i.e., production cycles and related risks, prevention and protection measures necessary to protect workers’ safety and health) and contribute to defining the user’s employment and social skills, as well as suitable employment categories where EP may take place. In the Emilia-Romagna Region, where the present study was carried out, the national legislation based on Act 68/99 was transposed into Regional Law 14/2015 (17).

This study is part of a four-stage research project launched in 2010 by the Section of Psychiatry at the University of Modena and Reggio Emilia, Italy, to investigate the impact of socio-economic factors on the health of the Italian population (20). After providing a general, nationwide overview of the topic (21, 23), more local and specific issues were examined (22). Furthermore, findings are being implemented in clinical practice and disseminated by means of congresses and seminars. Special attention is being paid to strengthening collaboration between OHPs and mental health professionals in terms of research, educational and clinical activities, as well as to translate relevant results into actions with social impact (30, 34).

Aim

To explore the different points of views of stakeholders (namely, users and professionals) involved in VRPs developed in an Italian CMHC.

Methods

Study design

This study was designed according to the COREQ criteria for qualitative research (31).

A sample made up of users, psychiatrists, educators and nurses of the CMHC of Castelfranco Emilia (Province of Modena, Italy) was selected by means of a “snowball-sampling” method. The researchers were put in touch by the chief of the CMHC (Dr. N. Colombini) with mental health professionals (psychiatrists, nurses and educators) involved in vocational rehabilitation activities, who, in turn, contacted users. This sample was used for a focus group, which was audio-recorded and subsequently transcribed using a word editor.

Among the eight CMHCs at the Modena Mental Health Department, the one located in Castelfranco Emilia was chosen as a research site for two reasons. First, the long-term local collaboration between mental health and social services, on the one hand, and the industrial context, on the other, makes this facility a virtuous case worth studying. Second, this is the only university-based CMHC in the Modena Mental Health Department. As a result, the CMHC at Castelfranco Emilia was chosen as the site of the present research, that is intended as a pilot study to be further replicated in other facilities of the same Department.

Research team and reflexivity

The focus group was conducted by two researchers, GM (facilitator, male, M.D. fourth year resident in psychiatry at the University of Modena and Reggio Emilia, trained in the field of qualitative research) and VS (co-facilitator, female, third year nursing sciences student at the same University).

Data analysis

The thick description of the focus group was independently analyzed and coded by GM and VS by means of MAXQDA 12 software (VERBI GmbH), so as to develop a hierarchical code system a posteriori (derived from the data), with the independent supervision of the principal investigator, GMG. The transcript was analyzed according to the principles of content analysis (25). A neutral approach was adopted: participants were invited to join the focus group voluntarily and, if willing to join, to sign a written informed consent form. There had been no previous personal contacts between the researchers and participants. A final phase of respondent validation was carried out by means of a multiple-choice questionnaire, administered to all participants.

Results

The focus group took place on February 2, 2016, and lasted 1h39m. The sample was made up of three mental health professionals (two psychiatrists and one nurse), three users and one educator. All the individuals invited to take part in the focus group agreed to do so.

The majority of the participants were men, with age of the professionals ranging from 30 to 59. All but one of the professionals had more than ten years of seniority in the field of mental health services. The age of the users ranged from 25 to 60. All the users had taken part in a VRP just once, and were employed both in the private sector, as well as in the non-profit sector (Social Enterprises, [Cooperative sociali]). No more detailed sample features are provided for privacy reasons. Further focus groups were not planned, given that after content analysis it was determined that theoretical saturation was reached. Altogether, 86 emerging issues were coded, divided into two macro-areas: Positive Reinforcements (48 contributions, 56%) and Negative Reinforcements (38 contributions, 44%), further subdivided into three areas: professional (service) factors, personal factors (user-related) and work environment factors (including relationships in the workplace). Paradigmatic examples illustrating each area are provided (the letter and number between brackets indicating, respectively, the line of rough description and who is speaking: e.g., 70 N1 means line 70, nurse number 1).

Positive reinforcements

Professionals

The CMHC aims at promoting and reinforcing job placement by means of regular support for the user, mediating between the needs of the user and those of the company. In playing such a role, patience and adaptability are required.

The [vocational rehabilitation] program supports people during their difficult periods. It helps mediate between the needs of the companies and the needs of the patient. We should bear in mind that the final goal of the program is to help people to obtain permanent employment (68 N1) (our translation in this and all subsequent excerpts).

Having patience and even a bit of spirit of adaptability is crucial (50 ED1).

Personal Factors

VRPs are perceived as important opportunities in the users’ lives. Within this framework, users feel more protected, and able to realize their potential.

I feel quite lucky compared to my past work experience. This is a very positive experience in my life (5 U1).

Work is a way to tune with one’s personal aims, to test oneself (4 5P1).

[It is important] to learn everything as soon as possible so to start and enter the labor market (48 U2).

This is what allows you to hope you’ll find a job (54 U3).

Work environment

According to the users, the work environment, more specifically the relationships with colleagues, can provide significant forms of support. In particular, relational features may help to overcome limitations of the workplace, e.g. being assigned a task or job that does not exactly match one’s personal interests and expectations.

I have a good relationship with both the employer and my co-workers, we also go out for dinner three or four times a year (5 U1).

They are good, they are good to me, I must say that I’m fine with them (22 U2).

Interpersonal relationships are also very important. Even a job that doesn’t seem to fit exactly can be a positive experience if there are good interpersonal relationships. This contributes to a positive and relaxed professional environment (59 U3).

Negative reinforcements

Several contributions focused on the gap between training, expectations and job demands.

I found myself in situations in which people did not accept our programs [work proposal] because they disliked them (50 ED1).

A noticeable issue that became evident from the analysis is the lack of information provided, concerning users involved in VRPs.

It is the lack of information that many times creates a lot of problems, because so many times we do not understand, we do not know our rights, or maybe someone can think ‘If I say those things, then the others, my co-workers, the employer may think I’m not well’ (70 N1).

Another negative factor is the lack of motivation, frequently observed among the young; in addition, socio-economic environmental factors do not always help those who are motivated to succeed.

These days, I think that young people have been deprived of their dreams. The bad thing is that the young cannot afford to dream. These days, I think the young put their head down and take whatever is coming and I think this is very disappointing (54 U3).

Remarks were also made concerning self-stigma and stigma at workplace:

If you have a crisis or a depression, they leave a sign on you forever (63 U2).

Maybe she [a user] was not really ready to work closely with people who, let’s say, normally do not have [psychiatric] problems (9 U1).

The fear of losing one’s job was frequently addressed, connected to general considerations about the atmosphere of economic and financial instability.

These days, if you have a precarious job and you are employed on a new contract such as the Jobs Act, you are, in a way, always ‘susceptible to blackmail’. Today, even if you are hired on permanent contract, there is a risk of being fired suddenly, and there is not even the labor court judge, now you get a minimum level of compensation and then you stay at home (54 U3).

Sometimes companies tend to make greater requests than those stipulated, favoring their own interests. This attitude may increase users’ work-related stress, and may ultimately impact on their mental health.

Many companies are only interested in profit, and sometimes they require a commitment that goes beyond what is required by law. But there is a law that needs to be enforced and it is important to ensure that this law is respected without the fear of being fired or similar things (65 N1).

Work is gratifying but sometimes it’s a source of stress and problems (68 N1).

Under these conditions, work ‘kills you’, depression returns, thus creating a vicious circle (88 U3).

Responding validation

Figure 1 shows the results of responding validation. Five questionnaires out of 6 were returned (response rate: 83%) and used for the analysis.

Figure 1

Results of the respondent validation phase

Discussion

The aim of the present study was to explore the different views of stakeholders (users and professionals) involved in VRPs. Several positive aspects emerged during the focus group, from both users and professionals, consistent with the idea that social inclusion and vocational support may decrease the severity of psychiatric symptoms and increase the quality of life (8).

Noticeably, a gap between training and the demands of the job was pointed out; in some circumstances, users felt their training was not sufficiently related to the requirements of work. Also, they pointed out a possible gap between their expectations and what their job is supposed to be, thus requiring a certain adaptation. These issues may impact negatively on the outcome of VRPs, and may be overcome by the adoption of newer approaches to vocational rehabilitation, such as Individual Placement and Support (1, 3, 5).

Despite being employed in Social Enterprises [Cooperative Sociali], that have special regulations and are generally more sensitive to their employees’ needs, the users reported a fear of losing their job and of being punished by their boss, for example in the event of a refusal to work overtime.

In 2012, about 600 users of the Mental Health Department of the Province of Modena were included in VRPs: of those, 43% successfully concluded them and were employed (27). Results from the present study may help explain why this percentage, though higher than the 21% reported for traditional approaches to vocational rehabilitation, was lower than the 60% reported in studies adopting more advanced models (2, 14, 16). In fact, several users’ unmet needs concerning VRPs became evident from the analysis, such as the need for developing coping strategies that may help them deal with stressful situations in workplace, the need to cope with stigma and possibly stigmatizing attitudes of co-workers, and so forth.

These factors and needs could be partly addressed by specific clinical interventions, e.g. psycho-education group interventions (PGI), frequently carried out according to the groundbreaking model of Falloon (10, 24, 32, 33). Psycho-education is a therapeutic intervention, generally based on a cognitive-behavioral framework. It may involve users, as well as their families, in individual or group sessions. The aims of psycho-education are to provide information about psychiatric disorders, available treatments, medications prescribed, and access to psychiatric services. Also, psycho-education aims to empower users and families, providing them with coping strategies. PGIs are generally made up of fixed (also called “regular”) topics, assigned to each meeting, and repeated cyclically (e.g. once a day, once a week). Fixed topics concern, e.g., psychotropic medications, the vulnerability-stress model, and early warning signs. Alternatively, no fixed topics address VRPs. Additional, “optional” topics could be introduced, according to needs. Even in this case, work issues are generally not addressed. As a result, the findings of the present study suggest that specific “optional” topics concerning VRPs could be developed and implemented in the PGIs currently carried out in psychiatric facilities (CMHCs and residencies). Such optional topics might be conceived starting from those listed in table 1.

Table 1

List of the sessions of the group psycho-education intervention, with highlighted topics and main themes

Sessions	Topic	Themes
1.	Information	Addresses the need of information reported by users, concerning rights, duties and laws.
2.	Job-education gap	Displays the differences between users’ expectations toward work (frequently based on their education background) and job offer.
3.	Work environment and relationship	Explores difficulties in interacting and adapting to social and working with co-workers	dynamics; also provides knowledge about mechanisms to cope with difficult relationships.
4.	Psychiatric disorders and workplace	Explores the topic of stigma in the workplace
5.	Coping with company requests	Explores the topic of how to cope with stressful company requests. Provides techniques to address job-related stress

Some issues stemmed out from our analysis, specifically those coded as ‘work environment factors’, may interest occupational health professionals. For example, the fact that sometimes companies make greater requests than those stipulated, able to increase users’ work-related stress requires attention, since this may ultimately impact on users’ mental health. Therefore, this issue has implications for both psychiatric services as well as occupational health ones, though their interactions are not always easy: notably, OHPs often complain of difficulties in interacting with mental health services, and point out the need to improve relations with them (30). Therefore, it would be helpful to strengthen the relations specifically between psychiatric services and the OHP working in the company where the VRPs is started and the user might be employed. Notably, the information stemmed out from the above-mentioned PGIs may help the OHP with respect to risks assessment and health surveillance. This topic is currently in our research agenda (30, 34).

This study has several limitations. First, due to its qualitative nature, external validity is limited. Also, data for the present study came from just one focus group, held in only one CMHC. Since other focus groups were not held, it is not possible to assess whether this CMHC and the analysis we made are representative of the whole Modena Mental Health Department. At the same time, the present research was conceived as a pilot study, i.e., an initial step for further and larger studies on these topics currently in our research agenda, involving larger numbers of users and professionals from other research sites of the same Department, and adopting quantitative methodology when appropriate. Some of our conclusions may appear speculative, and surely need further assessment by means of further research. Secondly, even if the role of the OHP was discussed, no OHPs participated in the focus group. This represents, at the same time, a limitation of the present study, as well as an aim for further research. Third and final, since only one focus group was held, a rigorous research methodology was adopted, both in the analysis and validating phase, to try to overcome this significant limitation.

In conclusion, the analysis of stakeholder views on VRPs suggested to address specific issues concerning work and VRPs by means of PGIs currently carried out at CMHCs. Also, the findings of the present study point to the need to foster collaboration between mental health professionals and the OHP of the company where the VRP is started and where the user might be employed.

No potential conflict of interest relevant to this article was reported by the authors