Employability of people with mental illness and substance use problems: Field realities.

BACKGROUND: There has always been a strong association between mental illness and work-related disability. According to the "World Health Organization," of all disabilities, severe mental illness is associated with the highest rates of unemployment. People with mental illness and problems with substance use have especially low employment rates. AIM: To identify the employability factors among people with mental illness and substance use problems.
OBJECTIVES: To assess the barriers and to identify various strategies to overcome barriers to employment for persons with mental illness and substance use problems and to identify instructors' responses about the functionality of the person who works in the vocational training center, to assess the social support experienced by the respondents.
MATERIALS AND METHODS: This is a qualitative study used the purposive sampling method to conduct the study on 15 respondents (five people with mental illness, five caregivers, five instructors) from Department of Psychiatric and Neuro Rehabilitation, NIMHANS, Bengaluru.
RESULTS: Various themes have identified to assess the barriers, aiding factors, and strategies to employment. Barriers to employment have categorized into individual factors, interpersonal factors, employment factors, and social factors. Health, communication, family support, treatment, and training are strategies to improve employability. Proper treatment and continuous adherence to medication, emotional support by family members and colleagues are the employment aiding factors.
CONCLUSION: Identification of barriers and facilitators in the Indian context will help us to address the employability of persons with mental illness and substance use problems. Copyright:

Introduction

People with psychiatric disabilities experience disproportionately high rates of unemployment. According to WHO, the unemployment rate is high when mental illness is associated with substance use problems. In Indian settings, studies related to employment barriers associated with a person with mental illness and substance use problems are less focused.[1] This will help mental health professionals to plan and provide appropriate interventions to those who require assistance in vocational aspects. This gap in information would benefit from further research to improve the employment rates of people with mental illness and substance use problems in India.

The study was a part of the 1-month training program on psychiatric rehabilitation services conducted in the department of psychiatric rehabilitation (OTHERS/002/207/2013/00653)

Objectives

To assess the barriers to employment for persons with mental illness and substance use problems

To identify various strategies to overcome barriers to employment among persons with mental illness and substance use problems

To identify instructors response about the functionality of the person who works in a vocational training center. Table 1 depicts the Socio-demographic profiles of the participants.

Table 1

Sociodemographic profiles of the participants

Variable	Person with mental illness (1-In patient + 4- day boarders) n=5	Family members n=5	Instructors n=5
Age	25-40 years	35-70 years	30-40 years
Sex	Males	2- males 3- females	3- males 2-females
Education	10th Std- undergraduate	10th Std- secondary	10th Std- undergraduate
Marital status	2- single 3-married	5- married	5- married
Work experience	3- unemployed for 1-5 years 2- private settings	Except for two mothers, others all are working in private settings or run own business	4-8 years in computer, candle making, printing, plastic molding, and baking sections
Diagnosis	BPAD Schizophrenia and problem with substance use	----	----
Relationship with patient	----	1-father,2-mother,1-brother,1-sister	----

To assess the social support experienced by the respondents.

Purposive sampling method is used to conduct the study. A total of 15 respondents were taken in which comprehensive management plan that includes pharmacological and psychosocial interventions like vocational training, job placement, individual/family interventions, cognitive retraining, disability assessment/certification, training in independent living skills, social skills training, and day boarders attend services daily for a few weeks or months.

Interviews and data collection

A semi-structured interview schedule was consisting of sociodemographic details and 15 open-ended questions were asked to three different populations (person with mental illness and substance use disorder [SUD] + family members + instructors) concerning barriers to employment for patients with mental illness and substance use problems, strategies to improve employment outcomes and to assess instructor's response about the functioning of people with mental illness (PWMI) and SUD.

The questions that were asked to the respondents were:

To PWMI:

What do you see as the things that you need to work on, or that make it difficult for you in finding and keeping a job?

What services or strategies have you found to be the most helpful for you in finding and keeping job?

What do you think potential employers see as your greatest strengths and weakness?

To the family members:

What do you think potential employers see as his greatest strengths and weakness?

What services or strategies have you found to be the most helpful for job seekers in finding and keeping job?

What are the main strengths that you think which help in finding and keeping job?

To instructors:

What do you see the main barriers to employment for job seekers?

In your experience, what do employers say are the main barriers to employment?

In your experience what strategies are most useful for improving outcomes for people with MI and SUD?

How do you identify those clients who have problems with MI and SUD?

The study was conducted in the month of November 2014 in the premise of the National Institute of Mental Health and Neuroscience, Department of Psychiatric-Neuro Rehabilitation (DPNR).

Results and Discussion

The following table shows the sociodemographic details of the respondents included in the study:

Themes regarding barriers to employment

Some responses highlight these concerns

One of the main objectives of the study was to understand an emic perspective of barriers to employment. The themes identified were individual factors, interpersonal factors, employment factors, and social factors.

Individual factors

Individual factors are those which are more or less intrinsic to the individual irrespective of their environment and larger social domain. Some of the major barriers that have been voiced by all (PWMI, family members, and rehabilitation instructors) are the symptoms of mental illness itself and the physical health of the individuals.[23] The nature of symptoms, the side effects of medication, and adverse physical health conditions were pointed out as barriers to work for long hours, being able to travel to the destination and meet the needs of the employment.

As stated by PWMI (2) “I have to improve my health then I can work anywhere,” similarly, the family member can be quoted “Good body fitness will be his biggest strength and will help in keeping a job.” Instructor 5 commented, “Mental illness will be the main barriers to employment for mentally ill people.” In an organization, employers will think about his mental illness. “Mental ill person eats medicines and goes to work that time they might become drowsy and tired which effects on their work nature”.

Thus, it is seen that the illness itself primarily poses a challenge. Often the disability associated with the illness hampers the possibility to seek and hold a consistent job. Studies[4] also point out a similar issue where MI itself increases the risk of employment termination be it voluntary or involuntary. The employment spells are also shorter and have 22% higher hazard rat[56] considering the diagnosis, Erica et al. (2010)[7] found that persons with schizophrenia have 1% point lower probabilities of obtaining noncompetitive or competitive employment as compared to persons who do not have schizophrenia. Also, persons with bipolar affective disorder have a 5% point's lower probability in the abovementioned domain. Apart from the abovementioned areas, another set of key concerns was slowness in work and poor concentration.

Some responses highlight these concerns

”In workplace, I can’t concentrate on a new job and have to adjust with new job which is difficult” (PWMI 1) I have to work fast; my previous employer removed me from job because I work slow and was not paying concentration in work. If I work fast and am regular to work they would have continued my job (PWMI 2) other issues for the barriers to employment are low education and long-term unemployment. A recent study from the USA has also found that the level of education is a significant outcome factor for employment.[8] expressed by one PWMI “Most of the employer expect fast work and good performance but I don’t have any work experience outside other than bread making so I may find difficult if I start work outside in other organization (PWMI 5) I have work experience in the marketing field but long period of unemployment make me feel low self-confidence (PWMI 4).”

These findings are supported a meta-analytical study that points to age, previous work history, lack of motivation/confidence, and long duration of unemployment being the barriers to getting employment for a person with mental illness.[9] Other studies also show similar domains related to personal and illness factors namely age, education, premorbid social and occupational history, cognitive functioning, negative symptoms, duration of illness, number of hospitalization, and tiredness.

It is known that severe mental disorders like schizophrenia and psychotic illnesses of long duration affect the cognitive functioning of the person like attention and concentration. These impairments can hinder the ability to work adequately. Due to the impact of illness clinical deterioration of physical health, general reduced energy, relapses, cognitive slowing and cognitive deficits are evident.[10]

Interpersonal factors

The person in the environment model explained how an individual is not devoid of his/her surroundings and is in constant interaction with the same. The individuals’ personal experiences are subjectively intertwined in the ever dynamic interactions with the environment.[1112] This is aptly uncovered by the narratives of the respondents. The main theme that was replete in their conversations was that of communication difficulties and lack of social skills. Studies show that there is a relationship between a social skills deficit and the symptoms of schizophrenia.

The cognitive deficits in schizophrenia can impair social skills[13] and hinder the performance of social roles.[14] This, in turn, alienates the PWMI from social circles. Thus, tasks of gaining and maintaining friends and social communication seem even more difficult for them. Society's responses and stigma just make these fears real and this uphill task nearly impossible for them. In the absence of any active interventions to impart them these skills, social communication deficit becomes a very key reason for job loss, job bullying, and stigmatization.

In this study to the narrations of the respondents verged on the sense of inadequacy to meet the set standards of relationship maintenance and difficulties, therein PVWH 1 shares “I have to improve my self-confidence and improve my communication. Now I have fear to talk with people and maintain the social relationship.” It was also pointed out that severely mentally ill people requiring rehabilitation can be identified mostly by their appearance and behavior. For example one of the responses was “We can identify by their way of communication and how they behave in the workplace. Some person shows anger, some resist to work and some prefer easy task here and easily can be identified by their physical appearance.”

Another response also is similar to this “Sometimes it is difficult to identify a person with mental illness and substance use problems but their way of talking, behaviors in the workplace can guess about their illness.” All the instructors expressed communication difficulty and inappropriateness in behavior as a common theme of concern. This, in turn, exposes the PWMI to undue labeling and stigma and eventual loss of a job.

In the meta-analysis by Marhawa and Johnson, 2004 they also found expected conflict with colleagues as one of the external barriers of employment.

Employment factors

An effort was made to segregate factors that directly involve mechanisms related to employment, for example, employers, colleagues, workplaces, etc.

This is no doubt connected to the next segment of social factors too and may be understood from an ecological perspective of the mesosystem where an employer's attitudes and expectations, colleague's adjustment to the PWMI and overall workplace environment impact the functioning, work performance, and retention of jobs. It has been known that employers are more receptive and understanding about visible disabilities than invisible ones like mental illness.

Also, they have concerns regarding their abilities to provide qualitative and quantitative work, frequent absenteeism, non-flexibility, difficulty following instruction, etc.[15] The major concerns of employers found in another study are the social and emotional skills of the PWMI.[16] Employers having prior experience of interacting and/or hiring PWM l have positive attitudes toward employing them.[17] Views expressed by respondents in our study was in keeping with these research findings, most of the respondents shared their concerns about high expectations of employers and the uncertainty of the PWMI to reach up to that goal. It is nearly a steep unattainable challenge which becomes a barrier to employment.

As PWMI 2 says “my previous employer removed me from a job because I work slow and not paying concentration in work.” Similarly, PWMI 5 shares “most of the employers expect fast work and good performance but I don’t have any work experience outside.” Paradoxically, if employers come to know about the mental illness, they may expect too low of them and not trust in their capacities, hence, affecting the chance to get employed in interesting jobs. Instructor 2 aptly points out “I think employers will suspect that whether this person is capable to work or not.” Instructor 5 also mentions “.low expectation from employers will be (one of) the main barrier to get into the job. The employers will observe his work and if their expectations are not fulfilled by the effected person then they remove him from work.” Family member 1 also voices similar concerns “employers expect good work performance and commitment but he might fail to reach employers expectation.”[18]

Social factors

It is well documented that society's attitudes and stereotypes influence individuals. The primary and unanimous area of concern was social stigma regarding mental illness and its impact on the employment of PWMI.

As told by instructor 2 “they may be teased by other employees and employers and may lead to drop the job.” Some other comments also highlight the same. Instructor 5 says about the harsh reality that “even if the mentally ill person is highly qualified also he will not get a job based on their education due to mental illness tag.”

Most of the family members also express their fears about the mentally ill person being accepted and meeting the society's expectations in performance, communication, and behaviors. It is like a lost battle where either the standards are too high to meet or too belittled due to the fact that they have a mental illness.

Studies on social stigma and mental illness

Employment aiding factors

All the PWMI, family members, and instructors prioritized proper treatment and continuous adherence to medication as the primary need to achieve health and therefore employment.

As told by instructor 4, “main thing is treatment for his mental illness.”

Work experience was felt to be a very important factor in keeping a job as told by all the family members. Followed by this was education. They considered years of education as an important aspect of getting a job. “Education and earlier work experience will help in the current workplace” (family member 5).

All of the family members and PWMI felt communication as a major area for employment. Proper communication was felt to be of utmost importance.

The response of family member 4 summarized all of the above “past work experience, poorer communication and if the person is educated then it will be helpful for him to get into the job and continue job for long.” Everyone responded similarly to the role of family members and friends (social support) in helping a person achieve employment goals. A study from Kenya also reported the same that support from family and friends was the highest facilitator for employment.[19] “Friends and family members support will be the most useful way to find a job” PWMI 5, “I need to continue medication and with family and friends support I can find job” PWMI 3, “Support from families and friends in terms of finance support, regular follow up and motivation will be good strategies” family member.[20]

A person who had friends and family in their network or who had a family dominated network were more likely to be in full-time employment.[212223] All these point out to the fact that a good social network aid in employability.

Strategies to improve employability

The PWMI considered their health, communication, family support, and concentration as main strategies to improve their employment skills.

The family members considered the treatment and family members’ support to be the primary strategies to improve employability.[424] The instructors considered training as the hallmark for preparation for employability provided the person is adequately receiving treatment and is on his way to recovery. All of them mentioned job training to be given to the person preferably in an agency or supported employment. The person should get training in the required field, in communication, and skills to work long hours. The instructors also mentioned the need for family support in these endeavors. To quote instructor 2 “proper job training based on their interest and psychiatric treatment to reach recovery state would be the best option to improve the employment to the outcome of the mentally ill and substance use problems.”

One of the instructors pointed out an important aspect—training of employment agencies regarding mental illness. He said, “I think, giving training to employer regard handling mentally ill persons and improve their knowledge about mental illness would be the best method to improve employment outcome of mentally ill.”[2526] This is often a neglected area which is also reflected in the responses. However, without a societal change in attitude, it is an uphill and unfair challenge to PWMI to reach up to standards of employment agencies regarding set unduly.

Employment strategies for a person with psychiatric disabilities include integrated clinical and vocational services; safe and stable housing, remedial and postsecondary education and vocational training,[19] benefits counseling and financial literacy education, legal aid for dealing with employment discrimination; peer support.[27] Individual placement and support (IPS) model by Becker and Drake (1994) which is a standardized approach to supported employment with the primary goal of not changing the individual, but to find a natural match between individual's strengths, experiences, and a job in the community.[28]

Conclusion

Identifying barriers and facilitators to employment for people with mental illness and substance abuse will enable the specialist to better support the clients in overcoming them, thus, promoting work integration and functionality.

Implications

The primary care and family physician are the first to be approached by the people during the symptomatic phase of the illness, as illness leads to disability and this sometimes results in the person remaining unemployed.

Highlighting the need for occupational functioning from the very first contact with the hospital rather than addressing this issue when the person becomes unemployed or underemployed is essential.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their images and other clinical information to be reported in the journal and patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.