Employment Outcomes After Vocational Training for People With Chronic Psychiatric Disorders: A Multicenter Study

In-House Vocational Training Programs

The in-house vocational training (IHVT) programs are government-funded services for newly discharged inpatients or current outpatients with CPD of four regional psychiatric hospitals in Taiwan. The IHVT programs use existing hospital spaces, facilities, and manpower and community sources and networks to train participants in a range of job options. Each program has three to five occupational therapists who serve as program director, case manager, or training therapists. The hospitals’ psychiatrists, psychologists, social workers, and nurses and community vocational specialists and paid or volunteer job coaches are available during some program sessions.

The Person–Environment–Occupation–Performance (PEOP) model (Christiansen et al., 2014) guided IHVT program design. This design considers each patient’s work-related strengths and limitations and potential environmental supports and barriers. Job training options include bakery, coffee shop, culinary, computer data processing, auto wash and detailing, janitorial, and laundry service work. Placement is determined on the basis of the participant’s interests, demands of the local job market, and results of a case manager or team evaluation. IHVT programs are generally 6–10 mo long (with duration varying with job options), 5 days/wk, 4–6 hr/day. Before participating in an IHVT program, occupational therapists are encouraged to complete basic job-specific training or serve a short-term apprenticeship related to the job options, sometimes earning a board-issued entry-level job certification or license. This training ensures that occupational therapists are equipped with hands-on skills and experience to support specific job analysis and accommodations when working with job coaches and participants at a job site.

IHVT programs have three areas of focus: (1) work-related behavior training, (2) on-the-job skill training, and (c) life balance counseling. Work-related behavior training includes lectures and discussion, group activities and presentations, and take-home assignments related to proper appearance and attire; punctuality, attendance, and responsibility; communication and self-assertion; engagement, concentration, and work completion; workplace social skills and etiquette; problem solving and conflict resolution; and job search and interview skills.

On-the-job skill training consists of a half- or full-day unpaid internship in which participants gain job-specific training and hands-on experience and receive necessary supervision, guidance, and intervention from a job coach and an on-site occupational therapist. The training occurs in hospital facilities or affiliated businesses (bakeries, coffee shops, restaurants, cafeterias, offices, janitorial departments, laundry facilities, and car wash or detailing workshops), located either in or near the hospitals. Many are open to the public.

Life balance counseling involves individual and group counseling to enhance clients’ ability to tackle hardships and barriers to work. Stress management and relaxation techniques, coping strategies, work and leisure, time management, medication issues, self-advocacy, and community outreach and resources are common areas in which counseling is offered by occupational therapists (case managers) or cross-disciplinary personnel (e.g., psychiatrists, psychologists, social workers, nurses, or other). Posttraining vocational counseling provided by the IHVT case manager or other community therapists or specialists is also available. Of note, although all four hospitals had the essential IHVT areas, each had variations in program parameters (e.g., length, staffing, job training options, posttraining counseling services) as a result of differences in their infrastructure, manpower, and resources.

Purpose and Method

We determined IHVT program outcomes (employment rate) for participants 1, 3, and 6 mo after the intervention. We also determined whether participants remained employed during the first 6 mo posttraining. The unintentional variations in IHVT program parameters across the four hospitals enabled us to be among the first researchers to explore the effects of program parameters on employment outcomes. Previous studies have primarily examined the social, economic, and client factors (e.g., lack of service and support, stigmatization, inadequate job opportunity, diagnostic and functional characteristics) that affect employment outcomes for people with CPD.

Results

Discussion

Our findings indicate that the IHVT programs had positive employment outcomes for people with CPD. Satisfactory employment rates were found at 1, 3, and 6 mo posttraining. These rates were higher than the 21.5% employment rate found for European participants with schizophrenia who received vocational services (Marwaha et al., 2007). They were also higher than the employment rate of 50.7% found for Taiwanese people with CPD who had government-sponsored Disability Employment Services (Jang et al., 2014). Although more participants held sheltered or supported employment shortly after the training program, most were competitively employed at 6 mo posttraining. Given the low accessibility of competitive or supported employment for people with CPD in Taiwan (Jang et al., 2014; Lee et al., 2010), the employment rates found in this study are impressive.

Our analysis confirmed that the 6-mo time parameter was a significant predictor of employment. We assume that the 6-mo interim is a reasonable posttraining period for participants to secure competitive employment. However, this assumption needs further validation because of the paucity of current empirical findings in this area. Moreover, among participants in our study who were employed at least one point in time posttraining, nearly half demonstrated high sustainability of employment. This finding coincides with the finding of a previous review of six randomized controlled trials (RCTs) of an average job tenure of 22 wk for clients with CPD who received Individual Placement and Support (IPS) services (Bond et al., 2008). Similarly, a more recent RCT on employment outcomes after IPS services for people with CPD reported an average job tenure of 25.3 wk (Waghorn et al., 2014).

Although the IHVT programs were found to yield satisfactory outcomes, we were intrigued by the potential effects of the varying program parameters on employment. Parameter estimates suggested that, with client factors controlled, the therapist having specific job certification or licensure, posttraining vocational counseling service being provided by a community-based occupational therapist, and a 6-mo posttraining period (discussed earlier) had significantly positive effects on participants’ employment rates. However, posttraining vocational counseling services provided by a community-based occupational therapist significantly strengthened employment sustainability.

Although the number of participating occupational therapists who had earned an entry-level job certificate or license after pertinent training was low, those therapists’ clients had a higher employment rate than their counterparts’ clients. Occupational therapists serving in an intensive, multicomponent vocational training program for people with CPD may often feel challenged in situations in which they have to address clients’ functional limitations along with the demands of jobs that are unfamiliar to them (Arbesman & Logsdon, 2011). Therapists should obtain specific hands-on job skills training and experiences relevant to clients’ chosen job options so that they can understand the necessary job analysis and recommendations and be better able to communicate and collaborate with job coaches. Moreover, ongoing vocational counseling service posttraining is instrumental in enhancing clients’ employment outcomes (Waghorn et al., 2015).

Our findings on both employment rates and employment sustainability favored vocational counseling implemented by occupational therapists in a community mental health setting as opposed to certified vocational service specialists or job coaches. Employment specialists and job coaches often require substantial guidance in how to accurately identify their clients’ functional deficits and how to determine what accommodations are appropriate (MacDonald-Wilson et al., 2003). In contrast, occupational therapists have expertise in discerning clients’ functional limitations and in designing individualized strategies based on job demands while emphasizing the necessary skills for life balance (Auerbach & Jeong, 2005).

The provision of well-rounded counseling services by occupational therapists provides the scaffolding for enhanced client job performance. It is interesting that although vocational counseling provided by occupational therapists working in community mental health settings surpassed that provided by job coaches, this result did not hold true in the case of the occupational therapists who served as IHVT case managers in the hospitals. Despite the similarities in their skill sets, community-based occupational therapists are more likely than hospital-based occupational therapists to have strong connections to potential employers, resources, and social networks in the community and to have more frequent updates on the opportunities in and demands of the local job market. These factors may explain the corresponding difference in results.

Limitations and Future Research

This retrospective cohort study has limitations that merit consideration. First, the lack of control and randomization limits the interpretation of IHVT program efficacy. Second, analyses were limited to data available in the participants’ files. Other employment factors and outcomes, such as family support, income, government benefits, employment history, and job title and wages, were not fully assessed. For example, studies conducted in the United States and other Western countries have found that governmental income support programs are a disincentive to work for many people with CPD (Danziger et al., 2009; Frutos & Castello, 2015). Whether this phenomenon exists in the client population in Taiwan is unknown. Similarly, we did not investigate whether family support was an incentive or a disincentive to participants’ employment in the collectivist and family-oriented culture of Taiwan. Moreover, we had no information about the relationship between participants’ job training options and acquired employment or employment status beyond 6 mo. Last, some service and job parameters explored in this study may be culturally and contextually specific to Taiwan. Caution is warranted in generalizing the findings.

Future studies should use a prospective longitudinal design that uses systematic measures of the employment and outcome variables not documented and analyzed in this study. Likewise, experimental research with randomization and control procedures should be prioritized to further test the effects of program parameters on employment outcomes as well as the role of occupational therapy in vocational service for people with CPD.

Implications for Occupational Therapy Practice

The implications of this study for occupational therapy practice are as follows:

Conclusion

Supporting employment of people with CPD is a complex but rewarding endeavor, and it requires an all-encompassing approach to those factors that are remediable. Through their specialized knowledge and training, occupational therapists play an important role in helping people with CPD develop the skills and obtain the supports necessary for employment. Our study introduces the systematic PEOP-based IHVT programs and services that are led by occupational therapists. The demonstrated training and program parameters, albeit embedded in vocational training, reflect the typical and critical components of employment services for clients with CPD (Arbesman & Logsdon, 2011; Williams et al., 2015). Therefore, these parameters can be applied to or modified in other employment service models such as supported employment. The positive employment outcomes found in our participants support the efficacy of the IHVT programs.