Unemployment rates are high among people with mental illness despite available vocational rehabilitation and their willingness to work
. As an alternative to traditional vocational rehabilitation (train-and-place), supported employment emphasises rapid and direct job placements and support of patients and employer (place-and-train)
. A higher effectiveness of ‘Individual Placement and Support’ (IPS), an intensively studied supported employment intervention in the USA, than of vocational rehabilitation has also been proven in a randomized controlled trial in six European countries with differing labour markets and welfare systems
In the IPS model, a job coach is an integral member of a mental health care team who helps patients to find competitive employment corresponding to their wishes as soon as possible, and who continues to support them and their employer, so that jobs can be held down as long as possible. Various studies have shown that for every second patient with severe mental illness competitive employment could be found within 18 months
. However, the goal of taking up employment within two 2 months was rarely achieved. The main question of this study, therefore, is whether limiting the ‘Placement-Budget’ leads to a faster take-up of competitive employment, thereby resulting in a better utilization of the overall resources of a job coach.
The idea of placement budgets is new, probably because IPS studies addressed the group of people with serious mental illness, i.e. those who hardly seem to have a chance for competitive employment. Such high moral standing seems incompatible with discussions on limits of cost or of time needed for IPS interventions. However, as IPS has proven to be effective for people with serious mental illness, why should unemployed patients with milder forms of mental illness be excluded from IPS interventions? If, for example, all patients of an out-patient facility of a psychiatric hospital can receive IPS interventions, it is inevitable that the resources invested must be justified towards cost providers. Moreover, seen from the perspective of a cost provider, it is not very attractive to fund an intervention in which every patient will need a job coach for 18 months, but with only a 50 percent chance of finding competitive employment for one day or longer. If competitive employment is found, it is probably much easier to convince cost providers that a budget for support is a meaningful investment, so that the job coach can assist with long-term vocational integration.
According to the IPS model, the caseload of a full-time job coach should not exceed 25 clients
. Thus, using resources for clients who did not find a competitive employment after a longer time period reduces the resources available to the job coach for the placement of new clients and helping other clients to keep their competitive employment.
Meaningful duration of the intervention
The new concept of placement budget can be understood as the question of how much of an intervention is initially needed. The next question from the standpoint of a cost provider doubtlessly concerns the meaningful duration of an intervention. Therefore, in order to ascertain whether a period of up to two years of support by a job coach is sufficient to stabilize the vocational integration and ensure that it will not change during the year after the end of the intervention, we set the time frame of the study accordingly. A period of up to two years of support by a job coach is longer than the duration of support in most trials, which typically last 18 months
. Moreover, those trials usually have no follow-up after the intervention period, probably due to the last core principle of supported employment enumerated by Crowther et al.
: ‘(f) follow on support is continued indefinitely’.
Other research questions focus on clients’ outcomes. For most individuals there are more advantages to competitive employment than disadvantages and there is evidence that the concerns among clinicians about possible detrimental effects of working and supported employment are out of place
. Working is important in several ways. Unemployment deprives people of the social and psychological functions of work such as social support and structuring of time
[5, 6]. Being without work and a regular income puts people at risk of poverty, even if they receive social benefits
. But vocational integration does not always mean financial independence, as some clients of supported employment have unskilled jobs and work only a few hours per week
. There might be even a benefit trap, e.g. a loss of disability payments upon returning to work
Predictors for rapid job placement
Overall, it is not well understood which clients’ chances of finding competitive employment are higher. A meta analysis found only very small effect sizes for age, gender, race, and diagnosis
. Even having prior employment, one of the strongest predictors in many studies, did not result in a significant effect in every study
. The study in the six European countries tested a variety of socio-demographic and illness-related variables as predictors for entering competitive employment but found a substantial effect only for previous work history
In opposition to socio-demographic and illness-related factors there is a lack of research with respect to the client motivation. This is surprising as it has been repeatedly stated that the motivation of the client is central to the success of IPS
. One reason for the lack of research on factors influencing client motivation could be that ‘much of the body of psychiatric rehabilitation research consists of atheoretical empirical investigations’
. The theory of reasoned action of Fishbein and Ajzen
, one of the most important theories on the relationship between attitude and behaviour, is suitable to be applied to supported employment. Not only the attitude of the client, i.e. the self-rated importance of obtaining competitive employment, but also the subjective norms of the social environment probably influence the intention to find and to maintain competitive employment. Here subjective norms means how the client thinks that significant others view client’s being competitively employed, weighted by the importance of those attitudes to the client.
According to the Modified Labeling Theory of Link et al.
 people with mental illness avoid potentially stigmatizing situations if they believe that people with mental illness are generally discriminated. Thus, people who score high on the perceived discrimination scale could probably have a low vocational outcome. Moreover, we observed for people with a more recent onset of illness that how they had perceived the social support of their social network during their inpatient treatment modified their perceived discrimination score
. Thus, new experiences in a competitive employment situation could probably also modify perceived discrimination.
Over the last decade there has been a growing interest in the subjective experience of stigma among people with mental illness and on the relationship of stigma and work
. We therefore are interested whether IPS has an influence on the appraisal of stigma-related stress
, and on the internalization of the stigma of mental illness
Social-cognitive tests for interaction skills
Among job coaches there is often considerable variance in employment outcomes within supported employment programmes
. These differences appear to be related to their clinical skills. Those skills comprise specific interactions (transactions with clients, with other staff members, and with employers) and their activity during stages of supported employment (engagement, assessment, finding a job that matches talents and interests, insuring success by addressing skills and supports, leaving a job appropriately, and finding another job)
. As in most trials the number of job coaches is very small
, it is almost impossible to find general factors that could explain the variance among them with regard to employment outcomes. As we aim to explore the influence of social-cognitive abilities of clients on employment outcomes, the six job coaches also performed those social-cognitive tests, as this might partly explain their clinical skills. These tests consist of a prosody test (affect recognition in speech according to the methodological propositions of Edwards and colleagues
), the reading-the-mind-in-the-eyes test
 to measure the ability to visually recognize complex emotions in pictures, an attribution style test
, and a socio-physiological test of resonance capability in terms of contagion by yawning or laughing
. Four separate aspects of empathy are assessed using the Interpersonal Reactivity Index
The main objective of this study is to assess whether the effectiveness of IPS can be improved by using limited placement budgets. If this is true, the job coach could invest more working hours to support both the patient on the job and his/her employer. Thus, the main study hypotheses are:
Primary: The more limited the amount of working hours available to a job coach to find a job, the faster a placement in open, competitive employment.
Secondary: Ascertain factors for fast job placement and long-term job tenure. Primary issues are motivation, stigmatization, social network and social support, quality of life, job satisfaction, financial situation, and health conditions. Cognitive and social-cognitive tests will be conducted to control for confounding variables.