Employment related barriers and facilitators for people with psychiatric disabilities in Spain
Abstract
BACKGROUND:
People with mental health-related disabilities still experience difficulties in obtaining and maintaining a job. Previous international studies inform about employment barriers and facilitators but there is insufficient research in Spain.
OBJECTIVE:
To explore what type of employment barriers and facilitators were important for people with psychiatric disabilities with past work experiences in competitive and protected work settings.
METHODS:
In-depth, semi-structured qualitative interviews with 24 participants selected through purposive sampling.
RESULTS:
The personal sphere was the content most closely related to barriers, followed by the social environment. Facilitators were more closely related to the interviewees’ social network, followed by elements in their personal sphere and job environment.
CONCLUSIONS:
The findings suggest the need to implement supported employment services in Spain to promote hiring people with psychiatric disabilities in competitive companies. The results also indicate the need to implement new services aimed at supporting the management of disability information during the process of obtaining and maintaining a job, while there is still a need to conduct anti-stigma and anti-discrimination campaigns.
1Introduction
In different countries in the world, the statistics on the employment of people with mental illness and their presence in the active workforce are very scant. For every unemployed person without mental disorder there are an estimated four to five unemployed people with serious mental illness [1, 2]. Individuals with serious mental illness will also probably spend more time unemployed or stop seeking employment because of lack opportunities and results, and the functional impairment which interferes with work and other life activities is commonly the cause of a psychiatric disability [3]. Furthermore, the use of public benefits for disability (e.g. receiving services or money) is strictly necessary to give these people a minimum life quality, but on the other hand it also appears to be a barrier for their future return to work [1, 2].
While this specific situation seems to change slowly [1], international research suggests that it is possible to implement better support solutions for people with this kind of disability in work. Several supported employment programs have been tested as a more inclusive work modality, serving to obtain better work results for people with mental health-related disabilities [4]. However, people with these kinds of disabilities still find it difficult to obtain long-term employment or to maintain it for a significant period of time, as they also encounter several difficulties in getting more stable, better paid quality jobs [5]. There are many barriers related to employment at different levels of analysis. For example, discrimination at work and attitudes toward people with mental illness are only two of the issues that suggest possible reasons for the persistence of the very poor work outcomes among this population [6]. Connected to this important social element, self-stigma and the process of anticipating work discrimination are other largely studied barriers that showed the importance of taking into account the cultural, communicating and value assimilating processes as important factors for the inclusion of people with mental illness into the work force [7–10]. Studies from other countries provide relevant information, while in Spain the research associated with the work difficulties of people with psychiatric disabilities has not received adequate attention from academia.
1.1The situation in Spain
The Spanish context reveals a similar situation where people with mental health-related disabilities usually obtain the worst employment outcomes (e.g., a number of different jobs as well as poor quality and durability). In 2019, official employment statistics showed the lowest employment rate for people with psychiatric disabilities (16.9%), and also for other groups with labor insertion problems, such as people with intellectual (20.4%) or physical disabilities (32.1% or more) [11]. The work results trend from 2017 to 2019 reveal that people with psychiatric disabilities obtain increasingly worse results year after year (2017, 18%; 2018, 17.6%; 2019, 16.9%). In 2019, this group was also the least economically active population (27.8%), while they were the ones that most often gained access to disability benefits (65.7%) [11].
In Spain, there are two types of pensions for helping people with some kind of permanent disability: contributory and non-contributory pensions. The contributory pension is awarded when disabilities reduce the individual’s capability to work and two modalities of this pension are specifically important: “total,” which is granted if the disability prevents people from working in their usual occupations, and “absolute,” which is granted when people’s functionality is compromised for any type of job. On the other hand, the non-contributory pension is granted without considering the person’s specific work capability but the general effect the disability in question has on the person’s life quality [12].
These types of benefits are compatible with work activities but with limits. For example, the “total” pension is not compatible with the person’s usual work (often the work in which people have their best competences), while the “absolute” pension is not compatible with any work. In the case of the “absolute” pension, people may work provided the job is not detrimental to their health, but this could potentially cause an administrative procedure to a new assessment of the person’s functionality and his or her pension. On the other hand, non-contributory pensions are not specifically related to work so people have no limitations in this sense, but they cannot exceed certain monetary limits as an aggregate of work and pension incomes. These benefits are necessary but they can also be a barrier limiting people’s return to work when their health improves [12, 13].
Historically, in Spain, special employment centers (CEE) have been developed as a work rehabilitation service oriented to offering work opportunities to people with at least 33% disability. However, these services have focused more on creating social enterprises and work opportunities in sheltered work settings. Moreover, in recent years, there has been much criticism of CEEs and their difficulty in supporting people’s return to a regular job, often due to a lack of services to do so, as is the case of supported employment programs or general services oriented to work inclusion [14, 15]. In 2006, the number of people employed for having some type of disability was similar in competitive companies (29,033) and CEEs (26,290). In 2018, more than ten years later, the trend appeared clear. In competitive companies the situation had not changed substantially (33,892), while many more people with disability were employed in CEEs (82,981). Moreover, in general, people with disabilities seem to find more jobs in the services sector, such as cleaning work or waiting on tables, and almost half in low quality elementary occupations (we have not found available data on the types of jobs obtained in protected or competitive companies) [16]. This situation suggests that research on the specific work experience of people with mental illness and psychiatric disability in Spain and the barriers they face to find and maintain a job is extremely necessary.
1.2Qualitative research about employment barriers and facilitators
The most recent qualitative research provides a considerable amount of interesting information about direct experiences of people with mental health-related disabilities in work and their opinions related to possible barriers and facilitators to obtain and maintain employment [17]. Following the categorization provided by a recent qualitative literature review on barriers and facilitators to work for people with psychiatric disabilities [17], in this study, the personal sphere is defined as a set of elements that participants considered important for their work activity, like barriers or facilitators strictly related to the person him/herself and not pertaining to the environment. Most of those elements are connected to the impairments derived from having a mental illness and the consequent difficulties in executing work activities, such as the expected negative consequences related to having a work activity and the necessary abilities and skills to work, self-efficacy, as well as the personal contextual factors that participants also consider important [17]. People seem to refer more to elements connected to the personal sphere when they talk about employment barriers, such as the lack of competences in managing one’s own illness and the difficulty in dealing with stressful situations at work [18–21]. Generally, the negative expectations arise from past negative work experiences of discrimination or failure, and from a poor perception of oneself as a potential worker, apart from several other barriers like the loss of free time, the insignificant differences between work and pension incomes, or the concerns derived from the likelihood of losing pensions if they are working [9, 18–21]. On the other hand, people with mental health-related disabilities, when talking about employment supports and facilitators, refer more to external factors than to self-related ones. First, the presence of an extended network with more or less intensive relations seems to be essential as an emotional and professional support to work and for successful integration into the work environment. Second, the type of work (schedule and activities), the work adaptations and the presence of work relations committed to helping people and to maintaining a good supporting environment also appear to be factors needed to obtain and maintain employment [10, 19–24]. In this work, these external factors have been arranged into three different large categories. First, the social environment is used to refer to general environmental factors perceived by individuals as important barriers and facilitators for employment, such as the stigma and discrimination toward mental illness and disability, as well as laws promoting job opportunities, the trend of the economy, and the situation of the work market. Second, elements of the job environment, which refer to barriers and facilitators related to this specific environment, such as work relationships and job configuration. Finally, the social network, which refers to relationships external to the specific work environment but perceived by these people to be important employment barriers or facilitators, involving relatives, friends, or mental health workers [17].
The importance of work as a cultural practice has been recognized by many researchers, some specifically oriented towards studying the meaning of work for people with mental illness [22, 25, 26]. Work provides the power to access new and further material and cultural elements, and the corresponding sense of independence and satisfaction in gaining that power through socially recognized productivity. People with mental health-related disabilities, who commonly have difficulty in obtaining and keeping a job, and who are in situations of strong economic and social dependence, probably give more importance to work and to the benefits obtained from it. Working is fundamental for people with a psychiatric disability because it provides an occupation and stable daily organization, with a clear definition of the difference between work time and leisure time [22, 25, 26]. Access to new work and leisure practices and relationships strengthens people’s social identity and allows them to recognize themselves with that positive sense of satisfaction provided by the work activity. Working thus becomes a practice that can move people away from the socially shared negative meanings related to having a mental illness and a psychiatric disability, providing a recovered sense of life worth [9, 18, 20, 22, 25, 26].
1.3Purpose
People with psychiatric disabilities may react actively to potential discrimination at work, developing strategies to manage the impact any information of their personal disability might have on their work opportunity (if they are seeking a job) and work environment (if they are working), when they are in the competitive labor market. On the other hand, people might have had bad work experiences, which could be one of the reasons for leaving a job, or, more specifically, it could be the reason for starting working in a sheltered work program. Moreover, work experiences in a sheltered program could generate changes in self-identity leading to consequences related to possible future work choices and planning [6, 7, 22, 25]. For these reasons, we decided to explore the stories of work experiences and the opinions of people with psychiatric disabilities who worked in a competitive setting (with no supports) and in sheltered programs. The aim of this study was to explore what kind of employment-related barriers and facilitators were important for these people, and identify the most relevant perceived differences between competitive and sheltered settings.
2Method
A general inductive approach was adopted in this study to understand the work experiences and the explanations related to employment barriers and facilitators. This qualitative approach allowed us to discover the meaning that people give to their work history and how they explain the situation in which they currently find themselves [27, 28]. Consolidated criteria for reporting qualitative research (COREQ list) were used for this study [29].
2.1Participant selection
We used a purposive sampling procedure to select and interview 24 people that worked in a competitive (12) or protected (12) work setting after the psychiatric disability assessment of having a mental illness. Our aim was to study people that were in different work situations and how they explained their condition, so when we contacted participants we selected people that were working (13) or seeking a job (seven), or not seeking any employment (four). We used two resources to recruit candidates for this study. First, we contacted the human resource agency of ONCE Foundation, the most important Spanish organization for disability work inclusion, and sent an invitation by email to people with psychiatric disabilities that were working in competitive employment. Second, we contacted the INTRAS Foundation, an organization specifically oriented to working towards the integration of people with mental health-related disabilities. We made face-to-face contact with people that were working there or training in its special employment center. In both communications we explained the aim of the research and that the interview would be in a data-collecting modality. Nobody refused to participate but two people dropped out. They contacted a researcher before the agreed date for the interview and claimed they had no time for it. It was not necessary to propose a second date because the data analysis at the time revealed sufficient conceptual saturation related to the categories found.
2.2Setting
We collected the data in the region of Castilla y León and conducted the interviews in different places. In the cities of Valladolid and Zamora we used small meeting rooms. When people did not feel comfortable for some reason (two cases), or lived in other more distant cities (four cases), we conducted the interviews in a different place, comfortable for both (typically the interviewee’s home). Nobody else was present besides the participants and researchers during data collection.
All participants had a mental illness; they stated schizophrenia (13), a bipolar disorder, anxiety disorder, mood disorder (three for each type) or personality disorder (two). At the time of the interview, the people were either seeking a job (seven) or working (13), while four people stated that they were not interested in returning to work at that time. Their ages ranged from 25 to 54 years (mean age = 41), and most of them had had experience in competitive employment before being diagnosed with a mental illness (19). After the disability assessment, only half of the participants accessed competitive jobs (five of them had experience in both competitive and protected employment), while the other half only worked in a protected work setting.
2.3Data collection
The Clinical Research Ethics Committee of the Health Area of Zamora approved the study protocol. All participants read the study description document before signing the informant consent form.
We developed the interview guide using the most relevant results from a review of the literature [17]. It consisted of twenty-five questions related to four content themes: 1) social employment barriers and facilitators; 2) expectations about job consequences for a person with psychiatric disability; 3) changes related to seeking or obtaining a job; 4) barriers and facilitators related to the current or last job experience. Moreover, all the interviews started with a question about a summary of personal work history, and ended with a question about what had been the most important employment barriers and facilitators when working with a mental illness. The researchers obtained a high level of engagement through long interviews, in which the interviewees raised sufficient trust to share their personal experiences in depth. Thus, interviewers were able to encourage participants to provide examples to support their statements when necessary. We gathered the data in multiple spaces and times of the year, and summarized them upon completion of each interview, allowing participants to correct mistaken interpretations. We recorded audios of the interviews and transcribed them literally later. We did not conduct repeat interviews but participants reviewed the transcriptions, adding comments and corrections where necessary. The majority of the interviewees (62%) were reluctant to meet for further follow-up, preferring to check the quotes and the resonance of findings with their experience once the electronic or printed final report was available. The duration of the interviews ranged from a minimum of one hour and 15 minutes to a maximum of two hours, depending on the richness of the participant’s work history and his or her discursive style (mean words = 2,195; average word length = 7.4 letters). We recruited participants until we reached data saturation with the contemporary data analysis process. The entire research process lasted from October 2017 to January 2019 (15 months).
2.4Data analysis
We used a general inductive approach to analyze the data [28]. First, we performed independent parallel coding. A coder read and labeled the text data related to the research objectives and developed a set of categories. After this, a second coder repeated the codification process with the same data frame but without the codification the first evaluator had developed. We compared both category sets to establish adequate category overlapping and then merged them into a unique data set. Second, we gave the category set (with labels and explanation of items) and the text that the first coder had pre-coded to a third to check the similarity of text assignment to codes and the clarity of the categories. The third evaluator coded the same text the first evaluator had pre-coded but without access to his text assignments to categories. Following general coding rules, the evaluators were able to assign the same text segment to more than one category, but coding only text that they considered relevant for the objectives of the study. We checked the assignment of the text to categories for coincidences between the first and third coder. We used NVivo 12 software for all analyses. We calculated Cohen’s Kappa to confirm an adequate inter-rater reliability of the codification process (K = 0.76) [30]. We discussed the reduction of redundancy among categories in subsequent meetings until we had created a model with the most important categories. We derived results from the data and, for the sake of clarity, organized them into a tree with four large content domains of barriers or facilitators: 1) personal sphere; 2) social environment; 3) job environment elements; 4) social network.
All the participants reviewed the transcripts and provided comments and corrections where necessary. Before proceeding with the preparation of the final report of results, a researcher discussed with six participants whether or not to approve the most important categories and their explanations. The participants were selected from those with competitive or exclusively protected (three for each group) job experiences after mental illness diagnosis and the disability assessment, and considering that they claimed to be available to participate in the results approval procedure during the first interview and before data analysis. We held this meeting with the participants to correct possible misinterpretations and to confirm the resonance between our findings and the participants’ experiences before sending the draft report to the rest of interviewees [31]. Finally, all the participants received a printed or electronic copy of the report with the final results, and agreed with the results presented, thus approving them for a research publication.
The investigator triangulation procedure, the member checking and the in-depth engagement the researchers obtained during interviews lent credibility to the study. We obtained confirmability with the help of two academic advisors with experience in mental health and qualitative research, who overviewed the data collection and analysis.
3Results
The main content areas related to employment barriers and facilitators were the personal sphere, the social environment, the job environment elements, and the social network. The personal sphere is defined as the set of elements participants considered important for their work activity, such as barriers or facilitators strictly related to the person him/herself and not pertaining to the environment. The social environment is used to refer to general environmental factors individuals perceived as important barriers and facilitators for employment. Job environment elements are barriers and facilitators related to the specific work setting, while the social network refers to relationships external to the specific work environment but that people perceived to be important employment barriers or facilitators. The personal sphere was the content most related to barriers, followed by the social environment (Table 1), while facilitators were more closely related to the social network of the interviewees, followed by the personal sphere and job environment elements (Table 2). In the following two subsections we present the most relevant findings related to employment barriers and facilitators, and some differences between groups of participants with work experiences in competitive and protected jobs. The quotes will be identified as originating from the protected (Pr) or competitive (C) work experience group.
Table 1
Coding structure of barriers for employment, frequency of sources and codes, general themes definition and sub-themes quotes
| Themes | Fs* | Fc** | Themes definition and sub-theme quotes |
| Personal sphere | Barriers related with the person him/herself | ||
| Age | 5 | 5 | “Now I am 47 years old, companies are already looking for young people, it is increasingly complicated. ” |
| Mental illness | 13 | 25 | “You go from being active working 8 hours to being in bed 12 hours. Mental illness changes your life. ” |
| Negative expectations | |||
| Losing pension | 14 | 16 | “I don’t think they let you work with a pension. And it may be one reason why I haven’t been looking for work for a while. ” |
| Worsening health | 16 | 21 | “It scares me that working I might feel bad again. ” |
| Personality | 4 | 4 | “Also my way of being, that I am very shy. ” |
| Self-efficacy | 11 | 14 | “When I left work it was because they corrected me about how I was cleaning, and I felt that I did not know how to clean. ” |
| Skills | 8 | 10 | “Not having more training has limited me. Not having done a university degree. ” |
| Social environment | Environmental general factors perceived as barriers | ||
| Socio-economic context | |||
| Economy | 5 | 7 | “Today people who are well cannot find work, imagine those of us with a disability. ” |
| Work market | 7 | 11 | “The work market is very bad, and it is getting worse. ” |
| Work discrimination | |||
| For any disability | 14 | 22 | “It is like in the stores, the employer who goes to the greengrocer wants the perfect apple. ” |
| For mental illness | 17 | 25 | “They ask you what disability you have, if it is due to mental illness, and it is to know whether to hire you or not. ” |
| Job environment | Barriers related to the specific job environment | ||
| Environment | 4 | 6 | “In ordinary companies the environment is too competitive. ” |
| Relationships | 9 | 14 | “The boss’s son said that I wasn’t really sick. He would tell his father to fire me, and that’s what they did in the end. ” |
| Social network | Relationships external to specific job environment | ||
| Not supporting | 6 | 7 | “No one in my family is motivating me to work. ” |
*Sources-frequency assigned to code; **Code-frequency within all information sources.
Table 2
Coding structure of facilitators for employment, frequency of sources and codes, general themes definition and sub-themes quotes
| Themes | Fs* | Fc** | Themes definition and sub-theme quotes |
| Social network | Relationships external to specific job environment | ||
| Natural support | |||
| Family | 13 | 18 | “My sister helped me a lot. She has always been supporting me at all times. ” |
| Friends | 8 | 10 | “I had good friends, and thanks to them I started to move a little and find out about jobs. ” |
| Professional support | |||
| Mental health | 10 | 14 | “She always told me to try to go back to work, that it was very good for my self-esteem. ” |
| NGOs | 14 | 19 | “The Association was guiding me and mediating a lot to help me. And that’s when I started to find those first jobs. ” |
| Other | 4 | 4 | “Caritas has indirectly helped me. They helped me to give up alcohol, which was when I started planning to look for work again. ” |
| Personal sphere | Facilitators related with the person him/herself | ||
| Skills | |||
| Behaviors to achieve the goal | 12 | 14 | “I have changed my life a lot to keep the job. Now I don’t go out, I lead a very healthy life, since the disease appeared. ” |
| Improving work skills | 6 | 8 | “I did not know how to write on a computer, or work on the Internet. As soon as the course was proposed to me, I didn’t think twice. My life project changed totally at that point. ” |
| Managing disclosing | |||
| Not disclosing | 11 | 17 | “I think it is better to hide it, because it is better to try to have some normal employment experience. ” |
| Disclosing | 9 | 13 | “At work, it is good that people know it, because people have guidelines on how to behave if something happens. ” |
| Job environment | Facilitators related to the specific job environment | ||
| Job configuration | |||
| Part time | 7 | 11 | “A part-time job is better, I see it as more practical. ” |
| The right job | 11 | 14 | “I think you have to like work and it has to motivate you, it has to feel good to you. ” |
| Relationships | 12 | 17 | “When my colleagues discovered that I was ill, they continued to treat me the same way. And that for me was very important. ” |
| Social environment | Environmental general factors perceived as facilitators | ||
| Laws for work | 7 | 9 | “Laws help. Companies receive a series of subsidies and it is convenient for me to be working because I have a salary and can live. ” |
*Sources-frequency assigned to codes; **Code-frequency within all information sources.
3.1Employment barriers
3.1.1The personal sphere barriers
The barriers most commonly referred to were related to the personal sphere, specifically to people’s negative beliefs and expectations concerning employment, the difficulties resulting from having a mental illness, the lack of personal skills needed to work, and low self-efficacy.
Negative expectations: More than half of the participants stated that their return to work could be limited by their fear of a worsening of their mental illness due to work, especially on account of the possible stressful situations they might encounter, specifically in competitive work:
“I am afraid to go out to a new job. I think that it could cause me stress and that I could go back to feeling bad. [. . . ] It depends on the work. It depends on the stress. Ordinary companies will always generate stress, and there will always be the risk to feeling bad again. Stress is not good for mental illness.” (C1)
“The worst for these illnesses is stress, if you get into a stressful job there are more chances of getting sick. That’s a bit why I’m not looking for a job. I think that in a situation of anxiety or stress I would fall again.” (Pr6)
Another important negative expectation that seems to limit the work activity of many people is related to the belief that they could lose a pension or have to return aid money if they are working. The Spanish legal system allows for compatibility between contributory and non-contributory pensions and work activity [12, 13]. However, some participants appear not to have this information, resulting in beliefs and fears that limit their work activity:
“One barrier was the fear of losing the pension. After retirement it was not very clear legally whether I could work. I had family pressure not to do so because there was a family member who had gone to work and had lost his pension.” (C2)
“I had to return about three thousand or four thousand euros. [...] This stopped me a little. One says: why am I going to work if I have to return it? I think this has taken away my desire to work.” (C7)
Mental illness: For many participants mental illness occurred while they were working and it was recognized as an important reason that caused them to leave one or more jobs. Moreover, some people indicated that mental illness is the direct cause of functionality difficulties in their work activity:
“I had to leave work because the illness appeared at work, because I got a depression. I have lost many jobs because of the illness.” (C4)
“Sometimes it is true that you cannot, because of the difficulties caused by the illness. I do not work with the speed of a normal person. For example, if I am going to sweep, I go more slowly.” (C6)
Skills: Participants also explained their difficulty in obtaining and maintaining a job because they lacked the abilities to work like anyone else. Moreover, they related this to the time spent not working and the need to improve their training to go back to work:
“A person with a disability is less productive than a person who is well. For example, working as a waiter, you have to have relational capabilities. This issue holds me back. I think I’ve wasted a lot of time. I do not have skills” (Pr2)
“If you intend to go back to work you have to go back to study, you have to prepare yourself again to get to work in a company, and I’m not prepared for all that.” (C6)
Low self-efficacy: Different interviewees explicitly described how their low self-efficacy was one of the causes that limited them in seeking or maintaining a job and that it came as a result of bad work experiences they had had:
“I lost a part of myself, a lot of esteem and confidence, I felt useless. This because of bad experiences I had at work. He marked me in a very negative way.” (C2)
“I always thought about where I had made mistakes, not what I had done well. Sometimes there were mistakes in the orders that came out, and the continual concern was that I was going to make mistakes. [...] And that has not changed. I do not see myself able to return to work, I am afraid and I feel very insecure.” (C1)
Almost half of those interviewed stated that having low work self-efficacy is an important personal barrier that influences behaviors related to seeking and keeping a job. To analyze this theme in greater depth we explored the category related to the negative self-concept of all the interviewees as potential workers, comparing all the verbal fragments related to feeling incapable and unready to work for both groups of people who had experience in competitive employment or only in a protected work setting. The findings suggest that most of the people that stated they cannot work, or do not feel totally ready to work (sources-frequency [f s] = 11), are people who had had more competitive than protected work experiences (C = eight, Pr = three).
“What happens is that you do not perform well. I cannot go to a company and ask for a job because I cannot perform like another normal person. I tried to work, and I cannot. I had to rationalize it and admit it.” (C6)
3.1.2The social environment barriers
Work barriers are also related to important elements of the social environment in which people are immersed. Work discrimination toward people with mental illness is the major social barrier interviewees individuated, while there are also others more specifically related to the socio-economic context in which people live.
Work discrimination: This is defined as the most important social barrier that limits the inclusion of people with psychiatric disabilities to obtain jobs. Many of the interviewees relate this phenomenon to the employers’ lack of knowledge and to the consequent stigma typically related to mental illness in society:
“There are companies that do not want to know anything. For example, you have an interview and you give them your curriculum, you tell them your experience, and at the end you have to say “I have a mental illness.” And then after saying that, you are rejected.” (C4)
“I believe that there is work discrimination. People are still afraid. They associate mental illness with schizophrenia. So they think that if you begin to feel bad you will start lashing out at everyone. It’s when you are aggressive, you hear things. That’s what’s scary. They assume that everyone has the same.” (C1)
According to the opinions of many interviewees, employers seem to discriminate people with mental illness in the selection process, preferring to hire people with other types of disabilities because they prefer to seek more predictable workers who have a visible disability:
“Those who have intellectual disabilities have it easier. They receive less prejudice. They take time to learn the job but after they’ve learnt it they do the job perfectly. Unlike mental illness, where employers never know how it will go.” (Pr1)
“I think it’s easier for companies to hire a person with a physical disability because it’s more noticeable for the image, you know? It is easier for them to get jobs than for one with a mental illness.” (C5)
The socio-economic context: Some interviewees also associate their greater difficulty in getting or maintaining jobs with the economic difficulties of companies and with the scarce presence of job offers specific to the environment in which they live:
“What happens is that last Christmas there were no sales. So if there is no income you cannot keep a worker. Then he wrote me a letter saying that on January first I was going to stop working because of income.” (C11)
“And here there are no industries, it is an old city, and there is no work.” (C1)
3.1.3The job environment barriers
Negative work relationships: For some interviewees another important barrier consisted of the relationships generated in the work environment, which led them to leave jobs they had managed to get:
“I was driver for fruit delivery, here in León. And the owner of the greengrocer started treating me badly. And then after working for six months, I got tired of the situation and I quit the job.” (C2)
“In my previous jobs the relationship was more complicated. In my first job, the coworkers did not treat me very well. What has limited me is also the people who did not believe in me, who put obstacles in my way. This happened when I worked as a bricklayer, but in a restaurant and a butcher’s shop too. A lot of people, yes.” (C5)
People with competitive experiences (f s = eight) indicated bad relationships at work as the most important barrier related to the job environment, while these are isolated occurrences when we consider those who have worked only in a protected work setting (f s = one).
3.2Employment facilitators
Our findings suggest that the most important facilitators to obtaining and maintaining a job are related to the network of professional and natural relationships, and also to elements of the personal sphere and job environment (Table 2).
3.2.1The social network support
Most of the interviewees defined the network of professional and natural support for reintegration into the work environment as fundamental.
Professional support: Mental health professionals have generally been identified as human supports able to encourage reincorporation into the work environment thanks to their counseling activity, but in many cases the work of NGO professionals is considered essential for providing access to protected job opportunities. This point is important because some participants consider protected work as the best option for them –the only one in some cases:
“I would not have been able to do anything without the Foundation. The Foundation has been my salvation. Not to return to work in a competitive job, but to work in the Foundation. If the jobs had been in a competitive company, I would not have taken them. Going back to work like that (protected) has not been very hard for me.” (Pr1)
“You have to understand that you can work despite the disability, and professionals of the Foundation are good at motivating you to try to work, as well as helping you to understand whether you are a good or bad match for a possible job.” (Pr5)
The natural support: If NGOs are defined as important for obtaining jobs in special employment centers, it is relationships with family and friends that allow access to the world of competitive work, either seeking job opportunities directly or facilitating information about job opportunities:
“When I worked as a cleaner it was is because my aunt knew the boss of the company, and when I entered the products company, my uncle knew the boss.” (C11)
“The ice cream shop is owned by a family member, a cousin, so thanks to my uncle’s mediation I spent four or five summers working with them.” (C7)
Natural support from people appears to be important not only to facilitate work opportunities, but also to feel encouraged to work thanks to the emotional support provided:
“Friends also support you talking to you, motivating you to become active, to feel useful again.” (C12)
“It has been fundamental to feel obligated, in the sense that I had to get up every day and study, go forward until I reach my goal. The obligation came from my mother; she woke me up every day supporting me. All my family encouraged me.” (C10)
The network of family and friends seems to be important because it can give access to job information and opportunities. Additionally, the intensity of support relationships seems important because it offers emotional support to people for the difficulties that may arise during the process of seeking and maintaining employment. These elements are much more common in people who have had competitive work experiences (f s = 10), while they are less common in those who have only worked in protected jobs (f s = three).
3.2.2Personal sphere facilitators
Skills: Facilitators in the personal sphere are related to the development of skills for work. These are mainly the management of disability information to avoid work discrimination and to obtain more work chances, as well as the attitudes and behaviors participants considered important to perform well at work, while at a lesser level they are connected to the improvement of specific work skills.
Managing disclosing: As we have seen, people consider discrimination for having a psychiatric disability one of the biggest barriers to finding a job. At the same time they know that companies receive public subsidies for hiring people with disabilities. So managing the information about having a disability resulting from mental illness seems to be a key element facilitator for work inclusion. On one hand, not disclosing the information of having a mental illness makes it possible for the candidate or worker to avoid possible work discrimination:
“Not sharing the information is better, because it is socially frowned upon (the mental illness). There is a lot of discrimination. Companies prefer to hire a person who does not have any type of mental disability. As far as possible, I have always kept it hidden.” (C7)
At the same time, disclosing information of the psychiatric disability can be another strategy for employment since there are companies interested in hiring people with disabilities, partly to become eligible for subsidies, and partly because this can facilitate possible work adaptations:
“The best strategy for me is to say it, because if a company is looking for a worker, and all the candidates have the same job capability, if one of them also has a disability, the company will receive subsidies for hiring him.” (C12)
“I want them to know that I have a mental illness and that sometimes I may have difficulty, that a lot of pressure is not good for me. That if I can, I will do the work. But they have to know that if I slow down sometimes, it’s because I have to.” (Pr9)
Behaviors to achieve the goal: Half of the interviewees speak of a positive attitude and perseverance as the key elements of their behavior to have successful job experiences:
“I realized that I had to look at the present, to have more confidence, and that I had to dedicate my time to my life. Fighting and being persistent. Life is a struggle, but you have to try to be positive, have a good attitude. Attitudes defend the way. I try to see the positive side of everything without facing problems that cannot be solved, trying to change paths when I need do it.” (C2)
Always on a personal level, it seems to be important to implement a healthy lifestyle to avoid the appearance of symptoms as much as possible, and if they do appear during work activity, it is fundamental to have developed certain skills to successfully manage the situation:
“At first I established a lot of discipline, in leading a healthy life, playing sports, and sleeping hours. Sport and also socializing more. I do not isolate myself, and maybe that was the most important thing, to try not to isolate myself.” (C2)
“I can continue to work with small symptoms, but it is more difficult. If you concentrate on work, work helps you control those symptoms. My symptoms are auditory, so I relate them to the people around me, so if I stop paying attention to those persons, I can try to focus more on the work, and it is like a distraction that can help me to control symptoms.” (Pr11)
3.2.3Job environment facilitators
Work relationships: Good relationships at work are an important element as they facilitate a comfortable working atmosphere. For some people in particular, the importance given to this stems from bad relationships experienced in former jobs:
“I know that if there is a person who understands me, who is committed, I know that I can do the job well.” (C4)
“Today I feel totally integrated, as one more person. I do not see any barrier. I do not accept a possible bad work environment. I give more importance to personal relationships. At my previous job, I was affected by the work relationships. Mentally I needed to rest. In fact it took me a month to recover my health.” (C2)
All the interviewees who identified past bad work relationship experiences as work barriers (f s = nine) also identified the good relationships at work as a determinant for their positive work experience. Some of these affirmed the importance of this topic for their choice to leave a job for a better one (f s = four), but a small group of interviewees identified this topic as important in deciding to get only protected jobs in future (f s = three):
“Having good relationships at work is essential, and in a competitive environment it is more difficult for them to be willing to understand you. And that’s when problems with others arise [...]. That is also why I decided to stay in the special employment center and I have stopped looking for work in other companies.” (C9)
Job configuration: This is related to the participants’ need to fit the work into a healthy configuration. For many people, the possibility of enjoying the job appears to be fundamental; it could be a part-time job, in which the work is less stressful:
“I think you have to like the work you do and feel well with the job. Even if they pay you less, if you are comfortable you feel good. And a person with a mental illness appreciates this even more.” (Pr3)
“Part-time jobs are best for people with mental illness. You encourage yourself. You get up in the morning with an aim but you do not get too tired. And you come home with more sense, you feel more normal, more useful.” (Pr8)
4Discussion
The findings of this study can be understood as a small but important contribution to research related to employment barriers and facilitators experienced by people with psychiatric disabilities in Spain. Research on this topic is important because, in different countries, people with psychiatric disabilities have been shown to be the disability group that experiences the most difficulties in accessing or maintaining employment [1, 2]. Moreover, very little qualitative research on this topic has been published in Spain, so we consider our study to be only the first work on a phenomenon that needs further research.
The findings presented suggest that when participants have to explain the difficulties they come up against to obtain and keep a job, they tend to refer more to personal elements, such as negative beliefs and expectations related to employment, the difficulties resulting from having a mental illness, the lack of personal skills needed to work, and low self-efficacy. Secondarily, they refer to important barriers related to the social environment, such as work discrimination for having a mental illness and a psychiatric disability. The onset of mental illness and its consequences related to work functionality are barriers that we expected to find. In fact, many people experienced difficulties related to the mental illness while they were working or when they started a new job after the psychiatric disability assessment. At the same time, there are important negative expectations that seem to limit the choice of working, and of doing so in a competitive environment. The opinion that stressful work could be worse for mental health or that people could lose all or part of their pensions if they worked, along with the issue of mental illness, are barriers that also appear in other studies [9, 24, 32, 33]. The uncertainty related to the possibility of combining work and pensions suggests that people probably need more attention and counseling related to this topic. On the other hand, the fear associated with past work experiences in unprotected work contexts reveals that an improvement of services and programs related to work inclusion support is also needed. It is difficult to estimate the number of people who could resign from, or limit, their work for these reasons, but in all cases we still need to improve interventions to inform and provide advice to people with psychiatric disabilities desiring to work.
Continuing with the findings presented in this study, people consider that another strong personal barrier is the lack of competencies to work as a consequence of not having had enough experience and training and also of having had long periods of inactivity. This point reinforces the findings of other qualitative studies [9, 19, 33]. Employment history has been considered in research that sought to identify the predictors of work outcomes of people with psychiatric disabilities too, showing how their value may vary according to the type of support program and specifically as a good, clear predictor when vocational programs have competitive employment as a primary goal [6, 34].
Always related to the personal sphere, for many participants, low self-efficacy about job capability is defined as something that has limited their return to work. Several previous international studies also identified low self-efficacy as a barrier to work for people with mental illness [7, 9, 10, 21, 35]. In addition, our findings suggest an interesting difference of opinion between people in relation to their sense of ability as workers. In fact, those who reported having worked in competitive environments seem to have a worse personal opinion of themselves than those who had only worked in protected and supported jobs. We explain this result considering that when people talk about their own capabilities, they are considering their work history apart from their current situation. We therefore take into account that those who worked in unsupported competitive jobs might have faced more negative experiences and that these events might have determined a lowering of self-efficacy as workers, while those who worked exclusively in protected environments had a better reinforcement of self, thanks to more positive experiences and support from professionals. Applying the “why try” effect model to these findings [36], we assume that all participants had previously interiorized the idea of incompetence associated with the stigma of mental illness, but that only those who had had negative work experiences could confirm this belief with regard to their performance. On the other hand, participants who had only worked in vocational support services in protected contexts might have improved or not changed their sense of self-efficacy thanks to better work experiences that contrast with the belief of incompetence typical of the stigma of mental illness.
In this study, participants identified work discrimination in their social environment as an important barrier to obtaining jobs because of a lack of knowledge regarding what a mental illness is and the subsequent public stigma associated with having a psychiatric disability. Thus, interviewees perceived this issue as a relevant cultural barrier that limits access to work for people with psychiatric disabilities, as a consequence of the general discrimination toward people with mental illness in society. Although interviewees did identify bad relationships at work as another important barrier, they never actually explained them as work discrimination for being treated unfairly in the workplace because of having a psychiatric disability. However, labor force discrimination of people with mental illness is a barrier that has been reviewed for several years [6, 37–39] and some recent studies have shown that experiences of discrimination at work limit the improvement of self-esteem for people with mental illness [40]. Moreover we have to consider that negative work experiences facilitate negative expectations regarding future work opportunities, and that people could easily decide stay out of the work market because they anticipate work discrimination [20, 24]. The possible negative relationship with employers or coworkers is another important barrier participants identified in this study. Our findings suggest that work relationships are a key element that could facilitate positive or negative work experiences, as some previous studies support [18, 20]. In fact, some interviewees claimed that it is a determining factor when it comes to deciding whether to leave a specific job and search for a better one. Work relationships also appear to be related to the choice of seeking new employment but only in a protected environment, and abandoning the idea of returning to competitive jobs. In both cases, people react to bad past experiences by seeking employment with better work relationships, but not all of these seek competitive employment again.
Negative past experiences seem to serve as information to strategically direct future decisions but this is not only related to changing jobs. People can adopt a variety of strategies to try to improve their situation directly in the work environment. First, with actions related to managing disability information. For example, people decide not to disclose information about their own psychiatric disability to avoid possible work discrimination. At the same time, some participants claimed that disclosing the information could improve their chances of finding a job because there are employers interested in hiring people with disabilities in order to become eligible for fiscal benefits from the Social Security Agency. Disclosing is also defined as good because it opens up the possibility of demanding some types of work adaptations. The complex decisions related to managing disability information are important not only for people seeking work with autonomy but also for those who receive vocational support services. The need to help people with the management of personal information at work has already been dealt with in other countries by creating programs specifically oriented thereto [41, 42], and our findings reveal that the development of such services in Spain is strictly necessary too.
Second, people can improve their future choices by identifying a suitable job configuration and considering their experiences and expectations. In this sense, our findings suggest that the type of work sought is as important as the opportunity to work part-time. The first point has already been reviewed in other studies, showing how vocation and the possibility to enjoy work activities could be important employment facilitators for the inclusion of people with psychiatric disabilities [19, 25]. Also, with respect to part-time jobs, there are some earlier European studies that show how they might be better for people with disabilities, particularly considering how work-time is combined with other daily needs [43]. These studies analyze survey data that do not consider differences between types of disability and we have to take into account that the situation of every disability group (in pensions or daily needs) can vary greatly. In this sense, some participants in our study stated that the part-time modality is a healthier job option because it helps to avoid a potentially too stressful job situation while maintaining the satisfaction of feeling productive through doing paid work. In all cases, the type of pension that people receive as well as uncertainty related to the fear of potentially losing it may be a determining factor for making the part-time modality a better choice for them.
Lastly, and most importantly, we discuss the field of social networks, such as the network of relationships that support people in returning to or maintaining work. It is particularly interesting to observe the importance people with psychiatric disabilities give to social networks because of the stigma associated with mental illness and the consequent work discrimination people receive [44, 45]. Social isolation, as a possible emotion after perceiving a certain configuration of network ties, may be of great importance because it appears to be closely connected to personal well-being and recovery [46, 47]. Moreover, the specific characteristics of the social network seem also to determine different results regarding access to relevant community activities [48], suggesting the importance of also considering the configuration of networks to gain access to work. Our findings indicate the importance of considering emotional and employment support from family and professionals as employment facilitators, confirming the observations of other earlier studies [10, 19, 22, 24]. Professional and natural networks also seem to provide links to different types of work opportunities, for either competitive or protected jobs. Our study did not focus on social network analysis but it does reveal that future attention to this topic is needed.
Since its origin, the social network theory has centered on how weak ties can determine an expansion of job opportunities, connecting people to information and work possibilities embedded in other social groups [49, 50]. Recently, the social network analysis has been connected to the study of work opportunities of people with disabilities. This suggests that people with disabilities have a different social network building process as a result of the characteristics of the social group in which they move. The employment social networks of people with disabilities seem to be smaller and have greater density (people that know each other), with a greater presence of strong ties (for example family members) and less likelihood of weak ties when compared to the networks of people with no disability [51].
Our findings suggest a different usability of natural and professional ties to find and keep employment (protected and competitive). People with psychiatric disabilities can increase their social interactions thanks to support activities provided by mental health professionals. At the same time, their strong ties with family and friends can be maintained after the onset of mental illness. Both types can facilitate job opportunities but these processes need to be observed in greater depth. First, if NGOs only provide protected work opportunities without developing more inclusive employment programs, people will be limited to closed-circle work opportunities (with fewer connections to competitive companies). Second, family members and friends are a valid tool for obtaining competitive job opportunities but our findings seem to reveal that this occurs even more so when people are not receiving professional support to work.
5Conclusion
People with psychiatric disabilities still remain a social group with difficulties in obtaining and maintaining jobs. The Spanish context appears to offer more protected employment through special employment centers. However, people with mental health-related disabilities are also able to obtain competitive employment. This study offers a first exploration of the employment barriers and facilitators experienced by people with psychiatric disabilities in Spain. Secondly, it allows us to observe the differences between people who, after the psychiatric disability assessment, have worked in protected or competitive jobs. Our findings suggest the need to implement services oriented towards support in competitive jobs more emphatically, such as the supported employment services. At the same time, it is still necessary to conduct anti-stigma and no-discrimination campaigns. In addition, results suggest the need to implement new services aimed at supporting the management of personal information during the process of obtaining and maintaining a job, and at promoting participation in social areas that encourage the construction of more extensive networks with strategically useful ties for people with psychiatric disabilities to be included in the work environment.
Acknowledgments
Appreciation is extended to all participants in this study for the precious time spent during and after the interviews, and to ONCE Foundation and INTRAS Foundation for the information and resources facilitated during the sampling procedure.
Conflict of interest
None to report.
References
[1] | OECD. Sick on the Job?: Myths and realities about mental health and work. Paris: OECD Publishing; (2012) . |
[2] | OECD. Fit mind, fit job: From evidence to practice in mental health and work. Paris: OECD Publishing; (2015) . |
[3] | Linden M . Definition and assessment of disability in mental disorders under the perspective of the international classification of functioning disability and health (ICF). Behavioral sciences & the law. (2017) ;35: (2):124–34. |
[4] | Suijkerbuijk YB , Schaafsma FG , van Mechelen JC , Ojajärvi A , Corbière M , Anema JR , Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis. Cochrane Database of Systematic Reviews. (2017) ;9: (9):CD011867. |
[5] | Baldwin ML . Beyond schizophrenia: Living and working with a serious mental illness. Lanham: Rowman & Littlefield; (2016) . |
[6] | Lettieri A , Díez E . A systematization of the international evidence related to labor inclusion barriers and facilitators for people with mental illness. A review of reviews. Sociologica. (2017) ;3: (3):1–17. |
[7] | Fox AB , Smith BN , Vogt D . The relationship between anticipated stigma and work functioning for individuals with depression. Journal of Social & Clinical Psychology. (2016) ;35: (10):883–97. |
[8] | Wang K , Link BG , Corrigan PW , Davidson L , Flanagan E . Perceived provider stigma as a predictor of mental health service users’ internalized stigma and disempowerment. Psychiatry Research. (2018) ;259: :526–31. |
[9] | Prior S , Maciver D , Forsyth K , Walsh M , Meiklejohn A , Irvine L . Readiness for employment: Perceptions of mental health service users. Community Mental Health Journal. (2013) ;49: (6):658–67. |
[10] | Schindler VP , Kientz M . Supports and barriers to higher education and employment for individuals diagnosed with mental illness. Journal of Vocational Rehabilitation. (2013) ;39: (1):29–41. |
[11] | El empleo de las personas con discapacidad. Serie 2014-2019 [Internet]. INE. [cited 2021 Mar 25]. Available from: https://www.ine.es/dynt3/inebase/es/index.htm?padre=5426&capsel=5429 |
[12] | Asociación Española de Salud y Seguridad Social. Las incapacidades laborales y la seguridad social en una sociedad en transformación: I congreso internacional y XIV congreso nacional de la asociación española de salud y seguridad social. Murcia: Laborum; (2017) . |
[13] | Malo MA , Cueto B , Rodríguez V . Compatibilizando pensiones por discapacidad y empleo en España. Papeles de economia española. (2019) ;161: :55–70. |
[14] | Bellostas A , López-Arceiz F , Mateos L . Social value and economic value in social enterprises: Value creation model of Spanish sheltered workshops. Voluntas: International Journal of Voluntary & Nonprofit Organizations. (2016) ;27: (1):367–91. |
[15] | Calderón Milán MJ , Calderón Milán B . Los centros especiales de empleo como mecanismo de tránsito hacia el mercado de trabajo ordinario. CIRIEC-España, Revista de Economía Pública, Social y Cooperativa. (2012) ;(75):223–50. |
[16] | Integración laboral y tendencias del mercado de trabajo [Internet]. Fundación ONCE. 2019 [updated 2019 Mar 6; cited 2019 Apr 23]. Available from: https://www.odismet.es/banco-de-datos/1integracion-laboral-y-tendencias-del-mercado-de-trabajo |
[17] | Lettieri A , Soto-Pérez F , Díez E , Franco-Martín MA . Facilitadores y barreras para el empleo, una aproximación desde las propias personas con enfermedades mentales. In: Rodríguez-Pulido F, Caballero-Estebaranz N, editors. Empleo, recuperación y ciudadanía en las experiencias psicóticas. Madrid: Asociación Española de Neuropsiquiatría; 2021. pp. 85-102. |
[18] | Gladman B , Waghorn G . Personal experiences of people with serious mental illness when seeking, obtaining and maintaining competitive employment in Queensland, Australia. Work: Journal of Prevention, Assessment & Rehabilitation. (2016) ;53: (4):835–43. |
[19] | Netto JA , Yeung P , Cocks E , McNamara B . Facilitators and barriers to employment for people with mental illness: A qualitative study. Journal of Vocational Rehabilitation. (2016) ;44: (1):61–72. |
[20] | Peterson D , Gordon S , Neale J . It can work: Open employment for people with experience of mental illness. Work: Journal of Prevention, Assessment & Rehabilitation. (2017) ;56: (3):443–54. |
[21] | Hatchard K , Henderson J , Stanton S . Workers’ perspectives on self-directing mainstream return to work following acute mental illness: Reflections on partnerships. Work: Journal of Prevention, Assessment & Rehabilitation. (2012) ;43: (1):43–52. |
[22] | Saavedra J , López M , Gonzáles S , Cubero R . Does employment promote recovery? Meanings from work experience in people diagnosed with serious mental illness. Culture, Medicine, and Psychiatry: An International Journal of Cross-Cultural Health Research. (2016) ;40: (3):507–32. |
[23] | Malmanche J , Robertson L . The experience of KAI MAHI, an employment initiative for people with an experience of mental illness, as told by Zarna, Zeus, Lulu, Mary, Paul, and Hemi. Community Mental Health Journal. (2015) ;51: (8):880–7. |
[24] | Millner UC , Rogers ES , Bloch P , Costa W , Pritchett S , Woods T . Exploring the work lives of adults with serious mental illness from a vocational psychology perspective. Journal of Counseling Psychology. (2015) ;62: (4):642–54. |
[25] | Baum N , Neuberger T . The contributions of persons in the work environment to the self-identity of persons with mental health problems: A study in Israel. Health & Social Care in the Community. (2014) ;22: (3):308–16. |
[26] | Torres Stone RA , Sabella K , Lidz CW , McKay C , Smith LM . The meaning of work for young adults diagnosed with serious mental health conditions. Psychiatric Rehabilitation Journal. (2018) ;41: (4):290–8. |
[27] | Creswell JW , Poth CN . Qualitative inquiry and research design: Choosing among five approaches. Los Angeles: SAGE Publications; (2016) . |
[28] | Liu L . Using generic inductive approach in qualitative educational research: A case study analysis. Journal of Education and Learning. (2016) ;5: :129. |
[29] | Booth A , Hannes K , Harden A , Noyes J , Harris J , Tong A . COREQ (consolidated criteria for reporting qualitative studies). In: Moher D, Altman DG, Schulz KF, Simera I. and Wager E, editors. Guidelines for reporting health research: A user’s manual. Wiley; (2014) . pp. 214–26. |
[30] | O’Connor C , Joffe H . Intercoder reliability in qualitative research: Debates and practical guidelines. International Journal of Qualitative Methods. (2020) ;19: :1609406919899220. |
[31] | Birt L , Scott S , Cavers D , Campbell C , Walter F . Member checking: A tool to enhance trustworthiness or merely a nod to validation? Qualitative Health Research. (2016) ;26: (13):1802–11. |
[32] | Charette-Dussault É , Corbière M . An integrative review of the barriers to job acquisition for people with severe mental illnesses. The Journal of Nervous and Mental Disease. (2019) ;207: (7):523–37. |
[33] | Thomas TL , Prasad Muliyala K , Jayarajan D , Angothu H , Thirthalli J . Vocational challenges in severe mental illness: A qualitative study in persons with professional degrees. Asian Journal of Psychiatry. (2019) ;42: :48–54. |
[34] | Mahmood Z , Keller AV , Burton CZ , Vella L , Matt GE , McGurk SR , et al. Modifiable predictors of supported employment outcomes among people with severe mental illness. Psychiatric Services. (2019) ;70: (9):782–92. |
[35] | Juurlink TT , Vukadin M , Stringer B , Westerman MJ , Lamers F , Anema JR , et al. Barriers and facilitators to employment in borderline personality disorder: A qualitative study among patients, mental health practitioners and insurance physicians. PLoS One. (2019) ;14: (7):e0220233. |
[36] | Corrigan PW , Larson JE , Rüsch N . Self-stigma and the “why try” effect: impact on life goals and evidence-based practices. World Psychiatry. (2009) ;8: (2):75–81. |
[37] | Gmitroski T , Bradley C , Heinemann L , Liu G , Blanchard P , Beck C , et al. Barriers and facilitators to employment for young adults with mental illness: a scoping review. BMJ Open. (2018) ;8: (12):e024487. |
[38] | Krupa T , Kirsh B , Cockburn L , Gewurtz R . Understanding the stigma of mental illness in employment. Work: Journal of Prevention, Assessment & Rehabilitation. (2009) ;33: (4):413–25. |
[39] | Lettieri A , Soto-Pérez F , Franco-Martín MA , de Borja Jordán de Urríes F , Shiells KR , Díez E . Employability with mental illness: The perspectives of employers and mental health workers. Rehabilitation Counseling Bulletin. (2021) ;64: (4):195–207. |
[40] | Rüsch N , Nordt C , Kawohl W , Brantschen E , Bärtsch B , Müller M , et al. Work-related discrimination and change in self-stigma among people with mental illness during supported employment. Psychiatric Services. (2014) ;65: (12):1496–8. |
[41] | Brohan E , Henderson C , Slade M , Thornicroft G . Development and preliminary evaluation of a decision aid for disclosure of mental illness to employers. Patient Education and Counseling. (2014) ;94: (2):238–42. |
[42] | Waghorn G , Spowart CE . Managing personal information in supported employment for people with mental illness. In: Lloyd C, editor.Vocational rehabilitation and mental health: Wiley-Blackwell; (2010) . pp. 201–10. |
[43] | Pagán R . Is part-time work a good or bad opportunity for people with disabilities? A European analysis. Disability and Rehabilitation: An International, Multidisciplinary Journal. (2007) ;29: (24):1910–9. |
[44] | Friedman C . The relationship between disability prejudice and disability employment rates. Work. (2020) ;65: (3):591–8. |
[45] | Lettieri A , Díez E , Soto-Pérez F . Prejudice and work discrimination: Exploring the effects of employers’ work experience, contact and attitudes on the intention to hire people with mental illness. The Social Science Journal. 2021;1-15. doi: 10.1080/03623319.2021.1954464. |
[46] | Lim MH , Gleeson JF . Social connectedness across the psychosis spectrum: Current issues and future directions for interventions in loneliness. Frontiers in Psychiatry. (2014) ;5: (154). |
[47] | Maulik PK , Eaton WW , Bradshaw CP . The role of social network and support in mental health service use: Findings from the Baltimore ECA study. Psychiatric Services. (2009) ;60: (9):1222–9. |
[48] | Sweet D , Byng R , Webber M , Enki DG , Porter I , Larsen J , et al. Personal well-being networks, social capital and severe mental illness: Exploratory study. The British Journal of Psychiatry. (2018) ;212: (5):308–17. |
[49] | Gee LK , Jones JJ , Fariss CJ , Burke M , Fowler JH . The paradox of weak ties in 55 countries. Journal of Economic Behavior & Organization. (2017) ;133: :362–72. |
[50] | Ryan L . Looking for weak ties: using a mixed methods approach to capture elusive connections. Sociological Review. (2016) ;64: (4):951–69. |
[51] | Langford CR , Lengnick-Hall ML , Kulkarni M . How do social networks influence the employment prospects of people with disabilities? Employee Responsibilities and Rights Journal. (2013) ;25: (4):295–310. |
