https://orcid.org/0009-0009-5010-6851
Introduction
The World Health Organization identifies that mental health problems are one of the top ten reasons for disability. Furthermore, the United Nations (UN) have recognized that people with disabilities often face difficulties in fully participating in society sometimes due to obstacles in finding work and attending school. The UN Convention on the Rights of Persons with Disabilities (CRPD) states that all individuals with disabilities should have access to the same rights and opportunities as the average citizen. In Article 1 it is stated that the purpose of the CRPD is to promote and ensure full and equal human rights for people with disabilities that may experience barriers that hinder them to fully participate in society. Without support, mental health problems can develop into long-term impairment affecting not only mental health and well-being, but also the possibilities to become self-sufficient and achieve full inclusion in society. This is especially important for young people transitioning into adulthood. Higher education and employment can be viewed as natural steps in becoming an adult and it is widely known that mental health problems often appear in the teenage years, a period of time where the transition into adulthood starts. This makes it even more important to offer support and services in order to give them the same possibilities as the average citizen.
My point of departure
Before I started my PhD-studies I had worked for over ten years as a social worker in four different social service organizations in different municipalities in Sweden. As a social worker I came in contact with young people and adults with varying degrees of mental health problems that hindered them from partaking in society in terms of employment or having to quit their university studies as a consequence of their mental health problems. I saw how difficult it has been for them to re-enter these arenas, even when highly motivated to do so. It is therefore of interest to explore, from a welfare perspective, how social work in the Swedish welfare system can support individuals with mental health conditions and what obstacles can be found in their vocational and educational pursuits. Even though I had worked with disabled people, it wasn’t until I became a PhD-student and a part of the research project, Investing in young adults with mental health problems – Career-oriented outcomes and responsibility in the Swedish Welfare system, that I came in contact with Individual Placement and Support (IPS) and Supported Education (SEd). It came as a surprise to me that IPS have been given the highest priority in the national guidelines for people with schizophrenia and similar conditions since 2011 but that most municipalities in Sweden have not implemented the method. It made me wonder why a method with a large body of evidence is not offered by more Swedish municipalities for people with mental health conditions. Especially regarding young adults, it should be a priority to support them to a successful future.
Vocational and educational support
Individual Placement and Support (IPS) and Supported Education (SEd) are two methods developed in the USA for people with severe mental illnesses. The methods are person-centered with a focus on the individual’s motivation to work or study with support individually tailored to the individual’s conditions. Individual Placement and Support is often described as the evidence-based model of Supported Employment and is based on a place-then-train model, in contrast to the traditional train-then-place model. The assumption is that people with severe mental illnesses or mental health problems are competent to get competitive employment without pre-vocational training provided they are offered the appropriate employment for the individual’s conditions. The support given by the work-specialist should be individually tailored to the person’s preferences and based on integration of vocational and mental health care services. While there is a large body of evidence that IPS leads to higher employment rates than traditional vocational rehabilitation there are some recent studies suggesting that educational support in combination with IPS can increase the possibility to a sustainable work-life with more qualified employment. Therefore, methods such as Supported Education (SEd) in combination with IPS might be a good choice, especially for young adults that may switch between educational and vocational goal in their path to a sustainable career.
IPS and SEd in a Swedish welfare context
Most municipalities in Sweden offer some sort of vocational support/rehabilitation for persons with mental health conditions, mostly in form of the traditional train-then-place model. The National Board of Health and Welfare (NBHW) in Sweden publishes guidelines for certain groups with recommended methods for municipalities and health care providers. IPS has been the given the highest priority in the guidelines for people with schizophrenia and related conditions since 2011. There is however still only about a third of Swedish municipalities that offer the support, even though both international and national studies show that IPS is more effective than traditional vocational support. So why are IPS and SEd not more widely implemented in Sweden? There are a few factors regarding the Swedish welfare system that may provide some explanation.
Great municipal autonomy
In Sweden, as in other countries, there has been a growing interest for evidence-based social work over the last decades. There are difficulties in organizing social work in Sweden according to the classic critical appraisal model of evidence-based practice. The strive for more evidence-based social work has therefore been focused to a governmental level where agencies like NBHW compiles national guidelines of methods that are proven to be effective and have a large base of evidence. As mentioned above, IPS has been given the highest priority and it would be easy to assume that this would lead to municipalities implementing the method. As for SEd, which is only recommended as to be offered within a research and development context due to lack of evidence-based studies, it is easier to understand the lack of implementation in Sweden. However, it is important to underline that the government agencies only publish guidelines and recommendations and that these are not mandatory. Here the strong local autonomy plays a great part as the 290 municipalities in Sweden are largely self-governed by local politicians. This results in a large variety in organization of the social services in each municipal and what methods are offered. In addition, the Social Services Act, SSA (SFS 2001:453) is consciously designed as a framework law leaving great room for flexibility in the interpretation of what support and services are to be provided. In practice this means that local politicians often have great power to not only distribute economic resources, but also what methods and supports to implement in their respective social services. Local politicians can therefore decide whether or not to implement evidence-based methods even though they are prioritized and recommended by the NBHW.
A fragmented welfare system
Another reason might be that the Swedish welfare system is made up of different actors and agencies that all adhere to different laws and regulations and are responsible for different target groups and areas. For people with mental health problem the main actors are the municipality social services and the regional health care services. One of the basic principles of IPS is that community mental health services and psychiatric care are to be integrated, a collaboration that has proven to be difficult in the Swedish context with a fragmented welfare system with multiple welfare actors responsible for different areas. There is existing legislation stating that municipalities and regional councils are to cooperate but there is no regulations that specify that this should also be in regards to vocational support. While the municipalities are primarily responsible for the social support the health care services are responsible for general and specialized health care. Even though this might seem straightforward, in practice it is not as easy to define the responsibility for vocational support for people with mental health problems. Where does the social and medical support start and end? Studies of IPS in Sweden have also showed that the collaboration between these agencies are often difficult, something that can be a consequence of local governance and perceived area of responsibility. Apart from above mentioned agencies it might also be necessary to collaborate with other welfare actors such as the Employment Agency and Swedish Social Insurance Agency and for educational support the Swedish Board of Student Finance as well as universities. Since offering support as IPS and SEd are voluntary this means that many different actors may need to find a common ground for collaborating in ways that are not mandatory or regulated by legislation.
Different views on disability and services
A third factor has to do with the term disability and its usage. Disability, described by the United Nations, includes long-term physical or mental impairments that in interaction with societal barriers limits full participation in society and major life activities. It is furthermore often described that disability can be either life-long or transient. While mental health problems or mental illnesses can lead to disability, there are some differences in eligibility of support between different disabilities. The Swedish Act Concerning Support and Service for Persons with Certain Functional Impairment, abbreviated to LSS (SFS 1993:387), is an entitlement law for people with extensive functional impairments to guarantee good living conditions. While the law includes mental impairments which cause considerable difficulties in daily life, in my own experience few individuals with mental health conditions such as depression, post-traumatic stress disorder as well as others will be considered eligible for support through LSS. These individuals can be eligible for support through the Social Services Act (SSA), however, while LSS is to guarantee good living conditions the SSA is formulated as to promote reasonable standard of living, a lower level of ambition. Even for the individuals eligible for LSS services there are notable differences between different impairments. Individuals with intellectual disabilities, autism and acquired brain injuries in working age who are not in employment or studying have the right to participation in what is called daily activity (municipal provided day services that are mandatory to offer for these groups). For individuals with mental health problems or psychiatric disabilities this service is not available, even if they are eligible for other services through LSS. This means that for people with mental health conditions, even if severely affecting their daily lives and possibilities to participate fully in society, there is no existing legislation that ensure them vocational or educational support facilitated to their needs.
Closing words
With a growing recognition of increased mental ill health it should be prioritized to support young people, for which employment and higher education can be viewed as natural steps in transitioning to adulthood. However, for young adults with mental health conditions these steps can be hard to achieve without support. Mental health problems often occur in the teenager years and without support young adults with mental health problems may face long lasting effects in terms of social exclusion and disability. IPS and SEd are two methods especially developed for people with mental health problems and that have gained international evidence but as shown in this paper there are factors in the Swedish welfare context that may constitute obstacles in implementing them. Above mentioned factors may give some explanation as to why IPS (and SEd) are not more widely implemented in Sweden. These components have to some extent been acknowledged in Swedish IPS-research but are important to address and look further into if more municipalities are to implement IPS and SEd. Finally, I want to acknowledge that even though there are barriers that may be hard to break through it is important to recognize that there are Swedish municipalities that have implemented these methods, giving people with mental health problems the possibility to increased quality of life, mental health recovery, but that adaptions to the Swedish as well as local context has had to be made.
Disclosure statement
No potential conflict of interest was reported by the author(s).