General support versus individual work support: a qualitative study of social workers and therapists in collaboration meetings within individual placement and support

ABSTRACT

This study aims to increase understanding of how social workers and therapists contribute to cooperation meetings within the individual placement and support intervention. The individual placement and support model of supported employment is expanding worldwide. Although several quantitative studies have shown this model`s effect, the need for qualitative studies on collaboration within this intervention is evident. The individual placement and support fidelity manual presents clear expectations to the social workers and therapist in the cooperation. Still, few previous studies investigate how these expectations are met in praxis. This study draws on sixteen collaboration meetings, recorded, transcribed, and analysed using reflexive thematic analyses. It shows that the social workers and therapists did, to a limited extent, adapting their support to the expectations of personalised work support inherent in the individual placement and support intervention. They underestimated their importance in collaboration meetings, and this limited the dialogue. Further qualitative studies are needed to understand how social workers and therapists experience their contribution to individual placement and support and their reasons underestimating their importance. Still, we suggest that more individualised work support from the social workers and therapists could help people who choose individual placement and support to succeed in work life.

ABSTRAKT

Studien bidrar til økt forståelsen av hvordan NAV veiledere og terapeuter bidrar i samarbeidsmøter i intervensjonen ‘individual placement and support’. Utbredelsen av denne modellen for jobbstøtte øker i store deler av verden. Kvantitative studier har vist at intervensjonen har effekt. Det er imidlertid behov for kvalitative studier av det praktiske samarbeidet. I kvalitetsmanualen for individuell jobbstøtte foreligger det klare forventninger til hvordan samarbeidet med NAV veiledere og terapeuter skal foregå. Det er imidlertid lite kunnskap om hvordan disse forventningene blir gjennomført i praksis. Denne studien bygger på lydopptak av seksten samarbeidsmøter som er transkribert og analysert ved hjelp av refleksiv tematisk analyse. Studien viser at NAV veilederne og terapeutene i liten grad tilpasset sin støtte til forventningene om individuell jobbstøtte slik de er beskrevet i kvalitetsmanualen. De undervurderte sin betydning i samarbeidsmøtene, noe som begrenset dialogen og nytten av møtene. Vi mener at mer individuell jobbstøtte fra NAV veiledere og terapeuter vil være til hjelp for at jobbsøkere som velger `individual placement and support` skal lykkes i arbeidslivet. Det er imidlertid nødvendig med flere kvalitative studier for å forstå hvordan NAV veilederne og terapeutene selv opplever sitt bidrag til individuell jobbstøtte og deres begrunnelse for å undervurdere sin egen betydning.

KEYWORDS:

• IPS
• mental health
• employment
• recovery

NØKKELORD:

• IPS
• psykisk helse
• arbeid
• recovery

Introduction

Challenging conditions concerning work and in the work market are common experiences among people with mental illnesses, making this group`s unemployment rate high (OECD, 2012). However, many of those not employed include social circumstances in their understanding of mental illness and recovery and have employment as a goal (Drake & Whitley, 2014).

In Europe, there is a long tradition for vocational rehabilitation in sheltered work (Pelizza et al., 2020a). However, research shows that individual placement and support (IPS) is the most effective work rehabilitation method for achieving competitive employment (Brinchmann et al., 2020), also in young patients (Pelizza et al., 2020).

Brinchmann et al. (2020) conducted a meta-analysis of the generalisability of IPS efficacy and concluded that the evidence for IPS efficacy is robust and generalisable between countries. The method is expanding worldwide, and the governments of Norway and several other countries encourage the expansion of IPS (Helsedirektoratet, 2013; Omsorgsdepartementet, 2019; Reme et al., 2019, p. 33; Topor & Ljungberg, 2016, p. 278). Despite IPS being the most effective method, only about 40 percent of those gaining work within IPS remain employed (Reme et al., 2019), which means there is room for improvement.

IPS is an evidence-based vocational rehabilitation method that emphasises the importance of coupling vocational rehabilitation with mental health treatment (Bond et al., 2012; Larson et al., 2014). The method follows eight principles: (1) The patients choose to participate (zero exclusion). (2) The goal is competitive employment. (3) Job searching follows the work applicant`s preferences, and (4) starts immediately. (5) The employment specialist is a member of a mental health team. (6) The IPS team provides personalised financial counselling. (7) Job development is systematised. (8) IPS support is time unlimited (Drake et al., 2012). These principles are described in the IPS fidelity manual, which presents a norm of clear expectations to organisations that choose to implement IPS. The fidelity manual states that professionals within these welfare and mental health organisations are expected to collaborate in supporting the work applicants developing strategies to acquire a job and succeed in work, based on his or her preferences and employment goals. Services who choose to implement an IPS service are expected to highlight these expectations in their organisation (Becker et al., 2015, p. 49).

Bonfils et al. (2017) conducted a systematic literature review to identify and evaluate research on facilitators and barriers to IPS implementation. They found that national policy and regulations regarding employment and a negative attitude towards IPS among professionals in the involved organisations hindered IPS implementation. Skilled employment specialists and local leaders, who served as implementers and following the IPS fidelity manual, were critical facilitators of successful implementation. Inadequate cooperation was an organisational barrier. They found that the organisational and contextual barriers often challenged the employment specialists’ effort to perceive individualised support, and emphasise that more studies are needed to clarify the attitude towards IPS among professionals’ and the collaboration barriers met in integrating this user will centred method in existing mental health- and welfare services (Bonfils et al., 2017).

Brinchmann et al. (2020) underline that IPS operates in a crossover position between welfare and mental healthcare. They recommend further studies to understand the barriers to success in such a position and to explore how these can be surmounted (Brinchmann et al., 2020).

Although the majority of studies have been quantitative, qualitative studies are increasing. These qualitative studies contribute to a deeper understanding of how IPS functions in practical life. A recent systematic meta-ethnographic analysis of the qualitative studies investigating experiences of participating in IPS showed there is a significant body of knowledge from the work applicants’ point of view (Moen et al., 2020). The work applicants highlighted the significance of the personalised recovery-oriented support they received from the employment specialists. They appreciated that the employment specialists saw their preferences and needs as crucial for successful work rehabilitation.

Employment specialists experienced their crossover position as being culture brokers among mental health services, welfare services, and employers (Moen et al., 2020).

Furthermore, the meta-analysis revealed that no previous studies had explicitly investigated the social workers and the therapists’ experiences of IPS collaboration. A few of the included studies indicated that both professions found it challenging to provide the personalised work support, which the work applicants found crucial. The study concludes that in order to know more about potential obstacles and facilitators affecting the collaboration, there is a need for more knowledge about how social workers and therapists contribute.

This present qualitative study aims to enrich the knowledge of IPS cooperation by exploring how social workers and therapists contribute to cooperation meetings within the individual placement and support intervention. It investigates the collaboration in authentic meetings within a well-established IPS team from the southern part of Norway. No previous studies have explored real collaboration meetings focusing on social workers and therapists` contributions. Such knowledge might give an understanding of how they meet the expectations inherent to the IPS method and serve as valuable input to improve the implementation of IPS.

The social workers and the therapists

Because this study was conducted in Norway, we provide background about the Norwegian services in which the studied social workers and therapists were working.

The Norwegian Labour and Welfare Administration (NAV), incorporates state-funded social and employment services and a variety of other financial services. NAV has the goal of enabling as many people as possible to participate in the workforce (Røysum, 2013). The social workers at the NAV offices, called ‘supervisors’, provide employment orientated supervising and information about benefits. The organisational culture in NAV is characterised by bureaucracy and control, imposed through rules and regulations. However, the social workers` professional role as supervisors gives room for autonomy and individualisation (Helgøy et al., 2013; Røysum, 2013). NAV offers a standardised approach for all employees and more specialised and individualised methods for specified groups (Røysum, 2013). In this study, the term ‘social worker’ is synonymous with the NAV supervisor.

In Norway, the mental health services are divided between the state specialist services and municipal services. The specialist services support the municipal work and treatment of more severe conditions (Government.no, 2020). The Norwegian government provides implementation support for starting IPS both in the specialist and in the municipal mental health care (Omsorgsdepartementet, 2019). In the specialist services, IPS is offered in the outpatient clinics, which is the case in the present study. The therapists in these clinics consist of nurses, psychologists, doctors, and psychiatrists (Malt, 2020), which might influence their understandings of what a ‘treatment’ might be.

Most `IPS employment specialist` in Norway are employed in NAV and work within mental health services to support work applicants with moderate to severe mental illness in gaining employment. However, in this specific study the employment specialists are employed in the mental health service.

The collaboration unit in IPS, i.e. ‘the collaboration team’, in this study consists apart of the work applicant of three persons. The work applicant’s therapist who works in the psychiatric service. The social worker who represents the local vocational and welfare services. Besides, the employment specialist specialised in the IPS methodology. The employment specialist leads the IPS collaboration, but has no formal power in the cooperation. They all attend based on the work applicants wish for them to participate in IPS (Becker et al., 2015).

Method

This present study aims to enrich the knowledge of how social workers and therapists contribute to cooperation meetings within the individual placement and support intervention. These meetings are the gathering arena of the collaboration teams, consisting of the work applicant, their therapist, their social worker, and their employment specialist.

The first author attended collaboration meetings as a passive observer, tape-recorded and transcribed the dialogue. A phenomenological hermeneutic approach with textual interpretation of what is actually said, allows us to improve our understanding of such human experiences and dialogue (Malterud, 2001).

Selection procedure and participants

We made a pragmatic choice of IPS service, as we chose to study the service where the first author is a team supervisor. An IPS supervisor leads the IPS team and helps the employment specialists to develop and improve their methodological skills and knowledge in line with the IPS fidelity manual (Becker et al., 2015, p. 61).

The studied IPS service had moderate to high fidelity on the quality evaluations, and situates in three outpatient departments in a mental health clinic in Norway. This service had five employment specialists during the ‘study period’ from January 2017 to December 2018. The first author informed all five about the study and requested their participation. All five were positive, but one ended up declining participation because of practical hindrances. The employment specialists provided work applicants with information about the research and asked for their participation. To maximise variability in the sample and capture heterogeneity, we wanted to include a variety of therapists and social workers, both males and females, as well as work applicants with various diagnoses. Some work applicants in the studied IPS service had the same therapist or social worker. Since we wanted to attend two meetings with each group, we recruited work applicants that would possibly have support from IPS for at least six months after recruitment. Five of the requested work applicants did not want to participate because they did not want more people than necessary in their meetings. One said yes but could not attend because the treatment had ended. At the end of the recruitment, it turned out that the four employment specialists had recruited two work applicants each. After including one work applicant in the study, the employment specialist informed the therapist and the social worker in their respective collaboration team and asked them to participate in the study. All consented to inclusion apart from one social worker who declined to participate because she thought it would take too much time. The work applicant ended the treatment and thus the whole group was excluded. All the participants entered the study voluntarily.

The inclusion ended with eight collaboration teams, eight social workers, eight clinicians, eight work applicants and four employment specialists. During the study, three of the groups changed the social worker or the therapist. One group had one new social worker, while another group changed social worker twice, because of changes in their area of responsibility. One group obtained a new therapist because the work applicant moved from inward to outpatient service. In one meeting, the therapist did not turn up because she was on sick leave. All participants signed consent forms. Time available was a contextual and pragmatic considerations that informed the sample size (Malterud, 2001). The consent form covered sociodemographic information about the participants, as presented in Table 1A–D.

Table 1. Sociodemographic information about the participants.

A. Work applicants
Variable	Category	n = 8
Age	20–30	8
Gender	Female	5
	Male	3
Diagnosis	Psychosis	2
	Major Depression / Anxiety	5
	Other	1
Ethnic origin	Native	7
Work history	Worked in the past five years	5
Work during IPS	Yes	6
B. Therapists
Variable	Category	n = 9
Age	25–40	3
	41–60	6
Gender	Female	7
	Male	2
Ethnic origin	Native	8
Profession	Psychiatric nurse	5
	Psychologist	4
Years in this job	0–2	2
	3–10	3
	More than 10	4
C. Social workers
Variable	Category	n = 11
Age	25–40	4
	41–60	7
Gender	Female	9
	Male	2
Ethnic origin	Native	11
Education	Social work	9
	Other	2
Years in this job	0–2	1
	3–9	8
	More than 10	2
D. Employment specialists
Variable	Category	n = 4
Age	30–40	2
	40–55	2
Gender	Female	2
	Male	2
Ethnic origin	Native	4
Years in this job	0–3	4

Data collection

In a total of eight collaboration teams, the first author was a passive observer in two meetings with each group, 16 meetings altogether, and tape-recorded the dialogue. The employment specialist led the meetings by following an agenda where each participant was asked about their view on the work applicants’ status regarding work, treatment, economy, and any unsolved concerns. The researcher did not interfere with the structure or implementation of them. The meetings took part between 23.03.17 and 13.12.18, and they lasted from 23 to 66 min. The first author transcribed the recorded meetings verbatim.

Thematic analysis

We analysed the written material using reflexive thematic analysis. Accordingly, we interpreted, developed and conceptualised patterns and themes (Braun et al., 2019; Braun & Clarke, 2006) regarding the social workers` and therapists` contribution in the collaboration meetings, and how they influenced the work applicants and the employment specialists and vice versa in the studied meetings.

To provide a coherent and compelling interpretation of the qualitative dataset we developed themes by following the recommended six phases: familiarisation with data, coding, generating initial themes, reviewing themes, defining and naming themes, and producing the report (Braun & Clarke, 2006). We moved back and forth between the six phases several times and discussed all parts of the analysis.

To become familiar with the dataset, the first and last authors read the transcripts repeatedly. After that, we coded the transcriptions independently by writing down casual notes based on the text. One example of notes was ‘Points out that there is a need for the work applicants and the therapists to look at challenges together’. The notes and impressions from the first phase were used to code the material by systematically identifying meaning throughout the dataset. Thereafter, we discussed the codes, and the first author added new views.

In the third phase, we looked at both the whole dataset and the meaning and essence of the coded text. Based on this, we created initial themes and developed an understanding of patterns. One pattern was ‘The structure and schedule of the meetings’, another was ‘The concerns of each of the participants’. All three authors read and discussed the initial themes, and the first author discussed parts of the transcriptions in two research groups. Analytical thoughts from these reflections were added.

The themes were developed according to the research question during phase four, based on the themes and patterns from phase three. One theme was ‘How they talked about work in the therapy’. We reflected on what the social workers and therapists said, how they said it, how they influenced the dialogue, and how they were or were not influenced by other participants.

In phase five, we finally defined the themes, keeping the link to the material by moving back and forth between phases five, four, and the transcriptions. When the themes had been satisfactorily defined, we made the names based on the core of each theme. One theme concerning the therapists was, ‘Made a distinction between work rehabilitation and treatment’. Although producing the report was the final phase, the writing was naturally an integral part of the analysis.

Ethical considerations

The participants entered the study voluntarily, were informed of confidentiality and their right to withdraw, and gave their written consent. In this study, they permitted the researcher to attend meetings they would have held anyhow and thus did not spend extra time on the study.

We did not have any indication that the study caused any harm. The Norwegian Centre for Research Data (NSD) approved the study, (project number: 47448).

Results

The overall findings were that the social workers and the therapists, to a limited extent, adapted their support to the expectations of personalised support towards employment, incorporated in the IPS intervention. This continuation of their typical tasks resulted in concerns and questions that often did not fit with the expectations and goals within the IPS collaboration and limited the dialogue in the meetings. Various examples of mismatch between expectations and praxis gave the foundation of this interpretation, and the limited dialogue had multiple consequences. We present the situations and consequences in the following, for the social workers and the therapists separately. In the quotes, the following abbreviations refer to the different participations: social worker (SW), therapist (T), work applicant (WA), employments specialist (ES).

The social workers

Confident and supportive when their usual responsibilities met the expectations

The social workers had an essential role in explaining rules and rights regarding benefits, which they mostly did in a way that reassured the work applicants. For example, several work applicants who wondered if they had to reapply for the work assessment allowance, became confident about their economic situation. One social worker said:

SW7:

No, you do not have to reapply. When it eventually expires, we will extend it. You do not have to worry about that.

WA7:

Yes, that is great.

When their answers fitted in the current situation, and the social workers were sure about the rules, they specified the answers to the questions from the work applicants and linked the answers to what corresponded with the situation.

Another of the social workers’ essentials tasks that fitted with IPS expectations was to get an update regarding the work applicants` work situation. They did this by showing interest in the work applicants’ employment process, and by asking questions about current and former workplaces. For instance, one social worker asked:

SW4

How did the colleagues welcome you?

WA4:

Above all expectations.

SW4:

So nice.

WA4:

Yes, they are incredibly pleasant people to work with.

SW4:

That is important.

The social workers spoke positively of suitable working environments and thus supported progress concerning work. Asking about and responding to the work situation fitted the expectations of the collaboration, and their confidence seemed to make them able, to some degree, to individualise their responses, which constituted a form of support for the work applicants.

Explained their responsibilities without situational awareness

However, it was evident that the social workers did not always have adequate situational awareness. Although the purpose of the collaboration meetings is to provide individual work support, the social workers had a more general approach by explaining that their primary responsibilities were to apply for employment schemes and to answer financial questions.

SW6:

My role is mostly concerned with work. To help with a scheme or see what we could do to get you a job. Then we can provide some information about the work assessment allowance.

Because SW6 provided general information, which had no clear relevance to the current situation, he received little response from the others on this, and at this point the conversation about the social worker`s responsibilities ended.

There were however, situations where the social workers seemed to sense that contribution to the IPS cooperation entailed something other than just their familiar duties. For example, when the employment specialists directly asked them about their role:

ES1:

What has NAV‘s role been so far in this process?

SW1:

We have been peripheral.

Another social worker answered:

SW5:

I do not feel NAV does that much here. … We do not have to do anything. That is very okay though.

Questions about their contribution seemed to give the social workers the impression that they were providing too little and suggested they did not know what was expected from them. The peripheral position made them a little insecure. This insecurity spread to the others in the meetings and stopped them from asking more questions. The result was that the social workers` role in the collaboration and the process of helping the work applicant was not clarified.

Moreover, some social workers disclaimed their responsibility. For example, a social worker explained that it was wiser to contact the system if something was unclear about the payments:

SW6:

It goes a bit beyond my role. It is better if you contact the NAV system.

Here, the social worker did not seem to understand the importance of the work applicant`s emotional reactions to economic issues, and his need for personal help to achieve financial security. The therapist tried to make the social worker aware of this indirectly by turning to the work applicant:

T6:

You have the work assessment allowance (WAA) as security, now, right? You have started in a job, and things have gone a bit awry; something got in the way. It is good to know that a return [to WAA] is possible, at the same time as you are searching.

WA6:

Yes

The social worker neither caught this point nor responded. At this point, the conversation ended. When the social workers presented their usual general responsibilities without necessary sensitisation and flexibility, they missed the opportunity to provide personalised and customised help to the work applicant in the actual IPS collaboration.

Mediated opinions that overstepped boundaries

In some of the meetings, the social workers mediated opinions about the others` responsibilities that the therapists and work applicants did not agree upon. The social workers insistently explained their expectations, and thus overstepped boundaries. Examples of such topics were medical certificates and health-related questions. For example, one of the social workers had not received updated information about the treatment the therapist provided for the work applicant. The therapist did not consent to the social worker`s request about sending a medical certificate. He placed the responsibility for the medical certificate on the work applicant`s general practitioner (GP), according to formal instructions. The social worker suggested they could find a more straightforward solution, overruling the formality:

SW2:

You can just make a statement. It is not a specialist statement. Only a summary of what you have done, where you are today, what you think next.

… 

T2:

I thought the GP did this

… 

SW2:

Is it not possible for you to send over a medical certificate and tell [the GP] that NAV would like an update.

T2:

I am used to a written request, and then I could have done it.

Thus, the therapist talks about maintaining the formal guidelines that medical certificate require a formal request from NAV, which frustrates the social worker.

In another collaboration group, the social worker said that health-related issues slowed the process, and kept asking about progress:

SW4:

What are the hindrances?

WA4:

It is the everyday challenges. I have to go a few rounds with myself every time I start something new.

SW4 (later):

Yes, but you also have a responsibility for yourself in a way.

WA4:

Yes, I know.

SW4:

But you do not have to say more about it.

WA4:

No, no, definitely not.

ES4:

No, I do not have much more [to say].

Some social workers spent much time on these themes, asked many questions, and even said that the therapist or work applicant should take more responsibility than they did to find a solution. When the social workers talked in this insistent way, they overstepped some boundaries. For some reason, the other participants often were unable to hold a straightforward conversation. They seemed unpleasant, perhaps because the way the social worker spoke about the issues was not polite. They did not respond or changed the subject, and thus ended these conversations without an open dialogue. Hence, the social workers did not manage to create a fruitful dialogue and a shared understanding of these topics.

The therapists

Made a distinction between work rehabilitation and treatment

All the therapists made a distinction between treatment and work rehabilitation, and thus did not include work rehabilitation in the therapy. Their main concern was mental health in general. They experienced work as positive for mental health, but did not include the specifics of gaining and maintaining a work in therapy. They seemed to forget that when the work applicants choose IPS support, they are implicitly confirming that work is one of their recovery goals. Several of the employment specialists seemed to suspect such a lack of inclusion of IPS in the treatment, and demonstrated a concern about this by asking the therapists directly how they provided work rehabilitation within their treatment of the work applicant:

ES6:

From your collaboration, could you tell us about the focus on employment?

T6:

Yes. We have talked about work in general. You (to the patient) tell me how things are going at work. My focus has naturally primarily been on your health. You (to the employment specialist) have been with us twice. We talked a little about circadian rhythm, stress, that sort of thing.

As shown in this example, the therapists explained that they talked about work, but mostly in general terms. They viewed work proficiency as a result of the work applicants being mentally stronger by generally better understanding and mediating their thoughts and feelings. As shown in this example, they did not connect the therapy to the employment process:

ES3:

Have you, in the treatment, talked about anything specific related to work?

T3:

There is actually no difference. The stronger, how to say it, the stronger she is mentally or, for example, if she stays away from drugs and can recognise her feelings, explain and contain them more … it will give her better and better shape mentally and will automatically give her a better chances of coping with a job.

Although the therapists did not focus on work in their treatment, they experienced the process in the IPS cooperation of gaining employment and having a job as positive for the work applicants’ mental health in general. They saw that not having a job affected mental health negatively. For instance, one therapist said that she noticed a change in the work applicant’s mood when he had met his employment specialist and made appointments with employers.

T4 (to the work applicant): When you two (the work applicant and your employment specialist) have met and made some appointments, I can see that your mood is elevated.

In the next collaboration meeting, the same therapist said, to the work applicant:

T4:

Your mood and life have got better as you have found a job and decided when to start. That is evident. In many ways, I think being without a job was what made you very ill.

W4:

Yes, I think so.

Furthermore, it was evident in several of the collaboration meetings that the therapist and the work applicant had not talked about what to say and emphasise beforehand. Their lack of planning was reflected in their questions to the work applicants during the meeting concerning what to say and concerning which of them would answer the questions.

T4:

We can talk completely openly?

WA4:

Yes, yes

It was also made obvious that the therapists were unsure about the expectations of them in the collaboration meetings, which seemed to lead to uncertainty regarding what to say.

Hence, the therapists emphasised that health is different from coping with work, in contrast to the work applicants who attended IPS because they viewed work as an important part of their recovery from their health problems. IPS was not directly included in the therapy, nor did the work applicant get the opportunity to prepare what to focus on in the meetings with their therapist. Thus, the therapists’ participation during the meetings became limited.

Underestimated their importance

The therapists did not seem to define themselves as central in the IPS collaboration team. In all the meetings, the work applicants and the employment specialists highlighted the importance the therapists had as essential partners in IPS. Still, the therapists did not seem to consider themselves as central, even after their significance was explained to them. For instance, one employment specialist asked the work applicant what he really needed from his therapist when he started working, and the work applicant answered:

WA5:

I guess it is primarily that I need to have someone to talk to, and, yes, someone that supports me. Because, if I suddenly had to go to work without anyone nearby, I think I would not have managed (the work).

… 

ES Yes 

The employment specialist recognised what the work applicant said, but since the therapist did not say anything, the work applicant did not speak further on this and the employment specialist switched to another theme. By not addressing the work applicants’ need for support, the therapist missed the opportunity to explore this and maybe to give adequate support.

Furthermore, the employment specialists pointed out the importance of therapy to the work applicant, thereby trying indirectly to make it evident to the therapists that they had a crucial role in the IPS collaboration. For instance:

ES1:

We often experience that when you start working, then things show up. That is why it is essential to have treatment (included in work support).

The employment specialist also emphasised the importance of having a supporting team:

ES1:

The point is to be a team that supports.

… 

T1:

I feel my role as somewhat withdrawn in this phase.

ES1 (later):

You define your role as a little withdrawn in this phase, but to have you here [as a partner] is tremendous security for her (the work applicant) and me.

The work applicants and the employment specialists called for support, and underlined that they wanted more involvement from the therapists in the IPS collaboration. In contrast, the therapists did not seem to understand this and gave no response, or they described their role as peripheral.

The employment specialists even explained directly to the therapists that they were essential partners for them in helping the work applicants to master a job, and brought up detailed examples of what could be fruitful to talk about in treatment. For instance, one employment specialist asked the therapist if he could explore the obstacles that reduced the work applicant`s working capacity:

ES2:

Can you tell me a little about your challenges at work?

WA2:

I have great anxiety about making mistakes and not being able to do the job properly or getting complaints from customers.

… 

ES2:

But I think a little bit about the treatment, is there anything more one could do in the treatment, to increase [working capacity]?

T2:

No, I do not think so. I do not know.

… .

T2:

We are no longer in the treatment … so I don’t know how long I’m going to follow you.

As shown in the dialogue, the therapist did not seem to appreciate the significance of the situation, or the need for a more specific focus on work in treatment for the work rehabilitation to succeed.

Even though the work applicants and the employment specialists demanded more involvement explicitly and clearly, several of the therapists said that they did not meet the work applicants often and that they had even considered ending the treatment.

Used their therapeutic skills to nuance the understandings

Although they were fairly withdrawn in the dialogue, the therapists used their therapeutic skills and patience when they found that the others did not understand what the work applicants said. They saw the need for a more nuanced understanding, and initiated elaboration on what the work applicant meant. They also contributed to a constructive conversation by explaining the work applicants’ health issues and further exploring the situation to obtain a more nuanced picture. For instance, one work applicant said that he had lost his motivation. The social worker and the employment specialist sighed when hearing this statement. The therapist responded by providing support and explored the topic further:

WA6:

To be honest, I have lost my motivation … So I do not look forward very much to starting working.

… 

ES6:

I believed that you enjoyed this job; it was good for you last time you worked there?

WA6:

Yes

ES6:

This lost motivation for the job is somehow new to me.

… 

T6:

When you start working, because you liked it there last time, do you think you will become more motivated when you start working?

WA6:

Maybe, yes … 

T6:

You have been entirely passive for an extended period … It is not unusual to lose some energy.

By bringing in more information and nuances, the therapists contributed to re-activating the dialogue that was about to become deadlocked.

Discussion

As we have shown in this study, the social workers and the therapists mostly contributed to work support and the collaboration meetings more generally than individually, and made a distinction between IPS and their responsibility for the service to the work applicants. The social workers supported progress concerning work by asking the work applicants` about their work situation and speaking positively about suitable working environments in a general way. Although the therapists contributed to a constructive conversation by explaining the work applicants’ health issues when they saw a need for a more nuanced understanding of the situation, they mostly made a distinction between work rehabilitation and treatment. Both the social workers and the therapists thus underestimated their importance in the IPS collaboration.

Our results indicate that the social workers and the therapists have not implemented the expectations regarding their contribution to the collaboration inherent in the IPS fidelity manual (Bond et al., 2012). This present study does however not reveal why the social workers and the therapists did not contribute as much as expected. According to Lipsky (2010, p. 72), most people who choose to work in a type of street-level bureaucracy like the social workers and the therapists in IPS, are attracted by the prospect of helping others. One could assume that they want to give personal support. On the other hand, their understanding of their responsibility in personalised work support is probably affected by fellow workers, professional standards and role expectations in their ordinary environment (Lipsky, 2010).

One possible explanation is that therapists and social workers might have different opinions and knowledge about the importance of work for mental health and the recovery process (Moen et al., 2020). Another is that the social workers and therapists have to manage a more extensive caseload than the employment specialists, which might interfere with their ability to contribute. These unequal working conditions might be analysed as the social workers and therapists’ lack of adherence to IPS. A third possibility is that social workers and therapists had not been introduced sufficiently to the IPS fidelity manual and the IPS collaboration expectations, indicating resistance at an organisational level and reducing their possibilities to follow the expectations. Further studies could reveal some of these possibilities or other factors that might influence how social workers and therapists understand their contribution and responsibilities in IPS.

The findings in our study clarify one main difficulty in implementing IPS as a collaboration method. The social workers and therapists did not contributed to individual work support in a way that acknowledged work as central in the individual work applicant`s life, mental health, and recovery as studies on IPS define it to be (Brinchmann et al., 2020). This finding strengthens the knowledge from other qualitative studies on IPS who found that the work applicants` experienced IPS as receiving help from the employment specialist to reach their personal work goal. The therapists and social workers were experienced peripheral in this process (Moen et al., 2020). Additionally, our study reveals that their lack of commitment to the special expectations in IPS resulted in limited dialogue and collaboration and continued this practise. Since only 40-50% of work applicants who participate in IPS stay employed over time (Bejerholm et al., 2015; Reme et al., 2019), more individualised work support from the social workers and therapists could help people who choose individual placement and support to succeed in work life. Additional qualitative studies with in-depth interviews of the social workers and therapists about what they consider as their responsibility in their contribution to IPS, their reasons for this, and what place they believe that work has in recovery are needed to explore these implementation barriers further.

Methodological consideration

We wanted to complement the existing knowledge with an inside understanding of how social workers and therapists contribute to cooperation meetings within the individual placement and support intervention. To achieve this aim, we attended authentic collaboration meetings, an approach that was appropriate to the research question.

All researchers are influenced by their experiences. The first author’s experience as an IPS supervisor led to the choice of searching field. It also affected the participants. We strived for this familiarity to contribute to trust an inside understanding.

The participants could have felt forced to attend but gave their consent voluntarily and with enthusiasm. The studied IPS service had five employment specialists. One of them did not participate in, nor did one of the requested social workers, which shows they felt not forced to participate.

The involved therapists and social workers were familiar with the researchers’ double role.

The researchers’ familiarity could have made the participants cautious about what they said, but that was not our impression. However, having one passive observer present and being recorded could have limited the dialogue. Some of the participants were a little nervous when the meetings started, but they seemed to forget the research part early.

We have made an effort to divide the supervisor and the researcher’s job and done the research as conscientiously as possible. Throughout the whole study, we tried to keep an analytical distance. The other authors were not involved in the IPS team, and the first author discussed parts of the analysis in two different research groups from other fields, reducing the bias.

The choice of using thematic analysis allowed us to identify themes and patterns, according to the purpose. Our overall assessment is that the study design gave an abundant amount of qualitative material suitable to achieve the aim of this study.

Ethical approval

Ethical approval of the PhD thesis which this article are a part of, was sought and granted for by NSD – Norwegian Centre for Research Data with project number: 47448., Harald Hårfagres gate 29, NO-5007 Bergen Tlf: ([phone] [email protected] www.nsd.no.

Acknowledgement

All three authors have made substantial contributions and comments on the paper. Ellen Ånestad Moen will act as guarantor for the paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was funded by Sørlandet Hospital HF contribution of Ellen Ånestad Moen and Liv Tveit Walseth in this study. University of Agder found the contribution of Inger Beate Larsen.

Notes on contributors

Ellen Ånestad Moen

Ellen Ånestad Moen is working as PhD candidate and IPS Supervisor at Sørlandet hospital. She is educated as an occupational therapist with a master degree in psychosocial health. She is member of three research groups at University of Agder and one at Sørlandet hospital.

Inger Beate Larsen

Inger Beate Larsen is professor in psychosocial health. She is educated as a psychiatric nurse with a major in Health Sciences and a PhD from the University of Bergen. She has years of experiences from an acute psychiatric ward, and since 1994, she has been working in a scientific position at the University of Agder. From 2009 she has been the manager of the research group ‘An including society’ at the department of health-and sport sciences.

Liv Tveit Walseth

Liv Tveit Walseth is an M.D., specialist in general practice, and is working as chief physician at Department of Elderly Psychiatry and as supervisor at the Research unit, Sørlandet hospital. She has a PhD from 2012 concerning democratic processes in conversations between doctor and patient. She is also member of a OCD research group with responsibility for the qualitative research part of the projects.