What is the evidence of successful interventions that increase employment and livelihood participation for people with psychosocial disability?

Challenge #1: A lack of clear and operational definition of psychosocial disability can undermine rights-based efforts.

• The fact that many psychosocial disabilities are associated with episodes of relapse, may vary in level of support required, and may be 'invisible', means that employers have struggled to formulate clear policies, compared to the area of physical and sensory disabilities.
• Legal requirements and policies in many countries in relation to workplace rights for people with psychosocial disability fall far behind those with physical and/or sensory disability, and psychosocial disabilities in many countries remains outside of out-dated official definitions of disability.

Challenge #2:  Stigma and discrimination can take several forms and can adversely have an impact for people with psychosocial disability to effectively participate in employment on an equal basis with others.

• Attitudinal barriers such as stigma and discrimination remain primary challenges for inclusion and participation of people with disability in different spheres of life including education, employment, and health. Institutional or systemic discrimination and assumed competency or capacity of people with psychosocial disability is a common barrier for inclusion. Perception that people with psychosocial disability do not want to, or cannot, work at all is still prevalent. Internalised stigma can lead to a lack of confidence, and the resulting low-esteem has also been found to negatively affect people with psychosocial disability’s ability to secure and retain employment.
• People with psychosocial disability are more likely to have experienced discrimination while securing employment as well as retaining their current employment. Additionally, people with psychosocial disability also tend to report anticipated discrimination that prevent them from proactively searching for work or returning to work following a period of absence due to worsening of mental health symptoms.
• Socio-cultural factors such as gender roles and local beliefs and practices put women at higher risk of experiencing workplace discrimination. Furthermore, women with psychosocial disability are more likely to report both experienced and anticipated discrimination compared to men with psychosocial disability.
• Evidence around effective workplace anti-stigma interventions for people with psychosocial disability have some indication of positive impact on employees’ knowledge, attitudes, and supportive behaviour towards people with psychosocial disability. One review reported the following intervention types: Educational (e.g. presentations, self-study, public campaigns); Communication (e.g. discussion, reflection, posters, workshops); Technology (e.g. videos, websites, instant messaging); Creative (e.g. film screening, role play, drama), Social contact (e.g. direct, simulation, video); and Therapeutic (CBT).

Challenge #3: Assessing workplace accommodation needs are complex and there is no one-size-fits-all solution

• Vocational success for persons with psychosocial disability is characterised by the positive fit between employees’ employment interest and skills, the tasks, and the workplace environment. Workplace accommodation need to address the environmental and structural barriers such as quiet office space, flexibility of working hours, and frequent breaks. Additionally, occasional disruption of work and periods of time off need to be managed. Facilitating stable mental health through a supportive work environment can help individuals maintain productivity.
• People with psychosocial disability may have unique workplace accommodation needs depending on the stage of employment such as recruitment, selection, social integration, and performance management. Furthermore, experience of negative symptoms can interfere with their cognitive or sensory processing skills that can have an adverse impact on their work performance. This needs to be recognised and not result in poor performance reviews.
• Experienced discrimination: participants might also be unwilling to disclose their mental illness on account of the heightened stigma against mental illness in the setting which might work against securing reasonable accommodation in employment.

Challenge #4: Multi-sectoral approach including integration of mental health and employment services is needed to address the multiple barriers faced by people with psychosocial disability.

• One review highlighted the following facilitating factors of employment among people with psychosocial disability: stability or reduced severity of mental illness; use of mental health services; and resolution of psychological conflicts.
• Internalised stigma experienced by those not in employment can undermine their abilities to seek help as well as their motivation to explore employment opportunities. Similarly, concerns about disclosure may impede help-seeking and service use. Psychological interventions are recommended to promote coping skills, increase self-esteem, and improve confidence to address internalised stigma.
• Effective employment models alone would not address the employability issues among people with psychosocial disability unless the barriers to employment such as lack of efficient mental healthcare, education, and stigma are addressed. This needs multi-stakeholder co-ordination between various sectors including health, education, and employment. 

Challenge #5: Models of employment - Individualised planning and support is essential to obtain and retain employment

• Interventions to obtain and maintain employment for people with psychosocial disability depends on the type of employment model. Commonly used models include: Prevocational training (e.g. Social skills training, Cognitive training); Transitional employment (e.g. Sheltered workshop); Social enterprise; The Clubhouse model; and Supported employment.
• Evidence coming mostly from HIC have found positive effects of supported employment, particularly Individual Placement and Support (IPS) and on several employment outcomes such as entry to competitive employment, number of days in employment, and the time to obtaining first competitive employment opportunity. In Supported employment, people with psychosocial disability are placed in a competitive employment first and then trained through hands-on experience. The emphasis in IPS is on ‘place-and-train’ compared to the ‘train-and-place’ approach adopted in the traditional employment programmes such as the prevocational training model.
• The evidence around augmented supported employment programmes, combined supported employment with other interventions such as social skills training, is mixed. As augmented supported employment is a very heterogeneous group of programmes, further research is needed to confidently confirm the specific combinations of additional interventions along with support employment for people with psychosocial disability in LMICs.
• The majority of opportunities for people with psychosocial disability (as with most of the workforce) is for work in non-formal sectors such as agriculture or self-employment. Self-employment through farming was reported as a major form of employment for people with psychosocial disability. It should be noted though, that people with psychosocial disability should be given equal opportunity to aspire to the same range of careers as their peers.
• Lack of finance and government support have been reported as a major barrier to provide supported employment and self-employment of people with psychosocial disability in LMICs. This informal sector is hard to regulate and challenging to influence on a large scale through centralised programmes. There is scope for Social protection systems and other financial assistance, including cash transfers and integrated benefits packages, to address this barrier.