Mental health policy and practice across Europe: an overview

300 Mental health policy and practice
training and supported employment. Pre-vocational training is the older of the
two approaches and encompasses a range of interventions which have evolved
in line with developments in general psychiatric treatment over past decades
(e.g. the move away from hospital-based to community-based care). It may
include any approach to vocational rehabilitation that involves a period of
training or work experience prior to seeking work in the competitive labour
market. The aim is to ultimately encourage clients to compete on the open job
market, but in some cases the activities of pre-vocational training do not necessarily
focus on returning the person to such work environments; rather, they are
seen as an integral part of the treatment and rehabilitation process. Return to
work may also be achieved through some kind of graduated process eventually
moving, for example, from sheltered work schemes or clubhouse programmes
to open employment supported by training and perhaps other interventions.
Sheltered employment typically refers to an intervention that arose from
the old tradition of hospital-based workshops that provided structured and
segregated employment. These workshops aimed to place people in open
employment after a period of pre-vocational training, but without much success
(5–10 per cent). The clubhouse movement represents one alternative type of
pre-vocational training that originated in, and is predominantly found in, the
United States (Macias et al. 1999) but increasingly can be seen in some parts of
Europe, particularly in Scandinavia and the Baltic states. It began in the 1950s
and moved away from hospital-based services to seek to foster independent
living and employment. There are two separate activities of preparation – the
work-ordered day and transitional employment. In the work-ordered day clients
join a work crew operating in the clubhouse, while transitional employment
involves working outside of the clubhouse (but controlled by it) in a structured
way. Current evidence suggests that rates of employment are lower than those
reported for people in supported employment (Schneider 2005).
The distinction between the pre-vocational training and supported employment
approaches has been characterized in terms of ‘train and place’, where
training is provided prior to competing on the open labour market for the
former, and ‘individual placement and support’ (IPS) where open employment
is found and training and other supports are provided on-the-job for the latter.
The concept of supported employment evolved in the mid-1980s, being originally
developed for people with learning disabilities, and subsequently expanding
to other client groups. This approach is based on criticisms that pre-vocational
training encourages dependency and does not foster work-related skills. In supported
employment clients can for instance receive support from job coaches
which may involve some element of training. A major influence on supported
employment has been the development of the IPS framework (Becker and Drake
1993). This framework has synthesized some of the key concepts connected
with supported employment, including the principle of obtaining paid work in
a normal setting where the majority of employees are unlikely to have any
disability. It also implies that the choice of job should be that of the client rather
than that of any agency or professional, and furthermore, there is no specified
time limit for support that individuals may receive following employment.
Another key feature of IPS is the emphasis on close links between rehabilitation,
employment and mental health services.