Employment mayhem for stable mental health patients

Psychiatry and Mental Health Services of the Ministry of Health Malaysia has set the standard of at least 60% of patients enrolled in supported employment programme to be employed in the open market at any year. The current workflow process for stable mental health patients expressing desire to work is depicted in figure 1.

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Figure 1

Current workflow process to supported employment programme for stable psychiatric patients.

The yearly employment rate among stable mental health patients seeking employment from 2020 to 2021 was 28.6% (2/7) and 30.0% (3/10), respectively. There were four drop-outs recorded in the year 2021. Reasons cited for drop-outs include poor adjustment to working environment (ie, not able to take constructive criticism to improve work performance) and poor compliance to morning routine in getting to work.

We further categorise issues related to poor employment and retention into patient-related factors and industry-related factors. Patient-related factors include the lack of specific skill set to perform intended task, poor discipline to follow routine, poor adjustment in working environment and not being able to mix well with colleagues. On the other hand, the main limitation to recruitment was employers’ scepticism on mental health patients’ work performance, as some potential employers were worried that the patients might turn violent or suicidal at the workplace. Discriminatory attitudes from the coworkers presents another challenge for the patients to adapt and adjust to the new workplace.

Our study was designed as a quality improvement project targeting mental illness patients in remission, active follow-up and assessment by our department. Patients in the acute stage of illness, active substance use or who could not comply to the study procedures were excluded. We employed qualitative data collection methods through questionnaire that included assessments performed by healthcare providers on patients’ disease status, patients’ compliance to medication, assessment of lifestyle habits and adherence to work routine, and its impact on overall well-being that were recorded in their medical records. Apart from that, designated job coach assigned to individual patient also documented patient’s progress in their medical notes, including both patient’s and employer’s feedback on serial monitoring over 6 months. The job coach also acted as the intermediary to facilitate interaction and expectations between both parties. Our main outcome was the number of patients able to secure job placement in an open market for a minimum of 6 months.

Innovative model on work inclusion for psychiatric patients

We developed multifaceted strategies to ensure a three-dimensional optimisation to the present supported employment programme: (1) strengthening clinical service to ensure stable disease and appropriate patient selection through battery of assessments including detailed evaluation of patient’s work preferences: preferred job, working environment, location, nature of work, wages; assessment of disease status: compliance to medication, trend of relapses and possibility of future relapses; assessment of social support, (2) provision of psychosocial support to boost self-esteem among patients and (3) encouraging willingness and confidence among stakeholders and local market to host job opportunities to stable psychiatric patients.

Specific major improvement to the supported employment programme was made with the addition of compulsory patient attachment to a local community mental health centre. Enrolment to a local community mental health facility had the inclusion of occupational therapist and social rehabilitation activities,4 run twice per week. Social activities include gardening, cooking, handcrafting (ie, making lanyard, crocheting bottle holder) and social trips to nearby vacation spots to encourage independence and social interaction. During the 6-month programme, the patient was also subjected to a bimonthly supported employment clinic to evaluate their disease status, monitor compliance to medication and employment progress, assess for any personal difficulty and social functioning. We encourage patients to adapt to new responsibilities and learn to identify and solve problems with the assistance of the employer, coworkers and the treating psychiatrist. We also ensure strict patient selection and refined job-matching to ensure eventual positive outcome.

Apart from that, we also provided education to relevant industries to ensure they are willing to accommodate their level best to safeguard the safety of the patients at the workplace. Hiring psychiatric patients in remission requires risk stratification and adjustment as the employers need to be flexible whenever there are conditions that constitute risks to the patients’ mental health.5 For example, some patients may need to be let off during working hours to allow for medical visits. Some patients may have cognitive impairment, and thus need more time to adapt in the new working environment.6

Government initiatives to encourage employment of disabled (mental or physical) individuals include allotment of tax deductions up to double the amount of pay given to disabled persons. Additionally, any modifications made to their building to accommodate handicapped personnel gets a single deduction while any extra training provided for them enjoys double deductions in tax revenues. We applaud this as a big step in the right direction.

Employment outcome

There were five patients enrolled in the programme. Before the enrolment, four patients lost their work after being diagnosed with mental illness. One young patient was unable to complete his diploma study due to the sequelae of mental illness.

After receiving treatment, they all achieved remission from mental illnesses, were interested in working, wanted to be hired, and had a strong family support system. They all, however, had low self-confidence as a result of public and self-stigma, which led to social avoidance and isolation. Furthermore, two patients lacked vocational skills, two struggled with executive functioning and one struggled with social skills.

After going through the structured programme, two of them were successfully employed. The successful employment rate at 6 months (up till June 2022) was 40.0% (2/5). Industries commonly accepting psychiatric patients were from the service provision. Our patients were employed for the position of food stall helper and as a worker in the plantation sector.

Future developments

Despite efforts to increase employment among mental health patients, we still fail to reach the bare minimum standard set by the ministry. Furthermore, COVID-19 era had witnessed a significant economic downfall with limited job openings as physical businesses turned online.7 Strong social stigma and sceptics that surround individuals with psychiatric disorder further hinder their employability in open market,8 while discriminatory attitude from their work circle remains major challenges to job retention. Hence, we believe enhanced public education through social media and mainstream outlets may foster better public acceptance and inclusion of psychiatric patients in the society.

Limitations

Our study is mainly limited due to its small sample size and the lack of objective assessment tools. The approach required many professionals and contacts to achieve the reported result and not sure this is sustainable.