Exploring the non-vocational outcomes of the individual placement and support (IPS) employment model

Purpose – Individual Placement and Support (IPS) is an evidence-based employment model, effective in supporting individuals with severe mental health dif ﬁ culties to gain competitive employment. Irish mental health policy recognises its value and IPS is being rolled out in a national programme. Employment is recognised an important contributor to mental health recovery and social inclusion. However, research on IPS has tended to focus on competitive job outcomes. The purpose of this study was to explore the non-vocational outcomes of IPS in an Irish context. Design/methodology/approach – A qualitative research approach was used to interview participants taking part in IPS within community mental health teams. Twelve interviews were included in the data analysis process which was informed by a thematic analysis approach. Findings – Participants experienced increased con ﬁ dence and positivity, both within a work context and whilst job seeking. More purposeful time use, participation in activities and engagement with society were also experienced by those employed and those at the job search stage of IPS. Originality/value – This study contributes to the literature about the non-vocational bene ﬁ ts of IPS within an Irish context, highlights the mental health recovery bene ﬁ ts of taking part in IPS and supports the need for ongoing development of IPS throughout mental health services in Ireland.


Introduction
Employment is a key social determinant of health and wellbeing (Drake and Wallach, 2020), recognised as a cornerstone to mental health recovery (WHO, 2021).The European Strategy for the Rights of Persons with Disabilities 2021-2030 (European Union, 2021) and Article 27 in the United Nations Convention on the Rights of Persons with Disabilities (United Nations, 2008) outline the right to employment.Yet, in Ireland, working age individuals who have mental health difficulties are nine times more likely to be unemployed (Watson et al., 2015).Furthermore, persons who experience enduring mental health difficulties are at greater risk of problems related to unemployment such as poverty, poor housing and social isolation (Killaspy et al., 2022).The Irish mental health policy "Sharing the Vision" acknowledging the role of employment in facilitating "full and effective participation in society" (Department of Health, 2020, p. 66), proposes a number of employment initiatives, including the Individual Placement and Support (IPS) model.A national programme supports the roll-out of IPS, built on a partnership model between employment support organisations and the The current issue and full text archive of this journal is available on Emerald Insight at: https://www.emerald.com/insight/2398-8819.htm mental health services, and guided by the National IPS Steering Group.Sharek et al. (2022) explored how IPS was integrated and embedded within the Irish context.
IPS is an evidence-based employment model developed for individuals with severe mental health difficulties (Modini et al., 2016).IPS is guided by eight core principles: 1 focus is on competitive employment (i.e.work in the community paying at least minimum wage which anyone can apply for); 2 everyone with a desire to work is eligible; 3 employment specialists (ES)employed by an employment support agency to facilitate IPSare integrated into community mental health teams (CMHTS); 4 job search process is based on the person's preferences and choice; 5 rapid job search; 6 personalised benefits counselling; 7 systematic job development; and 8 individualised time unlimited support (Drake et al., 2012).
The emphasis on competitive employment and rapid job search distinguishes it from other employment models.

Literature review
Strong international evidence demonstrates the effectiveness of IPS for adults with severe mental illness.All bar one of 28 randomised controlled trials (RCTs) comparing IPS to traditional vocational rehabilitation services showed superior competitive employment rates for IPS (J onasson et al., 2022).This is mirrored in an Irish study, in which 74% of participants were engaged in productive roles at follow up (Turner et al., 2019).However, non-vocational outcomes have been largely overlooked in many studies.Non-vocational outcomes include aspects central to mental health recovery, for example, social inclusion, self-esteem, quality of life and life satisfaction.
There is some evidence of the positive link between IPS and quality of life (QoL).In a study by Areberg and Bejerholm (2013), a significant difference was found between the IPS group and traditional vocational rehabilitation group (p ¼ 0.002), while within the IPS group, QoL showed a statistically significant increase (p ¼ 0.000) between baseline and 18months.One large American study found that IPS had a small but significant effect on QoL (d ¼ 0.18) and mental health symptoms (d ¼ 0.23) (Drake et al., 2013).IPS participants reported significantly better results for optimism for future well-being (p ¼ 0.038) compared to traditional vocational rehabilitation, and significant improvements in symptoms of depression, functioning, and global well-being using the WHO Disability Assessment Scale (p < 0.001) (Sveinsdottir et al., 2020).Interestingly, Schneider et al. (2009) reported, regardless of their employment status, self-esteem and hope scores increased for participants, although not significantly.
A small but growing number of qualitative studies have explored personal experiences.Gaining competitive employment through IPS facilitated feelings of acceptance, normality, a sense of belonging, inclusion, and contributing to society (Gammelgaard et al., 2017;Koletsi et al., 2009).A UK study reported the value of IPS for building relationships with colleagues and providing a sense of structure and routine (Raeside and McQueen, 2021).Interestingly, Nygren et al. (2016) found that while only two of the five participants were employed at follow-up, each experienced positive changes throughout the IPS process (Nygren et al., 2016).This emphasises the need to capture more than job outcomes to better understand the benefits of the IPS model.
A recent meta-ethnographic review highlighted the significance of the IPS individualised support and called for more qualitative studies (Moen et al., 2021).The ES role within the IPS model is crucial to its effectiveness (Vukadin et al., 2021).Improvements in self-esteem, self-perception and general recovery have been attributed to the ES's acknowledgement of individuals' needs and preferences (Gammelgaard et al., 2017).Koletsi et al. (2009) found that participants felt that their ES was unprejudiced and assisted them in disclosing their illness to employers.
As part of the National Standard Operating Procedure for the delivery of IPS (revised April 2023), effectiveness is routinely evaluated by an IPS fidelity review which captures employment outcomes and feedback from employers and participants.At the time of the study, the service scored fairgood on an external fidelity review.Although this provided valuable information on IPS staffing, organisation and services, less was known about non-vocational outcomes.This study aimed to fill an identified gap by exploring the experiences of non-vocational outcomes (e.g.social inclusion, well-being, quality of life) when taking part in IPS within one community mental health service of the HSE.

Methodology
Design This qualitative descriptive study explored the non-vocational outcomes and benefits of taking part in IPS using semistructured interviews.A qualitative approach allowed for exploration of personal experiences and elaboration on what non-vocational elements were important to IPS participants to gain a deeper understanding of participation in IPS.

Context
In 2019, a partnership was developed between the HSE and an employment agency to employ two ESs.A review of this, including rates of employment gained, suggested that the partnership was successful.In March 2020, funding for four additional ESs was granted.At the time of the study, there were six IPS ES within the CMHTS of this mental health service area.

Participants
Participants were purposively sampled from the ES client lists and were included if actively engaging with the ES at the time of the study and mentally well.All participants had ongoing contact with their CMHT.Once ethical approval was received (Beaumont Hospital ref 20/76 & HSE Dublin North City Mental Health Service ref 03/2020), participants were invited to participate in the study by a member of the CMHT who acted as gatekeeper.Following the informed consent process, participants were contacted by the researcher and invited to be interviewed.

Data collection
The semi structured interview was developed by the research team with reference to the existing literature and clinical experience, and piloted with one person to enhance dependability.It included opening questions related to the experience of IPS (see sample questions) and interviewers followed up with probing questions.The interviews were carried out in locations convenient to the participants by members of the research team who were not known to participants and included occupational therapists, an occupational therapy lecturer and a research assistant.All bar one of the interviews were audio recorded and transcribed verbatim.Detailed handwritten notes were taken during the interview of the participant who preferred not to be recorded.

Sample questions:
What, if any, has been the most thing that has changed for you?
How has this job changed your relationships with other people?
How has work with IPS changed how you spend your days?Your weekend?
How would you would describe the benefits of work with IPS to someone who is thinking about it?
Source: Created by authors

Data analysis
A thematic analysis approach (Braun and Clarke, 2013) was used by the research team to identify themes.Analysis began after the completion of the first five interviews to produce the initial coding and theme development (authors: A, B, C).
Researchers independently coded the data to compare analysis for agreement.Following the completion of the remaining interviews, the themes were cross-checked, refined, defined and named through ongoing dialogue in workshops (authors: C, D, E).Strategies used in this study to enhance trustworthiness included accurate transcription, maintaining an audit trail, a thorough and inclusive coding process, peer debriefing within the research team, and reflexivity to identify personal biases and assumption (Nowell et al., 2017).The analysis workshops included diagramming and discussion to further refine and define themes.

Findings
Thirteen participants were interviewed between June 2021 and November 2021.Twelve participants were included in the analysis process, as during the interview it emerged that one person did not meet the inclusion criteria.All participants were attending their local CMHT.Four participants (33%) were female.At the time of data collection, seven (58%) were in competitive employment and five (42%) were in the job search process (see Table 1 for additional demographic information).
The purpose of the study was to identify the non-vocational outcomes following participation in IPS.Two interconnected themes were identified (see Figure 1) and are explored in the following section.
Theme 1: Increased confidence and positivity Participants' confidence increased through engagement in job seeking and employment.In turn, enhanced confidence and selfesteem, borne of IPS involvement, extended beyond experiences of job seeking and work to influence the nature and extent of participants' engagement in everyday activities.Their renewed sense of purposeful engagement gave way to a recognition of possibilities for meaningful occupational engagement and future planning.
Confidence and esteem building through IPS.The process of both looking for paid employment and being employed had a positive effect on participants' confidence and self-esteem.As Jeremy explained "before I started this job, I was feeling pretty demoralised.It's really helped my self-esteem to be working again [. ..] and to feel competent".Many participants attributed this to the relationship they had with their ES.This crucial relationship was described in numerous, albeit similar ways: "totally on their side" (Mary); "someone being there" (Dexter) and "believing in you" (Eric) as well as "being proud of me" (Emma).Regina described the ES as being "the switch I needed [. ..] instead of knocking myself down, he started building me back up" and attributed her improved self-perception and efficacy to "the confidence he (ES) gave me -I felt valid".
Other elements of the IPS process such as skills building during the job search stage, regular meetings with the ES, and ongoing support while in employment, also facilitated the development and maintenance of confidence and self-esteem.Curriculum vitae and interview preparation led to a decrease in anxiety in applying for work and doing interviews.Roisin recalled previously being "petrified" about interviews but now "knowing what to do [. ..] makes you calmer and each time it gets less stressful".Regular meetings "really helped build up a gradual confidence [. ..] and know, I'm not the only one struggling to find a job" (Emma).
Confidence, developed through involvement with IPS, had reach beyond the sphere of employment.Ian noted that, whilst he had not secured a job, engaging in IPS gave him confidence to explore other options related to productivity, "I decided to go back to further education as a result really of the process".People close to the participants also recognised these intrapersonal differences.Emma said her family noticed "that I'm a bit more confident; that I'm a bit more outspoken".
Optimism for engagement in activities and relationships.Involvement in IPS enabled many participants to view themselves in a more positive light.Steve commented "it's such a downer to say I'm not doing anything [. ..] but to be able to say oh I'm working, ya know, it's amazing".The mental health benefits of the ongoing support of the ES in the job search process were recognised by participants.It "lifted my mood" (Nick); "worked at my pace" (Regina); "they were listening and ready to offer support.That was tremendously helpful for my mental health" (Dan).Regina described the impact of job searching in IPS: Similarly, the positive impact of paid employment on mental health was noticed by many participants, "my mood really picked up after one week into the job" (Jeremy).At both the job search and employment stages, IPS provided the participants with personal challenge and sense of productivity.This gave them purpose and was valued for supporting their mental health.Nick commented "I have to push myself, to use my brain".Dan confirmed that "purpose is very important for one's mental health".
Participants were aware that the challenges, inherent in securing employment, were compounded by mental health problems and consequently perceived themselves as lucky to be involved in the IPS process.Tim acknowledged that he was "not expecting to get a job".Mary discussed experiences of previously seeking work; "the job market, it's a fairly eh rejectful place [. ..] mental health can often be a barrier to getting employment".Several participants appreciated the accessibility of IPS as part of the CMHT with Mary commenting that "employment being tackled inside the mental health centre is a real step forward".Some participants also reflected that their IPS involvement had a positive influence on their work with other members of the CMHT.
IPS positively affected some participants' hopes for the future such as securing a "better job" (Nick) and being more open to trying "new things" (Ian).Increased optimism and direction were noted by participants.Dan discussed that "there's light at the end of the tunnel.You're working toward something.To have hope is very important".Similarly, Ian discussed how the ES "really helped me realise things are still possible".The financial benefit of engaging in paid employment was acknowledged by multiple participants, which afforded the chance to socialise and attend events.Jeremy noted "I have more money to go out, it's hard to socialise with people when you have very little money'.Increased finances also enabled planning for life changes: Getting me own place and getting me own girlfriend, getting me own independence really and I think when you get a job like you're much more able to do that (Dexter).
Theme 2: More purposeful time use and engagement with society By virtue of their involvement in IPSthrough job searching and/or workingparticipants were required to change how they used their time daily resulting in the restructuring of their weekly routines and the introduction of additional activities, relationships and connections with society.
Purposeful time use and activity engagement.Several participants identified the value of employment to add routine and structure to the week, as well as differentiate days and distinguish between weekdays and weekends.Tim explained employment "breaks the week up" and Eric noted "keeps me more on track because I would be more thinking about what I'm doing week to week".Participants appreciated having order and regularity to their job search, for example "job searching for one hour a day" (Emma), "my calls from IPS are during the week and tend not to look for jobs at weekend" (Dan), and this was a result of structures and processes suggested by their ES.
Time use became more purposeful and participants' engagement in activity changed in nature and extent.Employment allowed participants' use of existing skills as Jeremy explained he got a job in "tech and that's what I had studied for" as well as development of new skills.Participation in a productive role, through work or job search, had a positive knock-on effect on time use and activity engagement overall.A sense of energy for engaging in interests was noted.Describing his hobby of creative writing, Dan acknowledged "I'd pretty much given it up before and now I'm actually trying it again".Similarly, Regina stated "now I'm up every day walking the dog [. ..] and do a little bit of exercise".This was echoed by other participants who described being "more active and spending less time playing on Xbox" (Eric); trying new things like yoga (Roisin) or "focussed on a lot of my own hobbies recently" (Dexter).Jeremy identified spending time outside of work in "better ways, doing other things outside of work" and Emma noticed increased activity levels and regulation of her sleep.Beyond hobbies, some participants noted more incentive to do chores, for example "get laundry done without overthinking the doing of it" (Dan).
Feeling part of society.A principal change that was experienced for participants involved in the IPS process was how they perceived themselves as contributing members of society.Interestingly, this was experienced by both those in competitive employment as well as those at the job search stage.Dan explained that previously he felt "I was a leech on society; but this has changed with the whole process of applying for work again. ..." And similarly Steve stated; "I think it's more to do with feeling useful" as many participants had acknowledged feeling disconnected prior to engaging in the IPS model.Participants recognised a link between employment and their identity; irrespective of whether they were in employment, the act of authentic involvement in the work arena, including job searching, developed a sense of kinship with society.Dan discussed that prior to getting involved in IPS "you can just sit there and think about yourself.What are you?Who am I?" but this was changed by "the whole process of applying for work again [. ..] now I am one of the many looking".
Employment and the job search process contributed to a sense of acceptance of participants by others and provided them with a reason to connect with society.Those who were in competitive employment described feeling included in the work culture: "I've plenty of interaction with co-workers [. ..]I have chats with one colleague in particular but like video chats with the bosses [. ..] it's great, it's friendly and it's helpful, like it's not just social. .." (Mary).For Dexter, work was about "connecting with other people and being accepted for who I am".Looking for a job not only gave Regina an aim and purpose but formed the bases of her interactions with others and in this way gave her a reason to connect "I had something to tell people about because I had something to work towards".
Positive changes in the domain of societal engagement were not restricted to the area of work.Increased satisfaction with participants participation and engagement in society generally was noted and included "meeting friends" (Steve), "engaging in conversations more" (Tim) and "relationships in general" (Jeremy).Emma noticed an improvement in communication describing how she was "a lot more comfortable in my everyday interactions".Some participants perceived a change in the dynamic of their interactions as result of taking part in IPS."I got respect from quarters that I didn't expect, like my friends, about my tenacity despite my difficulties about trying to get work' (Ian).A greater sense of connection with their local community was also reported, for example Ian spent more time "looking in windows and walking around the city".Even those who had not secured work described changes in their community participation and sense of belonging in spheres not directly related to paid employment e.g.going to the shop (Ian) and feeling more involved in college (Roisin).

Discussion
The aim of the study was to explore non-vocational outcomes when participating in IPS.The main themes identified in the analysis related to increased confidence, well-being and positivity which contributed to more purposeful and satisfying time use, participation in activities and engagement with others.Reflected in these themes were the five elements of personal recovery identified by Leamy et al. (2011) connectedness, hope, identity, meaning and purpose in life, and empowermentalso found by Gammelgaard et al. (2017).In keeping with studies by Coombes et al. (2016) and Raeside and McQueen (2021), participants described increased participation in activities outside of IPS as they had more energy, confidence and purpose, which in turn led to enhanced connections with the community and sense of belonging (social inclusion).
Feeling part of society, even during job searching, reduced feelings of being a burden on society.Engagement in this activity had the power to change how participants considered themselves to be perceived by society.Unlike the Coombes et al. (2016) study, nobody identified negative aspects of the IPS process.A number of the participants reported to feel lucky to be involved in IPS rather than viewing participation in employment as a basic right.Perhaps this reflects experiences of stigma in employment or attitudes around employment prospects projected by mental health services.Moen et al. (2021) noted some clinical have low expectations regarding work expectations.
Multiple participants acknowledged the key role of the ES and how it was different from traditional vocational support.They described "having someone believe in you" as the key element, regardless of the outcome of the job search.This contributes to the growing research outlining the powerful influence of the ES relationship in the IPS process to support a recovery-oriented service (Vukadin et al., 2021).The accessibility of the IPS services was facilitated by having the ES on the CMHT, which, as outlined in the National IPS Standard Operating Procedures, is fundamental.
Occupational therapy is compatible with the IPS model (Chen and Lal, 2020), as both offer a person-centred approach that enables maintenance of employment (Raeside and McQueen, 2021).Prior et al. (2020) introduced an enhanced IPS based on the Model of Human Occupation delivered by occupational therapists for people with more complex needs, highlighting the relevance of using the Worker Role Inventory.The findings of this study indicate that occupational therapy could further support recovery by building on the increased feeling of confidence and belonging to enhance participation in other activities of meaning in society.Occupational therapy may be beneficial, in collaboration with the ES, to facilitate the IPS process in building skills or providing support if expected employment outcomes are not achieved.
A sole focus on competitive job outcomes overlooks the need for a more nuanced understanding of the impact of the process.IPS has reached beyond vocational outcomes which demands exploration and research.Individualisation of recovery is critical to ensure value is not being placed on a couple of hours in low wage competitive employment to the detriment of other aspects of mental health recovery.This study reveals the value in continuing to invest in IPS for people with severe mental illness throughout Ireland as part of routine community mental health practice.

Limitations and implications for future research
The study was conducted in one urban area within the HSE which may reduce transferability.The context of COVID-19 at the time of the study impacted the delivery of the IPS service, the climate of employment and the jobs market in Ireland.There was no patient or public involvement (PPI) in the research study.The recruitment strategy included active IPS participants, consequently omitting the experiences of those who stopped engaging in the process.Interviewees had the opportunity to review their transcripts but not member check findings.The point-in-time study design did not capture longer term benefits.A longitudinal research design may increase understanding of the outcomes of IPS over time.Future cost benefit research to investigate the impact of IPS on mental health service use, as well as its economic value, is warranted.

Conclusion
This study contributes to the literature regarding nonvocational benefits of IPS within an Irish context for participants during the job-seeking stage as well as those in competitive employment.It highlights the mental health recovery benefits of participating in IPS and the need for IPS to be delivered as standard practice across Ireland for people who experience severe mental health difficulties.

I
was a shell of a person; I was completely introverted; I had shut everyone out [. ..]I didn't answer my phone [. ..]I felt I didn't deserve friends like them because I was such a failure.So, through working with [the ES] I regained confidence [. ..]I had something that gave me an interest again.
Exploring the non-vocational outcomesLeonie Boland et al.

Table 1
Demographic information