Occupational therapists’ perspectives of the individual placement and support (IPS) approach in mental health services in Ireland

Employment is a positive determinant of health, well-being and recovery for people with mental illness (Bond and Drake, 2012). It fosters independence and routine, promotes inclusion, enhances financial supports and re-establishes self-worth (Netto et al., 2016). However, stigma, discrimination and fears around disclosure of mental illness are reported as barriers to gaining employment (Waghorn et al., 2012). In Ireland, people with mental health difficulties are nine times more likely to be unemployed than those without a diagnosis (Watson et al., 2015). Recognising this, a National Steering Group was set up to support the establishment of Individual Placement and Support (IPS) within the Irish mental health services. A pilot project, resulting in at least 50% of the 65 participants obtaining paid competitive employment, led to the scaling up of IPS in Ireland (Mental Health Reform, 2017).

IPS differs from traditional “train-then-place” vocational rehabilitation approaches by having a focus on competitive employment from the start, an emphasis on finding a job that suits the person’s preference and then supporting them to develop skills while working (Drake et al., 2012). Other core principles include that everyone with a desire to work is eligible, that individualised time-unlimited support should be provided and that employment specialists should be integrated into community mental health teams to facilitate IPS successfully. Research suggests that IPS as an evidence-based intervention is three times more effective than other vocational rehabilitation programmes (Drake and Wallach, 2020; Bond et al., 2008) reviewed 11 randomised controlled trials and found that IPS achieved significantly higher employment rates (61% for IPS vs 23% for controls) and that IPS participants were in employment earlier. In an Irish study (n = 38), IPS “successfully assisted 50% of those without a job to attain one” when enhanced with a job retention group-based intervention (Turner et al., 2019, p. 120).

Qualitatively, IPS is highly valued by participants and results in people feeling more like part of society, more engaged in activities in their communities and in experiencing more satisfying and purposeful time-use (Boland et al., 2024). It is the recommended approach for facilitating people with mental health difficulties to seek and maintain employment by many expert groups, such as the Centre for Mental Health in the UK (Centre for Mental Health, 2022), the NICE guidelines [NICE (National Institute for Health and Care Excellence), 2015] and is embedded in mental health service provision in Ireland (Working Well Ireland, 2024). However, some authors argue that IPS should be augmented with more long-term support for participants in job retention – recognising that sustaining employment alongside enduring mental health and social difficulties is highly challenging (Cameron et al., 2012; Turner et al., 2019).

Supporting engagement in work is a core domain of occupational therapy practice, particularly in mental health settings. The introduction of IPS services has led in places, to occupational therapists withdrawing from their employment facilitation role (Machingura and Lloyd, 2017) and a call for them to re-claim this area of practice. There is strong alignment and compatibility between occupational therapy and IPS. Shared values include the client-centred approach, engagement in valued occupations and the facilitative process in assisting individuals to return to and maintain work (Turner et al., 2019). During the rollout of IPS in Ireland, occupational therapy was highlighted from the start as a key profession that could enhance its success. When IPS employment specialists were recruited, their work and integration into mental health teams were supervised by occupational therapy managers (Sharek et al., 2022). Most referrals to IPS come from occupational therapists (Machingura and Lloyd, 2017). Researchers have evaluated IPS augmented by occupational therapy clinical support and/or theoretical frameworks (Turner et al., 2019) and in some cases, delivered entirely by occupational therapists (Zhang et al., 2017). Nevertheless, focus groups with occupational therapy managers exploring how IPS was embedded in Irish mental health services raised a number of challenges; including that health professionals may show resistance, doubt and reluctance to embrace this new approach (Sharek et al., 2022).

Currently, IPS is implemented with “good” fidelity (Burke, 2017) across all mental health services in Ireland as a national programme, and is subject to an ongoing quality review process (Sharek et al., 2022). IPS employment specialists not only are often supervised by occupational therapy managers but also work closely with other occupational therapists as part of the multidisciplinary team. The experience of managers (Sharek et al., 2022) and service users (Boland et al., 2024) with this model has been explored. This study aims to explore the perspectives of occupational therapists who work alongside IPS employment specialists on community mental health teams in Ireland, but who are not in a management role. The research objectives were to explore occupational therapists’ experiences of and perspectives on the following:

• the IPS approach in Irish community mental health services;

• the enablers and challenges to successful implementation of IPS; and

• The potential inter-relationship and interconnection between occupational therapy and IPS.

The researchers took a qualitative descriptive approach to this study. This approach stays close to the data and uses the participant’s language during data analysis, in contrast to more interpretive/inferential approaches (Sandelowski, 2000). A qualitative approach was more appropriate than, for example, a survey, as we wished to gain rich description and a comprehensive understanding of the phenomenon of IPS from the therapists’ perspectives.

Once ethical approval for this study was granted by the ******* Research Ethics Committee in January 2024 (Application No: 23.24–108), occupational therapists (of all grades) were recruited through the Association of Occupational Therapists of Ireland (AOTI), who emailed an information sheet to therapists who had given permission to be contacted for research purposes. Occupational therapists who contacted the interviewer and who had experience working in community mental health services and had experience working with/alongside IPS programmes or staff, were recruited. A sample size of 5–10 individuals was sought, considering the homogeneity of the participants (occupational therapists in similar roles), the specificity of the area being researched and that participants are speaking to their own direct experience (data-rich respondents) (Conroy, 2016). Hagaman and Wutich (2017) state that 12–16 participants can be large enough for focused qualitative research with homogenous participants. However, the current study was carried out within the defined timeframe of an academic programme – leading to a shorter-than-ideal recruitment period.

In total, 11 people expressed interest in the study. Six signed consent and agreed to participate in an interview. The participants were all female senior occupational therapists with a range of years of experience (range = 6–34 years, mean = 13.16 years). Participants were in their current role for an average of 4 years (range = six months – 10 years).

A semi-structured interview protocol was developed to include questions addressing first impressions and expectations of IPS; experiences of working with and alongside IPS staff; challenges and enablers to effective IPS interventions; and perceptions of how IPS and occupational therapy intersect/interact/have commonalities or differences (see  Appendix for the interview protocol). The interviewer (first author) carried out a pilot interview with a colleague who had experience of community mental health services and IPS to refine the questions and their interviewing technique. The interviewer was not known to participants prior to the interviews, and was in an academic, rather than clinical, role.

After written consent was obtained (digitally), an online interview was arranged using Microsoft Teams™. The interviews ranged in length from 15 to 38 min. Online interviews help with recruitment, are convenient for participants and can reduce potential power imbalances in research but may make reading non-verbal cues more difficult during interviews (Brown, 2022). The interview recordings were deleted once the interview transcripts were completed. Confidentiality was maintained by using a pseudonym (e.g. P1) and all references to places of work or other potentially identifiable information were removed.

Reflexive thematic analysis (Braun and Clarke, 2019) is an approach to qualitative data analysis that has a broad literature base to guide researchers. The process involved; deep reading of the interview transcripts, inductive coding, organising the codes into potential themes and a cyclical process of reviewing and refining the themes and subthemes. The first author carried out the initial coding phase, and, in meetings with the second author, the codes and themes were refined and reviewed. A pragmatic paradigm guided the coding. This meant that, while the inductive coding kept the analysis close to participants’ words, it was also important that the specific research objectives were addressed and that the results could be applicable to practice or further research (Ramanadhan et al., 2021). An example of the initial coding is in Figure 1.

To increase rigor, the first author used reflexivity practices, such as completing a reflective journal and showing clearly how findings were drawn from the data in meetings with the second author. Reflection helped to illuminate areas of potential bias or “leading” of the interviews and an extract is presented in Figure 2 for transparency.

Following thematic analysis, the results were organised in three themes (Figure 3): characteristics of IPS, facilitation of IPS and interplay between Occupational Therapy and IPS.

The occupational therapists interviewed clearly felt that the distinctive structure of the IPS intervention was separate but complementary to the clinical care that mental health service users receive, stating, “It’s a business model within a clinical setting” (P4). It was viewed as a “a model that’s got very clearly defined terms” (P2), that when followed systematically, helps people achieve positive outcomes:

The therapists saw these positive outcomes for service users in a wide range of aspects, not just in employment. These included vocational success, confidence building, community involvement and identity development:

These outcomes were felt to be linked to the clear programme structure, which allowed for “fidelity reviews….makes it so evidence-based” (P5). The outcomes could be seen over a long-term period, giving the therapists better confidence in the IPS intervention:

One contrast to this was the area of early intervention in psychosis, where IPS has only more recently been established:

In general, IPS was seen to tap into an area of life that is very important for service users. For example, P3 stated that, “service users are extremely motivated and they’re very invested in their recovery and they only want to go forward” (P3). The IPS service was felt to have the resources and opportunities to explore options and choices for individuals for employment and beyond:

In some cases, the occupational therapists in this study had been involved in the initial rollout of the IPS service in their areas but all participants were well-versed in the theoretical background of the model and how it had developed in other contexts. So, they were very optimistic and had positive first impressions of the intervention:

Participant 3 in particular had been highly involved in setting up the IPS service, including in “looking at funding, getting the training and seeing what employment partners might be out there”. Unfortunately, this work coincided with the outbreak of the COVID-19 pandemic and now, even after the pandemic had ended, IPS had not been fully implemented:

Another challenge that participants reported as an impediment to the successful facilitation of IPS was the challenge of retaining talented employment specialists, which was felt to affect the consistency of service provision for service users. Consistency was mentioned by several participants as being important for the IPS approach:

The main factors affecting whether talented employment specialists are retained in posts was the nature of their contracts, which in the view of these participants, were short-term, temporary and lacking career advancement opportunities:

A factor that supports the facilitation of IPS, and the retention of valued employment specialists, was the successful integration of the employment specialist into the multidisciplinary (MDT) team “like any other MDT member” (P5). Collaboration and successful MDT working was enhanced by having shared spaces and full participation in activities of the MDT, such as meetings:

Where integration of IPS and the employment specialists had been successful, participants emphasised the significant impact its removal would have on practice:

All six participants reported positive experiences collaboratively working with the employment specialist in their teams, described as “an OT working hand-in-hand with an employment specialist” (P2). The therapists were in regular communication with the employment specialist, usually “twice a month” (P1) or “once every two or three weeks” (P3), possibly because, as one participant noted, occupational therapists were “employment specialists biggest referrers” (P6). For one participant, this had extended to being almost a mentoring or supervision relationship, with the occupational therapist providing support to the employment specialist on working with people attending the mental health services:

The occupational therapists interviewed saw their professional role and expertise as being highly aligned to the IPS model, but also as distinct and separate. One participant raised the potential of role overlap [“there can be a bit of a blur in roles” (P4)], but other interviewees noted distinction between the two – possibly reflecting differences in referral procedures in different services:

Three participants noted that the roles were clear partly because all aspects of employment and job exploration in their services were now dealt with by the employment specialist, which they were somewhat ambivalent about – one reflecting that if occupational therapists had adequate staffing, “we would be doing the same” (P1):

This ambivalence was seen in contradictory statements, where therapists described IPS both as potentially taking over occupational therapy work, but also as a separate role:

There was a sense that the introduction of IPS had diverted occupational therapists into more specialist areas of work, outside vocational rehabilitation, and again, there was ambivalence here. One participant used the phrase; “we got pushed into different aspects of other work” but also stated that “it eases the pressure off” (P1). This increased specialisation was seen as somewhat inevitable, as Participant 2 concluded:

However, most occupational therapists recognised that while there are commonalities in approach [“being client-centred” (P3)], the employment specialists have a distinct skill-set and outlook that is complementary and necessary. This was seen as including skills in the areas of workplace recruitment, advocacy and employer engagement:

This study explored the perspectives of six occupational therapists with experience of working alongside the IPS service in an Irish mental health context. Their perspectives answer the research objectives of this study and have a number of implications for practice and research in the Irish context.

Participants acknowledged that the shared (and overlapping) values of the IPS and occupational therapy approaches, particularly the client-centred and supportive principles (Auerbach, 2002; Bejerholm et al., 2015; Turner et al., 2019) supported service users to engage in work and furthered their recovery. Because of these shared values, the occupational therapists had a positive initial response to the IPS approach being introduced in Ireland. IPS was recognised as an evidence-based approach that had shown efficacy and workability in other countries (Bond et al., 2023; Muesser et al., 2016; Noyes et al., 2018).

Once in place, the participants noted that the positive benefits of IPS, particularly purpose, financial stability, confidence and self-identity, were also seen for their service users. Research with IPS service users confirms these perceived positive outcomes in the Irish context (Turner et al., 2019). IPS was viewed as a well-embedded approach, with a structured pathway, confirming that it has been implemented with good fidelity in this context (Burke, 2017).

The findings of this study would suggest that a collaborative, cohesive relationship between the occupational therapist and employment specialist is critical to the smooth establishment and facilitation of the IPS intervention – a finding confirmed among occupational therapy managers (Turner et al., 2019). The occupational therapists interviewed played a vital role in the successful integration of employment therapists into the multidisciplinary teams.

Because employment specialists may not have received clinical training in supporting people with mental health diagnoses, the need for clinical support, supervision and mentorship was raised by Participant 4 in this study and was found in other studies discussing the challenges of integrating colleagues without health-care training into teams (Shepherd et al., 2012; Waghorn et al., 2012). Because of their extensive history in vocational rehabilitation in the mental health context, occupational therapists are well-placed to be leaders in advocating for, and supporting, the implementation of IPS in new contexts (Williams and Lloyd, 2016).

The participants identified an issue with the recruitment and retention of IPS employment specialists in Ireland. This was a barrier to cohesive service delivery and team-building. Employment specialists have a significantly higher than average rate of turnover in comparison to other public sector employees (Butenko et al., 2022). Reasons for this include poor job satisfaction, limited supervision opportunities and large caseloads. Employment specialists report a challenging work environment, including negativity from team members (Butenko et al., 2022) and poor pay (Vukadin et al., 2021). A priority for the successful implementation of IPS, and the retention of employment specialists (Hillborg et al., 2021), is the supportive integration of these staff within existing multidisciplinary teams. This can be done by training healthcare professionals on IPS and the employment specialist skillset (Butenko et al., 2022), as well as longer, more permanent contracts and pay progression opportunities (Vukadin et al., 2021).

The overlapping, but complementary, perspectives of IPS and occupational therapy were reflected in the accounts of the occupational therapists interviewed here. Work and productivity have long been within the domain of practice of occupational therapists (Machingura and Lloyd, 2017). It is unsurprising therefore, that the participants interviewed felt, at times, that their role in supporting service users in productivity had been lost. With the current pressure on the Irish mental health services however, they recognised that employment specialists were necessary and valued. IPS specialists have the skill-set to “go out and advocate and hustle” (P2) on behalf of service users to employers and workplaces. This specialist and in-depth knowledge of employment specialists is highly valued by service users (Poremski et al., 2017). However, long-term outcomes of IPS are dependent on the level of long-term support provided (Dudley et al., 2014). Studies where occupational therapy and IPS employment specialists work collaboratively over longer periods appear to show better outcomes (Turner et al., 2019; Williams and Lloyd, 2016). As some participants noted in the current study, both professional groups have a valuable skillset that, if successfully implemented in partnership, could be more powerful for service users.

This study did not compare perspectives of occupational therapists and IPS employment specialists on their working relationship in the mental health services. Shepherd et al. (2012) note that because employment consultants usually do not have clinical backgrounds may mean they have a different perspective in the healthcare team – sometimes taking less of a symptom-focus. They note that “the notion that symptoms must disappear before the person is ‘ready’ for vocational rehabilitation is ubiquitous and deep-seated in the culture of health services” (Shepherd et al., 2012, p. 32). The occupational therapists in the current study saw a part of their role as supporting employment specialists with their mental health knowledge and skills – perhaps moving away from their own client-oriented, occupational focus (Machingura and Lloyd, 2017). The experiences of IPS employment specialists on this close, but potentially overlapping relationship warrants exploration.

Future research should explore the role and effectiveness of IPS in supporting employment for the most marginalised people with mental health difficulties, especially those experiencing multiple challenges, such as homelessness, migration or co-morbid diagnoses. Interventions to assist the retention of IPS employment specialists in posts should be evaluated, as rapid turnover in these roles was identified by these therapists as disruptive. Evaluations of IPS, such as Prior et al. (2020) could explore how occupational therapy can collaborate with, and enhance, the work of employment specialists – particularly those with more complex mental health difficulties.

This study used purposive sampling to gather comprehensive data from experienced and knowledgeable participants. However, as participants volunteered to be interviewed, it is possible that occupational therapists with a strong viewpoint on IPS were included. The data were collected and analysed during a short period of time in January–March 2023 as part of a time-limited academic programme, so this may have affected the richness of analysis. However, a clear audit trail and codebook were produced and the codes were reviewed with both authors. Finally, the sample size of six participants may be considered small. This may not have been large enough to identify all potential themes from these participants on this topic (Hagaman and Wutch, 2017).

This study aimed to explore the perspectives and experiences of the IPS intervention among occupational therapists on community mental health teams in Ireland. These six participants felt that IPS was effective in supporting individuals with mental illness to find and retain employment. A collaborative relationship between the occupational therapist and employment specialist was felt to be important for effective and cohesive service delivery, as were distinct, yet mutually beneficial roles for each.

The authors wish to acknowledge the support of the AOTI in recruiting study participants and to thank the occupational therapists who contributed their valuable time and perspectives on this topic.

The authors declare that this work is entirely their own and that they have acknowledge the writings, ideas and work of others.

This research received approval from the College of Medicine, Nursing and Health Sciences Research Ethics Committee (University of Galway) on the 9th January 2024 (Ref: 23–24-108).

Interview Guide (Revised following piloting)

Welcome the participant and thank them for partaking in the study

Explain the purpose of the study, your interest in the area and what you hope to get from it.

Reiterate the voluntary nature of their participation and if any area of conversation becomes distressful, to alert the researcher.

Gain their informed consent (again) for audio recording of the interview

• Age

• How many years of experience in the service?

• What were the motivators to begin working as a mental health OT?

• What was your prior experience of IPS?

• What were your expectations of the IPS intervention?

• Can you describe how you felt when you started working in a service with IPS as a vocational rehabilitation approach?

• Were you involved in the setup of the IPS approach in an Irish community mental health service?

• If so, what were the enablers and positive factors relating to the establishment of the service?

• What were the challenges experienced at the time?

• How were these challenges overcome in the past to help with the establishment of the programme in Irish community mental health services?

• What solutions are used in current practice to manage workplace challenges in relation to IPS? Were the same solutions used at the initial implementation of the programme?

• What are the current challenges with implementing the IPS intervention in practice?

• Do you think IPS is an effective approach to obtaining and maintaining employment for people with mental health difficulties? Why? Why not?

• How effective do you think the IPS intervention is?

• How do you think service users perceive the IPS intervention?

• What are your general perceptions of the role of occupational therapy in the IPS programme?

• Have these perceptions altered with increased experience in the service? If yes, please explain.

• How would you describe your working relationship with the employment specialist? Are there any challenges or benefits to having a collaborative relationship with the employment specialist in the multidisciplinary team (MDT)?

• How do you perceive the IPS programme as a possible enhancement or threat to the OT profession?

• Is there anything you’d wish to change about IPS or the facilitation of the intervention? If so, how would you change it?

Thank the participant for their time and contribution to the study reiterate confidentiality and data protection policies.

Ensure they are aware of your contact details if any questions or concerns arise post-interview

Request any final comments or additional thoughts they may have on the topic debriefing (if necessary).