Epidemiology and Psychiatric Boosting the development of individual Sciences placement and support in Europe cambridge.org/eps Hlynur Jónasson1, Jaap van Weeghel2,3, Débora Koatz4,5, Gary Johnston6, Ulrika Bejerholm7 and Angelo Fioritti8 1 Editorial Landspitali, Psychiatric Hospital, Reykjavik, Iceland; 2Phrenos Center of Expertise, Da Costakade 45, Utrecht, The Netherlands; 3Tranzo Scientific Center for Care and Wellfare, Tilburg School of Social and Behavioural Sciences, Cite this article: Jónasson H, van Weeghel J, Tilburg University, Tilburg, The Netherlands; 4Avedis Donabedian Research Institute, Barcelona, Spain; 5Universitat Koatz D, Johnston G, Bejerholm U, Fioritti A Autònoma de Barcelona (UAB), Barcelona, Spain; 6Social Finance, London, UK; 7Department of Health Sciences, (2022). Boosting the development of individual Lund University/Research and Development Department, Mental Health Services, Region Skåne, Sweden and placement and support in Europe. 8 Department of Biomedical and Neuromotor Sciences, School of Hygiene and Preventive Medicine, University of Epidemiology and Psychiatric Sciences 31, e29, Bologna, Bologna, Italy 1–4. https://doi.org/10.1017/ S2045796022000129 Received: 22 February 2022 Introduction Revised: 15 March 2022 Accepted: 18 March 2022 Employment is a critical factor in the rehabilitation and recovery of people with severe mental health problems (SMHP). However, employment rates for this group are far lower than in the Author for correspondence: general population and well-known are the many barriers for people with SMHP to enter the Angelo Fioritti, labour market. The right to employment is recognised in the European Disability Strategy and E-mail: angelofioritti@gmail.com the European Pillar of Social Rights (principle 17) and the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD art. 27). There is a strong need for having access to effective programmes offering multi-faceted supports in regaining and maintaining com- petitive employment. Individual placement and support (IPS) is such a programme par excellence. Among the several policies, practices and interventions implemented in the last decades IPS stands out for its effectiveness and feasibility, demonstrated by an impressive amount of empirical studies. Among 28 randomised controlled trials (RCTs) comparing IPS to traditional vocational services, all but one showed superior competitive employment rates for IPS. From the 1990s IPS has grown rapidly, initially mainly in the US, proving to be easier than other psychosocial intervention to be transferred into routine practice and to be transported across different mental health systems (Bond et al., 2020). A strong driving force behind the expansion is the IPS learning collaborative, guided by the IPS Employment Center in New Hampshire (Becker et al., 2014). Established in 2002, this col- laborative coordinates education, training, technical assistance, fidelity assessment, quality assurance and outcome monitoring, as well as regular communications through newsletters, bimonthly calls and annual meetings. The growing size of the European IPS professional com- munity now generates the need to establish a similar IPS learning community, in close collab- oration with American colleagues, with a view to facilitate the sharing of expertise and the exchange of experience with regard to the dissemination, implementation, and evaluation of IPS practices across Europe in all its diversity. In this paper, we describe the development of IPS practice in Europe, and the establish- ment, objectives and intended activities of the IPS European Learning Community (ELC). Development of IPS in Europe At the beginning of this century the European scientific community viewed IPS with scepti- cism, doubting the possibility of replicating the extremely good results coming from the US, relying more on the long tradition of vocational rehabilitation based on sheltered workshops, training centres, social enterprises and legislated quota systems (Fioritti et al., 2014). IPS was first introduced on a limited scale in six European countries (Bulgaria, Germany, Italy, © The Author(s), 2022. Published by Netherlands, Switzerland and UK) that participated in the EQOLISE study, a RCT aimed to Cambridge University Press. This is an Open test the effectiveness of IPS. EQOLISE replicated the excellent results of American studies, des- Access article, distributed under the terms of pite extensive differences in labour market regulations, and in the organisation and culture of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), mental health services. IPS proved to be superior to treatment as usual for the number of peo- which permits unrestricted re-use, distribution ple entering the competitive market (55% v. 26%), the number of days and hours worked, and and reproduction, provided the original article the amount of money earned. Differences were found also as to hospitalisations, drop-out from is properly cited. treatment, or overall psychopathology, though not statistically significant (Burns et al., 2007). Following on the EQOLISE study, a growing number of countries started to implement and further evaluate IPS. IPS has also been recommended in European policy documents (OECD, 2015; The European Mental Health Action Plan, 2013–2020, 2015; EU Joint Action on Mental Health and Wellbeing, 2016). IPS programmes are currently found in Belgium, Czech https://doi.org/10.1017/S2045796022000129 Published online by Cambridge University Press 2 Hlynur Jónasson et al. Republic, Denmark, Finland, France, Germany, Iceland, Ireland, participating in the international IPS learning collaborative, fidel- Italy, Netherlands, Norway, Spain, Sweden, Switzerland and UK. ity monitoring and, in some countries, the rapid growth of And to date, nine more RCTs on IPS have been conducted, in long-term disability rolls. These factors, plus the international six European countries (Heslin et al., 2011; Hoffmann et al., consensus that IPS is a programme based on strong scientific evi- 2012, 2014; Michon et al., 2014; Bejerholm et al., 2015, 2017; dence, explain the spread of IPS outside the US, both in Europe Viering et al., 2015; Reme et al., 2018; Christensen et al., 2019; and in other continents (Bond et al., 2020; Drake et al., 2020). Sveinsdottir et al., 2020; Hellström et al., 2021), all with results in favour of IPS. Towards a European learning collaborative on IPS However, in Europe as a whole the diffusion of IPS is still pat- chy. The degree of implementation of IPS varies, as do implemen- In 2019 a few enthusiasts from various countries (Iceland, Italy, tation barriers that each programme has to face. In each European Netherlands, Spain, UK) came to consider to start an IPS ELC. country, the organisation of governmental services, funding of After some preparatory online discussion meetings, other IPS mental health and vocational services, labour legislations, disabil- practitioners from European countries were identified and con- ity policies, national history and culture have all shaped the evo- tacted by using professional networks, literature search and snow- lution of IPS services on a system level. Other critical components balling. They organised three webinars spaced over 6 months, in are also evident at the regional and local organisation levels which representatives from different countries presented the (Bergmark et al., 2018). state of affairs of IPS practices in their countries. Ultimately the Given this diversity, each country has followed its own path- face-to-face conference took place in Reykjavik, Iceland, on way to IPS development (Fioritti et al., 2014; IIMHL, 2019; 16–17 September 2021. For this meeting, an Erasmus application Drake et al., 2020), but mostly through two main ways. The was awarded to partly fund the event and member attendance. first one goes bottom-up, with pilot centres developing it and The primary goal of this meeting was to establish the IPS ELC then sensitising other professionals, managers and decision- with IPS leaders from as many countries as possible. A learning makers. The second way goes top-down, with leaders, stake- community is neither a scientific association nor an educational holders and policy-makers adopting it regionally or nationally enterprise. Actually, it is a community of practice, a partnership and lobbying by international bodies. among people who find it useful to learn from and with each In some countries of Northern Europe (Sweden, Netherlands, other about a particular domain. Participants use each other’s Norway, Iceland and UK), the dissemination of IPS has gradually experience of practice as a learning resource. And they join forces become a matter of national policy. In these countries national in making sense of and addressing challenges they face individu- investments are made with regard to mobilisation, implementa- ally or collectively (Wenger, et al., 2011). tion, training needs analysis, fidelity reviews, action plans and The inaugural IPS ELC conference in Reykjavik was held to local technical support, training and, research all as a combined discuss common objectives and activities: first, to build the case approach for quality assurance. In other countries, the dissemin- to support further scaling of IPS across Europe; second, to create ation of IPS is guided by regional policies adopted after successful resources and support for that scaling; third, to develop a learning local programmes, such as in Italy (Emilia-Romagna) and Spain community to guide IPS practice in the European context. (Catalonia, Tenerife Island) (Rodríguez Pulido et al., 2017; In total 48 individuals from thirteen countries participated in Hilarión et al., 2020). In yet other countries (Belgium, Czech this conference. The following topics were addressed extensively Republic, France) IPS is only conducted in some single pioneering by means of presentations, workshops and planning meetings: practices, and in a few countries IPS programmes are implemen- valuing and using personal experiences in IPS practice; fidelity, ted mainly for research purposes (Germany and Switzerland). challenges and chances for programme evaluation and quality Finally, most of Central and Eastern European countries are still improvement; peer support/co production of IPS services; man- in a preliminary phase. aging IPS and job retention; IPS and substance misuse; IPS and As a consequence, IPS practices are currently financed from sharing personal information (disclosure). The group also various sources: health-related funding, social welfare, labour acti- explored how to best harness the talents, passion and expertise vation funding, funding by charities and foundations, government of the participants to best support the scaling of IPS across funding, research grants, or a mixture of these funding sources. In Europe. It was agreed upon that the ELC will continue to organise a number of countries, IPS is provided by mental health care webinars every three months. And a face-to-face meeting will be organisations, as it was originally done in the US (Iceland, Italy, organised every year. Netherlands, UK), in other countries by municipal administra- tions or by NPOs under their allowance (Denmark, Norway, Reflections and future directions Sweden). In all countries, IPS is conducted by employment spe- cialists with various professional backgrounds: e.g. occupational What is needed is to support the completion of the process all therapists, professional educators, social workers, nurses, psychol- over Europe. How can a ELC Community help to bring IPS ogists. In some countries the training needed to become an IPS into routine use? employment specialist is offered by national certified bodies To answer this question Drake and Wallach (2020) made a (Netherlands, UK) or universities (Sweden). convincing argument that employment should above all be seen In most countries, quality assurance activities targeting IPS as a critical health intervention, based on five reasons. First, peo- practices are carried out through fidelity reviews and outcome ple with disabilities and those without disabilities deteriorate analysis. Some minor adaptations to the IPS model are made when they become unemployed. Second, people with disabilities locally, to make the language and delivery approach more congru- and those without disabilities improve their mental health and ent with present health and social organisations. Factors that sti- wellbeing when they become employed (Harnois and Gabriel, mulated the growth of IPS were: the impact of local IPS research 2000; Van Rijn et al., 2016). Third, we now have an effective inter- studies, local champions and dedicated national leaders, vention, IPS, that helps 40% to 60% of people with a wide range of https://doi.org/10.1017/S2045796022000129 Published online by Cambridge University Press Epidemiology and Psychiatric Sciences 3 health and psychosocial conditions to become competitively Nevertheless, ever more employers show an interest in ‘inclusive employed. Fourth, beyond the health benefits, we know that pro- employment’, i.e. in a company where the work is organised in viding more good workers in competitive jobs helps businesses, such a way that everyone is able to participate fully and to contrib- the economy and the welfare system. Finally, helping people ute to the operating result (Zijlstra et al., 2012). with disabilities to achieve a meaningful life is a moral imperative, This list of innovative elements in the implementation of IPS a disability rights issue and a human rights issue. in Europe (which are also visible in the US) is not exhaustive. The Helsinki Mental Health declaration (EUR/RC55/R2) in Other developments such as sharing personal experiences, peer- 2005 and the WHO European Mental Health Action Plan support workers in IPS programmes, and the use of virtual reality (2013–2020) made mental health a priority on the European interventions should also be mentioned here. These innovations Agenda, aiming at guaranteeing rights and integrating mental indicate the need for updating manuals and to write a health evidence-based policies for opportunities associated with European Manual leaded by the ELC. full citizenship including social affairs, education and employment. IPS can be very helpful in reaching these objectives, especially con- sidering the rapid evolution it had in a wide range of directions. Conclusions First, there are many innovative IPS practices in European countries (Van Weeghel et al., 2020). IPS gets more and more IPS is becoming more and more a full-scale strategy to attain extended to all individuals with mental illnesses. Initially, like in inclusive and sustainable employment for people with serious the US, IPS practice was limited to people with SMHP. health and psychosocial problems. We need to advocate jointly Nowadays, for instance in the Netherlands, IPS practices are not at international, national, regional and local bodies to promote only present in community mental health teams, but have also IPS as the first-choice method for all public, private and NPOs been developed successfully in psychiatric community housing employment services. programmes (De Winter et al., 2020). In Norway and Sweden, IPS balances economic and psychological elements by provid- IPS has been made accessible to clients with common mental dis- ing specific supports to help clients make rational choices regard- orders and substance use disorders (Bejerholm et al., 2017; Reme ing job seeking, combining personal goals, previous working et al., 2018; Hellström et al., 2021). experiences and objective opportunities either to work, to study, Second, there is an increasing variety of IPS providers. or to obtain a disability benefit. This approach has definitely Originally, mental healthcare organisations have been the main proved beneficial to people with serious mental disorders, but it actors adopting IPS practices. To attain optimal adoption and sus- may also work for the general unemployed population, possibly tainability, now systems tend to form broad coalitions and shared with some adjustments. Employment services in Europe have ownership of IPS, including at both local and national levels, men- had serious difficulties with the long-term unemployed popula- tal healthcare providers, general social services and employment tion, people who lost jobs in their 50s, people with lower degrees services, the vocational rehabilitation system, service users and fam- of specialisation, migrants, single women with children and gen- ily organisations and (in some countries) health insurance compan- der violence victims. IPS has all the ingredients to be considered a ies (Bond et al., 2020). In some European countries, IPS is mainly full-scale ‘active labour policy’ (Rizza and Fioritti, 2020) econom- provided by (contracting organisations of) municipal social service ically sustainable in this Covid-19 era, where the links between departments (e.g. in Denmark, Norway and Sweden). These work, mental health and welfare policies is stronger than ever. departments are responsible for the vocational reintegration of To attain this, good coordination and the integration of services the citizens that receive welfare benefits, who often have multiple of mental health care, social care and the vocational rehabilitation problems, including mental health problems, and may benefit system is needed (OECD, 2015; Bergmark et al., 2019). The aims of from the integrated approach that the IPS model offers. This devel- such service integration are to improve access to an array of ser- opment also raises the problem of how to ensure increased access to vices, improve continuity of care, reduce the overlap, inefficiency IPS without compromising fidelity (Bond et al., 2020). and cost of services and to increase the involvement and responsi- Third, there is also an expansion of IPS objectives, e.g. educa- bility of specialists (Konrad, 1996). IPS has proven to be successful tion. Many young people with mental illness want to resume their in realising such coordination and service integration. education, having been compelled to suspend it during previous The IPS model is ‘simple but not easy’. Although it is not periods of illness. IPS’s two-pronged approach (education and based on grand theory and is rather pragmatic in its approach, employment) is now mainly being put into practice in the treat- it requires strong commitment to be put into practice. ment of clients with first-episode psychosis, but this must be Therefore we need to recognise critical implementation compo- extended to people with other mental illnesses. nents and take stock over contextual barriers and facilitators. Fourth, there is also a development in the use of additional Strong local leadership will be the key to success for IPS for a interventions to reinforce the effects of IPS for clients. Examples long time forward. In spite of its simple theory, practice and train- of add-on interventions are workplace fundamentals (Glynn ing, IPS creates a cultural revolution within existing services that et al., 2017), cognitive remediation (McGurk et al., 2015; requires support and promotion by leading professionals. Christensen et al., 2019; Van Duin et al., 2021), Wellness Establishing through the ELC stable collaborations and Recovery Action Planning (WRAP) (Van Erp et al., 2015) and exchanges by centres that actively practice IPS will enhance fur- COnceal or ReveAL (CORAL), a decision aid for disclosure of ther development in Europe, improve sustainability and imple- mental health problems in the workplace (Henderson et al., mentation in a European context, and allow testing its 2013; Janssens et al., 2020). effectiveness in other target groups. Last, greater input is coming from companies and employers. Acknowledgements. The authors wish to thank Robert Drake, Deborah Although IPS could not exist without the active involvement of Becker and Gary Bond for their constant help, support and encouragement employers, as yet they have not had a clear role or position in in developing IPS in Europe and in establishing the European International the dissemination of IPS (Van Weeghel et al., 2020). 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