Vocational Rehabilitation and Mental Health - URI Soča

Vocational Rehabilitation Systems in Slovenia

In Slovenia, when we talk about Vocational Rehabilitation and employment of persons with disability, we mainly talk about two systems of Vocational Rehabilitation – both are meant for employed and unemployed persons.

VR under Vocational Rehabilitation and Employment of PwD Act

is meant mainly for unemployed;
a biopsychosocial model is used,
long-term expert support is provided,

VR under Pension and Disability Insurance Act

It is meant for mainly employed/insured persons.
A medical model is used.
Focus is on the assessment with limited possibilities of intervention.
Assessment is aimed to find/suggest one of the possible solutions: (non)formal education, workplace adaptation, or training for a new job.
There is no specific expert support after the assessment.

However, we don‘t have a systemic solution (in legislation) to provide professional support for early Return to Work for employees on sick leave (only URI carry out this service).

Sick leave in Slovenia – current situation

Another issue regarding employment persons with disability is the growing percentage of sick leave. The total percentage of workers on sick leave in recent years is between 4 and 4.5 %.

2015 > 2019

45% increase in people with a sick leave of more than 45 days
82% increase in people on sick leave longer than one year
Increasing growth of sick leave over 5 years - 20.7% growth (2019: 279, 2020: 337)

Mental and behavioural disorders are also among the most common causes of sickness absence and longer absenteeism and have been increasing recently.

One interesting fact is, that Slovenian legislation for people on sick leave is the least restrictive among European countries:

the compensation is generous (on average 80 % of the worker‘s wage),
the duration of sick leave is unlimited (which is not typical for European countries) but
there is no sickness benefit for the unemployed.

Vocational Rehabilitation & Mental Health

People with mental health problems are the largest group of Vocational Rehabilitation users:

the highest percentage, 88.3%, of service users were assessed with one of the ICF General and Specific Mental Functions; and
82.2% had one or more ICD-10 diagnoses of 'mental and behavioural disorders‘.

People with mental health problems continue to be one of the most difficult groups to employ.

The main barrier is prejudice and fear from employers due to a lack of knowledge about the nature of specific mental disorders and their impact on individuals.

Employers need more ongoing support and counselling, awareness raising, and information.
Crucial is psycho-education of people with mental health problems and employers and immediate crisis intervention in case of conflicts and personal problems of the service user.
Team meetings proved successful in facilitating reassuring and educational discussions with the employer.

Comparing Europe and Slovenia

More than one in six people in EU countries (17.3%) had a mental health problem - that's almost 84 million people (y. 2016).

Europe

Anxiety disorders are the most common mental disorder in EU countries, affecting 25 million people (5.4%), followed by
Depressive disorders, affecting more than 21 million people (4.5%).
An estimated 11 million people (2.4%) in EU countries have a drug or alcohol problem.
Severe mental illnesses such as bipolar disorder affect almost 5 million people (1.0%), while schizophrenic disorders affect around 1.5 million people (0.3%)

Slovenia

Depressive disorders are estimated to be present in 3.5% of the population, with a higher prevalence in older individuals.
Anxiety disorders are also approximately similarly prevalent.
Of particular concern is schizophrenia.
Personality disorders occur in 10-20% of individuals in the general population and in 40–60 % of psychiatric patients - making them the number one psychiatric diagnosis.
The prevalence of alcohol dependence is estimated at 8–10% of the adult population.

The situation has been further aggravated by the COVID-19 pandemic – the number of anxiety and depressive disorders increased by more than 25% in the first year of the pandemic. It had a significant impact on younger people (18-29 years). It can be assumed that the epidemic has had a similar impact on the population of Slovenia.

Mental Health Problems among Vocational Rehabilitation service users

Schizophrenia, personality disorders, depressive and anxiety disorders, and mental and behavioural disorders due to PAS are the most common mental health problems among Vocational Rehabilitation service users.

Personality disorders, schizophrenia, and psychosis are the most commonly reported as causing the most difficulties/challenges in the provision of Vocational Rehabilitation services.

These problems manifest in several areas:

Problems with participation, motivation, and active role in the whole Vocational Rehabilitation process – they need more adaptation of the process,
Conflicts often arise in interpersonal relationships – they are more self-centred and have difficulty accepting feedback.
They are also characterised by „learned helplessness“ – they often come into the process with a learned strategy that they are no longer employable.
Difficulties in accepting their disability manifest as difficulties in recognising their limitations, coping less well with them, or failing to see problems in themselves and look for them in others (especially users with schizophrenia and psychotic disorders).
They have limited social skills, especially difficulty fitting in with the group and can have a major impact on group dynamics.
They are often unstable, fail to meet agreed deadlines and are unable to work independently.
Regardless of the diagnosis, difficulties in setting career goals are manifested as unrealistic and poorly defined career goals, mainly due to overly high expectations, lack of career orientation, little or no previous work experience, and poor transfer of previous knowledge.

Integration into the work environment is also problematic for job retention due to misunderstandings, conflicts and other behavioural problems.

They are mostly integrated by employers who already have experience of on-the-job training through Vocational Rehabilitation.

Successful integration into the work environment requires first a clear definition of employment goals, followed by a gradual introduction/integration into the work environment and a structured plan of work activities, with clear instructions and steps.

Given that the Vocational Rehabilitation follows the principle that the service user is an equal partner in the Vocational Rehabilitation process, professionals consistently involve them in the co-design of the individual rehabilitation plan; it is important to define all the objectives and responsibilities together with them.

Focus is on jobs that interest them, as this increases their motivation, and on supportive, understanding, and compassionate/accepting work environments.

In particular, a combination of different methods and techniques is needed:

encouraging regular daily recording of well-being,
learning stress management techniques in and outside the workplace,
highlighting the person‘s strengths/potential,
building self-esteem and self-confidence,
communication training,
role-playing as part of preparing for certain situations,
learning problem-solving techniques and how to deal with conflict situations,
teaching social skills.

Organisational adaptations at the workplace: flexible working hours, working from home, adapted scope of work, sensory adjustments, support persons, development of a compassionate/accepting organisational culture, etc.

Approaches to working with people with mental health problems

person-centred approach; individualised treatment
active listening, empathic communication (understanding the user's situation, listening to their story and hearing their expectations of treatment)
continuous monitoring, ongoing and systematic psychosocial and emotional support
creating safe and accepting environment
psychoeducation, teaching social skills, stress management and problem-solving skills,
supporting their active role
ongoing problem-solving and evaluation of the process is key, and it is also essential that feedback is given in such a way as to give the service user insight into his or her real potential

Activation of people with MHP is important – professionals encourage them to take an active role in social inclusion, physical activity, taking on household activities, independence, acquiring work habits, solving current problems, active leisure time, participation in non-formal education, joining associations, attending events, etc.

A stable and trusting relationship between people with MHP and professionals is essential. We don‘t push the process of integration into on-the-job training – it is more important to establish a good relationship with the service user in the first place.

Group meetings between (different) service users are also important, as they allow people with MHP to share their experiences and to realise that others also have difficulties in finding employment and need help in doing so.

Working with relatives – the support and involvement of relatives is important for a successful rehabilitation process and enables them to better accept the condition of the person with MHP and to cope more easily and successfully. Relatives are most often present at the initial and final sessions. The involvement of relatives is always in accordance with the agreement with the person with MHP.