Elements Promoting Working For People With Mental Disabilities, As Perceived By Supporters

The concept of a symbiotic society in which everyone, irrespective of disability, lives as a member of society, respecting and supporting each other, is becoming increasingly prevalent in society [1]. Toward the realization of a symbiotic society, people with mental disabilities are expected to obtain employment opportunities, to participate actively, and to contribute to society. In Japan, relevant laws and systems have been revised since approximately 2000. In 2018, persons with mental disabilities were made subject to employment obligations. In addition, the legal employment rate has been raised step by step. The employment rate of persons with mental disabilities is increasing rapidly, leading to the quantitative expansion of employment of persons with disabilities. 

However, according to the "Survey on Employment of Persons with Disabilities," 4.2% of establishments "actively want to employ" persons with mental disabilities, which is lower than the 22.7% of those establishments wanting to employ workers with physical disabilities and the 6.7% of those establishments wanting to employ workers with intellectual disabilities. Conversely, 25.3% of the establishments which "do not want to employ" persons with mental disabilities were the highest, indicating reluctance of organizations to employ persons with mental disabilities [2]. In fact, the workplace retention rate after one year was 60.8% for physical disabilities, 68.0% for intellectual disabilities, and 71.5% for developmental disabilities, whereas it was only 49.3% for mental disabilities: markedly lower than other disability types [3]. 

People with mental disabilities show social behaviors such as poor interpersonal interactions because of their disability, inability to act spontaneously or in tempo with others, difficulties in communication and interpersonal relationships with others, difficulty in coping with stress or worsening of symptoms, and loss of energy and concentration [4]. Behaviors such as increased drowsiness and loss of energy and concentration attributable to medication side effects have also been observed [4]. Based on the characteristics of these diseases and disabilities, the 2013 amendment to the Law for Employment Promotion of Persons with Disabilities established the prohibition of discrimination and the obligation to provide reasonable accommodation for workers with disabilities. Nevertheless, many issues have been pointed out in actual implementation of the law [5]. 

Decent work is a term proposed at the 87th General Conference of the International Labor Organization (ILO) in 1999. In Japan, it is translated as "work that is worthwhile and humane" and means "creating an environment where people can work with a sense of fulfillment and security". Through the four strategic goals of (1) job creation, (2) expansion of social protection, (3) promotion of social dialogue and conflict resolution, and (4) guarantee of rights, the goal is to create jobs that stabilize the lives of all people and which enable them to maintain their human dignity, irrespective of whether they have a disease or disability [6].

According to the "Status of Employment Placement of Persons with Disabilities at Hello Work" [7], the number of new job applications by persons with mental disabilities exceeds 70,000, the largest number among persons with other disabilities. The employment situation of persons with mental disabilities has been characterized by qualitative shortcomings such as the fact that they are not able to make choices matching their own desires, work abilities, and aptitudes. Given this background, future employment support for persons with mental disabilities probably requires a qualitative shift to enable them to work with peace of mind and with a sense of fulfillment in life. 

A survey conducted by the Ministry of Health, Labour and Welfare [8] indicated that, in general, companies with favorable working conditions in terms of vacation, working hours, salary and bonuses, etc. have a higher awareness of "ease of working.” Moreover, people who find it easier to work have a higher awareness of their work and a higher intention to continue working. 

However, the specific emphasis of this study is on the employment promotion of persons with mental disabilities. The factors which contribute to qualitative improvement in the employment of persons with mental disabilities have not been examined adequately. For this study, we clarify the factors influencing the employment promotion of persons with mental disabilities as perceived by supporters involved in the employment of persons with mental disabilities (hereinafter designated as "supporters").

Definition of Terms

a. Mentally challenged person

The definition of persons with mental disabilities under the Law for Employment Promotion of Persons with Disabilities is defined as those who hold the Health and Welfare Handbook for Persons with Mental Disabilities or those who suffer from schizophrenia, manic-depression, or epilepsy. However, for this study, to extract elements of workability that are applicable to a wider range of people, we used the diagnostic criteria described in the Diagnostic and Statistical Manual of Mental Disorders by the World Health Organization (WHO) International Diagnostic Criteria [9] "Mental and behavioral disorders" or the American Psychiatric Association's DSM-5 (2014) "Diagnostic and Statistical Manual of Mental Disorders." The person must have been diagnosed as having a mental disorder based on the diagnostic criteria presented in the Diagnostic and Statistical Manual of Mental Disorders [10] of the American Psychiatric Association (2014). 

b. Being hired

Employment for persons with mental disabilities is classified mainly as welfare employment or general employment. Welfare employment is a system in which persons with disabilities work while receiving support to participate in society and to achieve self-realization. General employment, in contrast, is a system in which people with disabilities work at general companies or organizations irrespective of whether they disclose their own disability or not. They work under a contract of employment with the company and under set working conditions. For this study, the latter type of work is defined as general employment.

Method of Investigation       

a. Target Group

The survey participants were persons who support the employment of persons with mental disabilities at Type A and Type B employment support facilities, facilities that provide support for transition to and retention in employment, Hello Work, Regional Vocational Centers for Persons with Disabilities, and Vocational Comprehensive Centers for Persons with Disabilities in A Prefecture.

b. Method of Investigation

A cross-sectional survey using a self-administered questionnaire (web-based) was conducted during November–December 2022. A request letter and pamphlet were sent to the head of each facility. The purpose, methods, and ethical considerations of the study were explained in writing. The heads of the facilities who understood the purpose of the study and gave their consent were asked to post the request document and pamphlet for participants at their facilities. Supporters were asked to cooperate in the study using the posted request form. They were asked to read the QR code on the pamphlet using their own smart phone or other device and to respond to the survey. Explanations related to participation in the study, including the freedom of participation or non-participation and the fact that non-participation would not be detrimental to their work, were given in writing. A one-month response period was given, after which the participants were asked to complete the survey.

c. Survey Contents

The participants were asked to provide responses including their basic attributes such as the type of facility at which they work, the job type, and the length of employment. They were also asked to write their responses freely about what innovations and systems, such as working hours, working environment, and job content, would promote the employment of persons with mental disabilities.

Analytical Method

Descriptive statistics were calculated for the quantitative data of the basic attributes and survey items. The free response portion of the survey was analyzed qualitatively and inductively using the following procedure because there were several responses that could not be categorized strictly by item. (1) All responses to each free description question were integrated into a single spreadsheet (Excel; Microsoft Corp.). (2) The parts describing the factors influencing the employment promotion of persons with a mental disability were extracted and coded in units for which the semantic contents were comprehensible. After the codes were classified based on similarity, the subcategories, categories, and core categories were generated by raising the level of abstraction. To ensure the veracity of the results, a researcher with experience in qualitative research throughout the analysis process supervised and confirmed the interpretation of the data as necessary.

This study was conducted with approval of the Ethics Review Committee of the university (approval date, October 24, 2022; approval number, No. 22055). A letter describing the purpose, methods, and ethical considerations (freedom of research collaboration, handling of data, publication of research results, contact information for research inquiries, etc.) was sent to the heads of the participant facilities. Their consent was obtained. A document describing the purpose, methods, and ethical considerations of the research and a pamphlet with a QR code for accessing the web-based questionnaire was sent to the heads of the facilities from which consent had been obtained. We asked them to post the pamphlet in a place in their facility where supporters could see it. The purpose, methods, and ethical considerations of the study were explained to participants in writing. The questionnaire was anonymous. A participant's consent was deemed to have been obtained when the participant responded to the questionnaire. 

Results

As a result of the survey, forms from 201 respondents were obtained (18.5% response rate). Of these, 185 (92.0% valid response rate) were selected for analysis. 

Attributes of Participants

The facilities at which the participants worked were 81 (43.8%) employment support type B offices, 75 (40.5%) employment transition support offices, 5 (2.7%) employment support type A offices, 3 (1.6%) employment settlement support offices, 2 (1.1%) Hello Work offices, and 19 (10.3%) other facilities. The most common "Others" were employment support centers for persons with disabilities and multifunctional facilities. 

By allowing multiple job title responses for the participants, many of whom had double licenses, results showed 52 mental health workers, 34 social workers, and 11 physical therapists, in that order. Also, 117 responded as others, many were service management supervisors and employment support workers. 

The mean duration of employment for persons with mental disabilities was 7.6 years (SD 6.1), with a median of 6 years.

Contents related to working hours, work contents, and working environment were extracted as influential factors in promoting employment among persons with mental disabilities. Codes for free descriptions are shown as " ", subcategories as and core categories as < >. 

Working Hours Affecting the Employment Promotion of People with Mental Disabilities

The average number of days per week that persons with mental disabilities were comfortable working was 4 (SD 0.72). The median was 4 days. The most common comfortable working hours were 10:00 a.m. (71.3%) and 4:00 p.m. (41.3%). 

The results of the analyses of the descriptions of working hours were classified into two categories: and . was extracted from the following 5 subcategories: [Flexible working hours according to mental state and characteristics.] (e.g., "Working hours can be decided according to the person's mental state and intentions."), [Flexibility is allowed, subject to the establishment of a framework.] (e.g., "The start and end times are fixed, but the start time can be delayed depending on how you feel that day."), [Flexible hours at the beginning of employment.] (e.g., "The starting time can be delayed until you get used to the work."), [Flexible break times] (e.g., "Flexible breaks in case of illness") and [Consideration is given to vacation time.] (e.g., "You can take paid leave with a detailed time specification."). < un changing working hours> was extracted from the following 2 subcategories: [Fix working hours in consideration of characteristics] (e.g., "A basic working hours framework is in place.") and [No overtime work] (e.g., "Do not make you work more hours than you usually work") [Table 1].

Table 1: Hours of Work Affecting Employment Promotion for Persons with Mental Disabilities

Work Content Affecting the Employment Promotion of People with Mental Disabilities

Results of the analyses of the work content descriptions were classified into three categories: , and . 

comprises two subcategories: [The process is clear] (e.g., "Working phases are clear. ") and [The goal is clear.] (e.g., "The stages of learning are clear. "). 

comprises three subcategories: [Ability to work and work match] (e.g., "They provide work that is tailored to the person's skills. "), [Disability characteristics and operations are matched.] (e.g., "They adapt the work to the characteristics of the disability. ") and [Individual characteristics and operations are matched.] (e.g., "Can demonstrate the strengths of the subject").

< There are work-related innovations that lead to job satisfaction.> comprises three subcategories: [Work is possible at your own pace] (e.g., "Work efficiency is not questioned. "), [Some changes in operations] (e.g., "There is no uniformity. ") and [There is a motivational device.] (e.g., "They appreciate the process of work.") [Table 2].

Table 2: Employment contents affecting the promotion of employment for persons with mental disabilities

Work Environment Affecting Employment Promotion of Persons with mental disabilities

Results of the analyses of the work environment descriptions were classified into four categories: < There are options for places of employment. >, < Flexibility to adjust environment >, < Diverse consultation systems are in place.> and < An environment of individual understanding and care is in place. >. 

< There are options for places of employment.> comprises three subcategories: [You can choose where to work.] (e.g., " Several environments to choose from "), [You can choose to work from home.] (e.g., " Can be used in conjunction with working from home and going to the office ")and [ Easy commute to and from work can be selected. ] (e.g., " Numerous options for transportation and commuting "). 

< Flexibility to adjust environment > comprises three subcategories: [Able to devise an environment that is appropriate to the characteristics] (e.g., " Noise cancellers and headphones are available."), [A rest environment can be devised.] (e.g., " Have a resting place where you can block out surrounding sounds and eyes. ") and [Flexible vacation time] (e.g., " Hospital leave is granted. "). 

< Diverse consultation systems are in place.> comprises six subcategories: [There is a timely consultation system.] (e.g., " They can provide in-house counsel.") , [There is a regular consultation system.] (e.g., " They set aside time for communication on a daily, weekly, and monthly basis."), [There is flexible provision of specialized assistance.] (e.g., " Immediate consultation with qualified support staff."), [Main advisor.] (e.g., "Reporting, contacting, and consulting with a fixed number of people "), [Multiple consultants.] (e.g., " Assign more than one person to provide consultation ") and [There is an ingenious environment for easy consultation.] (e.g., " Seating is close to the consultant "). 

comprises three subcategories: [There is a human organizational environment that seeks to understand disease and disability] (e.g., "They learn about dealing with people with disabilities. "), [There is an environment of interest and care.] (e.g., "There is an environment where people can casually talk to each other.") and [There is an environment that does not require excessive communication.] (e.g., " Limited number of people with whom to come in contact") [Table 3].

Table 3: Work Environment Affecting the Employment Promotion of Persons with Mental Disabilities

Structure of Factors Affecting the Promotion of Employment for Persons with Mental Disabilities

Factors influencing the promoting working for persons with mental disabilities were extracted as those related to working hours, work content, and work environment. Further organization of these categories revealed that the factors which influence the promoting working for people with mental disabilities can be summarized into two core categories: Flexibility and Constancy. The elements of constancy were [Working hours are unchanged.] and [The process and goals of the work are clear.], whereas the elements of flexibility were [Flexible working hours], [Diversity in matching], [There are worked-related innovation s that lead to job satisfaction], [Options for employment], [Flexibility to adjust], [Diverse consultation systems are in place.] and [Environment of individual understanding and care is in place.] [Figure 1]. 

Figure 1: Factors Affecting Employment Promotion for Persons with Mental Disabilities

Background of Participants

In Japan, support organizations for employing persons with mental disabilities include Hello Work, Regional Vocational Centers for Persons with Disabilities, and Employment and Living Support Centers for Persons with Disabilities, which support general employment and continued employment, providing labor transition support offices and continuous employment support offices as welfare employment sites that present training and employment opportunities for general employment in the future. The study participants had been employed for a long period of time. Many of the study participants were engaged in welfare-type employment such as Type B continuous employment support facilities. The distribution of facilities in the area where the survey was conducted showed that the facilities at which the participants worked tended to be approximately equal to the population distribution. The participants had widely diverse occupations, mainly mental health workers, as professionals who support employment. Based on their specialized perspectives, we believe that we were able to extract various factors that contribute to the promoting working for people with mental disabilities. 

Factors Influencing Employment Promotion for Persons with mental disabilities

Factors influencing the promotion of employment among persons with mental disabilities were found to be working hours, the nature of the work, and the work environment.

The comfortable daily working duration for mentally disabled workers was approximately 6 hr. Persons with mental disabilities characteristically experience fatigue, which tends to engender flare-ups or worsening of symptoms. Therefore, it is reasonable to assume that the comfortable working hours for persons with mental disabilities are slightly shorter than the eight-hour workday expected in most full-time employment. In fact, 29.5% of persons with mental disabilities are employed as regular workers and 70.5% as irregular workers, with half of the irregular workers working fewer than 30 hr per week [11]. Against this background, in 2022, a "Bill to Amend the Law for Comprehensively Supporting the Daily Life and Social Life of Persons with Disabilities" will be passed to allow persons with mental disabilities, persons with severe physical disabilities, and persons with severe intellectual disabilities with particularly short prescribed weekly working hours to work 10 hr or more but less than 20 hr as a special case [12]. In other words, for the employment of persons with mental disabilities, setting flexible working hours that incorporate consideration of the promoting working for persons with mental disabilities is important, rather than applying existing employment rules. 

Among psychiatric disorders, schizophrenia is associated with widely diverse cognitive impairments including impaired attention, learning and memory, abstract thinking, problem-solving and executive functions, and delayed psychomotor functions, which are the main reasons why schizophrenic patients have difficulty finding work [13]. In addition, psychiatric disorders tend to cause sleep disturbances, which are accompanied by a vicious cycle in which sleep disturbances exacerbate the onset and aggravation of psychiatric disorder symptoms [14]. Constant work hours help persons with mental disabilities with such mental illness and disability characteristics to maintain a certain rhythm, which engenders the stabilization of symptoms as a precondition for employment. In addition, the clarity of the work process and goals reduces hesitation, confusion, and anxiety about work by clarifying the priorities, procedures, and goals of the work. In this way, incorporating elements of constancy in working hours and work processes might engender easier work for people with mental disabilities. 

Mental disorders are characterized by the instability of symptoms, such as the tendency for symptoms to flare up because of fatigue or stress. In fact, the job turnover rate of persons with mental disorders is higher than that of persons with physical disabilities and intellectual disabilities: reportedly, the job turnover rate is 80% within one year of employment [15]. According to results of a survey of persons with mental disabilities who left their jobs early because of difficulties at work, they cited lack of support for job performance, inability to take appropriate rest, effects of disability characteristics on work, lack of understanding of illness and disability, and difficulty dealing with human relations [16]. In other words, to promote of working for people with mental disabilities, one must work based on the social model of disability, which involves modifying and devising internal systems, including the work environment and systems, to suit the target population, rather than the medical model, which specifically examines the disability of the individual. 

For people with mental disabilities characterized by fatigue and instability of symptoms, "having a choice of places to work," "having flexibility in working hours," and "devising work that engenders job satisfaction" are expected to enable them to adjust their working hours and working environment flexibly according to the presence and degree of symptoms and to work while taking adequate rest during working hours, rather than not being able to work because of their symptoms. It is also important to provide flexibility according to individual characteristics, rather than considering and judging cases on the basis of disease or disability classification. 

Matching companies and persons with mental disabilities is important for the employment of persons with mental disabilities. Reportedly, it is particularly important for supporters to assess and understand the employment abilities of the target person accurately as support during matching. However, matching people with mental disabilities using their ability to work as an evaluation index can be regarded as a uniform method of "fitting" [17]. people with mental disabilities into places of employment based on their abilities, even if they do not match the needs of the people with mental disabilities. In 2022, the Law to Amend the Law for Comprehensively Supporting the Daily Life and Social Life of Persons with Disabilities will be promulgated. Actually, support for employment choice is scheduled to start in 2025 as a service to assist persons with disabilities to make choices that suit their wishes, work abilities, and aptitudes. In the case of employment choice support, as identified in this study, the accuracy of matching will probably be enhanced. Persons with mental disabilities will find it more rewarding and easier to work if various factors are considered, including emphasis on individual characteristics such as individual strengths and needs and individual circumstances, in addition to the employment abilities of persons with mental disabilities in the matching process. It can be said that the accuracy of the matching process will be enhanced and that persons with a mental disability will be more satisfied and comfortable in their work. 

Anxiety about not being able to consult and receive support [18] has been cited as a disincentive for persons with mental disabilities to continue working. It is therefore important to establish a consultation system to ensure the continued employment of persons with mental disabilities. However, no concrete measures have been clarified for what kind of consultation system should be established. For this study, the following consultation systems were identified to realize a comfortable working environment for persons with mental disabilities: consultation partners, timing of consultation, and the environment in which consultation is available. Findings suggest the necessity of establishing a more generous consultation system, such as a timely consultation system, when persons with mental disabilities feel a need for consultation. In addition, such a system must allow for regular consultations. For persons with mental disorders who are not adept at forming and maintaining interpersonal relationships, having a main counselor and a comfortable environment in which the counselor's seat is close to the patient might lower hurdles to seeking advice. Moreover, early consultation might prevent difficulties from becoming more severe. In addition, for persons with mental disorders who are highly anxious, the presence of multiple consultation partners not only makes them feel secure; it also reduces burdens on the consultation partners. Consequently, ensuring various consultation systems according to the individual characteristics of persons with mental disabilities can be expected to engender easier working conditions. 

Compared to people with physical and intellectual disabilities, people with mental and developmental disabilities are reportedly difficult to understand and have difficulty sharing with others because their disabilities cannot be visualized [19]. In the employment of persons with mental disabilities, a large range exists of what individuals "can cope with" and "cannot cope with" depending on the type and degree of disability or illness, even among professionals who have obtained the same certification [20]. 

Mental illness and disability are not easy to understand. Therefore, it is important to have an environment of individual understanding and care [21] reported that understanding the living situation of a person with schizophrenia is more likely to engender positive feelings toward schizophrenia than understanding their symptoms. In other words, not only acquiring knowledge of the illness or disorder, but also devoting attention to the person, communicating with the person in detail, and sharing information within the organization can deepen individual understanding, including the person's living situation. Moreover, it can enable people with mental disorders to experience more positive feelings in the workplace. In other words, it is important to discover the strengths and abilities of people with mental disabilities through efforts to understand them and to direct them toward the vector of cooperation, rather than the vector of discrimination and prejudice arising from ignorance. 

In recent years, the number of new job applications by persons with mental disabilities has been increasing. The employment of persons with mental disabilities is predicted to be increasingly promoted in the future. The employment of persons with mental disabilities will be not only a matter of training them to adapt to the employment rules and workplace environment of each company, but also of devising a comfortable work environment for persons with mental disabilities, incorporating elements of constancy according to the characteristics of their illness and disability and elements of flexibility according to their individual characteristics. Consequently, society as a whole can create an environment in which a person with a mental disability can work more easily, which will foster their empowerment and Japanese economic development. Eventually, this can engender the development of Japan's economy and the empowerment of persons with a mental disability. 

Utilization for Employment Support

To realize a society in which people with mental disabilities can work comfortably, it has been clarified as important to incorporate elements of constancy and elements of flexibility. Promoting  working for people with mental disabilities can be realized in future society by deepening understanding of individuals in addition to understanding of the disease or disability, and by considering and constructing flexible working hours, work contents, and work environments suited to individuals. In other words, employers can enable people with mental disabilities to work with peace of mind and a sense of fulfillment by adopting flexibility, which will lead to the realization of decent work. In addition, exposure to people with mental disabilities working with vigor and enthusiasm can help mitigate or eradicate unconscious bias and contribute to the achievement of inclusion. 

Limitations of the Study and Future Issues

This study identified factors influencing employment promotion for persons with mental disabilities, as perceived by supporters who provide employment support for them. Therefore, it cannot be said that these study results are consistent with the perceptions of persons with mental disabilities. Future studies must extract factors promoting employment as perceived by persons with a mental disability themselves, and must examine those factors from multiple perspectives. 

In addition, many study participants were persons with mental disabilities who were supported in welfare-type workplaces with the future aim of seeking general employment. In other words, the respondents might have answered questions about employment promotion for persons with mental disabilities based on the assumption that they would be supported in welfare employment. Therefore, it can be inferred that the study results might describe more generous considerations and innovations than those of the participants who are able to continue working in general employment. However, assuming that the employment rate of persons with disabilities will increase in stages and assuming that persons with mental disabilities with various illnesses and disability categories will be increasingly employed, these study findings are likely to be applicable to widely diverse participants.

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