MATTHEW MENEAR

ORGANIZATIONAL DYNAMICS OF SUPPORTED EMPLOYMENT PROGRAMS FOR

PEOPLE WITH SEVERE MENTAL ILLNESS

Mémoire présenté

à la Faculté des études supérieures de l'Université Laval

dans le cadre du programme de maîtrise en santé communautaire

pour l'obtention du grade de maître ès sciences (M.Sc.)

DÉPARTEMENT DE MÉDECINE SOCIALE ET PRÉVENTIVE

FACULTÉ DE MÉDECINE

UNIVERSITÉ LAVAL

QUÉBEC

2009

© Matthew Menear, 2009

Résumé

La présente étude qualitative visait à mieux comprendre l'influence des dynamiques

organisationnelles sur l'implantation des programmes de soutien à l'emploi (SE) pour

personnes atteintes de problèmes de santé mentale graves au Québec. Les résultats

démontrent la présence de deux coalitions en lien avec ces programmes, soit une reliée

au secteur de la santé et une reliée au secteur de l'emploi. La vision qui chapeaute les

services des acteurs de la santé en est une de rétablissement et leurs services adhèrent

·généralement aux principes du modèle «Individual Placement and Support» . Comme ces

acteurs, les acteurs de la coalition d'emploi visent aussi l'intégration de leurs clients en

emplois compétitifs. Par contre , leurs valeurs et croyances différentes et la nature de

leurs partenariats influencent ces derniers à organiser leurs services différemment des

acteurs de la santé. Ensemble, les deux formes de SE semblent répondre aux besoins

variés des utilisateurs de services vocationnels.

Summary

This qualitative study aimed to beUer understand how the organizational dynamics

between àctors has influenced the implementation and functioning of supported

employment (SE) programs for people with severe mental illness living in the province of

Quebec. Two main coalitions of actors related to SE programs were identified ; one

consisting primarily of actors in the health sector and another comprising mainly

employment sector actors. Health coalition actors organized their services around the

concepts of rehabilitation and recovery and promoted the delivery of SE services

consistent with the individual placement and support mode!. Though employment coalition

actors also aimed to facilitate their clients' integration into competitive employment, the SE

services they provided were different because of important differences in the nature of

their relationships and in the ir values and beliefs. Results suggest that both forms of SE

respond to needs in the population and that accessibility to both types should be improved.

Foreword

Working on this project has been a great joy and a tremendous learning experience. 1 am

extremely grateful to the many people who contributed and were involved in the project, as

weil as those who have provided me with their love , support and encouragement.

Over the course of this study, 1 was fortunate enough to meet many extraord inary

individuals who have devoted their careers to helping others ~scape exclusion and

integrate into society. Whether they were service providers , managers or decision

makers, their courage, dedication and passion has tru ly been an inspiration to me. The

experiences and points of view that they shared with me through their participation have

helped me gain a greater appreciation of the goals they strive for and the challenges that

they face. 1 sincerely thank them for their kindness , their amazing generosity and their

boundless efforts.

1 am also indebted to the fellow members of my research lab, who welcomed me so

warmly two years ago and whose support has never wavered since that time. Many of

them went out of their way to ensure that 1 felt comfortable and integrated in the lab, and 1

feel very blessed to have been surrounded by individuals like that. 1 would especially like

to thank Élisabeth Martin , my wonderful office-mate, for her friendship and guidance, as

weil as Nathalie Houle, the best coordinator a research team could hope to have, for her

frequent assistance, optimism and enthusiastic support. Finally, the possibil.ity of working

with Daniel Reinharz was one of the driving factors behind my decision to move to Quebec

and 1 am tremendously grateful for the opportunity he has provided me, as weil as the

limitless kindness and faith he has shown in me. Thank you for your encouragement and

for sharing your vast expertise with me.

1 have also been privileged to be part of a larger research team that featured some of the

most competent and renowned researchers from across the country. By way of their

curiosity , the depth of their expertise and willingness to implicate themselves, these

individuals have been able to make a positive difference in the lives of many people.

1 want to particularly like to single out the efforts of Marc Corbière and Nathalie Lanctôt,

who have been dynamic leaders and whose determination have been vital to the project's

success. My own involvement in the project was also facilitated by the financia l support of

the Fonds de la recherche en santé du Québec (FRSQ), and 1 thank them for making this

experience possible.

Finally, 1 would like to express my most profound thanks to my family and friends for the

love and support they have always provided me. 1 wou ld not be where 1 am today without

you. To my son, Noah, thank you for being the most wonderful baby boy a father could

have. And to my beautiful, amazing wife Amélie, you have been my greatest supporter

and my greatest inspiration. So much of this would not have been possible without you .

Thank you for ail thé sacrifices you have made for me. 1 love you , and 1 share th is

achievement with you .

Table of contents

Résumé II --------------------------------------------------------------------III Summary -----------------------------------------------------------------

Foreword IV -----------------------------------------------------------------L~tofFigures _________________________________________________ _ VIII

IX List of Tables --------------------------------------------------------------Annexes X -------------------------------------------------------------------Introduction 1 ----------------------------------------------------------------L Cu~~s~~~knowk~e ________________________________ _ 4

1.1. The role of work and its value as a tool for social integration ___________ _ 4

1.2. Mental illness and work in Canada: a historical perspective ___________ ~ 5

1.2. 1. Wo~inilie~y~m cra ________________________________________________ ~ 5

1.2.2. Work in the era of deinstitutionalization and regionalization _______________________ _ 8

1.2.3. The emergence of alternative psychiatrie resources and community-grown vocational ervices 12

1.3.Supported employment ____________________________________________ _ 19

1.3. 1. Origins and principles of the supported employment mode} _____________________ _ 19

1.4. Implementation of supported employment in a Canadian context _____________ _ 24

2 R~earcho~ectivesandquestions _______________________________ ~ 28

2.1. ~esearch objectives __________________________________________________ __ 28

2.2 ~esea rch q u estio n s ____________________________________________________ __ 29

3. Methods 30 ----------------------------------------------------------------3.1. An a Iytic a p p roa ch _________________________ _ 30

3.2. Sites ____________________________ _ 30

3.3." Theoretical frameworks 32 ------------------------------------------------3.3. 1. Coalition theory ___________________________________________________ _ 32

3.3.2 . Hinings and Greenwood 's theory of archetypes _______________________________ _ 34

3.4. Data collection 38 --------------------------------------------------------3.4. 1. Sources of information 38 -------------------------------------------------

3.4.2. ln strumentati on _____________________________________________________ _ 39

3.4.3 . ~ata collectionprocedure _____________________________________________ __ 40

3.6. ~alidation ofresults ______________________________________ ~ 43

3.7. ~thical considerations ________________________________________________ __ 43

4. Results 45 -------------------------------------------------------------------4.1. Health sector coalition 46

4.1.1. Coalition actors and obj ectives 46

4.1.2. Transactions 46

4.1.3. Links 52

4.1.4 . Controls 57

4.1.5 . Archetypes - Organizational structure 61

4.1.6 . Archetypes - Interpretive schemes 68

4.1.7 . Coherence between organizational structure and interpretive schemes 74

4.2. Employment sector coalition 76

4 .2.1 . Coalition actors and objectives 76

4.2.2 . Transactions 76

4 .2.3 . Links 80

4 .2.4 . Controls 81

4.2.5 . Archetypes - Organizational structure 86

4.2.6 . Archetypes - Interpretive schemes 93

4.2.7. Coherence between organizational structure and interpretive schemes 100

4.3. Interactions between coalitions and coherence between archetypes 102

5. Discussion 104

5.1. The implementation of supported employment in Quebec 104

5.2. Recommendations and limitations 113

5.2.]. Recommendations 113

5.2.2. Limitations 115

6. Conclusion 118

7. References 119

List of Figures

Figure 1: Theoretical frameworks used for the study _____________ 37

Figure 2: Health sector coalition Annexe 1

Figure 3: Employment sector coalition Annexe 1

List of Tables

Table 1: Characteristics of organizations and SE programs in the study ______ 31

Table 2: Distribution of interviews across the five organizations 42

Table 3: Summary of health coalition characteristics Annex 2

Table 4: Summary of employment coalition characteristics Annex 3

Annexes

Annex 1: Figures 2 and 3

Annex 2: Table 3

Annex 3: Table 4

Annex 4: Consent Forms

Annex 5: Sample interview guide

Introduction

Whether it be directly or indirectly, mental health problems affect ail members of society.

They touch men and women of ail ages, education and income levels, and cultural

backgrounds. Approximately twenty percent of Canadians will personally experience a

mental illness at some point in their lifetimes (Santé Canada, 2002). In addition , at least 2

to 3% of the population will have mental health problems that are considered severe.

While there is sometimes debate as to what constitutes a «severe mental illness» , mental

health problems are generally considered severe when they cause profound distress and

significantly hinder an individual's ability to function in one or more domains of their lives

(e.g. school, work, social and family interactions) (Santé Canada, 2002; The Standing

Senate Committee on Social Affairs Science and Technology, 2004). Further accentuating

the detrimental impact that mental illness can have on people's lives is the fact that the

onset of most mental illnesses occurs during adolescence and early adulthood ,

considerably altering the life courses of many young citizens and their famil ies and placing

a heavy burden on the health system and society as a whole. Indeed, for many people

with severe mental illness, the road to recovery is fraught with challenges and obstacles ,

challenges and obstacles that many fail to overcome, causing them to plunge downwards

to the margins of society.

For many decades now, the plight of people with severe mental illness and their exclusion

from society has been a major concern to numerous stakeholders. There is a wide

consensus that their reintegration into society is an important goal that benefits not only

the individuals touched by mental illness but also their communities and ail of society.

Moreover, those directly affected by mental illness have long expressed a desire for an

equal access to the fundamental elements of citizenship, including access to housing,

educa,tion and employment. Such a desire was famously articulated by renowned

consumer-survivor Pat Capponi, who stated that «the needs of members of the psychiatrie

community are not so different, really, from anybody else's needs - a home, a job, a

friend» (Capponi, 2003). Such sentiments are echoed by Gary Bond, who states that

individuals with severe mental illness want to «live, work, play, and lead their daily lives

without distinction from and with the same opportunities as individuals without disabilities»

(G. R. Bond, Salyers, Rollins, Rapp, & Zipple, 2004).

-------------------------------------------------------------- ---------

2

ln response to these needs, the last several decades have seen the emergence of a

variety of initiatives that have aimed to facilitate this process of social integration. In the

area of work, such services range from pre-employment services such as pre-vocational

assessment and counselling services, work readiness and skill development programs,

volunteer work and transitional employment to employment services such as supported

employment, adapted work centres, social enterprises, consumer-run businesses , and

self-employment supports. Within this array of vocational. services, supported employment

programs have been the type of service that has received the most attention from

researchers. According to the scientific literature, these programs yield superior work

outcomes than most other vocational approaches, thus helping more people integrate into

regular, competitive 1 employment (G. R. Bond, Salyers, Rollins, Rapp, & Zipple, 2004 ;

Cook, Leff et aL , 2005; Crowther, Marshall, Bond, & Huxley, 2001; Twamley , Jeste, &

Lehman , 2003). Indeed, the extensive documentation on supported employment and the

scientific support for the model has led it to be viewed as an «evidence-based practice»

and «best practice» by many researchers , service providers and policy makers (G. R.

Bond et aL, 2001; G. R. Bond, Salyers, Rollins, Rapp, & Zipple , 2004; Goldner, 2002).

As the literature on supported employment has grown, so too has the number of supported

employment programs. Implementation of the supported employment model has spread

from the United States to Canada , Europe, Asia and other parts of the world. Not

surprisingly, such widespread implementation efforts have led to questions about the

model's generalizability to contexts outside of the US. For example, service providers in

Canada operate in a social, political, economic and cultural environment that is different

than that found in the US. Aspects such as Canada's socialized health care system,

welfare laws, disability regulations and economic landscape seem to have an importa'nt

impact on the structure and effectiveness of supported employment programs developed

in this country, though to date only a few studies have touched on these issues (Corbière ,

Bond, Goldner, & Ptasinki, 2005; Latimer & Lecomte, 2002; Latimer et aL, 2006).

1 Competitive employment is generally defined as being a job in the community , paying at least minimum

wage, that anyone can apply for (G. R. Bond , Salyers, Rollins, Rapp, & Zipple , 2004).

3

ln addition to cross-country differences, there are also within-country differences that play

a role in shaping supported employment programs. As more research is carried out in

Canada , researchers are becoming increasingly aware of the high degree of variabi lity that

exists between programs operating in different provinces and even regions (Corbière ,

Submitted; Mercier, Provost, Denis, & Vincelette, 1999). Indeed , despite the vast literature

on supported employment and efforts to regulate its ~mplementation , the key elements of

the model remain unequally applied across settings. This variability could be a cause for

concern , as the faithful implementation of supported employment has been shown to be

positively correlated with vocational outcomes (O. R. Becker, Smith , Tanzman , Drake, &

Tremblay, 2001; D. R. Becker, Xie, McHugo, Halliday, & Mar:tinez, 2006). Thus, identifying

factors that give rise to this variability is important as a more complete implementation of

this evidence-based practice could lead to better vocational outcomes for clients.

One such factor underlying the observed differences between supported employment

programs could be that the stakeholders respons.ible for these programs differ in therr

values, ideologies, beliefs and philosophies about the best ways to operate their program

and address the needs of service users in their communities. Organizations and

stakeholders operate in a context where they must interact with a variety of other actors

and react to different environmenté;ll incentives and constraints. Understanding the

dynamics of these interactions and how they influence these stakeholders' values and

beliefs will likely shed some light on why programs are structured and operated differently

in different contexts.

Thus, the goal of the present work was to gain a better understanding of the organizational

dynamics related to supported employment programs in one Canadian province, the

province of Quebec, and learn more about how various factors, including the values of

stakeholders and their relationships with others and with their context, impact the

implementation of these programs as a whole, as weil as their key components

individually.

1. Current state of knowledg'e

1. 1. The raIe of work and its value as a tool for social integration

Work represents a significant part of the lives of most people. It is highly valued by society

and provides us with a sense of belonging and the feeling that we can contribute to

society's goals (Morin, 1996). It allows us to connect with others, build relationsh ips and

shape our social identity (Morin, 1996; Stuart, 20'06). Through work, we can gain the

respect of others and achieve a greater social status (Anthony & Blanch, 1987; Dorvil ,

Guttman, Ricard, & Villeneuve, 1997; Morin, 1996). We can provide for ourselves , build

our self-esteem and ensure our security (Dorvil , Guttman, Ricard , & Villeneuve , 1997;

Vézina , Cousineau , Mergler, Vinet, & Laurendeau , 1992). It offers us challenges and can

provide us with a sense of accomplishment (Dorvil, Guttman, Ricard, & Villeneuve , 1997;

Morin , 1996). It enables us to feel more in control of our environment and provides us with

a sense of empowerment (Dorvil, Guttman, Ricard, & Villeneuve, 1997). Indeed, work is a

fundamenta'i element of citizenship, a basic right and a powerful tool for promoting equality

and inclusion.

People with severe mental illness have long expressed a desire to work , and more

particularly work in regular, competitive employment (McQuilken, Zahnisher, Novak, & aL ,

2003; Mueser, Salyers, & Mueser, 2001). Yet, the regular workforce has remained largely

inaccessible to them despite a range of services developed to meet their needs . For

instance, studies have shown that approximately 80 to 90% of people with severe mental

illness wishing to engage in competitive work remain unemp~yed (Anthony & Blanch ,

1987; Crowther, Marshall, Bond, & Huxley, 2001; The Standing Senate Committee on

Social Affairs Science and Technology, 2006). Furthermore, they have been shown to be

three to five times more likely to be unemployed than the general population (Sturm ,

Gresenz, Pacula, & Wells, 1999). The social and economic costs that result from this

exclusion place a serious burden on individuals and on society, especially when one

considers that one in five Canadians will be touched by mental illness in their lifetime

(Santé Canada, 2002).

5

Helping people with severe mental illness integrate the workforce has been , and is still , a

major goal for many stakeholders. Indeed, many actors perceive employment to be one of

the most privileged routes towards recovery and social integration (Dorvil, Gutlman ,

Ricard, & Villeneuve, 1997). While a multitude of barriers to work integration exist (Cook,

2006; Leclerc, Bourassa, & Legros, 2008; Marwaha & Johnson, 2004), numerous studies

show that people with severe mental illness can integrate the workforce and make positive

contributions to society (O. Becker, Whitley, Bailey, & Drake, 2007).

1.2. Mental illness and work in Canada: a historical perspective

While interest in the socio-professional integration of people with mental illness can

sometimes seem like a relatively recent phenomenon, a look back into Canadian history

shows that work have long been described as an essential aspect of a normal life and , in

the case of those directly touched by mental illness, an important contributor to improved

mental health. In the following sections, 1 will outline how the relationship between work

and mental health has historically been perceived by some actors and how the

organization of psychiatrie services in Canada, and more specifically ·in Quebec, has

influenced work integration ideologies and services past and present.

1.2.1. Work in the asylum era

The history of psychiatrie services in Canada can generally be divided into two eras. The

first era began in the mid to late 1800s with the building of làrge, long-stay psychiatrie

hospitals, referred to often as the «asylums» ·(Davis, 2006). At the time, it was thought

that the asylums would play an important role in providing «safe settings for physica l and

spiritual care and to shield residents from the harm and peril that commonly befell people

with mental health illnesses in cities and towns» (Santé Canada, 2002 , p.1). Indeed ,

asylums were viewed by many as a medical breakthrough that allowed individuals with

mental illness to have access to the most progressive forms of mental health care (Moran

& Wright, 2006).

For many asylum operators, work was claimed to be an integral part of their residents'

medical and «moral» therapy (Moran & Wright, 2006). As explained by Geoffrey

Rheaume, «Physical exercise brought about by certain types of work, such as agricultural

6

labour or working in a laundry, was viewed as an essential way of redirecting a person's

alienated mind from their troubles onto the task at hand. As weil , doing regular, steady

work would supposedly lead to towards regular, steady, and above ail , rational habits and

away from mad thoughts» (Rheaume, 2006 , p. 70). Therapeutic benefits aside, other

factors motivated asylum administrators to encourage asylum residents to work, most

notably the rising costs related to hospital maintenance and expansion. Asylum residents

were often encouraged to participate in a variety of types of labour, though for the most

part their compensation would consist only of the occasional bribe or privilege2 (Moran &

Wright, 2006). Indeed , unpaid patient labour saved administrators and provincial

governments significant amounts of money and undoubtedly contributed to the survival

and proliferation of these hospitals. Despite some concerns regarding the exploitation of

patient labourers, the decades that followed saw hospital administrators and staff mainta in

the position that work, as opposed to idleness, contributed to the health and well-being of

its patient population (Rheaume, 2006).

ln Quebec, hospital administrators and medical staff were so convinced of work's

importance in terms of health , rehabilitation and social integration that the acquisition of a

regular, paid job became a necessary condition for permanent leave from the hospital

(Pagé, 1961). Residents who had responded weil to treatment and whose condition had

improved could apply to have their recovery recognized by a hospital tribunal consisting of

administrators and clinicians. If the tribunal was satisfied with their recovery , applicants

would receive medical clearance that would make their recovery official. They would then

be occasionally allowed to leave the hospital on a temporary basis in order to secure

employment in the community. If the applicant was successful in obtaining work and could

provide firm proof of this to the hospital tribunal, a long-term leave was typically granted.

However, those who could not secure employment, despite their official medical clearance,

were not granted their freedom and would have no choice but to remain andwork inside

the asylum. As Charbonneau explains, «For the medical and administrative authorities of

that time, the acquisition and guarantee of employment was considered to be among the

determinants of health and well-being. Work was perceived to be an essential part of

2 Such as coffee, beer or bread to supplement their diet.

7

social integration, normalization, recovery, and the maintenance and strengthening of

mental health» (Charbonneau, 2002).

As time passed however, the optimism that once surrounded the psychiatrie institutions

began to dissipate, giving way to a growing sense of insatisfaction with regards to th is

method of delivering care. Indeed, critics increasingly insisted that very little care was

being offered in the asylums and that these had gradually taken on a mere custodial role ,

in essence becoming hl1ge warehouses for the mentally ill (Davis, 2006 ; Santé Canada ,

2002). Several factors contributed to this insidious shift in roles, including outdated

treatment approaches that were largely ineffective, the public , religious and medical

community's growing belief that .mental health pro~lems were incurable and hospita l

funding methods that favoured the intake of patients (Dorvil, Guttman , Ricard , &

Villeneuve, 1997; Fleury & Grenier, 2004). As hospital costs continued to rise ,

administrators' capacity to meet these costs became increasingly difficult, in part because

of an aging and less productive population of patient labourers (Moran & Wright, 2006).

ln Quebec, the 1950s saw the arrivai of a new breed of psychiatrist, one that had been

trained in the United-States or in France and who had witnessed the emergence of new

medications and mental health reform (Dorvil, Guttman, Ricard, & Villeneuve , 1997).

These modern psychiatrists possessed a new perception of mental illness, one that saw it

as an illness like any other and, importantly, could be cured. They. began to advocate for a

more humane approach to psychiatry and actively sought to wrestle power away from the

traditional psychiatrists and religious comm~nities and gain control of strategic posts in the

mental health system (Dorvil, Guttman, Ricard, & Villeneuve, 1997).

Meanwhile, with psychiatric hospitals becoming understaffed and overcrowded, the quality

of care and life for residents within them deteriorated dramatically. Several sometimes

horrifying first-hand accounts of life within these hospitals from former patients began to

reach the public, further shifting public opinion and pushing policy makers to initiate

changes to the mental health system.

8

One particularly notable first-hand account was published in 1961 by Jean-Charles Pagé,

a former resident of St-Jean-De-Dieu hospital in Montreal (now Louis-H-Lafonta ine

Hospital). His shocking book entitled «Les fous crient au secours» (Pagé, 1961) described

the appall ing living conditions and care provided to patients and shed more light on the

exploitation of patient labourers.

Pagé's ~xperience initiated vigorous publ ic debates about the deplorable state of affairs in

Ouebec psychiatric hospitals, debates which served to mobilize various stakeholders, who

pressured the government to adopt changes to its deficient system of care. The

government quickly responded and appointed three modern psychiatrists to examine the

problems and needs of Ouebec's psychiatric hospitals and formulate recommendations

regarding the appropriate organization of services. A year later, the Bédard commission

as it is known produced a report that would trigger the onset of the second major era of

psychiatrie service organization in Ouebec, the era of deinstitutional ization and

regionalization.

1.2.2. Work in the era of deinstitutionalization and regionalization

The Bédard commission played a pivotai raie in the reorganization of psychiatrie services

in Ouebec in that it set the stage for a shift away from institutionalized care to community­

based care , a process referred to as deinstitutionalization . The commission called for the

creation of the Direction of psychiatric services within the Ministry of Health , an entity that

would be responsible for carrying out the commission's recommendations for reform.

Three main objectives guided this reform: 1) the provision of a greater accessibility to a

wide range of psychiatric services in the community and the transfer of some patients from

the psychiatric hospitals ta these community resources, 2) a greater follow-up of the

patients that leave the hospitals, and 3) the creation of programs that would facilitate

patients' rehabilitation and reinsertion into society (Dorvil, Guttman, Ricard, & Villeneuve,

1997).'

Interestingly, the importance of work and employment was not lost on the members of the

commission and the leaders of this reform. Indeed , the commission proposed measures

that aimed ta support individuals' pursuit of work and professional integration. One such

9

proposition was the creation of sheltered workshops, defined as a place where patients

could pursue productive and paid work in an understanding and non-competitive

atmosphere (Ministère de la Santé et des Services Sociaux, 1962). Accord ing to the

commission , the creation of these workshops , along with the establishment of half-way

houses, would allow hundreds of people who did not need to spend their lives in the

hospital to leave and live semi-independently in the community. The commission notes

that they were inspired by England's pioneering rehabilitation services, where 90 such

workshops employing roughly 100 people each had been established (Ministère de la

Santé et des Services Sociaux, 1962).

ln addition, the Bédard commission also recommended that Quebec's Provincial

Placement Office reorganize its specialized services and pay special attention to the

rehabilitation of people with mental i"ness through work, as it had had success doing in the

case of the physica"y handicapped. Again, England served as an inspiration , as the

British government's «Disabled Persons Act» required that industries have at least 3% of

their employees be people with either physical or mental disabilities. According to the

commission's report, this pol icy had resulted in the hiring of over 200 000 people with

mental i"ness in the year 1950 alone (Ministère de la Santé et des Services Sociaux,

1962).

While the reform guided by the Bédard commission led to several concrete changes in the

locus of psychiatrie care , most notably through the creation of psychiatrie departments in

the province's general hospitals and the establishment of multidisciplinary external clinica l

teams that could offer treatment in the community , other services that were supposed to

complement these clinical services did not take shape as quiékly (Dorvil , Guttman , Ricard ,

& V1l1eneuve, 1997). Indeed , as hospitals continued to significantly reduce their patient

populations, too little was done to ensure that the appropriate community resources and

social reinsertion mechanisms, such as patient follow-ups and work integration measures,

were put in place" to maintain and support these individuals (Charbonneau, 2002; Dorvil,

Guttman , Ricard , & Villeneuve, 1997; Goldner, 2002). According to Boudreau, «Half-way

houses and sheltered workshops are part of the plans, the projects, but rarely make the

transition from paper to concrete reality» (Boudreau, 1984, p. 127, translated to English).

Part of the problem was that very few funds were injected to support the development of

10

services that promoted the full integration of people into their community. Instead, for

many years the services that did appear in the community consisted mainly of personnel

transfers from psychiatric hospitals to the regional psychiatric departments, external clinics

and day centres, services that ultimately remained under the management and control of

the hospitals3 (Ministère de la Santé et des Services Sociaux, 1998). The situation gave

rise to a phenomenon some actors have called «transinstitutionalization» , or the

reproduction of the grim conditions of psychiatric hospitals by other institutions in the

community (Davis, 2006). Indeed, the development of services aiming to fully integrate

people into society and into the workforce remained unimportant to the dominant actors of

that time period.

Transinstitutionalization continued throughout the 1960s and 1970s, affecting vocational

as weil as clinical services. Several psychiatric hospitals relocated their sheltered

workshops to community settings, a move that 'was coherent with the growing notion of

«normalization» (Gagnon , Pilon, & Wallot, 1981), i.e. the idea that that a person 's

rehabilitation from mental illness would progress best if it took place in a normal

community environment. Some hospitals were more successful than others however in

setting up a variety of services that could support an individual's desire for normal work.

For example, in the early 1970s Robert-Giffard Hospital in Quebec City (then Saint-Michel­

Archange Hospital) succeeded in establishing four work-related programs, namely

workshops to help former psychiatrie patients develop their skills and initiate them to the

world of work, an adapted work centre where workers engaged in tasks such as carpentry,

cleaning , product assembly and kitchen work, and two workshops in the Quebec Hilton

hotel, including one that involved competitive4 placem~nts (Gagnon, Pilon, & Wallot,

1981). Essential to the development of these programs was 1) program coordinators'

belief that people with mental illness were capable of assuming responsibility for their

social and economic autonomy and 2) the desire of these coordinators to «prove to the

population in general and to employers in particular that people with mental handicaps

3 The domination of the mental health budget by psychiatrie hospitals was no accident, but indeed the work of

interests groups determined to maintain power, prestige and their recognition as experts by society.

4 ln this sense, competitive means that employees with mental illness were paid the same wages as other

employees and had access to a range of benefits.

11

were able to meet the norms and requirements of a regular job in the private sector»

(Gagnon , Pilon, & Wallot, 1981).

Unfortunately, such perspectives were not widely held at the time and frustration and

criticisms regarding the lack and poor quality of work integration programs were vo iced as

early as 1970. While the philosophy of normalization would often be cited in ministerial

documents, health authorities neglected to provide service providers with the operational

tools needed to translate this philosophy into reality (Gagnon, Pilon, & Wallot, 1981). In

consequence, the overwhelming majority of programs that existed were axed almost

entirely on occupational activities that never allowed people attain a level of employability

sufficient enough for them to integrate the regular workforce (Dorvil , Guttman , Ricard , &

Villeneuve, 1997). Workers would only often have access to dull, repetitive jobs in non­

stimulating environments, with no possibility of obtaining a diploma or being promoted

(Boudreau, 1984; Dorvil, Guttman , Ricard , & Villeneuve, 1997). As a result, these workers

could toi l monotonously for years in the workshops, losing ail hope of meeting the

requirements and standards of the labour market. In addition, economic changes ,

including a rise in unemployment, made employers less willing to contract out to the

sheltered workshops, further reducing the work options available. These factors led some

members in the mental health field to question whether shelter~d workshops were really

an appropriate and effective way of developing employability and supporting people's

rehabilitation.

The Ministry of Health's little success in putting in place appropriate community-based

services to support the integration and maintenance of people with mental illness into the

community had a number of important consequences. First and foremost, it accentuated

the burden that weighed on families who were increasingly responsible for the care of a

loved one with mental illness (Dorvil, Guttman, Ricard, & Villeneuve, 1997). These

families would often see their routines disrüpted, their activities limited and their finances

stressed , and ail the while never have access to information and supports that could help

alleviate their problems. Adding to the problem was the overall dearth of employment and

housing·options for individuals with mental health problems, a situation that gave rise to a

sharp increase in poverty and homelessness in this population (Dorvil, Guttman, Ricard, &

Villeneuve , 1997). Difficulties with respect to social reinsertion and integration also led to

------------------------------------- --- ----

12

the phenomenon known as the «revolving door syndrome», defined as psychiatrie

patients' incessant back and forth between the psychiatrie hospital and a community that

could. not meet their needs5 (Dorvil, Guttman, Ricard, & Villeneuve, 1997). In his

description of the plight of the mentally ill in the post-deinstitutionalization era,

Charbonneau paints a grim picture, «Using few services, discrete in their suffering ,

anonymous and forgotten, these people will slowly amass obstacles that, while remain ing

invisible, will become more and more severe and indelible. Cited in government policies

but forgotten by programs and services, incapable of getting access to effective treatment

and rehabilitation services, they'lI make several desperate attempts to integrate or

reintegrate the workforce and to insert themselves socially... However, their mitigated

success and repeated failure will finally wear on them ... Over the course of months and

years, these people would share their exclusion with a confusing diagnosis, a few

renewable prescriptions and a welfare cheque that condemns them to poverty. The

stagnation and weight of their sUffering would cause their partner, their friends and the ir

family to disappear. Their catastrophe will distance them from their children and atlack

their raison d'être ... These people will thus be forgotten , because we don't lock them up

anymore. They will become invisibre» (Charbonneau, 2002).

1.2.3. The emergence of alternative psychiatrie resources and commun ity-grown

vocational services

Though work and employment programs increasingly fell outside the scope of the mental

health system's priorities, they were still a major priority to families and especially people

with mental illness. In fact, these supports, so inaccessible to so many, have often been

the ones deemed most important by people with mental illness (Trainor, Pomeroy, & Pape,

1993).

Faced with a limited scope of services and an escalation in social problems, and buoyed

by the growing human and patient rights movements, a new movement of protest against

the psychiatrie establishment began to emerg~ and take hold over the course of the 1970s

5 To get a sense of the magnitude of the problem, in 1970, more than 70% of ail admissions to Louis-H

Lafontaine hospital were actually readmissions of people previously admitted (Dorvil, 1987).

~~-------------------------~----------------------~--------------------------~--~--~-- ----

13

(Dorvil, Guttman, Ricard, & Villeneuve, 1997). The consequence was the emergence of

various alternative psychiatric resources devoted to social reinsertion, housing, treatment,

self-help , and defence of rights (Dorvil , Guttman, Ricard, & Villeneuve, 1997; Fleury &

Grenier, 2004), services that were most often developed by families or individuals touched

by mental illness (Davis, 2006).

The services offered by these groups in the community were based on a vision of mental

illness that stood in stark contrast to the one that dominated in the medical and psychiatric

commun ity. For instance, the arrivai of psychotropic medications in the 1950s and other

advances in psychiatrie research6 contributed to the widespread adoption of a biomedical

focus by the mental health field, a view that would lead many health providers to place a

greater emphasis on medical treatment than other aspects of care. As time passed

however, it was becoming increasingly clear that these medications were not a panacea ,

causing many practitioners to be guarded in their prognoses, not wanted to incite false

hopes in their patients (Davis, 2006). Indeed, sorne health providers, having witnessed

patients' repeated setbacks and readmissions to the hospital, would lose hope altogether

and feel powerless and pessimistic about individuals' chances of recovery (Charbonneau ,

2002). Even worse, some of these attitudes would influence the perspectives of other

actors outside of the health system, infiltrating the sectors of employment and education

among others (Charbonneau, 2002).

Community groups, on the other hand, adopted very different perspectives of how to meet

the wants and needs of people with mental illness. ' White and Mercier describe the

approach adopted by these alternative, community-based groups in Quebec, «Alternative

practices in the field of health distinguished themselves from institutionalized m·edical

practices by emphasizing a holistic rather than biomedical approach, faith in a relationship

of support between caregiver and client rather than one based on domination , a minimal

amount of intervention rather than resorting to invasive technologies, and , above-all , the

respect of the dignity, autonomy and abilities of the person» (White & Mercier, 1989).

Rousseau echoes these assertions and emphasizes these resources' desire to take into

6 ln particular, research painting ta mental illness as a disease of the brain.

14

account an individual's «social, economic, cultural and affective environment» (Rousseau ,

1993). This adoption a more holistic approach was undoubtedly influenced by the growing

research on the determinants of health, which stressed that the health system represents

only one of the many determinants of health and weil being (R. G . . Evans , Barer, &

Marmor, 1994). Other authors have emphasized these groups' focus on · empowering

people with mental illness and their desire to help people increase their autonomy and

ability to assume responsibility for their rehabilitation and recovery (Charbonneau , 2002).

Authors such as Lecomte have also made reference to these groups' belief that social

networks offer therapeutic benefits to people with mental illness, «Humans are biological

and psychological beings enmeshed in social networks... This social network is

determinant to the extent that it facilita.tes, supports, or inhibits the bio-psychological

development over the different stages of a human being's life ... It is particularly important

when this being is faced with a difficulty, a crisis, or a ruptured relationship. The network

must then mobilize and provide the help needed to establish a new psycholog ical and

social equilibrium. These relationships of support and help from the social network

constitute the basis of the community support system with respect to the biological and

psychological human» (Lecomte, 1986). Finally, the majority of these groups would va lue

the principle of «people first» (Anthony, 1993) and share the belief that the way people

interact with each other is more important than where these interactions take place. They

denounced the depersonalization that people with mental illness increasingly experienced

during their encounters with health providers. The spirit of the principle of «people first» is

captured weil by Deegan, «Those of us who have been labelled with mental illness are first

and foremost human beings. We are more than the sum of the electro-chemical activity of

our brain .... We are people. We are people who have experienced great distress and who

face the challenge of recovery» (Deegan, 1995).

This opposing conception of mental illness and how it should be treated is reflected in the

types of rehabilitation and work integration services that these alternative psychiatric

resources would develop over the next few decades. One example of a particularly

successful model of services is the clubhouse mode/. The very first clubhouse was

founded in the 1940s in New York, where a group of individuals who had recently been

discharged from the same psychiatric hospital formed a mutual aid organization called

WANA (We Are Not Alone) (Davis, 2006). This organization, which later became known

15

as Fountain House, aimed to be a restorative environment where people with mental

illness could go, receive support, and be surrounded by people who believed that the ir

recovery from mental illness was possible (International Center for Clubhouse

Oevelopment, 2008a). It has served as the model for ail other clubhouses around the

world, including the ones that would be developed in Canada. The International Center for

Clubhouse Oevelopment (ICCO) defines these clubhouses in the following way , «A

Clubhouse is first and foremost a community of people. Much more than simply a program,

or a social service, a Clubhouse is most importantly a community of people who are

working together toward a common goaL .. A Clubhouse is a membership organization ,

and therefore the people who come and participate are its members. Membership in a

Clubhouse is open to anyone who has a history of mental illness. This idea of membership

is fundamental to the Clubhouse concept, as having membership in an organ ization

means that an individual has both shared ownership and shared responsib ility for the

success of that organization. To have membership in an organization means to belong , to

fit in somewhere, and to have a place where you are always welcome ... Clubhouse

commun ities are built upon the belief that every member can sufficiently recover from the

effects of mental illness to lead a personally satisfying life. Clubhouses are commun ities of

people who are dedicated to one another's success -- no matter how long it takes or how

difficult it is. The Clubhouse concept is organized around a belief in the potential for

productive contributions from everyone, even the member struggling with the most severe

effects of mental illness» (International Center for Clubhouse Oevelopment, 2008b).

Among the fundamental elements of the clubhouse model is the «work-ordered day» and

its employment programs, most notably its transitional employment programs7. The work­

ordered day is an eight-hour period, typically Monday through Friday, where members

work side by side with staff to accomplish the tasks needed ta keep the clubhouse

functioning. The work is organized into work units, these units representing members' first

opportunity to ease into the world of work and social interaction (Fountain House, 2008).

Traditional examples of work units are kitchen/care, janitorial/housekeeping, clerical work

(accounting work, preparing newsletters, etc.), security, social activity organization , etc.

7 Some clubhouses don't include transitional employment in their mix of services, whereas others have added

additional programs, such as supported employment , to members' list of work integration options.

16

(Fountain House, 2008; Marrone, 1993). Clubhouse staffing levels, purposely kept low,

promote productive co~tributions by members to the clubhouse and foster relationships

that form the key ingredient in clubhouse rehabilitation (Fountain House, 2008).

ln addition to these work units are employment programs that offer members the chance to

pursue paid employment outside of the clubhouse. In transitional employment (TE),

members are offered the chance to develop their work skills in a part-time job for a limited

time period, usually six to nine months (International Center for Clubhouse Development,

2008a). These transitional employment placements will represent for many clubhouse

members a first successful work experience outside of the clubhouse. Members are paid

at least minimum wage and are offered both on- and off-site support and encouragement

from the clubhouse staff. On the other hand, one criticism of the TE approach has been

that it tends to favour placements into entry-Ievel jobs, where it is easier and quicker to

train employees, rather than more highly skilled «white collar» jobs (Marrone, 1993). TE

thus seems much beUer adapted to the needs · of members who possess IiUle work

experience or who have been out of work for several years, as opposed to those who have

the skills and desire to rapidly integrate the regular workforce. Indeed, the program

reflects the view that some members, because of skill deficits or lack of work experience,

will always have difficulty securing employment (Marrone, 1993). Individuals who wish to

obtain a regular job can be directed to what is sometimes called the independent

employment program, where members can apply for work on their own and receive

support from the clubhouse. However, members are generally encouraged to start in the

TE program and use it as a potential stepping-stone to a competitive job (Fountain House,

2008).

Another well-known organization that provided a model of vocational services' is

Thresholds, one of the oldest psychiatrie rehabilitation centres in the United-States8.

Guided by the principle that «Everyone contributes to society ... Everyone has untapped

potential, with gifts and skills to develop» (Thresholds, 2008), Thresholds would see its

8 Thresholds was founded by the National Council of Jewish Women, after several members had attended a

conference on mental health. Sympathetic to the plight of people with mental illness, they established this

rehabilitation agency in the face of discouragement from most mental health experts they had consulted.

17

vocational services expand over the course of the 1970s and 1980s. Like in the clubhouse

model, new members would be encouraged to join a work crew (similar to the Clubhouse

concept of work units) that would allow them to practice various kinds of job skills (Cook &

Razzano, 1992). When ready, members could take advantage of a paid group placement

or a more independent form of employment. This latter service would initially consist of a

transitional employment program but would eventually be altered to provide more flexible

placements that no longer needed to be temporary (Cook & Razzano, 1992). Responding

to the expressed needs of their members, the agency would also develop two other

innovative services, namely the creation of member-run businesses (for example, delivery

services, catering services, printing/copying services) and mobile job support team made

up of staff members who could provide regular ongoing vocational support or intervention

at the work site (Bond, Drake, Becker, & Mueser, 1999; Cook & Razzano, 1992).

These ideas and models of work integration services, often originating in the United-States

or abroad , would slowly disseminate and inspire community groups in Canada. Beginning

in the late 1970s and continuing into the turn of the century, an increasingly broad range of

alternative resources and community services would emerge. The growth of these

commun ity groups would at times be stunted, however, by various factors including a lack

of funding and a lack of recognition from health authorities and the medical establishment ,.

(Dorvil, Guttman, Ricard, & Villeneuve, 1997). Nevertheless, in Ouebec, determined

organizations devoted to developing employability, professional training, work integration

through internships, management of social enterprises and integration to competitive

employment would eventually emerge ail over the province, with the majority of services

congregating in larger urban centres like Montreal, Laval and Ouebec City (Charbonneau ,

2002; Latimer & Lecomte, 2002).

These new programs would come to co-exist with the vocational services that were being

developed and managed in parallel by the psychiatric community. In the early 1980s in

Ouebec, the network of sheltered workshops, which had become increasingly criticized

and viewed as insatisfactory, was split into two separate networks, a network of skills

18

development programs offered by rehabilitation centres9 and a separately-funded network

of adapted work centres 10 (Dorvil, Guttman, Ricard, & Villeneuve, 1997). The same time

period would also see the creation of new programs and measures by the Ministry of

Employment that aimed to increase the social and economic contribution of people with

handicaps. For instance, the early 1980s saw the creation of subsidies offered to

employers to compensate them for the potentially increased costs of hiring a person with a

handicap 11, as weil as various other forms of financial incentives for unemployed

individuals and welfare recipients. Furthermore, in the mid-1980s, various community

organizations interested in the social and professional insertion of various clienteles were

regrouped together under the program service externe de main d'oeuvre (SEMO), thus

adapting their missions to focus on the integration of people with handicaps into the

regular workforce. Indeed, over the years new stakeholders from a variety of sectors

would join the cause, giving rise to a diversity of vocational approaches and giving birth to

new concerns with regards to the continuity and efficiency of services.

While a greater variety of vocational supports and services were gradually coming to light,

some actors maintained that many of these approaches still suffered from a variety of

weaknesses. Among the criticisms were that: 1) programs often encouraged or required

individuals to engage in unpaid prevocational services, even after these individuals had

expressed interest in being placed rapidly in 'competitive employment; 2) individuals

participating in work units or work crews would often stay in these types of jobs for

extended periods of time, rarely progressing to competitive employment; 3) protected work

environments, where the majority of employees have disabilities, are less normalizing than

regular work environments and prevent people with mental illness from having contact with

nondisabled workers; 4) in traditional rehabilitation programs, the starting point for locating

9 Les services d'apprentissage aux habitudes de travail (SAHT) were in essence still sheltered workshops.

10 Adapted work centres (CT A) are defined as organizations that offer long-term employment possibilities to

people with physical and mental handicaps who are seen as having major limitations that prevent them

fram integrating the regular workforce (L'Office des personnes handicapées du Québec, 1997). CTAs 'must

employ, at ail times, a number of individuals with disabilities that represents at least 60% of its total number

of employees.

11 These are ca lied contrats d'intégration au travail (CIT) and were established in 1980.

19

jobs is determined largely by these programs' relationships with employers and not by the

preferences .of clients (Bond, Drake, Becker, & Mueser, 1999). Faced with these

perceived weaknesses, some of these actors would advocate for a different approach to

vocational services, one that would emphasize the importance of competitive employment

in integrated work settings and with follow-along social and professional supports.

1.3. Supporled employment

An extensive literature exists on the topic of supported employment, dating back ta its

early beginnings as a program designed to assist individuals with developmental

disabilities. In the following chapters, 1 will briefly discuss the origins of this model of

services, describe its key principles and provide an overview of efforts to implement this

model in a Canadian context.

1.3.1. Origins and principles of the supported employment model

The origins of the supported employment model can be traced back to the late 1970s and

a supported competitive employment program at Virginia Commonwealth University's

Rehabilitation and Training Centre. This program, founded by Dr. Paul Wehman and his

associates, was conceived as a means for people with severe developmental disabilities to

integrate competitive work settings and work side-by-side with non-disabled persons

(Wehman & Moon, 1988). Indeed, the fundamental assumption of supported employment

is that ail person's, regardless of extent or nature of disability, should have an opportunity

to work in the community (Wehman & Moon, 1988). In this spirit, the program developed

in Virgin ia sought to place people rapidly in competitive employm~nt and provide the

intensive support needed to help them maintain their job.

The program would prove to be an effective way of helping peopl~ with disabilities

integrate the regular workforce. News of the program's success would disseminate and

arouse great interest in the vocational rehabilitation field. In particular, some stakeholders

believed that such programs could also be effective for other populations, including people

with severe mental illness (Mellen & Danley, 1987). Early experiments with this clientele

took place in New Hampshire in the early 1990s as community mental health centres

looked to implement supported employment programs and transition away from day

20

centres. Though the transition away from day centres, perceived to be a safety net for

people with mental illness, provoked fear and concern from service users, families and

clinicians, vocational outcomes proved to be more positive than expected , facilitat ing the

programs' acceptance (Drake, 1998).

While Wehman 's program for people with disabilities clearly influenced the vision

underpinning the programs developed for a mental health clientele, it was not the only

source of influence. Indeed, aspects of these programs were also influenced by the

development of Assertive Community Treatment (ACT) and by the professional and

clinical experiences of the program founders (Bond , 1998). These latter individuals wou ld

in essence take the best ideas from the literature, adapt them for a clientele with mental

illness and standardize them so that a minimal level of quality could be achieved in

different contexts (Bond, 1998). This process has produced resulted in a model of

supported employment that is characterized by several guiding principles (Bond , 2004 ):

Competitive employment is the goal

Eligibility is based on consumer choice

Rapid job search

Integration of vocational rehabilitation and mental health

• Attention to consumer preferences

Individualized and time-unlimited support

The first principle guiding supported employment programs is that the goal for clients is

competitive employment in integrated work settings, i.e. where the majority of employees

do not have disabilities. This principle is based on the belief that most people with severe

mental illness can achieve competitive employment (Bond, 1998). It is argued that

integrating clients into work settings where they are surrounded by colleagues without

disabilities fosters a greater sense of normalcy and facilitates a more complete integration

into the community , as clients are encouraged to move out of patient roles and adopt

normal adult roles (G. R. Bond, Salyers, Rollins, Rapp, & Zipple, 2004).

21

The second principle of the supported employment model relates to programs'

inclusion/exclusion criteria. Essentially, programs are available to any person with a

mental illness who expresses the desire to work in a competitive environment. Like in the

supported employment program founded by Wehman, the nature and extent of the illness

or disabi lity is not an exclusion criteria. Furthermore, individuals are not excluded on the

basis of their «work readiness» or perceived capacity to work (G. R. Bond, 2004).

Rapid job search is the third principle that guides these programs. This principle

distinguishes them from other vocational services that aim for competitive employment in

that efforts are not made to provide clients with extensive prevocational skills training or

pre-employment assessments. Instead, the goal is to move the individual directly into a

meaningful job and surround that person with the supports (for example , work

accommodations, on-the-job training , psychosocial or socio-professiona l support)

necessary to maintain that job. It is a «place-train» rather than a «train-place» philosophy

(Drake, 1998). According to the founders of the model , there is little empirical evidence to

support the view that approaches that favour lengthy pre-employment assessment,

training and counselling help people obtain jobs or keep them longer (Bond , 1998).

Indeed , some evidence suggests that such approaches actually reduce people's chances

of achieving competitive employment (Bond, 1992).

The fourth principle, the close integration of vocational rehabilitation and clinica l treatment

teams, is a cardinal feature of the model and one that was inspired by the ACT model (G.

R. Bond, 1998). The rationale underlying the historical non-integration of services was

that rehabilitation services should be provided exclusively by specialists in rehabilitation

and that clinical environments were typically stigmatizing and dominated by medical

perspectives (Drake, Becker, Bond, & Mueser, 2003). However, integration at a client­

level, such as the development of multidisciplinary teams, tend to promote services that

are better tailored to the individual client and have been shown to lead to better clinical

and vocational outcomes (Cook, Lehman et aL, 2005; Drake, Becker, Bond, & Mueser,

2003). According to the model's founders, the best way to achieve this integration is to

have the vocational rehabilitation staff work at the same agency and even be part of the

same team as the clinical treatment staff. They argue that while many attempts to

22

integrate these two fields have been made, whether it be through interagency agreements,

cross-tra ining or other strategies, the fact that there are multiple providers involved makes

commun ication and service coordination difficult and poses a challenge to clients who

must negotiate with numerous agencies (Bond, 1998). Drake describes four benefits to

achieving · integrated vocational and clinical services: 1) more effective engagement and

retention of clients , 2) betler communication between employment specialists ,and mental

heâlth clinici'ans, 3) clinicians learn to appreciate the value of work and as such focus more

on it when meeting with patients, and 4) the incorporation of clinical information into

vocational plans (Drake, Becker, Bond, & Mueser, 2003).

The emphasis placed on client preferences, the fifth principle, is consistent with the trend

of client-centred service, delivery and care and supported by evidence on vocational

outcomes and work satisfaction. For example, when a job placement matches an

individual's work preferences, they tend to be more satisfied with the job and likely to

remain in it (Bond, 2004). According to the founders of the supported employment model,

many other vocational programs ignored client preferences because they only offered

clients the jobs that were made available by pre-established relationships with employers.

Furthermore, Bond remarks «If consumer preferences were the deciding factor in the

design of vocational programs, it is questionable that unpaid work units would be such a

prominent feature in so many agencies. The reality is that providers usually make choices

for consumers about the structure and pacing of vocational services, regardless of what

consumers say they want» (Bond, 1998).

The last principle, time-unlimited and individualized support, is a fundamental tenet of the

mode!. Inspired again by Wehman's vocational program, it is understood that vocational

success is directly related to the duration and individualized nature of support that is

offered to clients. In other words, it has to be there when they need it and must

accommodate their unique needs. The time-unlimited nature of support is also viewed as

central given the episodic nature of many mental illnesses. Also, cQnsistent with the view

that rehabilitation services should promote the autonomy of people with mental illness,

such support can be tapered-off gradually as the individual's independence increases.

- ~---~~~-~-------~-------------------------------------------------------------------

23

It is important to note that as time has passed, several other principles have been

.considered as being important elements of supported employment. For instance, some

authors have emphasized the importance of counselling clients on the impact that

competitive employment could have on their disability benefits (Tremblay, Smith, Xie , &

Drake, 2006). Others have highlighted the need for creating of a therapeutic alliance

between the client and employment specialist (Catty et aL, 2008), negotiating work

accommodations (MacDonald-Wilson, Rogers , Massaro, Lyass, & Crean, 2002), involving

family members and developing career plans (Corbière, Submitted). Still others have

emphasized making good job matches and adopting a recovery approach (G. R. Bond ,

2004). As mentioned by Bond, «additions, refinements and deletions are ail ongoing

processes in an empirical approach to defining an evidence-based practice» (Bond , 2004).

While these other principles may be regarded as important elements of supported

employment, they have generally been less studied than the · original six principles which

remain the most commonly identified principles ~f the supported employment model.

Programs that adhere closely to these six key principles can be said to follow the

Individual Placement and Support (IPS) model of supported employment, described as the

standardized version of supported employment specifically for people with severe mental

illness (Bond , 2004). IPS programs are further characterized by a variety of critical

program components, such as small caseload sizes (ideally less than 25 clients per

employment specialist), vocational ' generalists (each employment specialist carries out ail

phases of the vocational service), vocational units (employment specialists form a

vocational unit with group supervision), and community-based services (employment

specialists spend at least 60% of their time in the community and outside of their offices)

(Bond, Becker, Drake, & Vogler, 1997). IPS is thus typically distinguished from other

forms of supported employment that may adhere less closely to the six guiding principles

and other components of the supported employment model or may cater to clienteles not

having a severe mental illness (Dartmouth Supported Employment Center)12.

12 For an exhaustive list of supported employment components or critical ingredients, please consult

(Evans & Bond , 2008).

24

1.4. Implementation of supported employment in a Canadian context

Supported employment and the IPS model in particular have gained in popularity over the

years for a variety of reasons. First, the IPS model has been weil described in the

scientific literature and its guiding principles have been delineated and tested to assess

their individual contribution to improving employment outcomes. Indeed , various stud ies

have shown that each principle contributes in its Qwn way to helping people with severe

mental illness obta in or maintain competitive employment (Bond , 2004; Bond et al., 2001 ).

Furthermore, a number of large, multisite randomized controlled trials have shown that

supported employment programs like IPS are more effective and produce better vocational

outcomes than traditional and other types of vocational rehabilitation services (Cook, Leff

et aL , 2005; Crowther, Marshall, Bond, & Huxley, 2001; Twamley, Jeste, & Lehman, 2003).

This demonstrated effectiveness has likely facilitated the model's adoption by managers

and policy-makers in an era where few resources exist and decisions must be made

regarding the best rehabilitation services to offer. As such , the model has inserted itself

weil in the current trend towards «evidence-based practices» and several authors have

made arguments describing the model as such a practice (Bond, 2004; Bond et al. , 2001 ;

Goldner, 2002; Mueser, Torrey , Lynde, Singer, & Drake, 2003 ; Twamley, Jeste, &

Lehman, 2003).

The supported employment model is also viewed by some to be consistent with other

philosophies that have taken hold in the mental health field, namely the psychosocia l

rehabilitation philosophy and more recently the recovery movement (Bond , Salyers ,

Rollins, Rapp, & Zipple, 2004; Latimer, 2005). While recovery is a multifaceted construct,

it can generally be defined as an internai and non-linear process of transformation by

which the individual with mental illness discovers a new sense of self that extends beyond

his or her illness (Anthony, 1993; Davidson, 2003 ; Deegan, 1988; Spaniol, Wewiorski ,

Gagne, & Anthony, 2002). Recovery is viewed to be unique to each individual ; an

experience that brings this person to adapt their attitudes, values, skills and roles to their

new reality, ail the while seeking a satisfying life despite the limitations that their illness can

impose (Anthony, 1993; Deegan, 1988). Work, and especially competitive work, is.

considered to play an important role in the recovery process and can lead people to

reassess their concept of self and personal identity (Eklund & Bejerholm, 2001). Indeed,

competitive work can play a crucial role in shaping this identity and can offer people a

25

place and status within society (Anthony & Blanch, 1987; Dorvil, Guttman, Ricard , &

Villeneuve, 1997). Furthermore, work can provide people with a sense of hope and

accomplishment that further contributes to their recovery (Cunningham, Wolbert, &

Brockmeier, 2000).

Conditions have thus been favourable to the diffusion of supported employment and the

IPS model to settings outside of the United-States. Indeed, the last decade or so has seen

evidence-based supported employment programs implemented in Europe (Burns et al. ,

2007; Reker & Eikelmann , 1999; Rinaldi et aL , 2004; Saloviita & Pirttimaa , 2000 ; van Erp

et aL, 2007), Asia (Fuller et aL, 2000; Wong et al. , 2008) and Australia (Killackey &

Waghorn , 2008). Canada has also witnessed efforts to implement IPS programs i~ recent

years, particularly in Montreal (Latimer, 2001; Latimer & Lecomte, 2002), Vancouver

(Corbière & Goldner, 2003; Oldman, Thomson, Calsaferri, Luke, & Bond, 2005; Thomson

& Oldman, 2003) and Toronto (Kirsh, Krupa, Cockburn, & Bickenbach, 2002). However,

as has been the case with the programs implemented in other countries, there is a growing

interest in determining to what extent the supported employment model is generalizable to

a Canadian context (Corbière, Bond, Goldner, & Ptasinki, 2005; Latimer & Lecomte,

2002). Indeed, a recent study by Corbière and cOlleagues revealed that considerable

variations exist between the supported employment programs developed in Canada and

that the majority of programs studied, including some IPS programs, achieved only

moderate fidelity to the supported employment model (Corbière, Submitted).

Such findings merit further attention given the demonstrated positive association between

program fidelity and vocational outcomes ( Becker, Smith, Tanzman, Drake, & Tremblay,

2001; Becker, Xie, McHugo, Halliday, & Martinez, 2006). In the United States, similar

observations of variations in program implementation have led some authors to emphasize

the importance of supported empl<?yment implementation models and standardized

methods of quality improvement (Bond, McHugo, Becker, Rapp, & Whitley, 2008; Drake,

Bond , & Rapp, 2006). According to Drake, «research indicates that offering a service that

resembles an evidence-based practice is not sufficient; adherence to specifie

programmatic standards, often referred to as fidelity of implementation, is necessary to

produce expected outcomes» (Drake et al., 2001, p. 180). Bond echoes this by stating,

«modest fidelity efforts lead to modest fidelity, which in turn leads to modest outcomes»

26

(Bond, 2007, p. 334). This perspective has prompted researchers in the US to examine

the factors that facilitate or impede the faithful implementation of supported employment (

Becker, Lynde, & Swanson, 2008; Bond et al., 2001; Bond, McHugo, Becker, Rapp, &

Whitley, 2008; Drake, Becker, Goldman, & Martinez, 2006; Marshall, Rapp, Becker, &

Bond, 2008). That being said, much less is known about the factors that influence

program implementation in contexts outside of the US, including Canada.

Some of the factors that have been hypothesized to play a role in 'program implementation

in Canada are the country's socialized health care system and welfare laws (Corbière,

Bond, Goldner, & Ptasinki, 2005; Latimer & Lecomte, 2002; Latimer et aL, 2006), language

barriers limiting access to supported employment information and training (Latimer &

Lecomte, 2002), labour market (Latimer et aL, 2006), institutional environments, and

uniqueness, quantity and philosophy of service provider agencies (Corbière, Bond ,

Goldner, & Ptasinki, 2005; Latimer et al., 2006; Oldman, Thomson, Calsaferri , Luke, &

Bond, 2005). However, no study to date has specifically examined the factors that

influence the implementation and functioning of supported employment programs in

Canada. A beUer understanding of the sources of variations between such programs and

the factors that impact implementation efforts in this country would seem warranted and

could help service providers increase the effectiveness of the vocational services they

offer to people with severe mental illness.

Among the factors that have been argued to play an important role in supported

employment implementation in the US are organizational factors, including aspects related

to administrative and governmental leadership, program funding schemes, resource

allocations and limitations, staff training and skills, and quality monitoring mechanisms (

Bond, McHugo, Becker, Rapp, & Whitley, 2008; Drake & Bond, 2008; Gowdy, Carlson , &

Rapp, 2004; Marshall, Rapp, Becker, & Bond, 2008). A beUer understanding of how

organizational factors influence supported employment programs has been identified by

Drake as one of nine main areas in which new research and innovation promises to

amplify the success of these programs (Drake & Bond, 2008). A great number of

organizational approaches and theories exist and have been proposed to analyze an

organization and its impact on the outcome of an intervention or a program. One of the

currently most used emphasizes the role of stakeholder values, interests and beliefs, as

27

weil as the interactions between stakeholders and their dependence on or autonomy from

pressures in their environment (Martin de Holand & Phillips, 2002; Rao, Morrill , & Zald ,

2000; Tolbert & Zucker, 1996): Though some studies have suggested that beliefs , values

and philosophies within agencies impact the way supported employment programs are

implemented (Boyce, Secker, Floyd, Schneider, & Siade, 2008; Corbière, Bond, Goldner,

& Ptasinki, 2005; Rogan, Novak, Mank, & Martin, 2002), litlle work has been done to

examine this issue more c1osely, especially in a Canadian context. Similarly, aside from

examinations of c1inical-vocational integration, few studies have examined how

interactions between key supported employment stakeholders influence program

implementation and functioning. As such, the main goal of the present work was to shed

light on these topics and examine the organizational dynamics related to supported

employment in one Canadian province, the province of Quebec.

2. Research objectives and questions

2. 1. Research objectives

The present study was part of a larger pan-Canadian research program entitled «A pan­

Canadian analysis of programmatic, organizational and individual aspects of supported

employment programs implementation». As the title suggests, this program examined

supported employment (SE) program implementation in three Canadian provinces (British

Columbia, Ontario and Quebec) and consisted of three inter-related components:

A programmatic analysis , in which the aim was to identify the key princip les or

components that had been implemented in each of the SE programs and to assess

the fidelity of these programs to the supported employment model;

An organizational analysis ;

An analysis of SE program components and their effectiveness with regards to

vocational outcomes (while taking into consideration individual characteristics) to

determine which components impact outcomes the most and which components

should be added, adapted, or omiUed in a Canad ian context.

The present study fell within the scope of second component of this pan-Canadian

program, namely the organizational analysis. The following objectives were pursued:

Describe the dynamics between some of the primary SE stakeholders in the

province of Quebec and examine how these dynamics influence the

implementation and functioning of SE programs

Shed light on some of the organizational and other factors that account for the

diversity in SE programs in this province.

It is important to mention that the term supported employment in this context does not refer

exclusively to those programs that aim to adhere to the IPS model but includes ail

vocational services that conform to the broader criteria for SE programs (see section 3.2.

Sites, p. 30).

29

2.2. Research questions

Given the objectives of the study, the following research questions were posed:

How do the dynamics between individuals, groups and organizations influence the

implementation and effective functioning of SE programs in the province of

Quebec?

What organizational and other . factors explain the variability that is observed

between SE programs in the province of Quebec?

3. Methods

3. 1. Ana/ytie approaeh

ln an effort to gather the perspectives of a variety of stakeholders and better understand

how the interplay between stakeholders influences supported employment implementation,

a multi-site, qualitative approach was adopted .. A qualitative approach seemed particularly

appropriate in the present circumstances given the scarcity of knowledge surround ing this

topic, and that such an approa~h enables the profound analysis of little studied subject

matters without the influence of predetermined analytical concepts (Patton, 1990).

3.2. Sites

Ali organizations in the province of Quebec that offered supported employment services

and that had agreed to participate in the pan-Canadian research program were

approached to take part in the organizational analysis. These organizations had in itially

been selected to participate in the pan-Canadian program based on their qualification as a

supported employment program as determined by the «Quality of Supported Employment

Implementation Scale» (QSEIS), administered as part of the programmatic analysis

(phase 1). The QSEIS scale assesses the degree of fidelity of a given program to the SE

model , its principles and practices , and helps describe the vocational services offered to

program participants. It effectively distinguishes supported employment from other forms

of vocational services (Bond , Picone, Mauer, Fishbein, & Stout, 2000). It is important to

note however that the QSEIS differs from the Individual Placement and Support (IPS)

fidelity scale in that it assesses a broader range of SE program components , thus allowing

the evaluation of approaches that depart somewhat from the IPS model but which still may

be characterized as supported employment. Thus, a given program can be characterized

as being faithful to the supported employment model, without it necessarily adhering to the

specific critical components of the IPS mode!.

ln ail , five organizations offering supported employment programs or services,

representing three different regions of the province, were included in the organizational

analysis (see Table 1). In addition, information about other SE programs in the province,

obtained during interviews with participants or available publicly, was also integrated in the

analyses when this was deemed informative and appropriate.

31

Table 1. Characteristics of organizations and SE programs in the study

Organization

Organization A

Organization B

Organization C

Organization 0

Organization E

Organization characteristics Program characteristics

Psychiatrie hospital Individual Placement and Support (IPS) program within hospital 's rehabilitation department

Location: Large urban centre (pop. 1 800 000) Years in existence: 8

General hospital

Location: Semi-urban centre

Program for Assertive Community T reatment (PACT) with in hospital's psychiatrie department

(pop. 90 000) Years in existence: 7

Psychiatrie hospital

Location: Large urban centre

Individual Placement and Support (IPS) program within hospital's rehabilitation department

(pop. 1 800 000) Years in existence: a (i.e. new program)

Organization specializing in the Service d'aide à l'emploi - Emploi-Québec integration and maintenance of employment Mental health clientele

Location: Large urban centre Years in existence: 32 (pop. 1 800 000)

Organization specializing in the Service d'aide à l'emploi - Emploi-Québec integration and maintenance of employment Pan-disability clientele

Location: Large urban centre Years in existence: 21 (pop. 230 000)

32

3.3. Theoretical frameworks

A conceptual framework inspired by two approaches commonly used in organizationa l

analyses guided the development of the interview guide used to collect data , as weil as

data analysis process. These two approaches were: 1) The theory of coalitions originally

developed by Gamson (Gamson, 1961) and updated by several authors since , and 2) The

theory of archetypes posited by Hinings and Greenwood (Hinings & Greenwood, 1988).

3.3.1. Coalition theory

ln organizational studies, the theory of coalitions originally developed by Gamson

(Gamson, 1961) is often used to describe the dynamics between actors that exist in an

organization or system. These dynamics are often expressed in the form of a coa lition ,

that is a temporary 'set of alliances that exist between individuals and/or groups that have

different objectives but whose shared concerns lead them to work together to achieve a

common goal.

Gamson 's theory describes four parameters that influence the formation of coalitions ,

namely the initial distribution of resources among the actors, the rewards sought by the

actors in joining the coalition , the non-utilitarian preferences among actors, and the means

by which decisions affecting the group will be controlled. Since its introduction in 1961 ,

Gamson 's theory has been scrutinized and further developed by other authors, notably

Vincent Lemieux. The present study adopted Lemieux's conception of coalitions , wh ich he

describes using the following three parameters (Lemieux, 1998):

Transactions, which relate to the benefits that actors expect to obtain by joining the

coalition and the assets they contribute to this end;

Links, which are based on non-utilitarian preferences and which can be ideological,

corporate, or affective in nature.

Controls, which consists of the capacity of one member of the coalition to impose its

views and control decisions that affect the other members of the coalition.

33

A key condition that . underlies the formation of coalitions is the realization by actors that

they are unable to achieve their desired objectives when working alone. This realization

often prompts them to seek out other actors that share their concerns so that their

combined energy and resources may deliver the mutually desired results.

Lemieux has elaborated on the various types of assets possessed by actors taking part in

a coalition, as weil as the types of benefits sought by these actors through their collective

action. These assets and benefits can be characterized as:

Normative (relates to a cause that drives the actors and the possibility of advancing

th is cause);

Positional (relates to the status tied to an actors' position and their need to further a

given mandate);

Of command (relates to an actor's ability to control resources and impose decisions

on the other actors);

Relational (relates to the personal . and professional contacts that an actor

possesses or seeks access to);

Material (relates to the human and material resources that an actor possesses or

seeks access to);

Informational (relates to the expertise that an actor brings to the group and the

information that one is privy to by joining the coalition);

Personal (relates to the charisma or reputation possessed by an actor and an

actor's personal motivations for joining the coalition).

Indeed , to be perceived as legitimate contributors to a. coalition, actors must possess the

necessary resources and skills to justify their involvement in the collaborative efforts (Gray,

1985).

The links that exist between individuals, groups or organizations can be described as

positive, negative or neutral. Alliances are more likely to occur when actors share similar

34

political and ideological positions, professional ties or develop personal affinities towards

other actors. However, links can also be negative when opposing views and competing

interests translate into hostilities between individuals, groups or organizations.

With regards to controls, the literature sometimes refers to the effective decision point or

threshold needed to control a decision (Gamson, 1961; Lemieux, 1998). For the purposes

of this study, we have chosen to address the concept of controls in terms of the means

used by actors to control decisions affecting the coalition, a conceptualization that refers

back to the assets each actor brings to the coalition.

Finally, leadership is recognized as a key independent factor that facilitates the formation

and maintenance of coalitions. Here, we adopt Mizrahi and Rosenthal's notion of

leadership, who define it as «the analytical and interactional skills needed to make

coalitions work» (Mizrahi & Rosenthal, 2001). According to the se authors, leaders need

«to do and know certain things and be a certain way to have a successful coalition»

(Mizrahi & Rosenthal, 2001), that is they have to possess specific knowledge, skills and

values. Examples of these 'relate to the leaders' ability to facilitate communication and

encourage participation, demonstrate persistence and identify commonalities between

actors. The issue of the leader's credibility and legitimacy is also crucial to the building of

coalitions and the management of collaborations (Gray, 1985; Mizrahi & Rosenthal, 2001).

Allow us to add to this the need to demonstrate traits commonly associated with

transformational leaders, i.e. to have a charismatic p'ersonality and possess the ability to

rally others around a common goal or vision (House, 2004; Knowles & Saxberg, 1971)

3.3.2. Hinings and Greenwood's theory of archetypes

The concept of archetypes provides a framework ' for describing an organization or

program, at any given point in its evolution, according to two fundamental dimensions that

are in constant interaction with one another: organizational structure and interpretive

schemes.

35

The first dimension, the organizational structure, describes the re lationships , both forma i

and informai, existing between actors or groups of actors operating within the organization

or program. Four elements help characterize an organization's structure:

The structure of roles and responsibilities, i.e. the individual's or group's formai and

informai roles and functions, and their positioning in relation to the organ ization's

hierarchy;

The organization's decision systems, i.e. the ways in which decisions are made with

regards to the internai functioning of the organization and its re lations with its

partners and other actors;

The management of human resources, i.e. the mechanisms in place that govern

the hiring of new members to the organization or which serve to control the

activities of each member of the organization;

The acquisition of resources, i.e. the level of control the organization has over its

ability to acquire and manage its resources.

The second dimension, the interpretive schemes, relate to the dominant values , ideas and

beliefs that prevail among the key stakeholders and which underpin and are embodied in

the organizational structure. These interpretive schemes act as the logical foundations on

which actors lean on when elaborating organizational practices and plotting courses of

action. They are composed of three elements:

The organization's domain , i.e. the fields of activity occupied by the organization or

else the fields in which they perceive themselves to have a certain legitimacy

(which may or may not be recognized by others);

The principles of · organizing, i.e. the valu~s and ideas underlying actors'

perceptions of how the organization should be organized and operated;

The self-evaluative criteria, i.e. the mechanisms by which an evaluation of the

organization's activities are evaluated.

36

The theory of archetypes has two main qualities that make it a useful framework for the

purposes of this study. First, it provides a means to characterize the organizational design

of the SE programs and other organizations being studied. However, it also provides a

basis for understanding organizational changes through the examination of coherence

between the SE program's structure and the dominant interpretive schemes. For instance,

the theory posits that a program or organization will be stable when its organizational

structure is coherent with the values and beliefs that prevail among the key actors within it.

If however the organizational structure is not coherent with the dominant interpretive

schemes, the program or organization 'becomes amenable to change and its structures

and systems more susceptible to being altered until a position of archetypal coherence can

be reached.

Thus, the theory has a temporal component that helps researchers understand why

organizations may evolve over time. That being said , organizations do not operate and

evolve in silos but are also influenced by various external pressures in their envi ronment.

These contextual factors, whether they be social, economic, political or cultural in nature,

can influence actors' ide as and beliefs about the best ways to operate and organ ize

themselves and can ultimately push organizations out of one set of coherent structures

towards another. The theory of archetypes takes these external constraints into account

and encourages researchers to examine actors' perceptions of the contextual factors that

impact their organizations and programs. Figure 1 iIIustrates the relationship between the

two approaches composing the conceptual framework.

Figure 1. Theoretical frameworks used for the study

--co : ~

Archetype 1

Time '1

Archetype 1

Time 2 , ~ l~----------------------~ : ...:.

""" o Q

~ ai Q.)

' ~

"""'" -= t';

rA C'). ' ---

Or ganizatio nal structure

Rolas Decision rnechanisnls Managernent of hUn'lan

resources Acquisition of resources

(Ie,ss coherence)

InterJnefive schenles

Or~Janilationis dornain Principles of organizing

Evaluation criteria

Orgnuizatio nal structure

Raies De cision rne chanisrns Managernent of hurnan

re sources Acqui sition of resources

(more coherence)

Intell>r etive sc.hernes

Organization's dornain Principles of organizing

Evaluation criteria

Intera,ctions between coalitions

Theory of coalitions (l elnieux, 1998)

• Transactions (benerîts obtained tty joining the coalition and aS:3ets co ntri b uted)

• Links (non-utilitarian relatîonships bet'lveen îndîviduals andlor groups) - C:üntro!s (eapa (:it~' of coalition rnernbet's to irnpose contro l decisions

affecting tt-:le coalition)

37

38

3.4. Data collection

Data collection aimed to gather information about the key stakeholders related to

supported employment and how interactions between these stakeholders have influenced

the devel'opment and implementation of supported employment in the province. Aiso

collected was information about each actor's specifie context and the way this context

influenced supported employment implementation and functioning (see Instrumentation

section, p. 39).

3.4 .1. Sources of information

Data for the organizational analysis were obtained from two primary sources: 1) semi­

structured interviews with key SE stakeholders from local , regional and provincial levels; 2)

documents relevant to the organizations providing supported employment programs

included in the study, as weil as to employment and mental health in general.

With regards to the selection of participants for the study, any actor possessing a deep

understanding of SE programs and/or the factors that could influence their implementation

and functioning was a potential candidate for the study. Given that the integration of

people with severe mental illness into the workforce concerns a panoply of actors , we

aimed to include a broad range of views from numerous sources in an effort to understand

how interactions between a variety of stakeholders could impact the development an-d

implementation of supported employment programs. As such, the types of actors

approached extended beyond actors working within SE programs and included other

actors in the health, employment and community sectors, including other local actors ,

regional planners, members of mental health associations and provincial decision makers.

That being said , because the study was mainly focused on studying the interactions

between actors involved in the provision of supported émployment services, no other

groups of persons, such as people with severe mental illness or employers, were

approached to participate in the study.

39

An inventory of documents pertaining to the supported employment programs examined in

the study, or on topics related to mental health and employment, was compiled. These

documents would often provide useful information about the characteristics of the

supported employment programs and structure the organizations offering these programs,

the values held by actors in these organizations, and in some cases information about the

relationships between actors. These documents were often provided voluntarily by

participants following their interview or else were publicly available via the Internet.

3.4.2. Instrumentation

ln order to ensure that we covered the range of dimensions related to our aforementioned

conceptual frameworks, an interview framework was constructed (Annexe 4). This

framework was composed of four main themes that .were discussed with every participant.

The first theme related to the organization's characteristics and the vision behind its SE

program. Topics covered in this theme related to the organization's mission and structure,

the participant's role and responsibilities within the organization, a~ weil as the roles and

responsibilities of other members of the organization. The key elements of the program as

weil as the reasoning behind the decision to operate in this way were also discussed.

Finally, elements related to the decision-structure of the program and monitoring of its

effectiveness were explored.

The second theme related to the evolution of the SE program. Here, participants could

provide . a brief history of the program and describe how various contextual factors had

facilitated or hindered the development of the program and its key components.

Participants were also able to discuss how their interactions with other actors had

impacted the program over the course of the program's existence.

The relationships and partnerships between actors was the third theme discussed. Topics

covered in this theme included the types of partnerships that exist between members of

the organization and other actors, the motivation behind these partnerships, the

formalness of relationships, the means of communication that exist, as weil as the

40

participant's professional and personal experiences when engaging with these other

actors.

Finally, the issue of leadership, both within the programs and outside of them, was the last

theme discussed. Participants were asked to offer their perceptions regarding the leaders

within their organization , as weil as those acting outs ide of their organization. They were

also asked to provide their opinion on the qualities of these leaders and to name some of

the challenges that these leaders had faced or were facing .

It is important to note that wh ile the same four themes were discussed with ail participants ,

the specifie topics covered were often adapted in accordance to the participant's position

in the system. For example, program coordinators and employment specialists were often

weil positioned to answer questions regarding their program's key components and

relationships with actors at a local level, whereas actors at more regional or provincial

levels were often beUer positioned to offer a more macro-Ievel perspective of the evolution

and organization of services and the various contextual factors that impact programs.

3.4.3. Data collection procedure

First contact with the majority of participants was made through the coordinator of the pan­

Canadian project, who sent a brief memo to each of the sites that provided information

about the study's objectives and the nature of their potential participation in the

organizational analysis. Recruitment of participants then began in March of 2007 and

ended in June 2008, with the majority of interviews (15/21) taking place in the period

between March 2007 to July 2007.

Our sample of participants was constructed following a snowball method of recruiting.

First, a contact person from each site (usually a program coordinator or manager) was

identified and each contact person was contacted by email. Contact persons were asked

to help the research team identify individuals within their organization who were most

knowledgeable about the workings of the supported employment program and the various

factors that have influenced its implementation and functioning. Actors identified through

41

this process were then contacted by email and their participation in the study was solicited.

Interviews took place at the time that was most convenient for them and at a location of

their choosing (most often their place of work). During the interviews, participants were

given the opportunity to identify other individuals, either from within or outside their

organization , who they deemed able to make an important contribution to the study. The

actors identified for the first round of interviews were chosen in such a way as to ensure a

diversity of perspectives. The second round of interviews was carried out in order to

gather further information about the different programs as weil as gain an appreciation for

the wider influences on each of the programs. Recruitment of participants continued until

saturation of information had been reached. Finally, follow-up inquiries were also made

with several participants in an effort to clarify aspects that remained unclear and validate

information regarding certain aspects of the SE programs.

A total of 29 people were approached by the research team to participate in the study. Six

of the individuals approached did not respond to emails, one was on maternity leave

during the recruitment period , one was not available due to professional obligations and

one refused. Thus, the study sample consisted of 20 participants who voluntarily

contributed their views to the study, including:

7 employment specialists or rehabilitation counsellors

5 team coordinators or program managers

2 managers in rehabilitation departments

1 researcher

2 provincial actors (former member of a provincial mental health advisory body,

member of provincial mental health association)

3 regional or provincial decisions makers (1 from regional health agency, 1 from

Emploi-Quebec, 1 from Ministry of Health and Social Services)

The distribution of interviews by organization is presented in Table 2. Interviews were

semi-structured and carried out in either English or French depending on the participant's

mother tongue. The interviews tended to be approximately 90 minutes in length but varied

42

depending on the availability of the participant. Interviews were tape recorded with the

permission of the participant and subsequently transcribed for the analysis.

Table 2. Distribution of interviews across the five organizations

Position Organization Organization - Organization Organization Organization Tota l A B C D E

ES or RC 3 1 3 0 0 7

TC or PM 1 1 1 1 1 5

Man. Rehab. 1 0 1 0 0 2

Total 5 2 5 1 1 14*

Legend: ES = Employment specialists, RC = Rehabilitation counsellors , TC = Team

coordinators, PM = Program managers, Man. Rehab. = Manager in rehabilitation

department

* This total does not include the 6 interviews conducted with actors at regiona l and

provinciallevels (details above).

3.5. Data analysis

Information acquired through interviews and organizational documents was coded

according to the dimensions of the conceptual approaches thosen for the study. In an

effort to reduce the possibility of subjective bias in coding and analysis, and increase inter­

rater reliability , coding was initially carried out by two members of the research team (one

being the present author) and then compared to ensure coherence. Through regular

meetings, incongruities in coding were identified and discussed and adjustments in coding

made following agreement. This process was carried out for the 6 first interviews out of 20

total interviews, following which coding was carried out uniquely by the present author

using an established coding guide. No qualitative data analysis software was used.

----- - -~~~----~--

43

The theory of coalitions was used to analyze the dynamics of actors underlying the

evolution of the supported employment archetypes, i.e. how groupings of actors -

potentially holding different perceptions regarding which services to provide clients in

supported employment programs - interact, and how they influence the SE program's

implementation. Key SE stakeholders were identified, the links between actors were

examined, and the transactions and mechanisms of control subsequently dissected. The

concept of archetypes was used descriptively, to characterize the major structural

elements of the supported employment programs and uncover the dominant values and

beliefs underpinning these elements.

The coherence between the organizational structure and interpretive schemes were then

examined for each archetype that had emerged from the analysis. Finally, the degree of

coherence between the archetypes linked to each coalition was explored.

3.6. Validation of results

Results were validated primarily through the triangulation of information provided py

participants' testimonies and extracted through organizational documents and the scientific 1

literature . In addition, several participants were recontacted in an effort to corroborate

information acquired and obtain more information that was then used to complete the

analysis.

3. 7. Ethical considerations

The data collection and analysis procedures carried out in this study conformed to the

ethical standards of the research ethics committee of Université Laval, which had

previously approved the study's research protocol. Consent forms were sent via Internet

to ail participants prior to their participation so that they could become informed of the

study's aims, as weil as the benefits and risks of their involvement. Participants were also

informed , usually via email, of the main topics to be discussed during the interview. On

the day of interview, the present author ensured that ail participants had read the consent

forms and were given the opportunity to ask questions about the study or express any

concerns related to their participation. Once participants were weil informed and had

voluntarily consented to participate, they signed the consent form, giving one copy of it to

44

the research team and keeping a copy for themselves. Data collected during the

interviews was treated in a way that respected the anonymity of participants and

confidential nature of the information shared. As such, n"o personal information related to

the participants or their organ izations appears in the present document. In addition f in an

effort to further protect participants' anonymity, ail extracts of interviews cited in the

present document are presented in one language, namely English.

4. Results

Results suggest the existence of at least two main coalitions of actors related to supported

employment programs, one consisting primarily of actors evolving in the health sector and

another consisting mainly of employment sector actors. Though these two groups of

actors share similar goals, for example to help people with severe mental illness integrate

the regular workforce, the way they have organized their supported employment services

has differed in some key respects.

The results for the present study have been organized into three main sections. The first

section describes the interactions between members of the first coalition and with their

other partners. ·The key structural elements of their archetype will be presented, as weil as

its coherence with the underlying interpretive schemes of the dominant actors in the

coalition. The second section will similarly examine similar aspects as they relate to the

actors in the second coalition. Finally, 1 will briefly examine the interactions between

coalitions and the coherence between these two archetypes.

46

4. 1. Health sector coalition

4.1 .1. Coalition actors and objectives

The health sector coalition brings together several actors affiliated with health institutions

who share a common concern for the welfare of people with severe mental illness and who

believe that these individuals' mental health can be improved through their integration into

the community and , more specifically , the regular workforce. At the core of the coa lition

are three supported employment teams, two of which function as a specialized vocational

program in the rehabilitation department of their respective psychiatrie hospital

(Organizations A and C). A third supported employment team is part of an assertive

commun ity treatment program (PACT) in the psychiatrie department of a general hospital

(Organization B). Aiso in the coalition are managers from these organizations whose

responsibility it is to oversee the supported employment programs and in some cases

other rehabilitation services offered at the hospitals. Finally, researchers from the province

of Ouebec and trom the United-States who are knowledgeable about supported

employment have also played a key role in its implementation in the province.

Core coalition actors ' shared goal is to facilitate the integration of people with severe

mental illness into the regular workforce by way of vocational services that are considered

evidence-based, driven by clients' preferences, and characterized by rapid placements

and intensive, follow-along supports. Core coalition members' desired outcomes relate to

clients' acquisition and maintenance of employment in competitive, integrated settings and

their continued rehabilitation and recovery from mental illness.

4.1.2. Transactions

An examination of the coalition's history and evolution helps bring to light some of the

benefits that coalition members actors sought in joining the coalition and some of the

assets they have contributed in an effort to achieve their shared objectives. The origins of

the coal ition dates to the late 1990's when a young researcher from Ouebec left the

province to pursue postdoctoral studies at an American university, during which time she

learned about the Individual Placement and Support (IPS) model of supported

employment. Upon her return to Ouebec, she accepted a position at one of the province's

47

psychiatrie hospital's research centres and shared her experience with the new director of

the hospital's rehabilitation services.

The vocational services at this particular psychiatric hospital (Organization A) had for

many years consisted of a variety of sheltered workshops and occupational activities ,

located mostly within the hospital. During the 1990's, however, a growing number of the

users of these services voiced their interest in obtaining regular, competitive employment

in the community. In response to the growing demand, a new internship program was

created where individuals could be placed in local businesses with the idea that their

unpaid internship would evolve into employment once they had acquired the necessary

skills and experience. As time passed, however, it became apparent to service users and

program managers and counsellors that these internships only rarely resulted in the

individual obtaining competitive employment. In some cases, individuals would spend

years working for a company and never receive an offer for a regular salaried position.

When the director of rehabilitation services learned about the IPS model of supported

employment, she was intrigued . She too had been dissatisfied with the vocational

outcomes being achieved by clients in the internship program and was interested in

helping service users become more engaged in the community. Indeed, she had recently

initiated a plan to restructure the hospital's rehabilitation services and move most of its

programs and activities outside of the hospital. Furthermore, the organizational context

also seemed to favour the creation of a vocational program like IPS, as the hospital's

director general was increasingly orienting hospital culture towards the adoption of

evidence-based practices.

To help guide the reorganization of vocational services, the director of rehabilitation

services consulted with researchers at the hospital's research centre and examined the

scientific literature to learn more about IPS and other modern trends in vocational

rehabilitation. She also initiated consultations with other actors from the hospital who

would be affected by changes to its rehabilitation services - including other hospital

administrators, clinicians and service users - in an effort to obtain these actors' points of

view regarding future directions for the hospital's vocational servic~s and the possibility of

48

implementing supported employment. Finally, capitalizing on links between researchers at

the hospital and the American researchers who had founded the IPS model, the hospital

arranged for these latter researchers to visit the hospital and present the model to its

members and service users. The event generated a positive reaction and it was not long

after that the director of rehabilitation services made the decision to transform the

internship program into a new IPS program.

Realizing that the IPS model represented a significant departure from the vocationa l

services previously offered by the hospital, the director of rehabilitation services reached

out to the founders of IPS for assistance with the implementation process. Once the IPS

team had been assembled , she requested and received funding from the hospita l that

allowed the team to travel to the US, me et the founders of the IPS model and rece ive

training designed to help them develop new skills and carry out new roles. Even after their

return to Quebec, the team profited from the American researchers' expe.rtise through

frequent contact throughout the implementation process. This partnership was perceived

as extremely valuable to the members of the IPS team in that it allowed them to ask

questions, discuss successes and challenges and work towards greater fidelity to the

model. For the American research team, active collaborations such as this one were

considered vital to the dissemination and successful implementation of best practices in

mental health.

As the IPS program was being put in place, the researchers at the hospital attached

research projects to the program in an effort to evaluate its implementation and

effectiveness in a Quebec context. Like their American counterparts, these Quebec

researchers strongly advocated that the team remain as faithful to the IPS model as

possible . . According to members of the IPS team, researchers' frequent interactions with

the team during its early stages of operation often prevented them from deviating from the

model's guiding principles. Said one participant:

... with research , we're always, we're always working with the conceptual framework of the model and thafs the guide, ifs a guardian angel that brings you back, because the principles, we named them moments ago, ifs the regular workforce , ifs part of the conceptual framework of the" model, and if

you don't have it, if you don't work with it, it's easy to go towards other types of employment. .. (team coordinator)

49

ln early 2001, the IPS team was ready to accept clients and began a series of visits with

the clinical teams attached to the hospital in an effort to establish a system of referrals.

Meetings were arranged with clinical teams located within the hospital, such as an

assertive community treatment team and several other teams focusing on intensive

rehabilitation, as weil as with those teams practicing in the hospital's externa l clin ics.

During such visits , IPS team members informed clinical staff about th~ new vocational

service they offered and the potential advantages of referring their patients.

The new service was perceived to offer a number of benefits. First, it seemed to

correspond with the needs of a growing number of service users who expressed an

interest in finding regular work and offered to provide these individuals with intensive, long­

term support. Clinicians in the clinical teams could thus refer their patients directly to the

new supported employment program affiliated with the hospital. Early successes of some

clients in employment further enhanced the perceived benefits of referring patients to the

IPS program, especially when work was perceived to be having a positive impact on the

individual's life and rehabilitation. Said one member of the IPS team:

There are definitely key people that have made significant changes, some 180 degrees from working, so a lot of the case managers are like, «woW», you know, «this somebody has evolved» and how much that person has become a lot more independent. The follow-up isn't the same and the intensity of the follow-up isn 't the same and even more so files are being closed at the clinic where they are being followed by their GP, sa a lot of evolution has happened in their lives. (employment specialist)

Partnering with the clinical teams was also seen as essential for the IPS team. Not only

were these teams their primary source of referrals bu~ they also provided IPS team

members with privileged access to their clients' clinical information and allowed them to,

ensure coherence between their clients' clinical and vocational plans.

50

Indeed, the launch of the IPS program was beneficial for the other members of the

coalition as weil. For instance, the program allowed the director of rehabilitation services

to transform the hospital's vocational services while remaining consistent with the

hospital 's values. Hospital administrators showed pride in the new evidence-based

program, making reference to its creation in the organization's annual reports . Finally,

researchers from both Quebec and the US benefited from learning more about how the

IPS model generalized to a new Canadian context and by sharing these experiences and

discoveries with the scientific community.

Actors from this psychiatrie hospital and particularly the members of the IPS team have

played an active role in encouraging the diffusion of supported employment to other parts

of the province. For instance, at roughly the same time that the IPS team was being

implemented, a general hospital (Organization B) in another region of the province

established a new PACT team as part of its repertoire of psychiatrie services. The new

PACT team coordinator had formerly occupied a similar position at the psychiatrie hospital

mentioned above (Organization A) and had maintained relationships with researchers from

the psychiatrie hospital's research centre. Like the these researchers , she believed that

many people with severe mental illness wanted to work and could work if the proper

supports were in place around them. Furthermore, she believed that helping people find

work they found satisfying would motivate them to stay as healthy as possible and

facilitate' their recovery from mental illness. Through her relationships with the researchers

at the psychiatrie hospital, she was aware of the IPS team's success as weil as the

supported employment model, its guiding principles and the literature supporting it. Her

former colleagues' firm belief in the model and their preaching of its principles led her to

integrate aspects of the 'model into the vocational services provided by the PACT team.

More recently , actors from a second psychiatrie hospital (Organization C) reached out to

the IPS team in an effort to develop their own supported employment services. Similar to

what had been the case at Organization A, vocational services for people with severe

mental illness at this psychiatrie hospital had long consisted of occupational workshops

that provided service users with limited wages and opportunities to integrate the regular

workforce. A growing problem was the needs of younger service users, who often felt

uncomfortable working in sheltered environments where older clients had been labouring

51

for twenty years or more. Though the hospital offered other service alternatives, none of

these options helped individuals move quickly or consistently into the regular labour

market. As such, a restructuring of the hospital 's vocational rehabilitation serv ices began

in 2006 and included the creation of a new program aiming to help people prepare for

entry into the workforce and maintain employment once a job has been obtained . .The

driving force behind the restructuring was the desire to more closely align services to the

needs of service users and adopt an approach that inspires hope, emphasizes people's

strengths and supports their recovery. In addition, managers responsible for the hospita l's

rehabilitation services had become increasingly aware of the success of Organization A's

IPS program and wanted to provide a similar service to the people with severe mental

illness in their catchment area.

A partnership was establ ished that would see the original IPS team assist with the

implementation of Organization C's new supported employment team and oversee the

team's training. Rehabilitation department managers viewed the IPS team as legitimate

leaders who possessed the expertise and knowledge needed to help guide them through

the implementation process. Further adding the IPS team's legitimacy was the fact that

team members had recently completed additional training in the United States aimed at

helping them acquire the ski"s and know-how needed to train new IPS teams. Some of

the benefits of the partnership include the funding secured by the original IPS team

through its training contract, but also the possibility for both programs to advance their

shared cause in helping people with severe mental illness integrate the workforce and

pursue their recovery.

While the actors ma king up the core of the coalition maintain important links with each

other, they also obtain benefits from a number of other partnerships that they have

established over the years. For instance, Organization A's IPS team has established a

partnership with an organization specializing in the integration and maintenance of

employment (OSIME) in its region. Such a partnership provides the IPS team with access

to social integration measures and salary subsidies funded by the Ministry of Employment

through its main governmental agency, Emploi-Quebec. These measures are used by the

team as incentives for either clients or employers and help facilitate the movement of

some harder-to-integrate clients into regular paid employment, an activity that contributes

52

to the social and economic development of the province. Each of the teams have also

made efforts to strike partnerships with employers, helping them acquire employees in a

context of labour shortages and providing support so that employees to be as productive in

their jobs as possible.

Given that the majority of clients receive welfare payments and have been designated as

having severe constraints to work, Organization A's IPS team has also found it beneficia l

to establish a partnership with agents from a local welfare office. Prior to the partnership ,

some welfare agents had been confused by efforts to help people - seemingly deemed

unfit to work - find competitive employment. Individuals with mental health problems

would typically meet regularly with these agents. and had sometimes encountered

stigmatizing attitudes and been discouraged from seeking work. Problems between

individuals and welfare agents could be further exacerbated when clients who were

working had difficulties keeping track of their income, a common occurrence given the

variable work weeks of clients making their initial attempts to penetrate the workforce. As

such, IPS team members found it helpful to intervene on their clients' behalf and help keep

track of their revenue streams,a practice appreciated by welfare agents. Furthermore,

IPS team members provided training to welfare ag~nts to increase their awareness of

mental health issues and help them learn how to interact with clients in a less stress

provoking manner.

Beyond these partnerships, members of the coalition have occasionally attempted to effect

change at a system level by lobbying for changes to the social policies that they believe

negatively impact their clients. In such occasions, they have established temporary

partnerships with members of health institutions, organizations from the employment and

commun ity sectors, service users and various associations to attempt to exert influence

policies that impact a shared clientele. In particular, links with some provincial mental

health associations provide coalition members with potential avenues for transmitting their

concerns and vision of services to decision makers at a ministry level.

4.1.3. Links

Figure 2 illustrates the actors comprising the health sector·coalition and their relationships.

53

Individually, core members of the coalition had formai links to health institutions. The two

IPS teams are services within the rehabilitation departments of their respective psychiatrie

hospital and the. PACT team is part of the psychiatrie services offered at a general

hospital. Researchers in the coalition are typically experts in health, psychiatrie and/or

rehabilitation services and operate in research centres affiliated with various hospitals and

universities in Quebec or in the US. Links between these core coalition actors have

. primarily been informai in nature, though more formai agreements have occasionally been

reached such as for training of IPS staff as mentioned earlier.

Core coalition actors have established over the years a multitude of key partnerships with

a variety of other actors from the health, employment and community sectors. As

represented in figure 2, many of these close collaborations have been established with

local level actors. These relationship's are also typically informai in nature. Examples of

such partnerships include: 1) relationships between IPS teams and some of the clinical

mental health teams in their regions, 2) partnerships that each of the supported

employment teams has established with local community organizations, social enterprises

and/or adapted work centres, and 3) links teams made with OSIMEs, organizations that

develop employability (DE) and/or local welfare and employment offices (centres locaux

d'emploi or CLE).

Close, positive collaborations seemed to be rooted primarily in the coherence between

actors' ideologies and values. Core coalition members' shared beliefs lead them to work

more closely together and the intensity of relationships with other actors appeared to vary

depending on the degree to which these actors share the core coalition members'

philosophies and vision.

For example, Organization A's IPS team works in closepartnership with several clinical

teams, and while relations with most clinicians were described as positive and productive,

there were clinicians with whom collaborations had been more difficult to establish. Such

impasses generally resulted in few referrals from that professional to the IPS team and

IiUle communication on both sides. From the perspective of IPS team members, part of

the problem stemmed from ideological differences between these professionals and the

54

employment specialists in that collaborations were more difficult to establish with

professionals (e.g. psychiatrist, case manager, etc.) who were guided by a more bio­

medical to care, which contrasted with IPS team members' psychosocial recovery

approach. These different viewpoints seemed to lead to differing beliefs as to the

relevance and appropriateness of work, and particularly competitive work, for clients .

Stated these participants:

... sometimes you have to convince the team that their client's desire is to return to work. Sometimes teams have a different vision of the client, they're more protective 1 would say (administrator in rehabilitation department)

Today anyways, over time, it remains those who are a lot closer to the medical model, 'you should not put too much stress on people'. As a clinician we cannot say or accept that, especially if the client wants to work, no 1 don't think it will work. 1 find that difficult. [ ... ] We say that you need to pick your baUles so we work with those who refer to us and in general these referrals come from clinicians who are convinced [that their patients can work] (team coordinator).

Interestingly, as interactions between the IPS team and the clinical teams increased over

time, several of the employment specialists noted changes in the perspectives he Id by

some professionals, most notably in their perceptions of their patients' ability to work. This

often translated into' greater communication and increased referrals between the

professionals and IPS staff.

Differing perspectives on clients' capacity to work were recognized in other groups of

actors as weil, including some welfare agents and employers . As in the previous case

though, opportunities to work more closely together often brought disparate perspectives

more in line with each other and fostered collaborations that brought benefits ta ail actors

involved.

Whether actors initially share similar philosophies or not, coalition members seemed to

recognize the importance of engaging actors from other sectors and creating partnerships:

We realized that ail that is external. .. outside of health, ail that goes on in the other ministries, has direct impacts on the job search, on the consequences of being in employment for these clients. For example with regards to welfare , things like that. So the agents work a lot, they'·11 know some welfare agents even personally and ail that. Links need to be made because there are always direct consequences on revenues because of the law (team coordinator).

55

Among the mechanisms that have facilitated communication between actors in the

coalition and other actors concerned by work integration or mental health issues are

regional issues tables. One example are the Comités santé mental/travail , which are issue

tables existing in several regions of the province that unite actors specifically interested in

the work integration challenges affecting people with mental health problems.

Representatives from three organizations in this study (Organizations A, C and 0 )

participated in such a table. These issue tables were founded by members of the

Association Ouébecoise pour la Réadaptation Psychosociale (AORP), an provincial

mental health association that since its inception in 1990 has strongly advocated for a

greater social inclusion of people with severe mental illness, particularly through their

integration into employment.

Usually involving actors from health, employment and community sectors , the tables

provide members with the opportunity to stay abreast with each other's activities and the

developments that occur outside of their respective sectors. One participant mentioned

that the table had been useful in helping disseminating certain ideas and beliefs , such as

the view that in rehabilitation activities it is important to focus on individuals' strengths and

potential and not simply focus on the limitations brought about by their illness. In recent

years, however, participation in some of these tables has declined, seemingly due to

members' familiarity with each other and the limited development . of new collaborative

projects. Said these two participants: «At the beginning, it was a committee that brought

together really a large collection of partners in the field of work integration [ ... ] .. . there

were lots and lots, bût as the years have passed it has declined. Since maybe two years

ago, we 're really not a lot. .. » (manager in rehabilitation department) « ... we have one [a

committee] 1 think by name but there's no , ifs not very active ... and ifs just because we

have no new projects, you know? » (program manager)

56

Coalition members were implicated to various degrees in other issue tables as weil , for

instance tables dealing with issues related to people with handicaps set up by the Office

des personnes handicapées du Québec (OPHQ). It should be noted however that few, if

any, tables bring together coalition members with decision makers from regional or

provincial levels. Indeed, as represented in Figure 2, a greater distance is observed

between core coalition actors and other supported employment stakeholders operating at

more regional and provincial levels, including regional health agencies, Emploi-Québec

and the ministries of Health and Social Services and Employment and Social Solidarity.

Few mechanisms seem to currently exist that link core coalition members to these actors

and in consequence interactions between them are relatively limited. Surprisingly,

authorities in the health sector have had a limited role in the implementation of evidence­

based supported employment by health coalition actors .

One explanation for this finding may lie in the different visions that these regional and

provincial health authorities have regarding the best ways to promote the socio­

professional integration of people with severe mental illnesses, as weil as the

responsibilities that should be assumed by each of the major stakeholders involved.

Briefly, these authorities seem to share the view that activities related to the integration of

people into the competitive workforce fall outside the scope of their responsibilities (see

domain section, p. 68). Rather than promote the implementation of programs like IPS,

they have aimed to encourage the ministry of employment to adapt its programs and

measures to beUer meet the needs of people with mental health problems, as weil as to

remove some of the so-called «systemic» barriers that slow individuals' integration into the

workforce.

Among the systemic barriers most often referred to by participants were perceived

disincentives to enter the workforce. These disincentives often relate to the income that

service users can generate when integrating into regular employment, especially on a part­

time basis, and their ability to maintain their social benefits while doing so. Briefly,

Quebec's social welfare policies tie the calculation of people's monthly welfare benefits to

their monthly earnings and place a cap on the amount that people can earn before the

amount of their benefits is reduced. Individuals can usually make up to 100$ in monthly

57

earnings without having the amount that they receive in benefits being adjusted.However,

once their earnings surpasses this 100$ permitted work income level, their benefits are

reduced in a dollar-for-dollar manner in accordance with their earnings. As a resu lt,

individuals on welfare who wish to integrate the workforce end up earning approximately

thesame amount regardless of whether they work 3 hours a week or 25 hburs a week.

Furthermore, welfare recipients earning enough to move off of social assistance lose

access to a free monthly bus pass, and if monthly earnings consistently exceed 1500$

they can lose the right to their medical benefHs as weil.

Although coalition members looked to the Ministry of Health to play a leadership role in

facilitating the removal of such systemic barriers, the Ministry's view that competitive work

integration falls outsi~e of the health sector's domain clearly conflicts with these actors'

own perceptions as to the types of vocational services that should be available in the

health system. Indeed, it would seem as though the limited development of supported

employment programs in the health sector is at least partly attributable to this conflict in

visions.

ln addition, core coalition members also expressed dissatisfaction with the progress made

by the different ministries regarding the removal of work integration barriers for their

clients, a fact they owed to the lack of concrete links between the various ministries and

particularly the Ministry of Health and the Ministry of Employment. Though inter-ministerial

issue tables have existed for some time, issues directly related to work integration and

mental health have, by ail accounts, typically not been a point of emphasis. Changes in

governments and health authority personnel have also contributed to the issue of work

integration being put on the backburner. This may be changing however as the Ministry of

Health has very recently designated personnel to be responsible for the issue of work

integration in mental health and concerted efforts have been made to reach out to ail

stakeholders involved to advance the issue further.

4.1.4. Controls

The development and delivery of supported employment in the health sector is strongly

influenced by the level of autonomy that individual actors, groups and organizations in this

58

sector possess. From an organizational perspective, psychiatric hospitals rely on the

Ministry of Health and Social Services for their financial resources, but once funds are

allocated they have enjoyed a certain latitude over decisions involving their rehabi litation

and vocational services. Administrators in rehabilitation departments have thus been able

to organize their services according to their own ideas about how best to respond to the

needs of service users. Hospital admi.nistrators from both Organizations A and C have

showed support for the IPS programs, providing teams with the funding needed to get

started, secure proper training and function effectively. The coherence between the

values underpinning the IPS programs and the values and interests of hospital

administrators is undoubtedly one of the main factors that has allowed these programs to

emerge in these settings.

The situation appears to be somewhat different however for the supported employment

services offered by the PACT team. The PACT team is affiliated to a general hospital that

is · integrated within a local health and social service centre. This organ ization has

important authority over decisions related to the resources allocated to the PACT team. In

recent years, new funding for mental health services in the region has primarily been

devoted to the development and strengthening of primary mental health care services ,

leaving little new funding for services like PACT. Furthermore, resources controlled by the

general hospital for its psychiatric services have been stretched to their maximum, leaving

most psychiatric services, including PACT, operating at below optimum levels (e.g. the

PACT team has currently half the personnel of a standard ACT team). This has had an

impact on the vocational component of program (see acquisition of resources section , p

66). That being said, vocational services provided by the team still reflect the principles of

supported employment, though their ability to adhere completely to each of the guiding

principles has been limited due to their lack of resources.

Given the autonomy of coalition members responsible for implementing supported

employment programs, stakeholders wishing to influence decisions related to the

implementation and functioning of programs have emphasized assets other than assets of

commando For instance, among the actors attempting to influence such decisions have

been the American researchers, who advocated strongly for the IPS model of supported

employment and attempted to regulate its implementation in Quebec. Given the

59

emergence of two IPS programs in the province, it cannot be said that their influence has

been inconsequential. Indeed, the influence of these actors seemingly stems from their

perceived legitimacy, largely due to the success that the IPS model has achieved in the

US and their years of experience studying and applying the model in the fie ld. As such ,

their opinions as to the norms and standards of supported employment were viewed as

highly credible.

And wh ile the partnerships that coalition members have established with these

researchers has clearly shaped the vocational services favoured by the coalition , each of

the supported employment teams have also deviated in some ways from the supported

employment model. This has sometimes been due to the perceived incoherence between

the model's principles and the realities of the teams' context. For instance, according to

the model, employment specialists should be integrated within the mental health teams

and work in the same physical location as clinicians. However, for both IPS programs in

~he study, this is not the case, as supported employment teams work in a central office and

travel to the various clinics to meet briefly with clinicians. Such an arrangement was

viewed as more realistic than full integration , especially given the small size of the IPS

teams and the large number of clinical teams referring clients to the program.

ln other cases, however, it would seem as though these researchers ' heavy emphasis on

the standards of the model would also infringe on the autonomy of these professionals ,

leading them to occasionally rebel from these standard practices and experiment with new

ideas. Said one participant:

... you have to experience things for yourself also. Sometimes it's a little bit away from the model, like for example we thought that, not to be a principle of the model Vou know but as a way of working, we thought we would ally ourselves a lot with the chambers of commerce and that it would help us with job development. You create a bank of employers to which Vou link your clients [ ... ] and them in the US said, «Of course not» and by experience we now know ... but what can 1 say, we had to try [Iaughs] (team coordinator)

60

Thus, while researchers from the US made efforts to control decisions affecting programs

and regulate these programs' implementation, ultimate control over the programs'

structure remained in the hands of program managers and coordinators, actors that value

their autonomy and capacity to make their own decisions affecting their services.

61

4.1.5. Archetypes - Organizational structure

4. 1.5. 1. The structure of roles and responsibi/ities

Supported employment programs in the health sector are a part of a larger network of

health services offered to people with mental health problems. In recent years , the

structure of this network has undergone significant changes. Responsibilities have been

altered and new structures have been created , most notably the local health and socia l

service centres (centres de santé et de services sociaux or CSSS)13. A hierarch ical

system of service delivery has been adopted, where primary mental health care services

are distinguished from more specialized, secondary psychiatric services and ultra­

specialized tertiary care . While people with mental health problems have trad itionally

entered the system through the psychiatric hospitals or departments of psychiatry in their

communities, they are now encouraged to enter through their local health and socia l

service centres, who liaison with these specialists when specialized care is needed .

With respect to each actor's specific responsibilities, the Ministry of Health and Socia l

Service is responsible primarily for defining the policy directions in the area of health and

social policies, allocating financial resources equitably among regions , funding tra ining and

research activities, and assessing, for the entire health network, the degree to which the

results obtained correspond the g6als set by the ministry.

The province of Quebec is divided into 18 healthcare regions and in each region is a

regional health agency that is responsible for developing regional priorities and policy

directions, coordinating and budgeting for the health and social services in its territory and

evaluating the performance of the regional health network. These agencies oversee the

management of ail primary and some secondary mental health services delivered in their

respective regions. At a local level, CSSS are responsible for knowing the health status of

the population in its territorïy and ensuring that service users are directed to the right

service at the right time. These organizations must also ensure the effectiveness of

services delivered in its territory and that continuity exists between health providers and

13 These structures resulted from the merger of one or more local community health centres, long-term care

facilities and sometimes a general hospital.

62

other actors in the local network. They play an important role in the delivery of primary'

mental health care services. These services are most often provided by health

professionals (e.g. general practitioners, psychologists , social workers) in the CSSS, as

weil as medical clinic~ or family medicine groups . They are also provided by general

practitioners or psychologists working in private practice, as weil as by some commun ity

organizations.

Secondary psychiatric services, i.e. specialized evaluation and treatment services,

hospitalization and intensive follow-up service, can also be offered in the CSSS,

particularly by psychiatrists and other professionals in the psychiatrie departments of

general hospitals. Otherwise , such services can be provided in the province's psych iatrie

hospitals, including five major psychiatric hospitals that have both regional and supra­

regional responsib ilities for mental health care. These psychiatric hospitals are associated

with the four universities in the province that possess a faculty of medicine, thus forming

four university networks referred to as Réseaux universitaires intégrés de services (RUIS).

The RUIS play an important role in planning and coordinating ultra-specialized services ,

training, research and evaluation.

-ln many cases, psychiatric hospitals in the province provide a wide range of rehabilitation

services that aim to promote the weil being of service users and their continued recovery

from mental illness. Such services further aim to help individuals become more active in

social spheres and better integrate into their communities. Rehabilitation services usually

include various types of workshops and occupational activities, community treatment and

rehabilitation programs, vocational services, supported housing programs and other

services supporting individuals' social integration. Assertive community treatment

programs are available in some psychiatric hospitals and some general hospitals. They

are multidisciplinary teams that provide most of the essential clinical , rehabilitation and

support services needed to help the people with severe mental illness live and integrate

into their community. However, not ail PACT teams directly provide vocational supports

for clients, and at the time of this study only one seems to offer services in line with the

supported employment mode!.

63

Whether part of a PACT team or rehabilitation service, members of the supported

employment teams in the health sector have a similar set of roles and responsibilities . The

main role of these programs is to help people with severe and persistent menta l illness

search for, obtain and maintain employment in competitive, integrated work settings. In

the IPS programs, any adult with severe mental illness who expresses the desire to work

is e.ligible to enter the program. In PACT, supported employment is available to those

service users accepted into the program, which is approximately 40 individuals with severe

mental illness who are at high risk for relapse without specialized treatment and

rehabilitation services. Following the client's entry into the program, employment

specialists perform a brief, initial assessment, usually consisting of the collection of clinical

information (e.g . medication , symptoms, history) and a description of the person 's work

history, interests and objectives. They will also discuss the advantages of employment for

the client and the impact that competitive employment could have on their disabil ity

benefits or their social assistance.

They will then typically accompany the individual through ail the steps of the work

integration process. This process normally begins with activities such as the creation of a

CV, the targeting of potentia l jobs and sometimes mock interviews. In Organization A's

IPS team , employment specialists will routinely leave the office to meet dire.ctly with clients

and potential employers. PACT employment specialists occasionally meet with clients in

community settings but have time constraints that limit their interactions with employers.

When a client obtains work, employment specialists are available to go to the work site to

help clients become. acclimated to their position and develop the skills needed to perform

their tasks effectively. They may also provide transportation to clients and help them get

prepared for carrying out their roles as workers. Indeed, support varies in intensity and for

some clients support may consist of occasional phone calls and after work meetings and

with others it may involve much more intensive and daily social and professional

counsell ing.

Employment specialists work to reduce the anxiety their clients feel when integrating into

employment or when dealing with welfare agents. One employment specialist mentioned

how she would spend significant amounts of time on clinical issues such as building self­

esteem and managing clients' insight. Indeed, it often becomes necessary for

64

employment specialists to me et with case managers to clarify the boundaries of their roles

and explain these boundaries to cl ients as weil.

Employment. specialists stay abreast of their clients' progress through frequent contact

with them and take action when their clients encounter problems at work. If a client

experiences health problems wh ile employed , employment specialists act as a liaison with

the treating clinician so that their clinical needs can be addressed quickly. Employment

specialists will often make time to meet directly with clinicians to discuss the progress of

clients and determine if treatment alterations should be made to support the client's return

to work. Employment special ists also act as a liaison between clients and employers and

will oftentimes negotiate helpful work accommodations for clients, especially those clients

that have disclosed to their employers that they have"a disability.

Each of the three supported employment team are led by a coordinator who oversees the

activities of the employment specialists and is responsible for the administrative aspects of

the program. Coordinators also often assume important leadership roles with regards to

the creation of partnerships that may benefit the program and its clients , as weil as

advocating on behalf of their programs and for increases in resources.

4.1 .5.2. The organization 's decision systems

Managers in rehabilitation and psychiatric services have generally had the autonomy to

decide how to organize their rehabilitation and vocational services. Nevertheless, program

managers in ail three organizations offering supported employment took steps to ensure

that services implemented would fall in li ne with their organization's mandates and values

and also be accepted by a variety of other stakeholders. Indeed, in each case , program

managers sought to consult a number of actors prior to program implementation, such as

other hospital administrators, researchers, health professionals, service users, and even

other vocational service providers. Consultations facilitated consensus building and

support for the implementation of supported employment programs.

1 "

65

Following program implementation , program managers and team coordinators were

. relatively free to adapt -services to best suit the needs of clients. Weekly 'team meetings

allow members of the team to exchange information on what works and what does not,

discuss work arrangements and create consensus on how to operate the program most

effectively. Employment specialists operate within the principles of supported employment

but have a certa in autonomy to determine the right course of action for each client involved

in the program. Some employment specialists spend considerably time in the commun ity

and at work sites and thus must be able to make decisions independently. Problematic

cases are discussed during team 'meetings and mutual aid is commonplace. In the case of

the two IPS teams, guidance is also sought from those actors who trained them (for

Organization A's IPS team, the American researchers, and for Organization C's team, the

IPS team from Organization A).

4.1.5.3. The management of human resources

ln the cases of both IPS teams, staffing of the teams has consisted of the reass ignment of

hospital personnel from other services to the IPS teams. In the PACT team, the two

employment specialists were recruited from organizations in the field of vocational

rehabilitation. Though professional backgrounds of supported employment team members

can be variable , several key criteria seem to guide managers in the hiring process. First , it

is perceived to be essential that team members believe that their clients can work in a

competitive seUing, regardless of their clients' clinical or personal circumstances. Second ,

it is perceived to be critical that they possess experience, and particularly clinical

experience, in the mental health field . One of the reasons for this is the emphasis placed

on understanding how their clients' mental health problems can impact their ability to work

and maintain employment. Indeed, it is generally considered important to be able to

develop a therapeutic alliance with the client, so that the employment specialist can beUer

understand their clients and react to problems quickly or even before they arise. Seing

creative, flexible and resourceful was also mentioned as important characteristics to have

as an employment specialist, as these specialists must be able to navigate in a variety of

clinical settings, sell their clients to employers, negotiate hiring conditions , and understand

the implications of working on clients' disability benefits and welfare payments. Finally,

program directors generally aUribute a great deal of importance to having had experience

working in the community , whether it be as a professional working in community settings

66

or as a member of a community organization . One of the reasons for this would seem to

be that it is mor~ likely that the agent will possess a set of values and ideals that are

coherent with the values underpinning the program, notably those related to the recovery

philosophy.

Several participants mentioned that supported employment, and in particular the 1 PS

model, represents an important shift from the traditional way of providing vocational

services. As such, most program directors and team members viewed their training as

highly important. Indeed, many employment specialists, when first joining their team,

possessed !iUle experience working with employers and navigating the employment sector.

ln opposition to the standard IPS model where employment specialists are completely

integrated with the mental health teams, the two IPS teams have their offices in a central

location in the community , which in some ways facilitates the management of these teams

by team coordinators and makes communication between team members easier. In

contrast, employment specialists in PACT are fully integrated within the treatment team

and work in the same clinic, which is also perceived as having important benefits:

The advantage that 1 see to having a model like that is precisely that the person is weil integrated in terms of treatment, rehabilitation, support , really integrated in ail the intervention plans, so they have a global vision of the clientele. And 1 also find, the biggest advantage 1 see in having [the employment specialists] is that the philosophy, the vision of the team has really taken on a more rehabilitation flavour compared to what 1 saw and experienced at [another hospital]. 1 remember in the beginning, the psychiatrists, we would be talking about employment and work reinsertion, they would write their notes, not too interested in the topic. They were at the meeting to talk about treatment. [ ... ] ... they listened, not to engaged. And now, 1 would say that five years later it's them that ask questions about work and are much more ... so 1 think the flavour of the person that is really impregnated in the team has really rubbed off on the other professionals. (team coordinator)

4.1.5.4. The acquisition of resources

Funding for supported employment teams is provided through their respective hospitals'

global budgets, part of which is allocated to rehabilitation or psychiatric services. Teams

tend to be small, consisting of four or five employment specialists and a team coordinator

67

in the case of IPS teams. In PACT, two counsellors working part-time provide supported

employment services.

Two of the teams perceived the funds they have been allocated insufficient to adequately

meet the growing vocational needs of service users in their regions. Specifically, in

Organization A's IPS team, employment specialist's case loads have started to exceed the

recommended limit, i.e. 25 active clients per employment specialist, and can sometimes

be on the order of 35 to 45 clients. This has an impact on the amount of time that can be

devoted to each client and limits the time' counsellors spend in the community. Waiting

lists for their services have also become increasingly lengthy, with some clients waiting .

several months before accessing supported employment services.

Limited access to resources was deemed to have a particular influence on the PACT

team's supported employment component as weil. According to the team coordinator, a

standard PACT team consists of 10 to 12 professionals, whereas this team had only 6

professionals., not ail working full-time. The lack of personnel in the team has meant that

the employment specialists are unable to devote their time solely to providing vocational

services and must assist the other members of the team with other duties, such as

responding to crises and providing clinical care in the community. Though employment

specialists felt it could be beneficial for clients to spend time making connections with

employers in the community, their time restrictions made it impossible for them to do so.

It should be noted however that supported employment programs are not inexpensive

programs to run, especially given the extent to which most employment specialists travel

and spend time working in the community. In a context where resources are limited,

funding for these teams has been relatively secure and teams feel supported by the

administrators at their hospitals. Furthermore, funding for teams is tied to the delivery of

services, not to the achievement of vocational outcomes or program performance. As

such, there is no threat that there funding could decrease if fewer clients achieve

employment in a given year.

68

4.1.6. Archetypes - Interpretive schemes

4. 1.6. 1. The organization's domain

The three supported employment teams in the health coalition regard themselves, first and

foremost, as a specialized rehabilitation service that promotes the recovery and wellness

of people with severe and persistent mental illness through their integration into the

competitive workforce. Teams work specifica"y with clients who have had or will likely

experience significant difficulties integrating into the community. Teams believe that their

role is to accompany these clients through every step of the work integration process.

Indeed, the nature of the support offered clients distinguishes these programs from other

programs in the employment sector. More specifically, support is intensive and often long­

lasting, i.e. for several years. Furthermore, it is a support that is both socio-professional

and psychosocial in nature.

It is interesting to compare perceptions of supported employment teams' domain to the

vision of services he Id by health authorities and in particular the Ministry of health. The

outline of these authorities' vision is presented clearly in the Ministry of Health's recent

Mental Health Action Plan for 2005 to 2010 (Ministère de la Santé et des Services

Sociaux, 2005). Essentially, the Ministry of Health recognizes that, with respect to the

socio-professional integration of people with mental health problems; it shares

responsibilities with the Ministry of Employment and Social Solidarity and the Ministry of

Education. In the Ministry's view, the most normalizing approach to work integration is

through the Ministry of Employment's work integration measures, most notably the salary

subsidies offered to compensate employers for hiring individuals with limitations. The

Ministry also seems to favour the furthe.r development of adapted work centres,

organizations funded through Emploi-Quebec. Indeed, the position of the Ministry of

Health and some of the regional health authorities as weIl is that activities related to the

i~tegration of peopl~ into the competitive workforce fall outside of their responsibilities,

which relate instead to the rehabilitation of people with mental health problems and the

delivery of clinical and psychosocial support as they move through the various stages of

the social integration process. As explained by the member of the Ministry of Health who

participated in this study:

More specifically with respect to work, the vision of the Ministry is that two elements are required in order for someone with a physical or psychological handicap to integrate a work setting. One the one hand, there is the capacity of the individual to adapt to their handicap, that's the part that belongs to the Ministry and its network. So, the parallel that 1 often make is with physical handicaps. If l'm in a wheelchair then 1 need to learn techniques to help me get around, be autonomous in my everyday life, etc. But once 1 learn ail that, it takes more than that to help me integrate into society and that's the process that doesn't belong to the Ministry but belongs to society so to the Ministry of Employment or the Ministry of Education [ ... ] ... if we return to the notion of work specifically, if l'm the [health] network, my job is to offer services to someone with a handicap, with a mental illness, so that they can be sufficiently equipped and autonomous enough to return to work. But it ends there in our responsibilities. As a network 1 have no impact on 'the Ministry of Employment or on the Ministry of Education. So the Ministry of Employment has the responsibility to ensure that there are local employment offices available to support people who are unemployed and who want to find a job (participant from Ministry of Health).

69

Indeed, it would seem as though the activities of the supported employment teams fall

both inside and outside of the health authorities view of their sector's domain. On the one

hand, the psychosocial support that teams offer clients as they take steps to integrate into

the · community are in line with the Minisitry's vision, yet their involvement in activities

related to competitive work integration is considered by the Ministry as an encroachment

on the Ministry of Employment's territory. As such, programs appear to be operating in a

grey area in terms of the services they provide.

4. 1.6.2. Princip/es of organizing

Members of the coalition share a number of values that are also generally shared with

other actors in the fields of mental health and work integration. For instance, they believe

it is important to treat individuals with respect, respect their privacy, and help people

become more active members of society .

. However, other key values and beliefs that prevail among them lead their services to

evolve differently than those of actors in other sectors. In many ways, these shared values

and beliefs are highly consistent with the values underpinning the supported employment

model and its guiding principles. Indeed, coalition members strongly believe that their

services should be based on the best available information regarding their effectiveness in

70

producing desired outcomes. Several participants in the study mentioned how their

perception of supported employment as an «evidence-based» practice influenced the

decision to adopt this model of services: «We looked at different models, the Clubhouse,

transitional employment models. We looked at different things and accepted this one

(Dartmouth Supported Employment Center), because i1's this one that had the most solid

evidence 1 would say. l1's this one that seemed to give the best results as weil» (program

manager).

Another shared belief is that work, and particularly work in competitive, integrated settings,

contributes to the well-being , rehabilitation and recovery of people with severe mental

illness. Indeed, participants noted numerous health benefits related to working , such as

increased self-esteem, greater clinical stability and less need for intensive clinical follow­

up, improvements in appearance and quality of life, etc. Indeed, that supported

. employment is perceived to have important benefits for health and recovery is viewed as

one of the strengths of the mode!. As such, the model is consistent with coalition actors'

recovery philosophy, which acts as a guiding framework for managers and supported

employment team members:

Like 1 told you, the overarching vIsion of ail of this is one of recovery [ .. . ] services have the responsibility to orient themselves to support people in their process of recovery. Recovery is really a process that belongs to the person. So 1 see services as an opportunity to accompany people precisely in order to be able to support people's recovery, with work being an important component of the person's recovery process (program coordinator).

We wanted to respond to needs and values that were closer to people's hearts, like hope and recovery, how in the services we offer we could arouse hope in people, use their potential and finally give them access to a more recognized role as a citizen (program manager)

Helping people find work in settings where they are paid a regular salary and surrounded

by individuals who are not handicapped is 8olso perceived by actors to be consistent with

the recovery model, as it is brings the individual closer to leading a normal life in the

commun ity. Coalition members firmly believe that people can work in these settings,

especially when provided with the proper supports.

71

Interviews with participants revealed a number of other values and beliefs consistent with

the guiding principles of the supported employment model, su ch as the belief that services

should be centred on clients' goals and preferences and that clients should be moved

rapidly into employment when this is their goal. Employment specialized often mentioned

how even those clients who seemed furthest away from regular employment could

sometimes surprise everyone and find and maintain work that they enjoyed. It was

important to employment members not to discriminate against their clients and work with

their strengths regardless of the extent of their illness or their apparent work readiness.

Supported employment teams also believe in the value of creating an alliance with their

clients, an arrangement that brings important benefits. Employment specialists keep

frequent contacts with their clients and continually assess their situations and progress

with respect to employment. Understanding clients better helps the employment

specialists determine what work arrangements work best for them and allows them to

react quickly to crisis situations that could impact a client's employment status.

Employment specialists perceived helping clients deal with the stress of a new job as an

important part of their work and critical to that client's ability to maintain their employment.

Interestingly, some of coalition members' values and beliefs may contribute to them

straying somewhat from full fidelity to the supported employment mode!. For instance,

coalition members desire to centre services around their clients needs and preferences

sometimes leads them to place less emphasis on work in competitive settirgs or rapid

entry into the workforce. Managers in the rehabilitation department of Organization C

shared the view that it was preferable to offer pre-employment services to those who

desired a slower integration into work. Similarly, managers in Organization A refused to

transform -other non-competitive vocational activities offered by the organization into IPS

on the belief that these activities still met the needs of an important subpopulation of

service users.

Coalition members also valued the autonomy they possessed in their positions. In the

case of the two IPS programs, team members were comfortable with the fact that they

were not fully integrated with the clinical team and some participants actually thought that

their lack of integration offered certain advantages. Said one participant: «1 value my

72

independence. l, you know, like in the American models, you're part of a clinical team. 1

value my independence, 1 really value it because it helps me avoid pitfalls sometimes, you

know, l'm not becoming involved in case management» (employment specialist).

Thus, coalition members clearly felt that adaptations to the supported employment

services were acceptable under certain circumstances. Participants mentioned that while

the model serves as an important guide, it should not impede them from doing what they

think is best for their clients in given situation: «It's kind of like we have a skeleton and

that's the model, you know you have the basic principles about the job search, interests ,

regul>ar markets, but again our clienteles are d ifferent. So there's some manoeuvring

within that skeleton that we ail feel comfortable doing» (employment specialist)

4.1.6.3. Self-evaluative criteria

The three supported employment teams use similar mechanisms to evaluate the ir services

and assess the need to adapt their practices. First, teams tend to meet on a weekly basis

and during meetings agents can talk about their experiences with clients and the team can

discuss courses of action that are in line with the principles of the model. Second, teams

tend to keep statistics on the number of clients that enter the program and the number who

are able to obtain competitive employment. In some cases, teams have had help tracking

vocational outcomes from researchers, who aUach their research projects to the program.

Researchers in the US have determined that an effective SE program should see

approximately 60% of clients integrated into the competitive workforce (Bond , 2004 ;

Corbière , Submitted), a statistic that provides the Quebec teams with a barometer of

success.

Researchers familiar with the IPS model, from both the US and Quebec, have also

maintained close contacts with the Quebec teams throughout the years, facilitating these

teams' access to information about the standards and norms related to this form of

supported employment. Teams have also evaluated their services using fidelity scales

such as the Individual Placement and Support fidelity scale (Bond, Becker, Drake, &

Vogler, 1997) or the Quality of Supported Employment Implementation Scale (QSEIS) (G.

R. Bond , Picone, Mauer, Fishbein, & Stout, 2000). Such fidelity scales are questionnaires

73

that determine a program's faithfulness to the supported employment model. For

example, the Individual Placement and Support fidelity scale is a 15-item questionnaire

that assesses the degree to which a program has successfully implemented the key

ingredients of supported employment (Bond et aL , 2001). Questions address aspects

such as staffing (e.g. employment specialists' case load size, their degree to which they

devote their time uniquely to vocational activities, etc.), the organization of services , (e.g.

the degree to which they are integrated into the clinical tearTJs, teamwork, etc.), and

services Uob searches are rapid and individualized, competitive settings are emphasized t

a variety of follow-along supports are provided, etc.). These fidelity scales have been

developed by the American researchers who developed the IPS model of supported

employment and are easily accessib'le to organizations wishing to evaluate their vocational

services.

Apart from the program's fidelity to the model , managers from Organization C have also

shown interest in assessing whether clients are satisfied with the services being offered.

Such evaluation~ are also a standard feature of the hospital's accreditation and

accountability procedures. Employment speciali.sts also maintain close relationships with

case managers, psychiatrists and other clinicians and receive feedback about the clin ical

impact that job placements have had on their clients as weil as these actors ' satisfaction

with their services.

74

4.1.7. Coherence between organizational structure and interpretive schemes

Given the interpretive schemes of the dominant actors in the coalition, it can be concluded

that in an overall sense the structure of supported employment programs offered by

coalition members is coherent with these coalition actors' values and beliefs. However,

the services offered by Quebec actors have in some ways deviated from the 1 PS model of

supported employment, despite efforts by American and Quebec researchers to

standardize implementation of the model to this context.

As mentioned earlier, one of the reasons for supported employment teams' non-adherence

ta the model is that they simply do not have the resources to apply certain principles in a

fully faithful way. This was particularly evident in the case of the ACT team , where the

team is relatively small and where there are only two employment specialists working part­

time. As a result, employment specialists are often forced to help out in emergency

situations and are not able to focus exclusively on vocational activities. In addition , they

have limited time to meet with employers in the community and have sometimes departed

from locusing exclusively on competitive employment for two main reasons: 1) because it

is not the goal expressed by their clients (clients are admitted into the ACT program

b~cause of their particular treatment and rehabilitation needs, not because of their desire

to gain competitive employment), and 2) because of thelimited number of employment

opportunities in their municipality.

Similarly, the two other IPS teams have also to varying degrees been influenced by a lack

of resources, most specifically in ternlS of their ability to keep caseloads low and integrate

themselves with the mental health teams. That said, program managers and coordinators

also believe that adaptations to the model are acceptable, and in some cases desirable in

order to betler respond to clients' needs. This belief would appear to go against the views

of American researchers, who believe that teams should strive to overcome local

constraints and apply the model as faithfully as possible.

At a more macro-Ievel, the core coalition members' vision of services is only partially

coherent with the vision expressed by health authorities. Aspects promoting the

rehabilitation and recovery of people with severe mental illness are clearly consistent with

75

their views, but activities related to the integration of people into regular employment are

not. VVhile these authorities control funding decisions that affect the widespread

dissemination of supported employment, the relative autonomy possessed by actors in the

health sector (such as hospitals) has allowed some programs to be implemented

regardless , meeting the needs of a non-negligible population of service users.

4.2. Employment sector coalition

4.2.1. Coalition actors and objectives

76

This second coalition is comprised of actors operating in the employment sector who work

to promote the integration of people with physical and/or mental handicaps into the

workforce. At the core of the coalition are organizations that specialize in helping. people

with handicaps integrate and maintain employment in the regular workforce (referred to

here as OSIMEs). These organizations, including Organizations D and E in th is study,

have their roots in the health and community sectors but gra'vitated to the employment

sector during the 1980s and 1990s. These organizations have joined together to form an

association called the ROSEPH , or the Regroupement des services spécialisés pour

l'emploi des personnes handicapées. Aiso at the core of the coalition is Emploi-Québec,

the Ministry of Employment and Social Solidarity's main public agency responsible for

providing services to individuals and businesses that aim to promote socio-economic

development and improve labour market stability and performance.

These actors share the goal of ensuring the delivery of high quality employment services

that will facilitate the socio-professional integration of people with handicaps, develop the ir

autonomy and reduce their social exclusion and dependence on government aid.

4.2 .2. Transactions

ln the late 1970s and early 1980s in Quebec, small clusters of actors across the province

began initiating projects and founding organizations aiming to facilitate the socia l and

professional integration of people with a wide variety of limitations. Among these actors

were those concerned by the significant exclusion faced by people with physical and

mental disabilities 'and the lack of opportunities available to these individuals to participate

fully in society. Among their concerns were the lack of employment opportunities,

particularly those involving competitive employment. At that time, employment services

were mainly available through federally funded Employment Canada, though these

services were perceived to be poorly adapted to the specific needs of people physical and

mental disabilities. The early 1980s also saw the implementation of adapted work centres

for people with disabilities, though these opportunities were targeted for p~ople unable, in

the short-term at least, to integrate the regular workforce.

77

Dissatisfied with the existing range of vocational services and motivated by the bel ief that

people with disabilities could indeed achieve regular employment despite the ir limitations ,

concerned actors set forth to help these individuals participate actively in the workforce.

Among the organizations that were formed at that time were the two OSIMEs in this study

(Organizations 0 and E). Organization D came together as a result of a partnersh ip

between actors from three psychiatrie institutions who pooled their resources to offer

vocational services to the psychiatrie patients receiving services from their institutions.

Organization E was founded by members of the community, including family members and

friends of people with handicaps, who shared a common interest in helping their loved

ones live more fulfilling lives.

Early financing for the services provided by these organizations was scarce, and

sometimes non-existent, and both operated for many years with limited budgets and staff.

To help create employment opportunities for their clients , they solicited the help of local

businesses in their communities, often going door-to-door to meet with potential

employers. As time passed, these organizations worked to refine their vocationa l services ,

establish ing frameworks based on their own experiences of what had led to vocationa l

successes. Actors in the se organizatlons also believed that their services needed to be

flexible in order to meet the needs of the diverse clienteles that sought their help.

ln 1988, these two organizations and others like them accepted funding from the Ministry

of Labour and Income Security in exchange for the delivery of services within a new

employment program, called the service externe de main-d'oeuvre or SEMO program.

The goal of the program was to facilitate, through the delivery of well-adapted services, the

professional integration of people who had experienced specifie difficulties when trying to

find and obtain competitive work. Indeed, the program targeted not only people with

physical or mental handicaps but also other groups who had faced challenges, such as

troubled youth, single parents, older workers, ex-criminals and immigrants. The

partnership provided organizations with the opportunity to acquire more resources,

stabilize their funding, and continue in their missions of helping their clienteles integrate

78

the workforce. And by profiting from these organlzations' expertise, the Ministry was able

to ensure the provision of a more complete range of services to the population , and

particularly to those whose needs were not being met by the sector's regular services.

Furthermore, the partnership ensured that these clienteles would have access to service

providers that could make a long-term engagement to them and support them throughout

the work integration process.

Over time , these SEMOs would continue to grow and experience success placing people

with handicaps in regular jobs. However, many clients still faced a multitude of barriers to

employment and sorne experienced repetitive setbacks. Resources devoted to salary

subsidies and other social integration measures were often inadequate to me~t rising

demands, further limiting incentives to .work and access to the labour market. Gaps in

services were also becoming apparent, with some organizations finding that new services

were needed for some clients whose progress towards employment was slower than what

the regulations related to social measures and subsidies allowed . As such , these SEMOs

created or reached out to other organizations that could provide clients with alternatives ,

such as organizations devoted to the development of employability (i.e. internships and

train ing), adapted work centres and social enterprises. Partnerships with these

organizations allowed clients to move towards competitive employment wh en they were

ready and when they had acquired the skills needed to maintain their employment. They

also created a sense of continuity between the employment services in a given region.

The mid-1990s saw the beginning of a significant restructuring in the employment sector,

as responsibilities for social assistance and the development of employability were

transferred from the federal government to the government of Quebec. SEMOs like

Organization 0 that had been partially funded by the federal government saw their

agreements with that partner come to an end , forcing them to look elsewhere for funding.

ln 1998, the Ministry merged its services with those previously controlled by the federal

government and formed a new entity, Emploi-Québec, whose role was to manage the

Ministry's employment programs and provide employment services to individuals and

businesses at local , regional and provincial levels. Seeking greater resource stability,

most SEMOs, including Organizations 0 and E, partnered with Emploi-Québec and were

funded as part of Emploi-Québec's service d'aide à l 'emploi program.

79

Though many of these organizations had been informally linked since the creation of the

SEMO program in 1988, they formalized their relationship in 1999, regrouping themselves

into the Réseau des services spécilalisés de main-d'oeuvre (RSSMO). This alliance

united ail the SEMOs, including those not working with handicapped people, in an effort to

seek greater recognition from Emploi-Québec and bargaining power over decisions

affecting their organizations. Not long after, however, organizations such as Organizations

o and E that worked only with handicapped clienteles began to question their involvement

in the association. Among the reasons for this was that their demands directed at Emploi­

Québec were being diluted in the demands of the other SEMOs whose clienteles were

complete ly differenl, at times creating competition among the SEMOs and limiting the

effectiveness of their efforts to improve their conditions and services for their clients.

As such, in 2004 , 25 organizations working with handicappe.d people left the RSSMO and

formed a new association, known as the ROSEPH. This association brought together

organizations whose values, beliefs, expertise and goals were more coherent with each

other. Partnering with Emploi-Québec, the ROSEPH has been able to express more

clearly the needs of handicapped clients to the government, as' weil as the needs of

organizations providing employment services to these clients. The partnership allows

them to have rapid access ta details of Emploi-Québec's programs and employment

measures and in return they provide the employment agency with data regarding the

vocational outcomes of handicapped people integrating the workforce. Indeed , the

information they exchange ensures that standards for employment services are being met

and that adjustments to Emploi-Québec's employment services can be made when

needed.

Throughout the years, organizations specializing in the integration and maintenance of

employment have also engaged other actors in important partnerships. Many OSIMEs for

instance work closely with ·Iocal employment offices, with some OSIMEs actually being

integrated within these offices, an arrangement that has increased continuity of services

for some clients. Several OSIMEs have also established links with other agencies outside

the umbrella of Emploi-Québec that provide funding for work integration measures, such

as Sphère-Québec, a recently created, federally funded agency that provides financial

80

support for various forms of work integration activities. Employers are also key partners of

OSIMEs. OSIMEs provide employers with a pool of potential employees and then support

these clients so that they can carry out their roles effectively.

Finally, many OSIMEs, including the two in this study, have also established partnerships

with actors from the health sector, including general and psychiatrie hospitals , cl inical

teams linked to these hospitals and , in the case of Organization D, IPS teams. OSIMEs

rely on these actors to provide the clinical and psychosocial support their clients need to

facilitate their integration into the workforce. In return , the OSIMEs provide these health

actors w ith a free work integration service option that favours access to competitivs

employment and, importantly, provides clients with access to the employment measures

and programs of Emploi-Québec, available only through OSIMEs. Also, in the case of

Organization D, formai agreements reached with the psychiatrie and general hospitals in

its region has made possible the elaboration of referral procedures that significantly

reduces the time it takes for the organization to process the clients ' clinical information and

provide the client with employment services.

4.2.3. Links

Figure 3 illustrates the actors comprising the employment sector coalition and their

relationships with one another. Organizations D and E, like the other 25 OSIMEs, are

formally linked to Emploi-Québec and service agreements detail the responsibilities that

each actor has to the other. Links between the OSIMEs have also been formalized

following the creation of the ROSEPH. Executive members of ROSEPH, i.e. the directors

of each OSIME, meet on a monthly basis to discuss common goals and challenges and

employment specialists from the OSIMEs meet on a biennial basis.

OSIMEs work closely with other organizations funded by Emploi-Québec. For example,

both OSIMEs in the study have partnered with one or more of the local employment offices

in their region, as weil as with organizations promoting the development of employability

(DE), adapted work centres and social enterprises. Oftentimes these relationships have

been informai, though Organization E has formally merged its services with an

organization that develops employability.

81

Organizations 0 and E have also established close partnerships with a range of other

local, regional and provincial actors with the aim of advancing its cause and gaining

access to new resources. At a local level, both organizations have established links with

health sector actors, though only in Organization 0 have such links been formalized, and

both worked closely with employers in their regions. Both organizations had informai links

to provincial associations such as l'Office des personnes handicapées du Québec (OPHQ)

and provincial employment committees such as the Conseil des partenaires du marché du

travail (CPMT) and the Comité d'adaptation de la main-d'oeuvre (CAMO). Both also had

relationshis with Sphère-Québec, a federal/y funded agency that provides subsidies for

helping handicapped people integrate the workforce. Interactions with members of the

Ministry of Employment and Social Solidarity were more limited as information was

normally conveyed via members of Emploi-Québec.

Final/y, members of the two OSIMEs also participated in many of the same issue tables

that members of the health coalition did, though they also were involved in a variety of

other regional and provincial committees and forums that brought together actors from

Emploi-Québec, the Ministry of Employment, employers and other actors in the

employment sector.

4.2.4. Controls

Autonomy of actors in Organizations 0 and E over decisions affecting their services is

constrained to a degree by the nature of their relationship with Emploi-Québec;

Importantly, these organizations are funded to focus exclusively on helping people obtain

and maintain competitive employment. Other activities, such as rehabilitation activities

and even pre-employment activities, are considered the responsibi"lity of other actors that

the OSIMEs can partner with. Furthermore, as the beneficiaries of Emploi-Québec's

financial support, the OSIMEs are occasional/y required to adapt to decisions made by

their funder and operate in a way that is more consistent with Emploi-Québec's interests

than their own.

82

For example, Emploi-Québec imposes restrictions on the types of clients that these

organizations can offer services to, the modalities of the measures the se organizations

use to integrate people into the workforce, and requires that OSIMEs meet various targets

pertaining to the number of clients that they should minimally serve and place into

employment. More specifically, with respect to its clienteles with mental health problems,

Emploi-Québec has delimited these organ izations' clienteles as those with «severe and

persistent mental illness». Yet, Emploi-Québec does not consider it appropriate that

OSIMEs work with just any person with severe and persistent mental illness. Indeed , they

are encouraged to work with those clients who are considered more ready to integrate the

workforce:

... but those are the basic criteria. For sure there are others that come from Emploi-Québec, on the clients that we can provide services to. For Emploi­Québec, the clientele that we must work with, ifs that which is closer to the labour market. So those that are further from the labour market, people who haven't worked in 3 years, 5 years, 10 years, we send them to the [organization that develops employability], who take a clientele that is further from the labour market, to prepare them. (program coordinator)

This fact is interesting and conflicts somewhat with the role that OSIMEs are stated to play

in official documents, which is to contribute to the professional integration of people

considered to be further from the labour market. Indeed, one participant mentioned how

her organization would sometimes feel torn between wanting to help certain cl ients who

fell just outside of Emploi-Québec's criteria for services, yet seemingly fell within their

mandate, and at the same time stay within the boundaries agreed upon with Emploi­

Québec.

ln addition, Emploi-Québec places restrictions on access to some employment measures,

such as their work integration contracts. These salary subsidies are typically only

available to individuals who can be recognized as having a severe constraint to work. As

such , clients who have severe and persistent mental illness but who have not been

accorded this designation can sometimes have difficulties obtaining a subsidy that could

help them integrate the workforce. This has led some OSIMEs to encourage health

professionals to give their cl ients this designation, a request that has been met with

83

resistance by some professionals on the basis that it applies a negative, stigmatizing label

on the client.

The service agreements negotiated with Emploi-Québec also require that these

organizations meet several minimum targets related to the amount of clients they should

provide services to and place into employment (see section on self-evaluative criteria, p.

98). However, it is important to note that these targets are co-determined with Emploi­

Québec during the course of negotiations and are not strictly imposed on the aSIMEs.

Indeed, though their relationship with Emploi-Québec may not be completely equitable,

OSIMEs perceive themselves to be partners of Emploi-Québec and not under their direct

authority, a fact that pushes both sides to collaborate with the other on the most equitable

terms possible.

That being said, the fact that aSIMEs have accepted to be a service d'aide à l'emploi

exposes them to Emploi-Québec's accountability procedures. aSIMEs are required to

justify and account for the services they provide clients and demonstrate to Emploi­

Québec that they are meeting the agreed upon targets. As a result, staff of these

organizations end up having significant administrative duties to go along with their duties

related to their work with clients and employers:

... the forms and the paperwork because [in our organization], we have enormous amounts to do, enormous ... 1 would say a minimum of 50% of what we do is clerical. There are a lot, weil, l've had a few employees who have . made a change, they have left to work rat an organization that develops employability] because they can work more with clients. Yes, there can be periods wh en we work more with clients, but when we work on requests for funding, there is a follow-up that must be done. Since we are funded by Emploi-Québec, we have to be accountable, so ail the clients that come to see us, we have to provide Emploi-Québec with a report related to, yes, the client has started to receive our services, there's been a placement in employment, there's been an end to our services ... So want it or not there's always going to be paperwork. (program coordinator)

These administrative tasks can o limit to a certain extent the amount of time employment

specialists spend interacting directly with clients and working in the community and they

also force administrators to spend considerable efforts compiling information to send to

------------------- - - - - - - --- --- - -- ---- - -- ._-- ---

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Emploi-Québec. Significant administrative duties are a product of Emploi-Québec's

adoption of a management approach based on results, but also of the way Emploi-Québec

finances these organizations. Specifically, since 2004 most organizations have been

funded using a payment method where they are essentially given a certain payment for

every new client that they provide services to (see acquisition of resources section , p. 91).

As such, it is necessary to detail the clients' situation and needs in terms of services in

order to justify the amount of funding reques.ted from Emploi-Québec.

Interestingly, another consequence of this payment method is that there is less financial

incentive to support clients for more than one year. Since funds received from Emploi­

Québec cover the costs of providing services to clients for only one year, OSIMEs that

work with clients beyond that time do so at their own expense (though OSIMEs can for

example request funds to renew salary subsidies). While most organizations have indeed

provided this uncompensated support to clients , this funding method incites these

organizations to emphasize a large intake of clients and rapid movement into employment,

with support that is less intensive and time-consuming than what is generally offered by

IPS programs.

ln recent years, OSIMEs have looked to gain a greater control over decisions related to

their funding and the services they offer clients. Indeed, this desire contributed to the

creation of ROSEPH, which plays an important role in ensuring that organizations can

further increase the equity in their relationship with Emploi-Québec. By joining together,

the ROSEPH is a strong voice for the employment needs of people with handicaps and is

perceived by Emploi-Québec to be highly credible. Their opinions have been solicited

when both Emploi-Québec and the Ministry of Employment seek to adjust employment

programs and policies that might affect the integration of people with disabilities into work.

It is also important to mention' that outside of the parameters negotiated with Emploi­

Québec, Organizations 0 and E have the freedom and flexibility to determine how their

services are organized. Management in the organizations have control over the activities

of their staffs and control the overall direction of their organizations, though important

decisions must pass judgment before a board of directors. There appears to be a high

85

degree of trust between OSIMEs and Emploi-Québec, which may be due to the fact that

these organizations have been functioning in their domains for several decades. Indeed ,

in some regions where more than one OSIME exist, organizations such as Organization 0

have been permitted to remain specialized and offer services to targeted clienteles rather

than become pan-disability service providers.

Certain actors within OSIMEs have also been able to influence decisions made by Emploi­

Québec, largely because of the considerable expertise they have acquired over the years

dealing with clienteles with disabilities. In the past, Emploi-Québec has initiated

partnerships involving training sessions with these actors in an effort to create greater

awareness of issues touching people with handicaps amongst Emploi-Québec and local

emp~oyment office staff and help them deal more effectively and respectfully with these

individuals.

4.2.5. Archetypes - Organizational structure

4.2.5. 1. The structure of roles and responsibilities

86

As mentioned above, OSIMEs are partners of Emploi-Québec, the main publ ic

employment service provider under the Ministry of Employment and Social Solidarity's

authority. The Ministry's role is to ensure the social development and economic prosperity

of the province. It does so by establishing policies that promote employment, the

development of the labour force and the strengthening of the labour market. It also

ensures financial· support to disadvantaged people and funds activities aiming to fighting

poverty and social exclusion. These latter responsibilities are managed by Emploi­

Québec, which since 2005 has had the dual responsibility of provid ing public employment

services and managing the Ministry's income security programs. Regional offices of

Emploi-Québec ensure that the government's mission is carried out in ail regions of the

province.

A key partner of both the Ministry and Emploi-Québec is the Commission des partenaires

du marché du travail (CPMT), an advisory committee composed of representatives from

the labour market, businesses, community organizations, organizations involved in

professional training, and several other actors interested in improving labour market

performance. The role of the CPMT is to bring together decision makers so that they can

share the ir expe"rtise and work collaboratively to strengthen the province's economy. The

CPMT also seeks to promote a greater equilibrium between supply and demand in the

labour market, and participates in decisions influencing the programs and measures that

are established and offered by Emploi-Québec. Among the partners of the CPMT and

Emploi-Québec is the Comité d'adaptation de la main-d'oeuvre (CAMO), a provincial

committee whose mission it is to elaborate and coordinate strategies aiming to facilitate

people with handicaps' access to employment and professional training. To achieve these

goals , the committee partners with members of various associations and organizations ,

professional syndicates, employers and government agencies.

Local employment and welfare offices are for many people the main entry point to the

erilployment sector's services and programs. Over 150 of these offices operate across the

province of Québec, providing employment services to bath individuals and businesses.

87

For people with handicaps, however, a potentially more adapted solution are services

provided by the OSIMEs. These organizations are private, non-profit corporations and

each is governed by a board of directors. OSIME managers establish the direction for the

organization and staffs carry out organizational action plans. Like in most other OSIMEs,

the supported employment services provided by Organizations 0 and E comprise three

major components: 1) welcome procedures and initial assessment, 2) orientation and

preparation for employment, and 3) integration and maintenance of employment.

When an individual first makes contact with an OSIME, they are provided with information

regarding the services offered by the organization and are asked questions to determine

their eligibility to receive services. In most cases, clients with physical handicaps can be

referred by numerous sources or can self-refer. However, clients with mental health

problems will most often be referred by a treating physician or mental health professional.

Unlike most OSIMEs which accept clients with various handicaps, Organization 0 provides

services exclusively to people with mental health problems. To be eligible to receive

services at an OSIME, individuals must prove that they have either a physical or mental

handicap and must express the desire to work in regular employment. Organizations D

and E -also required that clients with mental illness be clinically stabilized before beginning

the work integration process.

Once it has been determined that the individual meets criteria for services, they undergo

an initial assessment. Assessments typically involve collecting information about the client

that allows employment specialists in the OSIME to determine whether an individual

should receive supported employment services and move towards competitive

employment or be referred to other organizations that will help the client become more

prepared. Information factoring into these assessments typically consists of demographic .

and professional information about the individual (e.g. age, work experience, education

level, etc.), the nature of the person's handicap (e.g. limitations, strengths) and their

clinical profiles (e.g. diagnosis, medications and side-effects, hospitalizations, nature of

follow-up, etc.), as weil as their goals, motivations and interests with regards to

employment. Employment specialists from Organization E occasionally asked clients to

complete various psychometrie tests designed to assess cognitive and other skills. If the

88

client expresses an interest in working only a few hours a week, the organization will refer

that individual to another organization or redirect them towards other preparatory· activities.

Indeed, OSIMEs typically provide services specifically to people who demonstrate the

interest and capacity to work approximately 20 hours or more a week. If the evaluation

that is performed suggests that the person will be incapable of reaching this level of

activity in the not too distant future , the individual is typically referred to other services.

Preparatory · services can consist of workshops or internship programs that aim to develop

people's employability and help them acquire work experiences, skills and habits needed

to become employees in the regular workforce. Some clients would experience

considerable anxiety when returning to work and so for these individuals pre-employment

services were considered appropriate. In some cases, OSIMEs will refer clients .to

organizations that will allow them to receive more focused professional training. Adapted

work centres and social enterprises are also potential options available to clients. Clients

can usually move back and forth between the organizations depending Qn their needs,

interests and perceived capacities to work.

Once it has been decided that the person is ready and able to begin working more

significant hours in the competitive workforce, employment specialists will often meet with

that person to develop an individualized action plan. In particular, they will take a closer

look at the person's strengths and weaknesses and assess how different jobs identified by

the client match with the client's characteristics. If clients are uncertain as to what kind of

job they would like, employment counsellors can help provide them with information about

various types of work and explain to them their options. At this time the employment

specialists can also determine whether the individual is eligible to benefit from any of the

employment measures made available by Emploi-Québec. One of the most common

measures used for people with mental health problems is called the work integration ·

contract or contrat d'intégration au travail (CIT). CITs are offered to employers to

compensate them for any lack of productivity incurred from the hiring of an individual with

a handicap. For instance, if it is determined t;)y the employment specialist · that the

individual is only able to operate at 80% the productivity of a non-handicapped employee,

the employer pays for 80% of the individual's salary and the government compensates the

employer with the remaining 20%.

89

Once clients have identified the types of work they would like, employment specialists can

offer assistance in helping them prepare for and obtain those jobs. However, most

employment specialists are cautious not to do everything for their clients, preferring that

clients perform each of the steps as independently as possible. Once a job has been

identified , employment specialists can interact with employers and negotiate work

accommodations that will help the client perform tasks more effectively and make working

more manageable for them. Common accommodations negotiated for people with mental

health problems include adjustments to work hours, opportunities to be excused for

medi,cal appointments, increased supervision or training and adjustments to tasks and task

performance expectations (e.g. being able to work more slowly).

Once a client has been placed in a competitive job, employment specialists offer a regular

follow-up, most often consisting of weekly to monthly phone calls. This is also considered

to be a service to employers, as employment specialists work to provide clients with the

support needed to help them remain productive and fulfil their obligations to employers.

Close collaborations with the employers also help employment specialists be aware of any

problems that their client might be facing, thus allowing them to help employers deal with

problems in a timely and appropriate manner. Finally, if clients experience health

problems that affect their work, employment specialists can inform clinical teams so that

these problems can be dealt with quickly and possibly without resulting in the individual

losing their employment. In Organization E, if a client has been placed without a salary

subsidy for a full year, their file is closed. If a client still needs a salary subsidy after a

year, their subsidy is renewed provided that this can be justified.

As mentioned earlier, organizations offering these services, 25 in ail, have come together

to form the ROSEPH. The primary role of the ROSEPH is threefold: 1) to increase the

recognition of the specific expertise and skills possessed by member organizations, 2) to

convince the public decision makers of the need for high-quality, accessible and weil

funded employment services for people with handicaps, and 3) to develop, share and

ensure the coherence of practices facilitating', the integration of these clienteles into the

competitive workforce.

90

The ROSEPH has a board of directors and member organizations abide by a code of

ethics. Membership in ROSEPH is characterized by adherence to four criteria:

The organization must have a specifie service partnership with Emploi-Québec

re lated to the delivery of services to people with handicaps

The mission of the organization must be coherent with that of the ROSEPH

The organization must offer services to handicapped people in a way that is

consistent with the approach and practices adopted by the ROSEPH

The organization must offer services that conform to the code of ethics adopted by

the ROSEPH

4.2.5.2. The organization 's decision systems

As private corporations, decisions regarding the direction of OSIMEs and the types of

services provided to clients fall under the authority of the directors of these organizations.

Strategic decisions affecting the organization are presented to the board of directors and

carried out following their approval. Directors and managers usually meet on a regu lar

basis to ensure that obligations are being met and targets aUa ined. They and other staff

also meet with a variety of other actors through various issue tables, forums and

conferences. Information exchanged at these venues allow decision makers within the

organization to organize their services in a way that best meets the needs of their clients

and limit the gaps in services that their clients may face.

4.2.5.3. The management of human resources

The staffs of the two OSIMEs in .this study were made up of individuals with a variety of

professional backgrounds, from experiences related more to work with the clienteles (e.g.

experience in the mental health field) to experiences in business and the employment

sector. Diversity in the team was seen as a positive, as it allows teams to collectively

possess a broader range of expertise. In Organization D, employment specialists provided

ail . services related to the work integration process (Iike in the supported employment

/'

91

teams in the health coalition). In contrast, in Organization E, different team members

carried out specifie tasks, such that some employees helped people with job searches and

placements while others performed job counselling or specialized in job maintenance.

Some of the most important criteria guiding the hiring of employment specialists are that

they be open to the clientele and able to sell their clients effectively to employers.

Openness in particular is key, as employment specialists must believe that their clients can

work in regular work settings:

1 mean the job is to get schizophrenics back into the workforce. 40% of the people that come here suffer from schizophrenia. If you don't believe they can work, weil that means that 40% of your clients, 1 mean, can you imagine that? Two out of five people that come to your office, you've already decided that they're not going to work. How the hell are you going to help them? (program manager)

New employees who have little or no experience helping clients with mental health

problems are provided training by aSIME managers. Teams also hold regular meetings

where employment specialists can learn from each other and exchange information re lated

to their practices. Managers and coordinators oversee their staff and ensure that they are

perfdrming their duties in line with the organizations' mission and meeting the objectives

set with Emploi-Québec.

4.2.5.4. The acquisition of resources

A few years ago, Emploi-Québec altered the way it funds aSIMEs, moving towards a

funding method where organizations essentially receive a certain lump sum for each client

that they provide services to . Prior to their yearly negotiations with Emploi-Québec,

organizations specify the number of clients they intend to serve over the course of the next

year and outline the types of services that these clients will need. Services are classified

into several categories and each category is associated with a price range related to the

potential costs of delivering those services to a particular client. aSIMEs compile

information regarding the services they have offered in the previous year and use it to

estimate a cost-per-client for the clients they plan to serve in the future. Funding typically

92

covers the delivery of services for a one-year period, with any additional services provided

to clients coming at the OSIMEs own expense. However, if clients require fewer services

than initially expected, funds can be retained and used the following year. Access to

future funds is tied to OSIMEs' ability to meet the targets agreed upon following their

negotiations with Emploi-Québec. Hence, Emploi-Québec's funding method seems to be

arranged to maximize performance and efficiency.

If clients are placed in employment using a salary subsidy, this salary subsidy can be

renewed on a yearly basis provided that this can be justified. Indeed, these measures are

amang the mast camman measures used by OSIMEs to help people integrate the regular

workforce. Initially, Emploi-Québec did not have the resources necessary to ensure that

these subsidies were available to ail who needed them. Over the years however funding

for these measures, as weil as for placements in adapted work centres , have consistently

increased. Funding for OSIMEs has . remained relatively stable , though these

organizations' expansion was limited for several years due to constraints in Emploi­

Québec's budget. Staff sizes for OSIMEs are variable, averaging between ten and twenty

employees in Organizations 0 and E. Salaries of employment specialists and staff are

included in the funds provided by Emploi-Québec.

Each OSIME is responsible for negotiating with Emploi-Québec the terms related to the

costs of delivering their services and doing business. This arrangement had the

consequence that organizations that were more skilful in their negotiations were able to

procure greater funding from Emploi-Québec. However, . since the creation of ROSEPH ,

this association has been assigned the respon~ibility of negotiating the rules regarding the

range of priees aUributed to each category of services, allowing member organizations to

negotiate their funding on more equitable terms.

93

4.2.6. Archetypes - Interpretive schemes

4.2.6.1. The organization 's domain

Organizations 0 and E viewed themselves as specialized employment services that aim to

move people with various physical or mental limitations into competitive employment and

off of social assistance. Their clients are those who are stable and autonomous enough to

enter the workforce quickly and work a significant amount of hours per week (usually over

20 hours). Employment specialists offer support to their clients throughout the integration

process, though this support is uniquely socio-professional and not psychosocial in nature.

Indeed, participants were clear in stating that their organizations were not rehabilitation

programs and improving clients' health and promoting their recovery was not their main

conc.ern. This was expressed quite plainly by one participant:

... they're here to be moved. They're not here to . talk to us about their problems, they're not here to talk to us about, like, you know, their medication and this and that. That they do with their therapist [ ... ] We're financed by Emploi-Québec, we're an employment service , and we're not a therapy thing , we're not a rehab program, we're not here to make sure you're a beUer person , we're here to make sure you work. Once you are working, we will keep in touch with you, we will follow-up to keep you working. And if it is not working good, it is not working out, we will get you out, we will get you another job. (program manager)

It is important to note that the limits between employment activities and activities related to

rehabilitation are not as intuitive as one might think. Interestingly, finding employment for

only a few hours a week or month was considered by actors in Organizations 0 and E to

fall more within the domains of rehabilitation services and organizations that develop

employability rather than the .OSIMEs' domain , as explained by the same participant:

... but the guys has to want to work, and he has to be able to function , like someone who comes to our office who says « 1 want to work for 100$ a month», we won't help them. Because for 100$ a month is working two days a month and we don't have jobs for people at two days a month , 1 don 't have jobs for people at two hours a day. That's rehab, IPS does that. We don't do that, IPS does that. There's distinctions there. Vou know that's rehab. If you can only work two hours a week, weil it's because you're in rehabilitation, a vocational program that is developing skills that will bring you towards something else. When you get here you should be able to do more than two hours a week. (program manager)

94

The vision that actors from Organization 0 and E had regarding their domain seems to be

coherent with that of their main partner, Emploi-Québec. Indeed, Emploi-Québec and its

community partners recently co-produced a document14 where their shared values and

goals are described and where the important contributions made by OSIMEs and other

community organizations are formally recognized. The growth of these organizations and

their presence in ail administrative regions of the province would seem to be additional

evidence of the coherence between OSIMEs and Emploi-Québec's visions regarding the

kinds of supported employment services they want available to people with physical and

mental handicaps.

4.2.6.2. The princip/es of organizing

When examining employment coalition members' views about their employment services ,

1 several prevailing ideas and beliefs seem to influence the way these services are

organized. For example, one of the. key ideas that guides service delivery in the

employment sector is the concept of «distance from the labour market» , which is used

when characterizing individuals and the barriers they -face with respect to their integration

into the workforce. An individual's distance from the labour market is considered to be the

product of many factors, including their personal and professional history and· the demands

of the labour market. Examples of characteristics that can contribute to someone being

labelled as «distant» from the labour market are low education levels, lack of work

experience and skills, prolonged periods of unemployment, having had constraints to work

because of an illness, having been hospitalized or imprisoned, being responsible for the

care of young children, etc. The more of these characteristics a person has, the further

from the labour market they are considered to be.

This conceptualization has an important influence on the way services are organized in the

employment sector and the path that individuals with severe mental illness often take

when trying to integrate the regular workforce. In particular, it has contributed to the desire

14 Called the Protocol de reconnaissance et de partenariat entre Emploi-Québec et les organizations

communautaires oeuvrant en employabilité (2006)

95

to establish a continuum of services that caters to individuals' differing needs and

particularly their perceived readiness to work. Indeed, some participants suggested that

those considered furthest away from the labour market were probably unlikely to integrate

the regu lar workforce successfully without first acquiring the skills and qualifications

. desired by employers. When asked about the need to prepare certain clients for entry into

the labour market, a manager from Organization E said:

It depends on the clientele. Like 1 said earlier, the mental health clientele more often does because often they are further from the labour market, so ... they have been absent from the labour market for three, five years and more, which means that you just don't return to work like that [snaps fingers]. So there are preliminary services, that offer progressive internships, a progressive entry, but the person must, after one year, be able to go to work. So it's really short term. If we see that it's really going to be longer than that, at that time we would refer that person to another government program to go develop their skills, and after that they can continue on to an internship lasting a maximum of a year. If the person, after three months, things are going weil and the skills have been achieved, the person has regained the rhythm of going to work, at that time they can come t6 the [OSIME], so to integration into paid work. (program manager)

Indeed, integrating into regular employment is considered to be the final stop in the

continuum, and as such OSIMEs the final step in the return-to-work chain of services.

Such a view was further conveyed in the following statement: «Because us, we're the

ultimate. Employment is the ultimate. So, when they come to see us, sometimes we say

weil no, you have to begin at step 1, or go to step 3 before you can go to step 4, so you

can work on this or that aspect» (program manager).

This is no! to say that clients' preferences are not considered important when assessing

which services they should access and what types of employment are targeted. However,

their preferences are only one of several factors taken into account when staffs evaluate

how best to meet their clients' needs; factors such as their skills and limitations,

experiences and demands of the labour market are ail weighed when determining whether

clients are a right fit for their services and «ready» for regular employment. Participants

felt that they had a responsibility to place clients in the position that gives them the best

opportunity to succeed. In Organization E, staff tried to avoid having the client experience

failures that could discourage ·them from working in competitive employment, though this

96

attitude was not held by actors in Organization 0 who believed that the threat of failure

should not prevent clients from applying for jobs they wanted.

Though the responsibilities towards their clients were seen as important, actors from

OSIMEs perceived their relationships with and responsibilities towards employers as

equally important. According to the website of one OSIME, «The relationship with the

employer is thus essential and as important as the relationship with the handicapped

person». Employers hire their clients and expect these employees to be able to perform

the tasks asked of them. As such, participants mentioned how they would be reluctant to

send clients to employers if they were not convinced that they could effectively perform

their duties.

Indeed, as participants from the OSIMEs described their partnerships with employers , the

importance they placed in bu ilding equitable relationships became increasingly evident.

They recognized that both clients and employers had their own needs and interests and

made efforts not to place the needs of one side over the other. OSIME participants

generally believed that clients were ready for regular employment when they were

responsible and autonomous enough approach their jobs like other employees without

handicaps:

The client also knows, wh en he cornes here, he comes here to work, he doesn't come .here to learn things ... [ ... ] He's just a person going to an employment service and asking for a job. And once he's there, he's going to work, so it's like, it's total normality ... [ ... ] ... we can't control tardiness, we can 't control absences, we can't control not assuming responsibilities, we're not going to go get you at home and bring you to work. If you can't do that, we're not going to help you. Vou have to get up and you have to go to work. Vou might not like it, but that's, that's just normal, that's okay. (program manager)

So, by requirin9 clients to be as responsible as possible, OSIMEs can ensure that they will

become satisfactory employees and fulfill their responsibilities to employers. This is not to

say that these employees are always expected to perform at the same levels as

employees without handicaps. However, clients are expected to achieve a level of

97

productivity that satisfies employers once the appropriate accommodations and supports

are in place.

Indeed, the emphasis placed on equity and client responsibility has had an important

influence on the support offered clients, both in terms of the type and length of support

offered. In particular, while employment specialists are present to support their clients

through ail steps of the work integration process, they frequently encourage clients to

develop their autonomy by carrying out as many steps as possible on their own.

Employment specialists are asked to guide and 'support clients but not perform each step

for them: «we don't want the clients ta be dependent on us, sa basically we're present,

we're available, but we don't want them thinking that every time a problem arises '1 have ta

cali my counselor' because they have to try to resolve certain problems» (program

manager).

This remains the case once the client is placed · in employment, as employment specialists

will rarely go to a work site to help train a client. Indeed, one participant mentioned how

such an action can portray these employees as being incapable of performing their duties

independently, thus accentuating the differences between them and their non­

handicapped colleagues. Working with clients who are more autonomous also means that

fewer clients need intensive support for long periods of time, allowing employment

specialists to work with a greater number of clients and emphasize support during key

periods of the work integration process, such as in the first three months of regular

employment. Participants in b'oth Organizations D and E believed these first few months

to be critical because it is during this time that clients have to adapt the most to their new

life situation. And though they were not interested in emphasizing the health aspects of

employment, participants from both organizations felt that it was important to maintain links

with health providers and that clinical and psychosocial support was especially critical to

helping clients stay employed once they had found work.

Ouality in employment services is highly valued by Emploi-Ouebec and the OSIMEs and .

these coalition members have played active roles in promoting the adoption of high quality

practices . In 2008, for example, the ROSEPH funded research designed to describe the

98

services that its members provide across the province, identify best practices and ensure a

greater standard of care provided by OSIMEs. Standards of care are also a topic

discussed during yearly negotiations between Emploi-Québec and OSIMEs. Importantly,

however, these actors are not concerned uniquely with the quality of services but also for

providing services to the greatest number of people possible: « ... the difference [between

OSIMEs and other vocational service providers] is, we work in quantity as weil as quality.

[ ... ] we see 550 about new clients every year. We maintain over 200 people in the labour

market» (program manager).

Indeed, whereas production and performance targets may be viewed as a constraint by

some organizations in the health or community sectors, the notion that OSIMEs must be

productive is embraced by the members of these organizations: «We're financed based on

performance [ ... ] the reason why we're financed by Emploi-Québec is because we wanted

it. If we wanted to be financed strictly on service, weil then you should be asking for

money from the Ministry of Health. Emploi-Québec is there for performance, they're not

there for, you know, they're paying us to find clients jobs» (program manager).

4.2.6.3. Self-evaluative criteria

Several mechanisms are used to evaluate whether OSIMEs' supported employment

services are operating effectively and in line with coalition members' vision of services.

Emploi-Québec's accountability procedures are one of the primary mechanisms, as

OSIMEs provide Emploi-Québec with various indicators of production and impact. For

instance, Emploi-Québec requests that OSIMEs serve a minimum number of clients per

year and typically fixes as an objective a 50% placement rate, meaning that organizations

must- place 50% of their new clients in employment over the course of that year.

Organizations 0 and E kept many statistics on their clients and on these clients' vocational

outcomes. Organization 0 in particular emphasizes the importance of employment

outcomes at 3 months: «You see, last year we got 307 people back into the labour market.

We have a 75% success rate. Seventy-five percent of p~ople that we get jobs for keep

their jobs at least 3 months. Now, three months is, a lot of people say, weiL .. 85% of

people that are working after 3 months keep their jobs, are still working after 6 months.

The first few months is when they have to adapt the most, so that's where we decided to

make our niche ... » (program manager).

99

Organizations are also required to produce an annual report to Emploi-Québec, which

contains information about the organization's mission , objectives, clients, services and

results for that year.

Within the OSIMEs studied, managers and coordinators were often heavily implicated in

the training of employment specialists and met with them regularly to provide assistance

and ensure that their activities were consistent with the organization's mission , approach

and responsibilities.

100

4.2.7. Coherence between organizational structure and interpretive schemes

Overall , the way services are structured seems coherent with the interpretive schemes of

coalition members. Indeed, this would seem to more true now than it was perhaps a

decade ago, in large part because of t~e way Emploi-Québec has adapted its programs

and measures to be more responsive to the needs of OSIMEs and their clients. For

instance, Emploi-Québec has regularly increased the funds devoted to work integration

contracts and seems to have provided OSIMEs with more flexibility in terms of the length

of support offered clients (initially support was funded only for a 13-week period). The

ministry and Emploi-Québec have also tried to remove some of the barriers that made

integration into the labour market more difficult, notably by ext~nding the period of t~me

that clients on welfare can keep their disability benefits after obtaining competitive , work

and by providing welfare recipients various financial incentives for entering the workforce.

As one participant stated: <<l'd say Emploi-Québec is very open. For a government

institution, ifs quite impressive the way that they've managed to adapt their services for

handicapped people, more than handicapped people would admit and more than , the

associations would admit» (program manager).

This being said, there were times in the past where participants felt that employees of

Emploi-Québec were prejudiced towards people with handicaps and in particular people

with mental health problems. This too seems to have evolved, due most likely to the

efforts by Emploi-Québec to create more awareness among its staff about the needs and

issues facing people with physical and mental handicaps. In fact, actors from OSIMEs

have been part of this process, providing training sessions to staff members to demystify

mental illness and bring them closer to the realities of clients with handicaps.

Though there does appear to be an overall coherence between organizational structure

and interpretive schemes, it appears as though some minor exceptions still exist. For

instance, a manager in Organization E mentioned that it was difficult to be as selective

during the intake process as was required by Emploi-Québec. According to this

participant, there are still gaps in services that occur because clients don't always fit neatly

into the clientele descriptions promoted by Emploi-Québec. These individuals, who often

want to work in regular employment, are either taken on as extra, uncompensated clients

by the organization or they are referred to other organizations where competitive

101

employment may not be the goal. In a similar vein, various criteria needed to access

some of Emploi-Québec's employment measures (e.g. salary subsidies) also seem to box

out certain clients who could potentially benefit from them. Finally, few specifie services

exist for certain clienteles, such as young adults with mental illness · and handicapped

individuals with histories of violence. In sum, while services and accessibility has

improved in recent years, coalition members still felt that more could be done to open up

services to a broader range of physically or mentally handicapped individuals whose goal it

is to find regular employment.

-- ~~--~~~~~~~- -~-~----~-

102

4.3. Interactions between coalitions and coherence between archetypes

Supported employment services are, to a certain extent, available to people with severe

mental illness in most regions of the province of Quebec. In most regions, supported

employment is offered only by OSIMEs, though in one large urban centre both IPS

programs and an OSIME co-exist. In a broad sense, the supported employment services

promoted by both coalitions share several similarities, such as an emphasis on helping

people with severe mental iHness obtain and maintain competitive employment and on

providing support to individuals both before and after they find a job.

ln the region where both forms of supported employment are provided, the question could

be asked as to whether there is an overlap in services. Yet, in reality, there are important

differences between the two types of supported employment services, differences that

have been recognized by members of the two coalitions themselves. The main

differences between the services relate to: 1) the domain and goals of the service

providers , 2) the clienteles served, 3) the types of jobs found for clients, 4) the importance

of clients' preferences, and 5) the intensity and length of support.

Briefly, members of the employment coalition , notably Emploi-Québec and the OSIMEs,

believe that services should focus on employment outcomes. In contrast, health sector

coalition actors make their clients' rehabilitation one of their main objectives and believe

that employment can help further this goal. While there is a degree of overlap in the

clienteles of OSIMEs and supported employment teams in the health sector, health sector

teams tend to work with clients whose needs for support are the greatest whereas

OSIMEs work with clients that are more functional and autonomous. Health sector teams

seem to ease many of their clients into employment, such that a majority work in part-time

positions. In contrast, OSIMEs tendto expect their clients to work hours approaching a

full-time position within the year that ~hey are admiUed. If they feel that clients will be

unable to do this, the clients are referred to another service or organization. Due to the

increased needs for support of their clients, employment specialists in health sector teams

will try to carry low case loads, working intensively with relatively few clients at a time.

Employment specialists that worked in Organizations 0 and E on the other hand had . case

loads that sometimes exceeded 100 clients. The support they provided was generally less

- - -~-~ - ------~

103

intensive than that provided by their counterparts in health sector teams, even during time

periods seen as critical, such as during the first 3 months of employment.

While both approaches seem to be relatively effective based on participants' reports , the

contrasting values and beliefs that underpin these two interventions have sometimes led to

tensions between actors from the two coalitions. For example, OSIMEs have at times

been criticized for the lack of intensive support they offer clients, whereas supported

employment teams have been perceived to foster dependency in cl ients on the

employment specialists. Yet, while both approaches seem to have their weaknesses, they

also have important strengths and they bath seem ta meet needs expressed by people

with severe mental illness.

As such, the fact that services have evolved differently in the health and employment

sectors may in many ways be beneficial, especially when both types of services are

available in a region, as people with severe mental illness have more choice and can

choose the service that best meets their needs. Indeed, it is likely that a percentage of

clients would be more suited entering an IPS program, whereas other clients may benefit

more from the approach favoured by OSIMEs. This has been recognized by the IPS

teams and the OSIME that share the sameterritory and consequently referrals between

supported employment teams has become more regular. However, such an arrangement

does not exist in most other regions of the province due to the paucity of health sector

supported employment programs. As a result, participants in the study have noted

important gaps in services for clients whose full integration into employment is likely to

occur over longer periods of time than what can usually be managed 'by OSIMEs: «But 1

would say that in mental health, there's still a gap. Sometimes, they are too distant from

the labour market, they don't fit in certai~ programs, they don't fit with us, they don't fit with

the [organization that develops employability] ... » (program manager). Clearly , greater

efforts are needed to ensure that ail clients have access to the vocational services that

respond to their needs and interests.

5. Discussion

Discussion of the results from the present study will be organized into two sections. A first

section presents a synthesis of the main findings and examines how these findings fit with

the current literature on the implementation of supported employment services. In a

second section, 1 will briefly examine how supported employment services in both sectors

could be improved and discuss several of the study's limitations with respect to

methodology and analytical approach.

5. 1. The implementation of supported employment in Quebec

The present study aimed to shed light ,on how the dynamics between key supported

employment stakeholders influenced the implementation of supported employment in the

province of Quebec. A second objective was to learn more about some of the factors that

have contributed to the observed differences between supported employment programs

implemented in the province. It was posited that the values, interests and ideologies of

stakeholders, as weil as the ir interactions with other actors and their dependence or

autonomy from pressures in their environment, would likely have an important influence on

the implementation and functioning of supported employment programs in the province.

The theory of coalitions was used to examine the relationships between key supported

employment stakeholders and the impact of these dynamics on supported employment

implementation. According to this theory, actors seek out collaborations with others with

whom they share important core values and concerns in an effort to aUain objectives and

gain acce.ss to benefits that they may not have otherwise obtained by working alone . Each

actor has its own set of assets that allows them to contribute to the coalition's objectives

and sometimes control decisions affecting the coalition . The alliances that are formed are

usually described as temporary but can remain intact for as long as it takes for the

coalition to achieve its desired outcomes or else until the members of the coalition believe

that they can no longer obtain a sufficient amount of benefits given the assets they bring to

the coalition (Lemieux, 1998).

Hinings and Greenwood's (Hinings & Greenwood, 1988) theory of archetypes was also

adopted in an effort to, on the one hand, characterize the organizational structures related

105

to supported employment programs and, on the other hand, describe the dominant values ,

ideas and beliefs that prevail among the key stakeholders and that underlie these

organizational structures. In the current study, a key concept is that of archetypal

coherence , which describes the extent to which the observed organizational structures are

coherent with the beliefs and values held by actors responsible for the del ivery of

supported employment services.

Use of these conceptual frameworks has allo~ed us to identify and describe two main

coalitions implicated in the delivery of supported employment services. The first coal ition

unites aètors with links to health institutions that have worked together to implement

supported employment programs consistent with the guiding principles of the ind ividual

placement and support (IPS) mode!. A second coalition brings together organizations

specializing in the integration and maintenance of people with handicaps (OSIMEs) and

Emploi-Quebec, the main public employment service provider under the Ministry of

Employment and Social Solidarity's authority.

Dynamics between coalition members appears to have had a critical influence on the

forms of supported employment implemented by each of the coalitions. The core of the

health sector coalition brings together actors linked to three supported employment teams

in the province. Two of these teams were implemented following the IPS model of

supported employment and the third team offered supported employment as a component

of an assertive community treatment program (PACT). Managers in rehabilitation

departments and psychiatric departments played important roles in the implementation of

these programs, as did researchers working in the fields of health, psych iatric and

rehabilitation services. Interestingly, researchers from the United States have had a

particular influence on these programs and it is likely that without their implication these

programs would have taken shape much differently. Specifically, the expertise and

experience of these actors has lent them great credibility and influence over decisions

related to supported employment implementation. As such, they have played , and

continue to play, an important role in the diffusion of supported employment in the province

and the standardization of supported employment services.

106

It is interesting to consider how these American researchers have been able to gain a

certain control over decisions about the vocational services provided by Ouebec health

sector ·actors. These latter actors value their autonomy and have a relatively large amount

of control with respect to decisions affecting their services. However, several factors seem

to have facilitated the American researchers playing an influential raie over supported

.employment program implementation. First, a growing number of health organizations are

seeking to deliver services that are based on the best available scientific evidence with

respect to effectiveness. This was certainly the case in the three health organizations in

this study. In fact, the implementation of evidence-based practices seems highly

appreciated not only by hospital management but also by researchers and service

providers. Such practices were perceived to enhance the credibility of the institutions that

put such services in place. That being said, much research has shown that evidence­

based practices are often difficult to implement (Gold, Glynn, & Mueser, 2006; Goldman et

aL, 2001; Waddell, 2001) and that deviations from the faithful implementation of service

models can result in poorer outcomes than what is sought (Becker, Smith , Tanzman ,

Drake, & Tremblay, 2001 ;Becker, Xie, McHugo, Halliday, & Martinez, 2006; G. R. Bond,

2007; Drake et aL, 2001). As such, Quebec actors reached out directly to the researchers

that founded the model to assist in the implementation process. These researchers had

important assets not available ta Ouebec actors, notably informational assets related ta

the theoretical and practical knowledge needed to implement supported employment and

help programs function effectively. Researchers from Quebec with knowledge of the

model also played an important role in early supported employment implementation

efforts, as did an IPS team in more recent efforts. Yet, the involvement of the American

researchers, whether it was direct involvement through training of new IPS teams or

indirectly through their publications or. helping experienced teams train others, has clearly

been a critical factor in the emergence of evidence-based supported employment in

Quebec.

It is also important to mention that the values and ideologies of these American

researchers also seem to be quite consistent with those of the Quebec actors. Both

groups of actors have strong convictions regarding clients' ability to work in competitive

employment and the normalizing value of working in integrated settings. Furthermore,

both place clients' preferences at the centre of their interventions and believe that services

------- ------------ --------- ~- ------ -

107

should be organized to support clients' rehabilitation, recovery and social integration.

Thus, the pa'rtnership between these actors made sense given the values and beliefs that

they share. Not surprisingly, many of the values and beliefs espoused by these actors are

embodied in the main vocational intervention they promote, i.e. the IPS model of

supported employment. Furthermore, scientific support for the model seemed to further

reinforce these actors' beliefs about the importance of organi~ing voeational services

faithfully to the supported employment model.

That being said, supported employment services implemented by Ouebec health coalition

actors did depart in some ways from the IPS mode/. For instance , in the case of both IPS

teams in the study, employment sp~cialists were not fully integrated within the mental

health teams in their regions, i.e. they were not part of multidisciplinary treatment and

rehabilitation teams working in the same physical locations. Instead , they worked in

centralized offices in the community and made regular visits to the various clinical teams

they had partnered with. According to Drake, this functional separation of clin ical and

vocational services «militates against meeting the complex and individualized needs of

mental health consumers» (Drake, Becker, Bond , & Mueser, 2003, p. 56). Yet, members

of the Ouebec IPS teams considered this lack of integration to be a practical answer to the

, realities of their context, in particular the challenge of having small IPS teams provide

supported employment to a large number of clinical teams. Lack of integration also

otfered benefits related to team coordination and mutual aid and was perceived to give

team members a certain freedom that they would not have had as members of a single

multidisciplinary team.

Contrastingly, full integration is a defining characteristic of the PACT team in the health

coalition and here employment specialists work side by side with psychiatrists , nurses ,

social workers and other health professionals . In this case, full integration was perceived

to have important advantages, especially with respect to building a shared appreciation of

the importance of rehabilitation and employment goals for clients. However, this

arrangement had its downside as weil, as employment specialists in this team were

sometimes forced to engaged in activities outside the realm of vocational rehabilitation,

such as when they were called on to help with illness exacerbations and other crises.

Thus , these employment specialists could not focus exclusively on the delivery of

108

supported employment and take time to intervene in the community like a normal IPS

agent would.

The challenges experienced by the PACT team with regards to their vocational services

are consistent with those identified by Bond with respect to the implementation of

supported employment in American assertive community treatment programs (Bond ,

2004). However, there are some differences as Bond bases his arguments on the 'way the

vocational services are structured in the Madison Program for Assertive Community

Treatment program. In this program, employment specialists are expected to divide the ir

time between employment-related activities and more clinical activities (Russert & Frey,

1995). This was not the case for the PACT team we studied, as e.mployment specialists

were hired to specifically focus on vocational rehabilitation and supported employment.

Involvement in other aspects of patient care was a product of the lack of personnel in the

team. PACT employment specialists also deviated occasionally from the supported

employment model by directing some clients to non-competitive work options. Th is

occurred both as a result of their own values and because of pressures in the ir

environment. Specifically, though they encouraged clients to seek competitive

employment, they also respected clients' preferences when competitive work was not their

goal. In addition , the limited employment opportunities in their region sometimes forced

employment specialists.to consider alternatives to competitive work.

Indeed, one of the main differences between Quebec health coalition actors and the

American researchers appears to relate to their beliefs about whether deviations from the

supported employment model are acceptable. Quebec health coalition actors felt that

some adaptations were acceptable and necessary under certain circumstances and

oftentimes beneficial as weil. In contrast, American researchers have emphasized .«the

importance of implementing the critical components of the practice rather than adapting

the model to local conditions» (Becker, Xie , McHugo, Halliday, & Martinez, 2006, p. 309).

These researchers have thus produced various toolkits and fidelity measures to help

regulate the implementation of supported employment in new contexts. However, hospital

administrators and programmanagers ultimately have the final authority to decide how to

organize their services and as such have sometimes been willing to adapt the model

according to their own beliefs and circumstances.

109

It is also worth noting that if researchers have attempted to play an important role in the

regulation of implementation of supported employment, it is also largely due to the fact that

no higher health authority has been concerned with ensuring the quality of these

programs. Funding for the supported employment teams in this study came from the

global budgets of their hospitals and they were financed to provide services, not achieve

specific vocational or health outcomes. Indeed, each of the teams generally had the

authority to decide whether they wanted to be faithful to the IPS model or not. The fact

that they were relatively faithful to the principles of the supported employment model

stemmed mostly from the consistency between their values and those underpinning the

model, as weil as their conviction that greater faithfulness to the model would lead to better

vocational outcomes. While researchers have contributed to, thi~ belief taking hold and

have applied a certain pressure on teams to adhere to the standards and norms of IPS,

they simply do not have the authority to impose these standards and norms on teams.

Meanwhile , authorities in the health sector hierarchy such ' as the Ministry of Health and

Social Services and the regional health authorities have not shown a tangible interest in

developing supported employment and regulating its implementation despite claims that

work integration is a top priority (Ministère de la, Santé et des Services Sociaux, 2005).

One reason for this may be related to the perception that these authorities have regarding

the activities that fall within their sectors' domain. More specifically, it appears that these

authorities feel that services related to the placement of individuals into competitive

employment fall outside the domain of actors in the health sector and instead fall under the

responsibility of actors in the employment sector. As a result, these health authorities

have not specifically devoted reso'urces to develop supported employment initiatives and

not shown much interest in establishing accountability mechanisms to monitor its

implementation.

That authorities in Quebec's health sector have not actively contributed to the

imp1ementation and effective functioning of supported employment teams is not a novel

finding but in fa ct consistent with the literature on supported employment programs

implemented in the United States. Several researchers in the US have called on their

government decision makers to play a greater leadership role in the implementation of

evidence-based practices such as supported employment and have urged them to ensure

110

that these initiatives have the financing and support they need to be successful (Bond et

aL, 2001; Cook, 2006; Drake & Bond, 2008). Surprisingly, the limited involvement of

health authorities in the implementation of supported employment in Quebec was not

identified by most participants in the health coalition as problematic, though several actors

from supported employment teams expressed concerns over the funding for their

programs. Indeed, results from the present study suggest that until health authorities

modify their views regarding the place of competitive work integration services in their

s'ecto,r, their role in the diffusion and regulation of supported employment in this province

will remain limited.

Interestingly, the situation in the employment sector differs significantly from that in the

health sector. Emploi-Québec, the main public employment service agency under the

Ministry of Employment and Social Solidarity's authority, and organizations specializing in

the integration and maintenance of employment of people with handicaps (OISMEs) have

established formai partnerships and have influenced each other's domains throughout

years of interactions and negotiations. The vision that they share and the recognition of

their mutual dependence have allowed the OSIMEs to grow and gradually increase in

effectiveness. Their partnership brings clear benefits to both sides and each side

possesses important assets that are exploited to help meet their shared objectives. For

example, OSIMEs' main assets are normative and informational in nature and relate

specifically to the cause that they believe in and the expertise that they have acquired

while attempting to further this cause. Emploi-Québec for its part possesses important

financial resources and provides access to the employment measures and programs used

by the OSIMEs. They also have informational assets in that they keep OSIMEs up to date

with changes to these programs and other employment or welfare policies. By working

together, these actors strive to meet the employment needs of large numbers of people

living with disabilities in ail administrative regions of the province. In doing so, they also

help individuals adopt normal citizen roles, reduce their risk of exclusion and poverty, allow

them to leave welfare and contribute to the province's economy and social solidarity.

Like in the health sector, the issue of control is a critical factor that has an important impact

on the supported employment services implemented by OSIMEs. However, unlike in the

health sector where actors with informational assets gain influence over decisions made

111

by service providers, the assets that allow Emploi-Québec to influence services provided

by OSIMEs are those of command, i.e. their ability to control the resources that OSIMEs

need to operate. In becoming a partner of Emploi-Québec and accepting their funding ,

these organizatiolis have had to adapt their services and align them to be consistent with

Emploi-Québec's interests. This has had an impact on the criteria used to determine

eligibility to receive supported employment services, the number of clients receiving

services, as weil as on the nature and intensity of support provided to clients. The

partnersh ip has also exposed OSIMEs to Emploi-Québec's accountability mechanisms,

which increase administrative responsibilities for employment specialists and limit their

capacity to provide services in the community. On the other hand, those accountabi lity

mecha-nisms also ensure that actors from OSIMEs remain faithful to their negotiated

objectives and responsibilities.

It is important to note that while Emploi-Québec has had an influence on the functioning of

OSIMEs, so too have OSIMEs had an influence on Emploi-Québec. One factor that has

likely facilitated this is the fact that OSIMEs have been providlng vocational services for

many years and are perceived as legitimate and important partners by Emploi-Québec.

Trust has been built over the years and there are many mechanisms (e.g. yearly

negotiations, forums, committees , etc.) that allow frequent communication between these

two actors to take place. OSIMEs have been able to effectively communicate to

employment authorities the needs of people with physical and mental disabilities and have

succeeded in convincing these authorities ta adjust programs and measures to better meet

these needs. Furthermore, certain actors from OSIMEs who possess a particular

charisma and expertise with specific clienteles (e.g. mental health clients) have also been

involved in training staff from Emploi-Québec and helping create grepter awareness of

issues facing people with disabilities. Indeed, their mutual respect has led these actors to

build over time an equitable and productive relationship.

While their relationships with authorities in the employment sector have been positive, key

differences in values and beliefs have sometimes led ta tensions with actors in the health

and community sectors. Notably, OSIMEs do not strive to be faithful to the IPS model of

supported employment and do not share as an overarching goal the rehabilitation and

recovery of their clients. As such, these organizations have at times been criticized on a

112

number of points, such as their favouring of more stable, independent clients over clients

with greater needs for support, and the Iimited intensive support they provide clients.

Yet, this author does not think that it would be ideal for these organizations to completely

abandon their current structure of services in favour of the IPS model of supported

employment. One of the main reasons for this view is that there seems to ' be a place for

both types of supported employment programs given the diversity of needs expressed by

people with severe mental illness and other disabilities. More specifically, OSIMEs have

put in place services that address the vocational needs of a broad range of c1ienteles and

have emphasized the movement of large numbers of clients into the workforce 15. While

their supported employment services may not be adapted for clients with significant

support needs, they do seem effective for a large percentage of service users. In adqition ,

efforts have been made to routinely improve services and the length of support offered

clients has increased in recent years . Indeed , an across-the-board transition towards IPS

could produce greater gaps in services than what already exists and make accessing

supported employment services challenging for an even larger number of individua ls with

physical or mental disabilities.

Instead , results from this study suggest that an ideal arrangement would be to have both

types of supported employment programs available to service users in ail regions of the

province. Clients with severe mental illness who display the most needs for support cou ld

be directed to programs adhering to the IPS model of supported employment, while clients

with less needs for support who are more independent could be assisted by employment

specialists in OSIMEs. Ensuring that clients have choices and can be directed to the

services most suitable for them should be a goal shared by ail stakeholders interested in

the socio-professional integration of people with s~vere mental illness.

15 A recent estimate placed these organizations' combined annual placements at approximately 3000 cl ients

(ROSEPH, 2008).

113

5.2. Recommendations and limitations

5:2.1. Recommendations

Ensuring access to effective, efficient employment services should be a priority for ail

actors interested in the integration of people with severe mental illness into the competitive

workforce. 8elow are three recommendations intended to further increase the

effectiveness of supported employment programs implemented in Ouebec and ensure that

ail individuals with mental health problems who desire to work in competitive employment

have the opportunity to do so.

1) Studying access to employment and tracking service user trajectories:

How many people with severe mental illness and mental health problems in general in

Ouebec are not 'working yet would like to find work in competitive employment? What

services do they use to reach this goal and in what order? How successful are these

services in helping them achieve this goal? How long does it take for them to achieve their

goal and what factors influence the time it takes for them to obtain competitive

employment?

ln this author's opinion, most decision makers would find it a challenge to answer these

questions definitively. One reason for this is that service users often use a variety

employment services in both the health and employment sectors. Indeed, both sectors

offer pre-employment and employment services and service users might use any mix of

services depending on their interests and the availability of services in their communities.

There is an important need to gather information about the vocational needs of service

users and the types of services they seek out in order to ensure that they have access to

the services that correspond to their preferences and goals. Furthermore, they should be

able to achieve these goals within a time period that is satisfactory to them. Importantly,

this means that service providers must be able to provide relevant data to the authorities in

their sector so that this information can be shared and combined with data from other

114

sectors to paint an accurate picture of the overall situation. lhis necessitates a greater

collaboration and communication between many actors in both the health and employment

sectors, as weil as stakeholders from the transportation and education sectors. A greater

understanding of service user trajectories and the challenges they face when trying to

access services and reach their goals will undoubtedly help service providers and decision

makers shape services to be more responsive to the needs of people with mental hea lth

problems and more in continuity with one another.

2) Monitoring quality in health sector supported employment programs:

Currently, it does not appear as though there are sufficient accountability mechanisms in

the health sector to ensure that supported employment programs are operating as

effectively as possi~le. Teams are not formally required to complete regular fidelity

assessments and there are no standards are enforced regarding the qualifications of

employment specialists. Furthermore, though teams track the vocational outcomes of their

clients, their funding is not tied to these outcomes. This lack of accountability on the part

of supported employment teams is a concern and may hinder their evolution towards

increasingly efficient and effective services. Teams, administrators and decision makers

should discuss new ways of monitoring and improving the quality of services provided by

these teams, ail the while taking into account their autonomy and not restricting their abil ity

to centre their services around clients' goals and offer intensive, time-unlimited support.

3) Increasing access to supported emp!oyment services in ail regions:

ln most regions of the province OSIMEs are the only service available to help people with

severe mental illness integrate into the regular workforce. However, the criteria adopted

by Emploi-Quebec and its desire to work with «work ready» clients prevent some clients

from accessing these services, despite their goal to obtain competitive employment.

Instead of referring these clients to services that are inconsistent with their preferences ,

programs like IPS should be present in these regionsto ensure that these clients receive .

services consistent with their expressed interests. Furthermore, certain policies should be

adjusted to allow a broader range of clients to have access to OSIMEs services and

115

Emploi-Québec's employment measures such as its CITs. Finally, access could be

increased by allowing OSIMEs to provide some clients with longer-term support, such as

through financial incentives to integrate clients who have longer-term horizons with respect .

to employment. Such changes would require clear and concerted efforts on behalf of

authorities in both health and employment sectors to better meet the vocational needs of

people with severe mental illness.

5.2.2. Limitations

Researchers adopting qualitative approaches to the study of social phenomena do so with

the understanding that these methods possess certain advantages and disadvantages. In

the context of this study, the aim was to gain a greater understanding of a complex issue

that had received little attention in the scientific literature, i.e. the organizational dynamics

influencing the implementation of supported employment in the province of Quebec. To

gain this understanding, we d~cided to gather the viewpoints of a variety of supported

employment stakeholders in order to understand how they and their interactions with

others influenced the supported employment services provided to people with severe

mental illness. The flexibility associated with a qualitative approach allowed us to

continually adapt and refine our questions and deepen our understanding of the dynamics

related to supported employment programs.

That being said, this study has limits similar to those observed in other qualitative studies.

For instance, this study included the views of a relatively small number of stakeholders ;

especially when considering the great number of actors implicated in the socio­

professional integration of people with mental health problems ail across the province.

Indeed, our research team had neither the time nor the resources to meet with

representatives of each group or organization that plays a role in this issue. Our

interviews were restricted to actors from three main regions and as such it is difficult know

to what extent our findings are representative of the dynamics in other regions of the

province. Furthermore, we interviewed a small number of participants in each organization

and indeed only one participant for Organizations 0 and E. As a result, the reliability of

information acquired for each organization could be questioned.

116

We tried to address issues of representativeness and reliability by having as diverse a

sample of participants as possible and by favouring participants who had extensive

experience in the fields of supported employment, mental health or both topics. In

addition, several participants were able to discuss the services provided in organizations

other than their own, due largely to the familiarity with these services that they had gained

through their partnerships with them. This was the case in particular for Organization D,

which was located in the same large urban centre as two other supported employment

programs. Also, rehabilitation counsellors from Organization C that were not part of a

supported employment program but who collaborated closely with employment specialists

from Organization D shared their views of its supported employment program. Interviews

with participants from Organizations D and E were also substantially longer and more

detailed than those with other participants and these parUcipants were recontacted severa l

times in an effort to confirm the reliability of data on their services.

It is important to mention that this study used a nonprobability sampling method, snowball

sampling , as the method to identify and recruit participants. This sampling method

seemed appropriate given the exploratory nature of the study and the difficulty that was

inherent to pre-identifying actors with sufficient knowledge of supported employment

implementation and functioning. Of note also is that this study did not incorporate the

views of service users or employers on supported employment program implementation ,

though it may have been interesting to do so. While program managers in this study did

not seem to make decisions in direct consultation with service users, they did take steps to

gather information about their needs and there was communication between these actors

to ensure that services were consistent with these needs. With respect to employers , little

is known about their specifie influence on supported employment program 'implementation

and functioning. Future investigations of such topics are clearly warranted.

Inherent to ail qualitative research i~ the risk of researcher bias, which can influence

research design, data collection and analysis, and interpretation of results. We have tried

to minimize this risk through several strategies. First, we adopted a conceptual approach

that has been used often in the organizational literature. Second, we used an interview

guide that retained the same four themes for each of the participants interviewed. Third,

efforts were made to ensure consistency in the coding process. Specifically, more than a

117

quarter of the interviews were coded by two members of the research team allowing

coding disparities to be discussed and a coding guide established and used for the

remainder of the interviews. Finally, analyses incorporated several sources of information ,

including a large number of organizational documents, in an effort to triangulate our

. findings.

6. Conclusion

The present study suggests that stakeholder dynamics have had , and continue to have, an

important influence on the implementation of supported employment services in the

province of Quebec. These services have largely developed from the ground up and

closely reflect the values and beliefs of those involved in their implementation. However,

actors also face constraints that impact their ability to organize their services un iquely

according to their views.

This is the first study to thoroughly examine this issue in a Canadian context and one of

the few studies overall that specifically examines the organizational dynamics that

influence supported employment programs. Indeed, this study is particularly timely given

the pressing need for innovation in relation to the way services are usually organized and

funded (Drake & Bond , 2008). Clearly, more research, both quantitative and qualitative in

nature, will be needed to ensure that service providers and decision makers have the

information they need to organize their services in the most effective way possible whi le

remaining centred on the needs and interests of people with mental health problems.

7. References

Anthony, W. (1993). Recovery from mental illness: The guiding vision of mental health service system in the 1990s. Psychiatr Rehabilitation Journal, 16(4), 11-21.

Anthony, W., & Blanch , A. (1987). Supported employment for persons who are psychiatrically disabled: an historical and conceptual . perspective. Psychosocial Rehabilitation Journal, 11(2).

Becker, D. , Whitley, R., Bailey, E. L., & Drake, R. E. (2007). Long-Term Employment Trajectories Among Participants With Severe Mental IIlness in Supported Employment. Psychiatric Services, 58(7) , 922-928.

Becker, D. R., Lynde, D., & Swanson 1 S. J. (2008). Strategies for state-wide emplementation of supported employment: the Johnson & Johnson - Dartmouth Community Mental Health Program. Psychiatric Rehabilitation Journal, 31(4), 296-299.

Becker, D. R., Smith, J., Tanzman, B., Drake, R. E., & Tremblay, T. (2001). Fidelity of Supported Employment Programs and Employment Outcomes. Psychiatric Services, .52(6), 834-836.

Becker, D. R., Xie, H., McHugo, G. J., Halliday, J., & Martinez, R. A. (2006). What Predicts Supported Employment Program Outcomes? Community Ment Health J, 42(3), 303-313 .

Bond, G. R. (1992). Vocational rehabilitation. In R. P. Liberman (Ed.), Handbook of psychiatric rehabilitation (pp. 244-275). New-York: Macmillan.

Bond, G. R. (1998). Principles of the individual placement and support model. Psychiatric Rehabilitation Journal, 22(1), 11-23.

Bond, G. R. (2004). Supported employment: evidence for an evidence-based practice . Psychiatr Rehabil J, 27(4), 345-359.

Bond, G. R. (2007). Commentary: Modest implementation efforts, modest fidelity , and modest outcomes. Psychiatric Services, 58(3),334 .

Bond, G. R. , Becker, D. , Drake, R. E., & Vogler, K. M. (1997). A fidelity scale for the individual placement and support model of supported employment. Rehabilitation Counseling Bulletin(40), 265-284.

Bond, G. R., Becker, D. R., Drake, R. E., Rapp, C. A., Meisler, N., Lehman, A. F. , et al. (2001). Implementing supported employment as an evidence-based practice. Psychiatr Serv, 52(3), 313-322. .

Bond, G. R., Drake, R. E., Becker, D., & Mueser, K. T. (1999). Effectiveness of Psychiatric Rehabilitation Approaches for Employment of People with Severe Mental IIlness. Journal of Oisability Poliey Studies, 1 O( 1), 18-52.

Bond , G. R., McHugo, G. J., Becker, D. R., Rapp, C. A., & Whitley, R. (2008). Fidelity of supported employment: lessons learned from the National Evidence-Based Practice Project. Psychiatrie Rehabilitation Journal, 31(4), 300-305.

120

Bond, G. R. , Picone, J., Mauer, B., Fishbein, S., & Stout, R. (2000). The quality of supported employment implementation scale. Journal of Vocational Rehabilitation, 14,201-212.

Bond, G. R., Salyers, M. P. , Rollins, A. L., Rapp, C. A., & Zipple, A. M. (2004). How evidence-based practices contribute to community integration. Community Ment Health J, 40(6), 569-588.

Boudreau, F. (1984). De l'asile à la santé mentale. Montréal: Éditions St-Martin.

Boyce, M., Secker, J., Floyd, M. , Schneider, J. , & Siade, J. (2008). Factors influencing the delivery of evidence-based supported · employment in England. Psychiatrie Rehabilitation Journal, 31(4), 360-366.

Burns, T., Catty, J ., Becker, T., Drake , R. E., Fioritti, A., Knapp, M., et al. (2007). The effectivéness of supported employment for people with severe menta l illness: a randomised controlled trial. Lancet, 370, 1146-1152.

Capponi, P. (2003). Beyond the crazy house: Changing the future of madness. Toronto: Penguin Books.

Catty, J. , Lissouba, P., White , S. , Becker, T., Drake, R. E. , Fioritti, A. , et al. (2008). Predictors of employment for people with 'severe mental illness: results of an international six-centre randomised controlled tria l British Journal of Psychiatry, 192, 224-231.

Charbonneau , C. (2002). Développer l'intégration au travail en santé mentale, une longue marche à travers des obstacles sociopolitiques. Santé mentale au Québec, 27(1 ), 158-176.

Cook, J. A. (2006). Employment Barriers for Persons With Psychiatric Disabilities: Update of a Report for the President's Commission. Psychiatrie Services, 57(10), 1391 -1405.

Cook, J. A., Leff, H. S. , Blyler, C. R., Gold, P. B., Goldberg', R. W., Mueser, K. T. , et al. (2005). Results of a Multisite Randomized Trial of Supported Employment Interventions for Individuals With Severe Mental IIlness. Archives of General Psychiatry, 62, 505-512.

Cook, J. A., Lehman, A. F., Drake, R., McFarlane, W. R., Gold, P. B., Leff, H. S. , et al. (2005). Integration of Psychiatric and Vocational Services: A Multisite Randomized , Controlled Trial of Supported Employment. American J Psychiatry, 162, 1948-1956.

Cook, J. A., & Razzano, L. (1992). Natural Vocational Supports for Persons with Severe Mental IIlness: Thresholds Supported Competitive Employment Program. New Directions for Mental Health Services, 56, 23-41 .

Corbière , M. (Submitted). A Pan-Canadian evaluation of supported employment programs dedicated to people with severe mental disorders.

Corbière , M., Bond, G. R., Goldner, E. M., & Ptasinki, T. (2005). The fidelity of supported employment implementation in Canada and the United States. Psychiatrie Services, 56, 1444-1447.

Corbière , M., & Goldner, E. M. (2003). Work integration of people with severe mental illness: Determining the best environmental and individual ingredients for success: Canadian Psychiatrie Research Foundation.

~-- ---------

121

Crowther, R. E., Marshall, M., Bond, G. R., & Huxley, P. (2001). Helping people with severe mental illness to obtain work: systematic review. British Medical Journal, 322, 204-208.

Cunningham, K., Wolbert, R. , & Brockmeier, M. B. (2000). Moving beyond the illness: factors contributing to gaining and maintaining employment. . American Journal of Community Psychology, 28(4),481-494.

Dartmouth Supported Employment Center. Answers to questions about supported employment. Retrieved January 13, 2009 , from http://dms.dartmouth.edu/dsec/ask/answers.php

Davidson , L. (2003). Living outside mental illness: qualitative studies of recovery in schizophrenia. New York: New York University Press.

Davis, S. (2006). Community mental health in canada: theory, policy and practice. Vancouver: UBC Press.

Deegan, P. (1988). Recovery: the lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11-19.

Deegan, P. (1995). Recovery as a journal of the heart. Retrieved July 13th, 2008, from http://64.233.169.1 04/search?g=cache:ZI3Ny7GvMFMJ :www.aterhamtning.se/

o Recovery%2520As%2520a%2520Journey%2520of%2520the%2520heart.pdf+p at+deegan+we+are+more+than+brains&hl=en&ct=clnk&cd=4&gI=ca

Dorvil, H. (1987). Les caractéristiques du syndrome de la porte tournante à l'Ho D pita l Louis-H. Lafontaine. Santé mentale au Québec, 12(1),79-89.

Dorvil, H., Guttman, H. A., Ricard, N., & Villeneuve, A. (1997). Défis de la reconfiguration des services de santé mentale: Le comité de la santé mentale du Québec. Gouvernement du Québec, Minisère de la santé et des services sociaux. 264 pages.

Drake, R. E. (1998). A brief history of the individual placement and support model. Psychiatric Rehabilitation Journal, 22, 3-7.

Drake, R. E., Becker, D. R., Bond, G. R., & Mueser, K. T. (2003). A process analysis of integrated and non-integrated approaches to supported employment. Journal of Vocational Rehabilitation, 18, 51-58.

Drake, R. E., Becker, D. R., Goldman, H. H., & Martinez, R. A. (2006). oThe Johnson & Johnson - Dartmouth Community Mental Health Program: disseminating evidence­based practice . Psychiatric Services, 57(3), 302-304.

Drake, R. E., & Bond, G.R. (2008). The future of supported employment for people with severe mental illness. Psychiatr Rehabil J, 31(4),367-376.

Drake, R. E. , Bond, G. R., & Rapp, C. A. (2006). Explaining the variance within supported employment programs: Comment on "What predicts supported employment outcomes?". Community Ment Health Journal, 42(3), 315-318.

Drake, R. E., Goldman, H. H. , Leff, H. S., Lehman, A. F., Dixon, L., Mueser, K. T., et al. (2001). Implementing Evidence-Based Practices in Routine Mental Health Service Settings. Psychiatric Services, 52(2), 179-182.

Eklund, M. H. L., & Bejerholm, U. (2001). Relationships between satisfaction with occupational factors and health related variables in schizophrenia outpatients. Social Psychiatry and Psychiatric Epidemiology, 36(79-85).

122

Evans, L. J., & Bond, G. R. (2008). Expert Ratings on the Critical Ingredients of Supported Employment for People with Severe Mentalillness. Psychiatr Rehabil J, 31(4), 318-331.

Evans, R. G., Barer, M. L., & Marmor, T. R. (1994). Why are some people healthy and others not: the determinants of health: Aldine de Gruyter.

Fleury, M.-J., & Grenier, G. (2004). Historique et enjeux du système de santé mentale québécois. Ruptures, revue transdisciplinaire en santé, 10(1), 21-38.

Fountain House. (2008). Retrieved May 9, 2008, from http://www.fountainhouse.org/

Fuller, T. R., Oka, M., Otsuka, K., Yokoyama, N., Liberman, R. P., & Niwa, S. 1. (2000). A hybrid supported employment program for persons with schizophrenia in Japan. Psychiatr Serv, 51(7), 864-866.

Gagnon, M.-J., Pilon, W., & Wallot, H. (1981). Le travail et la réinsertion sociale en . psychiatrie. Santé mentale au Québec, 6(1),30-44.

Gamson, W. (1961). A theory of coalition formation. American Sociological Re vie w, 26, 373-382.

Gold, P. B., Glynn, S. M., & Mueser, K. T. (2006). Challenges to implementing and sustaining comprehensive mental health services programs. Evaluation and the Health Professions, 29(2), 195-218.

Goldman , H. H., Gangu, V., Drake, R. E., Gorman, P., Hogan, M., Hyde, P. S. , et al. (2001). Policy Implications for Implementing Evidence-Based Practices. Psychiatric Services, 52( 12), 1591-1597.

Goldner, E. M. (2002). Sharing the learning: The health transition fund. Retrieved March 3, 2008. from http://www.hc-sc.gc.ca/hcs-sss/ehealth-esantelinfostructure/finance/htf-fass/pubs-eng.php.

Gowdy, E. A., Carlson, L. S., & Rapp, C. A. (2004). Organizational factors differentiating high performing from low performing supported employment programs. Psychiatric Rehabilitation Journal, 28(2), 150-156.

Gray, B. (1985). Conditions Facilitating Interorganizational Collaboration. Human Relations, 38, 911-936.

Hinings, C. R., & Greenwood, R. (1988). Organizational design types, tracks and the dynamics of strategie change. Organization Studies, 9(3), 293-316.

House, R. J. (2004). Culture, Leadership, and Organizations: The GLOBE Study of 62 Societies. Thousand Oaks: SAGE Publications.

International Center for Clubhouse Development. (2008a). Retrieved May 12, 2008, from http://www.iccd.org/default.aspx

International Center for Clubhouse Development. (2008b). What is a clubhouse? Retrieved July 9, 2008, from http://www.iccd.org/article.asp?articleID=3

Killackey, E., & Waghorn, G. (2008). The challenge of integrating employment services with public mental health services in Australia: progress at the first demonstration site. Psychiatrie Rehabilitation Journal, 32(1), 63-66.

Kirsh, B. , Krupa, T., Cockburn, L., & Bickenbach, J. (2002). The social construction of work integration in Canada. Toronto: Social Sciences and Humanities ~esearch

Council.

123

Knowles, H. P., & Saxberg, B. O. (1971). Personality and Leadership Behavior. Reading: Addison-Wesley.

L'Office des personnes handicapées du Québec. (1997). L'intégration au travail des personnes handicapées: objectifs et orientations.

Latimer, E. (2001). Economie impacts of supported employment for persons with severe mental illness. Canadian Journal of Psychiatry, 46, 496-504.

Latimer, E. (2005). Organizational implications of promoting effective evidence-based interventions for people with severe mental illness. Mental Health Reform for the 21 st Century, 31 Suppl. (s47 -s52).

Latimer, E. , & Lecomte, T. (2002). Le soutien à l'emploi de type « IPS » pour les personnes souffrant de troubles mentaux graves : une voie d'avenir pour le Québec? Santé mentale au Québec, 27(1), 241-267.

Latimer, E., Lecomte, T., Becker, D. , Drake, R. , Duclos , 1. , Piat, M. , et al. (2006). Generalisability of the Individual Placement and Support model of supported employmertt: Results of a Canadian randomized controlled trial. British Journal of Psychiatry, 189, 65-73.

Leclerc, C. , Bourassa, B., & Legros, J. (2008). Cadre de référence: services spélialisés d'intégration et de maintien en emploi. Centre de recherche et d'intervention sur l'éducation et la vie au travail (CRIEVAT).

Lecomte, Y. (1986). Le système de soutien communautaire: hypothèse pour une réforme des services en santé mentale. Santé mentale au Québec, 11(1),5-18.

Lemieux, V. (1998). Les coalitions: liens, transactions et controles. Paris: Presses Universitaires de France.

MacDonald-Wilson, K. L., Rogers, E. S., Massaro, J. M., Lyass , A., & Crean, T. (2002). An Investigation of Reasonable Workplace Accommodations for People with Psychiatric Disabilities : Quantitative Findings from a Multi-Site Study. Community Ment Health J, 38( 1), 35-50.

Marrone, J. (1993). Creating positive vocational outcomes for people with severe menta l illness. Psychosocial Rehabilitation Journal, 17(2), 43-62.

Marshall , T., Rapp, C. A., Becker, D. R., & Bond , G. R. (2008). Key factors for implementing supported employment. Psychiatrie Services, 59(8), 886-892.

Martin de Holand, P., & Phillips, N. (2002). Managing in transition: a case study of institutional maangement and organization chance. Journal of Management Inquiry, 11(1),68-83.

Marwaha, S., & Johnson, S. (2004). Schizophrenia and employment - a review. Social Psychiatry and Psychiatrie Epidemiology, 39(5), 337-349.

McQuilken, M., Zahnisher, J. H., Novak, J., & aL, e. (2003). The work project survey: . consumer's perspectives on work. Journal of Vocational Rehabilitation, 18, 59-68.

Mellen , V., & Danley, K. (1987). Special issue: Supported employment for people with severe disabilities. Journal of Applied Rehabilitation Counseling, 9(2), 1-102.

Mercier, C. , Provost, G., Denis, G., & Vincelette, F. (1999). Le développement de l'employabilité et l'intégration au travail pour les personnes ayant des problèmes de

124

santé mentale. Rapport final de la recherche-action «Impact Travail». Verdun : Centre de recherche Douglas.

Ministère de la Santé et des Services Sociaux. (1962). Rapport de la comission d'étude des hôpitaux psychiatriques.

Ministère de la Santé et des Services Sociaux. (1998). Plan d'action pour la transformation des services de santé mentale.

Ministère de la Santé et des Services Sociaux. (2005). Plan d'action en ' santé mentale 2005-2010.

Mizrahi, T., & Rosenthal, B. B. (2001). Complexities of Coalition Building: Leaders' Successes , Strategies, Struggles, and Solutions. Social Work, 46(1), 63-78.

Moran, J. E., & Wright, D. (2006). Mental health and Canadian society: historical perspectives. Montreal: McGili University Press.

Morin , E. M. (1996). L'efficacité organisationnelle et le sens du travail, dans T.C. Pauchant et coll. La quête du sens. Gérer nos organisations pour la santé des personnes, de nos sociétés et de la nature. Paris: Éditions de l'organisation, Collection Manpower.

Mueser, K. T., Salyers, M. P. , & Mueser, P. (2001). A prospective analysis of work in schizophrenia. Schizophrenia Bulletin, 27,281-296.

Mueser, K. \.T. , Torrey, W. C., Lynde, D., Singer, P., & Drake, R. E. (2003). Implementing Evidence-Based Practices for People with Severe Mental Illnes. Behav Modif, 27(3), 387-411.

Oldman, J. , Thomson, L., Calsaferri, K., Luke, A., & Bond, G. R. (2005). A Case Report of the Conversion 'of Sheltered. Employment to Evidence- Based Supported Employment in Canada. Psychiatrie Services, 56(11), 1436-1440.

Pagé, J.-C. (1961). Les fous crient au secours. Témoignage d'un ex-patient de Saint­Jean-de-Dieu . Montréal: Les Éditions du Jour.

Patton, M. Q. (1990). Qualitative Evaluation and Research Methods (2nd ed.). Newbury Park, CA: Sage Publications.

Rao, H., Morrill, C., & Zald , M. N. (2000). Power plays: How social movements and collective action create new organizational forms. Research in Organizational Behavior, 22, 239-282.

Reker, .T., & Eikelmann, B. (1999). Predictors of success in supported employment programs: results of a prospective study. Psychiatrische Praxis, 26(5),218-223.

Rheaume, G. (2006). Insane asylum inmate's labour in Ontario, 1841-1900. Montreal: McGili University Press.

Rinaldi , M., McNeil, K., Firn, M., LKoletsi , M., Perkins, R., & Singh, S. P. (2004). What are the benefits of evidence-based supported employment for patients with first­episode psychosis? Psychiatrie Bulletin, 28(281-284).

Rogan , P. , Novak, J., Mank, D., & Martin, R. (2002). From values to practice: state level implementation of supported employment. Journal of Vocational Rehabilitation, 17(1),47-57.

ROSEPH. (2008). Communiqué: Une alliance plus forte que jamais ... Pour l'égalité en emploi! Retrieved July - 6, 2008, from http://www.google.ca/search?hl=en&g=roseph&btnG=Search&meta=

125

Rousseau, C. (1993). Community Empowerment: The Alternative Resources Movement in Quebec Community Ment Health J, 29(6), 535-546.

Russert, M. G., & Frey, J. L. (1995). The PACT vocational model: A step into the future. Psychosocial Rehabilitation Journal, 14(4), 7-18.

Saloviita, L., & Pirttimaa, R. (2000). The arrivai of supported employment in Finland. Int J Rehabil Res, 23(3), 145-147.

Santé Canada. (2002). Rapport sur les maladies mentales au Canada.

Spaniol, L. , Wewiorski, N. J., Gagne, C., & Anthony, W. A. (2002). The process of recovery from schizophrenia. International Review of Psychiatry, 14, 327-336.

Stuart, H. (2006). Mental illness and employment discrimination. Current Opinion in Psychiatry, 19(522-526).

Sturm, R. , Gresenz, C. R., Pacula , R. L., & Wells , K. B. (1999). Datapoints: labor force participation by persons with mental illness. Psychiatrie Services, 50( 11), 1407.

The Standing Senate Committee on Social Affairs Science and Technology. (2004). Mental health, mental iIIness and addiction: Overview of policies and programs' in Canada.

The Standing Senate Committee on Social Affairs Science and Technology. (2006). Out of the shadows at last: Transforming Mental Health, Mental IIlness and Addiction Services in Canada.

Thomson, L. , & Oldman, J. (2003). Working towards wellness- An evaluation report from a two-year Supported Employment Redesign Project. British Columbia: Canadian Mental Health Association . .

Thresholds. (2008). Retrieved March 9,2008, from http://www.thresholds.org/

Tolbert, P. S., & Zucker, L. (1996). The institutionnalization of institutional theory. In Cleggs, Hardy & Nord (Eds.), Handbook of Organization studies (pp. 175-199). London : Sage.

Trainor, J. , Pomeroy, E., & Pape, B. (1993). A new framework for support for people with serious mental health problems. Canadian Mental Health Association. Toronto.

Tremblay, T., Smith, J., Xie, H., & Drake, R. E. (2006). Effect of Benefits Counseling Services on Employment Outcomes for People With Psychiatric Disabilities. Psychiatrie Services, 57(6),816-821.

Twamley, E. W., Jeste, D. V., & Lehman, A. F. (2003). Vocational rehabilitation in schizophrenia and other psychotic disorders: a literature review and meta-analysis of randomized controlled trials. The Journal of Nervous and Mental Disease, 191(8),515-523.

van Erp, N. H. J., Giesen, F. B. M., van Weeghel, J., Kroon, H., Michon, H. W. C., Becker, D., et al. (2007). A Multisite Study of Implementing Supported Employment in the Netherlands. Psychiatrie Services, 58(11), 1421-1426.

Vézina , M., Cousineau, M., Mergler, D., Vinet, A., & Laurendeau, M.-C. (1992). Pour donner une sens au travail. Bilans et orientations du Québec en santé mentale et travail.: Le comité de la santé mentale du Québec.

Waddell, C. (2001). So much research evidence, so little dissemination and uptake: mixing the useful with the pleasing. Evid. Based Mental Health, 4, 3-5.

126

Wehman, P., & Moon, M. S. (1988). Voeational rehabilitation and supported employment. Baltimore: Paul Brookes.

White, D. , & Mercier, C. (1989). Ressources alternatives et structures intermédiaires dans le contexte québécois. Santé mentale au Québec, 14( 1), 69-80.

Wong, K. K., Chiu, R., Tang, B., Mak, D., Liu, J., & Chiu, S. N. (20·08). A Randomized Controlled Trial of a Supported Employment Program for Persons With Long-Term Mental Illness in Hong Kong ~ Psychiatrie Services, 59(1), 84-90.

ANNEX 1

Figure 2 - Health sector coalition

Figure 3 - Employment sector coalition

Figure 2. Health sector coalition

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.. ' .. .. . .... ",', / " /,," l ' ..............

........ -:-:.-:--.:::, \ ",,,,'" - -Il -- - - - -- --........ .....- --General hospital ..... ~.~,.......... ...;; ........... / '\ CSSS

_ ....

.: - - - - - - - - - - ...... ' '" '" '" '" " / 1) ... '" 1

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" '

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\

" .........

l '

_--- : CLE '1 ... .... \

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-----------7~---- ",'" " .. \,.... ... .. ,,1

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"..,..---- ...... , '" , " , " , l ,

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,/ Community \ \ organizations :

" ........... ').... -" ..... ; 1 1 .

"'),--......... ",,,," : "",'" .... ,

( Social \1 " enterprises / , " , / , '"

.......... _--- .",

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-.,. .... '" " CTA

, '"

, ..... ...

, , 1

1

"

\ 1 , \ , ,

" .... " ...","

1 1

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/" ........ _-:~_.:::.~-_ ....... "

( DE // ) Emploi-Qüébec " ..... ..' ." , : " ...... : /

...._- (~ ... ~ .. . " .

, , 1

1 1

Legend Core members

Ministry of Employment } and Social Solidarity ..... /

Close collaborators - - - -- .....

Peripheral actors .................

#*-- --- -.... Figure 3. Employment sector coalition

.. .. .

/ / , \ \

"

... .... " .... " ' " ' / \

( Employers " , 1 \ /

, 1 , " ~~-~~---~~ ~/

"",,"" ............. ...... ..... , ... ,..."".-"

1 ---~---- ------l ,....... ....

"'" / \ 1" "

t '"" CPMT /\ \

------- ..... ...... ..... .

Federal

.... .... ",.

(', .. .... ,' Sphère-Québec '~ ' .... ~L ....-/" government

.~/ ..

\ ""' " :" CAMO 1 Ministry of Employment \' .... ""'\ _.,..---------/~~~_ /1

and Social Solidarity ................... -f-------- ........ ... " ":-: ...................... ""

" "

........ -OPHQ

-_ ....

.... , , , 1

1

...... ,,"

", : -----..;;;. " .... " .... ,, ;' , ,, : , 1 : ,

l , l ,

/ /

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1

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" , , l , , 1 ........ \

Emploi-Québec

/ ........ , 1 ........ , .... ---.... 1"

, .... "' .... " , 1 ............

: CLE 1 /·--- _____ ~------r- .... \ 1/ ': DE , Il \

\ /1 CTA l " ", "I" \ " " .....

' ..... _--_ ............ / ', // ..... , /

' ..... _--*""

Associations

,.",.,; /,," .".,.,.,. .... ------- ....

Ministry of Health \

..... : ... ,::. . ... ::.,.:

CSSS

...... -----,,"';'-'~ ' ~ '''''<'' ' l ' 1 \

, ,' Rehabilitation '" 1 1 \ . Centres ,

\ 1 , 1

, 1

, " ....., ...... _-----",,/

---------- ........... ..... ....

", , \ 1"::""'" .............. " Psychiatrie and

/--:"/ ___ Psychiatry \, general hospitals

\ \ 1 1 ,

Legend Core members ,/ " ""....... - ..... " Rehabilitation \ , / , 1

1 1 1 SE \ , 1

1 1

/

Close collaborators - - - --Peripheral actors .................

~ \: 1 ;'

" '\ teams ;' / , " 1 1 " ,~ .... _--_ .... /" ",,"

' ...... '..... ,"" .......... ..... .......,.,."

1 1

"

------////

-----------

ANNEX 2

Table 3 - Summary of health coalition characteristics

Table 3. Summary of health coalition characteristics

Coalitions

Transactions - assets (core membersJ

SE teams: Expertise in mental health, knowledge of clientele. Knowledge of employment sector, welfare laws, relationships with employers. Recovery approach to the delivery of services. Expertise in. supported employment, practical experience with model. Desire to support the recovery of people with severe mental illness through their integration into the workforce .

Rehabilitation/psychiatrie departments: Authority over decisions concerning the structure of rehabilitation/psychiatrie services. Ability to manage resources of supported employment teams. Desire to help people with severe mental illness integrate into the community.

. QC Researchers: Knowledge of evidence-based practices and theoretical aspects of supported employment model. Relationships with American researchers possessing expertise in supported employment.

US Researchers: Knowledge of practical and theoretical aspects of supported employment implementation and functioning . Credibility due to expertise in vocational rehabilitation field. Desire to help people with severe mental illness integrate into the community, improve the effectiveness of vocational services .

Links

Transactions - benefits (core membersJ

SE teams: Hospitals provide teams with access to secure source of funding. Easy access to new clients and clinical information through contacts with clinical teams.

Researchers provide teams with assistance through training, information about SE program standards and guidance with respect to how to implement and operate the program.

Rehabilitation/psychiatrie departments: Possibility of offering people with severe mental illness services that are more aligned to their needs and desires and that facilitate their integration into the community. Offer services that are coherent with hospitals' values of best practices and services in the community. Credibility of offering services recognized as best practices .

QC + US Researchers: Ability to generate knowledge about generalizability of supported employment model in Canadian context. Carry out research projects tied to supported employment program and share knowledge with scientific community (e .g. presentations, publications, etc.). Possibility of influencing decisions regarding the organization of services. Standardization and regulation of supported employment implementation.

Coalition members formally linked to health institutions. Formai links between SE teams and managers in rehabilitation or psychiatrie departments. Links between other coalition members mostly informai , though formai agreements have been reached, for example when researchers provided training for IPS teams. Most partnerships with other actors are informai and occur with locallevel actors. Closeness of collaborations depends IClrgelYOn~oherence with coa li tion 's values and ideologies . For instance, relationships with professionals from clinical

teams varied depending on coherence of philosophies regarding relevance of supported employment for patients. Productive partnerships established with actors from the employment and community sectors at local levels. Participate in several issue tables (e.g. OPHQ, mental health and work committees, etc.). Limited interactions with health authorities at regional and provinciallevels. Difference in vision regarding the place of supported employment in the health sector, which has limited the role of health authorities in the implementation of supported employment in the province.

ContraIs

Important influence of American researchers on the implementation of supported employment services in the health sector. American researchers advocate strongly for fidelity to the supported employment model and exert influence during training opportunities, through contact during implementation process and by the utilization of fidelity scales. They set the standards for supported employment and encourage teams to adopt the practices that they deem acceptable given the model's principles and the scientific evidence. Over time, researchers in Quebec and SE teams themselves would also become advocates for the model when new supported employment programs were implemented in the province.

The majority of clients are referred to the program by clinicians. These clinicians exert control over the recruitment process and can decide not to refer if they judge that pursuing employment could negatively impact the health of their patients.

Ministry of health distributes resources to the health system and has prioritized the delivery of primary mental health care services, limiting funds for second line rehabilitation services like IPS and PACT.

Organizational structure

The structure of roles and responsibilities

Ministry of Health and Social Services: Define health and social policies, allocate resol:lrces to regions, fund training and research activities, evaluate the performance of health system.

Regional health agencies: Develop regional priorities and policy directions, plan and coordinate service delivery in its region and evaluate regional health network's' performance.

Local health and social service centres (CSSS): Evaluate health status of population in its territory. Manage and coordinate the delivery of general and specialized services, including mental health services, in its territory. Ensure effectiveness of services and continuity between services.

Psychiatrie hospitals: Deliver specialized and ultraspecialized psychiatrie services at regibnal and/or supra-regionallevels. Also carry out research and training activities.

Researchers: Generate knowledge on the best ways to organize mental health services. Promote the use of new knowledge in the field through close partnerships with service providers and decision makers. Carry out research on the factors that influence the adoption and effectiveness of best practices.

Rehabilitation services: Offer a wide range of services that promote the well-being and integration of people with severe and persistent mental illness into the community.

SE teams: Help people with severe and persistent mental illness search for, obtain and maintain competitive employment in regülar, integrated work settings. Perform brief initial assessment. Discuss impact of employment on social benefits. Assistance with CV creation, job search and preparation . Contact with employers, sometimes in the community. Negotiate work accommodations . Help train some clients on the work site. Wake up calls and transportation to work . Frequent follow-up by phone and meetings in the community. Professional and psychosocial advice and support. Keep treating physician and clinical teams abreast of client progress, and clinical and employment status. Provide support to employers and act as mediator between clients and employers.

Team coordinators oversee administrative duties for program. Coordinate employment specialists and encourage fidelity to the supported employment principles. Assume leadership roles with regards to the creation of partnerships and advocacy for the program.

Decision mechanisms

Managers in rehabilitation/psychiatric departments have autonomy over decisions related to the organization of vocational services. Team coordinators also have latitude to encourage adaptations and cerate partnerships that will benefit the team and its clients. Decisions related to the adoption of supported employment and its subsequent functioning usually arrived at by consensus following discussions and team meetings .

Management of human resources

ln IPS teams, employment specialists usually hospital personnel trained to become IPS agents. Initially, they generally possessed little experience in the employment sector. In PACT team, employment specialists had previous experience in their roles working for community organizations. Criteria for selecting new employment specialists: belief in potential of people with severe mental illness, clin ical experience in mental health, creativity and resourcefulness, community experience.

Proper training is considered essential , and was overseen in IPS by outside experts in supported employment. Once trained, employment specialists granted high-degree of autonomy in their work by team coordinators, they decide what is best for client, interact often with employers , clinicians , and clients in the community.

1

. 1

1

Acquisition of resources

Funding for supported employment programs is provided through their hospital's global budgets. Small teams usually consisting of four or five employment specialists and a team coordinator or, in the case of the PACT team , two employment specialists working part-time. In IPS, limited funds and small size of teams meant greater case loads per employment specialist than what is considered ideal for IPS standards and lengthy waiting lists for entry into the program by clients . In PACT, lack of personnel in team meant that employment specialists' time could not be protected, forcing them to perform duties unrelated to vocational rehabilitation. Recurrent funding meant that teams existence was not threatened .

Interpretive schemes

Organizationa/ domain Specialized, evidence-based rehabilitation service that promotes the recovery and wellness of people with severe and persistent mental disorders through their integration into competitive, integrated work settings. Aim to accompany the client through every step of the process, from job search ta finding a job and maintaining employment. Offer intensive and long-lasting support that is bath socioprofessional and psychosocial in nature.

Position of health authorities, including Ministry of Health and Social Services and Regional health agencies, is that activities related to the integration of people into the competitive workforce fall outside of the responsibilities of actors in the health sector. Health sector activities with respect to vocational services are perceived to relate to pre-employment and rehabilitation support activities, whereas integration into regular work falls under the domain of actors in the employment sector.

Princip/es of organizing Evidence-based practices, belief that people with severe mental illness can work, competitive work more normalizing and contributes to ' individuals' well-being and recovery, zero exclusion criteria, individualized services, follow clients' preferences, rapid job search, create therapeutic alliance with client, collaboration of vocational team and mental health teams, intensive and unlimited support, services in the community, belief that service users have a variety of needs and that supported employment only responds to a subset of these needs, willingness to deviate from the model in response to the context.

Evaluative criteria ln IPS teams, fidelity ta IPS model discussed in weekly team meetings. Teams keep statistics on clients' vocational outcomes (e.g. number of clients who obtained regular employment). Interactions with researchers who advocate fidelity to the model. Teams have also used fidelity scales developed by American research teams with expertise in supported employment. Client satisfaction assessed by managers in one rehabilitation de~artment.

ANNEX 3

Table 4 - Summary of employment coalition characteristics

Table 4. Summary of employment coalition characteristics

Coalitions

Transactions - assets (core members)

Organizations specializing in the insertion and maintenance of employment (OSIME): ln one OSIME (Organization 0) , long history and expertise with mental health clienteles. In another (Organization E), long history and expertise with clients with both physical and mental disabilities . Passion for cause. Links with Emploi-Québec, access to social integration measures and salary subsidies for employers funded through Emploi-Quebec.

Emploi-Québec: Control over resources allocated to OSIMEs. Provides employment programs and measures used by OSIMEs to facilitate their clients ' integration into the workforce.

Links

Transactions - benefits (core members)

Organizations specializing in the insertion and maintenance of employment (OSIME): Partnership with Emploi-Québec provides funding for their organizations, possibility of continuing their mission. Provides exclusive access to Emploi-Québec's employment programs and measures, information about these programs and policies at ministry level.

Emploi-Québec: Offer a more complete range of employment services in the province of Quebec. Provide services that are adapted to the unique and changing needs of people with physical and/or mental handicaps.

Formai links with Emploi-Québec, based on shared goal to facilitate the integration of people with handicaps into the regular workforce. Formai links between OSIMEs, forming an association called ROSEPH. Formality of links with other actors varies. Organization E has merged with an organization that develops employability in its region. Organization 0 has formai agreements with hospitals in its region . Otherwise, links are mostly informai based on shared values and interests. Links with organ izations in employment and community sectors help ensure the delivery of a continuum of employment services, with OSIMEs being the last step in the continuum. Participate in numerous local , regional and provincial issue tables (e .g. OPHQ, mental health and work committee, etc), forums and committees and communicate frequently with actors from employment, health and community sectors at various levels.

ContraIs

Nature of relationship with Emploi-Québec constra ins to a certain extent the autonomy of OSIMEs. Emploi-Québec exerts important control over decisions relating to OSIMEs role , services provided and functioning . Influence over the types of cl ients OSIMEs can provide services ta and accessibility of services and measures ta clients . Emploi-Québec accountability procedures impose important administrative responsib ilities on OSIMEs and funding method encourages high case loads for employment specialists and time-l imited support. Creation of ROSEPH aimed ta increase eguity in relationship between these actors and ensure that the same rules apply in interactions and negotiations between each OSIME

and Emploi-Québec. OSIMEs have some flexibility with respect to how services are organized ta meet the needs of people with disabilities as weil as their obligations towards their funder. OSIMEs have been existence for several decades and have gained credibility and trust from Emploi­Québec. Organization D for example has remained a specialized service for mental health clienteles and other OSIMEs have been able to remain specialized when other services in their regions completed the continuum of services for disabled clients . Actors from OSIMEs with considerable expertise and credibility have also been involved in training employees from Emploi-Québec and other organizations in the employment sector to create greater awareness of issues related to disabilities and ensure more effective and respectful interactions between clients.

Organizational structure

The structure of roles and responsibilities

Ministry of Employment and Social Solidarity: Define policies that promote employment, the development and strengthening of the labour market and ensure the economic prosperity of the province. Ensure financial support to disadvantaged people and fund activfties designed to fighting poverty and social.exclusion.

Emploi-Québec: Dual responsibility to provide public employment services to business and individuals across the province and manage the Ministry's income security programs. Regional offices of Emploi-Québec ensure that the ministry and agency's missions are carried out in ail regions of the province.

Conseil des partenaires du marché du travail: An advisory committeecomposed of representatives fram the labour market, businesses, community organizations, organizations involved in professional training , and several other actors interested in improving labour market performance . The CPMT's role is to regroup decision makers to share expertise and work to strengthen the province's economy. The CPMT also seeks to promote a greater equilibrium between supply and demand in the labour market, and participates in decisions influencing the programs and measures that are established and offered by Emploi-Québec.

CAMO: A provincial committee that elaborates and coordinates strategies aiming to facilitate people with handicaps' access to employment and professional training. The committee partners with members of various associations and organizations, professional syndicates, employers and government agencies to achieve this goal.

Local employment and welfare offices (or CLEs): Provide access to Emploi-Québec's programs and services at a locallevel. Over 150 of these offices operate across the province of Québec.

OSIMEs: Non-profit organizations that help people with severe mental illness that are deemed ready to enter the labour market search for, obtain and maintain competitive employment in regular, integrated work settings . Perform extensive initial assessment to determine relevance of OSIME services for client, assess client characteristics and goals, and readiness to work in competitive employment, typically at 20 hours per week or more.

Develop action plan with clients accepted into program . Discuss impact of employment on social benefits. Determine relevance of programs and measures offered by Emploi-Québec. Assistance with CV creation, job search and preparation. Contact with employers, usually by phone, and negotiate work accommodations. Professional advice and follow along support by phone . Act as liaison between clients and clinical teams, and clients and employers. Provide support to employers with respect to client status at work.

Program managers responsible for administrative aspects and providing direction to the organization. Provide training to new employees. Consultations with board of directors. Assume leadership roles with regards to the creation of partnerships and advocacy for the program.

ROSEPH: Association of 25 OSIMEs in the province of Quebec. Three main roles: 1) to increase the recognition of the specifie expertise and skills possessed by member organizations, 2) to convince the public decision makers of the need for high-quality, accessible and weil funded employment services for people with handicaps, and 3) to develop, share and ensure the coherence of practices facilitating the integration of these clienteles into the competitive workforce.

Decision mechanisms

Directors of OSIMEs have autonomy over decisions related to the organization of vocational services. Strategie decisions affecting the organization are presented to the board of directors and carried out following their approval.

Management of human resources

OSIME staffs made up of individuals with varied backgrounds (experiences primarily with clienteles, with labour market or work integration). Diversity seen as a positive. In Organization D, employment specialists provided ail services related to the work integration process. In Organization E, different team members carried out specifie vocational tasks (e.g. some employees focused on job search while others did job maintenance ).

Criteria for selecting new employment specialists : belief in potential of people with severe mental illness , creativity and resourcefulness, ability to sell client to employers. Training provided by OSIME managers. Once trained, employment specialists have ability to decide what is best for client and communicate regularly with employers, clinicians, and clients. Many administrative duties. Managers ensure that employees respect responsibilities towards Emploi-Québec.

Acquisition of resources

Funding for OSIMEs provided by Emploi-Québec. Yearly meetings between actors , funds for next year negotiated . Recent movement to fixed:' sum funding method. Unused funds can be retained and used in following year. Access to future funds is tied to OSIMEs' ability to meet the targets agreed upon with Emploi-Québec. Funding method aims to maximize performance and efficiency. ROSEPH determines the rules of play with respect to negotiatioQsarl(t~lJloLJn_tsn _é!vailab~ to OSLMJ~_~-,_ Acç~~~Jo~Q"lQ!Qyment measures such as salary subsidies (work integration

contracts) has increased gradually on a yearly basis. Expansion for other services has been limited, due ta limits in Emploi-Ouébec's budget.

Interpretive schemes

Organizationa/ domain

Organizations D and E viewed themselves as specialized employment services that aim to help people with physical and/or mental disabilities integrate rapidly the competitive workforce and move off of social assistance . Their clients are those who are stable and autonomous enough to enter the workforce "quickly and work a significant amount of hours per week (usually over 20 hours). Employment specialists offer support to their clients throughout the integration process, though this support is uniquely socio-professional and not psychosocial in nature. Their clients rehabilitation from mental illness was not their primary interest.

Domain of authorities in employment sector related to improving the strength of the province's economy, strengthening its labour market and ensuring a continuum of employment services that provide ail members of society to contribute to the prosperity of the province. The vision that actors from Organization D and E had regarding their domain seemed highly coherent with the vision held by employment sector authorities . This has likely contributed to th"e growth of OSIMEs, now present in ail regions of the province.

Princip/es of organizing

Belief that people with severe mental illness and other disabilities can work, competitive work more normalizing and allows them to be seen as equal citizens, individualized services, follow clients ' preferences, rapid job search, coordination between vocational specialists and clinical teams, support more intensive wlthin three months C)f job acquisition, less intensive support for more clients, support can be long-term but most often is time-limited , some clients believed to be more distant from the labour market than others , OSIME works with those closer ta labour market, client responsibility and independence encouraged, equity in relationships with clients and employers, OSIMEs the final stop in a continuum of employment services, focus on quality and on accessibility àf services to large number of clients.

Eva/uative criteria

Emploi-Ouébec'saccountability procedures require OSIMEs to serve a minimum number of clients per year and typically fixes as an objective a 50% placement rate , meaning that organizations must place 50% of their new clients in employment over the course of that year. Organizations 0 and E kept many statistics on their clients and on these clients ' vocational outcomes. Organization D in particular emphasizes the importance of emJ2loyment outcomes at 3 months . OSIMEs also required to produce _§D _~rlr1ual repQf! tg Emploi-Québec.

ANNEX 4

Consent Forms

· UNIVERSITÉ

. LAVAL Analyse pan-canadienne des aspects de

programmation, organisationnels et individuels de l'implantation de programmes de soutien à l'emploi

FORMULAIRE DE CONSENTEMENT

Vous êtes invité à participer au volet organisationnel du projet de recherche « Analyse pan-canadienne des aspects de programmation, organisationnels et individuels de l'implantation de programmes de soutien à l'emploi ».

PERSONNES RESPONSABLES

Daniel Reinharz, Département de médecine sociale et préventive, Université Laval

Marc Corbière, Département de réadaptation, Université de Sherbrooke

Éric Latimer, Département de psychiatrie, Université McGill

Bonnie, Kirsh, Département d'ergothérapie, Université de Toronto

Tania Lecomte, Département de psychologie, Université de Montréal

Paula Goering, Département de psychiatrie, Université de Toronto

Elliot Goldner, Département de psychiatrie, Université Fraser

ORGANISMES SUBVENTIONNAIRES

Cette recherche est financée par les 1 nstituts de la recherche en santé du Canada

(IRSC).

BUTS DE LI ETUDE

Les programmes de soutien à l'emploi sont une façon efficace d'aider les

personnes atteintes de maladies mentales graves à intégrer le marché du travail.

On note cependant qu'il existe présentement des variations majeures entre les

programmes implantés au Canada. Le but de ce projet est d'évaluer l'implantation

des programmes de soutien à l'emploi dans trois provinces canadiennes (Québec,

Ontario, Colombie-Britannique). Le projet comprend trois volets: 1) une

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évaluation de la fidélité et de la qualité des programmes de soutien à l'emploi

offerts aux personnes atteintes de maladies mentales graves, 2) Une analyse

organisationnelle afin de mieux comprendre comment la dynamique entre les

principaux acteurs associés aux programmes de soutien à ' l'emploi a conduit à

l'implantation d'éléments-clés particuliers à l'intérieur de ceux-ci, et 3) l'évaluation

de l'efficacité et de l'importance de chacun des éléments-clés des programmes en

mesurant les résultats obtenus en terme d'emploi par les personnes inscrites aux

programmes afin de déterminer lesquels peuvent être adaptés, modifiés, omis ou

ajoutés sans modifier les résultats.

NATURE DE LA PARTICIPATION

Nous vous sollicitons afin de participer au volet 2 du projet soit, l'analyse

organisationnelle. Si vous acceptez, votre participation consistera en une entrevue

individuelle d'une durée approximative de 90 minutes qui portera sur les pratiques

des acteurs, les valeurs, les intérêts et les croyances qui prédominent dans votre

situation et qui jouent un rôle important dans l'implantation et le fonctionnement

des pro,grammes de soutien à l'emploi. L'entrevue se fera en français ou en

anglais, à un endroit et un moment qui vous conviendra . Cette entrevue sera

enregistrée pour faciliter une analyse rigoureuse des informations recueillies.

RISQUES POTENTIELS ET AVANTAGES POSSIBLES

Étant donné la spécificité de certains postes professionnels, il est possible que

vous soyez reconnu nonobstant l'anonymat dans lequel vos propos seront

rapportés et les précautions prises à cet égard lors de la publication des résultats.

Cependant, votre décision de participer à cette recherche n'influencerait nullement

votre situation au sein de votre établissement. Le principal avantage découlant de

la participation est lié au fait que la présente étude devrait fournir aux

responsables de programmes de l'information suries processus qui influencent

l'implantation des éléments-clés des programmes. L'utilisation de cette

information devrait leur' permettrent d'évaluer la possibilité de modifier leurs

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programmes afin d'être plus cohérent avec les besoins et les caractéristiques de

leurs clients et de leur environnement.

DROITS DU PARTICIPANT

Votre participation à ce projet est volontaire. Vous avez le droit de vous retirer du

projet à tout moment, et ce, sans préjudice. Vous avez le droit de ne pas répondre

à toutes les questions.

QUESTIONS AU SUJET DE L'ETUDE

Si vous avez des questions au sujet de l'étude ou si vous désirez vous retirer,

vous pouvez contacter un des membres · de l'équipe de recherche, soit la

coordonnatrice du projet Nathalie Houle au (418) 656-2131 poste 4158, le

candidat à la maîtrise Matthew Menear au (418) 656-2131 poste .4233, ou le

responsable du projet, le Dr Daniel Reinharz au (418) 656-2131 poste 8360.

Si vous avez des critiques ou des plaintes concernant le projet, vous pouvez

communiquer avec le Bureau de l'Ombudsman de l'Université Laval (Pavillon

Alphonse-Desjardins, bureau 3320. Tel: (418) 656-3081).

CONFIDENTIALITE ET UTILISATION DES RESULTATS

Les renseignements recueillis lors de cette recherche seront traités de façon

strictement confidentielle. Les documents sur lesquels apparaissent votre nom

ainsi que tous les autres renseignements permettant de vous identifier seront

conservés dans un classeur fermé à clé auquel seuls les membres de l'équipe de

recherche ont accès. Un système de codes sur les transcriptions sera utilisé de

façon à ce que vos données d'identification personnelle ne soient pas

mentionnées. Toutes les informations permettant de vous identifier seront

détruites un an après la remise du rapport .final. Ce projet déroulera sur une

période de deux ans.

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Les résultats de la recherche seront utilisés à des fins de communications

scientifiques ou d'enseignement, exclusivement par le chercheur identifié au

feuillet d'information. Les résultats ne feront l'objet d'aucune utilisation ultérieure.

RÉSUMÉ

Le projet «Analyse pan-canadienne des aspects de programmation,

organisationnels et individuels de l'implantation de programmes de soutien à

l'emploi» vise à évaluer l'implantation des programmes de soutien à l'emploi dans

trois provinces canadiennes (Québec, Ontario, Colombie-Britannique). Je suis

sollicité afin de participer à la deuxième volet de cette étude, dont le but est

d'étudier les déterminants organisationnels de .Ia dynamique entre les acteurs

associés aux programmes de soutien à l'emploi et leur influence sur la mise en

œuvre des éléments-clés des programmes.

1) J'ai été informé(e) de la nature et des buts de ce projet de recherche, ainsi

que de son déroulement.

2) Je comprends que ma participation à cette recherche consistera en une

entrevue individuelle d'une durée approximative de 90 minutes. J'accepte

également que cette entrevue soit enregistrée pour permettre une analyse

rigoureuse des données recueillies.

3) J'ai été assuré que ma décision de participer à cette recherche n'influencerait

nullement ma situation au sein de mon établissement.

4) J'ai pu poser toutes les questions voulues concernant ce projet de recherche

et j'ai obtenu des réponses satisfaisantes. J'ai été informé(e) des risques et

inconvénients associés à ma participation.

5) Je sais que les informations provenant de la recherche demeureront

confidentielles et elles ne seront utilisées qu'à des fins scientifiques,

exclusivement par les chercheurs identifiés au feuillet d'information.

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6) J'ai été informé que la recherche se déroulera sur une période de 2 ans et que

les données seront détruites un an après le dépôt du rapport final.

7) Je peux me retirer de l'étude en tout temps. Si je me retire, je ne subirai aucun

préjudice.

Toute plainte ou critique dans le cadre de ma participation à un projet de

recherche de l'Université Laval pourra être faite au Bureau de l'Ombudsman de

l'Université Laval (Pavillon Alphonse-Desjardins, bureau 3320. Tél: (418) 656-

3081 ).

SIGNATURE

Participant

Je soussigné(e), ai lu et compris ce formulaire de consentement et je consens volontairement à participer à cette étude telle que décrite.

Signature du participant:

Fait à ------- , le ,2007

Engagement du chercheur

Je soussigné (e), , certifie avoir expliqué au signataire -------------

intéressé les termes de la formule de consentement et avoir répondu aux

questions qu'il m'a posées à cet égard et lui avoir- clairement indiqué qu'il reste , à

tout moment, libre de mettre un terme à sa participation au projet de recherche

décrit ci-dessus, sans préjudice quelconque.

Signature du responsable du projet ou de son représentant: ___________ _

Fait à ______ ~,Ie ,2007

Copie du participant Proj et de recherche approuvé par le comité d 'éthique de la recherche de l'Université Laval (dossier 2007-014) le (22/02/07)

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Analyse pan-canadienne des aspects de programmation, organisationnels et individuels de l'implantation de programmes de soutien à l'emploi

La coordonnatrice du projet Nathalie Houle peut être rejointe par téléphone au

(418) 656-2131 poste 4158, par télécopieur au (418) 656-7759 ou par courriel à

nathalie.houle@ext.msp.ulaval.ca.

Copie du participant Projet de recherche approuvé par le comité d ' éthique de la recherche de l'Université Laval (dossier 2007-014) le (22/02/07)

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Analyse pan-canadienne des aspects de programmation, organisationnels et individuels de l'implantation de programmes de soutien à J'emploi

RÉSUMÉ Le projet « Analyse pan-canadienne des aspects de programmation, organisationnels et

individuels de l'implantation de programmes de soutien à l'emploi» vise à évaluer

l'implantation des programmes de soutien à l'emploi dans trois provinces canadiennes

(Québec, Ontario, Colombie-Britannique). Je suis sollicité afin de participer à la

deuxième volet de cette étude, dont le but est d'étudier les déterminants

organisat,ionnels de la dynamique entre les acteurs associés aux programmes de

soutien à l'emploi et leur influence sur la mise en œuvre des éléments-clés des

programmes.

1) J'ai été informé(e) de la nature et des buts de ce projet de recherche, ainsi que de

son déroulement.

2) Je comprends que ma participation à cette recherche consistera en une entrevue

individuelle d'une durée approximative de 90 minutes. J'accepte également que

cette entrevue soit enregistrée pour permettre une analyse rigoureuse des données

recueillies.

3) J'ai été assuré que ma décision de participer à cette recherche n'influencerait

nullement ma situation au sein de mon établissement.

4) J'ai pu poser toutes les questions voulues concernant ce projet de recherche et j'ai

obtenu des réponses satisfaisantes. J'ai été informé(e) des risques et inconvénients

associés à ma participation.

5) Je sais que les informations provenant de "la recherche demeureront confidentielles

et elles ne seront utilisées qu'à des fins scientifiques, exclusivement par les

chercheurs identifiés au feuillet d'information.

6) J'ai été informé que la recherche se déroulera sur une période de 2 ans et que les

données seront détruites un an après le dépôt du rapport final.

7) Je peux me retirer de l'étude en tout temps. Si je me retire, je ne subirai aucun

préjudice.

Copie du chercheur Projet de recherche approuvé par le comité d 'éthique de la recherche de l 'Université Laval (dossier 2007-01 4) le (22/02/07)

6 de 7

Analyse pan-canadienne des aspects de programmation, organisationnels et individuels de l'implantation de programmes de soutien à l'emploi

Toute plainte ou critique dans le cadre de ma participation à un projet de recherche de

l'Université Laval pourra être faite au Bureau de l'Ombudsman de l'Université Laval

(Pavillon Alphonse-Desjardins, bureau 3320. Tél: (418) 656-3081).

SIGNATURE

Participant

Je soussigné( e), ai lu et compris ce formulaire de consentement et je consens volontairement à participer à cette étude telle que décrite.

Signature du participant:

Fait à ------- , le ,2007

Engagement du chercheur

Je soussigné (e), -----------, certifie avoir expliqué au signataire

intéressé les termes de la formule de consentement et avoir répondu aux questions qu'il

m'a posées à cet égard et lui avoir clairement indiqué qu'il reste, à tout moment, libre de

mettre un terme à sa participation au projet de recherche décrit ci-dessus, sans

préjudice quelconque.

Signature du responsable du projet ou de son représentant:

Fait à _______ ,Ie ,2007

La coordonnatrice du projet Nathalie Houle peut être rejointe par téléphone au (418)

656-2131 poste 4158, par télécopieur au (418) 656-7759 ou par courriel à

nathalie.houle@ext.msp.ulaval.ca.

Copie du chercheur Projet de recherche approuvé par le comité d 'éthique de la recherche de l 'Université Laval (dossier 2007-014) le (22/02/07)

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UN IVERSITÉ

LAVAL A Pan-Canadian analysis of programmatic, organizational, and individual aspects of Supported Employment implementation

CONSENT FORM

You are invited ta participate in the research project titled "A Pan­Canadian analysis of programma tic, organizational, and individual

aspects of Supported Employment implementation"

PERSONS RESPONSABLE

Marc Corbière, Department of rehabilitation, Université de Sherbrooke

Daniel Reinharz, Department of social and preventive medicine, Université Laval

Eric Latimer, Department of psychiatry, McGiII University

Bonnie, Kirsh, Department of occupational science and occupational therapy, University of

Toronto

Tania Lecomte, Department of psychiatry, Université de Montréal

Paula Goering, Department of psychiatry, University of Toronto

Elliot Goldner, Department of psychiatry, Fraser University

GRANTING AGENCY

This project is supported by the Canadian Institutes of Health Research (CI HR).

STUDY AIMS

Supported employment (SE) programs are an effective way of helping people with

mental illness to integrate into the work force. Currently howeverthere are

significant variations between programs implemented in Canada. The purpose of

this study is to evaluate the implementation of SE services in three Canadian

Participant' s copy

This research project was approved by the Ethics committee of Université Laval (file no. 2007-014) on (22/02/07)

lof 7

provinces (Quebec, Ontario and British Columbia). The study has three main

objectives: 1) to assess the

fidelity and quality of SE 'services offered to people with severe mental illness, 2) to

conduct a study of the organizational determinants of the dynamic between actors

associated with SE programs and their influence on the implementation of key principles

or components of SE programs, and 3) to determine the effectiveness of each SE

component by measuring vocational outcomes for people with severe mental illness

(while taking into consideration individual characteristics) to determine which

components can be adapted , modified, omiUed or added without affecting the

outcomes. The results of this study will help tailor vocational services to consumer

needs, individual characteristics and environmental circumstances, and they could

further assist in the development of best practices and enhancement of outcomes in

Canada.

THE NATURE OF YOUR PARTICIPATION

Vou are being asked to participate in the second component of this study

(organizational analysis). If you accept to participate, your participation will consist of

an individual interview lasting approximately 90 minutes on the values, interests, and

beliefs that are dominant in your environment and that likely play an important role in

the implementation of key principles of these programs. The interview will be carried

out in English or French, in a location of your choice and at the time most convenient for

you. This interview will be recorded, so as to facilitate a rigorous analysis of the

information collected.

POTENTIAt RISKS AND ADV ANT AGES

Given the specific nature of some positions, there is a chance that your comments could

lead you to be identified, despite our measures to protect your anonymity when

reporting your comments or publishing our findings. However, your decision to

participate in the study will not influence your situation within your establishment. The

main advantage of your participation is that this study should provide those who are

Participant' s copy

T his research project was approved by the Ethics committee of Université L~val (fil e no. 2007-0 14) on (22/02/07)

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A Pan-Canadian analysis of programma tic, organizational, and individual aspects of Supported Employment implementation

responsible for SE programs for people with mental illness with information regarding

the processes that influence the implementation of the key services of these programs.

This information could then be used to evaluate the possibility of modifying their

programs so as to offer their clients the best possible services.

PARTICIPANT'S RIGHTS

Your participation in this .study is voluntary. You have the right to withdraw from the

study at any time without prejudice. You also have the right to refrain from answering

any question you are asked.

QUESTIONS REGARDING THE STUDY

If you have questions regarding the study or if you would like to withdraw, you can

contact one of the members of the research team: the project coordinator Nathalie

Houle at (418) 656-2131 extension 4158, master's candidate Matthew Menear at (418)

656-2131 extension 4233, or the proj~ct leader Dr Daniel Reinharz at (418) 656-2131

extension 8360.

If you have any complaints or comments regarding this project, you can communicate

with the Office of the Ombudsman of Université Laval (Alphonse-Desjardins Pavilion,

office 3320, Tel: (418) 656-3081).

CONFIDENTIALITY AND USE OF STUDY RESUL TS

The information collected during this study will remain confidential. Documents on

which your name appears, as weil as ail other information that could lead to your

identification, will be stored in a filing cabinet that will be locked and accessible only to

members of the research team. A coding system will be used to ensure that no

personal information appears on the interview transcripts. Ali information that could

lead to your identification will be destroyed one year following the release of the study's

final report. This study will be conducted over a period of 2 years.

Participant's copy

This research project was approved by the Ethics committee of Université Laval (file no. 2007-01 4) on (22/02/07)

20f7

A Pan-Canadian analysis of programmatie, organizational, and individual aspects of Supported Employment implementation

The results of this study will be used exclusively by the researcher identified in the

information leaflet and solely for scientific communication and teaching purposes. The

results will not be used as part of a later study.

Participant's copy

This research project was approved by the Ethics conlmiUee of Université Laval (file no. 2007-01 4) on (22/02/07)

30f7

A Pan-Canadian analysis of programma tic, organizational, and individual aspects of Supported Employment implementation

SUMMARY

The project titled "A Pan-Canadian analysis of programmatic, organizational, and

individual aspects of Supported Employment implementation" aims to evaluate the

implementation of SE services in three Canadian provinces (Quebec, Ontario and

British Columbia). 1 am asked to participate in the second component of this study,

which aims to study the organizational determinants of the dynamic between actors

associated with SE programs and their influence on the implementation of key principles

of these programs.

1) 1 have been informed of the goals of this project, as weil as the sequence of events

following my accepting to participate.

2) 1 understand that my participation in this study consists of an individual interview

lasting approximately 90 minutes. 1 also -accept that the interview be recorded to

allowa rigorous analysis of the da~a collected.

3) 1 have been assured that my decision to participate in the study will not influence

my situation within my establishment.

4) 1 have had the opportunity to ask ail questions concerning the project and am

satisfied with the answers provided to me. 1 have been informed of the risks and

advantages related to my participation.

5) 1 know that the information collected during the study will remain confidential and

will be used exclusively by the researchers identified in the information leaflet and

for purposes related to scientific communications or teaching only.

6) 1 have been informed that the research project will be conducted for a period of 2

years and that the data will be destroyed one year following the release of the

study's final report.

7) 1 can withdraw from the study at any time. If 1 withdraw from the study, will not be

subject ta prejudice.

Participant' s copy

This r search project was approved by the Ethi cs committee of Université Laval (fil e no. 2007-014) on (22/02/07)

40f7

A Pan-Canadian analysis of programma tic, organizational, and individual aspects of Supported Employment implementation

Ali complaints or comments as they relate to my participation in a research study at

Université Laval should be directed to the Office of the Ombudsman of Université Laval

(Alphonse-Desjardins Pavilion, office 3320; Tel: (418) 656-3081).

SIGNATURE

Participant

l, ______________ have read and understand this consent form and

consent valuntarily ta participate in the study as described.

Participant's signature:

Signed at (location) __________ , the __________ , 2007

Researcher's agreement

l, _____________ _ attest that 1 have explained to the above-

named participant the terms of the consent form and have responded to ail of his or her

questions regarding this document. 1 have also made it clear that he or she may

withdraw from the study described above at any time without prejudice.

Signature of the person responsible for the project or his/her representative:

Signed at (location) __________ , the ______ """'"""---____ , 2007

The project coordinator Nathalie Houle can be reached by telephone at (418) 656-2131

ext. 4158, by fax at (418) 656-7759 or by email at nathalie.houle@ext.msp.ulaval.ca.

Participant' s copy

This research project was approved by the Eth ics committee of Univer ité Laval (fi le no. 2007-014) on (22/02/07)

50f7

A Pan-Canadian analysis af pragrammatic, arganizatianal, and individual aspects af Supparted Emplayment implementatian

SUMMARY

The project titled "A Pan-Canadian analysis of programmatic, organizational , and

individual aspects of Supported Employment implementation" aims to evaluate the

implementation of SE services in three Canadian provinces (Quebec, Ontario and

British Columbia). 1 am asked to participate in the second component of this study,

which aims to study the organizational determinants of the dynamic between actors

associated with SE programs and their influence on the implementation of key principles

of these programs.

1) 1 have been informed of the goals of this project, as weil as the sequence of

events following my accepting to participate.

2) 1 understand that my participation in this study consists of an individual interview

lasting approximately 90 minutes. 1 also accept that the interview be recorded to

allow a rigorous analysis of the data collected.

3) 1 have been assured that my decision to participate in the study will not influence

my situation within my establishment.

4) 1 have had the opportunity to ask ail questions concerning the project and am

satisfied with the answers provided to me. 1 have been informed of the risks and

advantages related to my participation.

5) 1 know that the information collected during the study will remain confidential and

will be used exclusively by the researchers identified in the information leaflet and

for purposes related to scientific communications or teaching only.

6) 1 have been informed that the research project will be conducted for a period of 2

years and that the data will be destroyed one year following the release of the

study's final report.

7) 1 can withdraw from the study at any time. If 1 withdraw from the study, will not be

subject to prejudice.

Researcher'·s copy

This research proj ect was approved by the Ethics committee of Uni versité Laval (file no. 2007-014) on (22/02/07)

60f7

A Pan-Canadian analysis of programmatic, organizational, and individual aspects of Supported Employment implementation

Ali complaints or comments as they relate to my participation in a research study at

Université Laval should be directed to the Office of the Ombudsman of Université Laval

(Alphonse-Desjardins Pavilion, office 3320, Tel: (418) 656-3081 ).

SIGNATURE

Participant

l, have read and understand this consent form and ----------------------------consent voluntarily ta participate in the study as described.

Participant's signature:

Signed at (location) __________ , the ___________ , 2007

Researcher's agreement

l, ______________ aUest · that 1 have explained to the above-

named participant the terms of the consent form and have responded ta ail of his or her

questions regarding this document. 1 have also made it clear that he or she may

withdraw from the study described above at any time without prejudice.

Signature of the persan responsible for the project or his/her representative:

Signed at (location) __________ , the ___________ , 2007

The project coordinator Nathalie Houle can be reached by telephone at (418) 656-2131

ext. 4158, by fax at (418) 656-7759 or by email at nathalie.houle@ext.msp.ulaval.ca.

Researcher' s copy

This research project was approved by the Eth ics committee of Université Laval (fi le no. 2007-014) on (22/02/07)

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ANNEX 5

Sample interview guide .'

Analyse organisationnelle

Thèmes pour les entrevues

Thème 1 : Caractérisation de l 'organisation et vision des services à offrir

(Question et POURQUOI?)

Organisation - points recherchés:

•

•

•

Caractérisation de l'organisme ( structure générale)

Rôle de l' organisme (niche)

Responsabilités des membres de l'organisme (formel et informel)

Services clés des programmes - points recherchés:

•

•

•

•

•

•

•

•

•

•

•

Clientèle ciblée?

Critères pour entrer dans le programme ou obtenir des services?

Des emplois compétitifs sont ciblés?

Importance accordée aux intérêts des clients?

Importance des activités préparatoires?

Délai approximatif entre l'entrée et l'intégration en emploi?

L'accent est uniquement sur l'emploi ou d'autres choses aussi (logement, aspects cliniques, etc.)

Type et duré du soutien? Un soutien dans la communauté?

Intégration avec les équipes cliniques (fréquence de communications, participations aux rencontres, accès ~ l'information)

Conseils sur les effets d'un emploi (Benefits counselling)?

Pourcentage de personnes qui réussit à intégrer le marché du travail régulier?

Mécanismes de décision et évaluation du programme

• Qui est impliqué dans la prise de décisions concernant les types de services à offrir? (Présent et passé)

• Quelles sortes d'informations utilisent-ils pour aider à prendre des décisions à propos des types de services à offrir?

• Comment la performance de l'organisation est-elle évaluée?

• Quels moyens est-ce que votre organisation a pris pour s'assurer que les services offerts en pratique correspondent bien à la vision que votre organisme a des services? (Formation, pratiques d'embauche, etc.)

Thème 2: évolution de l'offre de servIces (implantation des servIces clés du programme)

•

•

•

•

•

Histoire de l'organisme et du programme (Date de création', moments clés)

Valeurs et idéologies dominantes lors de l'implantation initiale

Évolution des rôles et responsabilités (évolution des visions et valeurs)

Facteurs qui ont influencé ces changements?

Barrières à la mise en œuvre des services clés du programme

• •

•

Facteurs facilitant la mise en œuvre des services clés du programme

Financement de l'organisme et du programme (Stabilité? Influence?)

Évolution des ressources (financières, matérielles, humaines) en lien avec le programme

Influence des aspects contextuels: Lois et influences politiques (Santé, Emploi)

Thème 3 : partenariats et coalitions

Économie

Caractéristiques des clients

Environnement physique

Autre

• Partenariats qui assurent le fonctionnement du programme et l'avancement du domaine

• Rôles et responsabilités des partenaires

• Motivations à entrer dans ces partenariats (apport de chacun)

• Avantages de ces partenariats (motivations, bénéfices recherchés)

• Moyens de communication et formalité des liens entre les partenaires

• Mécanismes de décisions entre partenaires

• Expériences professionnelles et personnelles lors des collaborations

2

Thème 4 : le leadership et son impact sur l'évolution du programme de soutien à l'emploi et l'implantation des éléments clés des programmes

• Identification des leader~

• Historique du leadership

• Légitimité, crédibilité, compétences du leader

• Défis auxquels font face le( s) leader( s)

• Moyens utilisés par le( s) leader( s) afin de rallier les autres à ses idées

• Reconnaissance d'un leadership à l ' extérieur de l' organisme?

3