The International Journal of Psychosocial Rehabilitation

Support Needs of People with Mental Illness
in VocationalRehabilitation Programs
-The Role of the Social Network
 

 Janki Shankar, PhD
Lecturer in Mental Health, Charles Sturt University, Australia
School of Humanities and Social Sciences,  Charles Sturt University, Wagga Wagga, New South Wales, Australia
(jshankar@csu.edu.au)
 

Fran Collyer, PhD
Lecturer in Sociology, University of Sydney, Australia.
School of Social Work, Social Policy and Sociology, University of Sydney, New South Wales, Australia
fran.collyer@social.usyd.edu.au

Citation:
Shankar, J. & Collyer, F.  (2002)   Support needs of people with mental illness in vocational rehabilitation
programs -the role of the social network.  International Journal of Psychosocial Rehabilitation. 7, 15-28


'The authors wish to thank Associate Professor Margaret Alston from the School of Humanities and Social Sciences, Charles Sturt University, for her valuable comments on the initial draft of this article.'

Abstract
This paper reports on a study of the social networks of people with mental illness who participated in a vocational rehabilitation program to gain employment. The study found that social networks were critical to employment outcomes. Furthermore the study challenged existing assumptions about the social network characteristics of this group, revealing that family networks, despite their limitations, have valuable resources to offer for the success of rehabilitation programs.


Introduction
The shift in the locus of care from mental institutions to the community in the last three decades has significantly changed the life conditions of people with mental illness. Though many of the needs of people with mental illness have yet to be met by the community mental health system, major innovations have been made in the areas of community treatment and rehabilitation. These programs are aimed at enhancing the skills and supports of people with mental illness and promote their reintegration into community life.

Paid work in open employment settings is now being increasingly viewed as one of the ways of helping people who have recovered from mental illness to participate more fully in community life, improve their standard of living and reduce their dependence on income support. The last few decades have therefore seen a surge in the development and implementation of a variety of vocational rehabilitation approaches to prepare people with mental illness for employment. Research suggests that these approaches have achieved only limited success in moving people into open employment (Lehman, 1995; Marrone, 1995). The latest approach is Supported Employment (SE) where clients are placed directly in integrated work settings at award wages and provided with training and support. Advocates of SE claim that this approach has been the most effective so far in helping people to progress into open employment (Bond, et al, 1997). Research however shows that even with this approach between 41% and 77% of clients terminate their supported employment positions within 6 months (Gervey et al, 1995; Becker et al, 1996).

Several explanations have been offered for the poor employment outcomes of people with mental illness. While some writers have claimed that people with mental illness are ill prepared for employment by education, work skills and work experience, others have ascribed to myths that symptoms make these individuals too unstable to undertake work (Akabas, 1994; Cohen, 1990; Black, 1988). In keeping with these assumptions most vocational rehabilitation programs have directed their resources largely towards improving the work competence of people with mental illness through various training and placement support activities. This primary focus however has reflected interest away from an important factor that can have a significant role in influencing employment outcomes. This is the mentally ill person’s social support network. Though vocational rehabilitation literature has acknowledged the importance of this network for successful employment outcomes (Storey and Certo, 1996; Danley, 1992), there is little information on the social networks of people who have recovered from mental illness and are participating in rehabilitation programs to gain employment.

Over the years a considerable body of literature has accumulated on the social networks of people with mental illness. This data suggests that the networks of people with mental illness are dominated by family members and that the mentally ill individual establishes dependent, non-reciprocal relationships with network members (Rosenfield & Wenzel, 1997). Studies have shown that such networks are positively related to pathology and rehospitalisation among ex psychiatric patients (Holmes-Eber and Riger, 1990). Expressed Emotion studies have suggested that the family’s attitudes (hostility, criticism, or emotional overinvolvement) towards their mentally ill relative may lead to relapse and rehospitalisation (Leff and Vaughn, 1985). Family burden studies have highlighted the stress involved in providing ongoing care to the mentally ill relative and that often this care is provided under the most difficult conditions (Hatfield, 1997, Lefley, 1995). While it is clear that social networks, particularly family networks of people with mental illness play a significant role in the course and outcome of their relative’s illness, their specific contribution to recovery and rehabilitation programs remains largely unclear.

Furthermore, research on the social networks of people with mental illness has several limitations. Firstly much of the research evidence is based on the self- report of hospitalised populations of the mentally ill and network assessments taken during hospitalisations are likely be biased due to contamination of assessments by the symptoms and mood experienced by people during these periods. Secondly, the onset of mental illness and subsequent hospitalisation is a crisis for the person and their network members (Hatfield, 1997). This crisis can generate feelings of hostility, fear and embarrassment for network members leading to a decrease in network support during such periods. Thirdly much of the research evidence is based on cross sectional studies that have investigated people (and their networks) only at a single point in time. Assessments taken at a single point in time cannot be generalised across different time periods because people (and their networks) can change during the process of recovery from the illness. Studies that have investigated how people with mental illness function over time suggest that many of them can achieve long term recoveries and that as people recover they can learn to adapt and develop supportive networks (Thornicroft et al, 1995). Lastly a significant limitation of research on social networks is that it has focused on their structural aspects such as size and composition and does not address the quality of network relationships and the kinds of support provided by networks members.

The limitations of research and the lack of information on the social networks of people with mental illness who have recovered and are participating in vocational programs to gain employment, can severely restrict the ability of professionals to access the valuable resources that these networks may be able to provide. It can also limit the ability of professionals to determine the nature, level and combinations of support participants in employment programs will need to achieve successful employment outcomes. Additionally in the current climate of funding cuts and increasing caseloads of mental health and vocational rehabilitation staff, their capacity to provide the level of ongoing support that may be needed for people with mental illness to be successful in employment is unclear. As pointed out by several writers (Carling, 1995; Lefley, 1993) establishing partnerships with social networks, particularly with significant family members, can only improve the capacity of professionals to provide effective support and improve rehabilitation outcomes.

In the context of the above discussion the purpose of the current study is to examine the network characteristics of people with mental illness participating in employment programs. This study differs from previous studies in the field of vocational rehabilitation in a number of ways. Firstly the current study collected data only from persons with mental illness who had identified open employment as their vocational goal and were participating in a community based vocational rehabilitation program to achieve that goal. Secondly all the participants in this study were residing in the community and their illness had stabilised at the time of their entry into the vocational program.

The specific questions that the study addressed were:

Methods and measures
The data on which this paper is based was collected as part of a larger study that investigated the work skills, work history, social networks and ongoing health related difficulties of people with a major mental illness who participated in a vocational rehabilitation program for open employment.

Sixty-five clients of the CRS Specialist Services (one of the largest providers of vocational rehabilitation services for people with mental illness in Sydney, Australia) who had been accepted on vocational rehabilitation programs were interviewed at different points during the course of their vocational programs. The treating professionals had certified that these respondents were well enough to participate in the vocational program. The sampling strategy used was purposive sampling, a procedure that is often used in exploratory and field research, and allows the researcher to gather in depth information on specific issues relevant to the study (Neuman, 2000:198). The respondents were first interviewed when they commenced their programs (T1). The purpose of these interviews was to gather information on their social support characteristics, and sociodemographic factors such as age, education and diagnosis. The respondents were again interviewed at the time of program closure (T2). The purpose of these interviews was to gather information on their experience of their programs and record any changes in their support characteristics. Since most of these interviews were carried out in the respondents’ homes it provided the opportunity to record some of the comments of their relatives. Employers who offered work-training placements to respondents were interviewed to obtain information on their work skills and behaviours. In order to address the research questions the respondents were sorted into groups according to the outcome-those who gained employment and those who did not (and those who sustained employment and those who did not).

Information on sociodemographic factors such as age, sex, gender, education and diagnosis was gathered from the files of the respondents. The social support measures used in this study included a social network map, a social support grid and a social support questionnaire. These were adapted from the measures used by Whittaker, Tracy and Marckworth (1989) as part of a Family Support Project. The advantage of the network map was that it displayed the network and network memberships visually. Thus the total size and the composition of the network with respect to seven domains, namely household (people with whom you live), family and relatives, friends and work colleagues, people from clubs and church, neighbours, and formal services such as doctors, psychiatrist, mental health professionals, were displayed on the map. The map could be employed again at the end of the respondent's program to indicate changes in network size and composition.

Since the map by itself would reveal little information about the relationships in the network, an accompanying support questionnaire and network grid to record responses about the functions of the network, (such as, who provided what types of support), were included. The support questionnaire also included questions related to stability of relationships, frequency of contact with network members, critical relationships, close relationships and reciprocal exchanges with network members.

Analysis
Since quantitative and qualitative data were obtained from respondents the analysis of both kinds of data were used. The first research question was concerned with examining the social support characteristics of the respondents using the information gathered from the questionnaires at T1 and T2. This was carried out by using descriptive statistics particularly means and standard deviation. The size of each respondent’s network was determined by adding the network members in all the domains. Adding the network members in each domain and then dividing this by the total number of members in the whole network calculated the proportion of network members in each domain. To examine the support availability for the respondents in each support item the proportion of network members available for providing each item of support was calculated.

The second and third research questions were concerned with comparing the two groups of respondents (those who gained employment and those who did not) on their social network characteristics. For this purpose the analysis of variance (ANOVA) using the ‘t test’ (or f test) for continuous variables was used. In the case of categorical variables, the relationships were examined using contingency tables and the chi square test. Correlation analysis was used to examine the strength of the relationship between the social network characteristics and employment outcome. Since the dependent variable in this study was categorical and dichotomous the point biserial correlation coefficient was used. This is a product moment correlation coefficient and it gives the degree to which the continuous independent variables discriminate between the two categories of the dichotomous dependent variable.

Qualitative data on the perceptions and experiences of the respondents of their networks and vocational programs was recorded verbatim on their interview schedules. This data was then used to add strength and context to the quantitative data.

Results:
Sociodemographic characteristics
The mean age of the whole sample was 31.5 years (range 18-55) and the majority of the respondents (42) were male. Schizophrenia was the most common diagnosis (37), followed by Major Depression (11), Bipolar Illness (9) and Anxiety Disorders including Obsessive Compulsive disorder (8). Thirty-eight respondents had year 10 qualifications, 18 had HSC level qualifications and 9 had degree qualifications. The majority (46) of the respondents had been unemployed for more than 2 years.

All, except one respondent, had worked in open employment prior to their entry into the vocational program. The majority of the respondents (48) had experienced difficulties maintaining open employment right from the beginning of their working career. These included pressure to meet deadlines and keep up with co- workers, feelings of lack of support from supervisors and co-workers and boredom resulting from repetitive jobs.

Assessing network characteristics
Network size and composition were assessed by asking the respondents to name important people in their lives with whom they had regular contact. The names of these persons were recorded in the appropriate section of the network map described earlier. The respondents reported a mean network size of 9.89 (sd=2.27) members at intake into the program and 9.21 (sd=2.62) at closure. Most respondents mentioned their immediate family members, friends, and their treating professionals as significant people in their lives.

Family members comprised by far the largest proportion of the respondents’ primary networks (46% to 55%), at both time periods. The next largest component comprised treatment professionals (30%) who included primarily treating doctors and mental health casemanagers. This finding provides evidence of the important role played by these professionals in the lives of the respondents during the recovery phase. Friends comprised 15% to 20% of the network at both time periods. Forty- four respondents mentioned at least one friend in their network. The proportion of community members and neighbours in the networks was minimal (0.045 or 4%).

The majority of respondents (41) lived with their families. Of the remaining respondents, all except 3, maintained regular face to face or telephone contact with their family members. A significant finding was that respondents perceived their family members as largely supportive although some members were reported to be critical and hostile at times. The majority of the respondents (60) perceived that they had reciprocal relationships with their family members and friends. Thus respondents perceived themselves to be playing useful roles within their networks rather than always taking on the role of the ‘helpee’.

Contact with treating professionals was, on an average, fortnightly to monthly. There was stability in the networks of these respondents. There was a primary core of significant network members who had remained in the network and who had been known for more than three years. This primary core comprised about 70% of the entire network and included members of their immediate family, some long lasting friendships and treating professionals particularly private psychiatrists, general practitioners and casemanagers from mental health services.

The perception of closeness to members of a social network can in itself reduce feelings of isolation and insecurity and enhance feelings of integration and well being Asking respondents to name people in their networks to whom they felt close assessed the availability of close ties. Except for 2, all the respondents in this study named at least one network member to whom they felt close. The network members most frequently mentioned as close were family members especially partners, mothers, sisters, children and sometimes friends. Some respondents also felt close to their treating professionals if they were long standing relationships. However close ties though largely supportive would be sometimes critical and exhibit overinvolved and overprotective behaviours from time to time.

This was illustrated by the following cases:

Larry had a bipolar illness for several years. He was a qualified tradesman and had worked for many years. He had also suffered several relapses during the course of his working career. He was married and lived with his wife and children. He said, ‘I feel close to my wife, she is always there when I am sick. She is comforting and supportive. But she can also be very critical. I can’t stand it when she puts me down in front of her brother. Because of this I cannot fully confide in her about everything. There are some things I discuss only with my sister’s husband. I feel close to him as well’.

Josefina was 25 years old and lived with her mother and her older sister. She was from a Greek background but Josefina and her sister had been born and brought up in Australia. Josefina had schizophrenia and was on the disability support pension. She reported that she was very close to her sister. Josefina’s sister who later joined the interview was very keen to know every aspect of her program. She seemed to be involved in every aspect of Josefina’s life. She said, ‘Josefina has this illness and is not capable of taking any decisions. She tells me everything and must consult me before doing anything’. During the interview her sister was also very critical of Josefina. She brought up all her failures at work. She also expressed her genuine concern for Josefina’s future and wanted her to get a job.

 
Despite the critical and overinvolved attitudes exhibited by close ties both these respondents perceived that their closeness had not diminished because they still provided supportive resources that were of great value. Both respondents were confident that that they could always rely on their close ties when they experienced problems. Thus it appears that supportive resources such as security, stability and feelings of belongingness that these close ties provided (or enhanced) may have compensated for some of their negative characteristics. In fact these perceptions may have maintained the recovered state of these respondents. This is a significant finding because it suggests that social networks that display critical, overinvolved or intrusive behaviours may still be supportive.

Assessing support availability and comparing the network characteristics and support availability of the employed and unemployed groups

Support availability refers to the different kinds of supportive resources that flow through the members in the network. This was broadly classified into 4 main areas, namely, concrete support, instrumental support, emotional support and vocational support. Respondents were firstly asked if the different kinds of support were available to them from their networks. Then they were asked to indicate the extent to which each network member could be relied on to provide each kind of support. Table 1 provides information on the kinds of support that respondents perceived their networks could provide. Respondents said that they could rely on their family members and in some cases friends for concrete support. They perceived that family members, friends and treating professionals could be relied on to provide some forms of emotional support particularly comfort and encouragement. Some respondents, who gained employment expressed that they could rely on their work colleagues and supervisors for work related advice, encouragement and support.

Confidante support is an important aspect of emotional support. Item 4 in table 1 was used to assess the availability of this support. Providers of confidante support were usually partners, close friends and in some cases treating professionals. Parents were frequently perceived as confidantes in the case of younger female respondents.

Table 1    Support availability for the two groups at T1 (n=65) 
Nature of support
Proportion of network available
Proportion of network available
 
EMPLOYED
UNEMPLOYED
Drive you to the doctor if 

needed

0.16 (16%)

sd =0.17

0.16 (16%)

sd = 0.14

Loan you money if needed

 

0.14 (14%)

sd =0.08

0.16 (16%)

sd =0.11

Comfort you if you are upset or feeling down
0.19 (19%)

sd =0.11

0.19 (19%)

sd = 0.15

Listen to you talk about your problems without being critical
0.21 (26%) **

sd = 0.11

0.14 (14%) **

sd =0.12

Give you appreciation and encouragement
0.22 (22%)

sd = 0.12

0.24 (24%)

sd = 0.14

Help you cope with the illness or relapse
0.21(21%)

sd =0.10

0.20 (20%)

sd = 0.12

Help you make a major decision
0.17 (17%)

sd = 0.11

0.17 (17%)

sd = 0.15

Give you information on job openings
0.12 (12 %)

sd = 0.09

0.12 (12%)

sd = 0.10

Suggest some actions you should take to help you progress in your career 
0.15 (15%)

sd = 0.11

0.14 (14%)

sd = 0.11

Suggest ways to cope with stressful situations at work
0.21 (21%)**

sd = 0.09

0.13 (13%)**

sd = 0.11

Liaise with your employer if you are experiencing some difficulties at work
0.12 (12%)*

sd = 0.08

0.08 (7. 9 %)*

sd = 0.8

Make job contacts for you

 

0.12 (11%)**

sd = 0.09

0.06 (6.2 %)**

sd = 0.08

Asterisks indicate significance *p<0.02; **P<0.001


Table 1 also illustrates the differences between the 2 groups with respect to support availability. Both groups perceived that their networks were capable of providing various kinds of support. However the significantly higher levels of confidante support and vocational support available to the employed group suggests that people in vocational rehabilitation programs whose networks have the capacity to provide these specific kinds of supports may have better employment outcomes.

Table 2    Network composition at intake (n=65) and at closure (n=62) 
T1 

Employed

Unemployed T2

Employed

Unemployed
Network size
 
 

Proportion of family members in network

10.31

0.46 

(46%)

9.45

0.47

(47%)

10.06

0.47

(47%)

8.18

0.55*

(55%)

Proportion of friends in network  0.19

(19%)

0.13*

(13%)

0.15

(15%)

0.15

(15%)

Proportion of mental health professionals in network 0.30

(30%)

0.31

(31%)

0.22

(22%)

0.24

(24%)

Proportion of workmates in network 0 0 0.15

(15%)

0
Proportion of others in network
 
 

 

0.03

(3%)

0.06

(6%)

0

 

0.05

(5%)

Close ties 0.268*

(27%)

0.148

(15%)

0.29**

(29%)

0.17

(17%)

*p<0.01, **p<0.001


Table 2 shows the differences in the network characteristics of the employed and unemployed groups. Though the groups did not differ significantly in network size and composition, both at the time of intake and closure of the program, the networks of the employed group had significantly higher proportion of friends (p<0.05) and close ties in their networks at both time periods (p<0.01at T1; p<0.001 at T2). Contrary to expectations the network size of the employed group did not increase significantly at the time of closure of their programs despite the fact that they were now working. This was mainly because friends and mental health professionals had been substituted by work colleagues, supervisors and ongoing employment support providers, who could now be relied on to provide various kinds of support. The family network had remained largely the same. Thus work had provided the opportunity for these respondents to diversify the scope of their network though the overall network size remained the same.

The group that remained unemployed on the other hand experienced a marginal decrease in their network size at the time of program closure. This was mainly due to the exit from their network of some of the shorter term treating professionals. Respondents perceived that these professionals no longer played a significant role in their lives and therefore dropped them from their significant network. Many of these respondents, especially those who had experienced relapse and hospitalisation during the course of their programs, reported more family members in their networks at the time of closure. Thus for this group their dependence on family members had increased. The changes in network composition reflect the temporal nature of networks and network relationships and suggest that networks and network relationships may change in keeping with the needs of the person and their situation.

Table 3 Correlations between employment outcome and network structure variables 
Networks characteristics point biserial correlation coefficient
Network size 0.18
Proportion of family 0.03
Proportion of friends 0.23**
Proportion of mental health professional 0.06
Proportion of close relationships 0.36***
The asterisks indicate that the correlations are significant.
***P<0.001
**P<0.05


Table 3 highlights the correlations between network structure variables and employment outcome. The findings suggest that people in vocational rehabilitation programs who have more friends and close relationships in their networks have a greater likelihood of achieving positive employment outcomes. They also suggest that the perceived supportiveness of the network and the kinds of support available to people from the network may be more important than network size in influencing vocational outcomes.

Influence of the family on the course of the program
There is accumulating evidence that the people with whom the individual lives or interacts on a regular basis has a significant influence on their rehabilitation outcomes (Lefley, 1997; Hatfield, 1997). Although most respondents expressed that their families were supportive towards them, the interviews suggested that not all families were as supportive of the individual’s goals to return to work. While some family members were able to play a key role in keeping their relative motivated to work, there were others who were clearly overburdened with their caring role or were very anxious that their relative would have a relapse if they returned to work. Many carers had little support, felt very isolated and were possibly exhausted and drained after several years of caring. The anxieties and burden experienced by family carers is illustrated by the following cases:

Linda was thirty years old, had schizoaffective illness and continued to live with her mother. Linda’s mother had this to say about Linda :

Linda cannot cope with work. Each time she starts working she becomes sick and has to be hospitalised. I have to then manage Jessie (Linda’s daughter) and the house work all on my own. The community centre people only show up when Linda becomes sick and needs to be hospitalised. Work is too stressful for Linda and she has only me to complain to. I am getting old and tired and cannot carry on like this. I wish Linda would stop looking for work and stay home.

Joe, a person from a Croatian background, was 35 years old, had schizophrenia and lived with his elderly parents. Joe’s mother said:

If going to work will make Joe sick again, we prefer that he stay at home. We have put in a lot of effort to keep him well and don’t want this to be disturbed by you people. Joe also loses his dole when he goes for work. They (Social Security Office) are too much trouble.

There were also family networks that wanted their mentally ill relative to work but had no resources in the form of knowledge or contacts to help them. They were totally reliant on professional support to help the relative find work. Some family networks were apprehensive about their relative’s ability to cope with the stress of work. There were also family networks that were keen that their relative should work but wanted them to work only in areas that were in keeping with their family values. This was evident in the case of Peter who had schizophrenia and was placed in a hospital laundry for work training. Peter said after one week of training:

I am not used to washing dirty clothes. My parents don’t want me to do such jobs. My brother is training to be a doctor. I prefer to work in a laboratory.

Peter subsequently enrolled in a 2-year course in laboratory studies. He had significant difficulties in the areas of attention and concentration and could find it difficult to gain employment as a laboratory technician.

Discussion
This study set out to examine the social network characteristics and the role of the network in shaping employment outcomes of people with mental illness participating in a vocational rehabilitation program to gain employment. So far there is little information on the network characteristics of these individuals. The available literature that is largely based on hospitalised populations and data collected at a single point in time has assumed that the networks are small, family dominated and lacking in support. The family network in particular is portrayed as a source of stress for the person. The results of this study clearly demonstrate that this is not the case. They suggest that family dominated networks can be supportive and provide valuable resources that can enhance rehabilitation outcomes.

Current findings that the networks of the respondents in this study were larger than some previous studies (Holmes-Eber and Riger 1990), had a degree of stability and that respondents perceived themselves as playing useful roles within their network suggest that these characteristics may be due to the recovered state of the respondents. It is likely that during the process of recovery from mental illness and as people experience fewer and shorter hospital stays they are able to expand their network, assume significant roles within their networks and give them a degree of stability.

In keeping with previous research family members dominated the network and most respondents lived with their families. However the finding that the family network was supportive and not hostile or stress provoking as indicated by previous studies could be attributed to the recovered state of the respondents. Though the experience of mental illness is traumatic for both the individual and their relatives and can invoke fear, hostility, and distress on both sides, these feelings may subside during the course of recovery and as both sides learn to accept, cope and adjust to the illness. These findings also suggest that networks and network relationships of people with mental illness are not fixed, and can change, depending on the stage of the illness and the needs of the individual at that point in time. Thus assumptions about networks of people with mental illness may be more valid if they are based on longitudinal rather than cross sectional research.

The literature has also assumed that the size of the network is an indication of its support availability. Contrary to previous findings, network size in this study was neither related to support availability nor rehabilitation outcome. These findings are significant because they suggest that the functional characteristics of networks such as the quality of network relationships may be more important than its structural characteristics such as network size in shaping rehabilitation outcomes. The implication of these findings is that network interventions by professionals may be more effective if they are directed towards enhancing the quality of network relations rather than increasing network size.

Present findings provide strong evidence that the closely-knit, family dominated networks of people with mental illness need not necessarily predispose the individual to relapse as indicated by previous research. Since the majority of the respondents in this study were staying with their families and were also maintaining their recovered state it is likely that their highly interconnected family dominated networks in fact helped to maintain their recovered state. As argued by Wortley (1989), highly interconnected kin dominated networks have their advantages because they may foster an intense social support system, thereby reducing feelings of isolation and decreasing the risk of relapse.

The various kinds of support that the family network provided and the close ties that respondents had established with some of their family members highlight the valuable resources that the family can offer towards achieving rehabilitation goals. The findings also suggest that families were however not always completely effective in providing support. There was evidence of stress, anxiety, carer burden and lack of resources in some networks to provide certain kinds of supports. Some family members, particularly carers, were in need of support and respite. There were others who were supportive of their relative’s vocational goals and even encouraged them to participate in the program. However when they had to take independent decisions these families exhibited overprotective attitudes. That the respondents in this study maintained their stable state and valued the support provided by these network members despite their critical and intrusive comments suggests that such attitudes may not always be signs of pathology that lead to relapse and hospitalisation as suggested by previous studies. Instead the intrusive and overprotective attitudes of family members may more likely be a reaction to their anxieties for the well being of their relative, fears of relapse and the associated trauma for the whole family.

The implication of these findings for rehabilitation and mental health service providers is that families play a key role in the recovery process by providing valuable resources and therefore must be involved as partners in the rehabilitation program. The findings also suggest that families experience anxiety and burden even during the recovery stage of their relative’s illness, especially when recovery involves milestones such as taking up employment. Hence support to families must be ongoing and cannot stop once the crisis of mental illness has passed. This study provides some evidence of the kinds of on going support that families may need when their relative has recovered and wants to pursue goals such as work. These include periodic respite from the burden of care, education about their relative’s capacity for work, alleviation of anxieties regarding relapse and loss of income support benefits if their relative starts working. Supportive family members may also need to be educated on ways to provide some forms of ongoing employment support. They may need advice on areas such as what to say to employers when their relative is sick, recognizing (or being alert to) signs of stress and relapse, and contacting the employment support worker or treatment professional early enough to prevent job loss. Since many people who have recovered from mental illness live with their families (or are dependent on them for various kinds of support) it is likely that providing timely advice and support to significant family members can enhance employment outcomes.

While the family network played a significant role in shaping vocational outcomes, current findings show that mental health treatment providers such as general practitioners, psychiatrists and mental health case managers, who constituted the second largest proportion of the network, were also perceived as serving important emotional and instrumental functions. These findings indicate that for people with mental illness dependence on their treatment professionals may continue even after they have recovered from the illness. Therefore employment outcomes can be enhanced if there is close cooperation between rehabilitation or employment support providers and treatment professionals. Furthermore, the finding that employed respondents included their co-workers and supervisors as part of their significant network suggests that these people also have important resources to offer. However, like family members, they will need ongoing professional support and practical advice on matters such as how to provide workplace support, supervision and reasonable accommodations for the worker with mental illness. The provision of this support however, will depend on whether the worker has disclosed their illness to the employer and the level of professional intervention they want at the workplace.

The findings of the study show that resources flowing through the network are in the form of different kinds of support and that network relationships may acquire significance depending on the kinds of support they provide to the individual. While different kinds of support are needed by individuals depending on their circumstances and their stage of recovery from mental illness, several studies have shown that the availability of emotional support, particularly, confidante support, can reduce stress and increase psychological well being (Brown and Harris, 1994; Wills, 1985). Thus individuals who have confidante support may be better able to withstand the stress associated gaining and maintaining employment.

The current finding of a significant association between emotional support, particularly confidante support and employment outcome suggests that the availability of this support may have helped in going through the stress of getting and maintaining employment. That emotional support from significant others can significantly influence employment outcomes is supported by a recent study by Rogers et al (1997). Here the authors state "clearly what was needed for people with mental illness in vocational programs was emotional support". The finding that emotional support and vocational support were significantly (though moderately) correlated with employment outcome suggests that the availability of these supports can positively influence employment outcomes. These findings are significant because they suggest the kinds of network support that must be mobilized if people with mental illness have to cope with the demands of open employment.

Conclusion
This study is exploratory and is limited by a small non random sample of 65 clients who were specifically selected to participate in a vocational rehabilitation program for open employment. However the majority of the clients had a major mental illness and had experienced significant difficulties in gaining and sustaining open employment. The findings of this study are important in the light of the current emphasis on preparing people who have recovered from mental illness to gain employment. The results demonstrate the important role that social networks play in shaping rehabilitation outcomes and lend strong support to the argument that if employment is to become a reality for people with mental illness a more holistic approach to rehabilitation of these individuals is needed.

Job training and placement support activities which currently comprise the major part vocational rehabilitation programs for the recovered mentally ill must be complemented by the cultivation of a supportive environment at different levels that can sustain their skills and accommodate their disabilities. Since the family forms the largest part of the network and has several resources to offer, the first level for professional intervention should be directed towards supporting and involving this network. Reluctance on the part of professionals to work with this network due to preconceived notions that families cause or exacerbate mental illness may be one of the reasons for the failure of vocational rehabilitation programs. From this broader perspective successful employment outcomes for people with mental illness will depend not only on the individual who is seeking employment but also equally on the coordinated efforts of professionals, family members, employers, work colleagues and several organisations.


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