Integration of mental
and psychomotor training in
vocational rehabilitation for persons with
illness improves employment
Annick Myszta, MSc1
Yves MoriŽn, MSc1
AZERTIE, Boddenveldweg 11, 3520 Zonhoven, Belgium
2. Department of Rehabilitation Sciences, KU Leuven, Tervuursevest, 101, 3001
Myszta A & MoriŽn Y.(2016) Integration of mental and psychomotor training
rehabilitation for persons with mental illness improves employment.
International Journal of Psychosocial Rehabilitation. Vol 20 (2)
Jan Knapen, AZERTIE Boddenveldweg 11, 3520 Zonhoven, Belgium
E-mail address: firstname.lastname@example.org
mental health problems, such as depression, burnout, personality disorders, anxiety-
and somatoform disorders are often associated with unemployment. Employment is
for many people with a mental vulnerability not only a source of financial
income, but employment also determines their social status and inclusion,
identity and self-image.
In order to increase the employment rate of people with a mental vulnerability
a centre for vocational rehabilitation in Belgium (AZERTIE) developed the I
The I Care program, a combination of psychomotor and mental training, resulted in
a employment over than 50% of people with a mental vulnerability. After
at least one year employment 90% was still at work. When we compare the
employment rate (over than 50%) with the rate of the period before the start-up
of the I Care program (10%), we can conclude that the I Care program increased
the employment of this vulnerable group five-fold.
Keywords: vocational rehabilitation, mental and psychomotor
An analysis of data
from the National Co-morbidity Survey Replication, a US nationally
representative household survey, found that overall impairment was
significantly higher for mental disorders than for chronic medical disorders
(Druss et al., 2009). Severe functional impairment was reported by 42% persons
with mental disorders and 24% with chronic medical disorders. Mental illnesses
increase the risk of decreased workplace productivity and absenteeism resulting
in lowered income, unemployment and social exclusion.
Common mental health problems, such as depression, burnout, personality
disorders, anxiety- and somatoform disorders (physical symptoms caused by
mental or emotional factors) are often associated with work absenteeism. In
Belgium, mental illnesses are the leading cause of work absenteeism, namely in
46.99% of cases (Rijksinstituut voor ziekte- en invaliditeitsverzekering,
2013). The percentages of unemployed disabled as consequence of disorders of
the musculoskeletal system (28.75%) and cardiovascular disease (6.67%) follow
in the second and third place.
Employment is for many people not only a source of financial income, but
employment also determines their social status and inclusion, identity and
self-image. For people with a mental vulnerability this is no exception.
However, to find and retain employment is for them not an easy task (Knaeps,
2015; Reme et al., 2015). In the Belgian healthcare sector, there is little
attention to reintegrating former patients into the labour market. While
resuming work right can contribute to the recovery. After all, to many people
with mental vulnerabilities, the participation in the labour market is seen as
a sign of recovery.
People with a mental vulnerability are typically characterized by low
self-esteem, depression and anxiety symptoms, and decreased physical and mental
resilience (Michon, 2006). This target group has more often than not somatic
health problems, primary or secondary associated to the psychological
vulnerability (De Hert et al., 2011). Many people with mental vulnerability
experience a weak physical fitness, low exercise tolerance, fatigue and a
reduced ability to focus, a reduced task tension and stress resistance and
increased irritability. In these patients, a weak physical fitness and a low
physical self-concept, combined with other barriers to participation in
exercise, such as deficient self-motivation and self-enhancement strategies,
psychosomatic complaints, lack of any internal locus of control concerning
their health, deficit of energy, and general fatigue may lead to a vicious
cycle of loss of self-confidence, decreased self-esteem, an increased avoidance
of physical activity, and a general physical de-conditioning (Knapen et al.,
2015). This downward spiral handicaps their working abilities and employment
opportunities. Moreover, personal issues such as family and parenting problems,
limited social skills, a low education level, loneliness, social isolation,
transport and housing problems, and stigmatization complicate their
re-integration into the labour market (Michon, 2006).
factors and impeding factors in the vocational rehabilitation.
Centre for Research and Consultancy in Care of the KU Leuven (Belgium) carried
out research on the vocational rehabilitation of individuals with psychological
vulnerability (Knaeps, 2015). The researcher interviewed 24 work counsellors to
their vision of the impeding factors and the success factors in vocational
rehabilitation. As impeding factors mentioned the work counsellors low
motivation, a limited self insight, lack of proper attitudes, serious
psychological problems, lack of proper housing and transportation problems,
while work readiness, adequate work attitude, self-insight, self-management
skills, a good physical health and fitness, and a solid social network right
contribute to success in vocational rehabilitation.
Care concept: integration of psychomotor and mental training in vocational
a centre for vocational rehabilitation in Belgium, guides for over 30 years
individuals with a work disability to various attendant functions such as
general clerking, networking, administrating or programming.
The past 5 years AZERTIE noticed a strong increase in the number of individuals
with a mental vulnerability. Initially the dropout of this target group was
very high, over than 50% (20% for clients without psychological vulnerability),
and the employment rate very low, approximately 10% (60% for clients without
psychological vulnerability). In order to reduce the dropout and to increase
the overall employment rate of this vulnerable group, the director and company
doctor of AZERTIE developed the I CARE program. This program is intended for
job-seekers with mental disorders, often associated with somatic diseases, that
are after a long period of inactivity attempting to reintegrate into the formal
labour circuit. From the start the I Care concept was based on the scientific
evidence of psychomotor and mental training on the mental and somatic health of
this very vulnerable group, under the maxim “doing what works" (Cooney et
al., 2013; Knapen & Vancampfort, 2014; Silveira et al., 2013). The
integration of psychomotor and mental training in the vocational rehabilitation
of people with mental vulnerability is an example of good clinical practice for
a structural collaboration between the work rehabilitation and the mental
health care in Belgium. The I Care team aspires to an efficient and sustainable
reintegration in the labour market.
approach with the focus on the success factors in the vocational rehabilitation
Care program strongly focuses on the most important personal success factors in
the vocational rehabilitation of people with a mental vulnerability namely,
work readiness, the work attitude, the mental and physical resilience, the self
image and self efficacy, the severity of symptoms, an internal locus of
control, and self-management skills (Knaeps, 2015; Michon, 2006; Reme et al.,
2015). The eclectic I Care concept integrates the basic principles of the
vocational rehabilitation, the recovery-oriented care, cognitive behavioural
therapy, psychomotor therapy, and solution-oriented therapy.
collaboration and method
interdisciplinary I Care team consists of the director of AZERTIE (clinical
psychologist), a company doctor who is responsible for the inclusion of the
clients, the medical follow-up and contacts with the treating physicians, and a
psychomotor therapist/physical therapist and a clinical psychologist who are
respectively responsible for the psychomotor and mental training. The I Care
team members work closely with the job counsellors who accompany the clients
during their training, internship and employment. The participants of the I
Care program follow during their training and accompaniment three sessions per
week mental training (1 h 30) and psychomotor training (1 h 30) over a period
of 10 weeks. Psychomotor training includes individually adapted fitness
training, stretching, yoga exercises and breathing exercises, education around
dealing with pain and fatigue complaints, desk gymnastics and ergonomic advice.
The mental training consists of various relaxation and stress management
techniques, assertiveness training, coping skills with crisis situations, goal
setting, verbal and non-verbal communication skills, job skills, and relapse
prevention (Reme et al., 2015). The basic philosophy is 'a healthy mind in a
objectives of the I Care program are to increase and improve the work
readiness, the labour attitude, the mental and physical resilience, self image,
confidence, target and solution-oriented action, and social skills.
primary objective of the study was to investigate the effectiveness of the I
Care program on the inflow and maintained employment of people with a
psychological vulnerability into the regular labour market.
The secondary objective was to evaluate the effectiveness of the I Care program
on a number of psychological and physical variables.
the period from May 2010 until present 141 clients participated in the study.
The group consisted of people with mood and anxiety disorders, burnout, autism
spectrum syndrome, personality problems, psychosomatic disorders such as
chronic fatigue and fibromyalgia. Fourteen clients suffered from psychotic
disorders. However, these persons were stabilized. Most participants had
somatic health problems as well, mainly musculoskeletal diseases and chronic
pain. In a number of patients the psychological vulnerability was secondary
related to a severe somatic pathology such as cancer. Written informed consent
was obtained from all participants before entering the study.
the 10 weeks I Care program 27 of the 141 (19.15%) participants dropped out.
Immediately after the I Care program 8 of the clients (7.02%) found a suitable
job. The remaining 106 clients followed after the I Care program additional
training at AZERTIE of which 49 (46.23%) were employed within the year.
Currently 24 clients are in training, of which 3 (12.50%) have a perspective on
work. Thirty-three participants (23.40%) ended the training without any
perspective on paid work.
At a follow up after at least one year employment 90% of the clients was still
After the 10 week program the participants improved on the variables
depression, anxiety disposition, self-esteem, coping style, cardio-respiratory
fitness, and fatigue and pain perception. These results will be published
integration of psychomotor and mental training in vocational rehabilitation of
people with psychological vulnerability resulted in a total employment over
than 50%. After at least one year employment 90% of the clients was still at
The major limitation of the study is the lack of a no-treatment control group.
Therefore the results should be interpreted cautiously. Nevertheless, when we
compare the total employment rate (over than 50%) with the rate of the period
before the start-up of the I Care program (10%), we can conclude that the I
Care program increased the employment of this vulnerable group five-fold.
Moreover the dropout rate (19.15%) is significantly lower than before (>
50%). The dropout is even significantly lower than those of a global
psychiatric-epidemiological study of the World Health Organization (n = 63678)
which reports that nearly a third (31.7%) of all people with mental illness
stop their treatment preliminary to the intends of the provider (Wells et al.,
The team strives to optimize the I Care program by a systematic satisfaction
survey and feedback from clients and a continuous internal evaluation by
the team members.
G., Dwan, K., Greig, C., Lawlor, D., Rimer, J., Waugh, F., McMurdo, M., &
Mead, G. (2013). Exercise for depression. Cochrane Database of Systematic
Reviews, Issue 9. Oxford: Cochrane Collaboration.
De Hert, M., Correll, C., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I.,
et al. (2011). Physical illness in patients with severe mental disorders. I.
Prevalence, impact of medications and disparities in health care. World
Psychiatry, 10, 52-77.
Druss, B., Hwang, I., Petukhova, M., Sampson, N., Wang, P., & Kessler, R.
(2009). Impairment in role functioning in mental and chronic medical disorders
in the United States: results from the National Comorbidity Survey Replication.
Molecular Psychiatry, 14, 728-737.
Knaeps, J. (2015). Vocational rehabilitation: people with mental health
problems, vocational rehabilitation counselors, mental health practitioners.
Doctoral dissertation. Leuven: KU Leuven.
Knapen, J., & Vancampfort, D. (2014). Exercise for depression and anxiety:
an evidence based approach and recommendations for clinical practice. In: M.
Probst, & A. Carraro (Eds.), Physical activity and mental health in a
practice oriented perspective (pp. 91 - 100). Milan: Edi.Ermes.
Knapen, J., Vancampfort, D., MoriŽn, Y., & Marchal, Y. (2015). Exercise
therapy improves both mental and physical health in patients with major
depression. Disability and Rehabilitation, 37(16), 1490-1495.
Michon, H. (2006). Personal characteristics in vocational rehabilitation for
people with severe mental illness. Doctoral dissertation. Utrecht: Trimbos
Reme, S., Grasdal, A., LÝvvik, C., Lie, S., & ōverland, S. (2015).
Work-focused cognitive–behavioural therapy and individual job support to
increase work participation in common mental disorders: a randomised controlled
multicentre trial. Occupational & Environmental Medicine, 72, 745-752.
Rijksinstituut voor ziekte- en invaliditeitsverzekering (2013). Jaarverslag
2013 - Vijfde deel statistische gegevens (Annual report 2013-part five
statistical data). www.riziv.fgov.be.
Silveira, H., Moraes, H., Oliveira, N., Coutinho, E., Laks, J., &
Deslandes, A. (2013). Physical exercise and clinically depressed patients: a
systematic review and meta-analysis. Neuropsychobiology, 67(2), 61-8.
Wells, J., Oakley, M., Browne, M., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso,
J., et al. (2013). Dropout from out-patient mental healthcare in the World
Health Organization’s World Mental Health Survey initiative. British Journal of
Psychiatry, 202, 42-49.