Why should employers be interested in hiring people with mental illness? A review for occupational therapists

Abstract

BACKGROUND:

Stigma and discrimination against people with mental illness have a negative impact on their vocational integration. The rates of their labor force participation worldwide are still low. The reason for this, from the perspective of employers, is their reluctance to employ them due to a number of fears and concerns.

OBJECTIVE:

This review examines the literature of the last 25 years on the employment of people with mental illness to identify employers’ benefits from their employment and to provide recommendations for occupational therapists.

FINDINGS:

The importance of employing individuals with mental illness is emphasized. This review identifies a research gap on the benefits of their employment from the perspective of employers, and presents the findings of studies that explore the benefits of employing individuals with disabilities.

CONCLUSIONS:

Information and greater awareness are pointed out to be the major ways of improving the employment rates of people with mental illness. The proposed challenge for occupational therapists is to demonstrate the effectiveness of their employment to all interested parties. Future research should focus on the economic impact of mental illnesses and on the outcomes of employing individuals with mental illness from the perspective of employers.

Keywords

Employers mental illness benefits labor market occupational therapists

1 Introduction

In the fields of vocational integration and mental illness, recent literature has clarified many issues that are to be addressed. Stigma and discrimination against people with mental illness are associated with less understanding, flexibility, and support from parts of society (Secker, Grove, & Seebohm, 2001), and have an economic impact on them (Sharac, McCrone, Clement, & Thornicroft, 2010), which is evident in their labor marginalization (Brohan et al., 2012; Brouwers et al., 2016), and the prevention of their full and active social inclusion (Krupa, Kirsh, Cockburn, & Gewurtz, 2009). There is an expressed and widely generalized opinion that people with mental illnesses are “dangerous”, and “unpredictable”, to which could be attributed some of the social distance from them (Crisp, Gelder, Rix, Meltzer, & Rowland, 2000; Reavley, Mackinnon, Morgan, & Jorm, 2014). Among people with mental illness, those with severe mental illness face even more intense stigmatization (Wood, Byrne, Varese, & Morrison, 2016). Severe mental illness can make the vocational integration of people affected by it significantly more difficult (Harvey & Henderson, 2009; Waynor, Gill, & Gao, 2016), resulting in obstacles, such as restricted employment opportunities (Boardman, 2003). Becker and Drake (2003) point out that people with severe mental illness are labelled as more different in comparison to people without mental illness rather than more similar to other employees.

Employers appear to hold stigmatizing attitudes toward persons with mental illness (Scheid, 2005). In Brohan et al. (2012) systematic review, the vast majority of studies found employers were less likely to hire individuals with mental illness in comparison to individuals without disabilities and those with other physical disabilities. The challenges that employers see when confronting a person with mental illness can act as a deterrent to their employment (Shankar et al., 2014). As a result, the rates of labor force participation of people with mental illness, and particularly with severe mental illness, worldwide are still low (Baron & Salzer, 2002; Burke-Miller et al., 2006; Contreras et al., 2012; Luciano & Meara, 2014; Marwaha et al., 2007; Waghorn & Chant, 2002; Waghorn et al., 2012), “unacceptably low” as characterized by Modini et al. (2016). These rates show the considerable extent of social exclusion of people with mental illness (Marwaha et al., 2007) and their workplace discrimination even in higher developed countries (Brouwers et al., 2016).

Even when the vocational entry of individuals with mental illness is achieved, questions concerning the quality of such employment and career development still remain (Gewurzt, Cott, Rush, & Kirsch, 2012). It is noteworthy that in the study of Halliday, Coveney, Henderson, and Dip (2014), participants with mental illness stated that if they did not have a mental illness, their career development would have been better. People with mental illness, however, are not only concerned for their employment in the first place, but also their chances of keeping their jobs as a long-term prospect (Secker et al., 2001). That is why many of them often do not disclose their condition to their employers (Toth & Dewa, 2014), as disclosure of mental illness is linked to risks in workplace relationships and to unclear effects on efforts at vocational integration (Jones, 2011).

The vocational obstacles that people with mental illness face are more intense when the mental illness is severe. It has been indicated that people with severe mental illness are less likely to be full-time employed and earn considerably less in comparison to people without mental illness (Luciano & Meara, 2014). The goal of people with psychiatric disabilities and severe mental illness in general in finding a job in compliance with their interests remains for many of them unattainable (Gewurtz, Cott, Rush, & Kirsh, 2014; Mueser & Cook, 2012). In addition, although people with severe mental illness, such as schizophrenia, work in a variety of jobs, “low status” or “entry level” job types, such as cleaners and janitors, are highly represented as in many cases these are the only jobs available (Baron & Salzer, 2002; Marwaha et al., 2007; Mechanic, Bilder, & McAlpine, 2002).

Despite the aforementioned issues, people with mental and even severe mental illness appear to want to work (Blank, Harries, & Reynolds, 2014; Mechanic, Bilder, & McAlpine, 2002). According to Boardman (2003), people with psychiatric disabilities want to work, but not all of them want to be employed. Work is something meaningful that you offer others without getting officially paid for it, as within employment (Boardman, 2003). The fear of loss of health insurance and of other economic benefits through employment (O’Day, Kleinman, Fischer, Morris, & Blyler, 2017), as well as the fear of more stressful conditions and responsibilities (Boardman, 2003), constrains many people with mental illness from taking up employment.

The current review examines the literature of the last 25 years on the employment of people with mental illness to identify the benefits of employment, provide recommendations for occupational therapists, and propose future research directions. As there is a lack of studies on the benefits of employing individuals with mental illness from the perspective of employers, this review also explores a combination of research in different spheres concerning people with disabilities to come to overall conclusions. This review aims to contribute to this literature by presenting the most current studies in this field and by pointing out the research gaps in the topic of open employment for people with mental illness, as well as the fact that studies are mostly concentrated on supported employment programs for people with this form of disability. An electronic search of the literature and research findings in the field of the vocational integration of people with mental illness was conducted in Google scholar, Pubmed, PsycINFO, Web of Science, and The Cochrane Database of Systematic Reviews, using key words based on terminology related to the benefits of employing people with mental illness and in general to their employment.

2 The meaning of employment

In general, employment is considered to enable the full and meaningful social participation of people with mental illness (Knapp et. al., 2013; Waghorn & Lloyd, 2005). The importance that society plays in employment is inherent to the values individuals with mental illness place on professional careers, so if they do not succeed in their field, a sense of failure follows that negatively affects their self-assessment (Halliday et al., 2014). Employment can have positive effects, even when the mental illness is severe. It has been indicated that employment has a positive effect on the quality of life of individuals with severe mental illness, and on their incomes, and can even lead to improvements in their clinical condition and their recovery (Baron & Salzer, 2002; Knapp et al., 2013; Luciano et al., 2014; Mueser, Drake, & Bond, 2016). Employment also appears to be a route to social inclusion after psychiatric hospitalization (Rogers, 1995), and can help individuals with severe mental illness detach themselves from the identity of the patient, be less dependent on mental health services (McHugo, Drake, Xie, & Bond, 2012), and more independent in general (Knapp et al., 2013). Employment is also connected to socializing opportunities for them, as well to a general sense of belonging and of having accomplished something (Blank, Harries, & Reynolds, 2014).

Thus, it emerges that employment opportunities should always be open for people with mental illness and severe mental illness (Harvey & Henderson, 2009), especially during the difficult and crucial period of the onset of their disability and their navigation of that disability process, during which they may need work flexibility, part-time work or other kind of work arrangements to manage, without being detached from the prospect of having a professional career (Halliday et al., 2014).

3 Employers’ fears and concerns

Only a minority of employers actually employ persons with disabilities (Bara, 2015), in particular with mental illness, even though they are in general willing to discuss and think about their employment (Sharac et al., 2010). Employers have fears and concerns with regard to the employment of people with mental illness, as many of them find mental illness “frightening” and consider that people suffering from it could be more aggressive and threatening (Biggs, Hovey, Tyson, & MacDonald, 2010).

Employers fears concern the level of danger of employees with mental illness, both for themselves and for others, as they think that their behavior can be unpredictable (Scheid, 2005). In addition, employers concerns relate to productivity factors, such as incompetence, higher absenteeism, the need for additional supervision, and an inability to apply regulations and rules (Biggs et al., 2010; Corrigan, 2004), as well as personal factors, such as issues of trust with regard to their ability to handle clients’ personal data or company’s economic data and behavioral issues (Biggs et al., 2010; Mechanic et al., 2002). Employers’ concerns are also related to the social and emotional skills of people with mental illness (Hand & Tryssenaar, 2006), and to the psychiatric symptomatology and its effect on the workplace (Diksa & Rogers, 1996). Moreover, Krupa et al. (2009) report that within the workplace, a climate of doubt and questioning as to the existence and the extent of non-visible situations, such as mental illness, is common.

4 Previous working experience and contacts with people with mental illness

In general, employers’ previous working experience with people with disabilities seem to eliminate their fears and concerns (Bara, 2015), and in the case of a positive interaction, to lead to more positive attitudes toward them (Chi & Qu, 2003; Hernandez, Keys, & Balcazar, 2000), as employers can realize more easily the benefits of their employment (Morgan & Alexander, 2005). Employers’ positive experiences with people with mental illness are also correlated with more positive attitudes toward their employment and more positive beliefs (Hand & Tryssenaar, 2006). Previous working experience has been shown to alleviate employers’ fears even with regard to the employment of people with psychiatric disabilities (Diksa & Rogers, 1996). It is reported that meeting people with severe mental illness, especially face to face, can be an effective way of reducing stigma among adults (Corrigan, Morris, Michaels, Rafacz, & Rüsch, 2012), as well as direct contact with persons with disabilities being found to have a positive effect on employers’ attitudes (Nota, Santilli, Ginerva, & Soresi, 2014). However, simple contacts with people with severe mental illness, do not seem to prevent more individuals who have such contacts adopting negative views about them, such as how dangerous people with schizophrenia can be (Crisp et al., 2000).

5 Answers to employers’ fears and concerns

What are the answers to the fears and concerns that employers have with regard to the employment of people with mental illness? As aforementioned, there is a lack of studies, apart from fragmented reports and findings from randomized controlled trials regarding supported employment programs, on the benefits of employing individuals with mental illness from the perspective of employers. In contrast, there is a relative wealth of studies with regard to people with disabilities in general that provide answers to most employers’ questions, the findings of which are discussed below.

5.1 Productivity and reliability factors

Graffam, Smith, Shinkfield, and Polzin (2002) argue that employees with disabilities are generally rated lower than employees without disabilities on productivity issues, such as speed and accuracy, but are rated higher on reliability and maintenance issues, such as absenteeism and safety, the outcome being a sufficiently productive and trustworthy employee who it is to employers’ benefit to keep in their employment. In the study of Hernandez and McDonald (2010), the overall performance of employees with disabilities was found to be almost equal to that of employees without disabilities, without any additional supervisory demands on the part of the employers. In the same study, people with disabilities also appear to hold a variety of job positions, proving that people with disabilities are not only capable of specific or low-qualified positions.

5.2 Workplace accommodations

With regard to workplace accommodations for employees with disabilities, it is found that most of them are of no or little cost for employers (Graffam et al., 2002; Hartnett, Stuart, Thurman, Loy, & Batiste, 2011; Hernandez & McDonald, 2010), and are beneficial for both employees with and without disabilities (Hernandez & McDonald, 2010). For people with psychiatric disabilities, unlike physical disabilities, workplace accommodations predominantly comprise some kind of support, such as more training or supervision on the part of the employers (MacDonald-Wilson, Rogers, Massaro, Lyass, & Crean, 2002). Becker and Drake (2003) mention that the cost of accommodations for employees with severe mental illness appears to be low.

Workplace accommodations for employees with disabilities also appear to be a way for employers to keep conscientious and loyal employees in their job positions, with obvious productivity benefits for them (Hartnett et al., 2011). In addition, it is reported that workplace accommodations for employees with disabilities can have a positive impact on employees’ productivity through the provision of necessary modifications that can correct previously wrong or ineffective work practices, concerning, for example, safety and supervisory issues, and these are beneficial for employers (Graffam et al., 2002).

5.3 Organizational benefits and financial profits

The main question for employers remains the financial profit or cost for their company in the case of employing individuals with disabilities (Hernandez & McDonald, 2010). In calculating the cost of the employment of individuals with disabilities, it should be taken into account that there are some specific costs connected with the employment of every employee (Graffam et al., 2002). Changes and modifications to the workplace for employees with disabilities are also linked to an improvement in the corporate climate (Hartnett et al., 2011). In Graffam et al. (2002) study, employers stated more organizational benefits than costs as a result of the changes and modifications to the workplace adjusting for employees with disabilities. Indicative explanations for this result are improved relationships within the work environment that can lead to higher productivity, as well as to the good performance of employees in terms of productivity and reliability factors that can lead to higher standards for the other employees.

5.4 Corporate responsibility and compliance with the law and the society’s values

Despite the, in many cases, discriminative beliefs of employers with regard to individuals with disabilities, employers appear to believe that nowadays it is more a matter of society’s values in showing positive attitudes to individuals with disabilities, and that is why they more willing now to change their attitudes toward them (Hernandez et al., 2000). The buying public also appears to have a preference for socially responsible and conscious companies (Siperstein, Romano, Mohler, & Parker, 2006).

The employment of people with disabilities is associated with compliance with the law, as employment can promote equal rights and opportunities for people with disabilities, as regulated by laws and dictated by society’s values (Graffam et al., 2002). Scheid (2005) argues that employers’ compliance with the Americans with Disabilities Act has actually to do with whether employers fear the consequences of not applying the law or believe that it is what they ought to do, as when they believe in the employment of people with mental illness and in the value of work place diversity, they are more likely to hold less stigmatizing attitudes and to provide more supportive work environments for them.

5.5 Supported employment

There is a variety of approaches for the vocational integration of people with severe mental illness, especially in terms of supported employment, such as sheltered work, enclaves, social firms, and individual placement and support (IPS) models (Burns, White, & Catty, 2008; Drake & Bond, 2008; Knapp et. al., 2013; Tsang, Chan, Wong, & Liberman, 2009). Supported employment is described as an alternative practice facilitating the successful vocational integration of persons with severe mental illness (Bond et al., 2007; Contreras et al., 2012), with positive vocational outcomes for them (Burke-Miller et al., 2006), especially for young adults (Wehman, Chan, Ditchman, & Kang, 2014). For example, it has been found that IPS can double the work potential for individuals with psychotic illnesses (Burns et al., 2008). In general, IPS appears to be one of the most cost-effective ways of managing competitive employment for people with severe mental illness (Bejerholm, Areberg, Hofgren, Sandlund, & Rinaldi, 2015; Bond, Drake, & Becker, 2008; Bond, Drake, & Campbell, 2014; Bond et al., 2007; Fioritti et al., 2014; Knapp et al., 2013).

According to Cimera (2009), supported employees with mild mental retardation have a much longer tenure in their jobs in comparison to their colleagues without disabilities. This finding can be attributed to the fact that supported employees are interested in job positions such as fast food restaurants, and are more willing to work there for longer periods of time in comparison to people without disabilities, who only see these kind of jobs as temporary and transitory stages to other positions. In these cases, Cimera (2009) characterizes supported employees as “viable alternatives” for employers. It is also noted that in the same study these employees scored higher in reliability in comparison to their colleagues without disabilities. In addition, it is noted that Mueser, Becker, and Wolfe (2001) connect the matching of work with persons’ with severe mental illness preferences with their longer job tenure.

6 The other side

Thomas and Morris (2003) tried to estimate the direct and indirect costs of adults’ depression in the UK in 2000. With respect to employment, the researchers reported that there were 109.7 million days of work lost from the inability to work due to depression, approximately one fifth of working days, leading unavoidably to a greater burden for colleagues and the probable need for a replacement employee. The higher rates of absenteeism among employees with mental illness in the UK and US were also pointed out by Almond and Healey (2003) and French and Zarkin (1998) respectively. Moreover, MacDonald-Wilson et al. (2002) study reported that employees with psychiatric disabilities had lower job tenure in comparison to the median job tenure of employees without disabilities. In the same study, difficulties were noted for employees with psychiatric disabilities in interactions with others, adjustment to the work environment, as well as sometimes in their cognitive skills and their ability to cope with their symptoms and job pressure.

The findings of this review are briefly presented in Tables 1 and 2.

Table 1
Open employment outcomes of employees with mental illness

Open Employment In comparison to employees without disabilities People with disabilities in general People with mental illness

Productivity factors Lower speed •

Lower accuracy •

Overall sufficient performance •

Capable of a variety of jobs •

No additional supervisory demands •

Difficulties in the adjustment to the work environment •

Difficulties in their ability to cope with their symptoms/job pressure •

Difficulties in cognitive skills •

Reliability factors Lower absenteeism •

Higher absenteeism •

Lower tenure •

Rated higher in safety issues •

Personal characteristics Conscientious •

Loyal •

Trustworthy •

Workplace accommodations Of no or little cost • •

Beneficial for the rest of the employees •

Organizational benefits/financial profits Improvement in the corporate climate/relationships within the work environment •

Difficulties in interaction with others •

Higher standards for the other employees •

Higher productivity in the workplace •

Corporate responsibility/compliance with the law and the society’s values Preference for socially responsible companies by the buying public •

Compliance with the law and the society’s values promoting equal rights •

Open Employment	In comparison to employees without disabilities	People with disabilities in general	People with mental illness
Productivity factors	Lower speed	•
	Lower accuracy	•
	Overall sufficient performance	•
	Capable of a variety of jobs	•
	No additional supervisory demands	•
	Difficulties in the adjustment to the work environment		•
	Difficulties in their ability to cope with their symptoms/job pressure		•
	Difficulties in cognitive skills		•
Reliability factors	Lower absenteeism	•
	Higher absenteeism		•
	Lower tenure		•
	Rated higher in safety issues	•
Personal characteristics	Conscientious	•
	Loyal	•
	Trustworthy	•
Workplace accommodations	Of no or little cost	•	•
	Beneficial for the rest of the employees	•
Organizational benefits/financial profits	Improvement in the corporate climate/relationships within the work environment	•
	Difficulties in interaction with others		•
	Higher standards for the other employees	•
	Higher productivity in the workplace	•
Corporate responsibility/compliance with the law and the society’s values	Preference for socially responsible companies by the buying public	•
	Compliance with the law and the society’s values promoting equal rights	•

Table 2

Supported employment outcomes of employees with mental illness

Supported employment	In comparison to employees without disabilities	People with disabilities in general	People with mental illness
Reliability factors	Longer tenure		•
	Higher reliability		•
Organizational benefits/financial profits	Interested in temporary/transitory job positions		•
	Cost-effective way of managing competitive employment		•

7 Conclusions

This review has found that mental illnesses are accompanied by stigma and discrimination in labor market outcomes for people suffering from them. Few studies have examined the exact forms that this stigmatization take in affecting the employment of people with mental illness. Most studies related to this matter have focused on employers’ attitudes toward the employment of people with mental illness, revealing their reluctance. Stigma has a cost for people with mental illnesses as units, but also for society overall, as stigma can prevent their employment, and social integration, reduce their income, and even worse exacerbate their health issues, while at the same time there is a loss in productivity for society (Sharac et al., 2010). These findings point to the need to consider the challenges that people with mental illness face in their everyday lives in any effort to enhance their employability and their social integration. Intervention strategies need to be developed to confront stigma and discrimination against individuals with mental illness, and there is a need for targeted interventions, not only for people with mental illness as a general group, but also for people with specific mental illnesses, e.g., depression or schizophrenia-spectrum diagnosis (Wood et al., 2016), whether in the form of group therapy or individual therapy, as Morrison et al. (2016) suggest.

The focus for the vocational integration of people with disabilities should be on employers, as they are the ones who finally decide whether to hire them or not (Wehman, 2011). Corrigan (2004) and Corrigan, Kerr, and Knudsen (2005) consider employers as one of the “power groups” that have a significant role in the life of a person with mental illness, and can form or affect discriminatory attitudes toward them; this is the reason why anti-stigma programs should target these groups. Better and more current information can help employers understand that people with mental illness can choose the pathway of competitive employment and be successful at it. Houtenville and Kalargyrou (2012) argue that communicating the benefits of employing individuals with disabilities to employers would make them less reluctant to hire them. Accurate information and greater awareness have been pointed out as the major ways to fight stigma and discrimination against people with mental illness and to improve the employment rates of these people (Biggs et al., 2010; Sharac et al., 2010). The emergent need for the provision of more accurate information to employers with regard to the employment of people with mental illness has been pointed out by Biggs et al. (2010). Indicative of that need is also employers’ statement that there is little guidance concerning the employment of people with mental illness (Biggs et al., 2010).

A crucial role in the enhancement of employment of people with mental illness appears to be played by the self-perception of their disability and not the actual existence of that disability (Goldberg et al., 2008). In Brouwers et al. (2016) recent study, approximately 60% of the participants with major depressive disorders had not applied for a job due to anticipated discrimination. Thus, it is not only what is actually out there, but also what people think could happen on the base of their disability. Consequently, occupational therapists have to communicate the benefits of employing people with mental illness, not only to the employers but also to people with mental illnesses themselves. It is highly important to understand that the reality of their mental illness can coexist with a meaningful professional career (Halliday et al., 2014). To this purpose occupational therapists could probable focus on the effect of “occupational balance” on well-being and health related issues of people with severe mental illness, as has been shown in the study of Bejerholm (2010) in individuals with schizophrenia.

Furthermore, occupational therapists should help people with mental illness to overcome the so-called “benefit trap” (Falkum et al., 2017), due to which they appear to be confused about their motivations to work. The benefits system is recognized as a major barrier to the vocational integration of people with severe mental illness (Secker et al., 2001), such as schizophrenia (Rosenheck et al., 2006). O’Day et al. (2017), in their recent review, also found that a focus should be placed on the prevention of people with mental illness falling into the disability trap. Occupational therapists have to help them see the necessity of work and also realize that even people with broad schizophrenia spectrum disorders can work, not only in sheltered work but also in competitive employment (Falkum et al., 2017). The challenge for occupational therapists, according to Perkins and Rinaldi (2002), is to demonstrate the effectiveness of employment to all the interested parties. Motivation for people with psychiatric disabilities is a crucial factor for their vocational success (Boardman, 2003), and that is why occupational therapists should focus on ways to motivate these people. On that point, Baron and Salzer (2002) argue that occupational therapists, in their effort to communicate the benefits of employment to their clients with severe mental illness, should first try give them a true picture of the labor market, without hiding the fact that they may not earn much or that they may have a “flat” career, but at the same time trying not to disappoint or discourage them, pointing out all the time the necessity of work. Boyer, Hachey and Mercier (2000) set “age” as an additional variable in the effort of occupational therapists to motivate individuals with severe mental illness, supporting that occupational therapists should help older individuals to set new vocational goals and overcome a possible loss of self-esteem and younger individuals to realize their actual potentials and goals.

In conclusion, there is a need for anti-stigma campaigns for people with mental illness, to conquer the negative views toward them, which according to Crisp et al. (2000) is a complex, slow, and long-term process in engendering results. These campaigns have to start in the early stages, such as school age, and focus on the provision of knowledge (Crisp et al., 2000). According to Corrigan et al. (2012), educational approaches for adolescents are crucial for changing stigma toward mental illness. These campaigns, however, should also bear in mind other variables, such as the power of the media in the formation of attitudes toward these people (Crisp et al., 2000). Media presentations of people with mental illness are likely to have a negative effect on employers’ attitudes toward them (Secker et al., 2001). The main message of these campaigns should be that disability does not have to be at the expense of the equality of the rights of people with disabilities to the rest of population.

With regard to this review, there are limitations that have to be taken into account. Due to the lack of relevant studies on people with mental illness, the review has considered a combination of research indifferent spheres concerning people with disabilities to come to overall conclusions about the benefits for the employers of employing people with mental illness. However, safe and accurate conclusions can be drawn only when the issue of the vocational integration of people with mental illness is faced separately from other disabilities, due to the wide range of mental illnesses (American Psychiatric Association, 2013), the dilemmas with regard to their classifications (Brown & Barlow, 2005), and the extra difficulties and the more intense labor stigmatization that already exists toward mental illness (Boardman, 2003; Wood et al., 2016). In addition, it has examined a combination of research areas to come to overall conclusions regardless of the cultural differences of the groups involved, the countries in which the studies took place, the disability policies implemented, or the legal framework. Moreover, issues such as educational level, gender, and age were not considered. However, this review can significantly heighten awareness of individuals with mental illness and employers concerning the benefits of their employment. This review can also advance occupational therapists’ understanding of the need to communicate these benefits to employers and to people with mental illness themselves.

Future research should focus on the true impact of mental illnesses on the working environment of people suffering from them and communicating this to their employers. The range of mental illnesses is wide, with huge differences among them. There is a need for accurate reports on the economic impact of mental illnesses, and on the positive and negative outcomes of their employment for employers. This need was pointed out in a sharp way by Knapp (2003). Almost 15 years later, the field is still sparse. Employers have to know whether employing a person with mental illness will benefit or harm them financially at the end of the day. Otherwise, employers’ fears and concerns will always rise and be a barrier for people with mental illness and actual employment. Despite the benefits of employment presented in this review, the first and most basic question among employers remains the economic impact. If the employer considers that an employee with mental illness will have a negative economic impact for the company, the other possible positive aspects of that employment will not be considered. That is a truth that vocational occupational therapists have to realize and anticipate in their efforts to promote the vocational integration of people with mentalillness.

Conflict of interest

There are no conflicts of interest to declare.

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