Learning the Principle of Zero Exclusion. Managers Challenging the Logic of Professionalism in Services for People with Psychosocial Disabilities

Previous Research and Theoretical Perspective

Research has identified various structural and social barriers to achieving equal work integration for individuals with disabilities. These barriers include employers’ capacity for inclusion and accommodation (Vornholt et al. 2018) as well as practices and mindsets within the support system (Hardonk & Halldórsdóttir 2021; Vornholt et al. 2018). Studies have indicated that despite the efforts of professionals within the welfare state to emphasise resources and opportunities, there has been a persistent focus on what individuals cannot do because of impairments. This ‘deficit approach’, often associated with a medical view on disability, has continued to influence the decisions made by professionals in their interactions with individuals with disabilities (Håvold, Harsløf & Andreassen 2018; Lundberg 2023; Møller & Stone 2013). Additionally, research has shown that healthcare professionals worry that work could cause harmful stress for persons with psychosocial disabilities and that they generally prioritise treatment before work is considered, even when service users express a desire to work (Andersen, Nielsen & Brinkmann 2012; Andreassen & Solvang 2021; Bonfils 2020). Moreover, practitioners have been observed to assess job readiness based on the service user’s health situation and exhibit limited confidence in their job readiness and ability to work (Andersen, Nielsen & Brinkmann 2012; Hasson, Andersson & Bejerholm 2011; Marwaha, Balachandra & Johnson 2008).

While a significant number of studies have looked at how employers and professionals perceive and support labour market participation for people with disabilities (e.g., Gustafsson, Peralta & Danermark 2018; Hardonk & Halldórsdóttir 2021; Meekosha & Dowse 2007) there has been limited research on the stage where candidates for employment-related interventions are identified, selected and referred. Welfare state professionals are gatekeepers who control access to resources (Meekosha & Dowse 2007) and decide ‘who gets what, when and how’ (Molander, Grimen & Eriksen 2012: 214), such as job support measures. The referral stage represents an overlooked area in disability research that is important to illuminate, as previous studies have indicated that attitudes among professional practitioners can influence who is deemed ‘job-ready’ and thus who is offered employment-related support (Andreassen & Solvang 2021; Knaeps et al. 2015).

The current article explores managers’ experienced challenges of fulfilling the zero-exclusion principle and how the principle is used to promote a shift in how professionals perceive the job readiness of people with mental health conditions, and who is viewed as the most capable of deciding when employment measures should start. It draws on a logic approach (Freidson 2001) to explore how managers experience the IPS method – which suggests increased self-determination – as adhering to or disrupting the logic that otherwise guides practitioners in their service delivery. According to Freidson (2001),

professionalism may be said to exist when an organized occupation gains the power to determine who is qualified to perform a defined set of tasks, to prevent all others from performing that work, and to control the criteria by which to evaluate performance. (12)

Furthermore, professionalism hinges on the exercise of discretion, drawing from formal knowledge, autonomy, and being entrusted to make ethical and moral judgments (Freidson 2001). By employing the logic approach, examining the implementation of the zero-exclusion principle can shed light on the interactions between professionals and service users and what it is that guides and influences decision-making in these interactions and how prevailing professional practices may hinder or support the realisation of efforts to reduce discrimination. Logics thus provide a framework to analyse the tensions faced by managers in promoting the zero-exclusion principle.

Research Setting

Individual Placement and Support (IPS) was developed in the US to integrate employment as part of mental health treatment. Since then it has shown promising results in randomised controlled trials across different settings (Modini et al. 2016). However, its implementation into routine practice has been difficult due to the method’s complexity and its potential to disrupt established organisational practices and mindsets (e.g., Bonfils et al. 2017; Moe et al. 2023). Despite implementation challenges, IPS has become a favoured and highly prioritised work inclusion model by both practitioners and policymakers in Norway (Holmås, Monstad & Reme 2021; Moe et al. 2023). The significant progress made to implement IPS as a routine practice in Norway can thus be seen as a critical case (Flyvbjerg 2006: 229–231), that can offer insights into the shared challenges faced in other contexts. The difficulties encountered in Norway are likely to be relevant and applicable to similar efforts in other countries.

In the Norwegian context, IPS is implemented as a cross-sectoral collaboration between mental healthcare organisations and employment services (The Labour and Welfare Administration – Nav) (Moe et al. 2023). The term ‘IPS programme’ refers to the IPS collaboration between healthcare and employment services and includes professional groups of employment specialists, healthcare professionals, and employment service caseworkers. Participants are mostly referred by healthcare professionals who identify candidates among the organisations’ service users, but service users may also refer themselves (Becker et al. 2015). The zero-exclusion principle mandates that practitioners should refrain from assessing whether the service user is ready for work and instead enable individuals to make their own decisions by providing everyone with sufficient information about job support and work possibilities.

IPS programmes are based in specialised healthcare in hospitals or outpatient clinics, serving individuals with a broad range of mental health conditions and support needs, spanning from conditions like schizophrenia, bipolar affective disorder, and substance abuse to anxiety and depression. Access to IPS largely depends on the target group of the healthcare services where it is implemented. IPS functions as job support alongside healthcare treatment, with the sole eligibility requirements being the receipt of such treatment and a desire for employment. Otherwise, there should be no exclusion. The healthcare professionals involved may vary based on the service’s organisational structure, encompassing psychiatrists, psychologists, psychiatric nurses, and clinical social workers.

In IPS, the employment specialist helps individuals secure competitive jobs on the open labour market as rapidly as possible and provides on-the-job support, distinguishing it from pre-vocational training programmes. In Norway, employment specialists are mainly hired by the employment services and collaborate with healthcare services, by participating in treatment meetings and sharing office space with healthcare professionals (Moe et al. 2023). Employment specialists and employment service caseworkers have diverse educational and professional backgrounds, for example, social work, social sciences, health care, or business. They are responsible for raising awareness among healthcare professionals and caseworkers about the potential benefits of employment for individuals with psychosocial disabilities (Bond 2004). In Norway, caseworkers typically refer service users to work-related interventions, but in IPS this responsibility is assigned to healthcare professionals. Caseworkers and employment specialists can, however, promote work and suggest IPS when the healthcare professional has not yet considered it (Swanson & Becker 2013). This approach distributes the responsibility of identifying IPS candidates among practitioners, with healthcare professionals primarily serving as gatekeepers due to their initial interactions with service users during treatment sessions.

Methodological Approach

In this study 14 semi-structured interviews were conducted with top or mid-level managers who had decision-making authority in implementing IPS in Norwegian healthcare and employment services. Interviews were chosen to capture individual experiences and perceptions (Brinkmann & Kvale 2015). The interviews primarily focused on IPS implementation in general, exploring both the possibilities and challenges, as well as the managers’ experiences of implementing this method in their organisational settings. Informants were selected for their involvement in the organisational implementation of IPS, specifically as managers with decision-making authority. This enabled them to justify the adoption of IPS and identify the targeted organisational structures for change. All participants had introduced IPS to restructure practices in their respective organisations in various ways. They shared similar professional backgrounds with frontline workers and most had prior frontline work experience.

Among the informants, six were top managers from local employment service agencies, responsible for deciding whether to implement IPS in their organisations. Their knowledge of IPS varied based on agency size and organisation, with three having basic knowledge and three possessing profound knowledge as IPS coordinators or long-term implementers. Additionally, eight interviews were conducted with healthcare managers, four from specialised mental health care and four from municipal services. These mid-level managers oversaw departments or teams where IPS was being implemented. Two managers were closely involved in frontline service delivery through regular practitioner meetings, while the remaining six had decision-making authority on IPS-related matters.

Six of the managers had extensive experience with IPS implementation, defined here as a period exceeding five years. IPS was introduced in Norway in 2012 and expanded in 2017. These insights provided perspectives on the IPS implementation’s developmental trajectory and potential organisational changes. Conversely, managers who had recently adopted IPS and were currently in the initial implementation phase provided reflections on their experiences during this stage.

The study received approval from the Norwegian data protection authorities, and informed consent was obtained from all participants. To ensure confidentiality, the informants and IPS programmes are anonymised in the data presentation. Cited informants are described based on their role and sectoral affiliation, preventing identification by others familiar with the Norwegian IPS context. Interviews were conducted, recorded, and transcribed in Norwegian. Quotes were then translated into English by the author and adjusted for readability.

Analytical Approach

The analysis followed an approach inspired by Thematic Analysis (Braun & Clarke 2021) to identify patterns across the data based on the themes emphasised by the informants. After reading through the interviews, I conducted an initial round of coding related to the empirical material. I developed categories like ‘justifications for implementation’ and ‘implementation challenges.’ It seemed like implementing the zero-exclusion principle posed significant challenges by challenging professional practices and attitudes about job readiness. However, the principle itself also provided a rationale for adopting IPS. This tension played a crucial role in understanding the implementation challenges and the managers’ motivation for change. Codes related to the zero-exclusion principle were then organised into thematic groups based on their content, such as ‘IPS target groups,’ ‘job readiness assessments,’ and ‘professional knowledge’.

As the managers frequently mentioned practitioners relying on professional knowledge and experience when assessing job readiness, I introduced the concept of professionalism logic (Freidson 2001) as an analytical category. Subsequently, I conducted another round of coding, specifically focusing on identifying the factors that the managers and practitioners relied on when assessing who they believed were job-ready or suitable for IPS. During this phase, I categorised the statements related to zero exclusion that could be interpreted as reflecting professionalism logic and ultimately identified three different ways in which this was manifested in the data. Using Braun and Clarke’s terminology, this process can be referred to as ‘refining, defining, and naming themes’ (Braun & Clarke 2021: 35–36). The themes I ended up with provided the structure of the analysis as presented below.

Tensions between Zero Exclusion and the Logic of Professionalism

The first tension that managers experienced was related to the difficulty of implementing zero exclusion because the professionals working in the services held beliefs about certain service users being too ill to work, reflecting a deficit approach. This became visible through the way the managers described the target group for their IPS program. The findings indicated that certain individuals or groups, such as those with psychosis disorders, were perceived as being too ill to work or as requiring more resources from the professionals:

We don’t include those with complex psychosis-related disorders now because we know that there are a lot of things to work with at the same time in these cases, and it will be very resource-consuming. We don’t intend to exclude these individuals at all, but we are in an establishment phase, and we need to make it a bit easier on ourselves just now until we are up and running. (Manager, healthcare service)

Such assessments also applied to drug abuse issues. The quote below indicates that this manager considers individuals with drug abuse problems to be ‘further away from work’ than others:

There must be a chance that work is possible. Those who are far away from work are not part of this [IPS]. And there must be hope for you to function in a job to some degree. So, [concerning IPS] we have focused on psychiatry [diagnoses] and not drug abuse. (Manager, employment service)

In the mentioned quotes, professionalism logic is visible in two aspects. Initially, managers believed that certain service users with specific diagnoses might have lower chances of successful employment, resulting in hesitation to refer them for IPS. Also, they signalled a belief that employment prospects could be predicted based on professional knowledge about the characteristics of certain diagnoses. This is in line with a medical understanding of disability.

Besides this particular case, which was a recently established service, managers in the study did not openly exclude individuals based on their diagnosis. More often they expressed concerns about practitioners occasionally applying exclusion criteria on a case-by-case basis. The manager of a well-established service mentioned that they had changed the referral procedure to avoid systematic exclusion of certain diagnostic groups but argued that ‘(…) it doesn’t mean that we eliminate exclusion from a therapist’s mind’ (Manager, healthcare service).

The managers who mentioned this concern found it challenging to estimate the frequency of such assessments as they occurred ‘in the therapist’s mind’. However, they noticed disparities among professionals in terms of how often they referred individuals to IPS. The managers believed that these differences were more likely attributed to variations in how practitioners assessed job readiness rather than actual discrepancies among the service users assigned to different professionals, turning attention to the role of the interaction between professionals and service users. They attempted to address the issue by discussing it with the professionals to gain insight into the situation:

We [the IPS project leader and employment specialists] have wondered why some therapists refer many people. And then some therapists don’t refer anyone. We try to find out if this is random or if they are assessed differently. (Manager, employment service)

According to the manager, it appeared that the practice was starting to change to some extent, although there was still a perceived need for improvement:

It [the variation in assessments] has improved, I must add. But I think that there are people today who are not offered it [IPS] because the therapist thinks they are too sick. That is why we must have visible brochures in all waiting rooms and posters so that they [the service users] can have the opportunity to refer themselves. (Manager, employment service)

This manager observed an increase in therapists referring service users and being more open to the idea that people experiencing mental health conditions could work despite health impairments. However, the manager was concerned that certain practitioners’ preconceptions might hinder service users from receiving information about IPS. To address this, brochures were made visible in waiting rooms, to ensure service users had an equal opportunity to explore job support programmes, regardless of whether therapists mentioned it or not.

Another tension arose from healthcare professionals’ role as trusted experts. Managers aimed to enhance IPS credibility among these professionals and achieve a consensus on the potential health benefits of employment. Concerns were raised about whether the attitudes of healthcare professionals, acting as gatekeepers, aligned with promoting job participation. For instance, a manager from an employment service pointed out the challenge of motivating service users to pursue work when a doctor or psychologist advised against it:

We [who work in employment services] can’t tell someone that they can work if the doctor says they can’t. Physicians and healthcare personnel have a high status. Service users often say: ‘but my psychologist says… or my doctor says that I should be on sick leave for a while longer… or that my symptoms will worsen if you put pressure on me.’ (Manager, employment service)

This statement suggests that service users saw healthcare professionals as authorities on their health needs, which could hinder employment services from promoting work as an opportunity. One manager specifically noted the difficulty of convincing the more experienced therapists to believe that the decision of when a service user is ready for work should be determined by the individual themselves:

They [the experienced therapists] have worked for many years, and they stick to the methods they believe work best. I think it’s somewhat important to challenge them on what the users’ needs are and what the users’ perspective is in this – simply, we shift the focus from ourselves to those we are here to help. (Manager, healthcare service)

This reflects how the professionalism logic that practitioners were guided by, might be more prominent among experienced staff members. The quote implies that they needed to be convinced to refrain from assessing job readiness and instead let the users make that decision, as the zero-exclusion principle suggests. The manager cited above aimed to shift the focus from the professional opinions and judgments of healthcare workers – to service users with their own perspectives on what they need to improve their life situation.

Learning the Principle of Zero Exclusion

The managers in this study largely embraced the zero-exclusion principle and justified their adoption of IPS by emphasising the value they placed on creating opportunities for individuals to pursue employment if they desired to do so. One of them explained as follows:

On my part, this is very much about attitudes. Believing that everyone can do something when given the right support. (Manager, employment service)

Managers from both employment and healthcare services justified IPS adoption to create an inclusive environment where everyone had the chance to try their hand at work. This is in line with a relational understanding, emphasising that mental health condition is not a disability per se, but depends on the situation. One manager argued that in the past, an emphasis on illness and limitations had influenced the interactions and support provided to this group within the healthcare system:

The group of people with more severe mental disorders have over many years been characterised by a great deal of illness thinking and limitations. They have suffered a lot from that medicalisation mindset that psychiatric services often represent. (Manager, healthcare service)

The quote suggests that the manager believed there had been (and still was) an excessive focus on individual limitations within the psychiatric services, that service users had suffered from it, and that the manager disagreed with such a mindset.

Accordingly, IPS was perceived by managers as a tool to challenge and overcome what can look like a deficit approach within the organisations:

IPS provides us with a very supportive tool so that we can succeed with a group that, in many cases, I think, would have been less prioritised or simply given up on in Nav – not all of them, but some, where we would think that this person is too ill or the ability to work is too low. It [IPS] helps us to prioritise the group that we must absolutely prioritise. (Manager, employment service)

In the quote, the manager highlights the impact of attitudes within the employment service agency on the perception of certain service users’ job readiness and the subsequent priority given to them. This statement reflects the manager’s aspiration to adopt a different prioritisation approach and acknowledges the role of IPS as a supportive tool for driving this change. By implementing IPS, the manager aimed to challenge previous assumptions that certain individuals are unable to work and to create a shift in the organisation’s approach to provide opportunities for those who were previously overlooked. The changes the managers aimed to implement were also related to a greater emphasis on asking the service users themselves about their preferences, rather than solely relying on professional assessments:

Now we ask service users what they need. We didn’t do that 20 years ago. Back then, it was the chief physician at the hospital who decided what you needed if you were mentally ill. Today, we ask the patient, ‘What do you want us to do for you to help you recover?’ and the answer is often housing and a job. (Manager, healthcare service)

This can reflect a departure from an individual, medical approach in which healthcare professionals hold expertise over service users’ needs, towards a mindset of self-determination, where individuals with disabilities are considered experts on what they need to improve their life situation. However, this shift could create tensions, particularly in situations where healthcare professionals believe that initiating employment measures might be unwise due to health-related concerns. The managers from the healthcare service acknowledged that the imperative for healthcare personnel to safeguard service users and prevent the exacerbation of symptoms could hinder the individuals’ ability to exercise genuine self-determination. One of the managers elaborated on this point, stating the following:

There are still challenges, absolutely. We probably have a way to go to ensure that therapists are no longer the barriers to employment. Because they have had an obligation to protect [the service users]. (Manager, healthcare service)

This quote highlights the manager’s perspective on therapists being the barriers to employment due to their ethical responsibility to safeguard service users from possible negative impacts on mental health, implying that the environment is in fact disabling (related to professional attitudes).

While discussing IPS as a catalyst for changing attitudes, the managers’ narratives also served as testimonies to the transformations that had already taken place regarding the role of employment engagement in the lives of people experiencing psychosocial disabilities. For example, one manager shared an experience of introducing the IPS mindset during the initial phase of implementation, which in this case took place a decade ago:

It was, in a sense, pure missionary work. Just getting people to believe that work was possible. It’s taken years, it sounds so easy now. There are still barriers, but it’s a completely different way of thinking and investing in it. Whereas back then, it was inappropriate [to say that everyone can work]. (…) But now, with all the work that is done everywhere to achieve less stigma and more openness and inclusion. So, I think that in society in general, there is a greater focus on an inclusive working life. (Manager, healthcare service)

This example demonstrates how the initial introduction of the IPS mindset disrupted prevailing beliefs within healthcare services. However, the manager had observed a subsequent shift in these beliefs, with a greater alignment towards beliefs that everyone can work despite mental health conditions, in line with a relational understanding of disability. Another informant mentioned that although some people still believed individuals needed to undergo rehabilitation before they could work, the manager considered this belief to be old-fashioned:

My experience is that many therapists think that work is important. At the same time, some have this old-fashioned mindset saying that patients must finish their rehabilitation before they become job ready. (Manager, healthcare service)

Yet another manager explained that while they were heading in what they considered the right direction, changing attitudes takes time:

I experience that we now, to a greater extent, try to say and acknowledge that… OK, so you have some health issues, but despite that, what can you manage, what do you wish to do? I think we are making progress. At the same time, I have learned that it takes time to change attitudes. (Manager, employment service)

One of the managers in the healthcare service emphasised that many within the organisation (including the manager) had been doubtful in the beginning. After witnessing, through IPS, that many people with severe mental illness could work if they had the chance, professionals gained confidence in the possibility of more individuals being ready for work:

Initially, there was considerable scepticism. These patients had been severely ill for many years, and I had little confidence in their ability to participate in this type of activity. However, I was proven completely wrong. We witnessed the job specialist successfully and effectively engaging these patients. It was at that moment we all recognised the immense value of IPS. (Manager, healthcare service)

The quote illustrates how practical experience with IPS and its zero-exclusion principle can contribute to changes in professional attitudes and beliefs.