Effectiveness of job coaching

To support people with SMI to find and keep paid or unpaid work, several effective rehabilitation approaches have been developed [10,11]. Individual Placement and Support (IPS) is widely considered as effective for helping people obtain and maintain paid employment and education [12–15]. Another example, is the Boston Psychiatric Rehabilitation (BPR) intervention [10]. This approach addresses broader goals, such as housing, leisure activities and their social and family network [16].

While these approaches show positive outcomes in obtaining work, evidence of their (long-term) impact on maintaining work, mental health and recovery is less clear. A systematic review [17] reported that the effects on secondary outcomes (e.g., job satisfaction, self-esteem, or the development of socio-economic and mental health outcomes) remain ambiguous. In The Netherlands one study found that IPS increased chances to find competitive employment, but did not improve health related outcomes [18]. A comparison of 22 (systematic) concluded that IPS has no consistent positive or negative effect on quality of life, functioning, or mental health [19]. Similarly, a Dutch RCT study on BPR showed improvements in paid or unpaid work, quality of life, and psychosocial functioning in both the experimental and the control group, suggesting indicating that outcomes are not determined by the specific methodology used [20].

Paid work is not a panacea

Despite the current attention in both academia and professional practice for supporting people with SMI to secure paid work, studies note that paid work is not without risks. It can also increase stress, anxiety, or feelings of exclusion [21–23]. It has been suggested that paid work should not always be seen as a ‘panacea’ for recovery (24). As underlined: “An important balance [is] to be struck here between the dangers of forcing people back to work and the dangers of excluding them from it through a combination of ignorance, prejudice, and lack of effective help” [24, p. 5]. Furthermore it was found that other forms of participation, besides competitive employment, can also be beneficial for people with SMI. This applies particularly to aspects related to quality of life, I [8]. Research indicated that sheltered work, work in social firms [25–28], or voluntary work [3,29] can also aid the recovery process. Such noncompetitive forms of work should therefore not be overlooked.

Our review of the literature demonstrates that supporting people in finding paid work, or other forms of employment requires a tailored approach. There is no “one-size-fits-all” solution [6, p.2]. Successfully establishing a trajectory depends on several factors. These include: the implementation quality (fidelity) [30,31], the dynamics between a client and a job coach [32,33], and the clients’ capabilities, desired goals, whishes, or motivation [34–36]. Contextual factors also influence the outcome of job coaching trajectories. On a personal level these factors include the client’s health situation (e.g., diagnosis or severity of symptoms), work and skills (e.g., work experience, underqualification, employment gaps) and socio-demographics (age, economic status, etcetera). Other relevant aspects are the social network (support from family and friends), financial situation (the use and type of social benefits, personal assets), and housing situation (stability in residency) [6,37].

The reviewed literature also shows that most studies adopt an RCT design comparing experimental groups to control groups or ‘care as usual’ to assess overall effectiveness. What remains understudied is how, for whom and under which conditions these approaches work. Specifically, there is a gap in understanding how job coaches can tailor their activities to clients’ personal circumstances and sustain motivation throughout the trajectory, thereby enabling them to obtain or maintain paid or unpaid work.

A realist approach

Researchers suggest Realist Evaluation to better understand the inner workings job coach trajectories, by examining the causal relationships within them. This approach offers a way to complement control-designed RCT studies [38]. Due to the ongoing changes in people’s ‘real life’ situations, we argue that context cannot be kept stable, as is assumed in controlled experiments [39,17]. From a realist perspective, context is seen as a ‘multifaced factor’ that impacts whether intervention mechanisms work as intended [40,41]. A realist evaluation approach makes it possible to investigate how in specific contextual circumstances job coaches intervene in order to foster mechanisms that subsequently result in specific outcomes (i.e., finding or maintaining work or other forms of participation) [42].

Research aim and setting

Using a realist approach, this study aims to better understand how job coaches tailor their activities to support people with SMI to find paid work or other forms of participation. We do this by investigating the experiences of clients with SMI living in supported housing settings (sheltered and outpatient), job coaches and supervisors. In this setting, job coaches offer support to clients with SMI to obtain several forms of participation (depending on their client’s wishes). This can be directed towards paid work, unpaid work (voluntary work or daytime activities) or education. In these trajectories, job coaches offer support from a recovery oriented approach [43]. When suited and possible, job coaches that are IPS certified establish trajectories based on the IPS principles, for example when specific funding structures or social benefit requirements allow for it [44]. In some trajectories job coaches combined or alternated between these approaches. Job coaches adapt their activities and interventions to the needs of their clients, guided by their professional judgment and discretionary considerations. For the purpose of this study, we focused on the configurations between the contextual factors in which job coaching trajectories takes place, the characteristics of the job coaches activities and the resulting mechanisms that contribute to obtaining and maintaining paid or non-paid work for people with SMI. In this study, variation in context was limited to differences in clients’ personal circumstances, as other contextual factors at the meso- or macro-level cannot be influenced within the scope of a job coaching trajectory.

Self-determination theory

We articulate the role of motivation as an important element to determine whether a trajectory towards paid or unpaid work becomes successful. Researchers frequently refer to motivation to understand human behavior, as it forms a core component of numerous theoretical frameworks. [45,46]. In this study we use self-determination theory (SDT) as a framework. SDT is a psychological theory of behavior change [47]. To clarify how this theory informs our approach, the following section outlines its theoretical foundations, examines its practical application within recovery-oriented care, and explains how these elements are integrated into this study.

SDT is based on the idea that people want to be ‘autonomous’ or ‘self-determined’, meaning: being able to choose how to satisfy your needs when interacting with others and pursuing activities you inherently enjoy [48,49]. Studies have shown its relevance in the work domain, as it contributes to our understanding of employee wellbeing and work-related behavior [50].

The framework is also considered useful to understand the underlying mechanisms of recovery processes for people with severe mental illness [51]. SDT shows several similarities with recovery-oriented practices for people with long term mental health issues as it is based on almost identical motivational concepts [51]. Following SDT, motivation is stimulated when people experience ‘relatedness’ towards others. From the perspective of delivering recovery oriented care, this implies that professionals focus on people’s ‘entire life’ (mind, body, spirit). They involve significant others (peers, family, colleagues, etc.) in their support. Furthermore, professionals are ‘present’ to help people to feel accepted in society, communities or systems of care [52]. Competence related activities refer to delivering the message of hope towards clients. It also involves adaptation of professionals to the unique strengths, needs, preferences, experiences and cultural backgrounds. This way they help clients to look for challenges that reduce one’s personal suffering [51,52]. The principle of recovery-oriented care emphasizes the importance of autonomy by allowing clients to choose their own path towards recovery. Clients should be able to choose among options and participate in all decisions that affect them. Professionals acknowledge that recovery is nonlinear and that it may involve setbacks. They do this so that clients can learn from these experiences. This also means that clients are responsible for their self-care and journeys of recovery. Professionals align with their clients’ personal life situation, they recognize and stimulate clients to empower and enable them to act in a self-determined manner [51,52].

SDT in relation to job coaching

Although job coaching for people with SMI and the role of motivation have received considerable attention [35], little is known about how job coaches apply motivational mechanisms in practice. This gap is critical because understanding these mechanisms can explain why some trajectories succeed while others fail across different contexts. To address this, the present study clarifies how motivational mechanisms operate in job coaching trajectories. Specifically, we examine how job coaches in successful trajectories address and acknowledge their clients’ needs for autonomy, competence, and relatedness to help them find or maintain employment. Within a realist framework, SDT identifies these needs as key motivational mechanisms that shape outcomes.

We expect that successful trajectories involve job coaches tailoring their intervention activities to the specific personal and contextual circumstances of their clients (e.g., their socio-demographical and general health situation, the amount of support from peers or family or financial situation). We hypothesize that relatedness is fostered through active presence and engagement, competence through encouragement and valuing experiential knowledge, and autonomy through supporting decision-making and avoiding undue pressure. Consequently, we predict that clients who feel autonomously motivated by their job coach are more likely to recognize the benefits of paid or unpaid work for their personal mental well-being and recovery. This, in turn, enhances clients’ perseverance in obtaining or maintaining employment (paid and unpaid) and ultimately contribute to personal recovery and quality of life. Fig 1 schematically represents the reasoning outlined above, illustrating the connection between recovery-oriented care and Self-Determination Theory, and depicting the causal relationship between the intervention strategies, the three psychological needs, and potential outcomes.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Recovery oriented care in relation to self-determination theory.

https://doi.org/10.1371/journal.pone.0343044.g001

By integrating a realist approach with SDT, this study contributes to the literature by uncovering how and why job coaching strategies work in different conditions. This provides a deeper understanding of the mechanisms behind successful job coaching trajectories and offers practical insights for designing more effective, recovery-oriented interventions.

Study design

This qualitative study followed the realist evaluation methodology with a focus on the role of motivation as an important mechanism in job coach trajectories. The study took place as part of a practice-oriented research project in collaboration with a supported housing (sheltered and outpatient) organization in Utrecht, he Netherlands.

Realist evaluation is considered a particularly suitable research method as this method focusses on the complexity of factors that influence the effects of social health care interventions such as job coach trajectories [37]. The premise behind realist methodology is that programs (or interventions) work differently in different contexts. This means that an intervention (e.g., a job coaching approach) that is ‘successful’ in one context may ‘fail’ in another, because the mechanisms needed for success are triggered to different degrees in different contexts [53]. From a realist evaluation perspective, interventions may enable specific mechanisms and outcomes subsequently. Mechanisms can be perceived as the ‘underlying causal processes’ that generate behavior [54]. Mechanisms are often not directly observable, but they are still considered ‘real’ (e.g., ‘trust’ in the relationship between a client and job coach) [55]. They exist within the cognitive or emotional reasoning of those who are the subject of a specific intervention and are triggered or not depending on the contextual circumstances. In realist evaluations the question asked is not ‘does the intervention work?’ but ‘what works, for whom, under what conditions and how?’

In this study we followed the context-intervention-mechanism-outcome (CIMO) logic [56], that stems from the concept of realist evaluation [57,58]. Box 1 offers the definition of realist terminology [59]. The unit of analysis in this study was the job coach trajectory itself. Context was defined as the differences in the personal circumstances that may influence how an intervention works, such as a client’s age, diagnosis or prior work experience. For example, a client with limited work experience may require more structured guidance than one with extensive experience. The intervention was defined as the actions and behavior of job coaches in interactions with clients such as weekly meetings and collaborative development of an individualized support plan. Mechanisms are the underlying responses and reasoning processes triggered from this. For instance, experiencing competence through positive feedback. Outcomes refer to the results of these processes, such as taking steps towards employment or engaging in work. In this case steps to find or maintain work).

Data collection and procedures

Clients were recruited based on (stratified) purposive and theoretical sampling [66] between April 1 and May 31, 2022. We selected clients who had already obtained paid or unpaid work and those still searching. To achieve a heterogenous sample, we focused on four case types [66, p. 50]: unique cases (e.g., clients with unusual circumstances, such as a severe illness combined with strong social resources), critical cases (e.g., clients meeting the conditions for a recovery-oriented intervention and illustrating whether key mechanisms operate as expected), extreme cases (e.g., clients who, despite severe symptoms, were able to find or maintain employment), and typical cases (e.g., clients with common diagnoses who follow standard job-coaching trajectories to secure and maintain work). Job coaches made a first selection of clients based on these criteria; the research team decided on the final research sample. Table 1 provides an overview of the included clients and their characteristics. Clients did not receive vocational support from other professionals. However, clients with paid or unpaid work often received support from an internal job coach or supervisor. All participants gave informed consent.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Client characteristics.

https://doi.org/10.1371/journal.pone.0343044.t001

Data collection involved dyadic interviews followed by individual client interviews. Thereafter, two focus groups were subsequently organized to refine insights from the interviews.

Relatedness

Competence

Autonomy

Summary of findings

This study shows how job coaches can tailor their activities to address clients’ needs for autonomy, competence, and relatedness, thereby activating motivational mechanisms that support people with severe mental illness in finding and maintaining work. To gain insight into these inner workings we conducted a realist evaluation. We applied CIMO logic [56] to explore the configurations between personal circumstances in which job coaching trajectories take place (context), the characteristics of the job coaches’ activities (intervention), the resulting client responses and reasoning (mechanisms) that motivate clients to find and keep paid or unpaid work for people with SMI (outcome).

We focused on motivation as a key concept for determining whether a trajectory towards paid or unpaid work becomes successful. As expected, depending on a client’s s needs and circumstances (context), job coaches must tailor their activities to trigger specific mechanisms. In line with self-determination theory [47], our findings underline the importance of autonomous motivation during job coaching trajectories. Appealing to intrinsic motivation can be considered the ‘generative causal force’ that is important for a trajectory to be successful. Using SDT as a framework enabled us to analyze how job coaches address and acknowledge their clients’ needs for autonomy, competence, and relatedness to help them find or maintain employment. Despite these efforts and the overall satisfaction of clients with the support they received, not every trajectory we studied was successful. Some trajectories showed limited progress, or did not result in obtaining a suitable job.

According to our data, mechanisms that address clients’ need for relatedness are realized by building an egalitarian relationship with clients and staying nearby during the trajectory. Competence is supported through helping clients to deal with setbacks and using their hopes and dreams for goal attainment. Mechanisms that address the need for autonomy are realized when job coaches support clients to increase their self-insight and by promoting self-direction. These mechanisms helped clients reach intended goals, such as finding paid or voluntary work that fits their skills and interests, and making progress in their health and recovery.

In addition to our expectations, our findings illustrate that job coaches continuously shift between or simultaneously address these different needs to keep clients motivated and persevering. For instance, they stay nearby to clients (addressing the need for relatedness) while promoting clients’ self-direction (addressing the need for autonomy). They empower clients to engage in situations where they can show what they’re capable of (competence), support them to make their own choices (autonomy), and help maintain meaningful connections throughout the process (relatedness).

Comparison with existing literature

The findings underline the importance of investing in a solid working alliance between professionals and their clients, as several other scholars also put forward [32,73,74]. This means that, throughout the trajectory, job coaches aim to establish an egalitarian relationship with their clients. This involves building a personal-professional relationship in which clients feel ‘seen’ and at ease [74]. Achieving this requires attention to topics beyond work-related issues. By doing so, job coaches can build trust, creating space for clients to develop, become stronger and increase their autonomy (ibid). Furthermore, our findings align with mental healthcare research that highlights the importance of self-management to empower individuals [75]. In this regard, the benefits of psycho-education were mentioned. These aspects are necessary to become receptive for support. To internalize support, clients must experience the trajectory as their own individual process, that cannot not be imposed by one another.

Our findings also support earlier research showing that paid work can be both beneficial and challenging for people living with severe mental illness [24]. Consistent with a recent realist synthesis [37] and a systematic mixed-methods umbrella review [6], we identified personal circumstances as crucial elements for job coaches to consider. These include a a client’s health situation (e.g., diagnosis or severity of symptoms), work and skills factors (e.g., work experience, underqualification, employment gaps), socio-demographics (age, economic status, etc.), social network (support from family and friends), financial situation (the use and type of social benefits, personal assets), and housing situation (stability in residency). Additionally, our results reflect the potential disincentive effects of the Dutch welfare system, which several scholars argue can discourage people from seeking paid work (known as the ‘benefit trap’) [7,14].

Taken together, the findings suggest that while IPS has been extensively studied and promoted, its role should be considered in a more nuanced way, as job coaching trajectories often require broader and more individualized forms of support.

Practical implications

This study focused on tailoring support towards paid work and other forms of participation. We found that, even in trajectories focused on finding paid work, IPS was used in only a small number of cases. This is notable because several job coaches in this study are IPS certified and the organization where our fieldwork took place has the highest IPS fidelity scores. Professionals tended to view IPS as an addition to their ‘toolbox’ at the end of the job coach trajectory. This may be due to the extensive and challenging recovery process. Participants often moved back and forth between the contemplation, preparation, and action stages of recovery [76]. Because of this precariousness, several participants (both clients and professionals) indicated they preferred voluntary work over paid work, as stepping stone towards paid work.

In every trajectory we studied, various life events, regarding health, housing or financial issues, affected the actions and attitudes of both clients and job coaches. These changes often altered the type of support needed. Maintaining continuity in the professional-client relationship is therefore essential for anticipating suchs shifts. Job coaches also need to understand that trajectories for people in supported housing settings often require a significant amount of time before they can be successfully completed. Professionals therefore need adequate training to guide clients through potential relapses or obstacles.

The support provided by the job coaches in this study resembled the Boston Psychiatric Rehabilitation Approach (BPR) BPR has a broader scope than IPS, considering outcomes beyond work, such as housing, education, and social networks [16]. It is suitable for people who are not (yet) sure if they want paid work, or for clients are convinced they are better off starting with voluntary work. Our data demonstrate the complementarity of BPR and IPS. This is also emphasized by scholars who describe IPS as a “framework of methodological and organizational preconditions,” while BPR provides “conversation techniques to support individual processes” [77, p. 231]. Both IPS and BPR begin with the clients’ wishes and stress the importance of setting goals before identifying the necessary skills and competencies to achieve those goals [78].

Despite the expected complementarity, research on integrating IPS and BPR is limited. Most studies look at ways to expand IPS, for example by adding skills training, cognitive support, workplace accommodations, or extra help from peers or family [26]. Combining BPR and IPS emphasizes the role and attitudes of professionals and their relationship with clients, which may lead to improved outcomes [79].

Strengths and limitations

This study has both strengths and limitations. The first strength is that this study, using realist research methodologies, provided complementary insights to understand the underlying contextual factors and mechanisms leading to the intended outcomes in job coach trajectories for people living in supported housing settings. A second strength lies in the the integration of recovery-oriented practice with SDT, offering a theoretically grounded lens to examine motivational processes. Another strength is the direct involvement of clients, job coaches, and supervisors reflecting a multi-stakeholder approach. Finally, this study is characterized by a substantial amount of interviews, follow-up conversations and focus groups that provided clarity and granulation to make generative causal statements.

There are several limitations to this study. The first limitation is that the job coaches signed themselves up to participate in this study. They subsequently suggested clients to participate. This may have resulted in a selection bias, for instance, when job coaches put their ‘successful’ trajectories to the fore. To avoid this, professionals were instructed to select both ‘successful’ trajectories, as well as trajectories in which realizing the intended outcomes was difficult or not realized. The research team reviewed and discussed the selected cases, in order to create a purposive sample, that reflects the heterogeneity of the clients based on age, gender, care type and focus (towards voluntary or paid work). As a result, we have no reason to assume that the reflections in this study differ from other samples. This, since even the participant’s reflections on ‘successful’ trajectories show the complexity of realizing these outcomes.

Another limitation of this study is that it may have been hard for clients to individually reflect on all interview topics. In order to receive as much information during the interviews as possible, we conducted the interviews in dyads, with clients and their job coach. The goal of a dyadic interview is getting participants to talk about topics in such a way that relevant data is generated [80]. Dyad interviews gave clients and job coaches the opportunity to reflect on the trajectory together and complement each other during the interview. This approach is suitable for this study because the trajectories can be perceived as recovery-oriented practices that assume an egalitarian relationship between professionals and clients [81]. Another effort to avoid that presenting theories was too abstract, the topics were – where necessary – introduced by a more general discussion that did not directly focus on theory testing or refinement. The researcher then asked more generally about the clients experiences with the intervention or other related topics [82,83]. To mitigate effects from power imbalances, as a result of conducting interviews in dyads, clients who felt uncomfortable discussing specific topics during the dyadic interview, were provided the opportunity to come back to this (in absence of their job coach) in the follow-up interviews. In this study the unit of analysis were the VR trajectories themselves. This means that mechanisms outside of the trajectories themselves (e.g., within the workplace) were disregarded.

Implications for future research

This study provided deeper insights into the complexity of job coaching trajectories by examining context, intervention, mechanisms, and outcomes (CIMO) to explain what works, why, and how for people living in supported housing settings [56,84]. As aforementioned, much attention in the field goes to IPS. This is well-justified, and moreover it is good that supported employment is gaining a stronger foundation in practice. Nevertheless, this study investigated what worked, for whom, and how. From this, we found that needs for people with severe mental illness living in a supported housing setting are often broader than just the ‘work’ domain. We propose that more research is needed to better understand the benefits of integrating IPS with other rehabilitation approaches, such as BPR. Additionally, it would be worthwhile to investigate how the core principles of rehabilitation [85] are applied and recognized by professionals who follow the main components of IPS. Although IPS is based on these rehabilitation principles, its focus on ‘paid work’ may make the connection between IPS and other rehabilitation principles too implicit.

The results of this study illustrate that in the Netherlands, having a paid job often does not ‘pay off’ financially, as clients’ work capacities frequently fall short of earning more than the social benefits level (see the aforementioned ‘benefits trap’). More research is needed to better understand how this type of welfare system influences job coaching interventions and to develop strategies to overcome these financial barriers. Additionally, our findings highlight that the opportunity for clients to make autonomous or self-determined decisions during their trajectory, based on a long-term relationship with professionals, is the most crucial factor for successfully completing a trajectory. This aspect, more than a specific ‘evidence-based’ methodological approach, may be key to tailoring a job coaching trajectory. Future research should further explore these suggestions.