Adding a vocational focus to Asian mental health services in New Zealand: occupational therapy opportunities.

Work is a key feature of successful rehabilitation from mental illness (Morris & Lloyd, 2004) and according to Moll, Huff, and Detwiler, (2003) the majority of people with mental illness want to work, preferably in open employment. The idea of work is of particular importance within Asian communities, and especially within immigrant Asian communities (Mei, Ngai, Latimer, Yee, & Cheung, 2001). This article examines the complex relationships between immigration, mental health and employment. It reviews national and international literature on vocational rehabilitation and Asian mental health. Adding a vocational focus to aspects of Asian mental health services is discussed with a particular attention to Asian people's work culture and their experiences as immigrants. From this we contend that occupational therapists have a significant role to play in providing vocational rehabilitation services for Asian people with our expertise in enabling occupation, including work-related activities. We identify some of the specific considerations occupational therapist will need to address in doing this within new or existing services.

Asian mental health

There has been a significant increase in the Asian population of New Zealand over the last decade. In the 2006 census, Asian ethnic groups increased by almost 50 percent to make up 9.1% of the population (Statistics New Zealand, 2006). Over half of the Asian population are immigrants, who have lived here for less than ten years. Asian people are extremely heterogeneous in terms of culture, language, and immigration status, with Chinese being the biggest sub ethnic group followed by Indian and Korean. The majority live in urban areas, with 63% residing in the Auckland region (Statistics New Zealand, 2001).

The prevalence of mental illness in Asian populations in New Zealand is estimated to be similar to that of the general population. However, a number of factors associated with immigration can make them more vulnerable to mental health problems. These include language difficulties, employment problems, changes in socio-economic status following migration, disruption of family support networks, traumatic experiences prior to migration, unfriendly receptions in the host country, and adolescence or senior age at time of migration. Recent Asian immigrants have been a focus in mental health research, involving two key themes, immigration adaptation and barriers to accessing mental health services (Ho, Au, Bedford, & Cooper, 2002).

The links between employment problems and mental health in migrant health have been well documented. Akhavan (2004) found reciprocal influences among health, work, and migration. Migration may cause poor health (resulting in unemployment and sick leave), and can disadvantage migrants in the labour market, which impacts individuals' health. Ho et al. (2002) summarized Asian employment problems (unemployment and under-employment) as more likely to affect recent immigrants. Unemployment is usually associated with low socio-economic status, loss of self-esteem and constrained social contacts, which negatively affects the person's psychological well-being and adaptation to the new country. Under-employment refers to employment of workers with higher skill levels in low-wage jobs that do not require the full use their abilities. This is associated with real or perceived loss of status, contributing to both personal frustration and family stress. Under-employment in Asian people is consistent with the argument that "it is not so much employment, but the quality of employment itself that is crucial to well-being" (Mental Health Commission, 1999, p.9). Abbott, Wand, Williams, Au, and Young (1999) suggested that unemployment is a predictor of minor mental disorders in Chinese migrants' resident here for less than two years. Similarly in Canada, Tang, Oatley and Toner (2007) found that employment related difficulties are the most frequent negative life events experienced by recent female Chinese immigrants. These difficulties were a significant factor in predicting mental health issues and could not be addressed successfully solely by social supports.

Occupational therapy has a key role to play in adding a vocational focus to Asian mental health services. This belief is based on the premise that employment difficulties are a mental health issue in the Asian population in New Zealand (Ho et al., 2002), specifically because of the strong work culture of Asian people and their life circumstances as an immigrant. In addition, there is evidence from psychiatric rehabilitation which supports the feasibility of developing such a focus, particularly in the Auckland region.

Vocational rehabilitation in psychiatry

The British Society of Rehabilitation Medicine defined vocational rehabilitation as "a process whereby those disadvantaged by illness or disability can be enabled to access, maintain or return to employment or other useful occupation" (Department for Work and Pensions, 2003, p. 5). In this article, emphasis will be placed on paid work, rather than other forms of productivity.

There has been an increasing awareness of the importance of employment in psychiatric rehabilitation, in which the value of work has been explicitly articulated and evidence based practice established. Vocational rehabilitation contributes to a good long-term outcome for people with psychiatric disabilities. Engagement in vocational activities, serves as a protective factor in prevention and relapse, and assists independence and recovery (Morris, & Lloyd, 2004). Work also leads to improved self-esteem and mental well being, which particularly benefits those who have greatest support needs (Seebohm, & Secker, 2003). Given this, the Royal Australian and New Zealand College of Psychiatrists (2005) guidelines for the treatment of schizophrenia and related disorders recommended that people should be actively involved with vocational services to improve economic and social participation. Vocational recovery staff should be in the team when developing new services or extending existing ones.

Provencher, Gregg, Mead and Mueser (2002) studied both employed and unemployed people with psychiatric disabilities and found close links between participation in work and the experience of recovery. They argued that work can generate two types of meanings, self-empowerment and self-actualization, and work in recovery is as "a vehicle of self-transformation" (p. 133). Likewise, Buckle (2004) who explored relationships between supported employment and social inclusion, suggested that the social and psychological needs of people with mental illness can be met by putting employment at the heart of health services.

There are many approaches to vocational rehabilitation, including the clubhouse model, transitional employment programmes, skills training, and supported employment. Supported employment (SE) is based on the assumption that people with severe and persistent mental illness can achieve employment success in the open labour market as long as tailored individual support is provided (Morris & Lloyd, 2004). The individual placement and support model (IPS) which was further developed from supported employment, has become evidenced-based best practice for people with severe mental illness. The principles of IPS involve: competitive employment being the primary goal, rapid job search, integration of employment specialists with mental health services, individualized vocational goals, continuous assessment, and no-time limit to follow-along support (Moll, Huff, & Detwiler, 2003).

The increasing awareness of vocational rehabilitation has been reflected in government policy. For example, the importance of employment in recovery is stressed in the Blueprint for mental health (Mental Health Commission, 1998); and practical guidelines provided for all vocational service providers in New Zealand (Mental Health Commission, 1999; 2001). Its increasing effectiveness is now being recorded in publications that tell the stories of people's successful involvement in work (Duncan, & Peterson, 2007; Peterson, 2007) and in occupational therapy literature (Porteous, & Waghorn, 2007). the overall trends at practice and governmental levels, it would seem that a specific vocational focus in Asian mental health is justified.

Cultural practice and Asian recovery

Employment, together with health and family, are the most important things in life for Asian people (Mei et al., 2001). Work values are culturally determined and derived through family life and interactions. They provide reasons for an individual to value work and have positive attitudes towards it (Williams & Sandler, 1995). to Yuill and McMillan (1998), there are four universal functions to paid work: income, structure of life, social status, and social relationships. The meanings attached to work are highly variable depending on the social context and the individuals. For example, in the western world, work is mostly associated with social status and financial ability to sustain one's lifestyle. However, in traditional Chinese culture, work entails extra meanings. Yip and Ng (2002) described Chinese work culture as "demanding" because work is viewed as "a means to occupy time, control misbehaviour, show consistency of words and deeds, and to glorify parents and ancestors" (p.197). For a male figure in traditional Chinese Confucian culture, work is regarded as the most important social circle apart from his family. and Sandler (1995) studied work ethics in the context of human resource management, and found that Protestant work ethics and Confucian work ethics are distinct and unrelated constructs. Both are predictors of positive organizational attitudes and desirable work commitment. Protestant ethics originated from individualistic features of western culture with a focus of personal achievement, whereas Confucian ethics reflects the collectivism of Eastern culture stressing "interpersonal harmony, hierarchy, family integrity, and kinship affiliation, in addition to individual responsibility" (p. 1).

Apart from their intrinsic work values, Asian people's life resulting from immigration contribute to their strong concerns about employment. The 2001 census showed that the Asian population has lower employment rates and income level than the general population, despite a relatively high proportion of people having tertiary qualifications (Statistics New Zealand, 2001). Unsurprisingly, the Auckland survey indicated that nearly half of the Asian families had negative experiences of employment in New Zealand (Mei et al., 2001). Multiple factors contribute to employment difficulties for Asian people, including English language difficulties, qualifications gained in their country of origin not being recognized in New Zealand, lack of social networks in a new country, and a lack of local work experiences. Additionally, employers' prejudice was reported to compromise their employment prospects in the labour market (Ho et al., 2002). New Zealand society considers full employment to be the social norm, hence unemployment is significantly stigmatized (Ellis & Collings, 1997). As a result, Asian people are susceptible to a triple dose of stigma associated with unemployment, mental illness, and being Asian in the labour market.

Warr (1984, cited by Ellis & Collings, 1997) asserted that the consequences of unemployment are varied depending on factors like "cultural norms, traditional levels of unemployment and social support networks" (p. 53). Consistent with this, a large scale study on social roles of Hong Kong women revealed that women who are unemployed experience a higher level of psychological distressthan those in paid work (Tang, Lee, Tang, Cheung, & Chan, 2002). This supports the notion that strong internal work values can impose extra psychological stress on individuals experiencing employment difficulties and that externally, migration can act as a barrier to achieving success in employment. Together mental wellness and long-term adaptation to New Zealand is jeopardized.

A focus on vocational goals would address Asian people's strong work value and their life circumstances as immigrants. Such an approach is congruent with the principles of culturally relevant practice and the emerging Asian recovery framework, which emphasises cultural sensitivity and cultural integration in service delivery (Yee, 2003). This could make mental health services accessible to Asian people, who have a lower (2.0%) utilization of these services, in comparison to other people and yet a marginally higher rate (4.1%) of participating in work opportunities programme (New Zealand Health Information Services, 2005). Furthermore, support in employment would provide Asian people with opportunities to interact with, and participate, in wider New Zealand society which is congruent with cultural integration. Other Asian mental health issues, such as social isolation would also be addressed.

Feasibility

A specific vocational focus in Asian mental health services is not yet visible in New Zealand literature or official documents; however, it is legitimated from strategic plans, and therefore is feasible, particularly in the Auckland region. For example, in the district strategic plans of the Auckland District Health Board (ADHB) (2006), "active participation in appropriate joint sector initiatives which focus on key health determinants" (p. 27) was identified as a priority action for the Asian communities. "Services that address resettlement issues and trauma" for "Asian, refugee and new migrant mental health population" are advocated (p. 48). Employment as a health determinant is agreed, and its impact on immigration adaptation and adjustment of recent Asian immigrants in New Zealand is well documented (Ho et al., 2002). The vocational services discussed here fit well within the regional mental health strategic priorities. Practically, adding a vocational focus could be implemented in the form of establishing new services or by making changes in the existing systems.

Opportunities for occupational therapists

Our unique professional interest in occupation makes us ideal service providers for Asian people, particularly in meeting the requirements of cultural practice and Asian recovery principles. There is potential for occupational therapists to enrich vocational rehabilitation practice by developing an occupation centred approach. Additionally, with the duel roles of occupational therapist and case manager, occupational therapists are well positioned to meet the needs of Asian people, considering the current complex and segregated vocational service provision systems in New Zealand.

Professional identity in vocational rehabilitation

Vocational rehabilitation is within the domain of concern for occupational therapy, as work related activities are one of three key occupational areas. Our philosophy and understanding of meaning in relation to human occupation, the person, and the environment is unique and has a strong link to vocational service provision.

Occupational therapists have traditionally been involved in vocational rehabilitation in mental health (Moll, et al., 2003). According to the Royal College of Psychiatrists (2003), occupational therapists are currently the only professional members of multidisciplinary community mental health services who have the expertise to assess function and activity, hence "they are well placed to play a central role in employment schemes"(p. 8). Occupational therapists are also valuable contributors in the IPS approach evident in both vocational rehabilitation and occupational therapy literature. Moll et al. (2003) commented that occupational therapy and IPS have shared values and philosophy, and "occupational therapists have a foundation of knowledge and skills that position us to be excellent providers of IPS services" (p. 308). Besides, occupational therapists have an extra duty to promote the IPS model. Further, Seebohm & Secker (2003) found that putting occupational therapists in a leadership role could enhance the partnership between the team and the offsite vocational specialist. Occupational therapists were also more "confident in developing client's skills in the workplace" than other disciplinary team members (p. 288).

There have been policy changes in New Zealand since 2001, highlighting the vocational service provision for paid work (Labour Market Policy Group, 2001). To maintain and strengthen their professional recognition in this area, occupational therapists need to continue to be proactive in response to any emerging service needs such as in Asian mental health.

An occupation or meaning centred vocational rehabilitation approach

As health professionals interested in human occupation in relation to well being, occupational therapists are specialists in utilizing meaningful activities to promote health. Supporting people in work-related activities is enabling occupation by looking at the person and the environment. A profound understanding of the meaning of work to each individual is key to enabling Asian people into employment. Hence, occupational therapists with their unique perspective of enabling occupation are particularly suitable for assisting Asian people to achieve their vocational goals.

The occupation or meaning centred perspective is consistent with research which shows that work can create meaning which contributes to recovery (Young & Ensing (1999). They proposed five stages in the recovery process: "overcoming stuckness", "discovering and fostering self-empowerment", "learning and self-redefinition", "returning to basic functioning", and "improving quality of life" (p. 219). Participation in vocational activities plays important, but different, roles in the last two stages. In "returning to basic functioning", vocational activities generate an increased sense of self-efficacy and well-being, which keeps a person active and prevents the illness from being the focus of life. In the last phase of "improving quality of life", apart from "simply serving as means of being occupied", engagement in vocational activities enables people to "have nice possessions and engage in enjoyable activities", thus becoming "a source of personal meaning and purpose" (p. 228).

Another form of employment difficulty is under-employment, usually associated with migration, and a stressor on mental health. However, under-employment is unlikely to be addressed by the dominant vocational rehabilitation approaches, such as supported employment, in which employment itself is more important than the quality of employment. This is reflected by the controversies regarding psychosocial outcomes in the IPS literature; research has not yet shown significant improvement in non-vocational outcomes such as self-esteem and quality of life, even when significant vocational success is achieved (Moll et al., 2003). In contrast, under-employment can only be addressed by an occupation or meaning centred approach concerned with the meaning of employment specific to the individual's cultural background and life experience.

Occupation focused case management

A study on occupational therapy practice in New Zealand mental health services showed occupational therapists were involved in both generic and discipline--specific work activities (Lloyd, McWha & King, 2003). Given these dual roles, occupational therapists are well positioned to ensure vocationally focussed services for Asian people: effective coordination is clearly important considering the low utilization of mental health services.

Vocational rehabilitation in New Zealand has been influenced by the Pathway to Inclusion, the government strategy for vocational services used by people with disabilities (Labour Market Policy Group, 2001). Rooted in the New Zealand Disability Strategy (Minister for Disability Issues, 2001), Pathway to Inclusion identified two objectives for vocational services funded through the Department of Work and Income (DWI): "To increase the participation of people with disabilities in employment ... and in their communities" (p. 11). As a result, a greater focus has been placed on the services that target paid work, especially those of training for employment and on-job support.

Through cross-sectoral vocational rehabilitation, services in mental health have now been well established either through work rehabilitation services of District Health Boards (DHBs) or Non Government Organizations (NGOs). For example, in Auckland, the Regional Work Rehabilitation Services of the Waitemata District Health Board (WDHB) covers both WDHB and ADHB; while NGOs (such as Job Quest of Affinity, and Edge Employment of Action Mental Health Services) provide vocational specialist services including supported employment. Currently, ADHB is funding a collaborative initiative with a NGO, Workwise Employment Agency, adopting the IPS approach to provide specialist employment support for service users (About us, 2004).

Given the low utilization of mainstream mental health services by Asian people, specific targeted services are warranted. Barriers to using services include immigration-related factors (such as language barriers and lack of knowledge of the systems), culture-specific factors like stigma, preferences for the use of traditional healing practices, and lack of responsiveness of the mental health care system (Asian Public Health Project Team, 2003). Though vocational services are assumed to be more accessible by Asian people than other services, there is still a need for strong service coordination, given the diverse nature of service provision at both organizational and disciplinary levels. As case managers, occupational therapists will be capable of supporting Asian people to access the right services and thus achieve their vocational goals, while ensuring a coherent occupation focus across services.

Challenges and considerations

In providing vocational services for Asian people, occupational therapists will also be challenged by some specific issues throughout the occupational therapy process. When prioritizing referrals, occupational therapists will need to identify those Asian service users who will benefit most from the service. For example, according to research, history and motivation are predictors of vocational outcome in the IPS (& Rinaldi, 2004). Vocational rehabilitation will be more effective with those recent Asian immigrants who were in work prior to coming to New Zealand, and who are strongly driven by their work ethic.

When assessing work readiness, occupational therapists would need to consider employability, which is affected by Asian work values and immigration circumstances. Employability could be described, using occupational therapy terminology, as performance capacities, an individual's capabilities in participating in employment comprising both objective and subjective components (Kielhofner, 2002). Objectively, Asian people's employability is generally compromised by the factors associated with migration, such as language barriers, unrecognised qualifications, lack of local work experience, and discrimination from employers. However, these immigration related factors do not necessarily affect the subjective or the overall employability, if individuals adjust their employment expectations.

Cultural work values influence the match or dynamic between subjective and objective components of employability, as indicated in Yip and Ng's (2002) Hong Kong study. They argue that the "demanding" Confucian work ethic could result in unemployability of male adults with psychiatric disabilities, as their high expectations of an ideal job were unlikely to be met. Asian immigrants, especially recent immigrants, do tend to adjust their work expectations down to gain employment in acknowledgement of barriers to local success. Accepting this strategy may increase the overall employability, which could be regarded as positive immigration adjustment. However, compromising vocational expectations can also result in underemployment, which can undermine psychological well being and become a source of dysfunction. Therefore, occupational therapists will need to be mindful of an individual's perceptions of the meaning of work and his or her immigration adjustment in assessing the dynamics of subjective and objective employability.

When goal setting, the challenge will be to balance short term and long term vocational goals, aiming both to improve employability and avoid underemployment. The long term vocational goal or the 'dream job' should be consistent with the person's work values and reflect his or her skills; while short term ones will involve pathways to achieving the person's aspirations. This may include explicit transient under-employment or other forms of productivity such as study or volunteering. The aim of engagement in short-term vocational activities is to improve objective employability, such as language abilities, qualifications, and work experience.

In implementing vocational interventions, occupational therapists may be challenged by the need to juggle dual roles of occupational therapist and case manager and adopting an occupation focused case management approach. Such an approach is culturally appropriate for providing vocational services for Asian people who share a strong work ethic, particularly in addressing underemployment. In case management, occupational therapists will need to liaise with families and Asian communities as well as various service providers, such as other multidisciplinary team members, vocational specialist services affiliated either to DHBs or NGOs, Asian community support workers, Asian cultural consultation services, and interpretation services. Cultural and language differences will add to the challenges of working with Asian people.

In evaluating service outcomes it may be necessary to have different outcome criteria, and this could create challenges within the team. For this reason, the criteria used in service evaluation might include quality of employment, social inclusion, satisfaction, and self-esteem. These are beyond employment outcomes commonly emphasised in the more dominant vocational approaches such as supported employment. Evaluation of such criteria, and the occupation focused approach, are areas in which active participation in research is desirable.

Conclusion

We have outlined a need for a vocational focus in Asian mental health services which includes occupational therapy involvement. Such a focus is of importance because of the cultural work values and migrant status of Asian people. Vocational rehabilitation should be prioritized in the mental health services either by establishing new services, or restructuring existing ones.

We advocate that occupational therapists should be proactive in identifying and playing a role in such services. Our unique perspective on occupation is particularly appropriate in meeting Asian people's vocational needs. We are also well positioned in the case manager role to support Asian people in utilizing the various services while maintaining an occupation focus in achieving vocational goals. Compared with other vocational rehabilitation approaches, an occupation-centred focus can potentially be more culturally sensitive to Asian people, particularly in addressing issues like under-employment. By strengthening services in this way, occupational therapists will enrich the concept of vocational rehabilitation for Asian people.

Key points

* A vocational approach to Asian mental health services is consistent with Asian work values and specifically with immigrant populations. Occupational therapists, because of their occupational focus, have a particular role to play, whether as specific therapist or as case managers, in these services.

* There are clear opportunities for further study on how this vocational focus could be implemented, to improve the quality of mental health services catering for the growing Asian population in New Zealand.

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Qi Liu (PG Cert Allied Mental Health, Bachelor of Occupational Therapy, Bachelor of Traditional Chinese Medicine, NZROT)

Manaaki House Community Mental Health Centre

Auckland District Health Board

Email: [e-mail]

Linda H. Wilson (PhD, MSc, DHA, NZROT)

Principal Lecturer

School of Occupational Therapy

Otago Polytechnic

Dunedin

Email: [e-mail]