Psychiatric Disability: This Unknown

Despite the growing attention of businesses to the theme of inclusion in the world of work, the stigma towards people living with various forms of psychiatric disabilities persists. In a long and passionate interview, Lucia Borso, the director of the Pino Cova Foundation, actively involved in the Job Station project sponsored by the Italian Accenture Foundation and Project Itaca, helps us shed some light on the topic of psychiatric disability and its relationship with the job market and organizations in Italy.

The AMBA, Association of MBAs, has recently named Sda Bocconi School of Management as one of the finalists for the "7 for the research project titled "People with disabilities and Employment: Beyond Barriers"[1]. The study was sponsored by the Italian Accenture Foundation, co-sponsored by Accenture Italia in partnership with Sda Bocconi School of Management, and specifically with the DIS - Diversity, Inclusion, and Smart Working Observatory. The research also involved collaboration with the Milan Polytechnic-Tiresia and the Free Thinking agency.

The Sda Bocconi group[2] managed the field research part, involving three companies that have hired people with disabilities: e-work Employment Agency, Google Italy, and Intesa San Paolo. In the case of e-work, the experience of employing a person with a psychiatric disability was analyzed thanks to the Job Station project, sponsored by the Italian Accenture Foundation and Project Itaca. The Pino Cova Foundation is a partner in this project and manages a "Station" in Milan.

Regarding psychiatric disabilities, the job market, and organizations, I interviewed Lucia Borso, the director of the Foundation, especially in anticipation of World Mental Health Day (October 10, 2023). We know that mental distress is on the rise, especially among young people, women, and individuals who are vulnerable from a socio-economic perspective.[3]

Let's start with the data concerning individuals with psychiatric disabilities who are employed. It is always very difficult to obtain them.

Yes, it's challenging regarding disabilities, and even more so for psychiatric disabilities, because diagnoses are protected by privacy laws, so it is difficult to cross-reference data across different systems. From a secondary analysis I conducted personally not long ago, it emerged that the percentage of individuals with a psychiatric or mental disability who are employed in Italy ranged between 5% and 10%. So, I would say, no more than 10%. To clarify, we are talking about the area - different from intellectual disabilities, which include cognitive delays - that encompasses mental psychiatric and mental disorders: mood disorders, depression, and then moving on to psychotic disorders (such as schizophrenia and paranoid disorders), anxiety disorders, for example, and personality disorders.

I'm thinking of the Basaglia law, from 1978.

Franco Basaglia deserves credit for having liberated these individuals: previously, people with psychiatric disorders were confined to closed institutions. Through his actions, he opened the doors of these facilities and considered people with psychiatric disorders as citizens with rights, possibilities, and even potential, free to build a life within society, rather than being excluded from it. To facilitate this, work is being done today on both the clinical front (psychological, psychotherapeutic, and pharmacological) and the social front, promoting individual autonomy. The two most important aspects for autonomy are "home" and "work": home regards housing independence and everything that comes with it (from managing finances to daily life management); and then the very important topic of work. These two issues are truly delicate because it is very difficult for people with psychiatric disorders to achieve autonomy. As a foundation, we focus on the employment aspect, meaning we seek to assist individuals in obtaining real jobs and contracts, as usually in this world there are endless internships and training programs in organizations that often lack the capacity to employ these individuals. However, it is often very difficult to secure an employment contract. Therefore, we promote pathways to employment within companies that have genuine needs, striving to make the best possible match between the individual's abilities and the company's requirements. This is the work we do through Job Stations.

Who are the companies that approach you? Or is it you who seek out the companies? How does the match between supply and demand work?

Very often, it is the companies that approach us. We primarily work with large and structured companies, often multinational corporations, but also with small and medium-sized enterprises. In the "Job Stations" system, there are about twenty companies involved. Often, they have already initiated inclusion programs, perhaps of a different kind, but they have gaps (related to Law 68/99), so they want to comply with legal obligations while trying a different, innovative model for managing people with disabilities. The challenge is ambitious.

Companies are generally scared when it comes to psychiatric disabilities. Are we talking about environments prepared to welcome these experiences?

These companies are prepared, often with established internal policies; or they may be companies that have people with disabilities but have not yet implemented proper inclusion policies. They trust the "Job Stations" model, which has already placed more than 100 people in employment. The process works like this: individuals enter the job station, go through a program, and if the conditions are right, they gradually transition to working within the company. Job Stations are centers within associations that have specific expertise in mental health.

In your opinion, what are the obstacles to inclusion and the facilitating factors?

Psychiatric disabilities suffer from the greatest stigma: there is significant prejudice, and also great fear associated with them. In the corporate context, these disabilities are perceived as linked to uncertainty, low productivity, and sometimes even to potential danger, due to incorrect or distorted information about psychiatric disorders. It is not understood that these are individuals who have a psychiatric disorder, such as depression that has become disabling, but they actually experience what a large part of the population goes through, just at a more intense level. We all see the data on psychiatric disorders; they are on the rise in all age groups, making it a common and widespread experience. As for the conventional "healthy/sick" dichotomy, the prevailing theory now is that there is a continuum, and everyone positions themselves on this continuum dynamically, depending on their life stage and circumstances. Therefore, this is what we try to convey to companies. The best way for a company to understand this is to get to know these individuals.

The factors that can facilitate employment are being in a protected environment, which can be an office within an association, a calm place where there may not be the same level of frenzy sometimes felt in businesses, a welcoming and secure space.

Most important is the presence of tutors, that makes a significant difference. In Job Stations, there is always a team ready to support the individual, not so much from a technical standpoint (because, and this is something that is often not known, individuals with psychiatric disabilities are typically cognitively capable and may have studied, earned degrees, and worked before), but from an emotional, affective, and relational perspective. For instance, if a person becomes anxious due to a small mistake, the tutor helps them manage that stress, perhaps reassuring them that the error can be rectified. We provide assistance in handling work-related stress but do not offer clinical support, as that is the role of mental health centers.

So, individuals have two levels of interaction, meaning they interact with the people in the job station and then with their colleagues in the company, as I imagine they go there to avoid creating an isolation effect.  

The majority of our workers spend some days in the company and some days with us at the job station.

What are the elements that favor a person being eventually hired by the company?

Certainly, the role of the tutor, beneficial first of all for the individual because they feel supported and not abandoned. For the company as well, having a competent and experienced point of reference is very reassuring.

Then, training is certainly essential. We provide a toolkit to colleagues who will be interacting with the individual.

But, above all, in my opinion, it's about getting to know the person because we often think in terms of categories, yet as often happens when you see the person, those categories crumble.

Have you noticed a change in the attitude of companies towards mental disability?

Sometimes when I present the project to companies, they say, "Don't bring us someone who's crazy." However, once they get to know a person, they understand that they are individuals like us who have a slightly stronger form of suffering, but they are people who have worked on themselves, with a great awareness of their own limitations and vulnerabilities. Prejudice still exists. There is a bit more sensitivity towards the topic of mental health, because it's an area where companies are providing more and more training. Furthermore, with the pandemic, mental distress has increased. Just look at how the demand for psychological support, the spread of anxiety and depression-related disorders, and the use of psychotropic drugs have all risen. So it is no longer seen as something distant. Franco Basaglia allowed us to move beyond the logic of asylums, so these individuals have started living integrated into society again. However, sometimes common perception, driven by fear, not knowledge, still mentally confines them to a different place, apart from the rest.

Once I heard someone make the comment: "Yes, the Basaglia law, but wouldn't it be better for them to be in separate places, not asylums, but still apart? They do harm, but maybe they also harm themselves."

In my opinion, we always need to start from the premise that every person is unique. We can't think of a category separated from the rest. There isn't a category of "crazy" people, and then there's us. It's not like that; every person has their own story, their own experience, their own suffering. We need to understand what the right path is for that individual.

Today, there is a lot of talk about diversity and inclusion. There's a lot of rhetoric, and also a lot of fluff. What do you think?
We need the courage and foresight to take actions that may seem counterproductive in the short term, but pay off in the long term; actions that are courageous in terms of the real inclusion of individuals, which means offering quality employment, dignified pay, and a truly inclusive work environment. In my opinion, it's very useful to gain practical experience. Knowledge is acquired more through concrete experience than through grand slogans. This is the point. Getting to know situations and people up close and experimenting; finding out what it really means. What does it mean to work with a person with a disability? Then there's another thing: don't always start from the rhetoric of success. Try to see the paths in their challenges and strengths. In a very realistic way.

Rhetoric generates false expectations. For example, something that often happens to us: now that we have opened the job stations to people with autism spectrum disorder as well, there is a false belief in the opposite direction. Just as there is an expectation that "crazy" people are dangerous, there is a belief that people with autism are all geniuses. Rather, individuals should be observed without judgments and prejudices, with their potentials, limitations, and struggles. In my view, only a realistic and concrete approach to these journeys can lead to appropriate and genuinely helpful actions.

To conclude, do you have any anecdotes to share, either positive or negative?

Having a job is closely tied to a person's identity. We have had individuals who returned to work after years of depression, people who couldn't even get out of bed. They found a profession again, a daily routine, a sense of self-efficacy, and over time, they started playing sports, going out with friends, and traveling. I think of two of our job stationers who found themselves in London together a few summers ago because they had started traveling again after years, and they met up, had a coffee together—it's immensely satisfying.

However, not all journeys are straightforward or linear. For example, there was a young man who started in a job station; he was a highly sought-after IT professional, an excellent developer. The company saw how fast and skilled he was, so they kept giving him more and more work until the person had to change his pace and couldn't take it anymore. He faced difficulties and eventually told me, "I want to do gardening."

This is also to say that there is no linear path.

Exactly. Obviously, the ideal outcome for us is that the person eventually finds employment in a company. There are cases, however, where the person faces difficult moments, but difficulty is not the end of the world. It can be managed, in part because there is a container (Job Stations) ready to welcome you.

To conclude, in terms of the job market and education, what can be done?

There are many positions available for people with disabilities, but it's challenging to find candidates because there is probably a lack of quality training. There are basic courses in computer skills, English, etc., but there is a lack of highly specific training tailored to the needs of the job market. Not generic training on everything, but training linked to the actual needs of companies, so that these candidates are prepared to fill the positions the market requires. Therefore, we need to start with the resources and capabilities of individuals, and at the same time, identify the specific needs of companies, using them to build high-quality, genuinely useful training programs.