To have and hold a satisfying and meaningful job is a crucial source of dignity and purpose for most people. For individuals with mental health and substance use conditions, work in some form (including competitive employment but also self–employment; cooperative work/employment; mutual exchange-based employment, work in a social enterprise, and volunteer work) is often a key to recovery.
Mental Health America supports vigorous enforcement of the Americans with Disabilities Act of 1990[i] and its mandate to eliminate unfair treatment of and discrimination against qualified workers with disabilities. Individuals with mental and substance use conditions who aspire to work should have access to the resources needed to seek, obtain, and maintain employment in their community. Affiliates and other advocates should work with federal, state and private employers and resources to study and implement innovative programs and social enterprises to secure work opportunities for people with behavioral health conditions in their communities.
Most people want to work and identify themselves by their work and by the rewards it brings. Developing or recovering the ability to work, support oneself, and contribute to society is critical for people with mental illnesses and addictions. These are people who have long been excluded from employment opportunities, and whose employment preparation programs have rarely concluded with a “real” (long-term) job. People with behavioral health disabilities often were discouraged from working, fearing that deadlines and other stresses might overwhelm them, and tight Medicaid income restrictions have only recently been loosened, and only in expansion states. Most people who work show improvement in their mental health and greater satisfaction with their lives.[ii]
Yet all too often, people with mental health and substance use conditions are unable to access employment services and gain employment. A 2014 federal survey (using 2009-10 data) found that employment rates decreased with increasing mental illness severity (none = 75.9%, mild = 68.8%, moderate = 62.7%, serious = 54.5%, p<0.001). Over a third of people with serious mental illness, 39%, had incomes below $10,000 (compared to 23% among people without mental illness p<0.001).[iii] Significantly, the gap in adjusted employment rates comparing serious to no mental illness was 1% among people 18-25 years old versus 21% among people 50-64 (p < .001). These data contrast with more recent NAMI survey data and older American Psychiatric Association estimates reporting serious mental illness unemployment rates of above 80%.[iv] However big the problem is, it is significant and increases with age.
Work is Beneficial
The core issue supported by research is that work is beneficial for people with behavioral health conditions:
- There are a limited number of work-related “evidence based practices” (supported by random controlled trials, or RCTs) concerning work for this population – principally the individual placement & support (IPS) model of supported employment, and the PACT (Program of Assertive Community Treatment) and Clubhouse models. The work of peer support specialists outside of the clubhouse model is also a promising practice, but lack of consistent service quality criteria has made study very difficult.
- Supported Employment/ Individual Placement & Support (IPS) is a well-defined, evidence-based approach to helping people with mental health and substance use conditions to find and keep competitive employment within their communities. Supported employment programs are staffed by employment specialists, who have frequent meetings with treatment providers to integrate supported employment with treatment services.[v] Supported employment programs that help people with the most serious mental illnesses place more than 50 percent of their clients in paid employment.[vi] A great example is the Village Cookie Shoppe in Long Beach, which has launched many cooking careers.[vii]
- The Thresholds program in Chicago is a compelling model of supported employment. Thresholds offers three evidence-based practices that complement supported employment—assertive community treatment, integrated treatment for co-occurring disorders, and illness management and recovery. In addition, Thresholds has introduced several recovery initiatives, including ongoing self-advocacy training, a recovery steering committee, and ongoing staff training on integrating a recovery orientation into routine service activities.[viii]
- Clubhouses. In 1948, Fountain House established the first clubhouse. It was opened in Hell's Kitchen in Manhattan. The Fountain House program became the template for what became the Clubhouse Model of Psychosocial Rehabilitation in 1977 with over 325 other programs eventually adopting the recovery model in 28 countries around the world.[ix] Clubhouses offer a tiered employment program designed to integrate interested members back into meaningful and gainful employment in the community.
- The first step of the Clubhouse employment program is Transitional Employment (TE), in which members can work in meaningful part-time jobs outside the clubhouse procured through partnerships with community entities and businesses. The member selected by the clubhouse community for these position(s) are trained by a clubhouse staff and/or member who are in charge of that particular placement. As an incentive to the employer, job attendance and performance are guaranteed, as a staff and/or member will support or even fill-in for the clubhouse member if he or she needs to be absent for any reason. Each member contribution at a Transitional Employment position is designed to be transitional and temporary, lasting for six to nine months, as these positions belong to the clubhouse, and are designed in such a way so that ideally all members will have an opportunity to work. Each member of a clubhouse who participates in a Transitional Employment position is guaranteed to earn minimum wage or above.
- The second step is supported employment, in which the clubhouse community helps an interested member obtain his or her own employment and serves as a resource and support for résumé makeup, interviewing skills, transportation, and employer liaisons. The third step is independent employment, in which the member is meaningfully and gainfully employed without the intervention (but always with the support) of the clubhouse community.
- In addition to in-house and community-based work opportunities, clubhouses generally offer a wide array of other member services, including housing support and placement, benefit advocacy, case management, financial planning, evening and weekend social programs, continuing education support, and regional and international conferences. As with all aspects of clubhouse operations, these services and programs are administered through the joint efforts of both clubhouse members and staff.
- Assertive Community Treatment (aka ACT or PACT) is an evidence-based practice promoted by SAMHSA for community-based treatment of people with serious mental health conditions. The primary goal of this treatment is “recovery through community treatment and habilitation.” A multi-disciplinary team provides assistance in a number of areas including daily activities, family life, health, medication support, housing assistance, financial management, entitlements, substance abuse treatment and counseling. The key to its success is a high staff to consumer ratio (at least one to 10 consumers), provision of services where they are needed (in the community), uninterrupted care as someone from the team is always available, a non-coercive and recovery-oriented approach, and time-unlimited support. [x] It has been extensively validated for employment as well as other aspects of recovery.
- The Clubhouse and the ACT/ programs have been found to be evidence-based in promoting employment. Participants from both the PACT and clubhouse models achieved high employment levels, with no significant differences in weekly employment or 30-month job placement rates over the course of the study. During this time, clubhouse participants earned significantly higher wages and remained competitively employed for significantly more weeks per job than PACT participants.[xi]
- Peer Support Specialists present an enormous opportunity to increase employment, using methods similar to the clubhouse model, with less staff support. Thousands of peers are currently certified by the states, but certification standards vary widely across the states, and the number of certified peers falls far short of the demand for peer services. Certification has been taken on by independent certifying bodies and by state behavioral health program offices, with wide variations among the states.
- Unfortunately, lack of clear and consistent service quality standards has made validation very difficult.[xii] To meet the project demand for peers and to establish testable fidelity standards, Mental Health America created and implemented in 2017 the first national advanced peer specialist certification. This lets peers show they have the highest levels of knowledge and expertise that qualifies them to support people wherever they are.[xiii] The MHA National Certified Peer Specialist (MHA NCPS) certification recognizes peers with the lived experience, training, and job experience to work alongside healthcare teams. The certification is designed to exceed the standards used in public behavioral health around the country. A major purpose of the certification is to meet the needs of private health insurers and private practitioners.
- The MHA certification program has been peer initiated and conceived. Within the peer community there has been much concern that professionalizing peer support will take away from its true nature. True to the spirit of peer support, the credential does not mean that a peer is a clinician. It emphasizes and expects that all duties reflect the principles, guidelines, and core values of peer support.
- Research has discredited some earlier models, such as traditional sheltered workshops, especially those that require people to remain in one place for a long time; require fine motor coordination, good near sightedness, and good concentration skills (all affected by some medications), and provide no or limited contact with those outside of the workshop, models that purport to predict who will be successful for what kinds of jobs (i.e., work evaluation models), and models which, based on evaluations, then aim to train people for the specific job skills they need.[xiv]
- Other Promising Practices. There are some very successful longstanding models that never had RCTs done on them (all of which involve work in businesses run by or populated by people with behavioral health conditions) – for example,
- The Italian social cooperative model that has become the European Union model for work in the guise of Work Integration Social Enterprises (WISEs). Users who prove not to be productive cannot be employed or maintain a job in the cooperative, which acts as any other employer in the market. Turnover is high. The job is a means to implement normalization and develop solidarity and integration but is not social assistance in itself. Still, the cooperative appears to be a successful transitional context that allows people a space for experimenting and developing their skills. The social enterprise is currently the only working context which has an organizational structure able to absorb, in terms of market strategies, such a high turnover.[xv] Gardening and maintenance have been the job focus, and career advancement remains an issue
- The Fairweather Lodge model of cooperative living and cooperative employment,[xvi] an American program begun in California in 1963, reports equivalent success with a wider variety of jobs. There are now over 90 lodges in 16 states. Typically, lodges are small groups of 4 to 8 people who share a house and own or operate a small business. Each group must select a business to operate, for which it will develop and implement a business plan. Lodge groups' businesses have included lawn care, custodial or laundry services, printing, furniture building, shoe repair, catering, and other services. There are no live-in staff members at any Lodge, although each lodge has access to a professional who is available for training and consultation whenever the group requests his or her help.
- The Affirmative Business model, e.g., Minnesota Diversified Industries. Through a Social Enterprise model, “MDI creates self-sufficiency by providing meaningful work in an inclusive environment, with nearly half of the workforce comprised of people with disabilities. Employees have access to Employment Support Specialists who support them, along with provide job placement services. This integrated workforce helps to manufacture a wide variety of totes, trays and boxes sold to businesses across the country. The highly capable and dedicated team also offers production services such as kitting, packaging, palletizing and assembly, along with environmental services.”[xvii] See also Grayston Bakery, described below.
The most obvious barrier is funding. Thus, the 2009 CMHS Uniform Reporting System Output Tables estimated that only 2.1% of U.S. mental health clients had access to evidence-based vocational services.[i] Increasing peer support and Clubhouse services is the principal avenue to address these deficiencies in the short term.
More generally, education is closely linked to opportunities for work, and people with mental and substance use disorders have the lowest educational attainment level of any disability group. Mental illnesses and addictions often begin when young adults are completing high school and looking at future opportunities and career plans, and education suffers accordingly.[ii]
For people with serious mental illnesses or addictions, additional obstacles to gaining and keeping a job include the fear of losing income and healthcare insurance by losing eligibility for the SSI or SSDI programs and Medicaid, stigma and discrimination at the job site, lack of housing, and diminished self-confidence. Traditional vocational rehabilitation services do not provide the appropriate level of support that people with a mental illness or addiction need in order to overcome these barriers to employment, and, as stated, evidence-based supportive employment programs are very rarely available.
Vocational histories may vary, ranging from being chronically or permanently unemployed to being continuously employed. Unemployed people in mental health or substance abuse treatment programs face many challenges and obstacles in obtaining and keeping jobs. Employed people often need help with finding more satisfying work or with identifying and resolving stresses in the work environment that may exacerbate ongoing mental health or substance abuse conditions or precipitate a relapse. Barriers may include difficult to explain gaps in work histories, specific and general work skills deficits, low levels of confidence, limitations in social interaction behaviors, and other factors unique to the person’s disability and work history.
Barriers also stem from society, scarcity of appropriate level jobs, prejudice against employing people with mental health and substance abuse disorders, and a criminal history.[i]
Criminal justice involvement is the greatest barrier of all. MHA Position Statement 59, Responding to Behavioral Health Crises,[i] documents the disproportionate police involvement with people with mental health and substance use conditions, which too often leads to a criminal justice record. According to a 2011 survey, 90 percent of companies use criminal background checks in making hiring decisions. Another study found that a criminal record reduces the likelihood of a job callback or offer by nearly 50 percent. A 2012 survey investigated the arrest experience of a national sample of American youth and found that 25–41% of those youth reported having been arrested or taken into custody for a non-traffic offense by age 23. This study was the first in a generation to examine progressive cumulative population arrest patterns and the first ever to do so using survey data based on a nationally representative youth sample. The implications of barring so many people from employment are staggering. Many jurisdictions around the nation have begun reforming hiring and expungement practices to reduce these negative consequences.
Principles for Employment Services
MHA endorses these principles in developing employment services for people with mental health and substance use disorders:
- Programs should center on a person's individual preferences for the jobs he or she wants, with job development tailored to his or her own career interests and capabilities.
- Psychosocial rehabilitative services should be built upon a person's strengths and abilities while de-emphasizing any job-related disabilities.
- Peer involvement and leadership in the design and delivery of employment programs are critical to success.
- If the focus is solely on paid employment, options for internships and learning on the job are more limited. Paid employment inherently lacks elasticity, and the person has to adapt to the job rather than the job adapting to the person.
- Instead, generally, the goal should be to promote involvement of every person able to work in meaningful activities, which is a much broader meaning of work. Developing confidence and competency toward employment should be the overall focus of recovery programs for people with mental health and substance use conditions.
- Whenever possible, employment programs should focus on moving people out of the category of "working poor" and into economic self-sufficiency, consistent with the foregoing principles.
- Personalized benefits planning should be provided whenever benefits are possible.
- Programs should follow the ten Research-Based Principles of Successful Vocational Rehabilitation Strategies outlined in Research-Based Principles of Successful Vocational Rehabilitation Strategies by the National Research and Training Center on Psychiatric Disability, University of Illinois at Chicago.
- Core components of employment services should include continuing vocational assessment, job development, job placement, and ongoing job support that emphasize opportunities for career growth.
- Job placement should provide an opportunity for advancement whenever possible, rather than jobs like gardening, cleaning and maintenance that offer little skills training and isolate individuals from the rest of society.
- Programs should be rigorously tested to evaluate how different approaches work, for whom they work, and under what conditions.
- Employment services should be integrated with provider service models. A fully integrated service model will necessarily include supported employment and assistance in gaining competitive employment, since both of these are essential to real recovery. Many funding sources do not allow this breadth of service, so cooperative agreements should be developed by mental health service providers with the department of rehabilitation and/or the employment development department in the jurisdiction.
- Employment focused programs should strive to address the common challenge that people won’t want to work if they don’t realize some personal benefit or if it isn’t worth their while Thus, programs should seek to emphasize skill development and progress toward realizing personal benefit as soon as possible.
- Cooperative Model. In a cooperative model one gets benefits from being a coop owner, but the benefit is not necessarily in cash.
- One viable path to employment for people in recovery is to start one’s own business.
- Mixing the workforce between people with different forms of disability and those without disabilities can be effective in building skills and teamwork
- A key strategy is to develop a niche product whose pricing is based on quality rather than efficiency.
- Identity Communities. All communities have economies, not all communities leverage the economies that they have. Typically, communities are based on geography, but no other shared identity. A goal for an Identity Community of people with serious behavioral health conditions could be to develop jobs/situations to support that community, such as peer support.
- To be successful, employment training and placement must be culturally competent.
Employment Options (in order of decreasing restrictiveness)
- Sheltered work (widely considered an inappropriate and discredited model)
- Enclave work (collective responsibility for a portion of the work of a business – can be as employees; contractors; a business. Enclave work is interactive with other employees, not “sheltered”), e.g. running the mailroom of a company; after-hours office cleaning; interior and exterior plant and flower maintenance; having responsibility for a portion of the production of a good or service.
- Transitional Employment (Clubhouse model – 3 month paid exposure to competitive work, but not a permanent job or job training)
- Various models of supported education that may lead to work opportunities.
- School-based models
- MH agency-based models
- Stand-along models
- Hybrid models
- Internship, employer-sponsored, and union-connected models.
- Assisted but not supported employment.
- Supported Employment/individual placement & support (IPS)
- (Small) Businesses capable of employing multiple people
- Work Integration Social Enterprises (WISEs) – aka Affirmative businesses, social firms.
- Independent WISE
- Worker owned
- Other business models
- Affirmative Businesses, e.g., Minnesota Diversified Industries
- Joint ventures (e.g., Ben & Jerry’s Partner Shops) (http://www.benjerry.com/values/how-we-do-business/partnershops)
- Sole source contractors for larger businesses, e.g., Greyston Bakery (supplies all the brownies for Ben & Jerry’s) (http://greyston.com)
- Contracting to operate a business within a business or a government owned building, e.g., a coffee shop in an office building.
- Identifying a community/business-community need or niche through the chamber of commerce or its economic development arm. (e.g., the snack bar at a public facility; baked goods for coffee shops; messenger service).
- Competitive employment
Call to Action
- The Centers for Medicare and Medicaid Services (CMS) should revise Medicaid regulations to broaden the Medicaid Rehabilitation Option to cover vocational and employment support services. Currently, only psychosocial services are covered.
- Supported-employment services should be available to veterans with mental health and substance use conditions who are under Veterans Administration care. The Veterans Administration should be granted the authority to provide these veterans the employment-supports they need to enter the workforce.
- The federal regulations governing the Protection and Advocacy for Beneficiaries of Social Security (PABSS) program should be made more flexible so that it can more effectively serve persons with mental health and substance use conditions. Specific provisions should be made for the continuation of health care benefits for persons participating in these programs so that employment does not entail a loss of essential health support.
- SAMHSA should redouble its efforts to meet its Strategic Initiative Goal 4.3: Increase gainful employment and educational opportunities, while decreasing legal and policy barriers, for individuals in recovery with mental and substance use conditions.
- This requires that SAMHSA “implement evidence-based practices related to employment and education for individuals with mental and/or substance use disorders throughout all service systems.”
- Training programs for peer support specialists should be authorized and funded in the federal budget.
State, Local, Provider and Employer Action
- States should take advantage of the full range of federal resources available for employment programs and initiatives. This includes opportunities for state Medicaid agencies to broaden their scope and become more involved in employment issues.
- States, providers and employers should take full advantage of options available through the federally funded Protection and Advocacy for Beneficiaries of Social Security (PABSS) program designed to serve SSI beneficiaries who want to work even though they have continuing disabilities.
- Additional funding should be provided for legal services to persons who have been the victims of employment discrimination due to a mental health or substance use condition.
- State regulations should be evaluated and changed as needed to ensure that employment services are provided in the most appropriate way for individuals with mental health and substance use conditions.
- State agencies responsible for employment services should improve their skills in building and sustaining rapport with people with mental health and substance use conditions so that people who want to work can successfully choose, get, and keep employment opportunities.
- Interagency partnerships should be created in order to provide a seamless service process so that a person in treatment for a mental health or substance use condition can move easily between providers as needed to successfully obtain, retain, and advance in employment.
- States, local communities and providers should pursue innovative funding and service models in order to expand access to employment. For example, in Chicago the award- winning Thresholds program engaged more than 130 employers, including both large national corporations and local businesses in its program. Funding for this program has come from the state, corporate donors and foundations.
- State and local governments should require and employers should adopt “ban the box” programs that remove any questions about the applicant’s criminal history from initial employment applications. When background checks are deferred until later in the interview process, job applicants have a better chance of being evaluated based on their qualifications for the job. As of July 2015, 52 U.S. municipalities and 18 states had in place legislation that "banned the box" for government job applications and also in some cases those of their private contractors. Many such ordinances exempt applications for "sensitive" positions, such as those involving work with children.
- Many states are moving to liberalize the expungement of criminal records, and all states should be encouraged to do so. Expungement is the best remedy to avoid long-term employment disparities due to early-life criminal convictions that do not accurately reflect a person’s current readiness to participate in the work force.
This policy was approved by the Mental Health America Board of Directors on December __, 2017. It is reviewed as required by the Mental Health America Public Policy Committee.
Expiration: December 31, 2022.
[i] Center for Substance Abuse Treatment, Integrating Substance Abuse Treatment and Vocational Services, Treatment Improvement Protocol (TIP) Number 38. Rockville, MD: Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services (2000), http://store.samhsa.gov/product/TIP-38-Integrating-Substance-Abuse-Treatment-and-Vocational-Services/SMA06-4216.
[ii] Source: Substance Abuse and Mental Health Services Administration, Leading Change: A Plan for SAMHSA’s Roles and Actions 2011–2014, HHS Publication No. SMA 11-4629, Rockville, MD: U.S. Department of Health and Human Services (2011), http://store.samhsa.gov/product/Leading-Change-A-Plan-for-SAMHSA-s-Roles-and-Actions-2011-2014/SMA11-4629.
[ii]. Becker, D.R., Drake, R.E. &William J Naughton, W.J. Jr., “Supported Employment for People with Co-occurring Disorders,” Psychiatric Rehabilitation Journal 28:4 (2005); Health Module. pg. 332; https://www.ncbi.nlm.nih.gov/pubmed/15895916
[iii] Luciano, A. & Meara, E., “The Employment Status of People with Mental Illness: National Survey Data from 2009 and 2010,” Psychiatr Serv. 65(10): 1201–1209 (2014), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182106/ .
[v] Supported Employment: Evidence-based Practice Toolkit. Rockville, MD: This document was produced for the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human
Services (HHS) by the New Hampshire Dartmouth Psychiatric Research Center and Westat, DHHS Publication No. SMA-08-4364 (2009), http://store.samhsa.gov/product/Supported-Employment-Evidence-Based-Practices-EBP-KIT/SMA08-4365
For a survey of the evidence, see https://en.wikipedia.org/wiki/IPS_Supported_Employment
[vi] The most comprehensive analysis remains that of Cook, J.A., Leff, H.S., Blyler, C.R., et al., “Results of a Multisite Randomized Trial of Supported Employment Interventions for Individuals With Severe Mental Illness,” Archives of General Psychiatry 62:505–512 (2005), http://jamanetwork.com/journals/jamapsychiatry/fullarticle/208591 . See also, Cook, J., et al., “Integration of Psychiatric and Vocational Services: A Multisite Randomized, Controlled Trial of Supported Employment,” American Journal of Psychiatry, 162(10):1948-1956 (2005), http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.162.10.1948
A 2014 review confirmed that the high level of research evidence for supported employment based on 12 systematic reviews and 17 randomized controlled trials of the individual placement and support model. Supported employment consistently demonstrated positive outcomes for individuals with mental disorders, including higher rates of competitive employment, fewer days to the first competitive job, more hours and weeks worked, and higher wages. Marshall, T., Goldberg, R.W., Braude, L., Dougherty, R.H., Daniels, A.S., Ghose, S.S., George, P. & Delphin-Rittmon, M.E.., “Supported Employment: Assessing the Evidence,” Psychiatr Serv. 65(1):16-23 (2014). doi: 10.1176/appi.ps.201300262. https://www.ncbi.nlm.nih.gov/pubmed/24247197
[x] MHA Position Statement 12, Evidence-Based Healthcare, http://www.mentalhealthamerica.net/positions/evidence-based-healthcare
[xi] Schonebaum A.D., Boyd, J.K. & Dudek, K.J., A Comparison of Competitive Employment Outcomes for the Clubhouse and PACT Models,” Psychiatr Serv. 57(10):1416-20 (2006), https://www.ncbi.nlm.nih.gov/pubmed/17035558
[xii] Lloyd-Evans, B., Mayo-Wilson, E., Harrison, B., Istead, H., Brown, E., Pilling, S., Johnson, S. & Kendall, T., “A Systematic Review and Meta-analysis of Randomised Controlled Trials of Peer Support for People with Severe Mental Illness,” BMC Psychiatry 14:39. doi: 10.1186/1471-244X-14-39 (2014), https://www.ncbi.nlm.nih.gov/pubmed/24528545 Accord, Repper, J. & Carter, T., “A Review of the Literature on Peer Support in Mental Health Services,” J Ment Health 20(4):392-411 (2011). doi: 10.3109/09638237.2011.583947, https://www.ncbi.nlm.nih.gov/pubmed/21770786
[xiv] There are few recent publications on the failed model of sheltered workshops since there has been general agreement by researchers since the late 1970s that the model is a failure. This does not mean that they are gone, however – just that there are no journal articles. The following 2013 review mentions the failure of sheltered workshops in passing: Prior, S., Maciver, D., Forsyth, K., Walsh, M., Meiklejohn, A., & Irvine, L., “Readiness for Employment: Perceptions of Mental Health Service Users,” Community Mental Health Journal, 49(6):658-667 (2013): “Our findings indicate that service users have conflicting views about the value of segregated employment interventions. On the one hand, they may be glad of the routine, limited responsibility and unlimited flexibility, but on the other they are aware that it is not “real” work and that the demands at times are too low to be beneficial. These sentiments are in line with contemporary professional consensus (Bond et al. 2008; Rinaldi and Hill 2001; Crowther et al. 2001; Perkins et al. 2009). Segregation limits the ability of individuals to appraise their own abilities; it also limits exposure to normal working environments and routines (Kielhofner 2008c). Added to this, social networks are limited within these segregated settings (Repper and Perkins 2003; Bates et al. 2002). While our participants valued the mutual support derived from shared experience this segregation also limits exposure to potential inspirational peers with positive journeys into work (Swarbrick et al. 2009). This then may perpetuate negative ideas about the ability of people with MH conditions to work (Rinaldi et al. 2008).” https://www.ncbi.nlm.nih.gov/pubmed/23334300
[xv] Savio, A. & Righetti. M., “Cooperatives as a Social Enterprise in Italy: a Place for Social Integration and -
Rehabilitation,” Acta Psychiatr Scand 88: 238-242. © Munksgaard 1993, http://www.psychodyssey.net/wp-content/uploads/2011/05/Cooperatives-as-a-Social-Enterprise-in-Italy-A-Place-for-Social-Integration-and-Rehabilitation.pdf