Mental health service users' perspectives of work: a ... - SAGE Journals

Alison Blank,1 Priscilla Harries 2 and Frances Reynolds 3

Key words: Mental health, employment, users’ views.

1 Lecturer

in Occupational Therapy, School of Health Sciences and Social Care, Brunel University, West London. 2 Senior Lecturer and Course Leader MSc Occupational Therapy, School of Health Sciences and Social Care, Brunel University, West London. 3 Reader in Health Psychology, School of Health Sciences and Social Care, Brunel University, West London. Corresponding author: Alison Blank, Lecturer in Occupational Therapy, School of Health Sciences and Social Care, Brunel University, Mary Seacole Building, Uxbridge, Middlesex UB8 3PH. Email: [email protected] Reference: Blank A, Harries P, Reynolds F (2011) Mental health service users’ perspectives of work: a review of the literature. British Journal of Occupational Therapy, 74(4), 191-199. DOI: 10.4276/030802211X13021048723336 © The College of Occupational Therapists Ltd. Submitted: 4 May 2010. Accepted: 18 February 2011.

Purpose: Much of the literature about the meaning and experience of work for people with mental health problems is limited in the extent to which individual perspectives are represented, because the evidence derives from studies that are mainly quantitative in design. This literature review focused on qualitative studies, which sought to elicit the experiences of returning to work with a mental health problem. Method: An electronic search of the databases SCOPUS, CINAHL and PsycINFO was carried out. Papers with a publication date between December 1989 and December 2009 were sought. This time period was chosen to reflect the developments in approaches to vocational rehabilitation that have developed during the last 20 years. Findings: The findings indicate that work holds multiple meanings for people with mental health problems, that there are advantages and disadvantages to working, and that many barriers to work exist. The crucial nature of support for the individual in accessing employment is emphasised, and what users want from supportive relationships is detailed. The findings suggest that barriers can be overcome if the right support is available. Conclusion: The findings provide support for the involvement of occupational therapists working in vocational services, and offer some pointers for developing relationships with clients. The findings highlight the importance of exploring clients’ feelings about work, including perceived barriers and benefits to working, and provide a deeper understanding of the type of supportive relationship required by a person with a mental health problem who wishes to access employment.

Critical review

Mental health service users’ perspectives of work: a review of the literature

Introduction Employment for people with mental health problems has been on the political agenda in the United Kingdom (UK) for more than a decade. It now forms part of a wider agenda, focusing on social inclusion and recovery approaches within mental health services (Office of the Deputy Prime Minister [ODPM] 2004, Department of Health [DH] 2006). Recovery may be broadly understood as an approach to mental health service delivery that acknowledges that people can claim or reclaim meaning and quality in their lives, despite the continuation of experiences that are consistent with a mental health problem (Blank and Hayward 2009). Previously, the UK government had demonstrated commitment to the issue of social inclusion and employment for people with mental health problems in the publication of the Social Exclusion Report (ODPM 2004) and through the commissioning guidelines for vocational services (DH 2006). Both these policy documents prioritised supporting people with mental health problems back into the workplace. In 2009, following an extended period of consultation, the Sainsbury Centre for Mental Health (2009) published a position paper that aimed to place recovery approaches centre-stage in mental health services. This position paper emphasised the central importance

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of employment within mental health services, coupled with a recovery approach to interventions. Following a general election in May 2010, a new government came to power in the UK: a coalition of Conservatives and Liberal Democrats. It has made clear its aim of getting people back to work, with an emphasis on reducing welfare support for those who can work. There is also renewed focus on back to work initiatives. It is suggested that employment and clinical care are two strands of a process, which need to be considered in tandem. As a consequence of the emphasis on work and recovery, there have been rapid service developments in the fields of mental health and employment, and the welfare benefits system has already undergone a review to complement the service developments (Department for Work and Pensions 2008). This looks set to continue under the coalition government. The majority of research within the field of mental health and employment has focused on the efficacy of specific approaches to supported employment, particularly Individual Placement and Support (IPS). The benefits of supported employment have already been demonstrated through systematic review (Crowther et al 2001), and findings have been incorporated into key policy documents (ODPM 2004, DH 2006). For the occupational therapy profession, Waghorn et al (2009) have provided a comprehensive account of the ways in which occupational therapists should redefine their practice in order to be consonant with this evidence base. The changes required reflect a paradigm shift in mental health rehabilitation because occupational therapists must consider new ways of working with people with severe and enduring mental health problems. A body of research that has explored mental health service users’ experiences of returning to work offers some useful insights. A review of this literature will be important to occupational therapists for a number of reasons. First, as a profession committed to a client-centred approach to practice, understanding individual experiences is consistent with the philosophy of occupational therapy. Secondly, many occupational therapists are already working as vocational champions and need to be aware of the existing evidence that supports a client-centred approach to their work. Finally, occupational therapists’ unique understanding of the occupational nature of humans relies upon a nuanced understanding of the meaning and experience of occupations to the individual. Such understandings, it is suggested, are most readily accessed through qualitative methods. Qualitative research is now recognised as providing valid and reliable evidence for practice, and supports a client-centred approach (Hennink et al 2011). Therefore, this review of the literature focuses on synthesising findings from qualitative studies that have explored the experience of returning to work for people with mental health problems, for consideration by occupational therapists working with people who wish to enter, or re-enter, the workplace.

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Method The search for literature that explored the views of mental health service users trying to return to work was conducted using the databases SCOPUS, CINAHL and PsycINFO. Papers dated between December 1989 and December 2009 were sought. Key words, used in combination, were work, mental health, vocational rehabilitation, employment, users’ views and users’ perspectives. Approximately 100 abstracts resulted from the initial search. The following inclusion criteria were applied: ■ Studies pertaining to a population of adults with serious and enduring mental health problems ■ Studies that sought to elicit the views of users of mental health services ■ Studies that used qualitative research methods. The papers were evaluated in the following way: abstracts and bibliographic information were reviewed and scored out of five for relevance to the research question, ‘What is the meaning of work for people with severe and enduring mental health problems?’ The full text was accessed for papers scoring four and five. The abstract, introduction and conclusion for each paper were read and re-scored. Citations were checked for all papers scoring four and five (Lycett, personal communication, 2007). In total, 13 papers fitting the criteria were included for review. Table 1 provides a summary of the papers.

Findings Three broad themes were identified in the literature review. These were perceived benefits of work, perceived barriers to work and support in accessing employment. The benefits of work were perceived in a multiplicity of ways encapsulating the individual meanings of work, and the role of work in recovery. Barriers were perceived to be related to such issues as stigma and anxiety about disclosing a mental health problem. Support refers to the type and quality of support needed by mental health service users to find and sustain employment. Support was perceived by some participants as being key in overcoming the perceived barriers.

Perceived benefits of work Ten of the 13 studies reviewed provided findings about the benefits of work as perceived by service users (Strong 1998, Provencher et al 2002, Gahnström-Strandqvist et al 2003, Honey 2004, Kennedy-Jones et al 2005, Marwaha and Johnson 2005, Gewurtz and Kirsh 2007, Boyce et al 2008, Dunn et al 2008, Koletsi et al 2009). Most people with mental health problems would like to be able to work (Grove et al 2005) and the majority of the participants in these studies either wanted to work or were already working. Boyce et al (2008) identified the key benefits of employment as job satisfaction, having a more structured day, the feeling of making a contribution, having a sense of achievement,

Alison Blank, Priscilla Harries and Frances Reynolds

Table 1. Mental health service users’ perspectives of work: a review of the literature – papers reviewed Authors and n Method Main findings Key strengths location of study Boyce et al (2008), 20 In-depth interviews Findings support existing evidence. Suggest Open-ended questions allowed UK disclosure of a mental health problem need participants to voice issues not be a barrier to employment. of importance to them.

Limitations Data gathered at a single time point.

Dunn et al (2008), US

23

Interviews

Findings indicate that work has a highly personalised meaning, and that it can contribute to recovery.

Supports findings from existing studies around benefits of work and the importance of balancing work with other occupations.

Study not explicitly focused on employment.

GahnströmStrandqvist et al (2003), Sweden

18

Semi-structured interviews

Highlighted the importance of the ‘normalising life-world’ provided by working.

Directly seeking users’ views. Data gathered at multiple time points.

Focused on a specific type of supported employment (cooperative).

Gewurtz and Kirsh (2007), Canada

10

Grounded theory study, using interviews to gather data

Findings established a link between mental health service users’ experiences of work and some of the theory that underpins occupational therapy.

Detailed report of findings including extensive verbatim extracts from interview transcripts.

Data gathered at a single time point.

Honey (2004), Australia

41

Grounded theory study, using interviews and focus groups to gather data

Perceptions of employment are highly individual and are subject to change over time. Describes model of ‘weighing up work’.

Use of unstructured interviews facilitated participants to reflect on a range of personal perspectives connected with work.

Some of the findings are specific to the Australian health care system.

Johannesen et al (2007), US

117

Interviews, case notes

Perceptions of barriers correlate with vocational outcomes. Common and illness-related barriers represent important differences and should be explored separately.

Longitudinal. Identifies common barriers to employment in addition to those faced by mental health service users.

Structured interviews may have limited participants’ responses.

Johnson et al (2009), UK

182

Interviews

The value of support was highlighted, especially emotional support, practical assistance and a client-centred approach.

Contributed an understanding of interpersonal dynamics, going beyond the organisational features emphasised in the IPS model.

Interviews not audio taped.


Highlighted importance of providing ongoing support to people with mental illness who seek employment.

Small sample size enabled detailed exploration of themes.

Focused on a specific type of supported employment (Clubhouse).

Kennedy-Jones et al (2005), Australia

4

Koletsi et al (2009), International – UK, Netherlands, Germany, Italy, Switzerland and Bulgaria

48

Semi-structured interviews; qualitative arm of EQOLISE study

Regardless of which model of vocational rehabilitation received, participants described similar positive and negative factors associated with working.

Multicentre, international study.

Study designed to explore experience of IPS, not of work in more general terms.

Marwaha and Johnson (2005), UK

15


Suggests that a stated wish to work might reflect the social desirability of work in western culture. Identifies importance of latent functions of work.

Sheds light on lived experience through analysis of in-depth interviews with a small number of participants. Includes the interview guide used.

Used a self-selected sample so may have been skewed towards those with an interest in work. Participants were aware interviewer was a psychiatrist.


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Table 1. Mental health service users’ perspectives of work: a review of the literature – papers reviewed (continued) Authors and n Method Main findings Key strengths Limitations location of study Provencher 14 Semi-structured Identified three ‘profiles of recovery’. Extensive verbatim extracts. Data gathered at a et al (2002), interviews How people experience recovery impacts single time point. US on the meaning that work holds. Secker et al (2001), UK

Strong (1998), Canada

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12

Interviews and focus groups

Open employment most commonly stated long-term goal, need for support emphasised. Absence of occupational therapists being cited as sources of support.

Service users as researchers a unique feature of the study.

Ethnography – designed to discover what makes work meaningful and how this relates to recovery

The meaning of work varies according to individual perception of illness and self-concept.

A frequently cited paper.

experiencing social contact, and accessing financial rewards. In addition, financial reward was cited as a key benefit in the study by Marwaha and Johnson (2005), followed by a sense that working would enable participants to become socially included, and to have a direction, purpose and structure to their lives. Some participants, however, had concerns that the stress caused by working might exacerbate their mental health problems. Social inclusion also emerged as being important in a longitudinal study by Swedish researchers, GahnströmStrandqvist et al (2003). They carried out a phenomenological study in which they interviewed 18 members of a working cooperative two or three times each over a period of 18 months. They identified the main constituent that characterised the cooperative as ‘the normalising life-world’ (Gahnström-Strandqvist et al 2003, p265). Although this approach to vocational rehabilitation is not consonant with evidence-based approaches to supported employment, this study has added to understandings of mental health service users’ perspectives on work. Aspects of a working life, such as having opportunities to inhabit socially valued roles, meeting a need for occupation, constructing a positive selfidentity and the experience of a supportive environment are all highlighted by the findings of this study. The study is also important because it has contributed to understanding change over time for people with mental health problems in their experiences of work, being one of few studies that have gathered data at more than one time point. Occupational therapists often work with clients over an extended period, so the effects of change over time are important to elucidate. The development of a sense of self as a worker also emerged as being important to participants in a study with a narrative approach, carried out by Kennedy-Jones et al (2005). These researchers gathered data through in-depth interviews with four Clubhouse members who were in open employment, in order to explore the work-related experiences of people with schizophrenia. The Clubhouse model was introduced by Beard et al (1964) and was one of the first approaches to helping people with mental health problems

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Used a self-selected sample so may have been skewed towards those with an interest in work.

back into employment. The analysis revealed four factors that contributed to a sense of self: support from significant others, the personal meaning of work, experiences within the Clubhouse programme, and the ongoing struggle with illness. The findings from this study are strengthened by the inclusion of extracts from the interview transcripts, which provide support for the themes identified. Gewurtz and Kirsh (2007) identified processes that enabled participants to frame their ideas about their future working selves, using a grounded theory approach with 10 users of community mental health services. They used in-depth semi-structured interviews to explore perceptions of work. The findings revealed that the theoretical concepts of doing and becoming (Wilcock 1998) were essential for developing an understanding of work potential. Gewurtz and Kirsh (2007) proposed that through doing work, people with mental health problems can develop a sense of their own capacity for work in the future, and, in so doing, construct an identity as someone with a possible work future. These concepts are important because they establish a link between mental health service users’ experiences of work and some of the theory that underpins occupational therapy; this is not a link that has been explored previously in the literature on work and mental health and, as such, it represents an important finding for occupational therapists to be aware of when planning interventions. The study also provides an important link with the body of work on recovery in mental health, and the central place of hope and a sense of self-efficacy in recovery approaches to practice, and links this with occupational therapy practice. Participants who were not occupationally engaged, or who had had negative work experiences, interpreted this as confirmation of their lack of competence as workers and, consequently, saw their working future as bleak. In the qualitative strand of the multicentre, international Enhancing the Quality of Life and Independence of persons disabled by severe mental illness through Supported Employment (EQOLISE) study (Koletsi et al 2009), participants described aspects of work that were important to them.


The four most positive factors were identified as financial stability, improved social life, increased self-esteem and satisfaction, and integration into and acceptance by society. Nevertheless, in common with the findings from Marwaha and Johnson (2005), participants were concerned about stress and tiredness, conflict with employers and colleagues, and lack of time, control and flexibility to enable them to do other things in their lives that were important to them. These findings are similar to those of Honey (2004), who conducted in-depth interviews and focus groups with 41 users of mental health services in Australia. Findings from this study revealed that perceptions of employment are highly individual, and are influenced by contextual factors that are subject to change over time. These individual factors led participants to do what Honey (2004, p386) called ‘weighing up work’; this model explains how people make decisions about employment based upon other factors in their lives. This study is important because it demonstrates the significance of contextual factors in the lives of people with mental health problems, and shows that people make judicious decisions about work based upon the interplay of these factors. For occupational therapists, Honey’s (2004) study is particularly useful because it describes a model for practice that offers a collaborative way in which to explore the potential for work in the lives of their clients. Dunn et al (2008) conducted semi-structured interviews with 23 participants with serious mental illness. The findings revealed many benefits associated with work. The authors grouped these under two themes: work has personal meaning and work promotes recovery. The participants described how work fostered pride and self-esteem, offered financial benefits, provided coping strategies for psychiatric symptoms, and ultimately facilitated the process of recovery. The findings from this study are described in detail, and are important in developing employment or other recovery focused interventions for people with severe and enduring mental health problems. A frequently cited ethnography carried out in the United States (US) by Strong (1998) examined what made work meaningful for people with severe and enduring mental health problems. The findings suggested that the meaning of work varied between individuals, and that it was closely connected with how individuals understood their illness and how they perceived themselves. For each person, their sense of self and individual understanding of their illness interacted in a dynamic way, which informed their experience of recovery. For example, participants who spoke with pride about recent successes at work were able to set themselves goals to achieve more, such as staying out of hospital for a longer period. Another study from the US by Provencher et al (2002) found that the meaning of work depended on how participants perceived their ability to integrate their illness into their daily lives; for example, if they were able to work whilst continuing to have experiences that were consistent with a diagnosis of mental illness. This study comprised 14 participants who took part in semi-structured interviews in

which they were asked about their experiences of recovery, including their sense of self-efficacy, their self-identity and the personal significance of work. The researchers identified what they called three ‘profiles of recovery’ (p132): recovery as uncertain, recovery as a self-empowering experience, and recovery as a challenging experience. Within ‘recovery as uncertain’, work was seen as a way of passing time or was seen as a duty. The participants who fitted this profile (four in all, of whom only one was working) were generally people who were struggling to manage their mental health problems, and were less well supported by friends and family. A sense of needing to protect a vulnerable self by maintaining the status quo pervaded the narratives of this group, and there was no sense in which work provided a vehicle for selfdevelopment. However, within ‘recovery as a self-empowering experience’, work was seen as being intrinsically tied to a number of advantages: the building of self-efficacy through providing a means to cope with emotional problems and to increase financial gain, and as a source of enjoyment. In the third profile, where ‘recovery was experienced as a challenge’, work was seen as a route to self-actualisation, improving abilities and providing opportunities to meet challenges and experience social connections. In common with Strong’s (1998) study, Provencher et al (2002) provided insights into the highly individual experience of working with a mental health problem. The study also demonstrated the ways in which people with mental health problems may choose to use work as a way of developing a sense of self and to engender feelings of empowerment, as well as providing connections to other people. The findings from Provencher et al (2002) also suggested that for people who were not well-supported, and who were having difficulty managing their mental health problems, recovery was less certain and hopeful attitudes around work were difficult to maintain. What these studies contribute to the evidence base is a deeper understanding of the multiple benefits of work as perceived by mental health service users themselves. They highlight the individual meaning that work holds for each person in his or her recovery process. This emphasises the need for client-centred approaches by occupational therapists and other health care providers, in order to maximise the beneficial aspects of work for each person.

Perceived barriers to work In seven of the studies reviewed, participants reported barriers to gaining employment (Secker et al 2001, Provencher et al 2002, Marwaha and Johnson 2005, Gewurtz and Kirsh 2007, Johannesen et al 2007, Boyce et al 2008, Koletsi et al 2009). The perceived stigma surrounding mental health was the most frequently described barrier to work (Boyce et al 2008, Koletsi et al 2009, Secker et al 2001). Secker et al (2001) and Boyce et al (2008) found that disclosing a mental health problem, and a disjointed work history, were also experienced as being obstacles. With support from employment services, however, these barriers were considered


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by participants to be surmountable. This echoes the views expressed by the participants in a study carried out by Koletsi et al (2009), who reported similar problems in finding work: the most significant barriers were stigma and the problems associated with their psychiatric symptoms. Additionally, these participants reported increasing age as being a barrier, along with a lack of work experience and an intrinsic lack of motivation. Fears around not knowing how to find a job and not being able to do the job were also described. With 117 participants from a larger evaluation of supported employment in the state of Indiana, US, Johannesen et al (2007) examined whether participants’ perceptions of barriers to employment provided a meaningful indicator of vocational rehabilitation outcomes. These authors found that participants’ own perceptions of barriers to work were consonant with those in the literature, and that there were important correlations between common barriers (that is, those that anyone seeking employment might encounter, such as lack of education or skill, or transport restrictions), illness-related barriers (such as poor concentration and medication side effects), and vocational success. They concluded that exploring perceived barriers to work with clients is an important intervention in vocational rehabilitation services.

Support in accessing employment The studies reviewed provided information about the nature and importance of employment support for people with mental health problems in their quest to find and maintain employment, with six of the studies providing detailed findings about the type of support that is most effective and valued by service users (Secker et al 2001, Kennedy-Jones et al 2005, Marwaha and Johnson 2005, Boyce et al 2008, Johnson et al 2009, Koletsi et al 2009). The largest study, in terms of the number of participants, was one carried out by Johnson et al (2009). This was the qualitative strand of the Social inclusion through Employment Support of Adults with Mental Illness (SESAMI) group of researchers, in which semi-structured interviews were carried out with 182 participants to elicit their views on supported employment. Emotional support was seen as being vital, and encompassed helping the client to remain focused and motivated about finding work, while providing encouragement and building confidence. The findings highlighted the central importance of the relationship between the client and the employment support worker, a relationship that was experienced as emotionally supportive, as well as giving encouragement and increasing motivation. This study is significant because it places emphasis upon factors beyond the organisational elements that are stressed in the IPS model, including relationship factors. However, although the findings of this study are important, the interviews were not audio recorded, but handwritten notes were made during the interviews. The authors identify this limitation of the study themselves, along with a concern that the analysis,

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having been carried out by the lead researcher alone, may have weakened the validity of the findings. However, the other researchers in the team contributed to the interpretation of findings by considering an early analysis of the findings to check interpretations; as a result, some rethinking and restructuring of the analysis took place. Further emphasis on the importance of support is provided by the findings from a study by Boyce et al (2008). These authors conducted in-depth interviews with 20 participants who were clients recruited from six employment support agencies in the UK. The aim of the study was to explore the experiences of mental health service users who had returned to work. Employment support was found to be crucial in overcoming psychological barriers and in tackling the perceived stigma surrounding mental illness in the workplace. Support was also found to be crucial in negotiating some of the obstacles encountered in the process of re-entering the workplace, such as the disclosure of mental health problems, support in accessing occupational health assessments, and help with addressing adjustments needed under the Disability Discrimination Act (1995). These two studies from the SESAMI group of researchers (Boyce et al 2008, Johnson et al 2009) have contributed greatly to the understanding of the nature of the individual alliance between employment support worker and client, an understanding that has not been explicated in other studies here. This is clearly important in directing how supported employment is delivered to users by health care providers. The desire for support is echoed in the study by Marwaha and Johnson (2005), who aimed to discover the advantages and disadvantages of work, the ways in which illness affected work, and the experience of looking for and keeping a job. They interviewed 15 people from inner-city mental health services about their views and experiences of work. The participants were critical about the lack of availability of the type of support they believed would be helpful, support which was described in strikingly similar ways to the support that was highly valued by participants in the study by Johnson et al (2009). It is interesting that the two groups had such different experiences of support. This could possibly reflect the way in which people were recruited to the two studies. Johnson et al (2009) had access to the clients of six agencies who provided employment support in different forms; Marwaha’s and Johnson’s (2005) sample was recruited via the staff of a community mental health team. This diversity in sample may reflect different attitudes to work for people with severe and enduring mental health problems, which are held by mental health professionals versus employment specialists. There is some evidence that suggests that mental health professionals are overly protective of clients with severe and enduring mental health problems, and hold beliefs about work being too stressful and likely to precipitate relapse and readmission to hospital (Rinaldi et al 2008), whereas for employment specialists, assisting a client in finding work is core business.


Secker et al (2001) conducted interviews with 156 participants and ran 11 focus groups in Sheffield. Their aim was to carry out detailed exploration of users’ employment, education and training needs. This study appears to be unique within this literature review, in that the authors employed mental health service users as interviewers and as focus group leaders. It could be suggested that this user involvement in research was more successful than other studies in obtaining an insider view of the phenomenon being explored because the researchers, as mental health service users themselves, may have had a deeper understanding of many of the issues faced by participants, and thus were able to pursue lines of questioning that a non-mental health service user may have left unexplored. In addition, the status of researchers and participants as mental health service users may have facilitated a more open and trusting relationship, in which the participants felt able to be more open about their experiences. Open employment was the most frequently identified long-term goal and, again, this study emphasised the need for support. For the participants in this study, support was desired in the form of an integrated approach to vocational guidance, strong links with agencies that could provide opportunities for employment, access to benefits advice, and for mental health services themselves to take a lead in providing and promoting employment opportunities. What these studies serve to underline is the importance of the practical support and assistance that is needed by users of mental health services who are seeking employment. The support referred to in the studies reviewed here has tended to come from employment support workers; however, the support referred to in the study by Kennedy-Jones et al (2005, p120) included ‘significant others’, which could denote family, friends or workers other than employment support workers. Many occupational therapists will find themselves working with clients who wish to return to work, so the findings given here about the type and quality of support that is valued by mental health service users are important for improving services. Furthermore, where occupational therapists are working in teams that include, or have access to, employment support workers, greater understanding of the role of the employment support worker and the nature of the relationships they forge with service users should enhance the integrated approach needed to facilitate effective supported employment. The findings also underscore some of the key components of the IPS model, namely that vocational and mental health services are well integrated and provide easy access to benefits advice.

Discussion and conclusion This review of the literature has shown that there is a small body of evidence that has contributed to a deepened understanding of mental health service users’ perspectives on work. Although most of the studies reviewed were

small in terms of sample size, they have contributed a more detailed and nuanced understanding of the meaning and experience of work for people with mental health problems, as well as highlighting some key areas for intervention by occupational therapists working in the field of vocational rehabilitation. These new understandings may be helpful for occupational therapists as they delineate their practice within vocational services. Although it is convenient to divide perspectives on work into benefits of, and barriers to, employment, these constructs can be viewed as two sides of the same coin, as illustrated by the participants in Honey’s (2004) study where a ‘weighing up’ of work was seen to be taking place. Balancing work with other elements of occupational performance is an area that occupational therapists already engage with, and this review confirms this as a meaningful approach. In addition to identifying the significance of ‘weighing up work’, Honey’s (2004) emphasis on the importance of acknowledging that an individual’s circumstances may alter over time is crucial: the changing and dynamic process of recovery, and the role of work within that for individual clients, is one with which occupational therapists must engage. The socially valued aspect of work highlighted by Marwaha and Johnson (2005), which may lead people to express a wish to work, is an important area for consideration by occupational therapists. Understanding an individual’s beliefs and values surrounding work is consistent both with client-centred and recovery approaches to practice, and should therefore form part of occupational therapy assessment and evaluation. Whether already working, or planning to work in the future, it seems from the findings of this review that mental health service users are able to identify multiple benefits of working. Those who are in work are clear about the need for a supportive, practical relationship with an employment specialist, and what they want and need from that relationship. One of the key ingredients of such a relationship is encouraging motivation. Mee and Sumsion (2001) previously identified the importance of occupational engagement as a route to increasing motivation. Some participants had discovered that, with supportive relationships in place, barriers could be negotiated or overcome. The importance of relationships has been highlighted by the findings from this review, and seems entirely consistent with a client-centred philosophy, which confirms the place of occupational therapists in the forefront of the vocational rehabilitation movement. Some of the studies that were carried out in the UK were with participants who were predominantly described as white British (Secker et al 2001, Johnson et al 2009). It is possible that different cultural groups experience and describe work and mental illness in different ways. A number of the studies are qualitative strands of larger quantitative studies which were designed to explore a specific approach to supported employment, that is, IPS (Boyce et al 2008, Koletsi et al 2009, Johnson et al 2009). There may, therefore, have


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been some inherent researcher bias towards asking participants about organisational elements, which are stressed in the IPS model of supported employment. The studies reviewed here go some way towards illuminating the lived experience of being mentally unwell and wishing to find and keep a job. It could be argued, however, that the research does not go far enough. Although some of the studies (Marwaha and Johnson 2005, Boyce et al 2008) carried out in-depth interviews with small numbers of participants (15 and 20 respectively), data gathering and analysis methods have limited the findings to revealing a perspective of users’ experiences that underscores aspects of the supported employment model. The understanding of the lived experience of work for people with severe and enduring mental health problems remains partial. Although some of the studies reviewed contained extracts from interview transcripts, the understanding of individual narratives has not been facilitated through an idiographic analysis of data. Such an approach to data gathering and analysis might yield more nuanced, individual accounts, as opposed to broad themes, such as have been distilled from the studies in this review. Furthermore, with the exception of the studies by Johnson et al (2009) and Gahnström-Strandqvist et al (2003), data were gathered just at one time point, and it is likely that people’s views and experiences of work alter with their employment experiences, the passage of time, and their individual recovery processes. This review of the literature suggests that further longitudinal research is needed to produce the nuanced description of the life-world of the individual, using an approach to research that is designed to facilitate detailed, insightful user accounts of particular instances of lived experience. By doing so, such research could build upon, and enhance, the findings accumulated by the studies reviewed here. Acknowledgements This critical review forms part of a larger study, for which funding was obtained from the Institute of Social Psychiatry and the College of Occupational Therapists Research Capacity Awards. Conflict of interest: None declared.

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Key findings Benefits of work are personally meaningful and intrinsically bound up with recovery. Individual perceptions of work are important for occupational therapists to understand.

What the study has added This study provides a deeper understanding of users’ perspectives on work in recovery, the benefits of working, the barriers that may be encountered, and the importance of supportive relationships in negotiating these barriers. There is an emphasis on client-centred approaches to practice for occupational therapists working in employment services.

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Grove B, Secker J, Seebohm P (2005) New thinking about mental health and employment. Oxford: Radcliffe Publishing. Hennink M, Hutter I, Bailey A (2011) Qualitative research methods. London: Sage. Honey A (2004) Benefits and drawbacks of employment: perspectives of people with mental illness. Qualitative Health Research, 14(3), 381-95. Johannesen JK, McGrew JH, Griss M, Born D (2007) Perception of illness as a barrier to work in consumer supported employment services. Journal of Vocational Rehabilitation, 27(1), 39-47. Johnson R, Floyd M, Pilling D, Boyce M, Grove B, Secker J, Schneider J, Slade J (2009) Service users’ perceptions of the effective ingredients in supported employment. Journal of Mental Health, 18(2), 121-28. Kennedy-Jones M, Cooper J, Fossey E (2005) Developing a worker role: stories of four people with mental illness. Australian Occupational Therapy Journal, 52(2), 116-26. Koletsi M, Niersman A, van Busschbach JT, Catty J, Becker T, Burns T, Fioritti A, Kalkan R, Lauber C, Rössler W, Tomov T, Wiersma D (2009) Working with mental health problems: clients’ experiences of IPS, vocational rehabilitation and employment. Social Psychiatry and Psychiatric Epidemiology, 44(11), 961-70. Marwaha S, Johnson S (2005) Views and experiences of employment among people with psychosis: a qualitative descriptive study. International Journal of Social Psychiatry, 51(4), 302-16. Mee J, Sumsion T (2001) Mental health clients confirm the motivating power of occupation. British Journal of Occupational Therapy, 64(3), 121-28. Office of the Deputy Prime Minister (2004) Mental health and social exclusion, Social Exclusion Unit Report. London: OPDM. Provencher H, Gregg R, Mead S, Mueser K (2002) The role of work in the recovery of persons with psychiatric disabilities. Psychiatric Rehabilitation Journal, 26(2), 132-44.


Rinaldi M, Perkins R, Glynn E, Montibeller T, Clenaghan M, Rutherford J (2008) Individual placement and support: from research to practice. Advances in Psychiatric Treatment, 14(1), 50-60. Sainsbury Centre for Mental Health (2009) Implementing recovery. A new framework for organizational change. London: SCMH Publishers. Secker J, Grove B, Seebohm P (2001) Challenging barriers to employment, training and education for mental health service users: the service user’s perspective. Journal of Mental Health, 10(4), 395.

Strong S (1998) Meaningful work in supportive environments: experiences with the recovery process. American Journal of Occupational Therapy, 52(1), 31-38. Waghorn G, Lloyd C, Clune A (2009) Reviewing the theory and practice of occupational therapy in mental health rehabilitation. British Journal of Occupational Therapy, 72(7), 314-23. Wilcock AA (1998) Reflections on doing, being and becoming. Canadian Journal of Occupational Therapy, 65(5), 248-56.

Focus on research Theses donated to the COT Library are available for loan, but are not downloadable. Please contact the Library for details. Wai-Ling Bickerton The cognitive neuropsychology of everyday action: an investigation into its application for rehabilitation. University of Birmingham, 2007. PhD.

Ruth Patricia Parker Missing opportunities? Independent access to physical play activities for mobility impaired children in Lincolnshire. University of Salford, 2010. MSc Accessibility and Inclusive Design.

Introduction: The cognitive rehabilitation of neurological patients’ everyday action is largely undertaken by occupational therapists, typically without being based on a theoretical framework on the cognitive mechanisms of everyday action. The recent developments of cognitive neuropsychological models of praxis processing (Rothi et al 1997) and routine sequential actions control (Cooper and Shallice 2000) have inspired investigations into model based rehabilitation. The aim of the current research was to describe and evaluate an attempt to apply cognitive neuropsychological principles to the rehabilitation process of everyday actions. In addition, the relationship between praxis and complex everyday action performance was explored. Method: A praxis screening tool was developed and validated with 85 control participants and up to 117 patients at various stages of recovery from brain damage. Further detailed analyses of praxis (n = 9 patients) and everyday action (n = 6 patients) were conducted to identify the nature of action failure. The benefits of treatment strategies targeted towards the identified deficits were also examined with rehabilitation studies of two patients with contrasting deficits. Results: Dissociable patterns of performance were identified at both the praxis and sequential actions level, using screening tasks as well as more fine-grained assessments. Targeted therapeutic approaches for the different deficits were indicated and their benefits verified. The relationship between praxis deficits and everyday tasks performance varied according to nature of the processing breakdown. Conclusion: Assessment of cognitive deficits through model-led observation of everyday actions performance was recommended. [Author abstract]

Access to physical play is an important part of child development, contributing to physical and mental wellbeing as well as assisting with the development of life skills. This research investigated the situation within Lincolnshire for mobility impaired children wishing to access physical play opportunities independently. This was achieved through establishing an age when physically able children begin accessing play without parental support and identifying the physical play activities accessed. To enable comparison with this group and mobility impaired children a questionnaire was sent to 485 disabled children in Lincolnshire, achieving a final sample size of 35 children. Questionnaire responses were compared with examples of physical play provision through access audits of play environments. These were supplemented by interviews with a number of respondents, managers of play environments and organisations offering advice on play provision. The results confirmed that opportunities for independent access to physical play opportunities are limited for mobility impaired children within Lincolnshire. The reasons for this include poor access and maintenance plus unsuitable choice of equipment. Children and families wished to access physical play environments; supported politically through legislation, local and national policies. This support has not, however, translated into a cohesive approach towards play provision, leading to isolated inaccessible instances of good provision resulting from providers focusing on individual elements rather than the bigger picture. The evidence supports respondents’ opinions that play provision within Lincolnshire does not offer opportunities for mobility impaired children and that without challenge the present situation is unlikely to alter. [Author abstract]


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