During the past decades absence from work because of sick leave has stood out as an enormous problem in our society. To an ever increasing extent, people have been placed outside the labour market; simultaneously, the granting of disability pensions has increased. Studies have accordingly taken up the subject of returning to work after a long period of sick leave, looking at such issues as motivation, being an active part in the rehabilitation process and regaining the ability to work (Gard and Larsson 2003; Moll, Huff, and Detwiler 2003; Rogers et al. 2006) or have attempted to identify factors that would facilitate a return to work among people who are unemployed and disabled (Hansen, Edlund, and Henningsson 2006; Isaksson-Mettävainio and Ahlgren 2004; Passmore 1998). A number of Swedish reports have indicated that people with psychiatric disabilities have low social status and high unemployment levels compared with people with other disabilities or the general population (Nationell psykiatrisamordning 2006). Studies in other countries describe similar findings (Burns et al. 2007; Mueser, Salyers, and Mueser 2001)
Psychiatric disability is a broad concept used in individuals with many different mental health problems, such as schizophrenia or other psychotic disorders as well as anxiety, mood or personality disorders according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association 1994). However, diagnoses are in many ways inadequate as a sole indicator of people's function and needs. A more holistic view, with the full contextual experience of an active, knowing person, is preferable in rehabilitation planning.
A contribution to this view is the structure of the International Classification of Functioning, Disability and Health (ICF; World Health Organization 2001), which describes domains that are classified from body, individual and societal perspectives. ICF describes how people live with their health condition together in their physical, social and attitudinal environment. Disabilities are classified as impairments, activity limitations and participation restrictions and, in this context, are related to mental health problems.
There are now many models and rehabilitation programmes that focus on activity and participation, for example the Model of Human Occupation (MOHO; Kielhofner 2007), Occupational Performance Process Model (OPPM; Townsend 1997) or methods to create opportunities and abilities to obtain and retain a working role, such as Psychiatric Vocational Rehabilitation (Rogers et al. 2006) and Supported Employment (Drake 1998; Moll, Huff, and Detwiler 2003).
Although vocational rehabilitation programmes often claim to promote independence and autonomy, studies have shown that people with psychiatric disabilities experience a lack of self-determination in their lives (Cook and Jonikas 2003). From this perspective, the concept of empowerment could be well-suited for consideration by rehabilitation professionals when promoting vocational rehabilitation outcomes.
There is a vagueness about the term empowerment (Chamberlin 1997; Hagquist and Starrin 1997; Svensson, Müssener, and Alexanderson 2006). The lack of a clear theoretical underpinning, different meanings of the concept as used by different users, measurement ambiguities and structural barriers that make empowerment difficult to attain are some of the critical issues in the concept (Rissel 1994). Yet, according to Hagquist and Starrin (1997), the concept has been freely used in discussions on how the influence of vulnerable groups can be increased. Studies have shown that it is important to have an empowerment perspective when supporting individuals in rehabilitation programmes (Chamberlin 1997; Hein and Lustig 2005). Accordingly, there is a need to gain a deeper understanding of the individual dimensions of work disability where a holistic view and empowerment are essential.
Although there have been many studies on the subject of return to work there remains a lack of knowledge concerning how living with psychiatric disabilities for long periods influences a person's beliefs, hope and volition when he or she tries to enter the labour market. Hence, there is a great need to deepen and broaden knowledge about psychological and social factors that have an impact and are significant when professionals assess and prepare vocational rehabilitation.
The aim of this study was to reveal the meaning some people with psychiatric disabilities assigned to important experiences related to long periods of participation restrictions owing to unemployment and sick leave. The research questions were: What in these informants' individual experiences could provide some deeper understanding of their expectations, hopes and volition in the face of the coming rehabilitation? How did these experiences influence their commitment to vocational rehabilitation?
The informants were selected through purposeful sampling (Patton 2000). According to Patton the advantages of purposeful sampling lie in selecting information-rich cases for in-depth study. We used what Patton calls typical case sampling (2000, 236). Our cases were selected with the cooperation of rehabilitation professionals at a rehabilitation centre in a medium sized Swedish town. They helped us to identify typical cases for our study. The informants were selected on the basis of their not being atypical, extreme or intensely unusual, and therefore could be seen as representing a summary of the characteristics of people in need of vocational psychiatric rehabilitation.
The potential informants were taking part in a vocational rehabilitation programme for unemployed persons with mental health problems in the public sector. The programme was inspired by Supported Employment (Drake 1998) and Psychiatric Rehabilitation (Anthony et al. 2002). Interacting authorities were responsible for follow-ups and rehabilitation professionals at the rehabilitation centre for follow-along support in the rehabilitation process.
The inclusion criteria were that the persons: (1) qualified as belonging to a target group for a vocational rehabilitation intervention as a result of participation restrictions due to unemployment; (2) that they were on sick leave due to mental health problems; and (3) that they were in the initial stage of their vocational rehabilitation process.
Professionals responsible for follow-up support passed verbal and written information about the study to potential informants who met the inclusion criteria. Potential informants voluntarily contacted the first author for more information about the study and were assured that participation in the study would not affect continued support in the rehabilitation process at the rehabilitation centre.
Four women and four men were selected. All took part voluntarily and consented to their participation in writing. This implied that they could discontinue participation in the study at any time. Although the ambition was not to focus on gender, a sample including both sexes was favoured to obtain a broad understanding of the informants' various experiences.
Table 1 gives a basic description of the informants with regard to age, their own description of the reason that they were on sick leave, periods of illness before the intervention, when they first experienced that their health affected participation in activities related to work integration or employment and previous work experience. The informants' names have been changed to prevent identification.
|Name||Age||Own description why on sick leave and time when mental health problems affected school or work-oriented activities||Time on sick leave before intervention (years)||Benefits during sick leave||Education and job experience|
|Helena||36||Panic disorder Participation restriction since nine-year compulsory school||3||Sickness benefit||Experience of being employed for shorter periods. Work training at a regular workplace in order to get practical experience for some periods through compulsory and high school|
|Mikael||21||Depression, social phobia Participation restriction since high school||3||Supplementary benefit||High school. Employed for shorter periods in the summer|
|David||28||Depression, stress syndrome Participation restriction since high school||5||Disability pension||High school. Regularly employed for shorter periods. Work training at a regular workplace in order to get practical experience for some periods through the Job Centre|
|Susan||24||Social phobia, self-harm Participation restriction since high school||2||Sickness benefit||High school. Regular employment for one-and-a-half year|
|Erik||19||Unsociability, depression Participation restriction since nine-year compulsory school||3||Supplementary benefit||No completed high school. No experience of being employed. Work training at a regular workplace in order to get practical experience for some periods through high school|
|Anne||23||Depression, self-harm Participation restriction since high school||3||Supplementary benefit||High school. Employed for a shorter period|
|Alice||52||Stress, burnout, depression Participation restriction for one period in life||1 ½||Sickness benefit||High school. Regularly employed since high school. Runs own business|
|Peter||40||Psychosis Participation restriction two longer periods (five years) in a decade||3||Disability pension||High school. Regular employment for eight years. Sheltered employment for five years|
Stories are recognised as a research tool in efforts to understand the point of view and personal experiences of one's informants (Mattingly and Lawlor 2000). Hence, the informants were asked to tell stories, as detailed as possible, of particularly hopeful and critical incidents and interactions with professionals from the time when they felt that their mental health problems started to affect activities related to school, work integration or as an employee. The interview covered the following question areas: activities during unemployment, experiences of support of professionals and authorities, making one's own decisions related to being unemployed and on sick leave and visions of the future.
Follow-up questions were used to guide the informants in covering the question areas and to inspire them to continue their stories. Three of the informants were interviewed twice so that all of the informants were at the same approximate level in their rehabilitation planning and to further clarify findings in the data. Each interview lasted 60–90 minutes and was conducted at a location of the informant's choice (all chose the rehabilitation centre). All interviews were recorded and transcribed verbatim.
The interpretation of the text followed hermeneutical principles, which in this study means the hermeneutical circle (Gadamer 2004). According to the hermeneutical circle, we always interpret and understand individual parts in relation to the whole. Gadamer (2004), 305) describes the process of understanding as a fusion of one's own cultural-historical horizon with the present (here the content of the text). Hence, there is a relation between pre-understanding and the hermeneutical circle. Pre-understanding means such understanding that has already been accomplished in the researcher's worldview and functions as a structure that makes it possible to understand something new. The aim in using the hermeneutical approach was to examine the informants' different views on how to conduct oneself in relation to vocational rehabilitation based on previous experiences.
A first step in the hermeneutical approach was to read and re-read the transcriptions of the interviews in order to expose the data in each of the informants' stories through a method of switching between the parts and the whole of the text. Our interpretation was advanced by actively inquiring about the conditions, requirements and situations described in the text. This was a way to expose our preconceptions and to open new possibilities for understanding the informants' statements. The process of interpretation helped us to identify actions and social interactions and gave us a deeper understanding of these lived experiences related to problem situations and planned future actions. Finally, questions were asked about the logical consistency between the interpretations and the data. The hermeneutical analysis showed three different views of how to conduct oneself in relation to the vocational rehabilitation.
Guidelines for comparative analysis (Patton 2000) were used to further identify similarities and differences in the informants' stories. The approach was to code the data from each interview in a line-by-line process where words and phrases were closely examined. The categories that emerged from the data were compared to make connections between them and to find themes that could be seen as an expression of the concealed content of the complete data. The emerging results were constantly discussed and reviewed by all the authors. The perspective of the first author was occupational therapy, while the other two authors had a sociological perspective.
The stories represent the informants' expectations, hopes and volition in the face of vocational rehabilitation. All had experienced inactivity and isolation during their periods of participation restrictions owing to unemployment and mental health problems. However, the expectations of taking part in a rehabilitation programme did not always generate a hopeful attitude toward rehabilitation and entry/re-entry into working life. Events, actions, interactions and circumstances in their lives influenced how they relate to the rehabilitation process and their prospects for success or failure.
The different views of the future could be organized into three categories. Although the categories are not distinct and unambiguous, they are identifiable as three separate categories:
Informants in this group spoke about a feeling of exclusion or alienation. Unsuccessful schooling, great difficulties in finding employment, little or no job experience, lack of support and unfitting demands on the part of authorities appear to have made having a positive attitude to the pending rehabilitation difficult and to have weakened the potential to manage the commitment. These difficulties were not solely related to their perception of their own personal abilities. There was an inclination to think that meetings with various professional agents without there having been any positive outcome in work integration had influenced their outlook. Their feeling was that the future was very unclear, and taking one day at a time, with great wariness, was enough for them.
These informants had much the same experiences in terms of a lack of support and understanding of professionals, lack of control and a disparaging self-image as were recounted by the informants described above. However, these informants had now placed some measure of trust in the support offered and, at the start of their vocational rehabilitation, were able to envisage a future in the workforce. Their visions were vague but they could see themselves striving towards a transition.
This group differed significantly despite their shared experience of a lack of support in the past when unemployed. These informants had spent many years in the labour market as business owners or regularly employed, with or without subsidies and/or in sheltered employment. Their work was significant in their lives, and this appeared to give rise to a positive attitude. They regarded rehabilitation as another step towards a future of gainful employment. They were quite aware that it would take time and effort to reach the goal, but a positive vision of how it was going to end existed. Unlike the informants above, this group also clearly described positive experiences in dealing with the authorities with whom they dealt in work integration and rehabilitation early in their period of ill health. This provided hope, and they believed that they would receive confident support during the course of the rehabilitation process.
Our analysis suggests that these different attitudes could be explained by the informants' varying perceptions of how to act in order to be successful in tasks that they were expected to manage. These include the demands of society, their current stage in life and the extent of support and collaboration between the informants and professionals in the past and present. On the basis of the comparative analysis, four common themes emerged as expressions of concealed content in the data. The themes describe events, feelings, situations and interactions with others that influenced their present view of vocational rehabilitation: the support and understanding of professionals, experience of control, the significance of time and self-image.
Excerpts from the interview manuscripts are supplied to support and illustrate our interpretation. […] means that some text has been omitted. Text within square brackets is explanatory remarks supplied by the authors.
After finishing school and entering adult life, most of the informants had contact with different authorities because of their mental health problems and unemployment. Common for most of them was an experience of insufficient support or lack of understanding from psychiatric care, social services, the social insurance office or the employment centre. The informants with a pessimistic view of the future and those with just a ray of hope shared a sense that these experiences negatively influenced their confidence and faith in authorities and their potential to assist in trying conditions:
Although most of the informants grew up with trying experiences lasting for very long periods, some of them now, at the beginning of their vocational rehabilitation, seemed to have a new, cautious, but somehow hopeful attitude to returning to work: a ray of hope for the future. Unlike those with a pessimistic view of their employment potential, these informants had contact with some professional who they felt honestly believed in them and their abilities. These new contacts had acted on their behalf, assisted them in dealing with the authorities and begun to create opportunities for them to experience being successful in tasks that were planned for their rehabilitation:
Susan: Right from the first time you're going to meet them you think they aren't going to do what they're supposed to. [General point of view about authorities]
It seemed that new confidence in authorities' ability to support, in addition to the support given by family, helped to change their attitudes.
Susan: It's better than I thought … figured not much was going to happen, but it has … Nice that it's not what you think. It's been great now. I'm getting some of that cognitive behavioural therapy and it's been really useful […] The occupational therapist has even been horse riding with me. She's been to see me, to see how I'm doing even though I'm not doing workplace practice. It's great to think you haven't been forgotten.
There were also informants who early in their period of ill health felt that they had received satisfactory support. Compared with the others, they almost immediately had a positive attitude and an optimistic view of the future when informed about the opportunity to join a vocational rehabilitation programme:
Overall, the analysis showed that it was not significant which occupational group provided support, as long as it was provided. What was essential was continuing, trusting and flexible support over time. This seemed to engender a positive attitude toward starting vocational rehabilitation.
Alice: I have great experience of this, and the same with the rehabilitation professional in this activity, very good. I'm so satisfied. And, there's a psychologist too, if one's needed. So she's been important and the social insurance office has been important and she's stood by me the whole time and the doctor has been important. I have, like, always gotten the help I needed in the health care system in the form of sessions with the therapist or sleeping pills from the doctor.
Several informants commented that being cautioned about a suspension of financial benefits often opened the way for a discussion about plans for the future. These informants described a vulnerable and exposed position. Criticism of not actively seeking employment contributed to anxiety and pressure that paralyzed rather than promoted their seeking, obtaining and retaining a job:
Erik: She was on my back, when I felt worst [social services], she wanted me to go to workplace practice five days a week, right away, like. Otherwise I'd lose my benefits, then I felt even worse, it felt like I already had impossible demands on me, like.
The informants' expectations varied according to who was most motivated for vocational rehabilitation. If professionals in authority were the most motivated or, conversely, were disinterested, the informants' feelings of control over the situation seemed to fade quickly. Several informants said that decisions or interventions that influenced their daily lives were beyond their control and often not suited to their needs and situations. These circumstances influenced their confidence about managing the undertakings that had been arranged:
The informants' experiences also influenced their views of their ability to accomplish what they needed to do during rehabilitation. This seemed to have an impact on their outlook on the future. Some said that they had encountered problems that were beyond their control and that they had been asked to do the impossible. Examples included inflexible regulations that did not fit with their needs and rendered them powerless:
Helena: Then this thing about having to approach working life. I know that I have to because of; that I must get this thing that I should get about people and things like that. But yet I felt great pressure from my hospital social worker and everybody. ‘You have to get out, and this is better for you!’ And in these situations I think: What the hell do you know about what's better for me! Everything at the greatest possible speed.
A feeling of powerlessness also emerged when professionals in authority did not have the power to deal with situations before they had obtained formal written opinions from other professionals. The informants' own stories about their circumstances may have been taken seriously, but the authorities could not act before receiving these formal professional opinions. This process generated a feeling among informants that they were not trustworthy in their descriptions of their life situations and needs:
Helena: Then I thought I'd ask the social insurance office if it was alright to study those subjects, if I could take it a little easy and get out that way. Nope, you'll have to declare yourself fit and then you'll have to take a loan, she said. […] Finally I just said yeah, yeah, that's the way it is (resigned) just because I couldn't take any more.
Nonetheless, some of the informants experienced situations and interactions where they had a feeling of control over their rehabilitation and that the decisions taken also fit their life situations and needs:
Anne: The procedure was that you have to apply for at least five jobs to get your benefits. They didn't mention anything about my mental health. My psychologist finally wrote a formal opinion to have me excused from seeking these five jobs every month. We [the person and her boyfriend] had just had a meeting with the person in charge of my case [social services]. We talked about my situation for at least an hour and she knew exactly what was going on. Still, she didn't do anything.
These informants also had a positive attitude to their rehabilitation planning and looked forward to starting their programmes. What was common for them, as mentioned above, were that, at an early stage of their psychiatric care and social rehabilitation, they had experienced support that was suited to their needs and that professionals had given them the opportunity to take part in the decisions taken about their future. All in all, our analysis showed that the informants who experienced control over future planning also thought that they were going to be able to manage their vocational rehabilitation.
Alice: The social insurance office contacted me and we were to have a meeting together with the doctor. I remember it as an unexpected success. She had stood by me the whole time and she had … or I made the arrangements myself […] so she has supported me and approved the whole thing.
Some informants had been unemployed for long periods before they were granted sick leave. Time was a shared concern and they perceived heavy time pressure. The lack of commitment and practical support of the employment office, together with the passing of time, from months to years, without changes for the better, created a feeling of hopelessness:
For one informant, who received benefits from the social services, it was a never-ending wait for support to find, get and keep a job. This was a change that was desired, and the waiting, without knowing when it would happen, created a feeling of hopelessness:
Anne: Oh my god, is this how it's going to be? Then it isn't worth living. I've been worse, much worse. That's when I started with the self-destructive stuff. And I really didn't have anyone who cared about me so I didn't care either.
Despite the description above, it was foremost the informants who received sickness benefits from the social insurance office that felt their time was running short. They considered that the rules at the social insurance office said that if they needed rehabilitation benefits for a longer period than one year, they had to apply for disability pension to continue their rehabilitation. Bearing in mind that they had lived with their mental health problems and participation restrictions for a long time (since their school years), an intervention lasting only one year felt like an impossible undertaking. The threat of failure, and the financial consequences coupled with the stigma of being a person with a disability pension, was described as paralyzing. This created a feeling of fear and an unwillingness to try – and the coming rehabilitation felt more like a hindrance than an opportunity:
Mikael: Considering that it took them more than a year to get into touch with me for a meeting and ‘Let me see if there's anybody who's looking after your case’, I don't have any great expectations. […] I don't really dare to believe it. If you don't have anything to believe in, then you won't be disappointed, so it's better not to believe.
Susan: It's hard to continue then. Especially when you have the problems that I suffer from, it's just like I couldn't do anything more when they said it. You can't stay [doing workplace practice], you are under such stress, and the feeling is that you're forced to recover from your sickness in the space of one year, and then you don't know how it's going to work. […] It puts me under heavy pressure … It really doesn't work to be granted a disability pension when your goal is to be employed.
The experience of one informant also showed, quite in contrast to the description above, that a change in benefits from the social insurance office from sickness benefits to rehabilitation benefits created a hopeful attitude towards the future and the coming vocational rehabilitation:
He was also one of the informants that were described above as feeling that they had sufficient support from professionals in the early stages of their psychiatric care and social rehabilitation and a bright view of the future. The other informant who shared this experience and attitude towards the future felt the same about efforts coming at the right time:
Peter: That's quite another matter; it's of great importance. Then, when this distinction comes from the social insurance office that they have seen that you have managed your commitments. I think this is very positive because now they think that you have the ability to increase your working hours. Then you are successively more useful, and soon you're back.
Alice: I was so motivated. This is great! In any case it's the best that could happen […] And my chances of getting a job are good.
The informants who had a positive attitude to the future were also those who had strong identities as workers:
Alice: I've worked a lot my whole life and never done anything like this before [suffered from mental health problems].
In these cases, vocational rehabilitation was viewed as a turning point leading to a positive transition. Even though they felt that they needed time, and continual, flexible and practical support or adjustments, they had an optimistic view in terms of their future plans and commitments from the start, and saw themselves as workers.
Peter: I worked for 13 years and not been on sick leave more than these two years and two years in the 1990s. It was the same procedure now as it was then.
However, the stories showed that most of the informants had no working role. A working role was seen to be far away for some of them, and for others the hope of a possible working role had just been woken. Many of them described themselves as excluded, without an ability to fit into employment somewhere. This seemed to be incorporated into their self-image and appeared to present a great obstacle when they tried to emphasize their needs, stand up for their rights and maintain their confidence about their personal power under trying conditions:
David: You're not allowed to participate, it's a little like that. […] The expectations [in working life] are outrageously high, the demands are way too high. Not everybody's designed for university studies. What happens to them? It's another case of class differences and exclusion…
To some extent it seems as though the informants' perception of who they are, what they are able to do and what they are worth is influenced by their experiences of the support and treatment of professionals. The meaning of emotions in interaction with others and how it can influence our belief in our own abilities and self-image is further reflected upon below.
Susan: It's like this, my problems aren't so important and so I don't get any help. You feel unimportant. Then it takes more time and then I'm on sick leave longer and cost even more.
This study explored the meaning that some people with psychiatric disabilities assigned to important experiences related to long periods of participation restrictions owing to unemployment and sick leave and how these experiences influenced their subjective feelings about managing a commitment to vocational rehabilitation. When people relate something about what happened in the past, they tell not only about past actions but of how they understand those actions, that is, their meaning (Riessman 1993). The intention in this study was not to make a rigorous narrative study but to ask the informants to relive moments in their past by telling about them. These rich stories helped to clarify the informants' ‘insider’ perspective. According to Mattingly and Lawlor (2000) rich narrative descriptions are much more useful than abstract generalizations or belief statements in helping to understand complex and often quite tacit meanings (including dilemmas, hopes, anxiety and the like). It is important to consider that the informants themselves chose what they wanted to share, and it is possible that their stories would be somewhat different under other circumstances (Kvale 1996).
The first author was involved in the entire research process in this study. To enhance the trustworthiness of the interpretations, examinations were made by all of the authors. The complete research procedure was continually scrutinized and discussed (Lincoln and Guba 1985). A heterogeneous sample, according to age, sex, diagnosis and life experience, was favoured to get a broad variation in experiences that could deepen our understanding of the phenomenon; the intention was not to find atypical or unusual cases for study. The aim was to learn from typical single cases and gain a deeper understanding of the conditions facing people with psychiatric disabilities who undergo rehabilitation for work integration.
The analysis revealed six types of mechanisms important for the outcome of the rehabilitation process: view of future, support, understanding, control, time and self-image. These mechanisms contribute to an understanding of what mechanisms are important in the rehabilitation of people with psychiatric disabilities. An overall aim in social science research is to explain events and processes. In this endeavour it is important to describe how different mechanisms manifest themselves under specific conditions, and our method is well suited for acquiring knowledge about such mechanisms. A well-known example in the social scenes is Erwin Goffman (1990) when he argues on the basis of qualitative studies that people's actions nearly always have the character of performances where, with the aim of influencing other people's views of us, we hide certain things about ourselves and accentuate others. As Silverman (1993)/2006) emphasizes, qualitative studies such as ethnographical studies are not limited to descriptions of actions in different settings. ‘On the contrary, ethnography shares the social science programme of producing general, possibly even law-like, statements about human social organisation’ (Silverman 1993/2006, 49). In this sense our study contributes to an understanding of the rehabilitation process by revealing the experiences and meaning that the informants attributed to the rehabilitation process.
On the basis of the meaning the informants assigned to their important experiences when living with psychiatric disabilities and being unemployed and on sick leave, we will now discuss how these experiences may have influenced their feelings about the commitment to vocational rehabilitation.
The present findings suggest that the informants' approaches concerning how to conduct oneself in the face of the coming vocational rehabilitation could be explained to some by their different experiences in the past and present. The informants' stories were largely focused on interactions with the authorities while they were in vulnerable circumstances. Most of them described not having the opportunity or support necessary to use their resources and described deficiencies in social interaction and their actions when they tried to change their situations. These experiences in turn seem to affect their capacity and their belief in successful performance. According to Hansen, Edlund and Brännholm (2005) optimism about one's future is one important predictive factor for the return to work.
Those informants who expressed mistrust or doubt about a future working life were also those who could be described as not yet having an identity as a worker. Isaksson-Mettävainio and Ahlgren (2004) explored the factors that job seekers with disabilities, who had managed to get a job, felt had been important for their return to work. Common features were a strong worker identity, a positive attitude and own power of initiative.
The results in this study show that informants with an optimistic view of the future and the coming vocational rehabilitation had long felt that they had the support of the authorities and control over their rehabilitation planning. These were also those who already had a work identity. They experienced that they had the power of initiative and the courage to seize opportunities presented to them and simultaneously felt that they had control over their situations. They also felt that they had the time they required when planning and collaboration had occurred between them and professionals. Courses of action and professional behaviour on the part of the authorities were well-suited to their needs. It seems that the support given by professionals was framed as a support to people who in some way were already empowered.
As a way to try to deepen the understanding of the informants' experiences and how these could have influenced their different points of views in their expectations, hope and volition to the coming vocational rehabilitation, one conceivable point of departure could be theories about empowerment. Although the informants often attributed their experiences to external barriers, those experiences seemed to have a close relationship to their ability to act. Rappaport (1987) claims that empowerment is a development through a relationship between the individual and that person's surroundings, including the community at large. Zimmerman and Rappaport (1988) describe psychological empowerment as the expression of this construct at the level of individual persons. The importance of looking beyond the person's pathology and including other individual and environmental factors in the context of vocational rehabilitation will therefore guide this discussion of psychological empowerment.
According to Svensson, Müssener and Alexandersson (2006) empowerment can be described as psychological or intrapersonal and in that way involves a person's actual personal capacities and resources in a wide sense, as well as the subjective perception of these resources. Chamberlin (1997) tried to identify key elements of empowerment and found that the concept included access to information, self-esteem, assertiveness and the ability to make choices. Chamberlin (1997) gave examples of decision-making power, being able to clearly state one's wishes, standing up for oneself in order to get what is wanted and a feeling that the individual can make a difference. These key elements indicate that one must have many skills and opportunities to be empowered. Rappaport (1981) suggested that the concept of empowerment implies that many competencies are already present, or at least possible given niches and opportunities. Empowerment is viewed as an individual process, and absence of empowerment is defined as powerlessness, alienation, learned helplessness and a loss of control over your own life (Rappaport 1984).
This seems to apply to the informants in our study that had a pessimistic view of the future and to those who only had a ray of hope for the future. They could be seen as in some way ‘disempowered’. When professionals tried to help these informants by behaving as though they were already empowered, that behaviour did not fit their situations and needs and could reinforce their sense of low self-confidence and lack of control over the situation.
As a means to deepen the understanding of this phenomenon Svensson, Müssener and Alexandersson (2006) suggested that theories of social emotions could be related to the emotional dimensions of sickness absentees' experiences of the rehabilitation process. They discussed empowerment/disempowerment as being closely related to pride and shame, which are emotions suggested by several writers to be of special importance. Applying this theoretical consideration, an explanation may be suggested as to how the informants' feelings of empowerment/disempowerment had emerged. Scheff (1988, 1990) proposed that shame arises out of the monitoring and negative evaluation of one's own actions from the standpoint of others. He also suggested that shame often becomes a further source of shame, depending on the particular situation and normative structure of the culture, and that shame can give rise to pathological shame, a potentially limitless spiral. Many of the informants in this study seemed to have a disparaging self-image and frequently expressed themselves in a way that suggested the presence of the emotion of shame. Svensson, Müssener and Alexandersson (2006) described feelings of pride and shame as very closely related to the way a person perceives herself/himself to be viewed and evaluated by others. They write that the strength of these emotions is related to the importance a person attaches to the one she/he interacts with. Further, they suggested that these emotions would be more rapidly evoked, and more deeply felt, in interaction with those on whom a person is dependent and those who have the power to decide over that person's future (for example, professionals).
Taking this into consideration, the informants' in this study who were described as disempowered also described interactions with professionals in school, psychiatric care, social services, the social insurance office or the employment office as being characterized by insufficient support, inappropriate time allowed, demands that did not fit with their situation, lack of understanding and not being trustworthy in their descriptions of their life situations and needs.
It seems reasonable to suggest that from those interactions emerged emotions of shame that in turn fostered disempowerment in these informants. This state then interfered with efforts to find, obtain and maintain a working role and the ability to act on one's own initiative and have the courage to seize the opportunities offered by the authorities. This suggests that professional organizations, procedures and preparations for vocational rehabilitation or getting a job did not always fit their clients' life situations and needs. In our study it seems that the authorities' organizations and procedures were frequently based on a pre-understanding that the informants were already empowered and possessed the ability to take an active part in the rehabilitation process. This did not reflect reality for most of the informants.
Despite long periods of disempowerment, some of the informants in this study had started to see a future as a worker in some way, with a new glimpse of hope. One possible explanation is that they sensed that someone affiliated with the authorities now believed in them and their abilities, was acting on their behalf in dealing with the authorities and creating opportunities for them.
Using the theoretical consideration of pride and shame (Svensson, Müssener, and Alexandersson 2006) as being very closely related to the way a person perceives herself/himself to be viewed and evaluated by others, we suggest that these interactions had given rise to feelings of pride and started the process of empowerment. That in turn encouraged them to appreciate attention, to increase interaction with others and in that way be more hopeful about the future, the support and the coming vocational rehabilitation. This result is very important since, despite very long periods of mental health problems and a feeling of disempowerment, in many cases for numbers of years, it seems possible to entice a new hopeful attitude and a feeling of mastering undertakings.
The ai m of this study was to reveal the meaning that some people with psychiatric disabilities assigned to important experiences related to long periods of participation restrictions owing to unemployment and sick leave. Our results indicate that environmental factors like support, understanding and time seem to have a great effect on the individuals' attitudes concerning the activities and measures they expected to carry out during their vocational rehabilitation. These experiences seemed to affect their belief in their own abilities, their sense of control and their belief in successful performance. Hence, it would be of great importance for the support that is given to persons who are going to start a rehabilitation process to be practical and flexible. This involves creating opportunities for the clients to experience being successful at tasks that are planned for their rehabilitation and at the same time to develop a relationship that contributes to an experience of pride. This in turn can start a positive process that facilitates a development of psychological empowerment where the individual can believe in a possible future as a worker.
The authors thank the informants for sharing their rich stories. They also wish to gratefully acknowledge the financial support for this research from the NTG, New ways to the labour market (Nya vägar till arbetsmarknaden) project. We also thank the referees for valuable comments on an earlier version of this paper.
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