Introduction

Individual placement and support (IPS) is internationally known to be an intervention that is effective in helping people with mental illness to gain employment and is defined as an evidence-based intervention (Crowther et al. 2001; Corrigan et al. 2008; Bond, Drake, and Becker 2012). Ever since the method was standardized in 1994, it has been implemented and evaluated foremost in North America (Crowther et al. 2001) but also in, for example, Australia (Killackey and Waghorn 2008) and in various regions of Europe (Burns et al. 2007). The employment outcomes regarding work in the open labour market have been shown to be significantly higher when using IPS than when using traditional pre-vocational training approaches.

IPS is inspired by the basic principles of the supported employment movement (Anthony and Blanch 1987), by the use of the assertive community treatment team as a community-based, easily accessible, flexible support (Stein and Test 1980), and by the principles of psychiatric rehabilitation (Anthony, Cohen, and Farkas 1990). There are eight key principles directing the use of IPS (Becker and Drake 2003; Bond, Drake, and Becker 2012), which can be summarized as follows: (1) a person's desire for work is the entry imperative, which means that a person's own motivation is more crucial than professionals' assessments; (2) competitive employment is the goal; (3) the consumer's preference is the guiding light in all phases of the rehabilitation process, i.e. interests, strengths, vulnerabilities and needs should always be observed and noticed along the way towards employment; (4) job search and job developing are rapidly initiated, which usually take place within a month; (5) individualized support, based on the consumer's need, is ongoing, elaborated and without a time limit. ‘Support’ means both vocational support and support for managing everyday life; (6) vocational rehabilitation and mental health services are integrated or work in close cooperation; (7) continuous up-to-date counselling is offered, since it has been shown that a person's worry for maintenance can be of hindrance for rehabilitation and (8) good relationships with employers are created.

Implementing high-fidelity IPS usually presupposes integration with psychiatric services, which means that the IPS coach is working within a psychiatric team and that vocational rehabilitation is part of the mental health treatment rather than constituting a separate entity (Becker et al. 2008). Another important condition is that the concept of IPS fits with the local community structures. Results from the first randomized controlled IPS trial in Sweden (Hasson, Andersson, and Bejerholm 2011) showed that the rules, regulations and attitudes within the social insurance and public employment offices constituted a hindrance to their clients' work rehabilitation. A lack of knowledge about people with mental illness, together with having a care perspective rather than a recovery-oriented rehabilitation perspective, made the use of IPS even more difficult. Similar results were found in an evaluation of an IPS project organized in the municipal social services in northern Sweden (Markström, Nygren, and Sandlund 2011). Other reports on the use of IPS in a Swedish context (Hillborg, Svensson, and Danermark 2010; Germundsson, Hillborg, and Danermark 2011) highlighted the hindrances and possibilities for the rehabilitation processes, from the perspective of both the clients and the professionals. The authors concluded that a close and flexible support with knowledge about processes of change and methods for creating strategies to solve ongoing and arising problems were beneficial to the clients' possibilities of getting work.

IPS was originally developed for people with severe mental illness in need of multiple supports, thus entailing mostly people with schizophrenia or other psychosis diagnoses (Becker and Drake 2003). IPS is now beginning to be also used for people with lesser needs or perhaps other types of needs for psychiatric treatment. People with anxiety disorders, depression and neuropsychiatric disorders, for example, are also in need of an ongoing, well-adapted, integrated support in rehabilitation to work (Nygren et al. 2011). The individual has to be in focus in order to be able to create such well-adapted support. Consumer preference is thus one of the cornerstone principles in IPS, and a study by Carlson and Rapp (2007) showed the importance of the IPS coaches' skills in identifying and using the clients' preferences in order to find a suitable work setting, appropriate work tasks, and appropriate number of hours occupied, and in being sensitive enough for the client's needs while at work.

The development of high-fidelity IPS programmes is of great importance for generating successful outcomes in terms of the percentage of clients competitively employed and their average number of weeks in work. There is a risk of too great a focus being put on quantitative outcomes through the large number of studies investigating the effectiveness, which can be at the expense of the processes and values that cannot be expressed in terms of percentages in gainful employment. Several other outcomes can also be of interest and importance for improving the quality of IPS, as the principles in IPS reflect core values inherent in the concept of personal recovery (Deegan 2002; Repper and Perkins 2003; Slade 2009), such as creation of hope, identity and feelings of meaning and personal responsibility. It is thus important to focus on the essence of the content of IPS programmes.

In the present study we have investigated the use of IPS in the social services, focusing mostly on younger people suffering from a variety of mental illnesses. The purpose of the study was to describe a number of unique processes and analyze these with a special concern for circumstances perceived as of importance for the individual IPS process. The specific research questions were:

  • Which circumstances appear to have an influence on the individual processes?
  • Which principles of IPS emerged among the identified processes and how?

Method

This study was part of a larger project related to evaluating the implementation of IPS in Sweden. The project was designed as a two-year follow-up of clients with psychiatric disabilities. During the project, 91 clients received services from one of two different IPS programmes. Sixty-five of these clients were willing to participate in the larger evaluating project and they entered the study between March 2007 and November 2008. For more details about those participants' sociodemographic data, see Nygren, Markström, Svensson, Hansson, and Sandlund (2011). The inclusion criteria were having a psychiatric disability, motivation for work and inclusion in one of the two IPS programmes. There were no exclusion criteria and the reasons for declining to participate mainly concerned matters of personal integrity and a desire to safeguard privacy.

In the present study, a collective instrumental case study was used (Stake 2000), permitting the use of multiple sources of data for enabling a deeper understanding of the processes involved in IPS as an intervention for work rehabilitation. This design makes it possible to investigate a complex phenomenon within the context where it arises, based on several sources of data that are both quantitative and qualitative. A case study provides the possibility to explore a situation from several aspects that involves one or more persons during a period of time, and can be used to understand and develop practice (Salminen, Harra, and Lautamo 2006). The cases were selected to represent variation of the phenomenon which was to be studied (Stake 2000; Yin 2009). Our phenomenon was IPS applied by teams working with social psychiatry within the framework of the local social services, but not part of the community mental health services.

Participants

Five cases were included in the present study, consisting of three women and two men, aged 19–28 years. All but one were living alone. The level of education varied, two participants had only compulsory schooling, two had completed residential adult colleges and one, high school. Previous experience of work was quite restricted and varied from none at all to one and a half years. The psychiatric disorders like depression, generalized anxiety disorder and bipolar disorder were represented among the cases.

The selection of cases was made from the 65 clients included in the larger IPS project, based on their individual occupational situation from baseline to 24 months. The inclusion criteria were having participated in all the data collection (at baseline, at 12th month and at 24th month), representing both sexes, having very different ‘journeys’ (occupational movements), having rich information in the interviews and both the IPS teams should be represented among the cases. Very different journeys means that the participants started from different occupational situations and that their journeys also ended in different occupational situations. Moreover, the successive movements from start to end also showed differences among the selected cases. Rich information in the interviews means that the individual participant was able to put into words on his or her experiences of participating in the IPS programme and the experience of the rehabilitation process. The descriptions of each participant's rehabilitation process have been presented in a way that assured the individuals confidentiality. The study was approved by the regional research ethics committee at Umeå University (Dnr 07-030M).

Settings

The five participants were enrolled in one of the two IPS programmes, which were located in two middle-sized towns. Both programme teams were organized within the municipalities' social services as time-limited projects. Clients of one of the IPS teams could be referred by any of the service providers: the local social services, the employment office, social insurance office and psychiatric services, but most commonly it was the first two of these. The referrals to the other team were only from the psychiatric services, with which the team had built a quite well-functioning relationship.

Data collection

The participants were contacted by the first author as soon as possible after inclusion in the IPS programme and gave informed consent to participate in this study. Different sources of data were collected at baseline and during two years of follow-up with the IPS clients and with the IPS coaches. The collection of data for some of the participants in the present study lasted for two hours, while for the rest of them the data were collected in 60 to 90 minutes. The qualitative interviews held at 12 and 24 months lasted between 35 and 50 minutes and were all recorded except for one of the interviews, where careful notes were taken. The reason for this exception was that one of the participants did not want to be recorded.

Data from three different sources were selected for investigation in the present study, which are discussed in the following sections.

Documentation performed by the IPS coaches

A structured questionnaire was used by the IPS coaches every second month, in which they documented their clients' work-related activities from baseline to 24 months, including the frequency and content of their IPS service. In the last part of the pre-made form, the IPS coaches were asked to describe reflections about what they perceived as constituting, facilitating and hindering circumstances in their clients' rehabilitation process. This documentation was sent to the first author every second month.

Outcomes from established and commonly used instruments for assessing people with psychiatric disabilities

Symptoms were assessed with the 18-item version of the Brief Psychiatric Rating Scale (BPRS; Kolakowska 1976; Nygren et al. 2011). The scoring scale ranges from 1, indicating the absence of symptoms, to 7, where the symptom is extremely severe. Lower values imply fewer and less severe psychiatric symptoms.

Self-esteem was measured by using the Rosenberg self-esteem scale (Rosenberg 1989; Nygren et al. 2011). The scale is a self-report questionnaire and consists of 10 items, to which respondents answer by using a 4-point scale. A higher score indicates greater self-esteem.

Subjective quality of life was rated on the Manchester Short Assessment of Quality of Life (MANSA; Priebe et al. 1999; Nygren et al. 2011). Patients rated their satisfaction with life in general as well as satisfaction regarding 11 different life domains, for example, occupation, economy, social relations and leisure. Ratings are performed with Likert-type scales ranging from 1 (could not be worse) to 7 (could not be better). Higher scores indicate that the person is more satisfied with essential areas in life.

Global psychosocial functioning was assessed with the Global Assessment of Functioning (GAF) Scale (Herlofson and Landqvist 1995; Nygren et al. 2011). The scale has a possible range between 0 and 100, where higher scores reflect better social, occupational and psychological adjustments.

Occupational competence and occupational value were assessed by using the Occupational Self Assessment (OSA), and the Swedish version (1.0) of the OSA was used (Baron et al. 1998, Hellsvik 2000; Nygren et al. 2013). OSA is a self-report instrument where the person responds to 21 statements by indicating his or her perceptions of how well he or she performs everyday occupational behaviours (occupational competence) and how important these occupational behaviours are for the person (occupational value). Higher scores imply that the person perceives more competence/more value, related to performing occupational behaviours.

Interviews with the clients

Qualitative interviews were performed using an interview guide in each interview, based on the following areas: the way of working of the client–IPS coach relation; collaboration with other rehabilitation actors; occupational situation and place of occupation, work tasks and the worker's role; the value of and perception of IPS and the rehabilitation process and view of the future. The interviews were held at the end of both follow-ups (i.e. after the use of instruments) and were performed as a dialogue with the participants, where the interviewer listened and asked for their unique experiences.

Sociodemographic data were collected using an interview-based questionnaire.

Statistics and analyses

Basic statistics were used to analyze the outcome of four of the five instruments used in the study (Nygren et al. 2011) and Rasch analyses were used for the OSA (Nygren et al. 2013). Median values for all five quantitative instruments (BPRS, Rosenberg, MANSA, GAF, OSA), and for the frequency of IPS provided, were calculated for the whole group of participants at baseline (n = 65) and at the 24-month follow-up (n = 45). This was performed due to the need for reference values for the five individual cases.

A directed content analysis approach was used for analyzing the qualitative data (Hsieh and Shannon 2005). This approach is used commonly when a theory or a phenomenon is incomplete or would benefit from further investigation. IPS is a widely used intervention for work rehabilitation that has basic principles (Becker and Drake 2003) and fidelity scales (Bond et al. 1997; Becker et al. 2008), while undergoing continuous examination and development. The directed form of qualitative analysis was thus identified as a suitable approach for achieving the aim of gaining a greater understanding of what happens within an IPS programme.

Two interviews for each case (at 12th and 24th month) were recorded and transcribed by the first author. The analyses were performed in the following five stages:

  1. Initially, in order to get an overview and insight into each case, all three authors read the interviews separately, including the IPS coaches' documentation of their support and reflections about their clients' processes. The outcomes from the instruments were also considered.
  2. The authors then reread the interviews and the documentation from the IPS coaches, identifying circumstances perceived as being of importance for the IPS process. These were marked in the text.
  3. In the third step, the authors met together, showing each other their findings, which were thoroughly discussed within the author group. This discussion and selection was carried out until consensus was reached about the most essential aspects of the different cases and was used first to create a summary chronological story for each case.
  4. In the fourth step, the directed content analysis approach was used to analyze the qualitative data, where the eight IPS principles were applied as initial key concepts. Three of the principles emerged distinctly from among the data and were operationalized (see Table 1). These operationalizations of the three key concepts were then sorted into four themes.
  5. Finally, in the last step of the analytical process, the four themes were related to the identified individual IPS processes in a more concrete way in the result. The theory of personal recovery was used as one reference in this directed analysis (Slade 2009). The documentation from the IPS coaches was analyzed together with the interviews in order to get a broader view and understanding of the IPS processes described by the clients.

Table 1.

An illustration of how the directed content analysis was performed.

Initial key concepts (IPS principles) Operationalization of key concepts Themes
The consumer's preference is the guiding light
  • Job coaches use open Socratic questions
  • Study visits are arranged in a large numbers of workplaces
  • Trustful relationships are established between coaches and clients
The IPS coach as a cicerone Time for reflected experiencesConstruction and reconstruction of one's occupational identity
Individualized ongoing support without time limit
  • Job coaches and clients evaluate every work placement together – taking care of ‘failures’
  • Exposure of a variety of environments – no standardized solutions
  • Absence of time limits in the IPS provided leads to feelings of security among clients
  • A coach who does not visit the client′s workplace faces difficulties in individualizing the support
 
Integration of IPS and mental health services
  • Weak matching between ongoing psychiatric treatment and job coaching
  • Bad treatment from mental health staff when meeting client and coach at the clinic
  • Regulations of employment office hamper the rehabilitation process
  • A civil servant at the social insurance office works closely with both the IPS team and psychiatric services to solve concerns about the client's financial situation
The importance of coordinated collaboration

Findings

The results are presented in two sections. Section one begins with an illustration of five individual ‘journeys’ depicting occupational movements during two years in an IPS programme (see Table 2). Each of these journeys is given a title that focuses on the core process for that participant, and a summary of the individual journeys is then described in the form of a short chronological story. Finally, after each story, a table (Tables 37) shows the individual outcomes based on the data from the instruments, and links between these quantitative data and the core process in the stories are made.

Table 2.

The occupational movements of the cases included in the study.

  Time from baseline to 24 months
Occupation 0 2 4 6 8 10 12 14 16 18 20 22 24
Employment E E C,E C C,E C,E C,E C,E C,E C,E B,C B,C B,C
Education       D D B,D B,D B,D B B B,D B,D B,D
Work practice   B,C,D,E E A,E A,E A A,D A,D A,D A,D     E
Sheltered work B                 E E E E
No occupation A,C,D A,B A,B,D B B           A A A,E

A, Anne; B, Benny; C, Cecilia; D, David and E, Ellie.

Table 3.

Individual outcome from questionnaires: Anne.

  Baseline Median value 24 months Median value
BPRS (psychiatric symptoms) 35 30 31 28
GAF (global psychosocial functioning) 54 55 65 65
Rosenberg (self-esteem) 2.30 2.40 2.70 2.70
MANSA (quality of life) 4.00 4.50 5.20 4.58
OSA (occupational competence) 0.57 0.84 1.84 0.92
OSA (occupational value) 1.70 1.55 2.01 1.84
IPS provided in hours/year 106 (0–12 m) 63 65 (13–24 m) 37

Table 4.

Individual outcome from questionnaires: Benny.

  Baseline Median value 24 months Median value
BPRS (psychiatric symptoms) 30 30 26 28
GAF (global psychosocial functioning) 65 55 80 65
Rosenberg (self-esteem) 2.60 2.40 3.60 2.70
MANSA (quality of life) 5.25 4.50 5.33 4.58
OSA (occupational competence) 1.70 0.84 2.41 0.92
OSA (occupational value) 3.15 1.55 1.40 1.84
IPS provided in hours/year 91 (0–12 m) 63 17 (13–24 m) 37

Table 5.

Individual outcome from questionnaires: Cecilia.

  Baseline Median value 24 months Median value
BPRS (psychiatric symptoms) 27 30 30 28
GAF (global psychosocial functioning) 68 55 54 65
Rosenberg (self-esteem) 2.60 2.40 1.80 2.70
MANSA (quality of life) 5.58 4.50 4.50 4.58
OSA (occupational competence) 2.87 0.84 0.84 0.92
OSA (occupational value) 0.84 1.55 1.55 1.84
IPS provided in hours/year 31 (0–12 m) 63 34 (13–24 m) 37

Table 6.

Individual outcome from questionnaires: David.

  Baseline Median value 24 months Median value
BPRS (psychiatric symptoms) 30 30 27 28
GAF (global psychosocial functioning) 55 55 68 65
Rosenberg (self-esteem) 1.80 2.40 1.60 2.70
MANSA (quality of life) 3.91 4.50 4.08 4.58
OSA (occupational competence) −0.12 0.84 −0.23 0.92
OSA (occupational value) 0.15 1.55 0.17 1.84
IPS provided in hours/year 76 (0–12 m) 63 37 (13–24 m) 37

Table 7.

Individual outcome from questionnaires: Ellie.

  Baseline Median value 24 months Median value
BPRS (psychiatric symptoms) 34 30 32 28
GAF (global psychosocial functioning) 55 55 55 65
Rosenberg (self-esteem) 2.70 2.40 2.20 2.70
MANSA (quality of life) 4.50 4.50 3.17 4.58
OSA (occupational competence) −0.50 0.84 0.04 0.92
OSA (occupational value) 0.84 1.55 1.70 1.84
IPS provided in hours/year 97 (0–12 m) 63 70 (13–24 m) 37

In section two, the four themes created from the identified content in the qualitative data are presented and related reflections are described. Quotations from the participants are used to illuminate the themes.

Anne 26 years: identifying a positive self-image

Anne was referred to the IPS programme by the psychiatric services after quite a long period of psychotherapy. Initially a great deal of time was dedicated and a number of occupations were tested in order to find out what Anne's interests were and she enjoyed this phase very much. She emphasized the value of being asked about what was really important for her and that someone was frequently asking for her opinion. After about six months in the programme, she started a part-time (50%) work training and stayed there for nearly one year. One of the things Anne mentioned about her experiences of work was that she had found that she likes being in social interactions with others. After a short holiday in the summer of her second year in IPS, the plan was to further extend her work time from 50% to 75%. This change more or less coincided with a psychosocial strain in her family and a depressive period. Anne chose to terminate her work training because of the deterioration in her mental health and because it had become clear that the company was not able to offer her employment, despite them being very pleased with her work. The aim of the IPS coach was to keep trying to maintain some sort of continuity in the work training, despite the deterioration in her mental health and then to successively complete the plan. Anne's key worker in the psychiatric services had a different opinion. At the same time Anne's ‘case’ was to be included in a vocational rehabilitation process at the employment agency, but some unfortunate misunderstandings caused a very long delay for Anne and her IPS coach.

When at last it became clear that Anne was to be included in the rehabilitation coordination process, further deliberations resulted in her decision to take the opportunity of reactivating a previously held interest and using it as a work opportunity. The IPS coach was still supporting Anne during this last process of rehabilitation, but from a more hidden and diffused position.

The outcomes from the instruments demonstrated a positive trend overall, but the changes in psychosocial functioning, subjective quality of life and Anne's perception of her competence were the most noticeable (Table 3). These positive trends could be understood in relation to the positive experiences at the workplace, both in developing competence in the worktasks and in social interaction with colleges and customers. The changes in the quality of life could be due to the fact that she had a long period of psychotherapy behind and the start of IPS has moved the focus on her interests and she got something to do.

Benny 23 years: developing an alternative career

Benny was referred to the IPS programme by an occupational therapy unit in the psychiatric service. A workplace was found that matched Benny's interests and physical capacity after two months in IPS. Two days after visiting this workplace he started to work there on his own, but after one day he suffered a dramatic attack of anxiety hysteria at work. He had no previous experience of this level of anxiety, so he phoned his IPS coach, who followed him to the hospital's emergency psychiatric services. Benny described the meeting with the psychiatric services as very unpleasant because of the nonchalant approach towards him and his coach. Benny never returned to the workplace after this incident.

A further period of eight months passed without him having daily occupation but with having weekly meetings with his IPS coach, where they talked about the important things in life while searching for alternative ways to get work. This period was characterized by reconsidering the view of him as a tough and strong man best suited for physically heavy or security work. Benny described his coach as a well trained, warm and caring man, and he was inspired by him to start considering a job in the human services sector. By support of the social insurance office, Benny decided to study and was starting quite soon. He discovered during his education, which included periods of practice, that this area of work really interested and suited him. He both studied and worked in his free time during the last half year in order to be financially independent from social benefits. His contact with the IPS coach became less frequent as he became more and more occupied. He was assigned a new IPS coach at the end of the second year, whose qualifications were to better match the new needs related to his worker role, for example, what he should do if he lost his job for a period of time and if he wanted to join a labour union. Soon after completing the education, Benny became employed and was able to work full time.

Table 4 demonstrates the overall positive changes for Benny, where the change in his psychosocial functioning is most apparent. His self-esteem has also noticeably increased, as well as his perception of occupational competence. The content in Benny's rehabilitation process, where, with good support, he could reach his new goal of occupation and make it work, would contribute to the positive changes. His lower rating for occupational value may be related to his everyday life being good, which can thus impact on the value rated for his occupation.

Cecilia 19 years: confronting difficulties

When Cecilia started in the IPS programme, after referral by the local social services, she had had no occupation at all during the previous year and was very tired of just being at home doing nothing. After three weeks in IPS she started to practise at a company, working with tasks similar to those she had done previously. Cecilia recalled that they never spoke about how many hours she was supposed to work at the beginning. She felt that she was only following what was happening and the work hours could vary from day to day depending on how much work needed to be done.

Cecilia became employed after about three months' at the company and worked there part time (50%) for the rest of the first year (8 months). She had a weekly contact with her IPS coach throughout the first year, mostly by telephone, and also some meetings together with the employer at the IPS office.

At the 24-month follow-up, Cecilia was still employed at the same company and had been working actively for 1½ years. She had also been diagnostically assessed for Asperger's syndrome and had been off sick leave for a total of about four months due to a work-related situation that did not function. Some complications had arisen with regard to her medicine and this coincided with some trouble between Cecilia and her employer about her worker role and the latter's role as a manager, which resulted in a serious depression and quite a long period of sick leave from work. She mentioned a need for more active support from the IPS coach during this period and more concrete support at the workplace before her sick leave. Shortly after this the employer went on partial sick leave because of too much work. Cecilia returned to the workplace and made a serious attempt to make it work, but was not successful. She took the view that she was not able to cope with her employer's way of managing the company. She described that when things did not work the way that was necessary for her, she became so tired, and when she was tired she became whiny and worked slowly. This resulted in Cecilia leaving her employment for personal reasons and being sick-listed during the period of notice and her return to the IPS programme for creating a new plan for her future occupation.

The outcomes from Cecilia's assessments show negative changes where the most apparent are the decrease in psychosocial functioning, self-esteem and occupational competence (Table 5). These changes were most likely related to the difficulties experienced at the workplace and the feelings of not being able to cope with the situations that arose, and of not being understood.

David 28 years: fulfilling a plan

David came to IPS after referral from the social insurance office after being sick-listed for a long time. There were initial difficulties in finding a workplace that matched David's interests due to a decline in this specific line of business. After nearly two months he started to practise part time at a company some distance away from where he lived. It was thus necessary for him to travel by bus and the agreed half-time schedule was exceeded causing complications for his morning routines. He remained at his work training for about two months but often failed to arrive and lost his motivation for everything in periods. At that time the IPS contacted the psychiatric services in order to establish a contact there for David and the social services were also contacted for assistance with his social benefits. He then took a break from IPS throughout the summer, but had previously written a long list of wishes that he presented to his IPS coach concerning what he needed in order to be able to attain his goals for work or studies and the support needed to achieve them. He also applied for a course at school before he left. According to David, the IPS coach handled his list of wishes respectfully and David pointed out that this treatment was perceived by him as a very crucial phase of the following process. His earlier experiences were that the authorities had never taken his desires and wishes seriously.

After the break from IPS during the summer David decided to study to complete his high school education and did that for 25% during one term. The IPS coach had a weekly meeting with David during this first period of study, where they talked about how the week's study had gone, and he also regularly showed which the coach assignments he had to complete each week. This was done because of David's difficulty in completing what he had to do. This generally went quite well, but David had some difficulties in completing assignments in time; for example, he failed to complete the last of these in time, and had to finish the final course at the beginning of the next term. He worked at a voluntary organization at the same time, which was part of an agreement between David and his IPS coach. He then started to study at a residential adult college for the final high school qualification, enabling him to go on to his desired education at the university. He was studying nearly full time and the support from IPS was still there, but only on an ‘in case of need’ basis.

The results of David's rating of the instruments were mixed (see Table 6). The most noticeable are an increase in psychosocial functioning and very low ratings for occupational competence. Probably, this most obvious change was related to his new and good experience of collaboration with others, foremost the IPS coach. David's prolonged difficulties to accomplish could contribute to his low ratings of competence.

Ellie 21 years: struggling through interruptions

Ellie was referred to IPS from the employment agency because they perceived that she needed more than they were able to offer her. She already had the opportunity to work a few hours in a shop, but did not feel well in that type of environment. After about 1½ months Ellie tried to practise 15 hours/week at a workplace within the care services, but after two weeks felt that it was not the type of work that suited her and she terminated her placement there, which was supported by the IPS coach. Cooperation with both the employment agency and the psychiatric services was activated at this period of time. It was very hard to get support from the psychiatric services because Ellie's mental health was perceived by them as not prioritized. She was not assessed as suicidal. Ellie then started to practise in a field that she knew she held a strong interest in and worked there part time for about four months, but decided not to continue due to a difficult psychosocial working environment. She then received the possibility to do a completely different job, because a firm in the industrial area was searching for a novice to be trained for the job. At the same time Ellie's mental health deteriorated and she had to visit the hospital for a few days. She then started to practise at the new workplace on a part-time basis and after two months she was employed part time.

The concurrent period of economic recession influenced the labour market, and Ellie's job was threatened fairly soon after she started her employment. She was made redundant after being there for 8 months because of a shortage of work. Ellie's mental health had deteriorated during this period and she had been in need of psychiatric support. There was no continuity in that support, however, and the IPS coach had to make special efforts in order for her to receive the support she needed. Ellie wanted something to do immediately after finishing the employment and sheltered work was found in the social services due to difficulties in finding a new job. She also tried a job in the transport sector for a week, but this did not work due to it being too stressful. In the last month of the two-year period Ellie did not have an occupation and had, according to her IPS coach, lost her motivation for work practice and was not feeling well. The IPS project was soon to be finished and Ellie and her IPS coach had therefore started preparing for the next step, which would include participating in a special group at the employment agency. According to Ellie, she felt the coming limit of time for the IPS project as more or less a catastrophe, because of the interruption of a valued working alliance with her IPS coach and her overall insecurity about the future.

The results from her ratings of the instruments also show a mixture for Ellie (see Table 7), where the most evident is the decrease in subjective quality of life and self-esteem. Her perception of her occupational competence has increased somewhat and she also values her competence in everyday living at a higher level. Since Ellie's process has been tough and went from being employed to having nothing to do, it would be believable that these experiences have had an impact on both quality of life and self-esteem. The changes in her perception of occupational competence and value of competence in everyday living could be seen in the perspective of her mental illness throughout the process. How the everyday activities functioned perhaps became more important because of being able to work.

Themes and reflections

The IPS coach as a cicerone

One of the themes concerned the specific relationship between the client and the IPS coach and the latter's role as a sort of cicerone on the client's journey towards employment. This role as a guide and pilot includes both emotionally supporting the individual and presenting different alternatives and solutions not only by the use of open Socratic questions and a dialogue, but also by showing ‘the real world’ through visiting different work environments. The foundation for the role of a cicerone is a trustful relationship where the IPS coach is an interested, curious and involved conversation partner. Our informants described how they, with the help of their coach, could begin to think in new ways and detect and find their interests and needs. Benny, for example, described how the support, via IPS, contributed to a number of windows opening for him towards alternative occupations and careers. He also described how his choice of education and work as an assistant nurse had been influenced by having his supporters in the rehabilitation process as positive male role models.

They are both educated assistant nurses and I have never had a male role model…. as a child….it's actually important for a child to have….//…how should I grow up….how should I be? They have really been male role models for me and they have their special style… which I like.

The function of the cicerone is not only to guide and pilot the individual into being able to find things of interest for themselves. Just the knowledge that the IPS coach was actually there with them when needed was perceived as being of importance according to the clients. Moreover, the value of not being guided in a uniform and routine-like manner became evident in the interviews. The clients liked to have their guidance adapted to their individual ways of functioning.

Time for reflected experiences

A second theme was associated with the framework of the IPS and the role of the IPS coach in the client's meeting with real work environments and the actual duties to be carried out. The theme illustrates the importance of providing support for the client to reflect on impressions and experiences from the workplace. By being exposed to different environments and tasks, the client was given the opportunity to find out what could be an appropriate occupation for him or her. Ellie, for example, had tried a number of different workplaces before she got the chance to try at a company in the industrial area where both the work tasks and the psychosocial environment matched her needs.

You see … I have learned to do the tasks as they come … the ones working at my place are very good at showing and explaining … and the very best … is that they are very supportive and good fun. They said that: she is one of us … let her stay here.

Taking care of situations that are at first experienced as ‘failures’ presupposes that the client can share his or her impressions with the coach. The value of interruption in an employment or work training does not show itself until the client can take a step backwards and together with his or her IPS coach in order to identify what can be learnt and which insights are to be gained from the experiences. There are some situations in our data where the IPS coach was absent and had not visited the work place in question. This circumstance makes it more difficult to make sense of the client's experiences.

An important condition for the creation of security in these regular visits and attempts at working in different parts of the labour market appears to be that the intervention should not have any time limitations. A sense of security might be created and thus also the courage to try other situations that one may feel unsure about if this time restriction did not exist.

Construction and reconstruction of one's occupational identity

This theme was created in terms of the clients changing views and descriptions of themselves in relation to their occupational experiences. These changes were associated with the previous theme about reflected experiences, but were more focused on the conclusions drawn from these and the consequences of them for the clients' future occupational choices.

The clients described several aspects of the perception of themselves: Anne had previously thought that she was not a sociable person, but her new experiences in a shop where she had contacts with customers made her aware that she enjoyed social interaction and that it worked quite well. She also reconstructed her view of herself as a worker:

Previously, I thought that I could hardly do anything … because I felt so bad and I also have all my physical problems … and so on. But now I have understood that I can … in fact! I can function at a real work place and I can realize things … which I really want to do …

Benny's view of what he was supposed to do changed radically, from being a guard to working in the care sector, from a more typically male occupation to a more typically female one. He also spoke of having learnt a lot about himself, how he was as a person and how he functioned as a worker:

Now when I look back … it feels that I have begun to see myself in a different way… I have begin to grasp who I am, how I am and how I function …//… this is something that is very valuable.//…It makes it easier to look for work…. I do not have to look for everything…//I look for what I know I can manage!

David received the opportunity to realize his desire to study with the support of IPS, but to achieve this he had to complete the study assignments and this was a challenge to his view of himself. He spoke of previously never being able to perform the things he now planned to do.

The clients' construction and reconstruction of their occupational identities were an important part of the process towards their future occupational choices and developments in competence. Even if only one of the participants was employed at the end of the journey, the others have been able to go through processes that were of importance for their future efforts to find occupations that suit them.

The importance of coordinated collaboration

One further theme concerned cooperation, but mostly in terms of the relationship between the IPS programmes and the psychiatric services and, in some cases, also with the employment office. The analyses showed that each case contained a number of different situations, events and circumstances, which were more or less complicated, and where there was support from other agencies than the IPS, or where there was a need of support. Collaboration could be developed towards a common goal if the different supports were coordinated and the most important factor for determining whether the coordination was to be successful was how the various services were coordinated.

When Anne was experiencing a difficult phase in her rehabilitation, which was related to an occurrence in her family and deterioration in her mental health, the IPS coach and the psychiatric services had differing views on the situation and what support Anne was in need of. Another situation, which affected Anne, was related to the regulations at the employment office when she was about to begin a process of cooperation. This situation revealed misunderstandings and the existence of different opinions and resulted in several months without regular occupation for Anne. She said:

You see … I became stressed … but I also felt that I became very annoyed and angry … so … because I thought that … Well … it didn't help me to be left hanging in the air and not knowing what was going to happen …

For Cecilia, the diagnostic assessment influenced her way of thinking, feeling and functioning at work. It appears that there was no plan for taking care of her reactions and thoughts after she received her diagnosis. There were also problems with Ellie's contacts with the psychiatric services. In spite of her not feeling well at all mentally during the two years of follow-up, her case did not receive priority. She received some treatment on an irregular basis, but there was no one who took an overall responsibility for her psychiatric treatment.

An example of a good collaboration was found when Benny had to decide if he would dare to start studying or not. A man at the social insurance office who worked with Benny's case was able to give him reassuring information, which made it possible for Benny to start his education.

In addition to the three aforementioned themes, which have included situations, events and circumstances that appeared to influence the individual processes, a fourth theme emerged concerning how the IPS intervention contributed to the participants' processes towards employment.

Discussion

This study focused on the content of the IPS intervention. A number of different types of data were combined, but the qualitative interviews with the clients performed at the two follow-ups were mostly used in the presentation of the findings. Some of the principles that IPS are based on were distinctly discerned in the material and a number of different aspects of them were identified in the analysis.

The relationship between the IPS coach and the client constituted the foundation upon which the interventions rest. The relationship was characterized by curiosity, interest and engagement in the unique individual. This approach is similar to those central to the philosophy of personal recovery (Slade 2009). Russinova (1999), for example, described the use of interpersonal resources to create strategies for promoting hope for the client. These strategies are based on values, attitudes and behaviours. Examples of these are valuing the person as a unique human being and showing belief in the person's potential and strengths. In a study by Johnson et al. (2009) where several service users from IPS programmes were interviewed, the interpersonal dynamics and the quality of the support were highlighted and the authors concluded that these components should therefore be included among the key ingredients of effective IPS.

One of the IPS principles is about focusing the client's preferences, which is to consider the interests, talents and special needs of a client. This approach is supposed to characterize and guide every step of the rehabilitation process (Becker and Drake 2003).

A second principle suggests that support should be individualized and ongoing without time limitations (Becker and Drake 2003). Examples of where this principle was put into practice was found in the material and appeared in the theme ‘Time for reflected experiences’. The content of this theme is an illustration of the role as a cicerone, where the safety and permanency in the relationship make it possible for the individual to take the risk of trying, of failing and trying again. It is a way of orientation by way of continuous re-orientation. Slade (2009) described such trials as positive risk-taking, and argues that there are nearly always benefits from this even if it all goes wrong. He also maintains that challenges lead to personal growth and development. The value of this process of discovering was described as gaining an opportunity to reflect and make use of the experiences from each attempt.

One reflection is that the principle of having no time limitation is a genuine challenge for the Swedish welfare system, where the interventions of vocational rehabilitation generally are time limited due to strict regulations. The interventions described in the study have been performed at units working with time-limited projects. In order for the implementation of IPS to be permanent it is necessary that there are organizations and regulations that allow the delivery of the intervention for as long as it is needed.

The IPS principle that most explicitly influences the organizational level is the one concerning integration of IPS with the mental health services. This principle was exemplified under the theme ‘The importance of coordinated collaboration’. Several significant situations were identified where a close contact and a common perspective between the different actors involved could support a client's rehabilitation. On the other hand, situations were also identified where a lack of collaboration obstructed the process both in the solving of acute situations and in reaching more long-range solutions. This principle about integration constitutes a real challenge to the Swedish welfare system which is highly sectorized with demarcated responsibilities for each authority. Settings, where the IPS intervention is organized outside the mental health services, such as those in our study would be especially vulnerable.

The cases chosen for this study were strategically selected in order to illustrate a variety of rehabilitation ‘journeys’. A number could be evaluated as failures if considered in a superficial way; however, by making the processes visible and by presenting the participant's own experiences, the picture becomes more nuanced. Participants, who after two years were still without employment, had experienced positive changes as was shown by the questionnaire data and can be assessed from their own narratives in the interviews. Examples of these changes were a decrease in psychiatric symptoms, perception of improved occupational competence and experiences of having gained a number of abilities and ways of being as a person. For some of the participants, who had been successful in gaining employment, but who had finally lost their work, the interviews, the measures and the reports from the IPS coaches revealed that their time in IPS had also included experiencing difficult conditions and a struggle to maintain their mental health.

A common feature in our material was the effect of the IPS intervention on the participants in terms of the way they perceived themselves and their abilities, which we termed ‘construction and reconstruction of one's occupational identity’ (Kielhofner 2008). One example of change in occupational identity was a movement from a perception of oneself as being incapable and not having a future, to a person with abilities to cope with situations and with a possible future as a worker. This is a process of doing and becoming, which is described by several occupational therapists (Wilcock 1999; Gewurtz and Kirsh 2007; Kielhofner 2008). Some participants discovered personal strengths and weaknesses, and learned to take this into consideration for future choices of working environment and occupation.

There are several limitations to our study, and one of them is of course the selection of cases used. If the selection of cases had been another, we would have probably seen other unique processes related to a diversity of circumstances. Despite these supposed differences, the same principles of IPS could have emerged among the identified processes. Qualitative studies are in important aspects dependent on space for nuances and details. In that sense our study is restricted by both the format for articles in scientific journals and the ethical responsibility not to expose details that would jeopardize the anonymity of the participants. The process of concentrating on the individual journeys implies including certain aspects and details, and excluding others. What can strengthen our analysis and the selection of described events and situations are the continuous discussions the three authors have performed through the whole working process – from the raw data to the phase of identifying aspects of content and themes. This consensus strategy can hopefully reduce the risk of presenting arbitrary results.

Another limitation is that the current study took place in two teams not working in integrated settings within the psychiatric care, which could have given another result, especially related to the theme ‘The importance of coordinated collaboration’. How the IPS intervention contributes to clients' process towards employment is, however, still of importance for understanding the effective ingredients in it. The authors of this study also find it necessary to find out what happens with clients who do not find their way to employment through participation in IPS.

Conclusion

The purpose of this study was to describe circumstances perceived as of importance for the individual IPS processes and aspects of the principles of IPS that emerged among these identified processes. We found that the relationship between the IPS coach and the individual client was the foundation for the intervention. Components of importance in this relationship were engagement, collaboration, emotional support, safety, and a reflecting climate. Three IPS principles emerged distinctly and they were operationalized and developed into the four themes: (1) the IPS coach as a cicerone, (2) time for reflected experiences, (3) construction and reconstruction of one's occupational identity and (4) the importance of coordinated collaboration. The third theme was found to be closely associated with the second theme, but more focused on the conclusions drawn from the experiences made and their consequences on the client's future occupational choices.

The study focuses on the content of the IPS intervention based on the clients' and IPS coaches' experiences, and reveals that performing IPS is a type of specialized relationship-based work that includes advanced problem solving. Close collaboration between agencies is necessary if the IPS service is organized outside and independently of the psychiatric outpatient services, but is a challenge both for the IPS coaches and for the others involved. This will probably be the case even in future IPS services in Sweden due to the legally delineated borders of responsibilities. The possibility of being able to work without strict time limitations is also a challenge for the future. Our cases illustrate the importance of continuity over time.