Cornelia Wulff Hamrin 1
1 Kristianstad University, Sweden
The purpose of the study was to explore factors related to recovery back to work life among clients in psychiatric outpatient clinics. An inventory was answered by 270 participants. Besides descriptives, chi2, ANOVA analyses and standard multiple regression were carried out. The main results were that about 20 % of the participants had experienced prejudices in their care contacts and 30% had experiences of prejudices at work sites. The participants who worked had experienced fewer prejudices and had higher recovery self-efficacy and fighting spirit than those who did not work. Multiple regression analyses revealed that fighting spirit and social support in work life were associated with the intention to work. The results partly reflect previous research but highlight the importance of work and fighting spirit in the recovery process. Improvements, such as incentives to employers and interventions which decrease prejudices, are suggested.
Keywords: psychiatric outpatient clinic, recovery, fighting spirit, prejudice, psychosocial strain
1.1 Job opportunities
Reports of mental ill-health have increased in recent years. The focus of this study is on recovery back to work life among clients in psychiatric outpatient clinics. As even people with illness value work highly (Mueser & Cook, 2016; Krupa et al., 2016; Åslund et al., 2012), work is considered essential in recovery (Mattsson et al., 2008). Despite its importance, in Sweden there were in 2021 fewer people with disabilities that worked compared to those without disability (SCB, 2023). Research shows that individuals with mental health problems to a large extent want to work and have the capacity to do so (Levinsson & Jiborn, 2013). However, individuals with lower workability were working less that other groups (Lagercrantz et al., 2014). The work situation for people with mental health problems or disabilities was hard (Levinsson & Jiborn, 2013). Financial support was often required, since the onset of mental illness tended to occur during adolescence when individuals were establishing themselves in work and education, often followed by a lifelong struggle with a low income and with state support (Levinsson & Jiborn, 2013). Hence, the focus in the present study is on the desire to work.
Difficulties in getting a job offer have been examined (Drehmer & Bordieri, 1985; Gouvier et al., 2003). One study involved made-up job applicants with a similar competence, divided into the following groups: a) those with no disability, b) those with a physical disability and c) those with a history of mental illness (Drehmer & Bordieri, 1985). Gouvier et al. (2003) asked students to role-play employers evaluating applications for a hiring decision (Gouvier et al., 2003). The applications were constructed as if coming from individuals with a) a back injury, b) a developmental deficit, c) a chronical mental illness or d) some head injury. Both studies reported that individuals with a mental illness were seldom hired. This is in line with what individuals with mental illness thought, in other words that a) employers did not want them and b) that they were disregarded as not being trustful or intelligent (n=200, Lundberg et al., 2007).
1.2 Work conditions
Although poor work conditions will affect recovery back to work negatively, adjustment possibilities and less requirement of presence at the workplace may have a positive impact on the recovery process (Johansson & Lundberg, 2004). Poor work conditions are often connected to and can be measured by psychosocial strain, as in the Demand-Control-Support (DCS) model (Karasek & Theorell, 1990). Psychosocial strain, which is related to health complaints was found in self-reported health in general, like anxiety, pain, sense of coherence and self-rated health (Wulff et al., 2010). Poor work conditions were also related to decreased mental health (Bonde, 2008¸ Stansfeld & Candy, 2006). High demands on time and workload as well as low levels of decision control over the work process are major contributors to psychosocial strain. In contrast, high demands and high control in active work decrease psychosocial strain, while it increases with low demands and low control. However, research has shown that social support may decrease psychosocial strain (Karasek & Theorell, 1990). Studies examining the impact of activities, supported work and work confirm that activities and work are important in the recovery process (activities-patients in hospitals, Ng et al., 2020; activities vs work, Eklund et al., 2021). While a future worker role and resources for it were important for personal recovery, activities had a positive impact on life satisfaction (Eklund et al., 2021). However, the rehabilitation of individuals with mental illness has often been a question of adaptation. Jagannathan et al. (2020) made an intervention study in India with the aim to facilitate for individuals with severe mental illness to get employment and keep it. Besides helping the participants, employers who were contacted and informed made various adjustments like allowing the individual to start working gradually with time flexibility and without too much stress. The process involved matching the individual with the selected worksite. The participants were hired for a variety of unskilled and skilled employments with the result that half of them obtained gainful employment. In Sweden, individual matching with a supported employment turned out better for the patient than ordinary work rehabilitation. It is suggested that one person (i.e. an employment specialist) should have responsibility for the process with interventions already in the treatment period (Bejerholma et al., 2017). Are common demands on work environment like many of the demands mentioned in Jagannathan et al. (2020) and in earlier research (Akabas, 1994) what are needed in recovery back to work?
1.3 Experiences in care contacts
This study focuses on the patient perspective, which is often lacking in older research (Cullberg, 1996; Johansson & Lundman, 2002; Lunsky & Gracey 2009). Patients’ negative experiences of contacts with care have a negative impact on their recovery back to work life (Lynöe et al., 2011). In Sweden, serious shortcomings within psychiatric care in Sweden have been noted (Docteur, & Coulter, 2012; Ljungvall, 2013, The Swedish National Association for Social and Mental Health, RSMH, 2012). Hence, according to LeVine (2012), more community-based services should be assigned to support the recovery process and provide incentives for the individual to recover (William, 1993). Care givers that were popular expressed positive attitudes and had extended their professional roles by small but important gestures (Borg & Kristiansen, 2009). Consequently, individuals’ experiences of their care contacts are crucial. Even professionals such as police officers, lawyers, psychiatrists and psychologists dealing with mentally ill individuals have prejudices against mental illness (Yunker, 1986). Similar negative attitudes among nurse students have been studied. Interventions by some of the authors decreased the negative attitudes (Itzhaki et al., 2017) but showed no long-lasting effects, and after clinical practise the negative attitudes almost grew worse (O’Ferrall‐González et al., 2020). Attempts have also been made in England to overcome negative attitudes. About 5000 mental health service users participated in a study by Sampogna et al. (2021), a majority of whom had experienced discrimination and rejection. Such experiences and expectations are harmful and self-handicapping. The harmfulness of such prejudices in client care contacts in general is the topic of the study at hand.
1.4 Social and economic factors
Research shows that social networks and improved financial conditions are among the factors that contribute positively to recovery for individuals with mental illness (Drehmer & Bordieri, 1985; Gouvier et al., 2003; Mattsson et al., 2008). In a randomized controlled follow-up study (n = 260) it was reported that social support assisted in recovery from severe mental illness in that those who had received scheduled social contacts increased their overall functioning and self-esteem as well as decreasing their symptoms (Davidson et al., 2004). However, evidence regarding the frequency of meetings was inconclusive (Davidson et al., 2004). In addition, Thomas et al. (2016) reported that social network size increased subjective recovery and functioning. Self-efficacy mediated most relationships and was improved by therapeutic relations, which also enhance patients’ social networks (n = 250, Thomas et al., 2016) as well as romantic and intimate relationships (Boucher et al., 2016). Furthermore, community status, social support, stigma awareness and status of mental health improved the perceived recovery, whereas demographics (in general), literacy or intelligence had no impact (Garverich et al., 2021). In India, working was more common, as well as having closer ties to family and colleagues than in the US, where the custom was relations to friends and within the mental service (Pahwa et al., 2020). Still, research of this kind does not always focus on work per se, but rather on social networks, which might be associated with work opportunities (e.g. Markowitz, 2001). In the study at hand the focus in terms of social support is on work and work relationships.
1.5 Individual factors
Several researchers have shown that individual factors and personal characteristics are essential for recovery (Casper & Fischbein, 2002; Dunn et al., 2008; Markowitz, 1998; 2001). For example, Dunn et al. (2010) found that the participants had attained different levels of functioning but that factors related to the individuals, including confidence, skills, motivation and acquiring work opportunities, as well as more contextual factors such as social support and client-oriented programs, contributed more to the process of recovery back to work. The participants created possibilities for work in acquiring skills and caring for their health by finding people they could trust and receive support from. In this process they adopted “…their work life to meet their needs rather than forcing themselves to conform to employment structures…” (Dunn et al., 2010, p. 191). Work gave the subjects stronger self-efficacy, an identity and greater financial independence (Dunn et al., 2008). Furthermore, as self-esteem was related to job satisfaction and success among individuals with mental illness, positive job experiences were important (Casper & Fischbein, 2002). In addition, having employment increased mental health-related self-efficacy and self-esteem “…which in turn may reduce symptoms” (Markowitz, 2001, p 75). Besides, work improves the financial situation (Markowitz, 2001). Self-efficacy and stigmatization have a great impact on individuals’ recovery from severe mental illness and on their life-satisfaction (Markowitz, 2001; Thor Olason & Roger, 2001). The impact of mental health-related self-efficacy was reported in an 18-month follow-up study with individuals in non-institutional mental care (RR = 60%, n = 520; Markowitz, 1998). About 70 % of the participants thought that people had prejudices against individuals with mental illness.
In a study (n=69) by Mackay et al. (2015), about 60% thought that their life had been destroyed because of mental health problems. Besides having negative feelings towards themselves, many subjects believed they were unable to get married. This may be perceived as exclusion, as confirmed in a study by Lundberg et al. (2007) showing that rejection was associated negatively with global functioning and employment. It was also shown that perceived rejections were connected to poor self-image among individuals with mental health problems (Markowitz, 1998). Furthermore, although life satisfaction as expressed in self-esteem had an impact on symptoms, the relationship was not reciprocal, at least not if the participants had high self-esteem. In addition, high life satisfaction and present symptoms had no negative impact on self-esteem. Self-esteem worked both as a result of and as a contributory force to rehabilitation (Markowitz, 2001). Since a positive self-concept improves the recovery process, this was focused on in the study at hand. Fighting spirit is here regarded as part of a positive self-concept.
Fighting spirit (such as courage to resist a disease) has been shown to be related to individuals’ capacity to manage health-related matters including cancer (Cordova et al., 2003; Nelson et al., 1989; Thor Olason & Roger, 2001). In a sample of cancer patients from support groups, fighting spirit, emotional suppression and age lowered mood disturbance (Cordova et al., 2003). Information seeking and fighting spirit were more useful than denial for endurance among cancer patients. Fighting spirit was in the sample favourably related to cognitive coping and optimism but unfavourably to negative affect and avoidance (Nelson et al., 1989). The study at hand will examine fighting spirit in relation to recovery from mental illness. This knowledge is, as far as the author knows, a fairly new approach.
Work can improve individuals’ self-efficacy, social interaction, financial situation and integration (e.g. Levinsson & Jiborn, 2013; Mattson et al., 2008). However, patients’ perspectives regarding factors that might facilitate recovery back to work-life are limited. Thus, the aim of the study was to explore factors related to the intention to work among clients visiting psychiatric outpatient clinics. These are the research questions:
- May individuals’ perceived recovery self-efficacy (RSE) and fighting spirit affect the possibilities for recovery back to work life?
- Are there prejudices against mental illness a) in the care contacts b) at the workplace (or at previous workplaces?)
- What are the requirements on workplace conditions when individuals visiting psychiatric outpatient clinics recover in work life?
- May RSE, fighting spirit and work-related factors be associated with the intention to work?
2.1 The Data collection
The participation of clients in psychiatric outpatient clinics was self-selected. All the participants had experience of mental care, but no specific diagnoses were collected. In total, 270 persons met the inclusion criteria and chose to participate. Out of 410 distributed inventories, 270 were returned (66 % response rate). The completion rate of the questionnaire regarding the continuous variables indexes was 91-92 %, with 94-97 % answering the categorical data, whereas around 90 % had answered the demographic variables.
An inventory was constructed by the authors of this study. The item construction followed regular methodology in asking questions properly, wording, avoiding specific words, using existing items (if any) and pilot testing (Oppenheim, 1998). The inventory was pilot tested on five persons from the target group, after which small adjustments were made in the wording of about four questions. Below, only the items used in the study at hand are reported.
2.2 Instrument .
The demographic variablesincluded age and highest educational level attained. Educational level was based on attended education without taking exams vs taking exams in the following stages of compulsory school: senior high school, education after senior high school and university. Gender was also reported (male, female, others, and no answer).
Employment status was measured by asking whether the participant had worked during the past year. The answering alternatives were “yes” or “no”. The 1-year cut off point was in line with the Swedish social insurance system as well as with the pronounced difficulties to find employment after long-term sick leave (see Table 2).
The answering alternatives for the continuous variables (see Table 1) were formed with inspiration from previous research (e.g. Moss-Morris e al., 2002). Self-efficacy was divided into Recovery self-efficacy and Fighting spirit. Recovery self-efficacy (RSE),based on the Mental Health Self-Efficacy Scale (Carpinello et al., 2000). Fighting spirit was constructed by the present author with some inspiration from Cordova et al. (2003) and RSMH (2012). Prejudices against individuals with mental illness in their contacts with care was inspired from e.g., Lundberg et al. (2007) and Lynöe et al. (2011). Psychosocial strain (demand, control, social support) was also measured with items from previous research. The dependent continuous variable Will to work (intention to work) was measured by asking whether the participant wanted to work. It was inspired from previous research (e.g., Mattsson et al., 2008; Åslund et al., 2012).
Table 1 Continuous variables
|Items||Cronbach’s alpha||Example questions||Further information|
|RSE||5||0.85||“I feel I have support from people around me”||5 indicating a high value|
|Fighting Spirit||3||0.62||“I am me, not my illness”||5 indicating a high value|
|Prejudices in contact with care||1||“Have you experienced prejudice as you received care”?||The answer options were collapsed to three groups.|
|Prejudices at workplaces||1||“While working I experienced prejudices against me”||The answer options were collapsed to three groups.|
|Demand||4||0.79||“Intrigues at work make work climate bad ”||Some items reversed 5 indicating low demands|
|Control||2||0.74||“I decide about my own work pace”.||5 indicating a high value|
|Support||4||0.84||“Do you get the information you need to be able to carry out your work”||5 indicating a high value|
|Will to work||1||“I want to work”||Reversed and transformed|
Note: Answering alternatives ranging 1-5 on interval scales
Initial contacts were taken with two county councils in Sweden, and the authorities responsible approved the study. After pilot-testing the inventory on a target group of five individuals, small adjustments in wording were made in about four items. Following response from the regional ethics board, the study was started and introduced by information from the researcher to the staff at the clinics some time before the data collection. An e-mail reminder was sent to the staff from the clinic conduit. Posters with information about the project were visible close to the receptions. The reception secretaries handed out the inventories and an information sheet with e-mail addresses to the researchers. The visitors put the answered inventories in a locked mailbox close to the reception. The box was emptied once a week by the researcher. The staff was informed that the visitors should fill in the form independently.
2.4 Statistical analysis
Differences between those working and those not working were examined with Chi2 performed to examine experiences of prejudices in care contacts. Prejudices were divided into the three categories “no”, “neither nor” and “yes”. Prejudices in care contacts; The item was trichotomized and transformed, answer options were formed so that 1 and 2 indicated “no”, 3 “neither-nor” and 4 and 5 “yes”. Prejudices at workplaces; The answer options were collapsed as following: (1 and 2) = “no”, 3= “neither nor”, and (4 and 5) = “yes”.
ANOVA analyses were performed to examine mean differences both in prejudices in work life between the groups (small effect size) and in demand, support and control with a medium effect size of social support and small effect sizes of demands and control (Cohen, referred to in Howell, 1997).
Standard multiple regression analyses were performed with the factors included in the multiple regressions based on significant bivariate correlations with the dependent variable “Will to work”. Independent variables comprised employment status, RSE, fighting spirit, and social support. As the dependent continues variable ‘Will to work’ was not normally distributed, it was reversed and transformed to be more normal distributed, and in the transformed variable a low value indicated a higher Will to work.
3.1 Participants background information
The participants were aged 18-77 (M = 36.8 years, SD = 12.45 years). Of 270 participants’, four subjects chose non-specified gender or abstained from answering, see Table 2.
The educational level in the sample was compared to the Swedish population (SCB, 2008; SCB, 2014) by a chi-squaretest which revealed that in Sweden at large there were more individuals with post-secondary education than in the sample.
Table 2. Participants background information
|Education, highest level|
|had not finished compulsory school||3||1.2|
|had completed compulsory school||9||3.7|
|had not finished secondary education||28||11.6|
|had completed secondary education||73||30.3|
|had not finished post-secondary education||16||6.6|
|had completed post-secondary education,||25||10.4|
|had not finished tertiary education at university||37||15.4|
|had completed tertiary education at university||50||20.7|
|Employment last year|
3.2 Recovery self-efficacy and fighting spirit
The relations of RSE and fighting spirit to possibilities for recovery were analyzed. The individuals’ RSE M = 3.49 SD = 0.85 and fighting spirit M = 3.96, SD = 0.76 RSE and fighting spirit were related to employment status, those who worked had higher RSE, M = 3.59 (t (202) = 3.504) p = 0.001, d = 0.4, and fighting spirit, M = 4.10 (t (201) = 3.804) p= 0.000, d = 0.4, than those who did not work. RSE and fighting spirit showed a higher distinction among employed than non-employed.
3.3 Perceived prejudices
The associations of perceived prejudices from care contacts to possibilities for recovery were examined. No such prejudices had been experienced by 60.8 % (n = 149), while about 21.6 % (n = 53) had experienced prejudices and about 17.6 % (n = 43) had not taken sides. No significant differences were found when comparing experienced prejudices to will to work. However, when examining the relationships with participantsʼ employment status, there appeared significant differences in frequency. Among the participants who worked, fewer had experienced prejudices than expected, while there were among those who did not work more had experienced prejudice, with a chi2 (2) =7.115, p = 0.029; see Table 3.
Table 3. Experiences of prejudice in care contacts and employment status
|Experienced prejudices in care contacts||Working Observed (expected frequency)||Not working Observed (expected frequency)|
|No||85 (76.6)||34 (42.4)|
|Neither nor||22 (23.8)||15 (13.2)|
|Yes||23 (29.6)||23 (16.4)|
Note: n = 202
There were no significant differences in perceived workplace prejudices against individuals with mental illness. With respect to employment status, perceived prejudices were for those working M = 2.60 sd = 1.35 and for those not working M = 2.83 sd = 1.26, but F = 1.269, p = 0.261, d=0.01 (n = 196). However, in workplaces as many as 32.1 % (76) had experienced prejudice, 16.5 % (39) had not taken sides, while 51.5 % (122) among the participants had experienced none.
3.4 Work life factors of importance at workplaces
In Table 4, means of psychosocial conditions are presented with respect to employment status. Employed participants perceived that they had had more social support than the unemployed; F = 8.873, p = 0.003, d = 0.04. As regards perceived demands and control, there were no significant differences between employed and unemployed, with demands F = 2.161, p = 0.143¸d = 0.01, control F = 2.403, p = 0.123, d = 0.01.
Table 4. Psychosocial strain and employment status
|Working mean (sd)||Not Working mean (sd)|
|Demands||2.94 (1.01)||2.71 (1.08)|
|Social support||3.65 (0.85)||3.24 (0.92)|
|Control||3.09 (1.00)||2.84 (1.05)|
Note: n = 195
Table 5 shows that working, fighting spirit and social support were associated with “Will to work”, i.e., they contributed positively to the intention to work. For the model, R2 = 0.384. F = 23,321, p = .000. (Further details concerning “Will to work” see Method section).
Table 5. Standard multiple regression, with Will to work as dependent variable
|Employment status||-.070||-.153||.027||-.124, -.004|
|Fighting spirit||-.152||-.522||.000||-.193, -.112|
|Social support||-.035||-.141||.027||-.066, -.004|
R2 = 0.384
The aim of the study was to explore factors related to recovery back to work life among clients in psychiatric outpatient clinics. The main results are that high RSE, fighting spirit and no exposure to prejudices were more common among those with work experiences as recent as the past year. The intention to work is related to employment status, fighting spirit and experiences of social support at the workplace.
4.1. Work and work conditions.
Social support, activities, work rehabilitation and subsequent supported employments have been tried earlier to promote the recovery process. According to Bejerholma et al., (2017), a clear work focus (supported employment) was better than traditional work rehabilitation among individuals with affective disorders. Jagannathan et al. (2020) reported success with small adjustments and a matching process in finding employment for individuals with serve mental illness. Work conditions have an impact on perceived psychosocial strain. This is a plausible explanation of the results in the study at hand, since those with recent work experiences had during their work life perceived more social support than those who had not been working. Besides, in India social network and support from family and colleagues were common (Pahwa et al., 2020). To conclude, more positive experiences in terms of social support favour the recovery process. The question arises whether individuals with mental illness who have recent work experiences will cope better with their situation than those without recent work experience? Or could this be a reflection of a lack of job opportunities?
Research has also demonstrated the importance of work for self-related concepts like self-esteem (Markowitz, 2001), social networks (Thomas et al., 2016) and financial resources (Mattsson et al., 2008). The results from the study at hand show that work per se is positive in the recovery process, in contrast to Eklund et al. (2021), who demonstrated that activities were more important, but in congruence with other research on supported employment (see e.g. Bejerholma et al., 2017).
In the study at hand, fighting spirit is associated with the intention to work for those with recent work experiences and is stronger than for those without recent work experiences. Besides job opportunities, it is most plausible that actually working or at least having the intention to work depends on the individual’s fighting spirit. The importance of fighting spirit in persons with mental illness is worth noticing, as documented in other patient-groups (Cordova et al., 2003; Nelson et al., 1989).
Perceived prejudices in care contacts have an impact on the recovery process (i.e. Lynöe et al., 2011; Sampogna, 2021). However, according to the results in the study at hand, the intention to work is not affected by such perceived prejudices but by actually having been working during the past year. The group with recent work experience perceives less prejudice than the group without. Lundberg et al. (2007) actually reported that more functional individuals have experienced less discrimination/rejection than those less functional. To conclude, prejudices in care contacts seem crucial for clients’ road back to work life, which could be of importance for future treatments.
4.4 Methodological aspects
The reliability of the indices was acceptable and ranged from 0.62 to 0.85. Fighting spirit had an index of 0.62, and the rest 0.70 or higher. Some measures referred to single items (continuous variables), which is a weakness. The “Will to work” item was reversed and logarithmized to more normal distribution. It was used as a dependent continuous variable in the multiple regression analysis. The categorical variable measured by the item asking whether the participant had worked during the past year is based on regulations in the Swedish social insurance system. In Sweden, the conditions for individuals with mental health problems vary depending on the county councils (Ljungvall, 2013), of which those involved have explicitly expressed goals for work rehabilitation. The response rate (66%) is good, and there was no data on diagnoses. The researcher personally emptied the mailboxes and encouraged the receptionists’ assistance about once a week, which probably had a positive effect on the response rate.
Fighting spirit and having work of some kind are important factors in recovery after severe mental illness. The intention to work is also affected by experienced social support. Working per se is positive, since it demonstrates that being without work for lengthy periods is negative. Improvements for clinical practise are a) interventions to decrease prejudices among health care staff and b) information, support and cooperation focusing on employers aiming to hire people with mental illness. Future research should involve factors that promote employers’ willingness to hire people with illness.
COI: There is no conflict of interest
Acknowledgment: I am grateful for valuable comments on the manuscript from Simon Down, and concerning language check from Staffan Klintborg.
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