Work experiences among attendees of day centres for people with psychiatric disabilities

Abstract

BACKGROUND:

It is possible that people with psychiatric disabilities who visit day centres have previous work experiences that may be seen as resources for their current engagement in day centre activities. Research in this respect seems to lack, however.

OBJECTIVE:

To investigate work experiences among attendees at day centres for people with psychiatric disabilities and relationships with current type of day centre (work-oriented, meeting place-oriented or mixed), engagement in day centre activities, motivation and socio-demographic and health-related factors.

METHODS:

Seventy-seven attendees responded to questionnaires. Global Assessment of Functioning, GAF, was also used. Work was categorised into Group I (professionals, semi-professionals), Group II (clerical support, services workers) and Group III (e.g. craft workers, elementary occupations).

RESULTS:

Almost everyone had previously had open-market employment; more than half for ≥10 years. Group I was more common in mixed centres, Group II in meeting place-oriented ones and Group III in work-oriented ones. Group I more frequently had college degree and was rated high on GAF functioning. Women were over-represented in Group II, and men in Group III and in meeting place-oriented centres. Attending mixed centres was more likely when having a college degree, scoring high on GAF functioning and being highly engaged in activities. Attendees at work-oriented day centres were characterised by being motivated for spending time alone and reporting a diagnosis of psychosis.

CONCLUSIONS:

The participants had unused working capacity. No clear-cut relationships were found between work experiences and the investigated correlates.

Keywords

Occupation mental illness motivation productivity

1 Introduction

Recent reforms in Sweden addressing people with psychiatric disabilities have strongly emphasized support to meaningful everyday activities [1, 2]. As a consequence, most local authorities now offer various alternatives for productive and/or social activities in day centres for the target group. Day centres for people with psychiatric disabilities are common in many other western countries; in Europe [3 –5], in the United States [6], in Canada [7] and in Australia [8]. Day centres and their effectiveness form an under-researched context [9, 10], and it is not known how the attendees’ previous experiences of open-market employment, if any, interplay with how they perceive their day centre participation and well-being at large. Many day centreshave a work orientation and provide a diversity of possibilities for productive activities, such as assembly work, carpentry, weaving, car wash, keeping of second hand-shops and food catering. Others have more of a meeting-place character, and those who attend such a day centre commonly socialize, have coffees together and play games. It is also common that day centres have a mixed orientation and provide services of both types [5]. In certain districts in Sweden presumptive attendees are allowed to choose for themselves which type and which specific day centre to attend [11]. Little or no known evidence exists as to whether the type of day centre the attendee chooses to visit is linked with his or her previous work experiences. More knowledge about that relationship would be important when planning for the best possible support in the day centre services.

Research so far on day centre has characterized the activities used [5] and described the target group [10 , 13]. Tjörnstrand et al. [5] found that day centres can grade activities from low demands to high demands and provide relevant challenges for the attendees. Research characterising the day centre attendees has shown that they are likely to have long-standing mental health problems and suffer from physical ill health [12], but also that their motivation for being at the day centre tends to be high [13]. A few studies have compared people attending day centres with non-attendees. Findings showed that the former group more seldom sought hospital care, expressed a stronger need for support regarding everyday occupations [10], valued their everyday activities more, [14], had a larger social network [15], and had a more asserted perception of having a worker role [16]. Bryant and co-workers [17] argued that day centres might feel like a safe place for the attendees, but also as a glass house that prevents participation in the surrounding society, such as open-market employment. These latter findings were recently confirmed by another research team [18], further underscoring that the occurrence of open-market employment and associated factors in the target group should be studied.

Research in outpatient care for people with psychosis has demonstrated that both having an open-market employment [19, 20] and being engaged in everyday activities, including productive activities, leisure, domestic work and self-care [21, 22] were positively related with psychosocial functioning and well-being, including quality of life. No studies seem to have investigated such relationships in the day centre context, however.

The principal aim of this study was to describe day centre attendees’ previous experiences from open-market employment. The aims were also to investigate:

whether the attendees’ work experiences were related to the orientation of the day centre they visited, to their motivation for being there, and to their current situation with respect to engagement in everyday activities, socio-demographic factors, psychosocial functioning and quality of life;

whether those who attended work-oriented day centres differed from those who visited meeting place-oriented and mixed day centres concerning their motivation for being there, and their current situation with respect to engagement in everyday activities, socio-demographic factors, psychosocial functioning and quality of life.

2 Methods

This study was part of a longitudinal project addressing day centre attendance in relation to a freedom of choice reform [23]. It was based on the fifth and final follow-up measurement, which included questions about previous work experiences. A local ethical review board approved the study and the ethical principles stated in Swedish legislation and in the Helsinki declaration were followed.

2.1 Study context

The study was performed in a major Swedish city and six day centres in four strategically selected districts were included. The districts were selected to represent a variety with respect to geographic location (north, south, east, west), the built environment (new/old, high-rise/low-rise) and socio-demographic conditions (educational level, income level, ethnicity). The six day centres composed all centres located in those districts.

The day centres were of three types; two were work oriented, two were meeting-place oriented and two had mixed orientations and provided both types of services. In the purely work-oriented day centres, the attendees were involved in productive activities, such as carpentry, sewing, bike repairs or selling things in a café or a shop. The attendees followed a schedule and were expected to fulfil certain expectations in relation to their assignments. In the purely meeting place oriented day centres, the attendees could come and go as they wished and there were no expectations that they should produce something. When at the day centre, they would play games, have coffees, read magazines and socialize. Some would also engage in creative hobbies, such as pottery and sewing, and in one day centre sing-along was common. The mixed centres included features from both of the other orientations and could adjust the challenges depending on the attendees’ needs. Regardless of day centre orientation, the staff consisted mainly of occupational therapists, social workers, orderlies and craftsmen.

2.2 Selection procedure and participants

All six day centres agreed to participate at the unit level. Information meetings were held at each centre, when first the staff group and then all attendees received information about the project. Since the staff knew about the project when the attendees were informed, the staff could help explain the project and answer questions. The attendees were notified that participation was voluntary and that they could withdraw consent at any time. They could think over their decision during two weeks and give their written informed consent at any time during those weeks. In all, 123 participants agreed, which was about 50% of those who were invited. Due to dropouts, for reasons such as no longer visiting a day centre or being unavailable, only 77 individuals participated in the final follow-up on which the present study was based.

The study participants are presented in Table 1. A majority was female, had housing without support, had completed at least high school and reported they suffered from depression and/ or anxiety. Not shown in the table, the participants’ mean age was 52 years (SD = 10.9) and 62 (82% ) stated they were on continued psychotropic medication.

2.3 Instruments

2.3.1 Background questionnaire

A questionnaire was developed for the study, asking for socio-demographic data (gender, age, education, family situation, housing conditions), self-reported diagnosis, current participation in day centres (type of day centre orientation, attendance in hours per week) and current and previous experiences from open-market employment (type of previous work, duration of work experiences and when in time any work experiences took place).

2.3.2 Motivation

Motivation for being in the day centre was estimated by four questions developed for the day centre context [13]. The questions target motivation for participating in the day centre activities, setting clear goals for what to do in the day centre, preferring spending time on one’s own and preferring open-market employment. Each question is answered according to a 100 mm visual analogue scale (VAS). Research has shown that the questions possessed face validity according to panels of mental health care users and mental health researchers and discriminant validity compared to different measures of health and well-being [13]. Internal consistency is not relevant since the questions do not form a scale.

2.3.3 Engagement in everyday activities

Two instruments were used to assess engagement in activities. One addressed the activities performed while being in the day centre and is termed the Profiles of Occupational Engagement in people with Severe mental illness – Productive occupations (POES-P) [24]. It consists of two parts, the first being a time-use sheet, where the respondent fills in what he or she did during the previous day in the day centre. The other part forms an eight-item questionnaire where the respondent rates his or her engagement in the day centre activities according to, e.g., taking initiatives, having routines and level of autonomy. The POES-P has shown god internal consistency and construct validity [24].

Engagement in activities was also assessed by the Satisfaction with Daily Occupations (SDO) scale, which generates two measures, an activity level score and a satisfaction score [25]. The SDO is performed as an interview targeting four areas of everyday activities; work-related activities (open-market employment, studies, day centre participation), leisure (organized hobbies, hobbies on one’s own, cultural activities), domestic tasks (household chores, gardening and repairs, organizing the home, caring for others) and self-care (personal hygiene, physical exercise, relaxation). Each item has two parts. The first asks whether the respondent presently performs the activity or not and the second is about his or her satisfaction with that situation. An affirmative response to the first part renders a rating of one and a negative gives zero, and the sum of currently (the previous two months) performed activities forms the activity level score. The second part results in the satisfaction score, but since the present study addressed engagement in activities as a factor of relevance to work experiences we only used the activity level score. The original SDO has nine items, but for the present study an extended 13-item version was used, shown to have satisfactory internal consistency and construct validity in terms of convergent and discriminant validity [26].

2.3.4 Psychosocial functioning

The Global assessment of functioning (GAF) [27] is a rating performed by a professional or a researcher, based on knowledge of the individual’s symptoms and psychosocial functioning. Two separate scores, one for symptoms and one for functioning, were used for this study. Both scores may range between 0 and 100, and a score ≥80 indicates the individual has no psychiatric illness. Two research assistants performed the GAF ratings in the present study, and inter-rater agreement was good at an intra-class correlation of 0.86. The scale has also shown god construct validity [28].

2.3.5 Quality of life

The Manchester Short Assessment (MANSA) of quality of life was used. It is a self-report questionnaire and includes one generic item about satisfaction with life and 11 about satisfaction within different life domains, such as work, finances, family, friends, health and security. The response scale has seven steps ranging from worst possible (= 1) to best possible (= 7). Responses to the 11 life domain items are summarized into a composite quality of life score. The Swedish version [29], used in the present study, has shown construct validity and satisfactory internal consistency.

2.4 Procedure

The research assistants made individual appointments with each participant and met in a secluded room at his or her day centre. The self-report questionnaires were sometimes tiring for the participants to complete, and in such cases the research assistants inserted a break. The assistants could also facilitate by reading the questions out loud and explain any questions, but they were careful not to impose on the responses.

2.5 Data treatment and analysis

Responses to the question about self-reported diagnosis were coded according to the ICD-10 system [30] by the second author, who is a specialized psychiatrist. Reliability of self-reported diagnoses among day centre attendees has been indicated by logical relationships with professionals’ assessments of psychiatric symptoms [10]. The diagnoses were further condensed into four major diagnostic groups, as shown in Table 1. Answers to the open-ended question about previous employments were categorized according to the ten main categories in the ISCO-8 classification: Managers; Professionals; Technicians and associate professionals; Clerical support workers; Services and sales workers; Skilled workers within the agricultural sectors; Craft and related trades workers; Plant and machine operators, and assemblers; Elementary occupations; and Armed forces occupations [31]. Based on this qualitative categorization, variables were then created for each of the possible ten employment categories and each participants was assigned a score of one (=had previously had that employment) or zero (never had that employment). Furthermore, the participants were bracketed into three groups depending on type of day centre orientation: work orientation, meeting-place orientation or mixed orientation.

The statistics were based on non-parametric tests, partly because the data were not normally distributed and partly because most of the instruments used produced ordinal scales. The chi2 test was used to analyse associations between categorical variables. Spearman rank correlations were employed to test association between variables and the Mann-Whitney U-test or the Kruskal-Wallis test to analyse group differences.

The software used was the SPSS 0.20 and p-values <0.05 were considered statistically significant.

3 Results

3.1 Open-market employments

At the time of the interview, three participants (4% ) had an open-market employment. Forty (52% ) had a sickness allowance, 21 (27% ) some kind of pension and 10 (13% ) were on social security allowance. Three respondents (4% ) did not respond to how they currently supported themselves.

Seventy-three (94% ) of the 77 day centre attendees reported that they had had previous work experiences, whereas three responded in the negative and one did not respond. The time period during which they had had an open-market employment varied greatly, from a couple of months up to 45 years. Thirty-two participants could not estimate the time they had been working. Splitting the time span (<1 year to 45 years) into decades for those 41 who did state the time they had been working showed that 18 (44% ) had been working for ≤10 years, 13 (32% ) for 11–20 years and 8 (20% ) for 21–30 years. One person had been working for 35 years and one for 45 years.

The 73 participants gave in all 109 examples of types of work they had previously had. As shown in Table 2, Services and sales workers formed the largest category, followed by Clerical support workers. Managers, Skilled workers within the agricultural sectors, and Armed forces occupations were not represented in the study group, and those categories are therefore not shown in the table.

The seven ISCO categories that were represented among the participants were further grouped as shown in Table 2. They differed with respect to the orientation of the day centre they attended (chi² = 15.39, p = 0.004). Those who belonged to Group I (Professionals; Technicians and associate professionals) were less frequently than expected represented in the meeting place-oriented day centres and more often found in the day centres with a mixed orientation. Those who belonged to Group II (Clerical support workers; Services and sales workers) were more likely to attend a meeting-place oriented day centre. Group III (Craft and related trades workers; Plant and machine operators, and assemblers; Elementary occupations) was more likely to visit a work-oriented day centre. There was no statistically significant difference between the groups regarding hours per week spent in the day centre (p = 0.798) or the time that had passed since their most recent experience of open-market employment (p = 1.0).

With respect to socio-demographic factors, there were more women and fewer men than expected in Group II. Conversely, there were fewer women and more men than expected in Group III (chi² = 14.07, p = 0.001). Those in Group I more frequently had a college or university degree (chi² = 16.54, p = 0.011). There were no differences between the three groupings based on ISCO regarding any other socio-demographic variables (age, civil status, having children, having a friend, housing; p-values ranging between 0.449 and 0.767).

The groups based on previous work experiences did not differ in any aspect of motivation (p-values ranging from 0.530 to 0.832). Nor did they differ on engagement in the day centre activities (p = 0.126), quality of life (p = 0.326), diagnostic groups (p = 0.669) or GAF symptoms (p = 0.474). There was a difference on GAF functioning (p = 0.037), indicating that the research assistants rated those belonging to Group I as better functioning than the other two groups.

3.2 Day centre orientation

Groupings based on day centre orientation did not differ with respect to hours per week spent in the day centre (p = 0.090), but they differed on years since their most recent experience of open-market employment (p = 0.012), those visiting meeting place-oriented day centres showing shorter time since the most recentexperience than attendees at both work-oriented day centres and mixed centres.

Time since past work experience might be related to age, and a check for that resulted in a correlation of r_s = 0.344 (p = 0.004). However, there was no difference between the groupings based on day centre orientation regarding age (p = 0.248).

The groupings based on day centre orientation differed regarding sex, such that women were less common and men more frequent in the meeting place-oriented day centres (chi² = 6.30, p = 0.043). Moreover, having a college or university degree was less common in meeting place-oriented day centres and more common in mixed centres (chi² = 14.07, p = 0.001). No differences between the groupings were found for civil status, having children, having a friend or housing (p-values ranging between 0.265 and 0.710).

Those who presently attended a work-oriented day centre were more motivated for spending time on their own hand compared to the other two orientations (p = 0.038). No other differences on motivation were discerned (p-values ranging from 0. 397 to 0.614). The groupings differed, however, on engagement in the day centre activities, those attending meeting place-oriented day centres scoring higher than those attending work-oriented and mixed day centres (p = 0.008). The groupings did not differ on quality of life (p = 0.054), but the tendency reflected in this p-value was in the favour of those visiting meeting place-oriented day centres compared to the other two orientations. The GAF ratings revealed no difference regarding symptoms (p = 0.366), but a statistically significant difference was indicated on functioning (p < 0.001), those visiting day centres with a mixed orientation being assessed as better functioning than those visiting the other two orientations. The groups based on day centre orientation also differed regarding diagnostic group, people reporting schizophrenia and other psychoses being more common and those reporting depression and/or anxiety less common in work-oriented units (chi² = 11.73, p = 0.019).

4 Discussion

The fact that a majority of the attendees had worked for more than ten years and 94% of them had experiences from having had an open-market employment is interesting. This is also new knowledge that may be used in the services for people with psychiatric disabilities. It can be questioned whether their experiences and skills are taken into consideration in the services offered by society. Despite that almost all participants had had salaried jobs, only a few were working today. This most likely reduces their general satisfaction life, since numerous studies have shown that people with mental illness highly appreciate productive work [16 , 33].

The most common types of previous employments concerned services and sales work and clerical support work. There was some variation in the study group, however, that needs to be discussed. Those who belonged to Group I based on the ISCO classification were less likely to visit a meeting place-oriented day centre and more likely to attend one with a mixed orientation. They were also more likely to have a university or college degree and to be rated as better functioning by the research assistants. Those in Group II were overrepresented among those who attended a meeting place-oriented day centre and were more likely to be women and to be rated low regarding psychosocial functioning. Participants in Group III were more likely to be visit a work-oriented day centre and to be men. They were also rated low on psychosocial functioning. The prevailing pattern in these results seem to be that education, type of work and level of psychosocial functioning are factors that are related, which in turn supports the status syndrome, proposed by Marmot [34]. His research has shown that people with lower socioeconomic position have poorer health, and this social gradient also applies within the group of people with mental health disorders [35]. Higher education and a previous high-status employment showed to be protective factors against poor health also in the present study, assuming that psychosocial functioning reflects an aspect of health. Having said that one can of course not exclude the possibility that the participants’ mental health conditions or a prodromal phase had prevented them from achieving better education and a high-status employment. The relationship between socioeconomic situation and mental health may reflect a reciprocal influence.

Those who visited meeting place-oriented day centres had more recent experiences from open-market employment than those visiting work-oriented or mixed day centres. This may be an artefact of the day centres forming a rehabilitation chain [5]. The meeting place-oriented centres are likely to be the first link in that chain, whereas orientation towards work comes later in traditional rehabilitation. This is just a hypothesis, however, and future research should investigate if this is the case.

Further differences between groups based on day centre orientation were found regarding socio-demographic data. Men visited meeting place-oriented day centres more often than women. This may seem surprising, but studies have indicated that men and women tend to choose and perform different activities within the same premises. For example, men were more likely than women to choose to use computers [36, 37], a common activity in meeting place-oriented day centres. It is thus likely that all three day centre categories discerned in the present study could offer activities that were attractive to both men and women, but gender aspects need to be further addressed in the day centre context.

Engagement in the day centre activities was greater in the meeting place-oriented centres than in the two other categories. Based on previous research, however, no difference would have been expected. Tjörnstrand and colleagues [5] found that the demands and challenges could be monitored in both meeting place-oriented and work-oriented centres in such a way that the needs of both higher and lower functioning attendees were met, thereby providing prerequisites for engagement. The higher degree of engagement in the meeting place-oriented centres might reflect that these centres offered more personally meaningful, self-chosen activities, whereas in the work-oriented ones there was work that needed to be done, some of which was routine based and even monotonous, such as assembly work and packaging. Another difference between the day centre orientations concerned self-rated diagnosis. Depression/anxiety was less common in the work-oriented units, whereas psychoses and the group of other diagnoses were more common there. It might be that people with psychosis were more likely to seek the structure and routine related to productive and work-like activities. The drop-in character of meeting place-oriented day centres might suit people with depressive and anxiety problems better.

4.1 Clinical implications

As mentioned above, almost every day centre attendee in the present study had previously had an open-market employment, but only four percent currently had one. Nordström and colleagues [38] also indicated a low employment rate, less than ten percent, among people with psychiatric disabilities. Those findings suggest that people with psychiatric disabilities are an unused resource. People with severe mental illness are able to work, but they need flexibility as their health status may vary [39]. Work rates among people with severe mental illness and/or psychiatric disabilities are higher in many other countries, particularly where unemployment rates are low and jobs requiring lower skills are available [40]. Supported employment is a work rehabilitation method where the main principle is to “place and train”, inferring rapid job search according to the person’s preferences, an open-market employment and then individualized support such that the person can manage the job tasks and requirements [41]. The method has been shown to be effective in many Western countries, including Sweden [42, 43], and should become part of the day centre practices. Enabling work is important, particularly since work has been shown to enhance personal recovery when balanced in accordance with the person’s capacities and needs [44].

4.2 Limitations

This study was based on self-reports regarding previous employments and the reliability of the data may be questioned, particularly since some responses concerned circumstances decades ago. Those who were able to specify their previous employments gave highly probable examples, however, and there is no reason to doubt those responses. Those who stated they had had a previous employment but were not able to describe the character of their former jobs might form a less dependable data source. Similarly, years of employment might be more difficult to remember accurately than the type of employment. This means that we probably got a reliable estimate of the type of previous occupations and employments, but perhaps a less trustworthy estimate of the time spent working. There could also be an overestimation of the proportion of attendees with experiences from open-market employment.

The selection of day centres might also be an issue. Six centres participated, and although they were strategically selected to represent a variety of socio-demographic contexts there might be some factors that were characteristic of a certain day centre, such as particularly engaged or unengaged staff, threats of closing down, etc. Such circumstances might have influenced the findings in some unknown way.

The number of analyses performed in this study infers a risk of mass significance, but this must be weighed against the explorative character of the study. The novel character of the study aim and findings infers that the study’s main value lies in serving as a basis for formulation and future testing of hypotheses.

4.3 Conclusions

A vast majority of the day centre attendees had experiences from having an open-market employment, but very few were currently employed. This suggests they compose an unused potential of working capacity. Those who had experiences from being professionals, technicians and semi-professionals also had a longer education and had a more favourable situation regarding psychosocial functioning, compared to the other groupings based on ISCO-8. This confirmed that there is a status syndrome also within the group of people with psychiatric disabilities, where socioeconomic status and health status might mutually influence each other. The comparisons between groups based on type of day centre orientation gave some results that need to be further explored. For example, those who visited a day centre with a mixed orientation had a higher education, men were overrepresented in meeting place-oriented centres and people with psychosis were more likely to attend a work-oriented day centre. We gave some tentative explanations to these findings, but future research needs to specifically target issues such as the importance of day centre orientation and more thoroughly highlight gender aspects.

Footnotes

Acknowledgments

We gratefully acknowledge that the Swedish Research Council for Health, Working Life and Welfare (FORTE) funded the project. We are also grateful to occupational therapists Inger Thurfjell and Gunilla Wahlström-Wärngård who organized and performed the data collection.

References

Lindqvist

, Markström

, Rosenberg

. Psykiska funktionshinder i samhället. Aktörer, insatser, reformer [Psychiatric disabilities in society. Actors, interventions, reforms]. Malmö: Gleerups; 2010.

Markström

. Den svenska psykiatrireformen. Bland brukare, eldsjälar och byråkrater [The Swedish mental health reform. Among users, enthusiasts and bureaucrats]. Umeå: Boréa förlag; 2003.

Kilian

, Lindenbach

, Lobig

, Uhle

, Angermeyer

. Self-perceived social integration and the use of day centers of persons with severe and persistent schizophrenia living in the community: A qualitative analysis. Soc Psychiatry Psychiatr Epidemiol 2001;36(11):545–552.

Bryant

, Craik

, McKay

. Perspectives of day and accommodation services for people with enduring mental illness. J Ment Health 2005;14(2):109–120.

Tjörnstrand

, Bejerholm

, Eklund

. Participation in day centres for people with psychiatric disabilities: Characteristics of occupations. Scand J Occup Ther 2011;18(4):243–253.

Drake

, Becker

, Biesanz

, Torrey

, McHugo

, Wyzik

. Rehabilitative day treatment vs. supportedemployment: I. Vocational outcomes. Community Ment Health J 1994;30(5):519–532.

Rebeiro

, Day

, Semeniuk

, O’Brien

, Wilson

. Northern Initiative for Social Action: An occupation-based mental health program. Am J Occup Ther 2001;55(5):493–500.

Crosse

. A meaningful day: Integrating psychosocial rehabilitation into community treatment of schizophrenia. Med J Aust 2003;178 Suppl:S76–S78.

Catty J, Burns T, Comas A, Poole Z. Day centers for severe mental illness: Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001710. DOI: 10.1002/14651858. CD001710.pub2; 2007.

10.

Eklund

, Sandlund

. The life situation of people withpersistent mental illness visiting day centers: A comparative study. Community Ment Health J 2012;48(5):592–597.

11.

Andersson

, Eklund

, Sandlund

, Markström

. Freedom of choice or cost efficiency? The implementation of a free-choice market system in community mental health services in Sweden. Scand J Dis Res 2015; early online:1–16. DOI:10.1080/15017419.2014.995220

12.

Catty

, Burns

. Mental health day centres. Their clients and roles. Psychiatrist 2001;25(2):61–66.

13.

Eklund

, Tjornstrand

. Psychiatric rehabilitation in community-based day centres: Motivation and satisfaction. Scand J Occup Ther 2013;20(6):438–445.

14.

Argentzell

, Leufstadius

, Eklund

. Factors influencing subjective perceptions of everyday occupations: Comparing day centre attendees with non-attendees. Scand J Occup Ther 2012;19(1):68–77.

15.

Argentzell

, Leufstadius

, Eklund

. Social interaction among people with psychiatric disabilities - Does attending a day centre matter? Int J Soc Psychiatry 2013, PubMed PMID: 24071687.

16.

Argentzell

, Eklund

. Perceptions of the worker roleamong people with psychiatric disabilities: Description and investigation of associated factors. Work 2013;45(3):289–298.

17.

Bryant

, Craik

, McKay

. Living in a glasshouse: Exploring occupational alienation. Can J Occup Ther 2004;71(5):282–289.

18.

Prior

, Maciver

, Forsyth

, Walsh

, Meiklejohn

, Irvine

. Readiness for employment: Perceptions of mental health service users. Community Ment Health J 2013;49(6):658–667.

19.

Eklund

, Hansson

, Bejerholm

. Relationships between satisfaction with occupational factors and health-related variables in schizophrenia outpatients. Soc Psychiatry Psychiatr Epidemiol 2001;36(2):79–83.

20.

Eklund

, Hansson

, Ahlqvist

. The importance of work as compared to other forms of daily occupations for wellbeing and functioning among persons with long-term mental illness. Community Ment Health J 2004;40(5):465–477.

21.

Eklund

, Leufstadius

. Relationships between occupational factors and health and well-being in individuals withpersistent mental illness living in the community. Can J Occup Ther 2007;74(4):303–313.

22.

Bejerholm

, Eklund

. Occupational engagement in persons with schizophrenia: Relationships to self-related variables, psychopathology, and quality of life. Am J Occup Ther 2007;61(1):21–32.

23.

Eklund

, Markstrom

. Outcomes of a freedom of choice reform in community mental health day center services. Adm Policy Ment Health 2015;42(6):664–71.

24.

Tjörnstrand

, Bejerholm

, Eklund

. Psychometric testing of a self-report measure of engagement in productive occupations. Can J Occup Ther 2013;80(2):101–110.

25.

Eklund

, Gunnarsson

. Satisfaction with Daily Occupations (SDO): Construct validity and test-retest reliability of a screening tool for people with mental disorders. Aust Occup Ther J 2007;54(3):59–65.

26.

Eklund

, Backstrom

, Eakman

. Psychometric properties and factor structure of the 13-item satisfaction with daily occupations scale when used with people with mental health problems. Health Qual Life Outc 2014;12(1):7. DOI: 10.1186/s12955-014-0191-3

27.

Endicott

, Spitzer

, Fleiss

, Cohen

. The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 1976;33(6):766–771.

28.

Startup

, Jackson

, Bendix

. The concurrent validity of the Global Assessment of Functioning (GAF). Br J Clin Psychol 2002;41(4):417–422.

29.

Bjorkman

, Svensson

. Quality of life in people with severe mental illness. Reliability and validity of the Manchester Short Assessment of Quality of Life (MANSA). Nord J Psychiatry 2005;59(4):302–306.

30.

WHO. The ICD-10 classification of mental and behavioural disorders. Geneva: World Health Organization; 1993.

31.

International Labour Organization. International Standard Classification of Occupations. ISCO-8. Structure, group definitions and correspondence tables. Geneva: International Labour Office; 2012.

32.

Leufstadius

, Eklund

, Erlandsson

. Meaningfulness in work - Experiences among employed individuals with persistent mental illness. Work 2009;34(1):21–32.

33.

Gewurtz

, Kirsh

. How consumers of mental health services come to understand their potential for work: Doing and becoming revisited. Can J Occup Ther 2007;74(3):195–207.

34.

Mehnert

, Koch

. Predictors of employment among cancer survivors after medical rehabilitation— A prospective study. Scand J Work Environ Health 2013;39(1):76–87.

35.

Jokela

, Singh-Manoux

, Shipley

, Ferrie

, Gimeno

, Akbaraly

, Head

, Elovainio

, Marmot

, Kivimaki

. Natural course of recurrent psychological distress in adulthood. J Affect Disord 2011;130(3):454–461.

36.

Leufstadius

, Gunnarsson

, Eklund

. Meaningfulness in day centers for people with psychiatric disabilities – Gender and empowerment aspects. Occ Ther Ment Health 2013;20(6):420–6.

37.

Eklund

, Eklund

. Doing or undoing gender? An explorative study of gender, activities and well-being among people with mental illness attending day centers in Sweden. Soc Ment Health 2015; early online:1–16. DOI:10.1177/2156869314568201

38.

Nordstrom

, Skarsater

, Bjorkman

, Wijk

. The life circumstances of persons with a psychiatric disability: A survey in a region in southern Sweden. J Psychiatr Ment Health Nurs 2009;16(8):738–748.

39.

Nagle

, Valiant

Cook J

, Polatajko

. I’m doing as much as I can: Occupational choices of persons with a severe and persistent mental illness. Journal of Occupational Science 2002;9(2):72–81.

40.

Burns

, Catty

, Becker

, Drake

, Fioritti

, Knapp

, Lauber

, Rossler

, Yomov

, van Busschbach

, White

, Wiersma

. The effectiveness of supported employment for people with severe mental illness: A randomised controlled trial. Lancet 2007;370(9593):1146–1152.

41.

Bond

, Becker

, Drake

, Rapp

, Meisler

, Lehman

, Bell

, Blyler

. Implementing supported employment as an evidence-based practice. Psychiatr Serv 2001;52(3):313–322.

42.

Areberg

, Bejerholm

. The effect of IPS on participants’ engagement, quality of life, empowerment, and motivation: A randomized controlled trial. Scand J Occup Ther 2013;20(6):420–8.

43.

Nygren

, Sandlund

, Bernspang

, Fisher

. Exploring perceptions of occupational competence among participants in Individual Placement and Support (IPS). Scand J Occup Ther 2013;20(6):429–437.

44.

Borg

, Topor

. The role of work in recovery from bipolar disorders. Qualitative Social Work 2013;12(3):323–339.