Getting back to work: Experiences of the individual placement and support model from those with mental health conditions,an interpretative phenomenological analysis

2.1 Recruitment

Ten participants from two IPS centres in Scotland were recruited representing a convenience sample. The convenience sample was identified by the employment specialist or occupational therapist involved in their rehabilitation. To be included participants had to be enrolled on the IPS program; currently employed in competitive employment; working 7.5 hours per week or more and diagnosed with a moderate to severe long-term mental health condition.

Referrals to IPS services were made by health professionals working in Community Mental Health Teams (CMHTs).

2.2 Participants

Of the 10 participants one participant withdrew due to deteriorating mental health at interview stage. Nine participants were interviewed from two mental health centres running IPS services throughout Scotland. The participants consisted of four males and five females aged between 24 and 64 years of age. All participants were in paid employment and working between 7.5 and 58 hours per week. Participants had been in current employment between 1 and 18 months, having been on the IPS program between 6 months and 3 years. Employment was found in a variety of different areas: social work, cashier work, project coordination, land management, cleaning services, event services and school tutoring.

2.3 Ethical approval/consent

This study gained ethical approval from the Glasgow Caledonian Universities Health and Life Science Ethics Committee, 23^rd of May, 2018. All participants received an information leaflet about the study and gave verbal and written consent prior to interview. Participants have been given pseudonyms and all data collected held in a password protected file on the researcher’s computer. Time was allocated before each interview to allow the participants to raise any questions or concerns.

2.4 Data gathering

The study was conducted from June to November 2018. All interviews were performed by an independent researcher via telephone, audio recorded and transcribed verbatim by the author. Interviews were typically 30 minutes in duration and consisted often semi-structured, open ended questions, designed to meet study objectives and developed using a guide on how to formulate IPA research questions [26]. The interview style allowed for unexpected topics to emerge, which could then be investigated with further questions. Areas of interest could therefore be explored in depth, permitting rich data gathering. Questions covered the journey back into work, positive and negative aspects to working.

2.5 Data analysis

Data was analysed using IPA; a research methodology which enables the researcher to capture individual’s lived experiences [28]. IPA was chosen as it recognises the researcher within the research and analytical process [28]. Alternative methods, such as content analysis could have been used, however, letting data ‘speak for itself’ allows for more original results [29]. The listening and re-listening of interview recordings, transcribing of data and reading and re-reading of transcripts, allowed for full data immersion, providing foundations for rich analysis. Notes on transcripts where transformed into subthemes. Master themes were identified by seeking relationships of subthemes, represented in Table 1.

3.1 “Working is good for me”: Positive aspects to working

This theme addresses the many positive aspects to working, expressed by participants. The realisation that maintaining paid employment was indeed possible with the right support, appeared to grant participants a greater level of self-respect. Work provided a sense of purpose, structure and routine and reduced isolation. It offered the comfort of getting back to ‘normality’, regaining independence and financial freedom. Participants commonly reported the welcome distraction from depressive thoughts engaging in work offered:

It (working) helps with mental health problems and depression. . . it helps alleviate them. . . the very fact that you are doing a job takes your mind off things. . . meeting people and contributing something to society (Paul).

As highlighted by Paul, employment brought opportunity to engage in appointed tasks within a social environment, providing distraction from depressive thoughts. He suggests employment provides greater relief from depressive symptoms compared to other day-to-day occupations. Meeting new people and contributing to society were identified motivational factors, echoed by Alice and Olivia below. Living on benefits made some participants feel uncomfortable and they wanted to give back to society, both financially and socially:

I was very good about feeling very guilty about the fact I wasn’t at work and I had to be supported by people. . . being in paid employment. . . having your own money has been a major thing (Alice).

Working actually helps with your mental health; it improves your mental health. You’re out there working, socialising, contributing, making a difference ‘cause all these things come with working [pause] and I wouldn’t be here just now if it wasn’t for IPS (Olivia).

This suggests that Olivia viewed the IPS service as providing a sense of purpose and a way to contribute to society as reflected by Adam below. This resonated with many participants in providing motivation to get out of bed in the morning and seize the day:

I didn’t do anything for about 5 years. . . just being at home, doing nothing. Having a job meant a sense of purpose. Not in a grand sort of philosophical sense, in a, OK, I need to get up today, I’ve got stuff to do (Adam).

Here participants appear to suggest that finding work helped to relieve the boredom of ‘being at home and doing nothing’. Finding work added a reason to get up and leave the house with meaningful, paid employment, based on personal preference, leading to increased job satisfaction. Self-respect as perceived by Jack came from his realisation of his ability to do the job and do it well:

Firstly, it gets me out of the house because unless it’s something that I need to do [pause] I find it difficult to leave the house. Secondly, it’s a bit of self-respect. I can actually to do some work, it’s difficult, it’s hard. . . but. . . I’m able to do it (Jack).

This demonstrates what Jack valued most from employment; reducing isolation and gaining self-respect. Fixed appointments that benefit either himself or others pull Jack out of isolation. Equally, work responsibilities led to commitment; and a routine which prompts him to leave the house. The determination and sense of achievement Jack alludes to when acknowledging the type of work, finding it difficult at times, contributes to his sense of achievement and the satisfaction that he is able to do it. The desire to reduce isolation featured strongly amongst participants:

I want to build up relationships with colleagues. Aye, to widen my opportunities because I’m still very, very isolated, very painfully isolated I am unless I’m out working (Olivia).

Here, Olivia valued the opportunity to build relationships with colleagues. She, along with the many of the participants, emphasised that isolation plays a big part in worsening of depressive symptoms. Participants spoke of two main contributing factors to isolation: internal battles with their mental health, and importantly, financial concerns:

People are always amazed that. . . you don’t go (out). . . if you have absolutely no money you very quickly learn that if you stay in the house you don’t spend money that you don’t have (Alice).

You worry about when you’re not working. . . I’m worried about going running cause that would mean more clothes I would have to buy, that’s more washing I would have to do. . . and these are all the things that go round in your head (Carol).

As highlighted by Carol, participants spoke of avoiding or cancelling social hobbies due to financial constraints when unemployed, and this financial hardship has an impact on their wellbeing. Most saw gaining a higher income as a route back to normality:

It means getting back out into the working environment, getting back to normality. . . being able to support myself financially once again (Olivia).

The goal of returning to normality was a common theme throughout interviews. Being able to support themselves financially, links with feelings of independence, reflecting on life before mental illness or spells of good mental health. All participants expressed concerns around getting by on benefits alone. Steady employment and higher incomes appeared to enrich the quality of time spent with loved ones:

It gives me a bit more freedom. . . I can get nicer things for my little girl and that’s a very, very important thing for me. It’s not just about buying her things; it’s about being able to do things with her and spend time with her (Jack).

Here, Jack is not overly concerned with the ability to buy possessions but values how a higher income buys lived experiences, enhancing engagement and time spent with his daughter. Participants voiced family was a motivational factor for achieving employment to enhance lifestyle changes for themselves and family members.

Continuing with positive aspects to work, Simon identifies that of routine, structure and how this helps him manage his mental health condition:

Its routine and structure for myself and. . . having that in place for me. I think it’s also a pride thing. You know, to tell people you are working hard. When you buy yourself something, you know you’ve earned it (Simon).

As for Simon and others the importance of achieving structure and routine featured highly in terms of the stability it grants them. Increased financial freedom and satisfaction of buying something with the money earned. Employment also provided structure and routine to days off, planning household tasks and social activities, around work which further enhanced overall sense of achievement.

3.2 “Rome wasn’t built in a day”: Time-unlimited support

This theme reflects on the journey of each participant in finding and maintaining employment through IPS, addressing the meaningful therapeutic relationships built with ESs though time-unlimited, person-centred support. Here participants spoke of the value of ongoing support with an employment specialist that believed in them:

Having someone neutral actually having faith in myself. . . it’s not something that I’d felt I’d had for a very long time and that was what sort of really, really helped (Jack).

Jack describes having someone ‘neutral’, who chose to see beyond the mental illness, empowering through recognition of his strengths. This was applied not only to the recruitment process but also holistically: taking into account mental health and wellbeing. With IPS, it is recognised that individuals do not necessarily have to be symptom free to start working:

I know I’m not fully recovered but it doesn’t mean to say I’m not ready for a job because IPS is supporting me along the whole road. If I’m having a meltdown, I just need to phone my ES and she’ll make arrangements for me to see her. . . I’m not fully well, she’s that added bonus for me. . . she’s. . . my crutch (Olivia).

Here, Olivia acknowledges that she is not fully recovered but looks at her mental health as a journey, in which taking on employment at this stage was a positive step. Both Olivia and Liz (participants from different IPS centres) referred to their ES as their crutch, not ready to walk the employment path alone, recognising they still require on-going, emotional support.

Three participants spoke about wanting to work, however, acknowledged periods where they felt incapable of starting the process. The below statement from Jack, highlights how the opportunity to access work came quicker than anticipated. This rapid job search appeared to both surprise and please Jack:

I never thought I would be. . . for a few months yet. . . even thinking about work and the fact I’ve been able to do it and do it well, it’s very impressive (Jack).

Through working with his ES and the IPS model, Jack returned to work quicker than planned and benefited from the realisation of his capabilities. This appears to bring him hope and encouragement, learning that competitive work can benefit recovery, highlighting that one does not have to be recovered to succeed in maintaining paid employment.

Most service users spoke of long periods of unemployment or going from job to job, with decreasing confidence. This extract from Alice demonstrates the model’s success in maintaining work:

I graduated from uni (university) seven years ago this summer and since then. . . this currently, over 18 months. . . is my longest stretch in employment. Most of them have been not even 6 months (Alice).

Like Alice, 80%of interviewees were receiving the time unlimited aspect of IPS often called ‘long-arm’ support, having been in their current posts for a prolonged period. Liz and Carol highlight the challenge of maintaining employment and how essential it is to have the right support in place. Importantly, Liz stresses the perceived stigma around disclosing mental illness to employers when in paid employment, despite this being a principle of IPS. Suggesting supportive management reduces stigma:

People quite often, they will get over that hurdle, they will get into a job and then when they hit glitches, they have no one to support them through it unless they have a very supportive employer. With mental health issues you quite often don’t want to let an employer know that this problem exists (Liz).

I’m actually on ‘long-arm’ support...it’s at the stage when I’ve been with them . . . you’re getting along fine . . . but then something happens and I need them. . . they are always there for you. . . someone who understands you (Carol).

Here Carol suggests that the time-unlimited support offered with the IPS model has been of value. Three participants spoke of volunteer work or workshops attended in previous VR programs they had engaged in. Although this is not part of IPS participants reflected fondly on these, for example:

Because of little workshops I went to. . . you know that you are not the only person but somehow it’s affirming when you think, oh, people in this room, they’ve had problems as well, you realise that they are normal (Liz).

Here, Liz highlights comfort found in normalising mental health. Entering a room with no stigma attached, having the opportunity to engage with others who have been through similar journeys. She suggests this provides a confidence boost and opportunities for reducing isolation.

3.3 “My inner critic”: Negative aspects to working

In conjunction with the many positives of competitive work, there are undoubtedly hurdles acknowledged, such as work-related stress, previous employment trauma and associated anxiety and self-doubt. For the majority of participants, their mental illness was in their opinion the seminal factor in not taking on more hours, but for one participant the financial support was a barrier to acquiring additional hours:

I was on ESA and I was doing permitted work, my ESA was £110, and my work was £90 so that’s £200 a week. I was doing 12 hours; I would have actually had to work 27 hours to break even (Carol).

Here Carol speaks of her frustration of how in relation to benefits work does not always equate to more money. Some participant’s highlighted negative aspects such as work-related anxiety with Jack, however, reflecting on these as being temporary., For example:

The anxiety comes to the full and you get the physical symptoms as well...I struggle to sleep the night before. . . you’ve got four hours acting on a stage; you’re going to be exhausted. . . it’s hard work but it’s been going well. . . I’d say on the whole, those things I mentioned are short term (Jack).

Jack describes putting on an act when at work, wanting to display a cheerful face to the public, despite feeling anxious. Anxieties could be around self-confidence and self-doubt in ability to provide a good service. Possibly, he feels pressure to put on an act for his work in customer services or it could be a coping mechanism, distracting him from depressive thoughts. Many participants revealed having an ‘inner voice’, which contributed to feelings of depression and reduced confidence. Jack may also associate his current work, with stress from former employment. He described how his mental health deteriorated due to unsupportive management, echoed by three other participants:

I’d worked in a place previously. . . they [management] were very quick to criticise but never actually praised or thanked you for anything...this sort of experience made me very anxious. . . the management (in his new workplace) was (is) absolutely brilliant. . . very people orientated (Jack).

I wasn’t being paranoid; they (management) treated me appallingly. I was only 17 and they were horrible to me. . . I went from being a very happy girl to. . . extremely depressed (Liz, reflecting on her first employment experience).

In addition, Olivia reflects on her perceptions of work place bullying and how this still has an impact on her several years later.

I always wanted to go back to work but then I never seemed to have the confidence and obviously that was right out the window after my bullying (Olivia).

These extracts demonstrate the potential impact managers behaviours and attitude can have on an employee’s perceived mental health and wellbeing. Previous negative work experiences potentially contributed to poor mental health. For Carol, despite support from her IPS employment specialist and the management at her work, poor reactions were encountered during sickness absence:

My boss said; “Oh it’s hard seeing you in here, shopping and speaking to people and you’re out and about” (Carol, speaking about current employment).

The employee, even with support available to managers through IPS, can still feel stigma, as the program cannot account for individual’s reactions. Additionally, Olivia highlights her desire to work with the reported barrier being self-confidence, triggered by previous work trauma associated with workplace bullying. To return to work, Olivia voiced a combination of psychiatry and medication, alongside the IPS program being vital in her recovery journey. This integration of employment support with health service provision is a core aspect of the IPS model and a component valued by participants.

Conversely, as mentioned by Jack above, good, person-centred management with an understanding of mental health, working in collaboration with IPS, can empower individuals, as reflected by Alice:

I was on sick leave for 5 weeks and my employer was saying well you can come back, and you can just do what you can and what you want. . . So, I started back two days a week (Alice).

Whilst this phased return works well for Alice, she goes on to say:

There is a colleague of mine who. . . doesn’t think that I actually do work when I’m not in the office. . . today was. . . particularly difficult. . . there were words said (Alice).

When a worker needs to take time off work or complete work from home, Alice perceived there can be resentment amongst colleagues in their absence. Working hours provided further discussion, with some participant’s voicing uncertainty regarding capability of part-time or full-time employment suggesting a preference at least initially towards part time hours:

I don’t know if I’m ready to have a full-time job just now because I still get [pause] my black days a couple of days a week (Paul).

Paul highlights the individual nature of mental illness and how he reflected on his decision to go for part-time rather than full-time employment which he perceived may be harder to achieve. The use of “black days” suggests, for Paul the fear of relapse and, fluctuating mental health appears to have contributed to his view that full time employment was not right for him at this time.

4.1 Strengths

This is, to the researcher’s knowledge, the first study to explore the meaning and purpose around finding work for those with long-term mental health conditions on IPS programmes in Scotland. The study design was appropriate for addressing the purpose of the research. Participants were interviewed from two IPS centres covering areas throughout Scotland. All interviews were undertaken by an independent researcher (not employed in the IPS centres) and transcribed verbatim by the author, which allowed for full data submersion. A rich description of the recruitment, data collection and data analysis processes were provided to facilitate transferability.

4.2 Limitations

Research suggests, the absence of visual cues by conducting interviews via telephone, can result in loss of contextual and non-verbal data [45]. Equally, telephone interviews may allow respondents to feel relaxed and able to disclose sensitive information, suited to the nature of this study. Using a convenience sample can result in a group of highly motivated individuals, with the study capturing the views of those who felt able to speak about their experience and possibly those with a positive experience of IPS. Nevertheless, one could argue that in the very nature of IPS, willingness to work is the first principle; therefore, enthusiasm for the program could be present in most recipients. In addition, the focus on the individualised job search based on personal preferences is likely to have an impact on the participant’s enthusiasm. The program inherently aims to find jobs and hours of work that individuals have expressed an interest and desire to do. Our participants represented a convenience sample and were from more than one service across Scotland. So, whilst it is possible that there may be some differences in the delivery of the IPS model this could add depth and richness to the data.

Furthermore, this was the principle researcher’s first experience of data collection and IPA. IPA can bring its own limitations as the author selects relevant quotes to highlight different themes; therefore, the researcher’s role in the analysis added a unique viewpoint [28].