The Meaning of Work

 

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     Occupational therapy is founded on the belief that participation in meaningful activities is beneficial to health and well-being. Some of the health-promoting effects associated with participation in occupation-based mental health services and in meaningful activities include improved perspective on quality of life, a sense of well-being, improved confidence and self-esteem, decreased use of crisis services and hospitalizations, and improved socioeconomic status (Gewurtz & Hirsh, 2006). While occupational therapy encompasses far more than engagement in paid employment, participation in work and related activities is recognized as contributing to the well-being and recovery of individuals labeled with serious mental illness, while the absence of engagement in meaningful work is associated with decreased signs of health and well-being for this population. The following serves to illustrate the perspective of individuals labeled with serious mental illness on the meaning of work, highlights the health benefits associated with participation in work, and enhances understanding of how occupational therapists can support the recovery process through supporting employment goals.

     A meta-analysis of qualitative studies on the perspectives of individuals labeled with serious mental illness found that this population identified many benefits of being employed, including “greater autonomy, status and acceptance within society, structured use of time, a sense of purpose or focus, feeling productive and useful to others, affirmation of ability, and opportunities for social contact and personal development (Fossey & Harvey, 2010, p.308). The perspectives of individuals labeled with serious mental illness in these studies further spoke to the meaning associated with work, including creating a sense of wellness, improved relationships, and greater optimism, which were also seen as helpful in sustaining employment throughout the process of recovery.

       A study by Eklund, Hansson, and Bejerholm (2001) explored relationships between health-related variables and satisfaction with daily activities in 74 adults labeled with schizophrenia. This study found a significant positive correlation between satisfaction with employment status and global well-being, and it was found that employed individuals were more satisfied with their overall daily activities. Employed individuals in this study were also rated significantly better by interviewers on global quality of life, internal locus of control, and psychosocial functioning.

 

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     Another study explored the importance of work as compared to other types of activities with 105 individuals who were separated into three groups: those who were participating in competitive work or formal schooling, those who participated in structured activities other than work or school, and those who did not participate in any structured activities (Eklund, Hansson, & Ahlqvist, 2004). Results supported previous findings that individuals who were engaged in competitive work or school displayed better psychosocial functioning and reported significantly better satisfaction with daily activities than the other two groups. Of note, there was no significant difference in satisfaction with daily activities between the group of individuals who participated in structured activities besides work and the group who did not participate in any structured activities, indicating that there is a characteristic of work that contributes to a greater sense of well-being than participation in other types of activities.

     Gewurtz and Kirsh (2006) noted that “there was something about working that encouraged participants and transformed them from being a person with a mental illness to being a productive member of society” (p.6). This study explored the constructs of doing and becoming as related to participation in work for individuals labeled with serious mental illness and described participants’ experiences with work while illustrating the meaning that work brought to participants’ present lives and their futures. Through interviews, researchers found that doing work provided opportunities [for participants] to connect with others, improve their economic situations, and motivated them to manage their illness to ensure their ongoing ability to follow through with their commitments at work” (p.6). Participants also described how reflecting on their experiences of work led to self-discovery of individual skills and limitations and the ability to imagine a future for themselves as workers. On the other hand, “some of the stories recounted in the interviews suggested that the absence of doing [work] was a state filled with hopelessness in which a possible future was unimaginable” (p.10).

 

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A study that further explored the differences in perspectives and experiences between individuals labeled with serious mental illness who were employed and those who were not found that, like the employed participants in the previous study, the employed individuals in this study talked about being actively engaged in improving and maintaining their health, which indicates that they perceived themselves as in a state of health (Woodside, Scholl, & Allison-Hedges, 2006) . Contrary to this perspective, the individuals in this study who were not employed held the perspective that their symptoms of mental illness were a barrier to obtaining work and they questioned the effectiveness of their medical treatment, indicating that these individuals perceived themselves as not in a state of health (Woodside et al., 2006). It is important to note, however, that both groups of individuals, employed and unemployed, valued feeling comfortable with people at work, which supports the findings in other studies that work provides opportunities for social participation.

      From the perspectives of individuals labeled with serious mental illness, participation in work is associated with increased satisfaction with daily activities, improved sense of self, better health and well-being, and feelings of hope for the future. Participation in work is associated with better functioning and provides opportunities for meaningful social interactions, personal growth, and improved socioeconomic status, while lack of participation in work is associated with hopelessness, lower satisfaction with daily activities, and decreased overall health and well-being.

     Occupational therapists can support individuals labeled with mental illness throughout the recovery process, both in helping individuals to obtain jobs and to sustain employment. The participants in the study by Gewurtz and Kirsh (2006) brought to attention the importance of having someone who “believed in them, encouraged them, or expected that they could do more” (p.8) and participants in other studies have emphasized valuing strong collaborative relationships in which a sense of optimism, interest, and encouragement in pursuit of employment goals (Fossey & Harvey, 2010). Occupational therapy’s client-centered approach in empowering individuals to do the things they want to do affords a natural fit to the purpose of supporting individuals in believing in their capacity to work.

 

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   Occupational therapists can also support individuals in navigating employment support systems, developing strategies to manage the stress of job seeking, developing self-advocacy skills, and reflecting on the characteristics of various employment settings to ensure a good fit between the individual and the job. Participation in paid work is meaningful and contributes to recovery in a variety of ways, and through bolstering efforts to obtain and maintain employment, occupational therapists can support individuals labeled with serious mental illness in realizing their full potential as positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

References

Eklund, M., Hansson, L., & Ahlqvist, C. (2004). The importance of work as compared to other forms of daily occupations for wellbeing and functioning among persons with long-term mental illness. Community Mental Health Journal, 40(5): 465-477.

Eklund, M., Hansson, L., & Bejerholm, U. (2001). Relationships between satisfaction with occupational factors and health-related variables in schizophrenia outpatients. Social Psychiatry and Psychiatric Epidemiology, 36, 79-85.

Fossey, E. M. & Harvey, C. A. (2010). Finding and sustaining employment: A qualitative meta-synthesis of mental health consumer views. Canadian Journal of Occupational Therapy, 77, 303-314. Doi: 10.2182/cjot.2010.77.5.6

Gewurtz, R. & Kirsh, B. (2006). How consumers of mental health services come to understand their potential for work: Doing and becoming revisited. The Canadian Journal of Occupational Therapy, 73(4 suppl.): 1-13. https://doi.org/10.2182/cjot.06.014

Woodside, H., Scholl, L., & Allison-Hedges, J. (2006). Listening for recovery: The vocational success of people living with mental illness. The Canadian Journal of Occupational Therapy, 73(1): 36-43. Doi: 10.2182/cjot.05.0012.

The Clubhouse: An Environment Where OTs Can Support Recovery

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       Occupational therapy’s distinct value in mental health lies in the emphasis on engagement in everyday activities, with the ultimate goal “to enable participation in personally and socially meaningful occupations that support health and well-being (Krupa, Fossey, Anthony, Brown, & Pitts, 2009, p.156). There are many settings within the community-based mental health service system through which occupational therapy has the potential support individuals labeled with serious mental illness (SMI), and a setting that stands out as an excellent fit is the Clubhouse.

          “Clubhouses are intentionally formed, non-clinical, integrated therapeutic working communities composed of adults and young adults diagnosed with SMI (members) and staff who are active in all Clubhouse activities. Clubhouse membership is open to anyone who has a history of mental illness. Membership is voluntary and without time limits. Being a member means that an individual is a critical part of the community and has both shared ownership and shared responsibility for the success of the Clubhouse” (McKay, Nugent, Johnsen, Eaton, & Lidz, 2018, p.29). A key feature of the clubhouse model is the work-ordered day, which refers to the expectation that staff and members work side-by-side, and the temporal flow of the clubhouse paralleling typical business activities and hours of operation of the working community where the clubhouse is located (Stoffel, 2011).

Painted Brain occupational therapy mental health     The clubhouse model implements several basic principles which emphasize individual strengths and potential, teamwork, the belief that work and work-mediated relationships support recovery, and empowerment through choice of activity (McKay et al., 2018, p.29). Clubhouses also provide support for gaining employment in the greater community through transitional employment, supported employment, or independent employment; participating in formal education; and connecting to resources in the community for health, finances, and housing. Also, 193 clubhouses responding to a survey regarding available activities reported offering some type of health promotion programming, including education on health, nutrition, and smoking sessions, and opportunities for exercise (McKay et al., 2018).

        Research has found many benefits to clubhouse participation. A study that compared clubhouse participants to participants in a program for assertive community treatment (PACT) found that “Clubhouse participants were employed more calendar days than PACT participants, worked significantly more hours, earned more during the study, and earned more per hour each week” (McKay et al., 2018, p.36). This same study also found that clubhouse participants reported greater quality of life related to social and financial aspects, and greater self-esteem and service satisfaction than PACT participants (McKay et al., 2018).

        Benefits of clubhouse participation are also found in the areas of physical health, rehospitalization rates, and social participation. A study on a 16-week structured exercise program implemented in a clubhouse called Genesis found that participants had significant improvements in aerobic capacity and perceived mental health, as well as positive changes in the domains of social and physical functioning, physical and emotional roles, vitality, and general health (Pelletier, Nguyen, Bradley, Johnsen, & McKay, 2005). A systematic review found results from 10 published studies that suggest clubhouse participants have lower rehospitalization rates, and the authors reasoned that evidence supported by at least 6 of the included studies suggest that Clubhouse participation may be beneficial in promoting social relationships by increasing social integration and supporting social competence (McKay et al., 2018).

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The first clubhouse, established in New York City in 1948, was known as Fountain House, and offered its members supportive experiences in job training, arts and crafts, and recreational activities; occupational therapists were involved in Fountain House by leading workshops in fabricating small items (Stoffel, 2011). The clubhouse environment presents an ideal setting for occupational therapists to support the recovery of individuals labeled with serious mental illness due to the shared principles between the clubhouse model of psychosocial rehabilitation and the foundational theories of occupational therapy. Occupational therapy is founded on the principle that engagement in meaningful activities provides structure to an individual’s day and purpose to an individual’s life, resulting in improved physical and mental wellbeing, while the clubhouse model implements principles that emphasize structuring participation around the work-ordered day and supporting recovery through engagement in work and work-mediated relationships.

 

       The clubhouse model of psychosocial rehabilitation offers an environment in which individuals labeled with SMI can enter the community and be viewed as having individual strengths and potential to lead personally satisfying lives. Clubhouse participation has been found to be beneficial for individuals labeled with SMI through bolstering employment and educational opportunities, enhancing social participation, and connecting individuals to resources for health promotion. The clubhouse goals of helping individuals engage in meaningful work, supporting the pursuit of employment and formal education, and engaging in culturally relevant social and recreational activities are consistent with the occupational therapy domain of engagement in occupation to support overall health and well-being (Stoffel, 2011). Through innovation and client-centered practice occupational therapists can implement services in clubhouse settings to support the recovery of individuals labeled with serious mental illness and facilitate the realization that all people can be positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

 

References

Krupa, T., Fossey, E., Anthony, W. A., Brown, C. & Pitts, D. B. (2009). Doing daily life: How occupational therapy can inform psychiatric rehabilitation practice. Psychiatric Rehabilitation Journal, 32(3): 155-161. Doi: 10.2975/32.3.2009.155.161

McKay, C., Nugent, K. L., Johnsen, M., Eaton, W. W., &  Lidz, C. W. (2018). A systematic review of evidence for the clubhouse model of psychosocial rehabilitation. Administrative Policy in Mental Health, 45: 28-47. https://doi.org/10.1007/s10488-016-0760-3

Pelletier, J. R., Nguyen, M., Bradley, K., Johnsen, M., & McKay, C. (2005). A study of a structured exercise program with members of an ICCD certified clubhouse: Program design, benefits, and implications for feasibility. Psychiatric Rehabilitation Journal, 29(2), 89-96. http://dx.doi.org.libproxy1.usc.edu/10.2975/29.2005.89.96

Stoffel, V. C. (2011). Psychosocial Clubhouses. In C. Brown & V. C. Stoffel (Eds.), Occupational therapy in mental health: A vision for participation (Chapter 39, pp. 559–570). Philadelphia, PA: F. A. Davis Company.