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Promoting enjoyment and self-belief through work rehabilitation
Promoting Enjoyment and Self-belief Through Work Rehabilitation Damian Mitchell There has been a resurgence of interest in work rehabilitation in recent years. A variety of service models are in operation in a number of countries, all, to varying degrees, assisting mental-health clients achieve an optimum level of employment participation. However, little research has been conducted to examine how (and if) such schemes are structured to promote psycosocial rehabilitation. To explore such issues, the author carried out a pilot case study of a work-rehabilitation organization in Lincolnshire, United Kingdom. Two of the main themes, that emerged during the study, Hedonic Experiences and Self-Efficacy, are discussed in this article. Copyright © 1998 by W.B. Saunders Company
HERE HAS BEEN INCREASING interest over recent years in vocational rehabilitation as a vehicle for psychosocial rehabilitation. In both Italy and the United States, vocational rehabilitation is a fundamental part of community-care programs, and in the United Kingdom there are now a number of models currently active (Pozner, Ng, Hammond, & Shepherd, 1996). However, little is known about how, or indeed if, such schemes create a suitable environment for rehabilitation. To investigate the concept of work rehabilitation within a real-life context, a pilot case study was recently conducted, focusing on the work of the Shaw Trust and their Richmond Park Project in Gainsborough, Lincolnshire, United Kingdom. The scheme is designed to assist people with enduring mentalhealth problems to develop employment skills, and, if possible, to re-integrate into local employment. The study took place between August 1997 and February 1998 and was supported by a grant from the University of Nottingham Medical School Trust Fund. Because its strengths lie in the ability to examine
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From the School of Nursing, University of Nottingham, UK. Address reprint requests to Damian Mitchell, R.G.N., R.M.N., B.A. (Hons), M.A., Education Centre, Lincoln County Hospital, Greetwell Road, Lincoln LN2 5QY, UK. Copyright © 1998 by W.B. Saunders Company 0883- 9417/98/I 206-000653.00/0 S44
a particular phenomenon in context, a case study design was used in the study. In designing an initial framework, an extensive literature review was conducted on work rehabilitation, and material was also collected from preproject visits to other work rehabilitation programs operating elsewhere in the United Kingdom. Following on from this process of conceptual clarification, a number of themes were developed; these initial research questions helped shape the data collection. The research sample was selected by purposive sampling in that it was chosen by using, "the researcher's judgment as to typicality or interest" (Robson, 1993, p. 141). The sample for interview was therefore drawn from a selection of clients (project workers) at the Richmond Park Project (all with serious or enduring mental-health problems) and all staff involved in the project. The resulting sample included five project workers (clients) and four members of staff. In addition to interviewing project workers, each was asked to complete a Self-Anchoring Self-Esteem Scale (SASES). The scale (an adaptation of Cantril methodology) requires individuals to create their own terms to define self-esteem on a 10-point ladder, anchored with the terms high self-esteem (10) and low self-esteem (1), and to give a past, present, and (predicted) future score (Carpenter, 1997). However, for the purposes of this pilot study, data were used solely in a qualitative w a y - - i n the identifica-
Archives of Psychiatric Nursing, Vol. XI[, No. 6 (December), 1998: pp 344-350
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tion of themes. Participant observation was also carried out on a number of occasions during the study. QSR NUD.IST (Qualitative Solutions and Research Pty Ltd, 1997) was used to analyze the data. An index system was designed comprising a series of categories and subcategories allowing material to be stored in a logical order. During the process of analysis, the original index system underwent a series of modifications as ideas developed, categories were merged, and others were removed. To elaborate the main findings of the study, the final framework was re-examined to identify the themes contained within the nodes of the new structure, and this was then used in recording the findings of the study. Two of the emerging themes will be discussed in this article, that of Hedonic Experiences and Self-Efficacy. HEDONIC EXPERIENCES
The philosophy of hedonism derives from the pleasure principle in which individuals' actions are interpreted in relation to the pursuit of pleasure or the avoidance of pain (Hewstone, Stroebe, Codol, & Stephenson, 1992). Hedonist theories focus on how individuals undergo particular conscious experiences, that is, whether certain experiences produce satisfaction, contentment, etc. (Brock, 1993). Within the data (both observational and interview) there were a number of themes that could be categorized appropriately under this broad heading. Of particular significance was the notion that humor played a major part in producing a pleasurable experience. This was commented on by both project workers and staff during formal and informal interviews, as well as witnessed on numerous occasions during participant observation. Fieldnotes: " . . . light-hearted banter," " . . . gentle legpulling," "Atmosphere relaxed and jovial," " . . . done in a light-hearted manner," " . . . passed-off with humour," " . . . a good-natured, jovial atmosphere," "There is considerable amusement that a number of people have been caught out."
Learning to laugh has been identified as one of the main criteria for judging the success of work rehabilitation (Davies, 1995, p. 1), suggesting that the creation of a relaxed, informal atmosphere that has the ability to produce amusement is a desirable organizational goal. This would seem to be supported by the literature on humor as a therapeutic
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strategy. It has been recognized that humor can help individuals keep experiences of pain in proportion and promote a sense of group membership (Tooper, 1984); promote intimacy, belonging, warmth, and friendliness among group members (Block, Browning, & McGrath, 1983); facilitate insight and broaden thought (Heuscher, 1980) and emotion (Young & Frye, 1966), and increase subjective value placed on activity and group cohesion (Banning & Nelson, 1987). All of these may be relevant to the implicit and explicit goals of work rehabilitation: 1. Keeping health (mental and physical) problems in proportion would help people move away from an illness-focused perspective (i.e., there are other important factors that affect well-being). 2. Promoting group cohesion and a sense of group membership will improve the completion of (simple) tasks (Manstead & Semin, 1980) and develop group skills required for adequate functioning in the community (Mosey, 1973). 3. Providing a sense of intimacy, friendliness, etc, is more likely to engender conscious experiences of pleasure and/or contentment (hedonic experiences). 4. Promoting insight and broadening of thought may lead to more positive self-evaluation. 5. Promoting the expression of emotion is a goal of psychosocial rehabilitation. 6. Increasing the subjective value of an activity may make it more meaningful and, therefore, worthwhile. Another pleasurable factor valued by project workers was that the work involved a level of physical exercise. Worker: "It is the physical work that I enjoy better and I feel good at the end of the day if I have got some exercise, you know."
Exercise has long been associated with reducing anxiety and depression. The precise cause-effect mechanisms are not known, but a number of hypotheses have been posited including the therapeutic benefits of raised body temperature and muscle relaxation (e.g., sauna bathing), alterations to the cardiovascular system and central nervous system, production of natural opiods (endorphins), and distraction from stressful stimnli (see Petruz-
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zello, Landers, Hatfield, Kubitz, & Salazar, 1991, for overview). It may be that the nature of the work activity itself (i.e., horticulture) is responsible for facilitating physical activity as pointed out by McDonald (1997): "Horticulture . . . provides a range of activities from strenuous digging, wheelbarrow use, raking, cultivation with small hand tools, or simply walking in the landscape" (p. 1). Again, participant observation corroborated this aspect of work as therapy in the subjective feelings of the researcher. A frequent theme that emerged in explanation of project workers' satisfaction and enjoyment at work was that of Variety of Tasks and Experiences. One project worker commented: Worker 4: "As you know we try different things like mushroom picking, looking after the park, down the allotment--a variation of activities . . . . I would sooner be out doing a few more varied things . . . . "
Variety within work has been identified as a key characteristic of motivation to work and another example of an intrinsic reward (Argyle, 1992). Numerous studies have found variety of work to be influential in producing worker satisfaction (Blackburn & Mann, 1972; Mackenzie, 1973; Goldthorpe, et al., 1968) and therefore could be seen to be an unsurprising finding. It does, however, underline the need to understand and consider the factors that make work a rewarding experience (or not) when work rehabilitation activities are developed. Also, as Ransome (1996) points out, • . . the various dimensions of our motivation to work are not random, but are concrete representations of our underlying motivation to act . . . . A number of the key aspects of this concept (work) at the very least remain constant over time, and may in fact be universal across and between different cultures (p. 62).
Reward for work carried out is an expectation that most people have about their participation in employment. For many this means earning money and, thus, improving access to hedonic experiences (i.e., purchasing things that give pleasure and satisfaction). It is argued that money has been the main incentive to work for "several centuries" and that it "really is an effective motivator" (Argyle, 1992, p. 76). Ransome (1996, p. 63) suggests that one of the "principles of action" in the contemporary concept of work is that it is a deliberate undertaking to satisfy certain recognized needs, the related "work expectation" is for "income and
security," and the "criteria of work" is that it is "performed in return for wages or salary." It is often suggested that people with enduring mentalhealth problems are no different in this respect and demand real wages for real work. In reflection of these arguments, a tentative proposition guiding the data collection was that the desire for financial reward would emerge as a clear theme. It is perhaps surprising then that evidence pointed to the contrary, and project workers did not appear to put this high on their agendas. Worker: "Money isn't the main reason why anybody comes here. It's mental and physical work and training yourself up to do something better later on."
Project staff pointed to the difficulties of paying workers, and workers themselves feared losing benefits and hence becoming worse off if they received wages. Worker: ". •. and also the best thing is that you don't loose your benefits." Researcher: "You still keep your benefits that you are on?" Worker: "Right, so I don't have to worry about being made redundant or becoming unemployed again• It is a safety net because if it wasn't for this project I would be still drawing £75 per week but I wouldn't be working. I wouldn't be improving or building up my self-confidence."
However, both staff and project workers recognized other payments-in-kind made instead of direct financial payment, and these rewards were greatly appreciated by project workers: Researcher: "Do you think you should be paid for the work you do here?" Worker: "Yes. I think we are being paid for what we do here. We may not be being paid money but we are being paid in other ways." Researcher: "What different ways?" Worker: "Like getting an education. Getting me through my exams is costing the project £350 . . . . That was a two-year course, and I had to pay my travel expenses and everything like that so I get paid in that w a y . . . . We get boots, we get clothes, we get holidays that include all members by the way. And also we get paid extra money from the mushrooms if we manage to sell them all . . . . "
Paradoxically, although financial reward had not been a motivator for one client who had been with the project for some years, the chance of accessing at least some of the surplus profits from the mushroom cooperative in the future did stimulate interest. Researcher: "But money motivates you (worker)?" Worker: "Yes, that's right."
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Researcher: "But you've coped for three and a half years without it? It hadn't motivated you up until this point but now there is a chance of i t . . . ? Worker: "Yes there is a chance of it; it's looking better, yes. I've always been used to earning lots of money." Researcher: "Do you think it will improve things for you?" Worker: "Yes, that's fight . . . . It will give me more incentive to do the job as well . . . . (Laughing) It keeps you off the streets! I don't think I would work any harder; it would just give me more incentive to do the job."
Interestingly, these findings concur with a previous study by Galvin et al. (1996, p. 32), who found that the majority of volunteers on an equivalent work scheme felt adequately rewarded by similar payments in kind, such as " . . . outings, social gatherings and annual gifts . . . . " It is not suggested that these findings can therefore be generalized to work rehabilitation schemes per se. A number of conference speakers on work-rehabilitation issues representing workers, volunteers, and staff have advocated payment of real wages as not only desirable but a necessary part of psychosocial rehabilitation. This, of course, begs the question, Why is it an issue for some people and not others? One possible explanation could be that project workers generally adopt the prevailing values and philosophy of the organization to which they are attached. Workers in an organization that espouses the merits of real wages as a right are possibly more likely to view financial reward as an important motivator and vice versa. So workers may be subject to a form of hegemony, that is, accepting as common sense the values and opinions of powerful others despite being disadvantaged by these tenets. This, of course, is not suggesting that project staff or organizations consciously set out to disempower or disadvantage workers (or indeed that powerful others could be identified), but is rather a reflection on how power is mediated in a capitalist society. Nor is it suggested that hegemony definitely exists in such a context, but it is an issue worthy of investigation. It will also be interesting to see whether the present Labour administration in the United Kingdom will actively relieve some of the well-documented difficulties of the benefit trap and provide " . . . a safer, better supported way back into employment" (Bray, 1997, p. 28). Much of the anxiety about payment for work from both project workers and staff stems from a fear of individuals sinking into the quicksand of the benefit system and becoming financially worse off as a result of financial reward. This obviously would have an
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effect on mental health because of the stress and worry resulting from such experiences. If this fear were removed, perhaps more people on work rehabilitation schemes, particularly those with serious or enduring mental-health problems would aspire to earning a living wage once more. SELF-EFFICACY A strong theme to emerge from the data was an emphasis on getting project workers involved in new challenges, stepwise progression, and the achievement of tangible results. Such an emphasis on the performance of tasks appeals directly to social cognitive theory and Bandura's (1977) theory of Self-Efficacy in particular. Bandura (1977) used the notion of self-efficacy to explain an individual's perception of how well they can perform in a given situation, that is, whether they have the skills or competence to complete the task. The importance of self-efficacy in relation to work rehabilitation is noted by Crist and Stoffel (1992) who suggest that To be successfully employed one must view oneself as employable. Employability is a match between workrelated skill, one's judgements regarding work abilities, and the job i t s e l f . . , work skill is the ability to do work tasks. However, one's judgement regarding one's ability to work may be an even more important contributor to employability than work skills themselves (p. 435).
Enduring mental-health problems, by the very nature of the long-term difficulties posed for individual sufferers, often erodes positive self-concept. Such negative self-evaluations were apparent in the reflections of project workers when they were ill. Worker: "I got really bad . . . when I was really rock bottom and burnt out--there is a photo in that drawer where I h a v e . . , a long beard, scruffy, unwashed, and they said bring it in and we can compare it, before and after sort of thing. It is somewhere in the file I think (laughing)!
Such a process has been described as "engulfment" (Estroff, 1989; Lally, 1989), whereby individuals begin to see themselves totally in terms of their illness. Social role construction is thought to be one of the main processes in the development of engulfment in people with serious mental-health problems (Estrofff, 1989), a process all too familiar to those working with such a client group, and frequently described by clients themselves wishing to break out of their role of service user. The ability to move away from the sick role helps the person develop and maintain a nonillness self-concept
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(Schur, 1971). Juhasz (1989) has identified work role as one of three major role dimensions, in addition to individual role and family role, and believes the search for self-esteem motivates the individual to strive for confidence in these roles. Confidence is seen as the core of self-esteem (Juhasz, 1989) and self-efficacy as a way of conceptualizing confidence (McCay & Seeman, 1998). The development of a work role, therefore, is crucial to the development of self-esteem for people with enduring mental-health problems. If self-efficacy is indeed the core of self-esteem, then providing opportunities for individuals to succeed in a work role will both help them to develop a more positive self-concept and move away from a patient/client role (diminution of engulfment). Developing such a role was identified by project staff as an important element of work rehabilitation.
volunteers with mental-health problems on a similar scheme had benefited from learning a range of new skills and that the achievement of new skills was valued by participants. Davies (1995), describing the same project, states that volunteers "believe that they have progressed . . . " and that they " . . . become more independent and self-reliant, as they move on in terms of their personal happiness and self-respect . . . . "(p. 4). As previously mentioned, there was a strong emphasis on achievement at the Richmond Park Project by project staff:
Staff member: " . . . a lot of the clients we work with have already been in employment rather than somebody with a learning disabiilty who maybe hasn't been in employment and so hasn't got into the structure of work and the social aspect of work. People that we work with have, you know, like civil engineers, music teachers, people who have had some status, although that is probably the wrong word, but if you know what I mean, a place in the community. All of a sudden they have lost it because of their illness, and particularly with mental health, because they see themselves as getting better, so then they will be able to go back."
So how can the mechanisms of achievement at the Richmond Park Project be explained by Bandura's model of self-efficacy? Bandura (1977) defined four interventions that can affect the individual's self-perception of competence: emotional arousal, verbal persuasion, vicarious experience, and performance accomplishments. Emotional arousal involves the experience of a stressful situation that over time will help the individual to develop competency skills to deal with the anxietyprovoking event. Verbal persuasion, as its name suggests, involves an individual being convinced by another that he or she has the requisite skills to competently deal with a situation. Vicarious experience is characterized by learning through modeling, i.e., observing how other people tackle difficult situations and noting the absence of adverse consequences. Finally, performance accomplishments requires individuals to take part in dealing with the anxiety-provoking event through guided participation and improve self-efficacy by achieving a sense of personal mastery. These interventions are ordered hierarchically from least effective to most effective (according to the Bandura Model, 1977). To some extent, all of these strategies are used at the Richmond Park Project, but clearly, performance accomplishments have precedence over other interventions. There seems to be an instinctive attraction to this mechanism of behavioral change for staff, and this is very much reflected in how the participation of individual workers on the project is organized--particularly in relation to structured,
Additionally, research has suggested that "a greater number of hospitalizations and decreased social adjustments" can result in "increased levels of engulfment" (McCay & Seeman, 1998, p. 41). As has already been suggested, participation in such a project as Richmond Park is likely to result in fewer admissions to the hospital, and social adjustment is one of the main goals of work rehabilitation. The development of new skills and the acquisition of new knowledge were seen by project workers as important aspects of their involvement in the project. In terms of self-efficacy, the development of such skills and knowledge can be seen as a key factor in the process of confidence-building. That is, if I have the skills and knowledge I am more likely to be able to do the job. However, as has already been pointed out, work skills themselves may not be as important as our belief in our ability to carry out the task (Crist & Stoffet, 1992). The study by Galvin et al. (1996) also showed that
Staff member: " . . . that is the project workers' (staff) responsibility, and to make sure that clients who are not achieving in one area are given another job to do so that they are achieving. This is where the more variety of tasks within a project that you have, then the greater the chance that you can find something that somebody could achieve in."
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stepwise, guided progression. Within the broad framework of psychosocial rehabilitation through work, performance accomplishments would seem to have a greater resonance over verbal persuasion in the development of self-efficacy because it is a very practical, hands-on environment. The comparison is a useful one because verbal persuasion is often the choice of strategy in more traditional therapeutic settings. Thus, the model of SelfEfficacy may have greater utility in a work rehabilitation setting than a more psychodynamic approach (more common in therapeutic communities, for example). It can be done with less intrusive reflection, which is perhaps important for those clients with a fragile sense of self, such as people who have experienced enduring mental health problems (Bednar, 1995). Rosenthal and Bandura (1978, p. 622) offers "some illustrative rules for inducing and maintaining desired changes": 1. Structure the tasks to be learned in an orderly, stepwise sequence. 2. Explain and demonstrate general rules or principles. Check client's understanding and provide opportunities for clarification. 3. Provide guided, simulated practice with feedback concerning success and error. 4. Once the desired behavior is established, increase opportunities for self-directed accomplishment. 5. Test newly acquired skills in the natural environment under conditions likely to produce favorable results. 6. Test skills in increasingly more demanding situations until a satisfactory level of competence and self-efficacy has been obtained. 7. Provide opportunity for therapist consultation and feedback during periods of increased independent mastery. Whereas the Richmond Park Project intuitively addresses many of these processes, there may be some value in making the interaction more explicit particularly, if as argued, self-efficacy is a core component of work rehabilitation (Crist & Stoffel 1992). Of course the term therapist should be dropped in favor of co-worker or project staff to denote the different type of relationship. As an example, Crist and Stoffel (1992, p. 442) have suggested the following guidelines for promoting personal self-efficacy in work rehabilitation:
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1. Reinforce or coach appropriate behaviors. 2. Test for job skills on the job around selfreport of abilities. 3. Place in job in which there is a model to follow or imitate. 4. Teach self-advocacy skills. 5. Provide successful job experiences. 6. Begin with close supervision and then cut back slowly as skills are maintained. 7. Maintain similarity or consistency in work tasks. 8. Encourage positive self-talk and eliminate negative self-talk. CONCLUSION
This pilot case study set out to investigate the issues surrounding work rehabilitation as a vehicle for rehabilitation for people with serious or enduring mental-health problems. As previously stated, there are a wide variety of work rehabilitation models in use in the United Kingdom at present, and therefore the findings of the study cannot be generalized to the different contexts within which vocational rehabilitation takes place. As Stake (1995, p. 43) argues, however, " . . . the function of research is not necessarily to map and conquer the world but to sophisticate the beholding of it," and in the tradition of qualitative inquiry, the uniqueness of the case as well as the context were viewed as important to understanding (Yin, 1994). It is hoped that the issues that arose during the course of this case study will add to the debate on work rehabilitation. The discussion has raised a number of research questions: 1. To what extent do work rehabilitation schemes provide enjoyable (hedonic) experiences for clients? 2. What factors influence the desire for financial reward for work done? 3. To what extent do schemes promote selfefficacy, and is there a correlation between this and successful work rehabilitation? Such questions need be tackled on a much larger scale and by collaboration among researchers, practitioners, and project workers. There is a need to move beyond the detailed description of the multidimensional world of work rehabilitation (as so ably done by Pozner, et al. 1996) toward critical and systematic inquiry of the competing models. Perhaps a multiple-case study approach can be
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taken, s a m p l i n g a r a n g e o f s c h e m e s a n d t e s t i n g at least s o m e o f t h e t h e o r e t i c a l p r o p o s i t i o n s p o s e d b y this study. T h i s m a y h e l p to e s t a b l i s h t h e o r e t i c a l g e n e r a l i z a t i o n s (Yin, 1994), w h i c h c a n o n l y s e r v e to assist p r a c t i t i o n e r s , p l a n n e r s , p u r c h a s e r s , a n d t h o s e w h o a c c e s s s u c h s c h e m e s w i t h m o r e inf o r m e d choices.
REFERENCES Argyle, M. (1992). The social psychology of everyday life. London: Routledge. Bandura, A. (1977). Self-efficacy: Towards a unifying theory of behavioural change. Psychological Review, 84, 191-215. Banning, M.R., & Nelson, D.L. (1987). The effects of activityelicited humour and group structure on group cohesion and affective responses. American Journal of Occupational Therapy, 41(8), 510-514. Bednar, R.L. (1995). Self-esteem: Paradoxes and innovations in clinical theory and practice. (2nd ed.). Washington: American Psychological Association. Blackburn, R.M., & Mann, M. (1972). Perceptions of work: Variations within a factory. Cambridge: Cambridge University Press. Block, S., Browning, S., & McGrath, G. (1983). Humour in group psychology. British Journal of Medical Psychology, 56, 89-97. Bray, E. (1997). Rehabilitation: A challenge for the next government. A life in the day, 1(1), 27-28. Brock, D. (1993). Quality of life measures in health care and medical ethics. In M. Nussbaum & A. Sen (Eds.), The quality of life. Oxford: Clarendon Press. Carpenter, J.S. (1997). Applying Cantril's methodology to study self-esteem: Psychometric properties of the self-anchoring self-esteem scale., Paper given to the 11th Annual Conference of the Southern Nursing Research Conference. Norfolk, VA: Author. Crist, P., & Stoffel, V. (1992). The Americans With Disabilities Act of 1990 and employees with mental impairments: Personal efficacy and the environment. The American Journal of Occupational Therapy, 46(5), 434-443. Davies, J. (1995). Moving on: SWOPs contribution to the Horticulture Therapy Conference: 'Gardening, mental health and community care'--Reading University. Bournemouth SWOP: Author. Estroff, S.E. (1989). Self, identity and subjective experiences of schizophrenia: In search of the subject. Schizophrenia Bulletin, 15, 189-196. Galvin, K., Sharpies, A., Hume, S., & Dumbrell, A. (1997). The impact of a sheltered work opportunities project on its users: An ethnographic account. Bournemouth: Bournemouth University, Institute of Health and Community Studies. Goldthorpe, J.H., Lockwood, D., Beckhofer, E., & Platt, J. (1968). The affluent worker: Industrial attitudes and behaviour. Cambridge: Cambridge University Press.
Heuscher, J.E. (1980). The role of humour and folklore themes in psychotherapy. American Journal of Psychiatry, 137, 1546-1549. Hewstone, M., Stroebe, W., Codol, J., & Stephenson, G.M.E. (1992). Introduction to social psychology. Oxford: Basil Blackwell. Juhasz, A.M. (1989). A role based approach to adult development: The triple helix model. International Journal of Ageing and Human development, 29, 301-315. Lally, S.J. (1989). "Does being in here mean there is something wrong with me"? Schizophrenia Bulletin, 15, 253-265. Mackenzie, G. (1973) The aristocracy of labour: The position of skilled craftsmen in the American class structure. Cambridge: Cambridge University Press. Manstead, A.S.R., & Semin, G.R. (1980). Social facilitation effects: Mere enhancement of dominant responses? British Journal of Social and Clinical Psychology, 19, 119-136. McCay, C.A., & Seeman, M.V. (1998). A scale to measure the impact of a schizophrenic illness on an individual's self-concept. Archives of Psychiatric Nursing, 8(1), 41-49. McDonald, J. (1997). Why is horticulture a good medium for work with people with special needs?: Available on the World Wide Web at: http://ourworld.compuserve.com/ homepages/Jane_Stoneham/jmcd.htm. (accessed November 11, 1997). Mosey, A.C. (1973). Activities therapy. New York: Raven Press. Petruzzello, S.J., Landers, D.M., Hatfield, B.D., Kubitz, K.A., & Salazar, W. (1991). A meta-analysis on the anxietyreducing effects of acute and chronic exercise: Outcomes and mechanisms. Sports Medicine, 11(3), 143-182. Pozner, A., Ng, M.L., Hammond, J., & Shepherd, G. (1996). Working it out." Creating work opportunities for people with mental health problems. Brighton: Pavillion Publishing. Qualitative Solutions and Research Pty Ltd (1997) Box 171 La Trobe University PO Victoria, Australia 3083. Ransome, P. (1996). The work paradigm: Theoretical investigation of comcepts of work. Aldershot: Avebury. Robson, C. (1993). Real worm research: A resource for social scientists and practitioner researchers. (3rd ed.). Oxford: Basil Blackwell. Rosenthal, T., & Bandura, A. (1978). Psychological modelling: Theory and practice. In S. L. A. B. Garfield, A.E. (Ed.), Handbook of psychotherapy and behaviour change. New York: Wiley. Schur, E. (1971). Labelling deviant behaviour: lts sociological implications. New York: Harper and Row. Stake, R.E. (1995). The art of case study research. London: Sage. Tooper, V.O. (1984). Humour as an adjunct to occupational therapy interactions. Occupational therapy in Healthcare, 1, 49-57. Yin, R.K. (1994). Case study research: Design and methods. (2nd ed.). London: Sage. Young, R.D., & Frye, M. (1966). Some are laughing, some are not--why? Psychological Reports, 18, 747-754.
HERE HAS BEEN INCREASING interest over recent years in vocational rehabilitation as a vehicle for psychosocial rehabilitation. In both Italy and the United States, vocational rehabilitation is a fundamental part of community-care programs, and in the United Kingdom there are now a number of models currently active (Pozner, Ng, Hammond, & Shepherd, 1996). However, little is known about how, or indeed if, such schemes create a suitable environment for rehabilitation. To investigate the concept of work rehabilitation within a real-life context, a pilot case study was recently conducted, focusing on the work of the Shaw Trust and their Richmond Park Project in Gainsborough, Lincolnshire, United Kingdom. The scheme is designed to assist people with enduring mentalhealth problems to develop employment skills, and, if possible, to re-integrate into local employment. The study took place between August 1997 and February 1998 and was supported by a grant from the University of Nottingham Medical School Trust Fund. Because its strengths lie in the ability to examine
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From the School of Nursing, University of Nottingham, UK. Address reprint requests to Damian Mitchell, R.G.N., R.M.N., B.A. (Hons), M.A., Education Centre, Lincoln County Hospital, Greetwell Road, Lincoln LN2 5QY, UK. Copyright © 1998 by W.B. Saunders Company 0883- 9417/98/I 206-000653.00/0 S44
a particular phenomenon in context, a case study design was used in the study. In designing an initial framework, an extensive literature review was conducted on work rehabilitation, and material was also collected from preproject visits to other work rehabilitation programs operating elsewhere in the United Kingdom. Following on from this process of conceptual clarification, a number of themes were developed; these initial research questions helped shape the data collection. The research sample was selected by purposive sampling in that it was chosen by using, "the researcher's judgment as to typicality or interest" (Robson, 1993, p. 141). The sample for interview was therefore drawn from a selection of clients (project workers) at the Richmond Park Project (all with serious or enduring mental-health problems) and all staff involved in the project. The resulting sample included five project workers (clients) and four members of staff. In addition to interviewing project workers, each was asked to complete a Self-Anchoring Self-Esteem Scale (SASES). The scale (an adaptation of Cantril methodology) requires individuals to create their own terms to define self-esteem on a 10-point ladder, anchored with the terms high self-esteem (10) and low self-esteem (1), and to give a past, present, and (predicted) future score (Carpenter, 1997). However, for the purposes of this pilot study, data were used solely in a qualitative w a y - - i n the identifica-
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tion of themes. Participant observation was also carried out on a number of occasions during the study. QSR NUD.IST (Qualitative Solutions and Research Pty Ltd, 1997) was used to analyze the data. An index system was designed comprising a series of categories and subcategories allowing material to be stored in a logical order. During the process of analysis, the original index system underwent a series of modifications as ideas developed, categories were merged, and others were removed. To elaborate the main findings of the study, the final framework was re-examined to identify the themes contained within the nodes of the new structure, and this was then used in recording the findings of the study. Two of the emerging themes will be discussed in this article, that of Hedonic Experiences and Self-Efficacy. HEDONIC EXPERIENCES
The philosophy of hedonism derives from the pleasure principle in which individuals' actions are interpreted in relation to the pursuit of pleasure or the avoidance of pain (Hewstone, Stroebe, Codol, & Stephenson, 1992). Hedonist theories focus on how individuals undergo particular conscious experiences, that is, whether certain experiences produce satisfaction, contentment, etc. (Brock, 1993). Within the data (both observational and interview) there were a number of themes that could be categorized appropriately under this broad heading. Of particular significance was the notion that humor played a major part in producing a pleasurable experience. This was commented on by both project workers and staff during formal and informal interviews, as well as witnessed on numerous occasions during participant observation. Fieldnotes: " . . . light-hearted banter," " . . . gentle legpulling," "Atmosphere relaxed and jovial," " . . . done in a light-hearted manner," " . . . passed-off with humour," " . . . a good-natured, jovial atmosphere," "There is considerable amusement that a number of people have been caught out."
Learning to laugh has been identified as one of the main criteria for judging the success of work rehabilitation (Davies, 1995, p. 1), suggesting that the creation of a relaxed, informal atmosphere that has the ability to produce amusement is a desirable organizational goal. This would seem to be supported by the literature on humor as a therapeutic
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strategy. It has been recognized that humor can help individuals keep experiences of pain in proportion and promote a sense of group membership (Tooper, 1984); promote intimacy, belonging, warmth, and friendliness among group members (Block, Browning, & McGrath, 1983); facilitate insight and broaden thought (Heuscher, 1980) and emotion (Young & Frye, 1966), and increase subjective value placed on activity and group cohesion (Banning & Nelson, 1987). All of these may be relevant to the implicit and explicit goals of work rehabilitation: 1. Keeping health (mental and physical) problems in proportion would help people move away from an illness-focused perspective (i.e., there are other important factors that affect well-being). 2. Promoting group cohesion and a sense of group membership will improve the completion of (simple) tasks (Manstead & Semin, 1980) and develop group skills required for adequate functioning in the community (Mosey, 1973). 3. Providing a sense of intimacy, friendliness, etc, is more likely to engender conscious experiences of pleasure and/or contentment (hedonic experiences). 4. Promoting insight and broadening of thought may lead to more positive self-evaluation. 5. Promoting the expression of emotion is a goal of psychosocial rehabilitation. 6. Increasing the subjective value of an activity may make it more meaningful and, therefore, worthwhile. Another pleasurable factor valued by project workers was that the work involved a level of physical exercise. Worker: "It is the physical work that I enjoy better and I feel good at the end of the day if I have got some exercise, you know."
Exercise has long been associated with reducing anxiety and depression. The precise cause-effect mechanisms are not known, but a number of hypotheses have been posited including the therapeutic benefits of raised body temperature and muscle relaxation (e.g., sauna bathing), alterations to the cardiovascular system and central nervous system, production of natural opiods (endorphins), and distraction from stressful stimnli (see Petruz-
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zello, Landers, Hatfield, Kubitz, & Salazar, 1991, for overview). It may be that the nature of the work activity itself (i.e., horticulture) is responsible for facilitating physical activity as pointed out by McDonald (1997): "Horticulture . . . provides a range of activities from strenuous digging, wheelbarrow use, raking, cultivation with small hand tools, or simply walking in the landscape" (p. 1). Again, participant observation corroborated this aspect of work as therapy in the subjective feelings of the researcher. A frequent theme that emerged in explanation of project workers' satisfaction and enjoyment at work was that of Variety of Tasks and Experiences. One project worker commented: Worker 4: "As you know we try different things like mushroom picking, looking after the park, down the allotment--a variation of activities . . . . I would sooner be out doing a few more varied things . . . . "
Variety within work has been identified as a key characteristic of motivation to work and another example of an intrinsic reward (Argyle, 1992). Numerous studies have found variety of work to be influential in producing worker satisfaction (Blackburn & Mann, 1972; Mackenzie, 1973; Goldthorpe, et al., 1968) and therefore could be seen to be an unsurprising finding. It does, however, underline the need to understand and consider the factors that make work a rewarding experience (or not) when work rehabilitation activities are developed. Also, as Ransome (1996) points out, • . . the various dimensions of our motivation to work are not random, but are concrete representations of our underlying motivation to act . . . . A number of the key aspects of this concept (work) at the very least remain constant over time, and may in fact be universal across and between different cultures (p. 62).
Reward for work carried out is an expectation that most people have about their participation in employment. For many this means earning money and, thus, improving access to hedonic experiences (i.e., purchasing things that give pleasure and satisfaction). It is argued that money has been the main incentive to work for "several centuries" and that it "really is an effective motivator" (Argyle, 1992, p. 76). Ransome (1996, p. 63) suggests that one of the "principles of action" in the contemporary concept of work is that it is a deliberate undertaking to satisfy certain recognized needs, the related "work expectation" is for "income and
security," and the "criteria of work" is that it is "performed in return for wages or salary." It is often suggested that people with enduring mentalhealth problems are no different in this respect and demand real wages for real work. In reflection of these arguments, a tentative proposition guiding the data collection was that the desire for financial reward would emerge as a clear theme. It is perhaps surprising then that evidence pointed to the contrary, and project workers did not appear to put this high on their agendas. Worker: "Money isn't the main reason why anybody comes here. It's mental and physical work and training yourself up to do something better later on."
Project staff pointed to the difficulties of paying workers, and workers themselves feared losing benefits and hence becoming worse off if they received wages. Worker: ". •. and also the best thing is that you don't loose your benefits." Researcher: "You still keep your benefits that you are on?" Worker: "Right, so I don't have to worry about being made redundant or becoming unemployed again• It is a safety net because if it wasn't for this project I would be still drawing £75 per week but I wouldn't be working. I wouldn't be improving or building up my self-confidence."
However, both staff and project workers recognized other payments-in-kind made instead of direct financial payment, and these rewards were greatly appreciated by project workers: Researcher: "Do you think you should be paid for the work you do here?" Worker: "Yes. I think we are being paid for what we do here. We may not be being paid money but we are being paid in other ways." Researcher: "What different ways?" Worker: "Like getting an education. Getting me through my exams is costing the project £350 . . . . That was a two-year course, and I had to pay my travel expenses and everything like that so I get paid in that w a y . . . . We get boots, we get clothes, we get holidays that include all members by the way. And also we get paid extra money from the mushrooms if we manage to sell them all . . . . "
Paradoxically, although financial reward had not been a motivator for one client who had been with the project for some years, the chance of accessing at least some of the surplus profits from the mushroom cooperative in the future did stimulate interest. Researcher: "But money motivates you (worker)?" Worker: "Yes, that's right."
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Researcher: "But you've coped for three and a half years without it? It hadn't motivated you up until this point but now there is a chance of i t . . . ? Worker: "Yes there is a chance of it; it's looking better, yes. I've always been used to earning lots of money." Researcher: "Do you think it will improve things for you?" Worker: "Yes, that's fight . . . . It will give me more incentive to do the job as well . . . . (Laughing) It keeps you off the streets! I don't think I would work any harder; it would just give me more incentive to do the job."
Interestingly, these findings concur with a previous study by Galvin et al. (1996, p. 32), who found that the majority of volunteers on an equivalent work scheme felt adequately rewarded by similar payments in kind, such as " . . . outings, social gatherings and annual gifts . . . . " It is not suggested that these findings can therefore be generalized to work rehabilitation schemes per se. A number of conference speakers on work-rehabilitation issues representing workers, volunteers, and staff have advocated payment of real wages as not only desirable but a necessary part of psychosocial rehabilitation. This, of course, begs the question, Why is it an issue for some people and not others? One possible explanation could be that project workers generally adopt the prevailing values and philosophy of the organization to which they are attached. Workers in an organization that espouses the merits of real wages as a right are possibly more likely to view financial reward as an important motivator and vice versa. So workers may be subject to a form of hegemony, that is, accepting as common sense the values and opinions of powerful others despite being disadvantaged by these tenets. This, of course, is not suggesting that project staff or organizations consciously set out to disempower or disadvantage workers (or indeed that powerful others could be identified), but is rather a reflection on how power is mediated in a capitalist society. Nor is it suggested that hegemony definitely exists in such a context, but it is an issue worthy of investigation. It will also be interesting to see whether the present Labour administration in the United Kingdom will actively relieve some of the well-documented difficulties of the benefit trap and provide " . . . a safer, better supported way back into employment" (Bray, 1997, p. 28). Much of the anxiety about payment for work from both project workers and staff stems from a fear of individuals sinking into the quicksand of the benefit system and becoming financially worse off as a result of financial reward. This obviously would have an
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effect on mental health because of the stress and worry resulting from such experiences. If this fear were removed, perhaps more people on work rehabilitation schemes, particularly those with serious or enduring mental-health problems would aspire to earning a living wage once more. SELF-EFFICACY A strong theme to emerge from the data was an emphasis on getting project workers involved in new challenges, stepwise progression, and the achievement of tangible results. Such an emphasis on the performance of tasks appeals directly to social cognitive theory and Bandura's (1977) theory of Self-Efficacy in particular. Bandura (1977) used the notion of self-efficacy to explain an individual's perception of how well they can perform in a given situation, that is, whether they have the skills or competence to complete the task. The importance of self-efficacy in relation to work rehabilitation is noted by Crist and Stoffel (1992) who suggest that To be successfully employed one must view oneself as employable. Employability is a match between workrelated skill, one's judgements regarding work abilities, and the job i t s e l f . . , work skill is the ability to do work tasks. However, one's judgement regarding one's ability to work may be an even more important contributor to employability than work skills themselves (p. 435).
Enduring mental-health problems, by the very nature of the long-term difficulties posed for individual sufferers, often erodes positive self-concept. Such negative self-evaluations were apparent in the reflections of project workers when they were ill. Worker: "I got really bad . . . when I was really rock bottom and burnt out--there is a photo in that drawer where I h a v e . . , a long beard, scruffy, unwashed, and they said bring it in and we can compare it, before and after sort of thing. It is somewhere in the file I think (laughing)!
Such a process has been described as "engulfment" (Estroff, 1989; Lally, 1989), whereby individuals begin to see themselves totally in terms of their illness. Social role construction is thought to be one of the main processes in the development of engulfment in people with serious mental-health problems (Estrofff, 1989), a process all too familiar to those working with such a client group, and frequently described by clients themselves wishing to break out of their role of service user. The ability to move away from the sick role helps the person develop and maintain a nonillness self-concept
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(Schur, 1971). Juhasz (1989) has identified work role as one of three major role dimensions, in addition to individual role and family role, and believes the search for self-esteem motivates the individual to strive for confidence in these roles. Confidence is seen as the core of self-esteem (Juhasz, 1989) and self-efficacy as a way of conceptualizing confidence (McCay & Seeman, 1998). The development of a work role, therefore, is crucial to the development of self-esteem for people with enduring mental-health problems. If self-efficacy is indeed the core of self-esteem, then providing opportunities for individuals to succeed in a work role will both help them to develop a more positive self-concept and move away from a patient/client role (diminution of engulfment). Developing such a role was identified by project staff as an important element of work rehabilitation.
volunteers with mental-health problems on a similar scheme had benefited from learning a range of new skills and that the achievement of new skills was valued by participants. Davies (1995), describing the same project, states that volunteers "believe that they have progressed . . . " and that they " . . . become more independent and self-reliant, as they move on in terms of their personal happiness and self-respect . . . . "(p. 4). As previously mentioned, there was a strong emphasis on achievement at the Richmond Park Project by project staff:
Staff member: " . . . a lot of the clients we work with have already been in employment rather than somebody with a learning disabiilty who maybe hasn't been in employment and so hasn't got into the structure of work and the social aspect of work. People that we work with have, you know, like civil engineers, music teachers, people who have had some status, although that is probably the wrong word, but if you know what I mean, a place in the community. All of a sudden they have lost it because of their illness, and particularly with mental health, because they see themselves as getting better, so then they will be able to go back."
So how can the mechanisms of achievement at the Richmond Park Project be explained by Bandura's model of self-efficacy? Bandura (1977) defined four interventions that can affect the individual's self-perception of competence: emotional arousal, verbal persuasion, vicarious experience, and performance accomplishments. Emotional arousal involves the experience of a stressful situation that over time will help the individual to develop competency skills to deal with the anxietyprovoking event. Verbal persuasion, as its name suggests, involves an individual being convinced by another that he or she has the requisite skills to competently deal with a situation. Vicarious experience is characterized by learning through modeling, i.e., observing how other people tackle difficult situations and noting the absence of adverse consequences. Finally, performance accomplishments requires individuals to take part in dealing with the anxiety-provoking event through guided participation and improve self-efficacy by achieving a sense of personal mastery. These interventions are ordered hierarchically from least effective to most effective (according to the Bandura Model, 1977). To some extent, all of these strategies are used at the Richmond Park Project, but clearly, performance accomplishments have precedence over other interventions. There seems to be an instinctive attraction to this mechanism of behavioral change for staff, and this is very much reflected in how the participation of individual workers on the project is organized--particularly in relation to structured,
Additionally, research has suggested that "a greater number of hospitalizations and decreased social adjustments" can result in "increased levels of engulfment" (McCay & Seeman, 1998, p. 41). As has already been suggested, participation in such a project as Richmond Park is likely to result in fewer admissions to the hospital, and social adjustment is one of the main goals of work rehabilitation. The development of new skills and the acquisition of new knowledge were seen by project workers as important aspects of their involvement in the project. In terms of self-efficacy, the development of such skills and knowledge can be seen as a key factor in the process of confidence-building. That is, if I have the skills and knowledge I am more likely to be able to do the job. However, as has already been pointed out, work skills themselves may not be as important as our belief in our ability to carry out the task (Crist & Stoffet, 1992). The study by Galvin et al. (1996) also showed that
Staff member: " . . . that is the project workers' (staff) responsibility, and to make sure that clients who are not achieving in one area are given another job to do so that they are achieving. This is where the more variety of tasks within a project that you have, then the greater the chance that you can find something that somebody could achieve in."
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stepwise, guided progression. Within the broad framework of psychosocial rehabilitation through work, performance accomplishments would seem to have a greater resonance over verbal persuasion in the development of self-efficacy because it is a very practical, hands-on environment. The comparison is a useful one because verbal persuasion is often the choice of strategy in more traditional therapeutic settings. Thus, the model of SelfEfficacy may have greater utility in a work rehabilitation setting than a more psychodynamic approach (more common in therapeutic communities, for example). It can be done with less intrusive reflection, which is perhaps important for those clients with a fragile sense of self, such as people who have experienced enduring mental health problems (Bednar, 1995). Rosenthal and Bandura (1978, p. 622) offers "some illustrative rules for inducing and maintaining desired changes": 1. Structure the tasks to be learned in an orderly, stepwise sequence. 2. Explain and demonstrate general rules or principles. Check client's understanding and provide opportunities for clarification. 3. Provide guided, simulated practice with feedback concerning success and error. 4. Once the desired behavior is established, increase opportunities for self-directed accomplishment. 5. Test newly acquired skills in the natural environment under conditions likely to produce favorable results. 6. Test skills in increasingly more demanding situations until a satisfactory level of competence and self-efficacy has been obtained. 7. Provide opportunity for therapist consultation and feedback during periods of increased independent mastery. Whereas the Richmond Park Project intuitively addresses many of these processes, there may be some value in making the interaction more explicit particularly, if as argued, self-efficacy is a core component of work rehabilitation (Crist & Stoffel 1992). Of course the term therapist should be dropped in favor of co-worker or project staff to denote the different type of relationship. As an example, Crist and Stoffel (1992, p. 442) have suggested the following guidelines for promoting personal self-efficacy in work rehabilitation:
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1. Reinforce or coach appropriate behaviors. 2. Test for job skills on the job around selfreport of abilities. 3. Place in job in which there is a model to follow or imitate. 4. Teach self-advocacy skills. 5. Provide successful job experiences. 6. Begin with close supervision and then cut back slowly as skills are maintained. 7. Maintain similarity or consistency in work tasks. 8. Encourage positive self-talk and eliminate negative self-talk. CONCLUSION
This pilot case study set out to investigate the issues surrounding work rehabilitation as a vehicle for rehabilitation for people with serious or enduring mental-health problems. As previously stated, there are a wide variety of work rehabilitation models in use in the United Kingdom at present, and therefore the findings of the study cannot be generalized to the different contexts within which vocational rehabilitation takes place. As Stake (1995, p. 43) argues, however, " . . . the function of research is not necessarily to map and conquer the world but to sophisticate the beholding of it," and in the tradition of qualitative inquiry, the uniqueness of the case as well as the context were viewed as important to understanding (Yin, 1994). It is hoped that the issues that arose during the course of this case study will add to the debate on work rehabilitation. The discussion has raised a number of research questions: 1. To what extent do work rehabilitation schemes provide enjoyable (hedonic) experiences for clients? 2. What factors influence the desire for financial reward for work done? 3. To what extent do schemes promote selfefficacy, and is there a correlation between this and successful work rehabilitation? Such questions need be tackled on a much larger scale and by collaboration among researchers, practitioners, and project workers. There is a need to move beyond the detailed description of the multidimensional world of work rehabilitation (as so ably done by Pozner, et al. 1996) toward critical and systematic inquiry of the competing models. Perhaps a multiple-case study approach can be
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taken, s a m p l i n g a r a n g e o f s c h e m e s a n d t e s t i n g at least s o m e o f t h e t h e o r e t i c a l p r o p o s i t i o n s p o s e d b y this study. T h i s m a y h e l p to e s t a b l i s h t h e o r e t i c a l g e n e r a l i z a t i o n s (Yin, 1994), w h i c h c a n o n l y s e r v e to assist p r a c t i t i o n e r s , p l a n n e r s , p u r c h a s e r s , a n d t h o s e w h o a c c e s s s u c h s c h e m e s w i t h m o r e inf o r m e d choices.
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