Scandinavian Journal of Occupational Therapy. 2014; 21: 277–286

ORIGINAL ARTICLE

Factors related to the return to work potential in persons with severe mental illness

ULRIKA BEJERHOLM & CECILIA AREBERG Department of Health Sciences/Work and Mental Health, Medical Faculty, Lund University, Sweden

Abstract Objective: This cross-sectional study aimed at investigating the relationship between the return to work potential, according to the Worker Role Interview (WRI) assessment, and clinical characteristics and level of empowerment and occupational engagement among persons with severe mental illness who express their own interest in working. Methods: 120 participants entered the study. The WRI, the Brief Psychiatric and Rating Scale, a sociodemographic questionnaire, the Empowerment Scale, and the Profiles of Occupational Engagement in Severe mental illness were used for data collection. Correlation and regression analyses were used for statistics. Results: The return to work potential was significantly associated with having fewer symptoms, rehabilitation support or productive activities, and higher levels of engagement and empowerment. A younger age had an inverse relation to the lifestyle component in WRI. Depressive symptoms and occupational engagement explained 42% of the variance. Conclusions: The findings support the use of an empowerment approach, taking into account the clients’ symptoms, age, and time use. In addition, involvement in vocational support and productive activities may be advantageous early on in the recovery process.

Key words: Empowerment, mental health, occupational engagement, occupational therapy, vocational rehabilitation

Introduction One of the main objectives for occupational therapists (OTs) in the field of psychiatric rehabilitation is to assist clients with severe mental illness (SMI) to return to work, after a longer period of sick leave (1). An individual is regarded as having an SMI if he or she has had a mental illness, most often a psychosis, for a period of two years or more that significantly impacts on everyday life including the ability to work (2). Most persons with SMI consider work an important part of their personal recovery (3). On that account, it is important for occupational therapists to turn to the clients’ own power to direct the vocational service, support their choices, and design interventions that meet each client’s vocational needs in that process (4,5). In fact, two qualitative studies of persons with SMI in vocational programs showed that the client’s own belief in and wish to return to work

was important for obtaining a job in the end or not (6,7). However, the constituents of the return to work potential have not been studied on a group level among persons with SMI. In the present study, work potential is being referred to as the possibility or likelihood of returning to work in contrast to the actual work performance. Accordingly, work potential refers to the anticipated, latent, and unrealized work ability and not to work ability in a real-life work context. It is vital that professionals in psychiatric rehabilitation have an empowerment perspective and a recovery approach, i.e. to provide support according to the client’s own preferences and goals, and to genuinely support his or her own capacity to mobilize the resources needed to succeed (8–10). However, many professionals in mental health care and welfare services assume a paternalistic stance and believe that persons with a severe mental condition cannot work

Correspondence: Ulrika Bejerholm, PhD, Associate Professor, Medical Faculty, Department of Health Sciences/Work and Mental Health, PO Box 157, SE 221 00 Lund, Sweden. Tel: +46 46 222 19 58. E-mail: [email protected] (Received 20 September 2013; accepted 28 January 2014) ISSN 1103-8128 print/ISSN 1651-2014 online
2014 Informa Healthcare DOI: 10.3109/11038128.2014.889745

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or make their own and “right” decisions about their return to work. In Sweden, persons with SMI are often referred to day centres or clubhouses to fulfil their social and occupational needs and to counteract isolation (11). As a consequence, they are rarely asked about or provided with the vocational opportunities to enter employment (12). This occupationally deprived situation, where the persons do not have the power and control to change structural, economic, social, attitudinal, and cultural barriers (13), should be a matter for occupational therapists to conquer. A first step in that direction would be to ask the client about his or her aspiration to work and then provide individualized support accordingly. However, no research has yet told us what important factors need consideration in such an individualistic approach. The literature reviewed for this study focused on concepts and characteristics that are likely to encircle and be related to own belief and willingness to return to work among persons with SMI. First, the early discovery of clients’ strength and obstacles to return to work has been stated as vital for the foundation of vocational rehabilitation (14), and is the key focus in the present study. The Worker Role Interview (WRI) has been stressed as a promising work assessment tool in mental health care to understand this potential for return to work in relation to psychosocial and environmental factors (15). The WRI was originally developed to support the injured worker, but has over the years been adapted to suit persons with disabilities who have not worked for a while. In 2012, the psychometric properties were assessed for WRI in mental health care exclusively. The WRI theory is derived from the Model of Human Occupation (MOHO) (4) and provides information on how volition, habituation, and perceptions of the environment influence work success. In clinical practice, this theoretical framework underpins the reasoning concerning the clients’ belief in their own work ability, i.e. motivational, lifestyle, and environmental characteristics in relation to a future goal as a worker. As a measure, the WRI makes it possible to evaluate the status and progress in the return to work process. However, since the WRI rating is based on the client’s own beliefs and experiences, it does not provide an objective measure for the clients’ mental problems or symptoms and level of skills in relation to return to work. Therefore the WRI also needs to be complemented or understood in relation to other measures (15). Hence, to explore clients’ own wish to work more fully, it is necessary to relate the WRI assessment to other characteristics too. As concluded in previous research, it is important to address clinical characteristics, such as problems with mental health and having symptoms, in relation to vocational issues

(16–18). Among positive, negative, depressive, and general symptoms, negative symptoms have been found to be related to work functioning in terms of social function, task orientation, and personal presentation (19). Moreover, negative symptoms have been shown to affect the engagement in a meaningful occupational pattern, in which work is likely to be a part (20). It can therefore be assumed that clinical characteristics may play a role in the possibility to return to work, and is a relationship we aim to explore. Sociodemographic characteristics might be other objective factors related to return to work. For instance, higher age, having a work history, and ethnic origin have been shown to be related to vocational outcomes, such as gaining competitive employment and increased working hours (21,22). However, no such relations have been found in occupational therapy research (23) and in relation to the return to work potential itself. The experience of being empowered has been concluded to play a key role in personal recovery for persons with SMI (24,25). Empowerment is conceptualized both as a cognitive construct, i.e. decisions about life and treatment goals, and as a behavioural construct, i.e. taking action within the community to control and fulfil one’s goals in life (24,26). In previous research and literature, being empowered has been shown to increase motivation for change, and commitment to rehabilitation (27,28). Thus, hypothetically, it can be assumed that if a client has made up his or her mind about returning to work, that person may very well experience empowerment. Occupational engagement, based on the assessment of time-use patterns of occupational performance, is a construct in psychiatric rehabilitation that in addition to empowerment sheds light on the personal recovery process among persons with SMI, and thus probably the potential for return to work after sick leave. Occupational engagement can be expected to range, vary, increase, and decrease along a continuum. A lower level of occupational engagement is anticipated to concern a more acute phase of the illness or when the occupational life is less intense and the process of recovery has just begun (29). Conversely, a higher level of engagement was found to be associated with an increase in sense of coherence, mastery, internal locus of control, and meaningful occupations (20). To the best of our knowledge, no research has yet encompassed the group of persons with SMI who express their own interest in working. Accordingly, our study aim was to explore the relationship between return to work potential and clinical and sociodemographic characteristics and the level of empowerment and occupational engagement. Furthermore, on the basis of the literature cited above, we hypothesized

Factors related to return to work potential in persons with severe mental illness that exhibiting a stronger potential for return to work would be associated with having fewer symptoms, and higher levels of occupational engagement and empowerment. Material and methods Research design The present study had a cross-sectional design and was performed in a mid-sized Swedish town with 300 000 citizens. Written informed consent was obtained from all participants, and the study was approved by the regional ethical review board in Lund (Dnr 202/ 2008). Participant selection The selection criteria for this cross-sectional study were: having a severe mental illness, which means having a psychosis or psychiatric disabilities on a long-term basis (>2 years), an age of 20–65 years, regular contact with mental health services, own wish to return to work in the near future, being on sick-leave for at least one year, and being able to communicate in Swedish. Procedure The recruitment process was initiated by the clients’ case managers in six mental health care centres. The case managers distributed verbal and written information including where and when they could meet the researchers for extended information. At these meetings the inclusion criteria, research design, and interview procedure were described. The prospective participants could choose to sign an informed consent form there and then, or after such a meeting. The period of enrolment lasted for 11 months and ceased when clients’ interest in participating in the study ended. A total of 141 participants submitted written consent forms and were then invited by research assistants to take part in an interview to collect data for the study. Those who did not show up for an interview after three appointments were not enrolled in the study. The final sample arrived at 120 participants. Data collection The interviews took place at an outpatient clinic and were performed by two interviewers who were also occupational therapists. They had no previous or ongoing contact with the participants. The participants were distributed evenly between the interviewers. The instruments were administered

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in the same chronological order during a single interview of each patient, which lasted for up to one and a half hours. The data were collected over a period of nine months, starting in the autumn of 2008. The interviewers underwent training in the use of the instruments by researchers who had considerable experience of using the Worker Role Interview (WRI), the Brief Psychiatric and Rating Scale (BPRS), and the Profiles of Occupational Engagement in Severe mental illness (POES). The training helped the research assistants to improve consensus through discussing and comparing assessments with the recommended score in the training material. Videotaped interviews and an interview guide were used as a means of training assessment skills with the BPRS. The agreement between the raters regarding the POES assessment increased after they had assessed and interpreted several previously completed time-use diaries. In addition to WRI training, it was considered important that the research assistants had sound knowledge of the Model of Human Occupation (30), as stressed in recent research (15). Instruments Sociodemographic characteristics were collected using a questionnaire concerning age, gender, ethnic group, diagnosis, age at first contact with psychiatric care, work history, years of unemployment, rehabilitation support/scheduled productive activities, marital status, living situation, and children. The Worker Role Interview (WRI) (31) was administered to assess the potential for return to work. The Swedish version 3 (WRI-S) was used (32). The WRI was chosen specifically since the assessment is based on an interview concerning the worker role, instead of a self-rated checklist for example. Thus, it was considered important that the assessment elaborated on the participants’ own comments on their situation and that the assessment stayed close to this narrative. The first part in the WRI comprises a semi-structured interview, the format of which is not standardized and can be moderated during the interview to follow the flow of the conversation between the interviewer and the interviewee. The second part consists of the rating scale and is standardized to help assess the potential for return to work, as indicated by the client’s reasoning regarding motivation, lifestyle, and environment components. The interview areas correspond to the 16 content items, as given in Table I. They are rated on a four-point scale, indicating their impact on return to work: SI(1) = strongly interferes, I(2) = interferes, S(3) = supports, SS(4) = strongly supports. A higher score indicates a stronger work

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Table I. Component and content areas, and items of the WRI-S. Components Motivation

Content areas and items Personal causation 1. Assesses abilities and limitations 2. Expectations of job success 3. Takes responsibility Values 4. Commitment to work 5. Work-related goals Interests

item is rated on a seven-point scale. The total score ranges from 18 to 126, a higher score indicating more symptoms. The instrument allows for the analysis of general, depressive, negative, and positive symptoms. The BPRS has shown good inter-rater reliability (ICC = 0.74) (36), and concurrent validity when correlated with the total scores of the Brief Symptom Inventory, as represented by the General Severity Scale (r = 0.55, p < 0.01), the Positive Symptom Total (r = 0.56, p < 0.01), and the Positive Symptom Distress Index (r = 0.50, p < 0.01) (37). Cronbach’s alpha coefficient in this study was 0.71.

6. Enjoys work 7. Pursues interests Lifestyle

Roles 8. Appraises work expectations 9. Influence of other roles Habits 10. Work habits 11. Daily routine 12. Adapt routine to minimize difficulties

Environment

Environment 13. Physical setting 14. Perception of family and peers 15. Perception of boss 16. Perception of co-workers

Note: Items in italics were not included in this study.

potential. Reliability has been assessed with the intraclass correlation coefficient (ICC). The instrument has shown satisfactory test–retest reliability (ICC = 0.95) and inter-rater reliability (ICC = 0.92) (33). The Rasch analysis results from two studies showed that the majority of the questions worked together to reflect a single construct and that the scale categories functioned well (15,34). No ceiling and floor effects could be discerned in a sample of persons with mental illness (15). According to the manual, the WRI can be used to assess individuals who do not have a job to return to, and those who do. In this study, four items were omitted since they referred to having a specific job to return to. Cronbach’s alpha coefficient (a) in this study was 0.81. Table I gives the characteristics of the WRI-S. Clinical characteristics. Psychiatric symptoms were rated using the 18-item version of the Brief Psychiatric Rating Scale (BPRS) (35). The assessment is based on the BPRS interview, where both verbal responses and observations of the client are considered. Each

Empowerment. The Swedish version of the Empowerment Scale (ES), called Making Decisions, was used (38). It consists of 28 statements which are scored on a four-point agreement scale ranging from strongly agree (1) to strongly disagree (4). The ES has five subscales measuring self-efficacy and self-esteem, power and powerlessness, community activism, righteous anger, and optimism toward and control over the future. An overall score of empowerment can also be calculated. Psychometric tests have shown satisfactory internal consistency (a = 0.86) (39), and construct validity when correlated with quality of life (r = 0.58, p < 0.05), psychosocial functioning (r = 0.47, p < 0.05) and symptoms (r = –0.55, p < 0.05) (38). Cronbach’s alpha coefficient was 0.73. Occupational engagement was assessed by means of the Profile of Occupational Engagement in people with Severe mental illness (POES) (40). Part I concerns data collection by means of a 24-hour, yesterday time-use diary and a supplementary interview. The diary sheet has five columns corresponding to (1) time, (2) occupation, (3) social and (4) geographical environment, and (5) reflections and interpretation. Each row represents a one-hour interval. The participant is instructed to fill in his/her doing in time as thorough as possible and a supplementary interview emanates from what is written down or not in the diary. Part II involves the assessment of the time-use diary on a four-point scale. The nine items: daily rhythm of activity and rest, variety and range of occupations, place, social environment, social interplay, interpretation, meaningful occupations, routines, and initiating performance, derive from previous research on time use and occupational engagement among persons with schizophrenia (29,40,41). A higher score indicates a higher level of occupational engagement. Part III concerns the assessment of occupational balance, but was not applied. The instrument has been shown to have satisfactory construct validity when correlated with the Global Assessment of Functioning (rs = 0.73, p < 0.001) and activity level

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Factors related to return to work potential in persons with severe mental illness (rs = 0.70, p < 0.001) (42). Inter-rater reliability has been calculated by using mean weighted kappa (k = 0.70). Satisfactory internal consistency (a = 0.95) has also been demonstrated (40). Moreover, Rasch analysis support that POES can be used on an interval scale (43). In this study, Cronbach’s alpha coefficient was 0.93. Data analysis The data were divided into groups to identify possible differences in return to work potential regarding gender, ethnic origin, diagnosis, work history, and rehabilitation support/scheduled productive activities. Regarding ethnic origin, participants born in Sweden (n = 77) formed one group, and those who had immigrated to Sweden from Europe (n = 19), Asia (n = 8), the Middle East (n = 7), Africa (n = 6), North America (n = 2), and Latin America (n = 1) formed the other (n = 43). The participants who had schizophrenia or another psychoses belonged to one group (n = 77), and the participants with bipolar disorder (n = 17), schizoid personality disorder, and social phobia (n = 25), formed the other diagnosis group (n = 42). The participants’ work experience was categorized as: having worked at some time during the past five years (n = 40) or not (n = 51). To note, missing data do not refer to the absence of work experience but to not having had filled in this sociodemographic question. The participants were grouped according to whether they were receiving rehabilitation support/engaged in scheduled productive activities (n = 52) or not (n = 63). The items from the WRI were divided into three work readiness components, i.e. Motivation, Lifestyle and Environment. The total sum score in WRI sum was in calculated, along with mean and range (see Table III). Student’s t-test was used for calculations of differences between groups and Pearson’s correlation test was used to calculate relationships among continuous and ordinal variables that were normally distributed. The rationale for using parametric statistics concerned normally distributed data and the fact that previous Rasch analyses on the WRI and the POES support calculations on an interval scale. To explore how well our set of variables predicted the return to work potential, a stepwise multiple regression analysis was performed. Variables significantly correlated with the WRI scores (p < 0.001) were included in the regression. To allow for the analysis of the various symptoms, the variable total score for BPRS was excluded from the regression. WRI was considered the dependent variable. We further assumed negative, positive, and depressive symptoms, occupational engagement, and empowerment to be independent variables influencing the return to work potential. The

Table II. Sociodemographic characteristics of the participants (n = 120). Characteristic Age mean (range)

n (%) 38 (21–58)

Gender Male

67 (56)

Female

53 (44)

Ethnic origin Native

77 (64)

Immigrant

43 (36)

Diagnosis (n = 119) Psychosis

77 (65)

Non-psychosis

42 (35)

Age at first psychiatric contact (n = 114), m (range)

24 (12–56)

Work history (n = 91) Worked in the past 5 years

40 (44)

Not worked in the past 5 years

51 (56)

Rehabilitation support/scheduled productive activities (n = 115) Yes

52 (45)

No

63 (55)

Marital status (n = 119) Single

73 (61)

Married/partnership

21 (18)

Separated/divorced

25 (21)

Living situation Owner

31 (26)

Rented accommodation

74 (62)

With parents

0 8 (7)

Supported/sheltered accommodation

0 4 (3)

Other

0 3 (2)

Children (n = 117) Yes

39 (33)

No

78 (67)

binary variable, having rehabilitation support or not, was included as a dummy variable. The level of significance for all calculations was set at p < 0.05. The statistical package used was IBM Statistics SPSS 20.0 for Windows. Results Sociodemographic characteristics are presented in Table II. Slightly more men than women were interviewed, and one-third of the participants were immigrants. The majority had a psychosis, were single, lived in rented accommodation, and had no

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Table III. Correlations between return to work potential and clinical, empowerment, and occupational characteristics (n = 120). WRI total score and components, m (range) WRI 38 (20–48)

Motivation 22 (7–28)

Lifestyle 13 (7–16)

Environment (n = 117) 3 (1–4)

Variable m (range) ES 78 (52–95)

0.359***

0.291**

0.277**

0.170

POES 27 (11–36)

0.613***

0.554***

0.598***

0.160

BPRS 27 (18–48)

–0.405***

–0.355***

–0.339***

–0.210*

General 5 (3–10)

–0.202*

–0.184*

–0.187*

–0.146

Positive 13 (10–29)

–0.221*

–0.179

–190*

–0.168

Negative 4 (3–13)

–0.348***

–0.335***

–0.275**

0.045

Depression 5 (2–10)

–0.359***

–0.299***

–0.302***

–0.249**

Notes: WRI total score refers to the sum of the items 1–9, 11, 12, 14. *p < 0.05, **p < 0.01, ***p < 0.001.

children. Almost half of the group did not report any recent work experience, although 52 participants were receiving rehabilitation support or were engaged in scheduled productive activities. This could mean taking part in educational preparatory courses (n = 3), attending day centres (n = 12), being involved in the Social Insurance Agency’s work capacity evaluation (n = 16), or receiving individualized support from a psychiatric team or Public Employment Agency staff (n = 21). Relationships to sociodemographic characteristics The total WRI score was not significantly related to gender, ethnic origin, diagnosis, work history, age at first psychiatric contact, or duration of sick leave. However, age was positively correlated to WRI lifestyle (r = 0.248, p < 0.01), and a trend towards a significant correlation with regard to total scores in WRI (r = 0.152, p = 0.053). Differences were found between participants who were receiving rehabilitation support (Yes) and those who had no support (No), with regard to motivation (Yes/No: mean score = 23/21, p < 0.01), lifestyle (Yes/No: mean score = 14/13, p < 0.001), and total score in WRI (Yes/No: mean score = 41/37, p < 0.001). Relationships to clinical characteristics and level of empowerment and occupational engagement Among the symptom variables, depressive symptoms were negatively correlated and had the highest correlations to the WRI total score. A moderate, negative correlation was found between the total scores in WRI and BPRS. Empowerment was positively correlated to all WRI components apart from environment. An engaged time-use in daily occupations was positively

correlated to all WRI components. Correlations are presented in Table III. Regression analysis The regression analysis rendered a model showing that occupational engagement and depressive symptoms explained 42% of the variance in work potential according to WRI, adjusted R2 = 0.41, F(2.110) = 38.07, p < 0.001. Occupational engagement accounted for 38% of the variance, F Change (1.111) = 68.49, p < 0.001, showing a higher beta value than depressive symptoms (b = 0.52, p < 0.001, vs. b = –0.21, p < 0.01). Depressive symptoms accounted for 4% of the variance, F Change (1.110) = 7.44, p < 0.01. Discussion Our results encompassed factors related to the assessed return to work potential among persons with SMI. What can we learn from this and what knowledge can occupational therapists bring into their practice when they support their clients? First, the way in which the participants spent their time and engaged in daily occupations in the social community, as assessed by POES, was the most important factor in relation to the work potential according to the WRI assessment. This may reflect the fact that those who say they want to work probably have a time use and occupational life that support these aspirations. This assumption was further confirmed in the regression analysis in this study, in which occupational engagement explained 38% of the variance in the work potential according to the WRI. Accordingly, the participants who spent their time in a variety of different meaningful occupations and kinds of social

Factors related to return to work potential in persons with severe mental illness and geographical environments, reflecting upon experience and interpreting meaningful experiences, initiating and having routines and structure to their day, were also more ready to return to work. This connection is strongly supported by what can be interpreted as being the heart of occupational therapy, namely that engagement and participation in occupations creates a sense of identity and meaning, through which experiences form new goals in life (44), such as a working goal. The positive relation between the WRI and the ES scores further points in this direction, as just described in relation to occupational engagement, that the more empowered the participants felt, the greater their capacity to maintain and adapt a routine to minimize difficulties became, despite their illness. Thus, to perceive one’s abilities to perform a given task or achieve a goal, i.e. self-efficacy, appears to be important to someone who is heading back to work. Since self-efficacy constitutes an important construct in the ES (39), our findings are in line with the results of a study by Bandura & Locke (45), showing self-efficacy to have a considerable impact on motivation and performance. In fact, the WRI item “Expectations of job success”, which belongs to the Motivation component and Personal Causation area in WRI, has been identified as a predictive factor for returning to work in a previous study by Ekbladh and colleagues (46), in which 53 persons with various sickleave problems were followed over a period of two years. Moreover, in a qualitative study (6), where the aim was to identify barriers to employment among 10 participants with SMI who participated in a vocational rehabilitation programme, most participants did not believe that they were going to achieve employment. In summary, it seems crucial to address personal causation, i.e. sense of personal capacity and self-efficacy (30), when supporting persons with SMI towards work. Although age did not stand out in the correlations or regression analysis, and, of course, no causal relations could be discerned, the higher score in the Lifestyle component of WRI and its inverse relation to a younger age needs further attention and reasoning, especially since young people today are a vulnerable group with regard to both mental health and employment (47). One speculation we have is that younger persons per se may not yet have had the time to develop their study or working role, which makes it difficult for them to envision themselves as workers. For those who in addition fall mentally ill, it might be even more difficult to have a future perspective. This speculation is corroborated by Basset and colleagues’ findings (48), where younger participants with psychosis were found to have difficulty in identifying employment goals, and had little knowledge of

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community vocational services. It thus appears that, apart from having limited work experience, young people have few occupational opportunities to support their development of a worker role. What we can learn from this is that occupational therapists could be a great support in the early intervention for persons with SMI. Research has already told us that supporting vocational goals functions well in early intervention teams (12,49). Work history has previously been shown to predict vocational outcome among persons with SMI (21,22). However, no relation was found between those variables in the present study. Accordingly, being motivated to work is not equivalent to having had the opportunity to secure competitive employment. As introduced earlier, persons with SMI often find themselves in an occupationally deprived situation in relation to studying or working. External factors, such as attitudes regarding whether or not professionals believe that persons with SMI can work irrespective of illness and symptoms, become a structural barrier, together with a fragmented welfare system that promotes a pre-vocational and stepwise vocational rehabilitation that involves several welfare services with different guidelines and national directives. Hence, if occupational therapists ask their clients with SMI if they want to work, help to empower them, and build the relationship with the clients on equal power and trust and not the expert role primarily, the chances of helping them out of an occupationally deprived situation could be mitigated (10,50). Although most participants had been on sick leave for the past two to three years or longer, about half of the group were receiving rehabilitation support, or engaged in scheduled vocational support in job centres, through the insurance agency, or social and/or productive activities at clubhouses or day centres. In other words, they were on their way and had probably cultured their beliefs in saying yes to work. To participate in such a supportive or occupational context was found to be related to return to work and may have enhanced participants’ motivation, goal setting, and orientation towards work. Moreover, the depressive symptoms turned out to be a predictive factor of the participants’ potential to return to work. It can thus be anticipated that long-term sick leave affects mood and self-esteem. Accordingly, even if clients do not want or are not able to gain employment, it is vital that occupational therapists support persons with SMI to cope with their lack of occupational structure and meaning in life. These assumptions put occupational therapy in its right perspective. Our focus should be on vocational rehabilitation, but also on occupational health and well-being, to support a working life in this group of persons.

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What can we learn from this? The results of this study can increase occupational therapists’ understanding of the constituents of the return to work in a group of persons with SMI. The findings indicate that occupational therapists can optimize clients’ return to work process by adopting an empowerment approach, supporting them through constructive use of their time, and focusing on symptom management. However, assessment of work potential according to the WRI assessment should not become a criterion for providing vocational support. Instead, the present results indicate that occupational therapists should address vocational support and raise the issue of employment at as early an age and stage in the recovery or return to work process of a client as possible, and thus mitigate an occupationally deprived situation. However, not every person with SMI can or wants to work. Of course, we need to support persons with SMI according to their own efforts to recover. Methodological limitations This study was carried out with unemployed persons with SMI receiving mental health care and who expressed their own wish to return to work, and the external validity of the study may thus be limited to such circumstances. The recruitment was performed stepwise which gave presumptive participants insight into the study, and time to reflect on the study aim and conditions. Furthermore, selection bias was decreased by allowing presumptive participants themselves to decide, instead of the mental health care staff. Accordingly, the participants should be representative of unemployed persons with SMI who make up their own mind about wanting to return to work. The Motivation and Lifestyle component scores in WRI were more strongly correlated to the BPRS, the POES, and the ES scores as compared with the Environment component score. This result may probably be explained by the fact that three out of four environment items were not applicable, which is in line with the instructions in the WRI manual when the interviewee does not have a job. This limitation prevented us from studying the dual environmental aspect of WRI, which in theory involves both the physical and social environment. The assessment and scoring of the instruments may have been affected by the fact that the same interviewer collected all data for one participant. Thus, an interviewer effect could have been present (51). The knowledge obtained and the assumptions resulting from assessment using one instrument may affect the next. To counteract this threat to internal

validity the interviewers met regularly. However, no inter-rater reliability was established. Yet, in an attempt to increase agreement between the two raters, they were provided with solid training material before the interviews were carried out. Finally, it is important to consider the cross-sectional design, the aim of which was to explore possible relationships between variables at one point in time. Asa result, thefindings of this study reveal nothing about a cause-and-effect relationship. However, we assume that the relationship between the variables is reciprocal, and hypothesize that the potential to return to work is influenced by mental health problems, occupational engagement, and empowerment, and vice versa. Conclusions Exhibiting a higher degree of work return potential according to the WRI assessment was associated with having fewer symptoms and higher levels of occupational engagement and empowerment. Receiving rehabilitation or vocational support, or participating in scheduled social or productive activities, was also related to the potential. However, it was having an engaged occupational pattern and fewer depressive symptoms that best explained the variation in WRI. This study has enhanced our understanding of how better to support persons with SMI to cultivate their motivation to seek, obtain, and keep employment, but also their occupational life as a whole, in their return to work process.

Acknowledgments Financial support for this study was provided by a grant from the Swedish Research Council for Health, Working Life and Welfare (Forte). The Medical Faculty of Lund University and Vårdalinstitutet contributed with the funding of researchers’ and research assistants’ wages. The authors thank the participants and staff of numerous outpatient centres and Pamela Andreassen and Åsa Sturesson Johansson for interviewing, and MSc in statistics, Lars Wahlgren, who assisted in data analyses. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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