'Without Occupation You Don't Exist': Occupational Engagement and Mental Illness.

This phenomenological study explores the meanings of work for people living with severe and enduring mental health conditions. The participants were three women and seven men who were attending a mental health day centre. Data were collected through up to three depth interviews with each participant over 18 months. The interviews were digitally recorded, transcribed verbatim, and analysed according to phenomenological principles. Two overarching themes were identified. Building and maintaining an occupational identity expressed the ways in which participants used occupations as the building blocks of an evolving identity. Most of the participants wanted to work, and participation in occupations was seen as essential to recovery from mental ill-health. Work and other ways of belonging encapsulated the need to feel connected to others. Many of the participants envisaged working as a way of achieving this. The longitudinal nature of the study facilitated engagement with the developing narratives and exploration of the changes and consistencies in the participants' meaning making about their occupations. Implications for understanding individuals' occupational participation which enhances a sense of self and promotes feelings of belonging are identified.

The worker role has been seen as central in the western world for decades, influencing initial impressions and judgments about an adult's status, wealth, and class. This phenomenological study brings an occupational perspective to exploring the meanings and experiences of employment for people living with severe and enduring mental health conditions. In the context of the study, employment is understood as an occupation that has the potential to influence health and well-being (Christiansen & Townsend, 2010; Hasselkus, 2002; Yerxa, 1998). The right to work is enshrined in Article 23 of the United Nations' Universal Declaration of Human Rights (United Nations, 1948), which states that everyone has the right to work, to free choice of employment, to just and favorable working conditions, and to protection against unemployment. The World Health Organization (2000) supported this position, noting that for people with mental health problems this can be challenging.

The advent of an evidence based model of supported employment (Becker & Drake, 1994) has focused the attention of policy makers and health care providers on work for people with mental health problems, challenging the notion that people cannot work until or unless they become symptom free (Grove, Secker, & Seebohm, 2005). Work for people with mental health problems has become linked with the concept of recovery (Dunn, Wewiorski, & Rogers, 2008, 2010; Provencher, Gregg, Mead, & Mueser, 2002; Strong, 1998; Woodside, Schell, & Allison-Hedges, 2006), where recovery is understood as having a meaningful and fulfilling life, despite the continuation of experiences associated with illness (Anthony, 1993). An exclusive focus on return to work as a successful outcome could risk overshadowing other important aspects of occupational participation (Holmes, 2007). Rather, as Sutton, Hocking, & Smythe (2012) identified, all forms of occupational engagement, including disengagement, can be meaningful in recovery from mental illness.

Many authors have shown that recovery is primarily a social process that takes place among the everyday occupations in a person's life (Borg & Kristiansen, 2008). Work is one such occupation, offering opportunities for social engagement, the development of new skills, and opportunities to feel valued (Davidson, Borg, Marin, Topor, Mezzina, & Sells, 2005). Additional ‘latent’ aspects of work include having a daily structure, a sense of purpose and agency, and being part of a collective (Jahoda, 1981). Beyond being a means to earn money, work can contribute to self esteem through holding a socially valued role, provide a way to establish a personal identity, offer opportunities to feel a sense of achievement, and facilitate social inclusion (Boyce et al., 2008; Gahnström-Strandqvist, Liukko, & Tham, 2003; Gewurtz & Kirsh, 2007; Koletsi et al., 2009).

Understandings of work are also informed by occupational science. For example Larson and Zemke (2003), Hocking (2009) and Russell (2008) have advocated greater appreciation of the form, function and meaning of occupations. Sutton, Hocking and Smythe (2012) pointed to the need for consideration of each person's experience, in the interpretation of their occupational engagement. Understandings grounded in the dimensions of meaning that occupations hold have also been called for, rather than categorizing occupations under the broad headings of self care, productivity and leisure (Whalley Hammell, 2004). Exploring work from an occupational perspective may add nuance to broad categorizations of occupational engagement. For example Reed, Hocking, and Smythe (2010) stated that the meaning of occupation shows itself in the way that occupation connects the past with the present and with the future (p. 145). Thus occupation can be seen as a thread, running through a lifetime, which suggests that there is temporality to the meaning of occupation that may be important to understand. Thinking about the meaning of work for an individual, this temporal aspect may be important to consider in terms of how people develop a career over a lifetime, or have gaps in their work histories due to illness or other reasons (Dunn et al., 2008, 2010).

Developing a positive personal and social identity through feeling accepted and approved of is a universal concern (Christiansen, 1999, 2004). Christiansen (2004) suggested that people become who they are through what they do, and thus introduced the concept of occupational identity. Engagement in employment may have important implications for the construction of an occupational identity. Conversely, lack of employment may influence the sense of self in negative ways, leading to loss of confidence, self esteem and self efficacy (Dunn et al., 2010; Seebohm & Scott, 2004).

Though engagement in occupations in general and work in particular has been a focus of inquiry in recent years, it has been noted that mental health service users' voices are largely absent from the literature on mental health and employment (Honey, 2004; Van Niekerk, 2009). However subsequent literature explored the views and perspectives on work of people who used mental health services (Blank, Harries, & Reynolds, 2011), indicating that work holds multiple meanings, that there are advantages and disadvantages to working, and that many barriers to working with a mental health problem still exist. To extend those findings a detailed exploration of work from the perspectives of people living with mental health problems and taking an occupational perspective may offer a more nuanced appreciation of the meanings attached to work. Therefore we formulated the following research question: “What is the meaning of work for people living with severe and enduring mental health problems?” The study was approved both by the University Research Ethics Committee, and by the local National Health Service research ethics committee (LREC).

Method

Both the aspiration to give a voice to a marginalised group of people and the desire to access rich, lived description through repeated interviews over time influenced the selection of a phenomenological research approach. Phenomenological methods are appropriate for exploring lived experience and turn on an understanding of people's perceptions of the world in which they live and the meaning that this holds for them (Langdridge, 2007). This study employed interpretative phenomenological analysis (Smith, Flowers, & Larkin, 2009), which Larkin, Eatough, and Osborne (2011) described as relying on an understanding of people as active beings (Anderson, 2003). This perspective fits well with viewing people as occupational beings and occupation as the natural mechanism for health and well-being (Christiansen & Townsend, 2010; Hasselkus, 2002; Yerxa, 1998).

Interpretative phenomenological analysis employs a hermeneutic (interpretative) approach to phenomenology and aims to explore individuals' experience by accessing their inner worlds as closely as possible. The use of a double hermeneutic (Smith & Osborne, 2008) acknowledges the role of the researcher making sense of the participants' own sense making. The analysis aims to provide insights which can then be explored in relation to the extant literature. These may in turn provide starting points in the development of a more complete account of the phenomenon.

Participants

The participants had been living with mental health problems, including psychosis, for between 1 and 14 years and attended a community mental health day centre between one and three times a week. The first author presented the study in the centre's regular community meeting and provided information packs containing the participant information sheets and consent forms. Participants volunteered, via staff in the centre, to be interviewed up to three times over a period of 18 months.

Table 1 gives relevant demographic details about the employment and service use histories of the 10 participants. Pseudonyms have been used throughout to preserve the participants' anonymity. One participant was previously known to the first author.

Table 1:

Study Participants

Name	Age	Previous Employment	Employment Status at First Interview	Time Out of Work at First Interview (years)	Future Work Plans at Time of First Interview	Number of Interviews
Chris	52	Office clerk	Voluntary work 2x ½ days per week	14	No plans to return to paid work	3
Ian	50	Teacher	Planning to start up own business	1	Continue to expand own business	3
John	50	Domestic	Occasional user consultation work	10	Would like to enter paid employment	3
Stella	35	Sales assistant	Not working	1	Would like to go to drama school	3
Anne	48	Care worker	Voluntary work ½ day per week	10+	Would like to train as a nurse	2
Harry	47	Horticulturalist	Not working	10+	Would like to return to previous type of work	2
Mark	35	Plant nursery worker	Not working	10+	Would like to go to art college	2
Matt	57	Carpenter and joiner	Working 1 day per week	N/A	No plans to increase paid work	2
Charlotte	42	Office worker	Occasional user involvement work	10+	Would like to work part time	1
James	60	Retired chef	Voluntary work 1 day per week	Retired	No plans to return to work	1

Data collection

Informed signed consent was obtained from each participant prior to commencing the first interview and checked verbally at the start of subsequent interviews. Individual, in depth interviews were conducted by the first author in a private space at the centre. Of the 10 participants, eight agreed to have a second interview 6 months later and four of them agreed to be interviewed for a third time. In all, 22 interviews were carried out. Table 1 shows how many interviews each participant gave.

In the first interview participants were encouraged to talk about their previous experiences of work, to describe any help they had received in preparing them to return to work and what working meant to them. Follow up or prompt questions were only asked to clarify points and to encourage the participants to speak at length and in detail about the meaning and experience of work. The second interview began by asking ‘How have things been in your world with regards work since we last met?’ This was followed by personalised prompt questions designed to probe more deeply into the participants' experiences since the previous meeting. The third interview followed up on themes identified in preliminary data analysis. These were shared with the participants during the interviews, offering them the opportunity to comment on and add to the analysis. The interviews, which lasted for between 30 and 90 minutes, were audio recorded and transcribed verbatim.

Focus of analysis

The type of analysis used in interpretative phenomenological analysis is sometimes known as layered analysis. Dean, Smith and Payne (2006) likened this approach to peeling away the layers of an onion. An iterative approach is taken, with each case explored separately in an idiographic manner before moving to look for themes shared across the cases. Analysis involved becoming immersed in each interview, listening to the recording, reading and re-reading the transcript, looking for contradictions, echoes and amplifications, similarities and differences, use of language, and pieces of text which gave a sense of the person (Smith & Osborne, 2008). All text was treated as data. The first author carried out the analysis, some of it in discussion with the second and third authors.

In the next stage, themes were clustered together. For example, all the initial themes from the interview with one participant that pertained to her desire to work and the positive feelings it gave her were clustered under a theme labeled The worker/wanted self. The initial themes that connected with her mental health problems and feeling badly about herself were clustered together and called The person with a mental health problem/unwanted self. The themes derived from these interviews were all clustered under the overarching theme Building & maintaining an occupational identity because they seemed to relate to how she saw herself.

Throughout the process of analysis an attempt to adopt and maintain a phenomenological attitude, as recommended by Giorgi and Giorgi (2003), was pursued. The first author's disciplinary background is occupational therapy and this was to the forefront in remaining sensitive to the phenomena being explored. Just as the participants are inextricably linked with the world, so too, are the researchers. Accordingly, a reflexive self awareness is needed on the part of the researcher (Finlay & Gough, 2003) and a reflexive diary was employed to facilitate this.

Findings

Data analysis revealed two overarching themes: Building & maintaining an occupational identity, and Work and other ways of belonging. The themes are supported by excerpts from the interview transcripts.

Building & maintaining an occupational identity

Participants presented accounts which concerned both past identities as workers and future, hoped-for identities, both as workers and in other spheres of their lives. Some of them described ways in which they had developed new means to express themselves through engagement in non-work occupations; others presented accounts that were concerned with finding or constructing new identities alongside illness. Central to the concept of occupation conferring identity was an existential concern connected with occupational engagement.Chris used the word “occupation” in this context to mean a paid job. However a reading of Chris's statement from an occupational standpoint implies that without occupation a person is a non entity. This interpretation of the importance he attached to occupation as a way of conferring existence powerfully illustrates the centrality of occupations in the lives of the participants and the critical need to engage in occupations in order feel alive and recognized as a fellow citizen. Support for this interpretation is found in another of the interviews with Chris.As none of the participants were in paid work at the time of the study and did not have access to the ‘shorthand’ identity of their job title (“I'm an occupational therapist”), many seemed to find meaning in non work occupations. Those occupations that had been part of their lives for many years seemed to have particular potency for conferring a sense of identity, as well as a way of making sense of illness. One participant, Matt, who had been a carpenter and joiner in his working life and who had been a wood carver in his leisure time for many years, considered himself to be an artist. This way of understanding himself and mental illness (he referred to famous artists, such as Van Gogh, who had mental health problems) offered a means to make sense of his experiences from his perspective, at the same time confirming his identity as artist.For many of the participants, stopping work and their first episode of mental illness coincided. They offered vivid accounts of the sometimes shattering impact of their experiences on their lives and their sense of self.In this extract, taken from his third interview, Chris commented on some initial data analysis which introduced the concept of occupational identity.Some participants reflected on the impact on their identity of using mental health services, or as a ‘psychiatric patient’. Two participants in particular offered accounts that were suggestive of a need to integrate the mental health user self, or to construct a new identity to replace a previous problematic identity. The participant who had previously been a teacher wished to recast himself as a self employed gardener and saw both the clothing and tools that went with this new identity as significant in building a new self.The tools of his newly adopted trade were the visible signs of his new identity. They could also represent a physically strong identity that perhaps he felt he needed to reassert following a period of being very vulnerable as a result of his mental health problems.

Unless you have some kind of occupation you don't really exist at all, do you, in society or as an individual? You're just nobody in a sense, aren't you? (Chris)

I mean a lot of people who are signed off [work] just do nothing at all. I don't quite understand how they justify their existence to themselves … I mean who are they in a sense … who are you is a lot to do with what you do isn't it?

I think there's quite a lot of artists have these sort of problems [mental health problems]. As I said, the man I worked for… he had a breakdown in his 60s.

I think I was just destroyed… everything was in bits really, and I've sort of rebuilt myself up. (Ian)

I don't think that occupational identity is whole identity you see. I mean in a sense … because if the work you've done in your life … you don't know [name of another person at the day centre]… but he used to work in a garage fitting exhausts to cars. Now occupational identity … I mean it's a job isn't it, and it's useful, but you might not feel too great about yourself if you thought that that was all there was to you.

I want as much as anything to have a van, have all the petrol gadgets, tools. You know this is completely different to being a teacher. (Ian)

Another participant spoke of using his experience as a mental health service user to deliver training to staff in hospitals and students on health education programmes. His account suggested that he saw this integration of his experience as a means to getting back into the workplace and earning the respect and validation that went with working.Another approach to managing the user identity was offered by a participant who had been an office clerk and who seemed to still strongly identify with his old role, even though he had been very unhappy in his working life.Chris’ rejection of an identity as a psychiatric patient is powerfully illustrated by his repeated statement of the case. Occupations that were not paid work also seemed important for providing a consistent sense of self identity.This theme highlights the importance participants attached to having something meaningful to do. The ways in which they used engagement in various occupations as a means to construct a sense of self in the absence of paid work is also expressed. Additionally, the theme conveys something of the ways in which the participants sought to manage their experiences of using mental health services, and to show that they were not defined by illness. Further, the theme captures the ways in which the participants were able to manage their identities and self presentation to others, by rejecting the patient role or by using their mental health experiences in positive ways. This was especially critical in confirming their existence to themselves and to other people.

All my working career, when I was paid, have been jobs that haven't required much input mentally – driving and cleaning and working in factories. They've been, for want of a better phrase, ‘donkey work’. The only jobs or things that I've done that have stimulated my head have been … voluntary work or presentations and such like – working with the user group [a local group of mental health service users which provided training and research] and such like. Because those things have drawn from my experience, my life, I feel I've got some expertise to offer back to them. I'm respected as an expert. (John)

I may not be working, but I'm still an office clerk… I don't think of myself really as a career psychiatric patient or as ‘being’ inverted commas a ‘psychiatric patient’, it's just … yeah I'm a retired clerk I suppose is what I am. I mean, obviously in a sense yes I'm a psychiatric patient because I see the psychiatrist, but I'm not sort of intrinsically a psychiatric patient or 100% a psychiatric patient ‘cos I'm capable of doing a lot of other things. (Chris)

I mean I get a lot of fun out of doing these things [his non-work occupations]. And on the one hand you get the same satisfaction as you do out of work, about doing a job well, but with less of the stress and aggravation that you have in work. (Chris)

Work and other ways of belonging

Besides a strong emphasis on ‘doing’ (Wilcock, 1998), the participants' accounts held very strong representations of the desire to feel connected to other people, with work being perceived as a potent way to feel part of society. Even though many of the participants had recounted very painful and traumatic work experiences, where at times they had felt isolated and unhappy, they still seemed to view work as a route to feeling included in the world. Some of the participants saw work as a way of providing a social network, which enabled a sense of belonging (Rebeiro, 2001; Wilcock, 1998), of feeling connected to others, being included and being ‘normal’.This extract illustrates the way in which some of the participants equated working with fitting in, which suggested there might be a converse position of experiencing painful feelings of not belonging if not working.Stella and John emphasized the excluded, left behind feelings that arose as a result of not being in paid work. Further interpretation of John's statement, likening working with going to war, is suggestive of how difficult and dangerous work could be but that it was, nevertheless, something he did not want to be left out of. The converse position, of being employed and hence connected, produced largely positive responses from the majority of the participants and was described with feeling.Participants also found engagement in non-work occupations important in instilling a sense of belonging. These included a keep fit class, being part of a family, doing voluntary work, and attending the mental health day centre. John described belonging at work as being like belonging to a large family.Here John used a work-related example, a work-place union, to illustrate his feelings about belonging through work. Some of the participants, however, spoke about ways of belonging that felt unwelcome – a teachers’ clique and an intrusive employer being two such examples.Ian's account suggested that he felt quite suffocated by the intensity of relationships within teaching, both at work and socially. He no longer wished to belong to that world, but to rebuild a life for himself as a self employed gardener with the freedom to work alone. Chris also found the lack of boundaries between work and his private life problematic and had no wish to return to his former worker role, even though he strongly identified as “a retired office clerk”.The participants described ways of belonging that they valued and that made them feel good about themselves, which were accessed through their different roles and occupations. All of them expressed the value of support from mental health services in the early days of being mentally unwell but shared a desire to move away from an intense focus on the role of mental health services in their lives as they progressed on their individual recovery paths. Ways of belonging that made the participants feel validated and valued, and which helped them to feel that they could manage their lives were identified as being of vital importance. Ways of belonging through work that were overly intrusive and unhelpful were also identified. As participants wished to move away from mental health services, it is possible to speculate how belonging in the day centre had been an unhelpful form of belonging. Painful feelings of not belonging, and of feeling excluded from work, family, friends and wider society, may be especially problematic for people who are living with mental health problems and the concomitant stigma.

There are some days when I think ‘Oh, can I get a job and be like everybody else and go to college and study, or something like that?’ (Anne)

You sort of feel in your head that you're a bit weird or a bit different and [you] don't want to feel like you don't fit in or you're weird or something. (Stella)

I just feel that I'm not part of the… part of the herd, you know. It's a bit like everybody else going off to war and I'm the one that's not going. (John)

Work's not just about money, it's… about relationships, it's about place in the community, it's about well-being, and it's about a feeling of satisfaction, a feeling that you've done this. (John)

I think we need to feel part of a community, part of a family… we used to have it years ago when unions… the best bit about unions was that you were part of something bigger than yourself and… you know they used to have colliery football teams and rugby teams and things.… The good side, not the militant side, of a union is a feeling of [being] part of something bigger than yourself, that cares for you and you care for it.

Teaching is a different world. They all relate to each other… I mean I can see it now – teachers talk to teachers, they go out with teachers, they all hang around with teachers. It's just… I mean many professions are like that, but I think teaching is particularly strong in that way. (Ian)

But… the idea of sort of being invaded by the employer and having them sort of supervising your life and the sort of thing is not something I find very attractive at all – and this has happened to me in the past and I don't want it in the future. I like to go in and do my work and go home and that be the end of it. (Chris)

Discussion

This study took an occupational perspective of work for people living with severe and enduring mental health problems. Encouraged by the perspectives promoted by occupational scientists (Hocking, 2009; Reed et al., 2010; Whalley Hammell, 2004), we sought to illuminate some of the complex meanings of work for the participants. The interviews elicited detailed accounts of the participants' engagement in a wide variety of occupations, including work. The interpretative analysis generated nuanced understanding of work and other occupations for people living with severe and enduring mental health problems. It highlighted some of the ambiguity and ambivalence about work from the perspectives of the participants, as well as emphasized the value of their non-work occupations.

For all 10 of the participants, paid employment had been a past occupation and the majority also envisaged paid employment as part of their future lives. Through their exploration of Wilcock's (1998) constructs of doing and becoming, Gewurtz and Kirsh (2007) described how people could understand their potential to become workers. However, a number of the participants in the current study recalled extremely negative experiences of work, often connecting the onset of their mental health problems to their work. Nevertheless, work remained a priority for many of them. At a macro level, it is possible that this reflects the high social value attached to work in the Western world; however the nuanced understandings made possible by the approach taken to the research revealed some ambivalent, complex and ambiguous responses to questions about work. As the participants were not currently in paid employment, their accounts privileged their non-work occupations. Interpretative analytic activity suggests that engagement in these occupations held meaning for the participants in terms of identity formation and facilitating a sense of belonging.

The value of engaging in occupations that fostered the sense of belonging described by the participants supports previous findings about the latent aspects of work (Jahoda, 1981). These include being part of a collective pursuit, and the conferment of status and identity. Blank et al. (2011), in their review of the literature addressing the views and perspectives on work of mental health service users, highlighted the multiple meanings of work, including the social networking opportunities that going to work provided and the feelings of validation that having a job conferred. In the absence of paid work as an option, either because of local economic conditions, or because the individual does not wish to access work, attention to other occupations that fulfill basic needs of belonging and a sense of self is important. This supports the findings of Sutton et al. (2012), who found that at times even non-engagement in occupation was important for people in recovery from mental illness.

The ways in which the participants spoke about themselves suggested that their occupations conferred a sense of identity (Christiansen, 1999). They described ways in which they were using occupations to effect identity change. There was some support among the group of participants for distancing the self from an unwanted or ‘spoiled identity’ (Goffman, 1963), or ‘threatened identity’ (Breakwell, 1986); of the need to create a brand new identity; of reconnecting with a previous and wanted identity, and of integrating elements of identity to form a coherent whole. Thus, while working could be a means to achieving a positive self identity, some participants identified other valued roles which appeared to be of equal importance in providing opportunities for social connection and to establishing a sense of self. For example, some of the participants described parenting and other family roles, some were actively involved with their local community, while others held key volunteer roles within the day centre itself. The findings support Slade's (2009) emphasis on establishing a positive identity as one of the tasks of recovery. We would advocate a primary focus on helping people to craft an occupational identity as a means to achieve this.

A sense of belonging has been considered a basic human need, and has been a concept of interest to occupational scientists for some years (Wilcock, 2006). Belonging is a complex topic which some argue has featured surprisingly little in mental health research (Stickley & Hui, 2012). One recent study of previously homeless people with mental health problems identified three modes of belonging (Fields, 2011). These are non-normative belonging, belonging from afar, and non-belonging. Fields (2011) proposed that there is an idealized understanding of belonging that might be longed for but rarely experienced by people who, because of their health needs, are often on the fringes of society. The participants in the present study, though they were not working and had previously negative experiences of working, gave accounts which suggested they felt that working would be a way to achieve a feeling of social connectedness and belonging. However their attachment to their non-work occupations and the ways in which they used these to feel good about themselves might suggest that they held some doubts about what work would really offer them. Marwaha and Johnson (2005) have argued that an expressed desire to work may reflect the social value that is attached to work in Western societies and that further enquiry can reveal ambivalence.

Implications for Occupational Science

The current rhetoric around work and employment for all, with the attendant welfare benefits reforms in the United Kingdom and elsewhere, is in danger of obscuring attention to the need for people to be able to participate in a range of occupations in order to influence their health and well-being. Small qualitative studies, informed by a phenomenological methodology are highly relevant to the current emphasis in the occupational science literature on describing occupations (Hocking, 2009), and the call to attend to the personal meanings of occupations for individuals (Reed et al., 2010; Sutton et al., 2012; Vaught & Wittman, 2011; Whalley Hammell, 2004) as way of contributing to knowledge. Interpretative phenomenological analysis, with its use of the double hermeneutic and consequent attention to the role of the researcher in the process, and its acknowledgment of people as active beings, seems of particular value in this endeavour.

Methodological considerations

There are some limitations to the design of the study. It may have been the case that participants who were not able to sustain a commitment to either work or the study, due to the nature of their mental health problems, felt that they needed to withdraw. Since this study has presented findings from a small sample, a cautious approach is required in applying the findings to other situations. However the longitudinal study design, the phenomenological approach and the interview style used were sufficiently open to enable the participants to share what was relevant to them around the topic of working and having a mental health problem.

Conclusion

This is the first study to use interpretative phenomenological analysis in a longitudinal exploration of the meaning and experience of work in the context of severe and enduring mental health problems. That approach to the study enabled some previous broad understandings of work for people with mental health problems to be further illuminated by engaging with them from an occupational perspective. Exploring occupations from a perspective of meaning to individuals has helped to illuminate some previously hidden facets of work and other occupational engagement for people living with severe and enduring mental health problems. A phenomenological method has allowed the importance of non-work occupations as a means to create and maintain personal and social identity, and to enable the participants to be socially included, to become apparent in the absence of employment. The findings also suggest that some of what Jahoda (1981) has referred to as the latent functions of work, such as giving structure to the day, being part of a collective pursuit, the conferment of status and identity, could be met through non-work occupations. The findings further reveal the value of exploring past identities and wanted future identities, and providing opportunities for engagement in occupations that facilitate the construction of identity and a sense of belonging as part of the recovery journey, contributing to a sense of self and of belonging.

What has emerged from this study is an added appreciation of the centrality of occupations and social relationships in people's lives, and the importance of these in facilitating a sense of self and of being included in the world. How each of these elements contributes to a sense of self and to health and well-being has been underlined by an exploration of the participants' life-worlds through a phenomenological approach. Although the study had a focus on work, it became clear that there were more fundamental issues of identity and belonging at stake for the participants.