The meaning of work in people with severe mental illness (SMI) in Iran.

BACKGROUND: Work is the key component for most people in regard to financial, social and wellbeing matters. Employment is an important factor underpinning mental health disorders. However, unemployment remains an unsolved issue worldwide. Numerous studies have focused on employment outcomes in people with severe mental illness (SMI) but, only a few have explored their perspective on employment. Therefore, this study aimed to clarify the meaning of work among clients with SMI in Iran.
METHODS: A qualitative research approach was used to conduct this research. Ten participants who were consumers of mental health services took part in this study. Data were analyzed by inductive content analysis approach.
RESULTS: Four themes emerged from data including: acquiring identity, work as a drive, passing the time and financial independence.
CONCLUSION: Meaning of work in studied people with SMI was probably similar to the general population. The different finding in this study refers to the dominancy of family relationships and spiritual believes which could cover some problems and in turn affect the meaning of work. Highlighting these meanings could direct mental health professionals to better planning for their clients have better understanding of their clients' work future and in turn provide more precise plan for them.

Introduction

Work is one of the dominant features of life (1) and sometimes it is considered more important than leisure, social and spiritual activities (2). Work and employment can provide people with financial independence, physical and mental health and a source for social relationship (3). People mostly have a fixed attitude toward work. They believe that their social respect and security can be designed by jobs (4).

The value of work for people with severe mental illness (SMI) is considered important as it is for general population (5). Up to the International Labor Organization, access to paid employment cannot be paused by mental health problems and work is a right for people with SMI (6). Although more than 50% of people with severe mental illness want to work (7,8), the major problem with this population is the high rate of unemployment which is estimated to be between 60% and 90% in previous studies (9-12). Such a situation may lead to problems like hospitalization(13), lower self- esteem (14,15), poverty and social exclusion(16).

Although numerous studies have focused on employment outcomes in SMI {for example, Wong, 2008; Macias, 2006; Gold, 2006; Bond, 2001 (15,17-19) }, only a few have explored the perspectives of clients with SMI on employment. Findings derived from qualitative research indicate that participants view work as their personal and social identity, structuring the days, a way of earning money (20,21), recovery promotion (22,23) and acquiring a new self-concept beyond the disability (24). Despite these studies, more should be learned about the meaning of work among people with SMI, as it is absolutely upon individuals’ perception (25). Although it appears that work simply meets many requirements of life, it contains deeper and more subjective meanings (26). In general, meaning of work encompasses six dimensions including work centrality, economic orientation, interpersonal relations, intrinsic orientation, entitlement norms and obligation norms (2). Nonetheless, what is the meaning of work in people with SMI? The answer could be a key for rehabilitation professionals. As Saunders has pointed out, better understanding of the meaning of work could encourage disabled people to return to work in spite of their illness (25). Moreover, because the meaning of work depends on the culture, it is necessary to explore its meaning in different contexts (27). Therefore, this study sought to address the following question: What is the meaning of work among clients with SMI in Iranian context?

Methods

Study design

This study was a part of a broader study exploring the process of job acquisition in clients with SMI in Iran. In the present study, a qualitative approach using latent content analysis was considered (28).

Participants and recruitment

By purposeful sampling, ten participants who were receiving outpatient mental health services were recruited for this study. Study participants included 8 men and 2 women aged between 24 and 50 years with paid- work experience for at least six months. Diagnoses were schizophrenia (N=6) and bipolar disorder (N=4). Inclusion criteria were willingness and readiness to participate in the study as well as ability to communicate with the interviewer, being at the chronic phase of illness, aged more than 18 and having job experience for at least six months.

The characteristics of participants are shown in Table 1.

Table 1

Demographic characteristics of participants

Participant's number	Gender	Diagnosis	Age	Education	Marital status
1	male	schizophrenia	30	bachelor	single
2	male	schizophrenia	50	Associated degree	single
3	male	schizophrenia	50	master	married
4	male	bipolar	32	diploma	married
5	male	bipolar	33	diploma	single
6	female	bipolar	24	Associated degree	single
7	female	schizophrenia	40	bachelor	married
8	male	bipolar	37	illiterate	married
9	male	schizophrenia	54	diploma	married
10	male	schizophrenia	40	diploma	single

Data collection

A semi-structured tape-recorded interview was performed and participants were asked open-ended general questions about their vocational goals and experiences (e.g. “How is your feeling about having a job?” “Why are you looking for a job?”) and followed by probing questions. Interviews lasted between 13 and 60 minutes since some participants could not stand long interview. Time and place of interviews were determined by agreement of parties. Three participants interviewed twice because they felt exhausted during the interview.

Data analysis

Each interview was transcribed and analyzed using qualitative latent content analysis. The transcriptions were read and reread line by line several times to obtain a sense of the whole. Then meaning units were selected from the text, condensed, abstracted and labeled with a code. The codes were compared regarding differences and similarities and grouped together into categories and subcategories (28). Finally four themes were formulated. During this procedure, all the research team members were involved at different stages of data analyzing such as immersing in data, coding and categorizing by going back and forth between the meaning units, categories and themes.

Trustworthiness

Credibility of data was provided through maximum variation in sampling (choosing different participants according to sex, age, education, social class, marital status, amount of family support and psychiatric diagnosis). For peer checking, research team members independently checked transcripts, codes, subcategories and categories and reached an acceptable agreement on them. Prolonged engagement with participants and data helped researcher to achieve a better communication with participants and have a deep understanding of context.

Ethical considerations

Befo re every interview, written informed consent was obtained from clients or their legal supervisor. Moreover, participants could leave the study at any time and could contact the interviewer at any time if they had any questions about the study.

Results

The findings describes perceived meaning of work within four main themes including: acquiring identity, work as a drive, time passing and financial independency. Results are presented in Table 2. Participants’ quotes are presented along with the description of the categories.

Table 2

Identified themes (meaning of work)

Theme/category	Subcategory	Code
Acquiring identity	Developing personal identity	*Having a right for self*Being like others*being effective
	Developing social identity	*Developing social interactions*Having a social class
Work as a drive	overcoming symptoms of disease	*Challenging stresses*Clearing out the rubbishes from mind*Encountering the inner puzzle*Self-rating
	Expanding abilities	*Acquiring new skills*Expending pervious experiences*Compensating lost times
Time passing	Escaping from boring routines	*Getting bored with unemployment*Keep away from monotonous life
	Having fun times	*Interaction with coworkers*Having fun & entertainment
Financial independency	Affording personal affairs	*Affording pocket money*Not asking money from family*Being not in debt
	Affording family affairs	*Affording family expenses*Helping out the spouse to manage family

Acquiring identity

Participants had a sense of identity when they were engaged in their job. This theme includes two subcategories; developing personal and social identity.

Developing personal identity

Exploring to this concept showed that participants as like as other people wanted to have a psychosocial identity acquired by working. They appreciated feeling of “being like others” and “being helpful”. They wished to have a situation in the community, have a right for themselves and being effective on others life.

“But as I was beside them (at work) it gave me the feeling that I am positive” (P2/ first interview).

Developing social identity

Participants mentioned meaning of work as a way toward taking social dignity or developing their social network. They reported satisfaction of “being approved” and having a “high social level”. However, these perceptions may change over time. One of the participants said:

As long as I was young, social identity was important to me, then salary (became important). Then I got the point that identity isn’t important. But before 34, 35 or 6 I kept telling myself, I’d find a job to have an identity, a social role for myself. Then at 38-9 I said to myself “No”! The salary would be enough (P3/ second interview).

Work as a drive

Participants described work as a motive to meet new circumstances and therefore to achieve more competency. This theme included two subcategories; overcoming symptoms of disease and expanding abilities

Overcoming symptoms of disease

Participants believed that work was effective for management of their mental symptoms.

Since I had severe stress I couldn’t sit down (at work) and always wanted to leave the damn chair. It (work) was a challenge for me. I tried to win by working and I did. And I defeated my stress.

This man who was a painter in another situation said:

Whenever I am painting I think that I am sweeping the rubbishes out of my mind (P1/first interview).

One participant defined work as a trial by which he could examine how the illness and its symptoms had affected his abilities. It seems that such investigation could offer more realistic picture of one’s residual skills:

Well I thought I work and learn. When I got the skill I go somewhere better and say that I know how to do that job, I’m experienced, I work for you. How much do you pay? Then we chat …. I wanted to see how much I could tolerate. I wanted to see how much powerful I am (P10).

Expanding abilities

Participants pointed novel experiences. They believed that the workplace is the best way for obtaining new skills. Moreover they wished to compensate their lost days and exploit their hidden potentials:

I thought it’s (work) a place I can get in and find new things. The things you see at work are not found at home. Although you sit on the sofa and watch programs at home and they bring you tea and respect you a lot but being at work is different (P4).

Time passing

This theme includes two subcategories; Escaping from boring routines and having fun times

Escaping from boring routines

Being inactive made participant feel bored, thus they tried to find a way to manage their time better. They preferred to fill their time by paid employment rather other activities. One of them said:

I didn’t have a job. I was bored a lot. From the morning when I got up (it wasn’t morning, 11 – 12 am) to 11 pm I really was tortured. I didn’t enjoy my life. I didn’t speak to anyone. I didn’t work out. This kind of style was bad for my illness…not having a job was getting on my nerve. When you don’t have a thing to do, your mind is obsessed with what to do. Your mind goes this way or that way. It cannot decide (P9).

Having fun times

Apart from being busy, some viewed work as entertaining activity which brought happiness and joy. As a participant (5) said:

My boss took me to box making room. As we were 2 people in cake baking factory. In box making room we were 4 or 5 that could chat and were busy. I think it was better being there because there were some other guys. We chatted and laughed and passed time.

Financial independency

The most perceived meaning referred to income issues. All participants received work as a mean to earn money. What was different between them back to their personal purpose of having money. This theme includes two subcategories; affording personal affairs and affording family affairs.

Affording personal affairs

Some participants wanted to earn money mainly for their personal requirements. They were single individuals who lived with their parents and were funded by them but they were eager to share a little of their financing. For example one person who was a single girl said:

I have to work to the extent that I could afford the cost of commuting and cloths. It should be to the extent that I could bear a bit of the burden of family. Because during my illness I caused a lot of expenses on my family for my curing cost, I feel weighed down. I like to compensate a part of it (P7).

Compensating the favors of family was not the only case. Some participants wanted to have their own packet:

I wanted to earn money……no. I wasn’t in need. I wanted to save money. Just that…… to save in my account .I didn’t teach during the year to earn money, so I should earn my pocket money (P6).

Affording family affairs

In contrast to pervious subcategory, some strongly needed money to struggle with poverty. They were married people who had to provide their families income.

For example they once said go and rub the floor. Or clean the toilets. I did all these things and they paid for them. Or they called and asked me” come and wash our rugs”. I went to their house and washed their rugs. I didn’t loose my dignity. I wanted earn some money for my children (P8).

Discussion

As the results of the study imply, the meaning of work in people with severe mental illness in Iranian context encompasses two main aspects: financial and nonfinancial domains. It is in agreement with the literature which reveals the work in general population has both obvious and hidden meanings (29). The obvious meaning refers to financial rewards of work while the latter indicates aspects like social contribution, mental well-being and self identity. Splitting these aspects looks nonsense since one’s non-work identity could affect his/her work (30).

A significant theme in this study was “Acquiring identity”. In the first subcategory of “developing personal identity”, participants stated that they did not like being humiliated and stigmatized sponging or indolence. They believed that through daily routines and work duties, they perceived a sense of being and accomplishment as they felt that they were much more than clients. The second subcategory, “developing social identity”, showed that work increased their sociality through daily contacts with coworkers and promoted the sense of belonging to a society.

These findings were consistent with some studies (11,24) and showed that being and becoming someone (23) or finding a place in this world (24) could be a pleasant destination for people with SMI. Moreover, it is a key for caregivers and emphasizes that engaging patients in work activities is much more important than stress on just earning money. Money seems to be in the second place. Iranian context can supply non-paid work activities for people with SMI rather easily because there are many religious ceremonies in Iran and participation in such duties is appreciated by the Iranian society.

Some participants expressed that they had a major contribution in the progress of their workplace. However, such a feeling strongly depends on the atmosphere of the work environment. It means that attitudes and approaches of employers and staff toward mental health problems have a direct effect on the sense of workers who have psychiatric difficulties. This notion is echoed by Wrzesniewski who stated that the meaning of work is reinforced by the feedbacks employees receive from others at work (31). In group work people have a feeling like a link in the chain or a cog in the wheel (27) .This notion is arisen from symbolic interaction and points that meaning is not fixed, rather a continuous phenomena that makes people act upon the communication they experience at work (31). Under the pressure of group, even people with unpleasant jobs prefer to maintain a positive approach toward their work (1). Therefore, in a workplace, it seems wisely to promote the staff’s viewpoints about mental health disabilities and work issues through regular psycho-education programs by any members of mental health team.

The second theme was “work as a drive”. As one of the subcategories indicated, participants perceived work as a motive to “overcome symptoms of disease”. Undoubtedly, as studies suggest, work helps people with SMI manage their emotional problems (32) or moderate some of their mental illness symptoms (33). Acquired abilities could in turn act as “internal strength” and promote the process of recovery (11). The novel issue in our findings is that our participants used work activities consciously and purposefully in order to handle their illness. They knew that which kinds of work duties could reduce or trigger their symptoms or how they can struggle with their delusional thoughts through specific work activities. Since all of the participants were longstanding consumers of mental health programs, it is likely that they adopted this property through yeas by attendance in mental health services. Further research seems necessary to explore this matter in the first episodes of psychosis in which patients are not familiar with mental health facilities.

Another subcategory is “expanding abilities”. Alongside with studies, work is a kind of motive that helps people with SMI develop their interests and skills which are necessary for the roles of worker (24). Work duties could trigger and expand one’s abilities and fulfill the mastery necessary for dealing with those duties (27).

Consistent with studies, work was perceived as a mean for “passing time”. Work could regulate the day (22,33) and provides balance between passive and active times (27). Our results also showed that participants had some personal (or non- work) activities in a workday (for instance, friendly communication with coworkers). Similar to D’Abate’s findings, it may be due to reducing boredom on the workplace and making balance between work and leisure time. Non- work domains are important because they contribute to the meaning of work and help people feel balance in their life (30).

The last theme was “financial independency”. Participants mostly regarded work as an economic pathway which is consistent with wide spread literatures on financial incentives and motivation to work. Researchers illuminate that money is a motivator toward work as it leads people feel self-sufficient (34), having more balance between their occupations (27), and improve their quality of life by obtaining their necessities (22). Not surprisingly, poverty is a unique entity that can restrict the meaning of work to monetary outcomes (1). However, there are some differences in Iranian context. By having strong family network patients receive overt and covert financial supports from their caregivers. Even in the poorest patients, philanthropists have a serious role in providing patient’s demands. Moreover the dominancy of spiritual and religious issues in Iranian context has led to a relative financial release for people with SMI.

Totally, the findings indicated that meaning of work in Iranian people with SMI is a bit different from general population that refers to the eastern culture and the dominancy of family relationships which could cover some problems. Apart from it, although people mostly believe that persons with mental health problems are not motivated to participate in work activities, it is meaningful for them (23,27) as meaningful occupation motivates the person’s participation in life (35). What makes it different is additional assistances they need. As Borg states, being an employee with occasional problems is different from being a psychiatric client who receive rehabilitation work training (23).

Conclusion

The results in the present study support some previous studies and show that the meaning of work in our participants with SMI is partly similar to the general population. Support from family and dominancy of spiritual believes can affect the meaning of work in Iran. Clarifying these meanings could convey vocational rehabilitation specialist to have better understanding of their clients’ future work, to shape family supports, to modify demands of the society and finally to provide more precise plan for these patients.

Limitations

There was limited access to females participants. However, it was resolved by searching several mental health centers. In Iranian context, psychiatric disabilities confine women more than men and access to open employment is more difficult for them.