The International Journal of Psychosocial Rehabilitation

The EMILIA project: The impact of a lifelong learning intervention
on the sense of coherence of mental health service users.



Christopher A. Griffiths BSc [Hons]

Researcher
Department of Mental Health, Middlesex University, London, UK
126 Broad Street, Coventry, CV6 5BG, UK.



Citation:
Griffiths, C.A. (2009). The EMILIA project: The impact of a lifelong learning intervention on the sense of coherence
 of mental health service users.
. International Journal of Psychosocial Rehabilitation. Vol 14(1).  35-49

Contact: Email: c.griffiths@mdx.ac.uk



Abstract
Objectives: The EMILIA project provides formal learning and employment opportunities to mental health service users. This study evaluates this intervention in terms of its effect on participants’ sense of coherence (SOC).
Method: This study employed a within subjects design with a measure of SOC and a qualitative assessment at follow-up. A combined analysis was employed to establish a deeper understanding of the quantitative results and to investigate factors, mechanisms and processes of the project associated with SOC and recovery.
Results: Among the 22 participants there was a significant increase in SOC. Qualitative analysis revealed factors, mechanisms and processes linking lifelong learning, recovery and SOC.
Conclusions: The findings suggest that projects that provide lifelong learning and employment opportunities can increase participants’ ability to cope, adapt and recovery. The study adds to evidence for funded provision of formal learning and employment opportunities for mental health service users
Conflicts of interest: None.

Key words: sense of coherence, recovery, lifelong learning, social inclusion, empowerment.


Introduction
Context
EMILIA (Empowerment of Mental Illness: Lifelong learning, Integration and Action) is a Framework 6 European Union project, funded at €3.4 million over a four and a half year period. The main aim of the EMILIA project is to facilitate social inclusion and empowerment of its mental health service user (MHSU) participants through specifically designed lifelong learning and employment opportunities.

Sense of Coherence
Aaron Antonovsky’s (1923-1994) work formed part of the movement in medicine towards studying the origins of health. His sense of coherence (SOC) theory relates to the adaptive capacity of humans. Antonovsky defined SOC as “a global orientation that expresses the extent to which one has a (A) pervasive, enduring, though dynamic feeling of confidence that stimuli deriving from one’s internal and external environments in the course of living are structured, predictable, and explicable; (B) the resources are available to one to offset the demands posed by these stimuli; and (C) these demands are challenges worthy of investment and engagement” (Antonovsky, 1987, p. 19). He labelled these components A) coherence, B) manageability, and C) meaningfulness. The development of the meaningfulness component was greatly influenced by the work of Frankl (1978; 1992). SOC can be regarded as a crucial element in the structure of an individual’s personality that facilitates the coping and adaption process (Antonovsky, 1979; 1987).

Those who are experiencing mental disorder face constant challenges and setbacks, both small and large, and the success of their recovery, at a biological, psychological and social level, is determined by their ability to cope with, overcome and recover from these challenges and setbacks. This ability depends on, according to Antonovsky’s theory, the strength of an individual’s SOC which is determined by an individual’s general resistance resources (GRRs) and their effective deployment. GRRs can be physical (e.g., a strong physic, strong immune system, genetic strengths), artefactual (e.g. money, food, power), cognitive (e.g., intelligence, education, adaptive strategies for coping), emotional (e.g., emotional intelligence), social (e.g., support from friends and/or family), or macrosocial (e.g., culture and shared belief systems). There has been extensive research in to the SOC concept (e.g.  Bengtsson-Tops & Hansson, 2001; Carstens & Spangenberg, 1997; Cederblad & Hansson, 1996; Eklund, Hansson, & Bengtsson-Tops, 2004; Johnson, 2004; Volanen, Lahelma, Silventoinen, & Suominen, 2004; Volanen et al. 2006; Wolff & Ratner, 1999). Feigin & Sapir’s (2005, p. 63) literature review found that “the concept of SOC has a broad theoretical base and a growing and impressive body of empirical evidence supporting its utility”.

EMILIA, recovery and sense of coherence
Lifelong learning and mental health recovery can be viewed as inseparable interrelated processes (Griffiths & Ryan, 2008). This is because mental disorder brings change to an individual’s life and new learning is required to enable that individual to cope and adapt in the recovery process. Lifelong learning and recovery can be involved in a cycles of development and progression (Feinstein & Hammond, 2004). Learning can aid recovery, and the process of recovery can lead to new learning.
   
The interconnections between these two concepts contribute to the research prediction that exposure to the EMLIA lifelong learning project would increase the ability to cope, adapt and recover (capsulated here as SOC). Eriksson & Lindström (2007) stated that the SOC concept can be applied to the process of learning – that the learning process is facilitated when it is structured, comprehensible and meaningful:  “The salutogenic framework facilitates the learning process and simultaneously promotes health” (p. 941). The qualitative analysis aspect of this article aims to investigate factors, mechanisms and processes linking lifelong learning, recovery and SOC in the EMILIA project. It also seeks to understand any changes in SOC from baseline to follow-up.
   
A review of research literature reveals that there are many factors, mechanisms and processes involved in formal learning that could lead to an increase in SOC. Hammond (2004, p. 551) found that learning can have positive impact “upon psychosocial qualities; self-esteem, self-efficacy, a sense of purpose and hope, competences, and social integration.” Research into specific examples of formal learning for those with mental disorder has found that they can bring benefits on a wide variety of measures, for example, improvements in measures of coping skills, stress management, goal setting, quality of life, and well being (Griffiths, 2006).

Formal lifelong learning can contribute to increased comprehensibility, manageability and meaningfulness and hence strengthen SOC (Landsverk & Kane, 1998). A direct positive effect of formal learning on individuals’ SOC has been shown by Suominen, Blomberg, Helenius, & Koskenvuo’s (1999) study which found that the degree of occupational training was strongly and positively correlated to SOC. SOC can be strengthened by factors such as teaching and reinforcing coping skills, the facilitation of social support and by enabling individuals to identify, access, and mobilize resources that are available to them (Landsverk & Kane, 1998).

EMILIA, as a lifelong learning and employment opportunity project, has the potential to increase the SOC strength of its participants through increases in a sense of hope, meaning, well being and self-esteem (Borg & Kristiansen, 2008) and also through social aspects (Antonovsky, 1979; 1987). Social aspects include interpersonal support from study peers, opportunities to express and validate concerns and questions, and being able to understand that you are not alone in your experience of mental illness (Ascher-Svanum & Whitesel, 1999). It also has the potential to increase SOC through increased empowerment (NIACE, 2004; Frankl, 1992), through the development of new areas of interest (NIACE, 2004), increased purpose in life by defining and setting personal goals (Frankl, 1978; 1992), and increased structure in life (Antonovsky, 1979; 1987). What's more, the service users who help deliver the learning modules can act as role models, allowing an individual service user to see that others can cope with and be successful despite their mental illness and this can have a positive effect on SOC (see Ascher-Svanum & Whitesel, 1999).

The components and practical delivery of the EMILIA learning modules can also had the potential to increase participating individual’s SOC. For example, EMILIA sought to meet participant expectations and adapt to them; it promoted peer to peer support; allowed learners to express and validate their concerns and questions; tried to create a cohesive learning group; employed a format that enabled participant interaction; sought to develop effective learner teacher relationships; employed teachers who believed in the learning potential of their students and who tried to instil hope and belief and be sensitive to the participants learning needs (see Ascher-Svanum & Whitesel, 1999; Emer, McLarney, Goodwin, & Keller, 2002; Hayes & Gantt, 1992; Mather & Atkinson, 2004).

The EMILIA learning intervention developed learning goals that were attainable to help facilitates success (Koplewicz & Liberman, 2003). It did this by allowing participants to complete assessment at Middlesex University levels from zero (below 1st year undergraduate) to level 4 (masters). Furthermore, it sought to provide solutions to everyday concrete practical problems of the participants through content grounded in reality of participant’s existence - so that the modules connected with participant’s lives and goals (Koplewicz & Liberman, 2003).

It is difficult to achieve a load balance (which Antonovsky described as essential in strengthening SOC) in a group that has various types and severity of mental disorder and different levels of educational attainment, ability, and experience. Of crucial importance in respect to the underload/overload balance is the learning support that the EMILIA project provided its participants. There was a high tutor to student ratio and the EMILIA tutors actively sought to identify students requiring additional support, clarification and counselling during the training sessions.

In conclusion the research prediction was that participation in the EMILIA project will cause a significant strengthening in the SOC levels of participants and that qualitative analysis will reveal insights into the factors, mechanisms and processes linking lifelong learning, recovery and SOC.

The intervention
The EMILIA project intervention provided a set of three core learning modules and one additional learning module, a certificate of completion, learning support, the option of academic assessment to obtain Middlesex University credits and opportunities and training for paid employment at Middlesex University (teaching and assessing student mental health nurses). The titles of the core learning modules were ‘Building on Strengths and Personal Development Planning’, ‘Empowering People in Recovery’, and ‘User Leadership and Advocacy’. The additional module was entitled ‘User Research Skills’. All teaching was conducted by MHSUs who were leaders in the mental health community.

Research Methods
Combined qualitative and quantitative analysis
A combined quantitative and qualitative approach was adopted. The employment of a combined qualitative-quantitative approach meets the recognition among many researchers of the need to establish the qualitative grounding of empirical research in order to increase its scientific value (see for example, Henwood & Pidgeon, 1992).

Qualitative analysis
This research utilised a deductive ‘top down’ approach and in doing so it employed theoretical thematic analysis. Thematic analysis is a method for identifying, discovering, analysing and reporting patterns (themes) within data. A seven phase analysis in a recursive process based on the guidelines provided by Braun & Clarke (2006) was employed. The results of this analysis were used to explore the effects of the EMILIA experience in relation to SOC theory.

A priori themes identified
Eight lifelong learning related themes were identified through a literature review before the research study was conducted:  learning, employment, social networks, success, failure, mental health issues, goals, and motivation.

Design
The study employed within-subjects pre- and post-test design.

Participants
There were 22 participants, 8 males and 14 females (see table 1). All participants had a current diagnosis of mental disorder, at least three years of using mental health services and did not have ‘real world’ employment (regular paid work of more than 18 hours a week) or a diagnosis of learning disabilities or dementia. Their ages ranged from 28-62 years, with an average age of 46. The number of years of contact with mental health services ranged from 3 to 36 years, with an average of 14 years. All of the participants were living in North London, UK at the time of the intervention.

The majority of the participants (over three quarters) who provided information for the follow-up measures completed the entire set of the core learning modules and over half completed the additional learning module. At the time of follow-up only two of participants had started taking up the paid opportunities offered through the EMILIA project.

Table 1. Participant information 

Name (names changed to protect identity)

Mental health disorder diagnosis

 

Age

Sex

Marital status

Years of contact with mental health services

Country of birth

Alvita

Bipolar disorder                                       

 

 47

F

Single

7

UK                 

Cathy

Personality disorder + depression + anxiety              

 

 46

F

Married

29

UK              

Dawoh

Bipolar affective disorder                             

 

 51

M

Married

11

Sierra Leone           

Eric

Schizophrenia                                          

 

 39

M

Single

18

UK                

Freya

Clinical depression                                    

 

41

F

Single

4

UK

Grace

Schizoaffective disorder                              

 

 41

F

Divorced

16

UK             

Hilda

Bipolar affective disorder                             

 

 37

F

Single

8

UK                 

Isabel

Bipolar disorder                                       

 

 40

F

Single

12

UK                   

Jameela

Bipolar disorder                                       

 

 28

F

Single

3

UK                    

Kay

Schizoaffective disorder                              

 

 43

F

Single

23

UK                    

Lokesh

Schizophreniform illness                               

 

 55

M

Married

12

Pakistan               

Maria

Anxiety                                                 

 

 48

F

Single

6

UK                    

Norris

Bipolar affective disorder                             

 

 35

M

Single

9

UK           

Olive

Premenstrual dysphoric disorder (PMDD)                  

 

 61

F

Married

36

UK                     

Paulette

Bi-polar affective disorder                            

 

 48

F

Divorced

29

UK                 

Rena

PTSD

 

 62

F

Divorced

20

UK                   

Steven

Bi-polar + clinical depression + anxiety       

 

 43

M

Single

18

Canada                 

Tracy

PTSD                                                   

 

 51

F

Married

5

Ireland                

Una

Schizophrenia                                          

 

 60

F

Single

15

UK                  

Vincent

Depression                                              

 

 43

M

Single

3

UK                    

Warren

Anxiety + depression                                     

 

 48

M

Married

10

Ireland                

Zack

Depression + anxiety                                 

 

 53

M

Married

5

UK                      

           

Orientation to Life Questionnaire measure
According to Eriksson & Lindström’s (2007) systematic review a measure of SOC is applicable in the evaluation of education/training and for use with both healthy people and people with serious illness and disabilities. The SOC measure employed for this research is the Orientation to Life Questionnaire abbreviated version SOC-13 (Antonovsky, 1987). The SOC-13 is measured on a 7-point Likert-type scale where each item has two fixed contradictory responses at opposing ends of the scale.

Feldt, Leskinen, Kinnunen, & Ruoppila (2003) reported that the SOC-13 measure has relatively high structural validity and high stability, Hart, Hittner & Paras (1991) reported high validity, and Antonovsky (1993a), Callahan & Pincus (1995), and Pallant & Lae (2002) all reported a high level of reliability and content, face and construct validity. More specifically, internal consistency testing has shown Cronbach alpha scores ranging from .74 to .95 (Antonovsky 1993, 1996a, Gallagher, Wagenfeld, Baro, & Haepers, 1994; Lundman & Norberg, 1993; Post-White et al. 1996; Volanen et al. 2006). In 1996(b) Antonovsky reported that the scale showed reliability and validity across social classes, different cultures, ethnic groups, ages and both genders.

Qualitative measures
A series of ten open-ended questions were designed for the project and these focused on education, training, employment, unpaid activities and social networks in the preceding 12 months and also on barriers, difficulties, problems, and goals in the present and future. They were labelled as self reports. Five of the participants also completed semi-structured interviews; these people are labelled in the project as ‘key informant service users’. They were selected on the basis that they met a diagnosis of schizophrenia F20 (ICD-10), schizoaffective disorder F25 (ICD-10), or bipolar disorder F30-F31 (ICD-10). The first five participants that met these diagnoses were selected. They were requested to answer 16 questions within a formal interview; these open-ended questions focused on aspects of quality of life, social inclusion, personal goals and the project itself.

Procedure
Ethical approval was obtained from the Institute of Psychiatry and Camden and Islington Mental Health & Social Care Trust. All participants provided informed consent and completed the SOC-13 measure and self reports and the ‘key informant service users’ completed the semi-structured interviews at baseline and at a ten month follow-up. For the ‘key informant service user’ interviews the format employed was a digitally recorded face to face interview. The interview was semi-structured to encourage two-way communication and to enable fuller answers to be provided and clarification of any answers given. For the self reports the participants were given the choice of writing the answers on a piece of paper, typing them into a computer or having their answers digitally recorded in a face to face interview. If an interview approach was chosen then the same procedure was employed as for the ‘key informant service user’ interview.


Results
Quantative results
The impact of the EMILIA intervention on participant’s scores on the abbreviated SOC checklist: SOC-13 was evaluated. Paired sample t-tests revealed that there was a significant increase in SOC-13 scores from baseline (M=29.54, SD=12.23) to a 10 month follow-up point (M=34.82, SD=10.80), t(21)=-2.58, p=.017 (two-tailed). The mean increase in SOC-13 scores was 5.36 with a 95% confidence interval ranging from -9.69 to -1.04. The eta squared statistic (.24) indicated a large effect size.

Table 2. Comparison of SOC means

 

General population mean SOC*

Participants baseline mean SOC

Participants

follow-up mean SOC

All participants

65.16

29.45

33.07

Male only

65.6

33.25

37.88

Female only

64.8

27.29

34.82

* Population means are from Konttinen, Haukkala, & Uutela (2008). This is a Finnish study - no recent large scale population figures were available from the UK.
 

Discussion
Quantitative
SOC significantly increased following the EMILIA intervention, matching the research prediction. This indicates that the project may have enhanced participants’ ability to manage potentially stressful situations. The results provide evidence for the direct positive effect of formal learning on individuals’ SOC shown by Suominen et al. (1999). They are a demonstration of the wider benefits of the intervention because SOC is negatively associated with psychopathology and negative affectivity, and positively associated with well-being, mastery, quality of life, general health, global well being, global psychosocial functioning and self-esteem (Bengtsson-Tops & Hansson, 2001).

Even though the average SOC scores increased significantly the mean scores of the participants were still below the mean scores for a general population (Konttinen et al. 2008). Not one of the participants in the study reached the mean score for a general population. This points to the continuing negative effect that having severe and enduring mental illness can have on SOC strength.

Combined quantitative and qualitative results discussion
Qualitative analysis revealed evidence for each of the a priori categories. The following discussion will use extracts from the qualitative analysis to describe the possible effects of the EMILIA intervention on the SOC strength of participants.

There were extracts relating to factors which have been identified as pathways through which SOC can be strengthened such as teaching and reinforcing coping skills, enabling individuals to identify, access, and mobilize resources available and the facilitation of social interaction and support (Landsverk & Kane, 1998). One participant relayed that:

Rena: “Doing the EMILIA course has given me more confidence in myself and I’ve realised I can do things even though I struggled.”

Having confidence is clearly a valuable resource which enables an individual to mobilise and access other resources. Also within this quote is the mention of persistence despite difficulties, which is a coping strategy often vital to ensure success in life. It is positively linked with confidence, hope and an active optimistic style labelled as ‘fighting spirit’ (Olason & Rodger, 2001). What's more, fighting spirit is linked to adaptive health behaviour and coping with disease (Pettingale, Morris, Greer, & Haybittle, 1985; Spiegel, 2001), and positively correlated with SOC (Johnson, 2004). Also in terms of psychological resources a participant mentioned an increase in dignity and a sense of importance:

Una: “I think that it [EMILIA training] has given me some dignity in my situation [having mental difficulties] and I absolutely hate receiving benefits and I think that it [EMILIA training] has given someone in my position the dignity to feel a bit important anyway.”

A sense of dignity is part of the human need to achieve and maintain various forms of integrity and it is linked to a sense importance, intrinsic worthiness and self esteem; and a sense of self esteem has been found to be positively related to SOC in a population at risk of psychiatric disturbance (Cederbald & Hansson, 1996). Deegan (1988, p. 15) described the mental health recovery as process “to re-establish a new and valued sense of integrity…” Dignity is an internal resource that can be viewed as forming a part of a person’s SOC.

Social support is a key GRR in the SOC model. Representing the sentiment of many participants one participant simply stated that: “I have made more friends” (Ben). Another participant expressed the feelings of many when they stated that EMILIA was very useful in terms of: “…drawing on the support and strengths within the community” (Dawoh). The following participant expressed the value to them of the social interaction with other service users that contributed towards more positive feelings and their recovery:

Norris: “I consider my participation in the EMILIA project to have gone well and enabled me to meet and interact with people with similar mental health issues in a positive and constructive way, that at the time it was happening made me feel better in myself and better able to face up to life in general.”

The qualitative analysis revealed comments relating to possible enhanced motivation and this is an indication of increased SOC (Antonovsky 1979; 1987). For example, “[Motivation] It developed, it progressed during the training” (Isabel) and “[EMILIA gave me] more motivation to pursue and maintain new social contacts” (Steven). The EMILIA project tried to motivate its participants to pursue and complete the learning programme by connecting the intervention with an individual’s personal goals. The following statement is representative of comments expressed in relation to this:

Dawoh: “It’s all positive stuff. I found that very very useful in terms of focusing and setting my goals and stuff. It helped to firm up my ideas and goals, I found it very useful.”

Many participants developed or found goals related to the mental health issues explored in the training, examples of which is provided through the following extracts:

Ben: “I want to do some voluntary training in order to eventually get paid employment in the mental health field.”
Isabel: “I may do something in mental health in the future because I am so passionate about it, you see.”

There were many other statements which revealed insights into the development of goals in other areas. Whilst no claim is made that the project installed all of these goals in the participants it did help many participants discover and set their own goals. The EMILIA teachers helped participants to understand how the information taught related to real-life issues and the participant’s life goals and roles (Parnell, 1994). This aspect is likely to be part of the contribution towards stronger SOC (see Antonovsky, 1979; 1987). Deegan, (1988, p. 15) stated that mental health recovery partially evolves through “the aspiration to live, work, and love in a community in which one makes a significant contribution”. Antonovsky (1979) explained that if individuals are engaged in goal orientated behaviour that encourages success then this can strengthen their SOC.

Connected to the formulation of goals is future orientation. Frankl’s (1985, p. 37) work demonstrated the importance of being “oriented toward the future, toward a meaning to be fulfilled… in the future” in order be able to successfully adapt and cope in life. The project may have reduced the negative effect of future-orientated uncertainty caused by the experience of mental disorder (McCann & Clark, 2004). There were a number of extracts describing future orientation, for example: “I started to think: ‘what do I need to do in the next year or so?’” (Ben) and: “Yeah. I am more hopeful for the future” (Alvita). One participant provided a direct reference to increased meaningfulness in their lives that had emerged from their experience of the EMILIA project:

Alvita: “It [EMILIA] has made me feel that what I went through was not in vane if you see what I mean. Because I went through what I went through and I was lucky enough to come out the other end I can help others and that is where I’m from if you see what I mean…

Helping to achieve a realisation that their experience of mental illness had provided participants with strengths, coping skills and expert knowledge of the health system that can help them in their lives, and also that they could use this experience to help others in their recovery, was one of the core themes of the ‘Strengths’ module and a goal of the project overall.

In addition, the increase in SOC recorded could also be partially due to increases in empowerment as all of the modules were partially aimed at achieving this. Empowering an individual to take greater responsibility for his or her life and health can strengthen an individual’s SOC meaningfulness factor (Frankl, 1992). Furthermore, taking action to help to develop agency and empowerment can facilitate recovery (Green, 2004). There were many comments made in relation to empowerment, for example:

Steven: “I have been able to begin to break the social restrictions I grew up with, and take ownership of my life, to build healthier boundaries.”
Isabel: “And also being honest with myself and being able to ask for help when I need it. Because I never used to do that.”

Increased empowerment may have enhanced self directedness (defined as how responsible, purposeful and resourceful a person is in working to achieve their goals and values) and this is factor has been found to explain variations in SOC (Eklund et al. 2004). Empowering an individual to take greater responsibility for his or her life unlocks resources and helps create hope for the future (Langeland et al. 2007). Representing the feelings of many one participant expressed the following: “Yeah. I am more hopeful for the future” (Alvita).
    
A sense of hope is vital for recovery and hope is positively related to the SOC component of meaningfulness (Mascaro & Rosen, 2005). Having hope for the future increases meaningfulness and it suggested that having a strong sense of meaning in life provides stronger immunity against hopelessness (Mascaro & Rosen, 2005). “Having some hope is crucial to recovery [from mental disorder]; none of us would strive if we believed it a futile effort” (Leete, 1989, p. 32).

Other aspects of the project that may have contributed to the increased SOC scores include the project’s paid employment opportunities (Volanen et al. 2004; Linhorst, 2006). How much contribution that this has made to the group’s overall SOC scores is questionable because at the time of the follow-up only two of the participants had been involved in EMILIA generated employment. However, many of the participants gained employment outside of the project, both paid and voluntary, in the 10 months from baseline. For example, four of the participants started to play an active role at a mental health charity, one became an administrator, trustee and legal advisory to a major mental health charity and another successfully helped set up a mental health related social firm. One participant described the benefits that they derived from their new employment:

Grace: “…it is all about getting back to the helping aspects and I like that. If I do something good in the day it makes me feel good. It makes me feel better.”

The analysis revealed that exposure to the EMILIA project also lead to the development of existing and new areas of interest for many of its participants; for example, interest in the service user movement, mental health research, and the process of recovery. This is likely to have stimulated minds (increasing comprehensibility), enriched lives (increasing meaningfulness) and lead to feelings of personal satisfaction (which can be important in a feeling of confidence which Antonovsky described as essential for strong SOC levels). It is likely that the development of new areas of interest will have made a contribution to the finding of increased SOC strength.

Many of the extracts in relation to goals, empowerment and areas of interest provide evidence that the EMILIA teachers were able to get participants to see both the specific objectives of learning and the larger meaning as it relates to real-life issues and to participant’s actual roles in life. This is what Parnell (1994) describes as essential in effective teaching. It also helps demonstrates that the modules had meaning for those who completed them, that they connected to the participants’ needs, problems, preferences, real-world existence, goals and ambitions (Parnell, 1994; Boree, 1991).

Increased levels of employment, working towards goals and new areas of interest are all a part of active engagement in life. There is a dynamic positive relationship between active engagement in life and meaningfulness strength (Carstens & Spangenberg, 1997; Frankl, 1985; Mascaro & Rosen, 2005; Yalom, 1980), and hence SOC.

Increased levels of employment, working towards goals and new areas of interest are also connected to purpose in life. As Mascaro & Rosen (2005) explained if a person finds increased purpose in life then it is likely that this would strengthen aspects of his or her mental health such as hope, well-being and self confidence. An increased sense of purpose helps explain the increased SOC found following the EMILIA intervention as it is linked to meaning in life (Antonovsky, 1979; 1987; Yalom, 1980; Frankl, 1985). The analysis helps confirm Hammond’s (2004) literature review which revealed that learning can have a positive impact on an individual’s sense of purpose and hope.

The increase in SOC found in this study points to the value of various components and practical delivery of the EMILIA learning modules. The analysis revealed extracts relating to eight different examples of this:

1. EMILIA’s efforts to develop effective learner teacher relationships.
2. Allowing learners to express and validate their concerns and questions.
3. Creating a friendly supportive environment.
4. Providing constructive feedback.
5. Providing opportunities for self reflection.
6. The projects efforts to take into account the needs of MHSUs by allowing frequent breaks during the training.
7. The size of the group (approx 10-12 students), which participants generally responded well to.
8. EMILIA group teaching style and its use of variety of methods of delivery of material.

The qualitative analysis also highlighted the positive effects of employing MSHUs as trainers which helps confirm Rummel et al.’s (2005) findings that peer led education for MHSUs is effective. MHSU trainers may have acted as role models, allowing participants to see that others can cope with and be successful despite their mental illness (see Ascher-Svanum & Whitesel, 1999). Young & Ensing’s (1999) literature review found that learning through role models and peers with a similar experience can have an especially large positive effect on recovery. The following extract is representative of participant comments:

Alvita: “It was good that the teachers were in the same position as us as well [i.e. mental health service users]. That was very good. I think that that helped [us] to open up. I think that if the teachers hadn’t experienced mental ill health I think that I would have probably opened up but perhaps some other people may not have done. That was a very good [aspect to the training]. It gave me more of a push to achieve as well.”

Most participants stuck with the project despite the challenges and problems which they faced. Challenge and overcoming challenges is crucial in the development of a strong SOC (Antonovsky 1979, 1987; Wolff & Ratner, 1999). Research suggests that successful coping can lead to the development of further adaptive coping resources (Aldwin, 2000). There is evidence from the qualitative analysis that EMILIA had a positive effect on mental health recovery:

Dawoh: “EMILIA had an [positive] impact. It came at a time when I was transitioning and it helped with the transition. The EMILIA strengths training help[ed] with my transitioning and focus on positive goals drawing on community supports.”
Norris: “I consider my participation in the EMILIA project to have gone well… that at the time it was happening made me feel better in myself and better able to face up to life in general.”

Isabel: “Sharing in the group activities, learning things about myself that I didn’t know. I thought I had lot things down in my mind about how I was and how I came to be here but I didn’t really. And learning different things and challenging myself. Things that I never thought I would do. It is changing and it is a positive change.

The recovery associated extracts support the findings of Borg & Kristiansen (2008) that employment, learning, and social interaction are all important in generating a sense of hope, meaning, well being and self-esteem. The extracts also reflect the core recovery processes identified by Green (2004): development, learning, healing and adaption. Lifelong learning and recovery are both part of the process of managing and forging a meaningful, coherent understanding of the experience of mental disorder.

Strengthening SOC can play an important part in the mental health recovery process. Charmaz (1991) describes recovery as involving the development of an understanding of abilities and limitations (comprehensibility factor), making adaptations and day-to-day life management decisions (manageability factor) and setting long term goals that take into account the reality faced in terms of strengths and capabilities (meaningfulness factor).

The results of this study link recovery, social inclusion, lifelong learning and SOC. They add to the findings of Hammond (2004) that learning can have positive impact upon factors that include self-esteem, self-efficacy, a sense of purpose and hope, competences, and social integration. They support the findings of Feinstein & Hammond (2004) that participation in formal learning is an important element in positive cycles of personal and social development and progression.

To foster recovery mental health services need to: “understand how to help people maintain resources, how to facilitate resource development, or how to help people prevent and stop loss spirals” (Green, 2004, p. 305). It follows that there needs to be an understanding of how to generate ‘gain spirals’, positive spirals in which people gain GRRs and hence strengthen their SOC. This present study’s results show that lifelong learning and employment opportunities can help provide gain spirals. The results show that EMILIA type interventions can: “provide opportunities for developing necessary competencies” in the recovery process (Green, 2004 p. 302).

In summary, the results showing an increase in SOC and meaningfulness and extracts related to motivation, goals, empowerment, optimism, hope, self-confidence, success, etc. demonstrate that EMILIA can strengthen MHSUs ability to effectively respond to the needs and demands of their lives. The results also reflect EMILIA participants increased ability to be flexible, to generate of alternative solutions and to be self-directed (Antonovsky, 1979). This study’s results indicate that recovery, the strengthening of SOC and lifelong learning can be viewed interlinked processes.

Limitations
There were a number of limitations associated with this study. There was no control group and the sample size was relatively small which limits the quantitative results generalisablity due to a lack of statistical power. Countering this was the use of triangulation: the qualitative results supported the quantitative. The participants can be considered to be reasonably representative of the MHSU population but self selection is likely to mean that the participants tended to be more stable, empowered, and socially included, and have higher self confidence and self efficacy than the average MHSU. The self selective method is also likely to have meant that the sample was skewed to those who had more of an interest in learning and employment than the average MHSU. This means that the participants were more likely to be motivated to do well, provide positive feedback, complete the training and take up employment opportunities than the average MHSU.


Conclusion and implications
This research points to the possibility of developing learning interventions based on SOC theory and salutogenic principles. SOC theory can be regarded as a theoretical framework for designing interventions for MHSUs that seek to enhance recovery, social inclusion and empowerment.

MHSUs, for the most part, live within the community. For them to prosper, take part in and contribute to the community they require access to lifelong learning and employment opportunities. This study’s results support the funding and delivery of programmes such as EMILIA which can be considered part of the responsibility of society to create the conditions that promote SOC strength (Antonovsky, 1979, 1987). It can be part of the vision of a salutogenic society.

Projects such as EMILIA enable an opportunity to participate in a normalising activity and thus help to reduce the problem of social marginalisation experienced by so many people with severe and enduring mental health disorders. The findings provide evidence for continued and embedded use of the modules designed for the EMILIA project and for extending EMILIA’s underlying principles and practical application to further groups of MHSUs. Project such as EMILIA could be implemented across and beyond Europe.

An EMILIA style opportunity could be an integrated part of mental health services. MHSUs could be offered a choice of different learning modules, and on completion of these they could be offered help in finding a job and supported in any employment found in the competitive market place. To provide embedded EMILIA style opportunities requires adequate funding, cooperation between health services, education providers, etc., and integrated and progressive systems that are sensitive to the individual, their needs and their right to be socially included in terms of learning, employment, etc.

Bergstein, Weizman, & Solomon (2008, p. 288) explained the “necessity of an integrative biopsychosocial treatment approach, which would include interventions aimed at enhancing elements of SOC.” Projects such as EMILIA could be part of a comprehensive, coordinated, compassionate, service user-oriented, and service user involved integration of treatment and rehabilitation for MHSUs. This integration should be based on a combination of salutogenic and pathogenic principles (Antonovsky, 1979; 1987).



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