The International Journal of Psychosocial Rehabilitation

Working Towards Recovery:
The Role of Employment in Recovery From Serious Mental Health Problems:
 A Qualitative Meta-synthesis.



 Fran P Walsh BSc.
Trainee Clinical Psychologist, School of Psychology, University of Lincoln.


Anna C Tickle, BSc., MSc., ClinPsyD.
Clinical Psychologist and Academic Tutor, Institute of Work, Health and Organisations, University of Nottingham.



Citation:

Walsh FP & Tickle AC (2013). Working towards recovery: The role of employment in recovery from serious mental health 
problems: a qualitative meta-synthesis.  International Journal of Psychosocial Rehabilitation. Vol 17(2) 35-49



Correspondence:     Anna Tickle
B Floor, International House
University of Nottingham
Jubilee Campus
Wollaton Road
 Nottingham NG8 1BB UK
Anna.Tickle@nottingham.ac.uk




Abstract
Objective: The objective of this review was to identify and synthesise existing qualitative literature relating to the meaning of work for individuals experiencing serious mental health problems, with particular reference to their recovery. Method: A systematic literature search and appraisal identified six qualitative studies to be reviewed. These were analysed using a meta-ethnographic methodology. Results and conclusions: Four key meta-themes were identified: self-efficacy, identity, belonging and the instrumental characteristics of work. The resultant analysis suggested that each of these interact with the intra-psychic and social domains of the individual to construct a nuanced picture of the meaning and value of work to people with mental health difficulties. The findings suggest that further research is necessary to distinguish the value of work from other meaningful activity in promoting recovery. It is hoped that synthesising existing qualitative studies will inform thinking and research regarding work and recovery from mental health problems.

Keywords: Mental illness. Recovery. Work. Qualitative. Meta-synthesis



Introduction
The role of employment in the lives of people in modern industrialised societies is complex and multifaceted. It provides day to day structure and activity, as well as the financial means for survival. It impacts on social inclusion, self-esteem, status and identity, which have been viewed as important aspects of employment in the lives of people living with serious mental health problems (Boardman, Grove, Perkins & Shepherd, 2003). Correspondingly, considerable evidence exists linking unemployment to poor mental health (Fryer & Fagan, 2003). In a meta-analysis of longitudinal studies  it was concluded that not only does unemployment have a negative effect on mental health but also that there is ‘an association between improved mental health and a movement into employment’ (Murphy & Athanasou, 1999, p.97)  In much of the work conducted exploring the relationship between unemployment and psychological wellbeing it is apparent that unemployment and its attendant problems, such as poverty and social exclusion, are  contributory factors in the development of poor mental health (Ritsher, Warner, Johnson, & Dohrenwend, 2001,  Winefield, Tiggerman, Winefield & Goldney,1997).

Given the role of work in promoting and maintaining social, psychological and practical wellbeing (Warr, 1987) and as an indicator of success and social approval (Stauffer, 1986) it is unsurprising that people living with serious mental health problems often cite employment, or the prospect of employment, as playing an important part in their recovery process (Provencher, Gregg, Mead & Mueser 2002). There is some evidence that employment and recovery are not necessarily positively correlated (Connell, King & Crowe, 2011),  but the re-establishment of previously held roles or access to the world of work inhabited by those who are seen as ‘fully functioning’ members of society, is often seen as a step on the road to acceptance and integration into the wider community (Brown & Kandirikirira, 2007). Despite this, rates of employment amongst people with serious mental health problems remain low, with figures in the UK suggesting that only 22% of people defined as having a mental health disability are in employment, a rate much lower than that of any other impairment group with the exception of people with learning disabilities (Sainsbury et al. 2007).  In response to these high levels of unemployment successive governments have focused on policy aimed at supporting people with mental health problems into work. Whilst some of this has undoubtedly been motivated by ideological and fiscal considerations, links have been recognised between employment, social inclusion and recovery (Sainsbury et al., 2007; Department of Health, 2011).

Recent developments in conceptualising recovery in relation to serious mental health problems describe the process using a continuum model. Rather than focussing on recovery as a distinct binary state, a cure, it is understood as a largely idiosyncratic process defined by individual experiences of living life with mental health problems, rather than eliminating them completely. Central to this notion is the concept of a ‘meaningful and satisfying’ life (Shepherd, Boardman & Slade, 2008, p.1) in which the individual experiences all the benefits of so-called psychologically healthy citizens, a sense of belonging, autonomy, hopefulness, and access to work and financial security ( Bradshaw, Peterson-Armour, & Roseborough.2007). This approach to mental health issues recognises that whilst distress in and of itself can be debilitating the social consequences can be devastating (Beresford, 2005).  As members of a wider social system people with mental health problems can often feel excluded and isolated and yet it is in this societal context that much of the positive work of recovery can be situated (Borg & Davidson 2008;  Repper & Perkins, 2003; Tew et al. 2011;).

From its inception the recovery approach has prioritised the lived experiences of those with mental health difficulties. The use of first person accounts to elucidate the processes and components of recovery can be found in an increasing number of qualitative studies (Brown, 2008; Davidson, 2003). However despite previous assertions of the value of employment as a factor in recovery there has been little exploration of the narratives of those who experience mental health issues and who also work or aspire to work. At a point when Government policy in the UK becomes ever more focused on encouraging people from benefit dependency and towards work, it is essential that we better understand the impact that these demands might place on people with on-going mental health problems

 Those qualitative studies which have investigated work and mental health difficulties suffer from the limitations of small participant numbers and diverse methodological approaches.  It is in the light of these difficulties that the present  literature review will synthesise the findings of recent qualitative research in an attempt to develop an understanding of the interplay of employment and recovery in the lives of those who are living with serious mental health problems.  The focus of this review was to explore in particular this issue of work for wages, obtained and maintained within a competitive marketplace, and integrated in the normal economic structures of the prevailing culture. In short it is about the impact of competitive employment, ‘real’ jobs out in the ‘real’ world. While this was the intended focus,  the limited amount of research available necessitated the inclusion of studies with participants with a variety employment experiences.  In such cases it was judged that the main thrust of the original research questions were directed towards participants’ experiences, beliefs and perceptions regarding competitive employment, as opposed to supported employment, unwaged work or volunteering.

Method
Conducting a Meta-synthesis Using Meta-Ethnography
Pioneered by Noblit and Hare (1988) in the field of educational research, meta- ethnography has become a valuable tool for synthesising qualitative research. Initially proposed as a method for use with very small numbers of studies (between two and five) more recent papers have proved its efficacy with larger numbers of studies under review (Atkins et al., 2008 Campbell et al., 2003). In order to meet the objectives of a metasynthesis, the studies reviewed are purposively selected from a range of professional disciplines, using a variety of methodologies and with an assortment of different objectives and findings (Doyle 2003).The aim of a meta-ethnographic synthesis is not to focus on the primary data of the studies under review but to concentrate on the original researchers’ interpretations of the data (Doyle, 2003). This may include drawing on direct quotes from the participants which have been selected by the original researchers or on the conclusions and interpretations drawn by the researchers themselves. In this way the approach respects the role of the relationship between researcher, research participants and findings, retaining the original context and resultant meanings derived through the interpretive process.

A meta-ethnographic synthesis builds on these original interpretations by producing an additional layer of meaning through a number of processes. Initially constructing a shared language of metaphor across the studies, through this process of reciprocal translation the key concepts within the individual studies can be ‘translated into one another’ (Noblit & Hare, 1988, p.11).The process of synthesising the studies in any given review not only attends to those accounts which appear similar and are therefore amenable to reciprocal translation but also to those which appear conflictual and can be integrated through a process of refutational synthesis. Ultimately the intent is to produce a line of argument synthesis which incorporates these similarities and differences to generate new meaning, and potentially develop new perspectives on the subject under review.

Searching
The literature search was systematically conducted by individually searching five electronic databases (PsychINFO 1990-2011; MEDLINE 1990-2011; EMBASE 1990-2011; CINAHLand Web of Science). Key terms  relevant to the initial focus of the review (recovery, employment, meaningful activity, volunteer, involvement,mental illness, mental health, schizophrenia, psychosis) along with a focus on qualitative methodologies were applied to all the searches with additional limits including dates (1990-2011), added where necessary (Appendix A). The start date of 1990 was chosen to reflect the point at which literature on the recovery movement began to become more widespread. Additionally the bibliographies of related literature and the references of all eligible studies were hand searched for any relevant material.

Selection Criteria
Initial selection of studies identified by the individual searches was carried out using the two initial screening questions of the Critical Appraisal Skills Programme (CASP, 2011) pro forma. CASP was developed in partnership with the NHS as an accessible appraisal tool and is commonly used in health and social care research, including meta-ethnographic meta syntheses (Barnett-Page & Thomas, 2009). Studies identified in the searches were screened using the title as the primary filter before reading the abstracts of any apparently suitable studies. This procedure yielded papers which were both qualitative and at first sight be relevant to the subject of the review.

Following initial screening, additional selection criteria were applied to identify studies which explicitly used individual accounts of experiences of, or beliefs about, employment. Papers primarily exploring  supported employment programmes, or written from the perspective of professionals or employers; or focussing on the impact of mental health difficulties on employment, rather than the impact of employment on mental health difficulties, were excluded. Given the limited amount of suitable literature available studies were considered for inclusion where participants were currently employed, unemployed, engaged in supported employment, or in unwaged work.

The remaining papers were subjected to a full CASP assessment to ensure that they met rigorous methodological and procedural standards. Studies which were reported in insufficient detail to ensure quality were excluded on the basis that the full CASP criteria could not be demonstrated.

Search Results
The initial searches returned 225 papers and additional hand searching produced a further three. Once the initial screening processes had been applied the number reduced was to 25. The application of the full CASP criteria and the additional specific selection criteria (see above) resulted in the selection of six papers for the review (Table 1).





Process of Analysis

Following selection of the studies to be included in the review, analysis consisted of a series of steps. Initially the papers were read and re-read with the intention of building a familiarity with the original texts and constructing summaries of their analyses. Next the studies were sifted for themes using both the primary voices of the research participants reported by the researchers and the results of the researchers’ interpretations. The emergent themes were recorded for each of the studies and once a comprehensive list had been constructed comparisons were made between the studies. At this stage the themes could be organised into key concepts which appeared to be emerging across the studies. This constitutes an ‘interpretation of the interpretations through a new lens’ (Doyle 2003. p.130).  As such it demands the same kind of reflexivity that researchers apply to original qualitative research. In order to maintain this, notes were kept charting any thoughts and reflections which might be influencing the process.

Results
Six studies were selected for inclusion in the review with a total number of 120 participants. Of these 53 were women and 67 men with an age range of between 18 and 62. Ethnic origins were not stated in many of the studies however the research originated from a range of countries At the point when the research was conducted those interviewed had various employment circumstances (see Table 2). Types of employment were not always identified however in the cases where it was, positions held included professional roles, such as accountancy or nursing, administrative and managerial occupations, skilled, semi-skilled and unskilled work. In the five studies where diagnoses were recorded the majority of the participants had been given a diagnosis of Schizophrenia or Bipolar disorder. The sixth (Borg & Kristiansen, 2008) asked that participants self identify as recovering from a serious mental ‘illness’.  All of the studies collected data exclusively or in part through interviews, and used various qualitative methods for data analysis (see Table 2). Five of the six used interview material collected specifically for the current study whereas Borg and Kristiansen returned to interviews from a previous study (Borg & Davidson 2008) and re-analysed them from a different perspective using a different research question.  

The Emergence of Meta-Themes
A number of recurrent themes appeared across the studies which could be grouped into four meta-themes around the impact of work, self-efficacy, identity, belonging and instrumental factors (Table 3).



The themes identified from the studies are explored in more detail below. Individual papers will be referenced using the numerical study codes allocated in Table 2.  Direct quotes from original participants of the any of the studies are written in italics.

Self – efficacy.
Throughout the studies references were made to the relationship between work and an experience of self-efficacy. This was conceptualised in a variety of different ways, as developing self–esteem (1, 2, 4, and 5) self-actualisation (6) and ‘becoming okay’ (3). It became apparent that these experiences had two distinct characteristics: the first was the impact of encountering the specific challenges of the work and the workplace and secondly the opportunities for personal growth offered through the context of working.

Meeting challenges.
Many of the studies reflected on the impact on people with serious mental health problems of meeting the challenges inherent in working life. Engaging with the demands and expectations of employment and being able to fulfil the requirements of work such as taking responsibility, having to complete tasks and relating to workmates promoted self–confidence and  increased self-esteem, a sense of competence and empowerment (3,4,6). One participant commented “(to have responsibility.)  Yes that is important to me and to my self -esteem…to show myself that I can do it” (1 p.28).

Unsurprisingly those who had positive experiences of work, either currently or in the past, seemed more open to the value of the challenges it poses. Conversely, those whose work experiences had been unsuccessful or who had not worked at all were more dubious. A number of the studies  proposed that higher levels of psychological vulnerability, lack of exposure to the working environment and external factors such as perceiving or experiencing discrimination contributed to this (2,4,5,6). For people with serious mental health problems the impact of meeting the challenges of work appears to be context dependent. For those who feel ready it can encourage a sense of achievement and promote individual empowerment and self- efficacy. However for some the demands of work need to be approached with care in order to limit the negative and self defining effects of failure, as one participant reflected in relation to work as a source of self-image and self-esteem “You think: look I’ve had five or ten jobs and I can’t keep one” (5, p.387).

Personal growth.
 Alongside the functional challenges of working or preparing to do so was a significant element in the participants’ personal growth process (1, 2, 3, 4, and 6). Many of the studies identified the significance of work as a factor in people taking control over their own lives, providing opportunities to enhance their psychological and physical well-being, improve their social skills and pursue new interests (3, 5, and 6). Testing out individual capacities through working allowed participants to learn about their own limits and potential and was valuable for personal development (3 ). For many, involvement in work provided the opportunity to cope with their psychological problems offering a focus beyond their individual difficulties and creating opportunities to develop new perspectives (1, 3, and 6). Many of the improvements in this domain were perceived as inextricably linked with shifts in identity, a greater sense of belonging and increased social functioning which will be explored in greater detail in the following sections.
 
 
Identity.
The construction of new positive identities which enhanced participants’ self-esteem and encouraged a sense of competence and self-efficacy were seen throughout the studies to play a part in the relationship between work and recovery. It would seem that participating in work provided a platform for the (re)construction of positive identities and thus contributed to on-going processes of recovery (1, 2, 3, 6)

Feeling normal.
For many participants, reintegration into work was a marker of becoming ‘normal’.  Engaging in work gave a feeling of living a normal life and being like ‘everyone else’ (1,3). Several studies made reference to the social and cultural desirability of working (1, 2, 3, 5). Fulfilling the social, cultural or familial expectations around working, together with decreasing dependency on external support whether financial or emotional, promoted feelings of self –worth, increased confidence and was felt to be empowering (1, 2, 5).  These experiences of feeling ‘normal’ were not just internally generated; the role of feedback from others, through social and professional interactions, was also remarked upon. One participant described this when talking about work in the context of friends and family “it feels really good to say to your friends and relatives and so on, that you are working, that you have a real job. Then there isn’t so much embarrassment at family dinners” (1, 26).  Not least, having work allowed participants to answer the ubiquitous question ‘what do you do?’ without the fear of disapproval or rejection (5).

Shedding the patient identity.
Moving from a predominantly patient identity to a worker identity was cited in a number of the studies as being one of the positive outcomes of engaging in work, particularly work integrated in mainstream society (1, 2, 3). For many of the participants, long histories of mental health problems had been characterised by periods of medication, isolation and hospitalisation (3).  Many felt defined by their illnesses, restricted to a world where their mental health was the focus and limited by the resultant low expectations and stigma attached to those with mental health problems (1, 2, 3, 5, 6). In three of the studies particular reference was made to the shift in identity from patient to functioning member of society, from being predominantly defined as unwell to being perceived as becoming well (1, 3, 6). Even in the studies where this was not referred to directly it was inferred through the text. For instance, one of the South African participants noted “I am working therefore I am fine. I am not crazy, crazy people cannot work” (2, p.459). As with some of the other themes relating to constructions of the self, the process of defining identity was comprised of a dynamic interplay of personal, social and cultural factors. In the context of this, work was very much seen as a signifier of shedding the passive disempowered role of the patient to becoming a person integrated into wider society capable of contributing on both micro and macro levels (1, 2, 3, 6).

Belonging.
Very much linked to the meta-theme of identity, but expressed in the social domain rather than the personal, is that of belonging. Throughout the papers there appeared a recurring focus on otherness and belonging.  For those participants whose lives were lived through and within the context of their distress, inhabiting the world of mental health services and restricted by an identity largely predicated on their illness resulted in a sense of exclusion from mainstream society (1, 2, 3, 4, 5, 6). The relationship between work and belonging could be seen through the literature under review as being expressed two particular areas: being part of the wider world and relationships.

Being part of the wider world.
Work was identified in five of the studies as having an impact on participants’ sense of belonging and integration into the wider world (1, 2, 3, 4, 5). In a number of the studies this was explicitly linked to the roles and practices of work itself (1, 2, 3, 5). Belonging to a workplace and being part of a team engaged in a shared purpose encouraged a sense of being part of a system, being needed and ultimately being missed when absent (1). For some participants, engaging in work which was seen as productive and purposive and which enabled a sense of contributing to society was cited as a positive result of working (1, 2, 5). One participant summed this up by commenting “ I’ve been doing something useful for a couple of years now….I think it’s about showing that I’m a part of this, and showing that you’re also participating in something bigger” (1, p.26).

For others, work was seen as offering a clear role and some purpose to their lives allowing them to feel more integrated into mainstream society. One man commented “It would certainly help to give me more of a purpose to life. On the mental health scene if all you do is visit day centres, it means you’re just drifting. It’s not like having a career or a job.” (4, p.307). Being engaged in ordinary work situations was felt to increase inclusion and integration into the wider community, belonging to the world of ‘normal’ people “instead of being one of ‘them’, a member of a diagnostic category requiring a special place” (3, p.517).

           Relationships.
One factor in (re)gaining a feeling of belonging was to be found in the area of relationships, both within and outside of the workplace. Belonging to a workforce provided opportunities to engage with others and build relationships which could extend beyond the working environment (1, 3). Colleagues could be seen as significant sources of support, validation and acceptance as well as providing the potential for expanding social networks (1, 3, 5). A participant from the Swedish study summed this up when he said “ Camaraderie, we meet in private too, do things together and so on…….we have worked together for a long time …..and during all these years when I’ve been ill my workmates and my foreman….have always been there for me” (1, p.27).

Building and maintaining relationships with people who do not identify as having a mental illness was proposed as a valuable element of employment in three of the studies (I, 3, 5). The opportunity to engage in ordinary conversations and to focus beyond the participants individual mental health issues fulfilled a number of functions, some of which have been discussed in other themes but can be seen as significant in the context of work and relationships. Being perceived both by self and others as a person with something to contribute was considered to have a beneficial effect on relationships outside of the workplace (1, 2, 3, 5, 6) and was considered a valuable result of working. Perhaps one way in which such perception was achieved was by fulfilling the expectations of friends and family to become something more than a person with mental health problems (1, 3, 5).  

Instrumental factors.
The impact of the process of being or becoming a worker on an individual and social level can clearly be seen in the previous sections. However it became apparent that there were certain instrumental factors inherent in work that affected the participants’ quality of life and their perceptions of the value of employment.   

           Structure.
 The provision of a structure to people’s lives was cited by five of the studies as a positive consequence of working;for  many participants having scheduled activities promoted a structure and balance in their lives that had previously been missing  (1, 2, 3, 4, 6).  This had further effects including increased energy promoting further activity, improved health and a sense of being more in control of managing one’s life (1, 2, 3). In a number of the studies this was compared favourably to the effects of inactivity (2, 3, 5), as reflected by one participant “Unemployment and inactivity are distress-provoking for people like me with severe mental health problems” (3, p.518). Managing the routines of work encouraged participants to focus on creating a positive work-life balance and to construct strategies for maintaining this (1, 2, 3).
 In relation to participants’ psychological health, a number of the studies commented on improvements in the management of mental health problems as a result of structure (2, 4, 6). One male participant commented “it’s extremely stabilising. It’s a form of creative Lithium if you like.” (4, p.307)). For people whose previous experiences had often been characterised by chaos, incapacity or inactivity the introduction of an external structure provided not only a sense of order and stability but was often functionally important as a source of motivation and a means of counteracting the potential inertia of their situation when unwell (1,6). A female participant summed this up in her comments  “But now like I’m getting into a routine, because I can see… when I was ill I’d lie in bed all day and just cry and scream …. So I’m trying to re-structure my life. ”  (2, p.460).

Finances.
 The financial implications of working extended well beyond the obvious advantages of access to a better standard of living and a greater sense of security. Increased access to capital afforded people opportunities for greater independence and autonomy and increased access to valuable social and cultural activities (1, 4, 5, 6). The significance of an improved financial situation seemed to lay in the freedom to choose; participants were able to participate in personally rewarding activities, create a better balance in their lives and experience a sense of satisfaction and increased self-esteem which accompanied earning their own money (1, 2, 5, 6). For some, generating their own income related to an increased sense of entitlement in deciding what to do with it and in being able to enjoy the rewards of working. One participant highlighted this in the following comment:“To earn money, above all to know that I’m able to earn my own money, so now they know that I can have my vacation, because I’ve earned my own days off.” (1, p.25)..

However whilst some of the studies referred to financial reward as a motivating factor and a source of benefit to people with serious mental health problems (1,2, 3, 4, 5) its importance was by no means universal. For many participants, being paid held a secondary role to the value of engaging in meaningful and rewarding activity and the sense of social legitimacy provided by the worker identity (5). For some participants unwaged work in the form of volunteering, studying, or caring for others proved equally valued and able to provide many of the benefits of paid employment  (3, 5, 6). An additional factor when considering the financial implications of working were the potential risks of working in low paid occupations, losing benefits in the process and ultimately becoming less financially stable (3, 5, 6).  

Nature of employment.
The properties of the work that people did were in many cases closely linked to its value to them as a vehicle for their recovery. Work which provided just the right balance of challenge and stimulation and adequately reflected their skills and values was particularly important to many participants (1, 3, 5). A number of the participants expressed concern that they would only be able to access work that in itself seemed without meaning. It was not necessarily the case that any employment was valued more than no employment, as one participant highlighted in her comment that for her, work needed to be “ something that was interesting, of value, that I felt appreciated in. I mean I’m pretty sure I could get a job stacking shelves in Safeways or whatever but I don’t want to do that.” (4, p.307)). For those who had previously held responsible positions, or whose current level of recovery was fairly high, the possibility of working in an unskilled job posed a particular threat to their self-concept (2, 4, 6), and was attributed in part to low expectations and prejudice towards those recovering from mental health problems ( 1,3,4). For some the very act of working, whatever the role, was seen as a valuable indicator that they were rebuilding their lives (1, 2,). However for many this function was met by other aspects of their lives which might not traditionally be considered work (1, 3, 5); one participant stated “I consider I’m already working. I’m a mother, I’ve been engaged in promoting good practices in mental health….I’m constantly doing things.” (4, p.307). 

Line of Argument Synthesis

 Within meta-ethnographic methodology the final level of synthesis requires the construction of a ‘lines of argument synthesis’,  ‘putting the similarities and dissimilarities  (of the studies) into a new interpretive context” ( Noblitt & Hare, 1988, p.64) The intention is to uncover the emergent relationships between the studies and the production of new perspectives on the question being explored in the meta-synthesis. In this particular instance there appeared to be four meta-themes operating on the realms of the intra-psychic world of the individual and the social domain, the context in which the person is situated. In many ways these themes can be seen to echo those which occur in the current literature relating to recovery, where the process can be seen as a combination of being and belonging.  In the context of this review the themes which arose can be seen to interact with one another and the individual to produce a picture of the meaning and importance of work in the lives of people experiencing significant mental health problems.  The lines of argument synthesis is represented by Figure 1.

Figure 1: Lines of argument synthesis.


Discussion

In many ways this review reflects the role that meaningful activity can play in promoting  the components previously identified as significant in the recovery process such as regaining control over one’s life, rebuilding positive identities, increased connectedness, and the development of meaning and purpose (Slade 2009).  Elements of these factors can be seen reflected in the various meta-themes which emerged in this review. It is important to recognise that these meta-themes do not represent self-contained categories but instead, are interactional, representing as they do the individual and social constituents of both work and recovery. For example, the meta-theme of self efficacy can be seen as linking to both belonging and identity with some of the individual components appearing in slightly differing forms within the functional, psychological and social aspects of work. This perhaps linked to Warr’s (1987) notion of work as promoting social, psychological and practical well-being. In the context of the meta-theme relating to identity, the (re)construction of positive identities and the shedding of stigmatised and limiting  definitions of self  as psychiatric patient promoted self- esteem and  encouraged  inclusion in mainstream society. Similarly, issues which emerged within the meta-theme of belonging such as feeling valued and valuable, relatedness to others and to the wider world can be seen expressed in slightly different forms throughout the meta-themes of  identity and self-efficacy. The findings therefore move towards a more nuanced understanding of the asserted importance of employment in relation to social inclusion, self-esteem, status and identity within the lives of people with serious mental health problems (Boardman, Grove, Perkins & Shepherd, 2003).

 The final meta-theme specifically highlighted some of the instrumental factors associated with work and the nature of working. It may be here that the influence of competitive employment as opposed to other meaningful activity becomes more identifiable. In order for this to be the case it is useful to explore the subthemes in a little more detail. Whilst all of the material presented in the subthemes represented reflections on competitive employment it is questionable whether the mechanisms inherent in either the nature or structure of employment, and their subsequent impact are unique to waged work. Clearly there is value in the structure and meaningfulness of work; however it was unclear from the results whether this value resulted from anything particular about competitive employment. The single defining instrumental characteristic of work in the context of competitive employment can be seen as the exchange of labour for capital. This appeared to be significant in four of the studies where links were identified between generating income, access to a better quality of life, and a sense of personal empowerment and entitlement.  However it appeared from a number of the studies that financial reward was of secondary importance to the meaning and value attached to work itself, and the personal reward experienced by the individual, which might equally be found in unwaged activities. This reinforces the importance of the notion of a ‘meaningful and satisfying life’ as key to recovery (Shepherd, Boardman & Slade, 2008). The secondary importance of financial reward was further complicated by the potential that low waged work could result in increased impoverishment when compared to benefits. It is possible that the present synthesis of qualitative research based on first-person accounts of the role of work in recovery can begin to illuminate the findings of quantitative research that has found that employment does not necessarily lead to higher levels of recovery (Connell, King & Crowe, 2011).

 Before examining the implications of this review it is important to consider its methodological limitations. The review is based on a relatively small number of studies and as with all reviews it is impossible to claim that the original search strategy captured all of the available primary research. It is possible that the search terms used restricted the number of papers retrieved, although systematic searching of the bibliographies of existing literature produced few additional references, suggesting that the limited results reflect the lack of research in the area to date. In addition, within qualitative meta-syntheses the intention is not to identify all of the literature on a particular topic, but specific groups of papers which provide information rich data relevant to the phenomenon being studied. As with primary qualitative research the aim is not to produce statistical representativeness but to yield meaningful accounts of particular phenomena providing additional opportunity for theory development (Booth, 2001). In this instance, the inclusion of peer reviewed papers only may have restricted useful resources available in the grey literature surrounding the topic and at some point in the future a review of this literature might add useful insights into the issue.

Qualitative meta-syntheses allow for the development and reinterpretation of findings across a number of studies with the intention of developing new insights into the issues under review (Bondas & Hall, 2007). In this instance the use of meta-ethnography facilitated the use of a small number of studies to synthesise the original findings and draw additional conclusions. The interpretive nature of meta-ethnography produces methodological questions in itself, one of the most significant of which is researcher bias, both primary and secondary.  It is therefore necessary to consider the following conclusions with the caution that should be afforded to interpretive methods.

Conclusions
Despite its limitations the review offers some useful insights into current understandings of the role of competitive employment in the lives of people recovering from significant mental health problems. Possibly the most significant is the lack of clarity that exists when defining the difference between the value of competitive employment as opposed to other meaningful activity. Whilst the findings suggested that the valued position of work in many cultures offered individuals an increased sense of belonging and purpose, these advantages were by no means universal. The meaning of any activity, both individually and culturally would appear to be as significant as any of the instrumental factors particular to the type of activity in supporting the recovery endeavour. Considerable further research needs to be undertaken into what distinguishes the role of competitive employment and the role of meaningful activity in promoting recovery from mental health problems.

For clinicians engaged in supporting individuals in recovery from serious mental health problems it might be useful to proceed with caution when engaging with the idea that work in itself is a valuable tool for recovery. Whilst there can be little doubt that having rewarding and meaningful activities provide  benefits to the individual, the nature of these activities cannot simply be defined as paid work. In this instance it could be considered as a case of function over form: the meaning and value of any activity to the individual engaged in it is more important than the nature of that activity. On a policy level the advantages of encouraging people into the open market and away from benefit dependency has obvious benefits, not least from an economic perspective, however the advantages to the individual remain unclear.



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