In the interviews, the therapists described the main goals and premises for their practice and how they sought to help participants move towards these goals through what we identified as processes concerning 1) ownership, 2) causes of sick leave, 3) relation to expectations, 4) the values of work, and 5) the scope of agency.
The therapists’ goals and the premises for their practice
The therapists described the overarching goal of the rehabilitation as twofold: to support participants in building both a meaningful life and sustainable work participation for the rest of their occupational life. Neither of the goals were perceived as definite endpoints, but rather as processual activities to be maintained continuously throughout life. The therapists described the goals as closely intertwined and emphasised that it was necessary to approach the participants as whole persons, not just employees, to help them achieve sustainable work participation. Both ACT and the biopsychosocial model were described as larger frameworks for practice that allowed the therapists to address and normalise the interrelationship between body, thoughts, emotions and behaviour. While the biopsychosocial model was referred to as a general framework, ACT was described as the theoretical and practical approach that permeated and guided all aspects of the rehabilitation. The main objective of this approach, increasing psychological flexibility, was described as so comprehensive that it proved beneficial to all areas of life, including work participation. While the therapists sometimes emphasised different processes in the ACT model as important to participants’ RTW-process, no conflicting perspectives were found in the data material. However, several therapists described that the diversity in therapist and personal experience sometimes provided them with different perspectives and understandings of specific participants and that frequent discussions benefitted them, and in turn, the participants. In addition to ACT, the therapists frequently referred to research on how to facilitate RTW. They commonly stated that work is health promoting, and that the most beneficial approach to secure sustainable RTW is a quick return in a graded position with a progressive increase in work hours. However, the therapists emphasised that the RTW process is highly context-specific and had to be attended to individually.
Processes of change
The therapists often referred to what they considered participants’ common challenges to move towards a meaningful life and sustainable work participation, and how they tried to facilitate this movement. We identified five processes the therapists attempted to instil: 1) enabling ownership of the process of change, 2) identifying the complex causes of sick leave, 3) changing how participants relate to own and others’ expectations, 4) unfolding the values of work, and 5) exploring the scope of agency. The therapists described how the changes they sought to facilitate were long-term processes that exceeded the timeframe of the rehabilitation program; they could only help instil them and enable participants to uphold them on their own. If not stated otherwise, the processes were attended to simultaneously throughout the rehabilitation program and did not follow a specific order.
1) Enabling ownership of the process of change
A recurring theme in all interviews was the necessity of enabling participants to take charge of and actively engage in their own rehabilitation process. Many therapists said that most participants initially expected to receive qualified advice and treatment that would improve their health situation and subsequently lead to work participation. They often sought external aid in their search for recovery as numerous previous attempts had failed. To counteract this passive search for a ‘quick-fix treatment’, the therapists said they let participants define their main challenges and personal agenda for the rehabilitation and refrained from providing advice.
The therapists all spoke of the importance of making the rehabilitation program personally meaningful to each participant; one way of ensuring this was to let them delineate their main challenges. According to the therapists, all participants found that their health problems had consequences for their life in general. If measured against RTW, the consequences concerning close relationships, such as family, were often perceived as more important. However, the majority of the therapists stated that addressing the topics chosen by the participant usually entailed simultaneously attending to their RTW process, as the underlying reasons for these difficulties often coincided with those causing sick leave. The therapists described the necessity of patiently building a trusting relationship with their participants by validating and normalising their experience, sometimes by sharing personal experience with the themes addressed. This was seen as a prerequisite for the participants to be open about their difficulties so the therapists could gain an understanding of their life situations, and later be able to address sensitive topics. Exploring and understanding the participants’ own assessments of their problems was referred to as a means to finding the core of participants’ difficulties, and was linked to being able to target the changes needed more effectively. A few therapists said that in some cases, they waited to address work participation until compiling the RTW plan towards the end of the program if the participants did not address it themselves. However, the therapists predominantly described that they gradually envisioned how the participants’ chosen topics were relevant for their RTW process.
There is nothing that cannot be talked about, and I believe this is new to many [participants]. “Wow! Can I talk about this? Can I be taken seriously and open up for things I have carried alone?” […] But after a couple of sessions, we start to address: “How does that affect my work situation?” and “what do you believe has to change for you to be able to stay at work, or return to work?” Because the pattern you have at home, you often have at work as well. There is a red thread increasingly leading towards the work situation, which, in the last session, results in a return to work plan. My sessions often concern the whole life [of the participant], and then we increasingly boil it down towards the work situation. – Phillip
The therapists further described how a key component of the rehabilitation program was to help participants move purposively towards what they considered meaningful in life, i.e. to live more in line with their personal values. Several therapists said that they refrained from presenting RTW as the sole agenda of the rehabilitation program, and rather attempted to show participants that they had their best interest in mind, regardless of their ability to work. The therapists described this as having the same goal, playing on the same team, or sitting in the same boat. Values were often likened to personal characteristics concerning whom you want to be and how you wish to be perceived, such as being a caring mother, being creative or contributing to something greater than yourself. Some therapists said that personal values did not necessarily coincide, and sometimes were at odds, with work participation. However, most therapists explained that they believed working towards a more meaningful life in general would create positive ripple effects in all areas of life and the likelihood of RTW would increase simultaneously. This was often referred to as the transfer value or spread of effect. Several therapists said that the participants’ closeness to resuming work had to be considered, and that prematurely introducing the topic of RTW was possibly counterproductive.
Sometimes it can be very advantageous to work solely on work participation, to push the topic of work. Then again, sometimes it is disadvantageous, and creates a lot of resistance. […] So, you often work with other life areas: relationships or self-care, health. You might work a lot in those areas. And then you have somewhat turned your back on the work situation. […] But then again, you know that you are working to increase quality of life. And if you increase quality of life, you most likely increase work ability as well. – Oscar
All the therapists explained that they strived to refrain from providing advice to spur the participants’ initiative to take charge of their own rehabilitation process and become more self-reliant. The therapists recognised that this could be uncomfortable for the participants since no alternative suggestions for action were presented, however, it was seen as a necessity to ensure that all new actions were initiated by the participant and experienced as personally meaningful.
They have tried so many things, things they have heard about from others, things they have read about, advice they have received. This is supposed to be more like something you have learned yourself, something you actually find important. That possibly makes it more persistent. Yes, something you truly believe in, that you have experienced works, or doesn’t work, or whatever it might be. I believe that’s the point. It’s more durable and more meaningful. – Nora
While the therapists said they believed not sharing their opinions was beneficial to the participants’ process, all expressed that they found it difficult or frustrating, especially if the participants’ perceptions diverged from their own. Some even said that they initially perceived it as counterintuitive to how they worked to help patients previously. Not providing advice was described as necessary to adhere to the ACT approach. The therapists explained that the alternative was to patiently pose numerous questions to help participants gain a new perspective of their situation and ask for their willingness to explore difficult thoughts and emotions as well as alternative actions. While acknowledging that this approach was more time consuming, the therapists believed it ensured greater commitment.
2) Identifying the complex causes of sick leave
A view commonly expressed by the therapists was that health problems often emerge and persist based on interrelated factors that, combined, affect health negatively. They said many participants perceived physical symptoms to be their main health challenge and believed these had to be significantly reduced before they could resume full work participation. While agreeing that physical symptoms were central to the difficulties participants experienced, the therapists said it was important to expand participants’ understanding of what caused symptoms to emerge, worsen and persist. Therefore, the therapists sought to help participants recognise how their symptoms were influenced by a complex mixture of burdens and by how they related to them.
The therapists all considered it important to help participants become aware of how the combination of burdens in their lives affected both health and work participation negatively. They explained that many elements in life other than work contributed to generating, sustaining and worsening symptoms participants experienced. A few added that being on sick leave only relieves one from duties related to work, not other areas in life. The therapists described helping participants identify challenges they experienced in all areas of life and investigating the connections between them. This was also addressed in an educational session on stress during the participant observation of the rehabilitation program, where the therapist used a metaphor of a glass filling up with water to exemplify how stressors accumulate over time and eventually spill over. He explained that while we have a natural tendency to identify the last occurrence as the reason for health problems to appear, the totality of stressors is often the cause.
The therapists also spoke of the need to make participants aware of how their health situations were influenced by the way they related to them. Several therapists stated that excessive focus on symptoms or arduous attempts to avoid them affects how symptoms are experienced in the present moment, and to what extent they are maintained. One therapist described this as a process of becoming increasingly aware of causation:
Pain is one thing; suffering is another. […] [Suffering] is all the collateral problems related to pain. The way you relate to it negatively affects all the areas it influences. It might contribute to sustaining some of the suffering instead of just refraining from that battle. […] Just realizing that often results in awareness of the problem and the cause. It’s a nice thing, that process of becoming aware and realizing how being affected by being in a conflict has resulted in chronic back pain because patterns, patterns, patterns have built up and problems have worsened. And you are tired because you fight against it all the time. So, I believe it is important to also work on that awareness. The experience of the cause and what has sustained it, often changes during those four weeks. – Oliver
The therapists often said that they aimed to help participants become aware of how patterns of thoughts, emotions and behaviours acquired throughout life influenced their current health situation. Several also spoke of the need to address participants’ relation to past experiences if they were considered to cause inappropriate patterns in the present. One therapist explained that he sometimes considered the relationship to traumas as the underlying cause of sick leave. While assuming that participants would possibly be able to resume work, he predicted that they would experience reoccurring sick leave if this relationship was left untreated. The therapists all described helping participants relate to thoughts and emotions as subjective assessments instead of representations of truth. One therapist stated that the common approach of the rehabilitation program was to expand participants’ view of their rehabilitation process by understanding thoughts, emotions and behaviour as an essential part of their health problems and recovery:
Those who come here, they come with their body. With pain, with exhaustion. And they say: “I am tired, and it is my body”. And then we say: “Rehabilitation is about something else. Rehabilitation has to do with the one who has that body, the one who has all these things. And that is why we start to talk about thoughts, emotions, behaviour, to start noticing what happens when you are in contact with that body”. Because this is often where the struggle takes place. […] And to start noticing yourself as an agent in relation to your body. What they have done has actually worked, until the body stopped. And they wish to continue the same way, but the body doesn’t allow it anymore. And then the question is: “What does that mean? Does it mean that you have a disease, or do you have to start relating differently to life?” – William
3) Changing how participants relate to own and others’ expectations
A recurring theme in the interviews was the importance of addressing the various expectations the participants experienced. The therapists described that many felt distressed by not being able to satisfy demands and expectations from society, their workplace, and close relations, but few had shared to what extent their health problems affected them. According to the therapists, many were hesitant to reveal information to their employers or colleagues, as they feared being perceived as vulnerable, having their health problems questioned or considered it private. While the participants often attributed expectations to their surroundings, the therapists considered them to frequently originate from participants themselves. To help participants relate more soundly to expectations, the therapists explained that they sought to help investigate the source of participants’ expectations and adjust them to a realistic level according to the current health situation.
The therapists said they wanted to help participants investigate the extent to which they themselves were generating and upholding the expectations that proved stressful. They acknowledged that all participants faced expectations from various sources; concerning work participation, several pointed to a general societal expectation of full employment and productivity. In addition, the majority used words such as shame and stigma to characterise the perception of long-term sick leave due to the diagnoses common to their participants. The therapists did, however, state that these perceptions influenced and shaped participants’ views of themselves, and mainly were present as internalised expectations acquired throughout life, some even instilled from childhood.
We see many parallels to upbringing. […] They bring with them this ‘productivity reflex’, that you should be productive all the time. […] And then they feel inadequate. But mother did it, grandmother did it, great grandmother did it. – Lucas
These internal expectations were considered potentially more harmful to participants’ health than expectations from others, and several therapists portrayed them as being unconsciously present and a constant driving force of action, one referring to them as an inner whip. Some also linked this to a tendency to assume that others have expectations, without having been told so directly.
In order to relate more soundly to various kinds of expectations, the therapists said they believed participants would profit from adjusting expectations according to their current health situation. One aspect of this was to help participants accept their current level of functioning; during the participant observation, this was explained by the gap model in an educational session on pain. The therapist drew two graphs on a whiteboard that gradually dispersed from one another to illustrate the increasing gap between the function participants tried to uphold and their true functional level. He then explained that this incoherence eventually leads to stress that influences health negatively and said that the ability to accept the current situation is crucial to lowering expectations of oneself to a realistic level.
The therapists further spoke of openness towards relevant others as either important or a prerequisite for reaching an alignment between level of functioning and expectations from others. Several therapists mentioned that participants needed to enforce their own limits, as no one else would do so for them, and that neither family, acquaintances, employers, nor colleagues could be expected to lower their expectations unless the participant explicitly communicated this need. The therapists also said they encouraged participants to expose their vulnerability instead of trying to uphold an image of themselves as strong and productive.
A lot of research shows that if you try to cover up vulnerability, hide it, then you spend a lot of energy on trying to be someone else. This concerns the participants’ own expectations as well as the employers’ expectations. […] It is hard to adjust expectations if the one you work with always portrays everything as okay. Then you are met with the same expectations. And you get frustrated because no adjustments are made. […] This leads to a downward spiral until everything stops. And then the employer is like: “Why did it stop? Wasn’t everything okay?” – William
While all the therapists said they encouraged participants to be open with employers and/or co-workers, several also emphasised that each participant had to delimit how much he or she wanted to share, to whom and when. They stated that ‘being open’ could be interpreted in several ways; one therapist added that the degree of openness had to be considered relative to each participant’s specific workplace:
You have to assess the individual context. “How is the dialogue with my employer or colleagues? What is the policy in our workplace?” You must figure out that for yourself because there are no explicit rules. […] I have experienced that they are not motivated for tears and openness at all in male-dominated occupations with a tough jargon. So obviously, being open might simply entail being explicit. – Emma
4) Unfolding the values of work participation
The therapists all explained that a central aspect of the RTW process was helping participants rediscover work participation as a personally meaningful activity. According to the therapists, almost all participants stated that they aspired to resume work and that work participation was very important to them. However, they predominantly referred to work participation in terms that suggested it to be a mandatory activity and an economic necessity. To expand this perception, the therapists said they attempted to help the participants unfold values connected either directly or indirectly to work participation and explore the connection to other areas of life.
The therapists described that unfolding values in all parts of life was essential to provide participants with a continuous direction that guided actions throughout life and led steadily towards a meaningful life and work participation. Exploring the values connected to the area of work was often portrayed as a perspective that was diametrically opposed to the participants’ focus on how health problems or external factors hindered work participation. A few therapists occasionally referred to work participation as a value in itself. However, the therapists predominantly considered work as a field or area where values could be attended to. They explained they sought to help participants explore what they found meaningful to their specific positions, or work participation in general, by posing different questions.
“Why do I go to work? What does my work give me? What can I contribute to at my work, and what can work contribute to for me?” And that is the colleagueship, the social interaction, to use your competency or the possibility to develop, to get paid, financial security, to contribute to something greater, like society. Be part of something bigger. Those things are often the values. […] Regardless of whether you are a mailman or a pilot, you will have some of those things. Community, pay, contributing, developing. And then the question is simply: “How does it play out in your life?” – Oscar
In addition, the therapists stated that they helped participants trace the link between work participation and other personal values. For example, the value of contributing to others could be attended to in the area of work, but also in everyday family life, by undertaking posts in organizations or engaging in voluntary work. Work participation could thereby be regarded as one of many activities that make it possible to continually fulfil personally meaningful values. This more indirect connection between values and work participation was considered particularly important in cases where participants did not experience their current work situations as meaningful. One therapist described how he helped participants discern how values connected to other activities could be brought into their work situation in the following manner:
Some of the time could, perhaps, be used to plan how you will find something that is meaningful and exciting, that which gives you something more. And you can find that when people start to talk about “I want to do that”, you can mirror it: “Now I see something happening to you!” Right? “Oh, I enjoy travelling”, “Okay! What do you enjoy about travelling?”, “Then I am optimistic, I am in a better mood, I cope better, I experience new things, I am curious, those kind of things”, “Okay, so you are curious and want to experience new things? Is it possible to bring that into the work situation, to give that some room?” – Oliver
The therapists generally described that unfolding the personal motivation for why one should work provided a stronger foundation to secure work participation than the normative assumption of having to work. Most of the therapists spoke of economic concerns as a poor incentive to uphold work participation. However, a few therapists said they sometimes adopted what they referred to as a pragmatic approach. At times, participants considered values that could not be realised through work participation as the most important in their lives, leaving the area of work irrelevant. One therapist explained that he would then acknowledge and address the economic necessity of work participation as a prerequisite for these values to be attended to:
You can always assume a more pragmatic approach. “What is most important in your life?”, “My family. Go hunting. Being outdoors two weeks a year”, “Okay, so work is not important?”, “No, I can have any kind of job, it doesn’t matter that much”. But for the clear majority, unless they wish to live a very ascetic life, in Norway, you need a job. If only to have the financial freedom to do the other things that are important to you. And as long as you perform well enough to keep that job, we can call that a daily goal: “Complete the workday so I can focus on what really matters to me. Tuesday: complete the workday so I can do what is important to me. Wednesday: the same”. – Lucas
5) Exploring the scope of agency
A recurring theme in the interviews was the importance of helping participants explore their true possibility of influence and encouraging them to take appropriate action. The therapists described that many participants came into rehabilitation believing that their surroundings and/or health situations had to change before they could resume work. According to the therapists, some participants undertook excessive activity in attempts to avoid difficult thoughts and emotions or change their work environment. In contrast, others remained passive, believing they had little influence. The therapists therefore considered it important to help participants explore limitations and possibilities of influencing various conditions and instigating actions coherent with personal values when appropriate.
The therapists all described that they aimed to help participants investigate whether they could influence and change a situation, or if doing would be a futile attempt inducing stress and further deteriorating their health. The therapists spoke of several external conditions as impossible to change or control, such as health and welfare services, the structural organization at work, or the personality of employer and colleagues. Internal conditions such as pain, exhaustion, thoughts and emotions were also identified as impossible to control through will. The therapists said they tried to help participants accept the circumstances they were not able to change. However, several emphasised that acceptance was a concept that could easily be misunderstood and thus had to be explained and treated cautiously.
I believe many connect ‘acceptance’ with resignation. It’s very important to address this when we use the concept of acceptance since many get provoked by it. And you have to use it respectfully, because it is not the same as resignation […]. You may refer to something as mundane as the weather: “I actually have to accept that it starts raining, I cannot change that. Or I can choose to spend a lot of energy. I can sit and talk about the rain all day, use all my energy on that. But is that what I want with my life?” That is one way of explaining acceptance. – Emma
The therapists further described that a key element of the rehabilitation program was to encourage participants to commence committed action regarding the situations they could influence and that ideally, these actions should be coherent with their personal values. Several emphasised that what they considered proper insight or understanding included the participants’ ability to practice the knowledge they developed during the rehabilitation program. The therapists all placed great importance on helping participants become aware of all the small choices they made during the day and question whether they actually had to do the things they perceived as mandatory. This was portrayed as diametrically opposed to unconsciously acting according to old patterns on autopilot, and was referred to as breaking habits and patterns, getting out of the usual track or giving oneself more room to manoeuvre. This availability of choice was described as liberating and empowering, but also frightening to some participants. One therapist pointed out that becoming aware of choices did not necessarily mean that participants chose different actions, but that it could lead to a feeling of assertiveness:
One of my recent participants said: “I have made a stop now and have felt that I actually have choices. And often I might make the same choice as before, but I feel that I made a conscious choice; it was not forced upon me by others”. And that became very important to her. I believe many acquire a perspective like: “I am at the helm. I drive this bus”. And that is not always easy, but at least there is more awareness of what you are doing. It doesn’t solely occur on impulse. You stop, check in on how you are feeling, and think it through. – Phillip
The therapists said they evaluated changes participants planned to make on the grounds of its feasibility to lead towards a meaningful life and work participation. While some participants suggested actions that the therapists considered appropriate, others did not. In these cases, the therapists described how they employed several approaches, but emphasised that they had to do so in a non-judgmental and curious manner to avoid creating resistance and to keep with the aim of enabling ownership. They explained that they initially attempted to help participants discover for themselves why their plans were inappropriate by posing questions intended to help participants become aware of how similar actions had not worked in the past or were incommensurate with their personal values. The therapists emphasised that not wanting to work or feeling unable to work could be a consequence of attempting to avoid difficult thoughts and emotions, since what is experienced as meaningful is not necessarily experienced as pleasurable. Several therapists spoke of their attempts to help participants differentiate between these emotions. Some did so by envisioning the ambivalence on a blackboard, others by encouraging participants to notice how thoughts, emotions and bodily sensations shape the experience of the present moment and asking if participants could make a conscious shift to act according to their values.
They get a tool, a specific tool: how to work on destructive thoughts and emotions, how to live with bodily symptoms that don’t disappear, to bring them along with you, and still work. I find that unique. Becoming aware of that choice can be a great change. They might hurt, have difficult thoughts and emotions, and still move in the direction they want. And many want to work. Becoming aware of that, wanting to contribute to society that way is important to many. That’s my experience, that the majority actually want to work. – Sarah
Several therapists described a feeling of being unsuccessful if participants nevertheless decided they were unable or did not want to resume work at the end of the program. However, they also said that they sometimes supported participants’ decisions to delay RTW, reduce their positions or resign to seek new employment if they considered it appropriate in a long-term perspective. While many therapists explained that they sometimes found it difficult not to follow up participants after the rehabilitation, several referred to their work as planting seeds that would continue to grow beyond the timespan of the program. Their role as therapists was thus to enable participants to continue their course autonomously.