RIWC_PARA_A046 Autonomy with Life Limiting Conditions
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This study explored consumers' perspectives on self-determination, vocational rehabilitation engagement, and recovery. Through qualitative interviews, participants described how self-determination influenced their motivation and ability to engage with vocational rehabilitation services and progress in their recovery. Key findings included that developing trust and an individualized approach in the counselor relationship supported engagement. Having intrinsic motivation, social support, and a view of recovery as an ongoing process also helped drive vocational rehabilitation and recovery. The study provides insights to help improve services and support consumers' self-determination.
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RIWC_PARA_A046 Autonomy with Life Limiting Conditions
- 1. SELF-DETERMINATION, VOCATIONAL REHABILITATION ENGAGEMENT AND RECOVERY FROM CONSUMERS’ PERSPECTIVE: A QUALITATIVE STUDY Jessica Brooks, Ph.D., CRC Geisel School of Medicine at Dartmouth, Lebanon, NH and University of North Texas, Denton, TX, USA *This project was supported by a mental health recovery-oriented research grant from the Hogg Foundation for Mental Health (#RRG-002).
- 2. Self-Determination Self-determination represents a paradigm shift from the “shoulds” to “informed choices” Enabling consumers to participate in treatment as they see fit is consistent with the principles of recovery, an increasingly important concept in mental health services research and policy-making. Recent improvements to the mental health system have included the addition of certified peer specialists (CPSs). CPSs are described as role models to instill hope, engage consumers in treatment, and help consumers access supports.
- 3. Research Questions & Methodology Research Questions: How do peer specialists define self-determination and the underlying meaning of self-determination? How does self-determination influence VR engagement and recovery? What contextual factors affect the self-determination and VR engagement relationship? Methodology used was consensual quality research (CQR)
- 4. Results
- 5. Past Experiences with VR Positive Aspects of VR services Encouragement, hope, support Collaboration in goal-setting and service coordination “It was excellent. I mean it made me want to work harder to begin with you know? She gave me hope and encouragement and she made me see that I was a better person… and just DARS is a great organization.”
- 6. Past Experiences with VR Negative Aspects of VR services Generic, non-individualized recommendations Recommending menial jobs Lack of following up and staying connected “I felt that the options and suggestions were pretty generic. They weren’t necessarily tailored to me and my interests, and my personal goals. It was more cookie cutter, that you know anybody can do this regardless of their skills or their education or their training. You need a paycheck so let’s just go and get you a paycheck. It wasn’t any suggestions that would
- 7. Past Experiences with VR Building the Counseling Relationship Adequate time must be given to develop the relationship between client and counselor “When she realized that I wanted to go to college, it was like OK this is a little bit different than what we originally talked about. This was like the 6th or 7th visit that I had with her.” “I would say the relationship has to evolve.”
- 8. Attitudes Toward Employment Work Values Sufficient time for self-care and other activities Feeling appreciated and welcomed at work Having the opportunity to pursue one’s passion No mention of pay, advancement opportunities “I talked to my doctor and we discussed me working part time, and I thought I could probably do that and not work a full schedule, and feel overwhelmed or feel like I can’t do what needs to be done in a day.”
- 9. Personal Motives for Employment Individual Incentives To be productive, feel accomplished, and have meaning Income (for self and family) Improve mental health and self-esteem More independence and autonomy“…it was a financial thing for me but it was also kind of self-esteem I guess. I wanted to be independent… when everything fell apart in my life, my diagnosis and just not being able to do anything anymore and I needed that, I needed that in my life to feel like part of society and feel like I was worthy… having a job and being out there makes a person feel good about themselves.”
- 10. Personal Motives for Employment Social Incentives To help others To participate in community and be member of society “I didn’t want to sit at home and be a homebody and isolate myself from the world. I wanted to get out..” “I have to feel like I’m doing something that makes a difference, that I’m putting someone’s needs above and beyond my own…”
- 11. Impact of Disability Benefits Chronic condition = lifelong need Benefits counseling does help alleviate anxiety about possibility of returning to work No ambivalence about how much to work “This is the first year that I’m going to probably go to 29 hours, because I feel very confident that if they review my case they can see everything that is in there… that there are no big changes and my recovery is moving forward. I don’t think that it will affect my benefits. So that is what my plan is for 2016.”
- 12. Conceptualization of Self- Determination Self-driven and motivated to reach potential Self-awareness (i.e. goals, needs, skills) Confidence and positive mindset Self-advocacy (and advocacy for other consumers) “I would define it [self-determination] as having a personal drive for self-betterment…How can you take one more step? How can you find the motivation to take one more step? …if you can take one more step ok now you have taken it maybe you can take one more and eventually see the bigger picture and the baby steps of how to get there.”
- 13. Effect of Societal Attitudes (Stigma) Many suggested stigma had little or no effect on VR engagement Others suggested that stigma motivated them to pursue certain jobs (i.e. mental health field) “I never really thought about the stigma…it had never occurred to me I guess. So it really didn’t affect me.”
- 14. View of Recovery Not going backward; keep moving forward Positive thoughts vs. “stinking thinking” Work is a big part of recovery Finding a healthy balance in life while meeting basic needs through working “Vocational recovery to me is being able to go back to work and be back in the work force but also to know what your limitations are. You have to know your limits…to be aware of when things are getting to be too much for you and you have to be able to take a step back. If I don’t take care of myself then I’m going to fall backwards in my recovery.”
- 15. Social Support Families were inextricably linked to recovery Encouragement, support, collaborative consultation Having a strong work culture in the family was a big influence for people Having peer support was also helpful
- 16. Intrinsic Motivation Being passionate about their work motivated participants to strive for excellence Perceived competence based on training and past experiences motivated participants to engage in their role as a CPS “I got certified in May and I started doing all the trainings. You only have to have 20 CEUs per 2 years… and right now I have 85. I want to have the knowledge. I want the knowledge of what I’m doing and how to help others, and what the best way to go about it is.”
- 17. Advice To Others Advice to Consumers Keep focus, do not give up, do not set limits Do your own research on potential jobs or schooling Must advocate for self and take charge of own situation“…just speak up and be your own advocate…nobody is going to do it for you, you have to do it for yourself and if you feel that you’re not getting the services that you need, if you feel that you’re not being bettered by doing what you’re doing, then it’s time to either speak up and change it or seek out something else.”
- 18. Advice To Others Advice to Service Providers Help consumer form realistic goals w/o dismissing consumer’s ideas Do not give up on difficult consumers; have patience Individualized process; do not judge consumer based on diagnosis “…we are people in recovery that have to take the time to learn it [vocational goal] on our own and pushing it on somebody isn’t gonna be the best way. But allowing someone else to make their own choices, giving the freedom to succeed or not succeed…and if they don’t succeed, try, try again.”
- 19. Conclusion
- 20. Rehabilitation Implications Quantitative research Self-Determination Theory and vocational rehabilitation engagement and recovery Self-Determination Theory and other recovery constructs (e.g., job well-being, job satisfaction) Intervention research Designing and conducting pilot interventions influenced by the self-determination theory
Notes de l'éditeur
- The primary aim of this stage of the research project was to conduct a participatory action research study with peer specialists with the lived experience of mental illness to gain insights about the underlying meaning of self-determination and its relationship with VR engagement. Vocational rehabilitation (VR) services can help people with SMI to overcome employment obstacles, refocusing them toward the world of work, and subsequently, onto the path to recovery. Although evidence-based VR practices often lead to successful recovery-oriented outcomes, many individuals with SMI do not seek help or terminate services prematurely (Corrigan, 2004). Hence, there has been a call for change in mental health service delivery approaches (Corrigan et al., 2012). SMI is a persistent mental health condition that significantly impacts functioning in multiple life domains, especially the work domain (Dunn, Wewiorski, & Rogers, 2010). The staggering low rates of employment range from 20% to 25% for people with schizophrenia and related disorders. Difficulties with finding/maintaining employment can be detrimental to the health-related quality of life and overall well-being of individuals with SMI.
- To improve recovery outcomes, the field of mental health is implementing a paradigm shift by encouraging consumers to be self-determined and active participants in all aspects of the treatment and rehabilitation process, including medication, interventions, and employment (Corrigan et al., 2012). Using principles of self-determination to guide mental health services can foster self-determined motivation, thus reducing mental health symptoms and enhancing treatment engagement (Saperstein, Fiszdon, & Bell, 2011; Strauser, 2014). Paradoxically, there have been limited studies on the theoretical basis for self-determination as a guiding framework for mental health recovery. However, the self-determination theory of human motivation (SDT; Deci & Ryan, 1985) has been used to enhance motivation and treatment engagement in other contexts (Ng et al., 2012). Ryan and Deci (2000) posit that people are more likely to participate in an activity when they have a sense of autonomy, competence, and relatedness. Furthermore, autonomy-supportive social environments play an important role in facilitating self-determined motivation, as well as optimal functioning in educational and work settings. The theory of self-determination (SDT; Deci & Ryan, 1985) describes how human beings achieve goals, reach self-actualization, and experience a higher quality of life while in treatment, healthcare, or other contexts that support the realization of fundamental human needs, including competency, autonomy, and relatedness or feelings of connectedness to others (Reeve, Nix, & Hamm, 2003; Ryan & Deci, 2000). Self-determined individuals are more capable of dealing with setbacks or difficulties related to their goals, whereas individuals less self-determined are prone to giving up, especially if contingent rewards are removed. For people with SMI, experiencing substantial personal (e.g., premorbid occupational functioning, cognitive functioning, severity of illness) and contextual barriers (e.g., work disincentives, perceived workplace stigma) to gainful employment, can be difficult to overcome without a self-determined recovery goal to sustain engagement in vocational rehabilitation services (Fitzgerald et al., in press).
- Gathering the Research Team Typically 2-3 coders, 1-2 auditors Develop a semi-structured interview protocol and conduct interviews with 12 participants The goal of the interview is to capture the phenomenon with as little researcher bias as possible Develop domains and core ideas Domains: List of topics that broadly describe participants’ experiences Core Ideas: Summarizes the domains Cross-Analysis Developing categories and common themes across participants Tallying the data Frequency of participant endorsement in each domain and/or category
- “To begin with we weren’t really on the same page, and I attribute that to the fact that I was closed off and you know I didn’t want to be there. But once we had a good relationship and I started opening up to her about who I was and what I was interested in and what I wanted to go to college for and all that, we were on the same page and she understood my passions in life more. And she didn’t really want me to have some just flipping burgers job, she really encouraged me to aim higher than that and go for something better.”
- “I was a pre-k teacher and I had a set back where I got locked in a psychiatric ward for a week mainly for medication management…I had to take a short leave of absence from work, and when I went back to work, the parents of the children in my classroom found out why I was gone…and suddenly after a year and a half I was no longer capable or fit to take care of their children, I was no longer trust worthy…so that affected my decision to leave and kind of put the thought in my mind that I was incapable of working anymore…I applied for disability and I was denied and decided at that point to go back to school, and get another degree this time in psychology, and work more towards mental health and try to fight that stigma. So it really affected me with not wanting to work, but at the same time, it affected me in wanting to go back into a different field.”
- Psychometric studies.. Which would eventually lead to policy changes if there is supportive evidence..