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The aim of the study was to investigate the following research question: How do participants perceive and handle symptoms and work, following metacognitive therapy and work-focused interventions? First we present themes related to ways in which the participants had changed their perception of their mental health and their situation and the context of this change. Secondly, we present themes addressing the ways in which the participants changed the way they handled their work and their mental illness.
Change in perceptions of mental health and work
Increased awareness and a new understanding of their situation
We found that most participants stated that they had reached a new understanding of their mental health problems. They had gained an increased awareness of the different ways in which their depression and anxiety affected them both physically and mentally in their personal life and at work. Several participants explained how, prior to therapy, they sought treatment for somatic symptoms, but later learned that these symptoms were related to their anxiety and depression, rather than being a somatic illness. In the quotation below, the participant worried that her symptoms indicated a serious underlying somatic disorder such as multiple sclerosis.
I was so tired, I had never experienced this, having physical symptoms, I had headaches every day, I was numb, my legs were tingling, my lips were numb and other strange things so I got very scared (…) I had started thinking that I might have multiple sclerosis or a brain tumour or something, that is why I went to see the general practitioner.
In therapy, they also learned how their worry and rumination were affecting their cognitive abilities, such as through reduced concentration, which resulted in difficulties doing their work or some parts of their work. Initially, many described how their anxiety and depression were affecting them with several negative consequences before they received therapy. They described situations where they felt that they had lost control over their lives and that they were not functioning at work. Below, two participants explained how this was affecting them in different ways:
If you have obsessive thoughts and anxiety of making mistakes at work as a nurse then you kind of have to do something about it before you can go back. I got a very physical reaction from the anxiety, like I almost collapsed at work.
I do feel a lot of sadness, loss of function; having a feeling of losing myself. I was not functioning. I do not have any experience with this from before so it was a very scary situation to be in, and the sick leave was like a confirmation; You are not well enough to go to work.
Some participants described how they initially felt ashamed about their situation. They had never imagined themselves struggling with mental health problems and being on sick leave. Some were worried that they would lose their mind as a result of all the strange thoughts they were having. However, meeting an empathetic therapist, who validated their emotions and feelings and gave support, not only contributed to a better understanding of their symptoms, but also to a reduction of their shame. They realised that depression and anxiety were common, and that others suffering from these illnesses often experienced the same mental processes, such as worry and rumination, and that the coping strategies that they had used before treatment maintained rather than reduced their mental health problems.
Improved self-confidence helped to get ready for work
We found that becoming more aware of their worry and rumination, and learning how to relate to these processes differently, created greater understanding. This contributed to a form of security, and gave the participants the feeling of regaining control of their thought processes and ultimately of their lives. The quotation below illustrates how one participant experienced reduced work functioning, and therefore believed that he had ruined his ability to concentrate and then also his ability to perform his work. As he learned to use the new techniques, his worry and rumination were reduced, and he then regained his concentration. This experience was important to him, increasing his self-confidence and self-belief as well as his ability to handle similar symptoms and challenges at work in the future.
It took a long time, and then suddenly I managed it one way or the other and found the concentration I needed, and then I had already started wondering if I had ruined my ability to concentrate, and yes, it is a lot about mastery, I believe in this process for me, to understand that you can, and then suddenly the thoughts calm down and then the concentration comes.
We found that several participants emphasised, in different ways, that they felt in charge of their own processes, and that this was another important way of increasing self-confidence. One participant explained:
I could gradually return to work, feeling that I was in control – now that I was ready for it. And then I felt very ready, and I went to work and it went well.
As mentioned in the quote, they felt in charge of when they should RTW, but also of what happened in the therapy itself.
He (the therapist) took things very gently, so I always felt that it was on my terms. However, he made suggestions and asked questions like: What do you think about this or is this something you would consider trying, after he had justified an exercise.
Being given different techniques and exercises that they could try out, feeling that the treatment was adjusted to them and their needs, and being able to do things at their own pace all helped them to get ready to RTW. Understanding the reasons for, and meaning of, the therapeutic exercises and interventions also gave them an insight into how their mental information processing worked which made the tasks more meaningful.
Even though they stated that they felt in charge of the process, several participants also emphasised that they felt pushed by their therapist, in a positive way, for example to try various exercises at work in between sessions. As one participant mentioned:
“Things that I found uncomfortable, I got pushed to do it anyway”.
This made them try things that they had thought they were not ready for, which often gave them positive experiences.
Handling work and psychological symptoms in a new way
Learning new strategies to handle work
During treatment, the participants became aware of how they reacted, and worked on changing how they related to their thoughts and thinking. One example of this was not engaging with thoughts that triggered ruminations. By doing this, they realised that the strategies they had been using had acted to maintain their problems. One participant explained how she realised this:
I thought maybe that my difficulties were related to the fact that I needed to control my thoughts and what was happening within me and if I were to let go, I would lose control. (…) I was afraid of my own head and afraid of what would happen if I did not stay in control. It was a huge step at the start of the treatment to dare to test out other things, and get a concrete proof of what I had thought the whole time was wrong. That it was not more control I should strive for, but maybe a more relaxed attitude to my inner self.
In the quotation, the participant states that she was trying to control her thoughts, and that trying to do this made things worse for her. When she discovered that she did not have to try to control her thinking but could choose whether to engage in her thoughts or not, then everything changed. For the majority, becoming aware of this was an eye-opener that enabled them to handle and relate to things both at home and work differently and then also reducing their symptoms and not taking up so much of their time.
Overall it was actually about just letting things be. Not ponder on things. If there is a thought that is strange or you think is scary then you should just leave it alone rather than worry about it. And if there are things I cannot do anything about, then there is no point in worrying about them. Also, then, it is actually just to leave it alone, not try to push it away, but just let it hang there. And that was something completely new. It was the opposite of what I had tried for the last 20 years.
Also, participants explained how they learned that monitoring and engaging with their very critical inner voice maintained their mental health problems which then took up a lot of their energy and capacity to for example conduct their work. Being able to refrain from the perseverative thinking process like worry gave them more energy.
I realised that I used a lot of time criticising myself, and I had not really thought about that. So, when I managed to stop with that, then I had a lot of energy left. That was really the turning point.
During the treatment, the participants were encouraged to increase their presence at work and try out their new strategies there. Many considered their work important, valuing its meaning and seeing it as providing a place of belonging. For some, the workplace was a positive place or a space where they could focus on work rather than their problems. Having increased their insight into mental health problems, some realised that avoiding work and, for example, avoiding meetings, was not good for them. If they were to get better, they had to learn how to handle it.
Another possible strategy to better handle work was making adjustments at work. As a result of reduced work function, participants were not able to work as fast or at the same level as they had before. Because of this, and also if they were partly on sick leave, they needed to adjust their work situation, for example by only doing certain tasks. Some noted the importance of doing things they enjoyed or found motivating, and that they needed to change their work routines and their attitude towards their work.
Specific things like before you leave work you should make a plan for tomorrow, focusing on completing one thing before you start another, and that kind of specific rules, that we made together, are very useful, so I have written it down, so when I start my computer, they are in front of me.
Being open about mental illness at work
We found that there were large variations in the participants’ attitudes towards openness about mental problems at work. However, they had all considered how to relate to this issue. Several participants stated that they were selective about the kind of information they disclosed and to whom. Also, some noted that they chose to share information with people who would give them support and recognition about their problems. However, for some, being open at work was not an option. This could have been because of the type of work or the work situation. It was also noted that it would be easier to talk freely about struggling with something else, rather than with a mental illness. A couple of participants described not being met with understanding when talking about their symptoms and that this was a painful experience.
That is probably typical, those who do not give support, take more focus than those who give support, I notice that it makes me feel a bit betrayed. It is complicated at a workplace, talking about it, it is of course a lot easier to break a leg, than to say that you have mental problems, but I stood for it facing most people at least, but it is exhausting to have it, it would have been easier to be home because of something else.
However, the majority of the participants who had been open about their mental illness at work said that they had been received in an accepting and empathetic way, and that this support and understanding was important when returning to work. Sharing information about their mental health facilitated an interaction with their supervisor or colleagues that made returning to work easier for them. For some, openness led to understanding from the supervisor, and this resulted in a temporary reduction of demands and pressure at work which facilitated the RTW process. One participant, who stated that she told her supervisor everything, said:
The most important thing was actually to go to her and tell her what was working for me or not. And that she understood why, and that I did not have to come to work and pretend that everything was fine when it didn’t really feel like that. It was one thing less to worry about, that I didn’t have to conceal how things were.
Handling future problems at work
At the time of the interviews, all the participants stated that they were doing better, and were feeling stronger and more secure in the ways in which they related to their problems, regardless of whether they had returned fully to work or not. Many felt that they had completely recovered and had a very positive outlook on the future. Some participants who had been struggling with anxiety attacks noted that they had stopped having them, while others explained how they had stopped ruminating and worrying. This resulted in a completely different life.
I handle things in a very different way. Have more energy, and I just feel that it has helped me a lot. In a short amount of time really.
Other participants explained how they were doing better but still struggling with different types of symptoms. They were glad to have fewer problems but also described that they had accepted that they had anxiety symptoms, and were now less worried about it. An important aspect was that they believed that they would recognise maladaptive thought processes earlier, and therefore, would be able to act sooner and handle future problems better. One participant explained:
Most importantly for me is that I know what to do and I know that it works so if I get worse again I know I have the tool, and that is a very big relief in itself which reduces the worries.
As in the quotation above, the participants in general described a more positive outlook on the future. Increasing their awareness and understanding of their own mental-health issues and learning new techniques and strategies made them feel more secure about themselves and gave them the sense that they would be able to handle potential future problems in a better way than before. However, a couple of participants, who were still struggling, were concerned about future problems and their ability to use what they had learned during the treatment to handle their work and their symptoms.
In a way I have instructions regarding how I can handle this, and I try to use them when I have these negative thoughts, I try to use the tool. But it is not very easy so I do not know, I do not know if I can handle it on my own.
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