Perspectives of unemployed workers with mental health problems: barriers to and solutions for return to work.

Abstract Purpose: To evaluate the barriers to and solutions for return to work (RTW) from the perspective of unemployed workers who were sick-listed due to mental health problems. Methods: We conducted semi-structured interviews with 25 sick-listed unemployed workers with mental health problems. Qualitative data analysis was performed, using a process of identifying, coding, and categorising the patterns in data. Results: All workers experienced multiple problems in different domains of life related to their disease, personal circumstances (e.g., divorced, debts) and their environment (e.g., labour market problems, issues with the Social Security Agency). Workers differed in the way they perceived their RTW process and in the extent to which they were able to envision and implement the solutions for RTW, thus resulting in three types of workers’ attitudes towards their own RTW process: (1) “frozen”; (2) “insightful though passive”; and (3) “action mode”. Conclusions: We conclude that the sick-listed unemployed workers with mental health problems have to deal with multiple problems, of which medical problems are only a part. These workers need help aimed at their coping methods according to one of the three types of workers’ characteristics. Moreover, they need specific help organising and structuring their problems, getting their life back on track, and finding employment. Implications for Rehabilitation Unemployed workers with mental health problems face considerable challenges which impede their return to work. Evaluating the workers’ attitude may provide useful information on their own return-to-work process. In many cases, workers indicate a need for coaching to help them with problem-solving, planning, gaining structure, getting their life back on track, and finding employment. Rehabilitation professionals should tailor RTW interventions to the needs of these workers, aimed at their specific problems and taking into account the workers’ coping methods according to one of three types of workers’ attitudes towards their own RTW process.


Introduction
In recent decades, sick leave due to mental health problems such as depression, anxiety, and stress-related disorders has increased considerably worldwide. Mental health problems are currently the number-one cause of absenteeism (40%) and work disability, including disability pension, in many high-income countries, causing a considerable economic burden on society. [1][2][3] Sick leave due to mental health problemsboth severe [4,5] and less severe [6][7][8] is associated with prolonged work disability, and contributes to permanent exclusion from the labour market. [1,2] Workers who do not or no longer have an employment contract (also known as nonpermanent workers), such as the unemployed, temporary agency workers and workers with an expired fixed-term contract, represent a vulnerable group within the working population. They are at even greater risk for work disability due to mental health problems than the general working population. [9][10][11][12] These nonpermanent workers are characterised by a poor mental health status and low socio-economic status. [10,11,13] Moreover, they have less job security, have attained a lower education level and are more often from non-indigenous ethnic backgrounds compared to workers with a permanent employment contract (employed workers). [10,11,13] Compared to sick-listed employed workers, sick-listed nonpermanent workers perceive their health status more negatively and encounter more psychosocial barriers (such as personal problems, debts, addiction, legal proceedings, and/or care issues) to their return to work (RTW). [10,11,[13][14][15] Moreover, these workers experience a greater distance to the labour market compared to sick-listed employed workers, because there is no workplace to return to when sick-listed. [13] In the Netherlands, the Dutch Social Security Agency (SSA) is responsible for occupational healthcare and sickness absence counselling of sick-listed workers who do not or no longer have an employment contract. There are no legislative mandates for these workers to be returned to their previous/last job. The SSA carries out the Sickness Benefits Act, which provides supportive income, i.e., sickness benefits during the first two years of sickness absence, for these types of sick-listed workers. Nonpermanent workers who are not sick-listed, are no longer sick-listed, or are declared fit for work can receive unemployment benefits and may be provided with further vocational counselling to facilitate work participation.
Considering the growing rate of nonpermanent workers due to the economic recession and changing labour market conditions [16][17][18] and the growing rate of sick leave due to mental health problems, we questioned why little attention has been paid to developing effective RTW interventions for these workers. [19] A review of RTW intervention studies for the unemployed shows several large programmes in the United States, Finland, and Austria that have attempted to influence RTW outcomes using various intervention components (such as job search skills, personal development, problem-solving skills, group-based job training) with unsatisfactory results. [19] Since previous research has shown that the workers' own perspectives, such as RTW expectations and assessment of their own health, can predict work participation, [20][21][22][23] it is interesting to use the perspectives of unemployed workers on barriers to and solutions for RTW during the first stage of their sickness absence. A better understanding of perceptions and factors that facilitate or complicate RTW according to unemployed workers can assist in developing timely and effective interventions targeted to the needs of these workers.
To the best of our knowledge, no previous studies have attempted to identify the RTW perspective of sick-listed unemployed workers with mental health problems. A qualitative interview study seems to be the most appropriate design to identify these RTW perspectives, since face-to-face interviews provide in-depth insights from workers using their personal perspectives and experiences during the RTW process. Knowledge about the background of the RTW perspectives of these workers can shed light on what might help these workers to RTW, and why many attempts, incentives, and interventions in different situations and/ or on behalf of different workers have failed to produce much success to date. This knowledge can be helpful to optimise sickness absence counselling and further tailor RTW interventions to the needs of the sick-listed workers with mental health problems, in order to achieve resumption of work.
Therefore, the aim of this qualitative study was to evaluate the barriers to and solutions for RTW from the perspective of unemployed workers who were sick-listed due to mental health problems.

Design
In this qualitative study, semi-structured interviews were conducted to explore workers' perspective regarding RTW. We used the consolidated criteria for reporting qualitative research (COREQ) as a point of reference. [24] Participants Using purposive sampling based on the variation in RTW expectations, we selected sick-listed unemployed workers from two offices of the SSA, which were situated in the eastern part of the Netherlands. As RTW expectations of workers have been shown to predict work participation, [20,21] we maximised variation in perspectives by recruiting workers with either a positive (expected RTW within three months) or a negative (expected RTW after three months) RTW expectation. The inclusion criteria were: (1) unemployed; (2) between 18 and 65 years of age; (3) recently sicklisted (less than four weeks); and (4) having mental health problems/complaints as the main reason for a sickness benefit claim, assessed by the nurse practitioner or insurance physician of the SSA.
Eligible participants received written information from the SSA concerning the aims and procedures of the study at their home address. The anonymity and confidentiality of the participants was emphasised. Once participants had decided to participate in the study, an appointment for an interview was made.
All participants provided written, informed consent to participate in the study. The Medical Ethics Committee of the Academic Medical Center (AMC), University of Amsterdam, declared that the study design did not require comprehensive ethical review, as the Medical Research Involving Human Subjects Act does not apply to this study. [25] Procedure Data collection Data were collected between June 2012 and January 2013 through semi-structured, individual, face-to-face interviews using open-ended questions and a topic guide. Each interview lasted between 45 and 75 min and was conducted by the first author, an experienced male insurance physician (48 years) with extensive knowledge on sickness absence counselling of sick-listed workers and significant interviewing experience. The interviewer used techniques of paraphrasing, summarisation, and clarification to gain a full understanding of the points made during the interviews. RTW expectation was measured with a single question following previous studies on RTW expectations. [26,27] Before the interview, the worker was asked within what time frame he/she expected to RTW: "How many months do you think it will take you to fully return to work?" When data saturation of one type of RTW perspective was reached, only the participants with another type of RTW perspective were selected for further participation in the study, by inquiring about the workers' RTW perspective by phone prior to the interview. The location (participants' home address or nearest SSA office) and time of the interview were chosen by the participants. Prior to the interview, the purpose of the study was explained. All interviews were tape-recorded with the participants' consent. The following interview topics were addressed: (1) RTW expectation; (2) cause and scope of the sicklisted worker's problems; (3) barriers inhibiting RTW; and (4) perceived solutions to overcome the barrier or barriers to RTW.
The sample size was directed by data saturation, [28] which refers to the point at which no new information is being generated or collected, given the aim of the study. Twenty interviews were initially planned and respondent inclusion continued until data saturation was achieved.

Data analysis
The analysis was performed in phases. The first phase of the analysis consisted of verbatim transcription of the recorded interviews. These transcripts were then used to explore and reflect workers' personal perceptions and beliefs. In the second phasethe open coding phaseevery text fragment relevant to the research question was assigned a code. To increase reliability and accuracy, three authors (SA, KN, JH) independently performed coding for all interviews, followed by comparisons and a negotiated outcome between the three authors. In the axial coding phase, relations between codes and large concepts were sought, including patterns in the RTW process of the included workers. Finally, in the selective coding phase, themes were structured to formulate an answer to the research question. The content, descriptions, titles, and final results were checked and discussed by the research team in each phase. To support the analysis, we used the software program MAXQDA (VERBI Software, Berlin, Germany, 2012).

Results
After describing the patients' characteristics, we present the perceived barriers and solutions with regard to RTW as perceived by the workers and two themes that were identified after analysis of the data: interaction of multiple problems (barriers) and workers' attitudes towards their own RTW process (solutions).

Participants' characteristics
Twenty-five unemployed workers participated in the study. The age of the workers ranged from 22 to 59 years, with an average of 43 years. Eight workers were male. Eleven workers expected an RTW within three months (positive RTW expectation) and 14 workers expected an RTW after three months (negative RTW expectation). For all 25 participants, the main reason for reporting sick was having mental health problems, ranging from mild to severe, such as adjustment disorder, major depression or psychosis. Fourteen participants had a low educational level (primary school, lower vocational education, or lower secondary school), nine participants had a medium educational level (intermediate vocational education or upper secondary school) and two had a high educational level (upper vocational education or university).

Barriers to RTW
The participants expressed several barriers to their RTW. We summarised these barriers in six categories: (1) a current decreased perceived ability to work due to mental problems (including psychosocial problems/traumatic experiences) and physical health status; (2) labour market problems; (3) inadequate psychological or medical treatment; (4) issues related to the SSA; (5) personal characteristics and beliefs; and (6) personal circumstances. See Table 1 for an overview of barriers to returning to work.

Solutions for RTW
The participants indicated various solutions for their RTW. We summarised these solutions in six categories: (1) appropriate treatment; (2) recovery from complaints/gradual RTW; (3) type of work and preconditions; (4) beliefs and being active; (5) support/communication with the SSA; and (6) adequate coaching and training. See Table 2 for an overview of solutions for returning to work.

Interaction of multiple problems
After several team discussions, and by constantly comparing the interviews, it was found that one theme emerged as a distinct barrier to RTW for the unemployed workers: interaction of multiple problems. Although many different barriers were described, the concurrent presence of many problems during the interviews showed a recurring pattern among all workers, despite the fact that the individual cases were very different. As shown in Table 1, participants experience barriers within multiple categories.
These barriers or problems represent challenges in different domains of life, related to their disease, personal circumstances or environment. In many cases, participants were dealing with several problems within multiple categories. The interaction of multiple problems is apparent from the fact that one problem usually led to other problems or exacerbated another problem. Moreover, while they may be dealing with one problem at one step, there were usually one or more other problems that they had had to face as well. The following multiple problems, within multiple categories, played a prominent role: psychosocial problems such as personal problems (e.g., divorce, care problems, financial problems) and negative work experiences (e.g., job loss or problems in the last workplace), traumatic experiences such as the death of loved ones, relatives, or acquaintances, and the presence of concurrent medical problems such as musculoskeletal complaints. Psychosocial problems and/or traumatic experiences were mentioned by all participants, and almost every participant had two or more psychosocial problems. Participants stated that, as a result Financial problems Not able to follow education, visit the gym, buy a computer or pay a ticket for public transport to get to the workplace Lack of childcare facilities Rapid return to work discouraged by the general practitioner or family of their job loss and unemployment, they felt insecure, felt burdened by being dependent on welfare, faced (more) financial problems and experienced problems in dealing with the SSA. Many workers were struggling to deal with the various problems impeding their RTW. Participants often reported that due to the multiple problems, a single solution was often not enough to address barriers to RTW. Due to the interaction of these multiple problems, they have lost sight of the bigger picture and saw no way out. A worker with multiple problems in different domains of life (e.g., loss of job, divorce, forced home sale, death of relatives, financial problems, bringing up a disabled daughter, mental and physical complaints) stated his barriers to RTW as follows: "I visit my therapist twice a week to help me cope with my divorce, to deal with a loss, and now I've lost my job for the third time; all that plays a role. … I forget a lot of things … and so I make mistakes. … If you're operating a forklift truck, you need to be able to concentrate so you don't make mistakes. … I have back problems. I'm in pain every day, I need varied work. … Financial problems. You can't even afford to use public transport or anything else for that matter; they've impounded my car. My bank account has been frozen. They've set the gas, water, and electricity to a minimum level.
… It eats you up, and you get even more depressed and then sometimes you just can't take it anymore. … Divorce and dismissals, a reorganisation. … I've got a disabled daughter who needs a lot of care … and it's no small matter when your father dies, your mother dies, your father-in-law dies, your mother-in-law dies, all in the space of six or seven years."(Participant 12, 45-year-old man with a depressive disorder and low level of education).

Workers' attitudes towards their own RTW process
Looking at the participant trajectories and comparing similarities, one theme regarding solutions for RTW emerged from the analysis: workers' attitudes towards their own RTW process. The workers' attitude towards their own RTW process reflects the extent to which the workers were able to envision and implement solutions for RTW. On the basis of constant comparison of interviews during several team discussions, we found that workers differed in the way they perceived their RTW process and in the extent to which they were able to envision and implement the solutions for RTW. Through several team discussions and by comparing the interviews of individual workers, we distinguished the following three types of workers' attitudes towards their own RTW process: (1) "frozen": orientation/focusing on problems; (2) "insightful though passive": orientation on solutions but not actively applying the solutions (or not yet); and (3) "action mode": application of solutions and orientation on solutions.
"Frozen" workers These workers make statements to the effect that they cannot do much, want to be left alone, are not able to work or are ready for work yet, and do not want to be bothered with it. They are mainly focused on their problems and barriers to RTW. Some workers express no ideas regarding barriers to RTW. Solutions for RTW are not verbally expressed and they do not request any help regarding RTW. Some participants in this category also expressed that the solution for RTW is to do nothing, that help is not necessary or that they do not know what the solution is. Seven "frozen" workers were identified and all of them had a negative RTW expectation. When asked by the interviewer what could help them RTW, one worker stated: "I can't do anything for the moment; let's just see how things go." (Participant 15, 56-year-old man with an adjustment disorder and low level of education). Another participant stated: "I really don't have any idea, no idea at all; at the moment I can't see it happening at all. I can't even bring myself to think about it." (Participant 13, 32 year-old woman with a depressive disorder and low level of education). Participant 4 (40-year-old woman with attention deficit hyperactivity disorder, personal problems and low level of education) stated: "Just give me a pill that will make me well again. … If they can make me better, then I'd start working. But considering I don't feel ready to work again, that's not going to happen." One worker described the decreased perceived ability to work as: "I can't take the work pressure anymore. I used to be able to do 25 things at once and now I have to be satisfied that I can do two things at once. … I can't make any choices. You just can't think clearly. You've got too much on your mind." (Participant 7, 41-yearold man with divorce issues, burn-out and low level of education).
"Insightful though passive" workers Workers in this stage show insight into their problems and barriers to RTW. They often have plans and ideas about what they have to do or what is needed to achieve RTW and express a desire to work. However, these workers remain passive and thus have not yet been able to execute their plans or ideas regarding RTW and its solutions. Nevertheless, these participants say that they want to be helped with their RTW. Some workers stated that they feel unsupported by the SSA if they wish to implement their ideas for RTW. They also stated that some rules of the SSA impede their RTW, because some activities which can enable RTW, such as gradual RTW or an internship, are prohibited during the sickness benefit claim period. One worker emphasised this rule by stating: "It's the obligation, whether you're actually sick or not. There's very little possible in between. I've indicated that it would help me get back into the employment process, even if it's an internship for just one day a week somewhere. That's not possible. I mean, the intention is that I'm back at work soon and I think that it lowers the threshold for me, and that it helps me get back into the swing of normal life, because that's not what I'm doing at the moment and I miss that a lot. But it's either one or the other, and that's a pity." (Participant 23, 30-year-old woman with a depressive disorder and high level of education). Moreover, most of these workers complained that barriers to RTW included poor communication with the SSA, difficulty establishing personal contact with the SSA, and unclear procedures concerning what is allowed during the sickness benefit period. One participant expressed the poor communication by stating: "The way you currently really don't have any contact with the SSA, but everything is done via internet: I can't manage that at all. I think it's very bad that you don't get to see anybody, or speak to anybody, so you don't really have a work coach with whom you make agreements." (Participant 24, 40-year-old woman with a depressive and anxiety disorder, and medium level of education).
Fifteen "insightful though passive" workers were identified, of which eight had a positive RTW expectation and seven a negative RTW expectation.
Workers in "action mode" These workers verbalise a positive attitude regarding work and want to RTW as soon as possible. They state their problems with and barriers to RTW, have some ideas concerning how to address these problems or barriers with regard to RTW, and are actually searching for ways to implement the solutions for RTW (to overcome barriers). These workers emphasise that they could use all the help that the SSA can provide to help them with their RTW process and to execute their ideas to address their problems with or obstacles to RTW. Most workers stated that they experienced a lack of support from the SSA, which impedes their recovery and RTW. Moreover, these workers have positive beliefs and an active life. Three workers who are in the "action mode" were identified and all of them had a positive RTW expectation. A worker in the "action mode" made the following statements: "I want to get back to work as soon as possible, because the longer it goes on like this, the more difficult it will get to return to work. … I really want to get back to work again, during the day. I would so love to have everything back to normal as soon as possible. … I'm a pretty positive individual myself. … I'm not the type to let my head hang and start thinking, well, my situation's really pretty bad." (Participant 20, 26-year-old woman with an anxiety disorder and medium level of education).

Discussion
The aim of this qualitative study was to evaluate the barriers to and solutions for RTW from the perspective of unemployed workers who were sick-listed due to mental health problems. Our study indicated that, in addition to medical problems impeding RTW, workers attribute many non-medical problems as being barriers to RTW. Workers faced multiple problems in different domains of life. All 25 participants expressed several psychosocial problems and/ or traumatic experiences. Finally, we identified three types of workers' attitudes towards their own RTW process reflecting differences in workers' abilities to envision and implement steps towards RTW: (1) "frozen"; (2) "insightful though passive"; and (3) "action mode".
The findings of this study show that an important characteristic of the sick-listed unemployed workers is that they have to deal with multiple problems in different domains of life related to their disease, personal circumstances or environment. These multiple problems are often perceived as being severe by participants, where one problem often leads to other problems or exacerbates other problems. As a result, some workers report ending up in a downward spiral, thus losing the perspective of improvement or work. Multiple problems mean that a single solution is often not enough to address barriers to RTW. These workers benefit from different solutions for their problems. Sick-listed workers with mental health problems, including cognitive problems, often cannot oversee which of the multiple problems needs to be addressed first. Therefore, they need support or coaching to grasp the bigger picture and obtain insight and a priority plan in addressing the barriers to RTW and implementing the solutions for RTW. In our study, many participants mentioned adequate guidance and help from a (vocational) coach as an important solution for their RTW. Besides the consequences of their sickness, and in line with findings in other studies, we found that most workers also suffer from the consequences of unemployment such as stress, financial debt, diminished social status, reduced selfesteem and feelings of guilt, [15,29,30] emphasising a need for support in problem-solving in different domains of life and health.
The major finding of this study is that we identified three types of workers' attitudes towards their own RTW process. The distinction between these three types was based on whether workers had insight into their problems, whether they had solutions to these problems, and whether they actually implemented the solutions to these problems. The characteristics of the three types of workers' attitudes towards their own RTW process shows similarities with the characteristics of the three stages of readiness for RTW described by Lam et al. [31] However, the stage of change model proposed by Lam describes behavioural changes over time in one person. Due to the observed similarities, it can be argued that the identified characteristics of workers' attitudes in this study may also represent possible changes over time, even though all workers were interviewed at the start of a sick leave episode. Our design does not allow for inferences about whether the identified workers' characteristics changes over time.
The worker's RTW perspective seems to be associated with the type of workers' attitude towards their own RTW process, as all the "frozen" workers had a negative RTW expectation and all the workers in the "action mode" had a positive RTW expectation. When guiding sick-listed unemployed workers with mental health problems, it is advised to take into account the type of workers' attitude towards their own RTW process, so that the RTW intervention can be tailored to the need of the worker. "Frozen" workers who had no insight into solutions for RTW and negative perceptions need specific help to overcome the barriers to RTW. These barriers could be negative cognitions informing the worker's RTW expectation, inappropriate coping with problems with or barriers to work participation, or insufficient targeted guidance to encourage problem-solving. In the case of negative cognitions, the intervention should focus on influencing these cognitions. This could be done with cognitive behavioural therapy. [32,33] Studies report positive effects of cognitive behavioural therapy on changing negative cognitions (e.g., negative thoughts about oneself, past experiences, and future expectations), negative selfbeliefs, negative emotions when reacting to and in reducing psychological symptoms in patients with mental health problems (depressive and anxiety disorder). [32,33] In contrast, workers in the "action mode" with a positive attitude regarding work and who want to RTW as soon as possible need a realistic action plan or final push to get back into the workforce.
In this study, most of the workers (15) had the RTW process of the "insightful though passive" type of workers. The gap between having solutions and intentions for RTW and implementing these solutions/intentions has been found in several qualitative studies of employed workers with mental health problems and was interpreted as an intention-behaviour gap. [34,35] The gap between intentions for RTW and implementation of these intentions could result in stagnation of the RTW process, relapse and recurring sick leave. [35][36][37] To reduce this gap, it has been advised that RTW interventions should not only focus on the individual, e.g., by enhancing coping strategies and reducing perfectionism, but also on the current or future workplace, and facilitate the social integration of the returned worker. This emphasises the need and role of a guidance coach to help the unemployed workers with their RTW process, to reduce the intention-behaviour gap and to prevent stagnation of the RTW process. In our study, many participants specified adequate guidance and help of a (vocational) coach as an important solution for their RTW. In order to prevent stagnation, the personal contact with the coach must take place in an early stage of sick leave. According to the workers, the help of a coach is also important to create workplaces or internships to facilitate gradual RTW. In the literature, gradual RTW is considered as an important factor to facilitate RTW. [34] The strength of this study is that we conducted 25 interviews with workers who had either a positive or a negative RTW expectation. In this way, we explore the breadth of perspectives among our participants and achieve a maximised variation of perspectives and data saturation regarding their RTW perspective. Our findings may not capture the perspectives of all nonpermanent workers, since we did not include temporary agency workers or fixed-term contract workers. Future qualitative research on barriers to and solutions for RTW should also focus on the perspective of temporary agency workers and fixed-term contract workers, and include workers who did RTW after sickness absence, to gain a better understanding of the RTW perspective of all nonpermanent workers. Whether RTW interventions tailored to the type of workers' attitude towards their own RTW process and workers' RTW perspectives combined with adequate guidance and support of a (vocational) coach actually leads to an increase in RTW needs to be evaluated in further research. Moreover, to gain insight into the complex RTW process of these workers with multiple problems over time, future qualitative research should also investigate their thoughts about the past and future (by conducting multiple interviews), as the RTW process should be seen as a continuous and coherent process in which perceived experiences from the past and present and anticipation of the future are dynamically interrelated and affect success or failure of RTW. [34] Conclusion We conclude that the sick-listed unemployed workers with mental health problems have to deal with multiple problems, of which medical problems are only a part. Besides interventions targeting the multiple problems of these workers, they need help aimed at their coping methods according to one of three types of workers' attitudes towards their own RTW process. Moreover, they need specific help organising and structuring their problems, getting their life back on track, and in finding employment.