Content uploaded by Mikael Elf
Author content
All content in this area was uploaded by Mikael Elf on Feb 14, 2020
Content may be subject to copyright.
Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=idre20
Disability and Rehabilitation
ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: https://www.tandfonline.com/loi/idre20
Strategies to keep working among workers with
common mental disorders – a grounded theory
study
Louise Danielsson, Mikael Elf & Gunnel Hensing
To cite this article: Louise Danielsson, Mikael Elf & Gunnel Hensing (2019) Strategies to keep
working among workers with common mental disorders – a grounded theory study, Disability and
Rehabilitation, 41:7, 786-795, DOI: 10.1080/09638288.2017.1408711
To link to this article: https://doi.org/10.1080/09638288.2017.1408711
Published online: 28 Nov 2017.
Submit your article to this journal
Article views: 265
View related articles
View Crossmark data
Citing articles: 1 View citing articles
RESEARCH PAPER
Strategies to keep working among workers with common mental disorders –a
grounded theory study
Louise Danielsson
a,b
, Mikael Elf
a,c
and Gunnel Hensing
a
a
Section of Epidemiology and Social Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden;
b
Angered Hospital,
Gothenburg, Sweden;
c
N€
arh€
alsan, Bed€
omningsteamet, Borås, Sweden
ABSTRACT
Purpose: Most people with common mental disorders (CMDs) are employed and working, but few studies
have looked into how they manage their jobs while ill. This study explores workers’experiences of strat-
egies to keep working while suffering from CMDs.
Methods: In this grounded theory study, we interviewed 19 women and eight men with depression or
anxiety disorders. They were 19–65 years old and had different occupations. Constant comparison method
was used in the analysis.
Results: We identified a core pattern in the depressed and anxious workers’attempts to sustain their
capacities, defined as Managing work space. The core pattern comprised four categories describing differ-
ent cognitive, behavioral, and social strategies. The categories relate to a process of sustainability. Two
categories reflected more reactive and temporary strategies, occurring mainly in the onset phase of illness:
Forcing the work role and Warding off work strain. The third category, Recuperating from work, reflected
strategies during both onset and recovery phases. The fourth category, Reflexive adaptation, was present
mainly in the recovery phase and involved reflective strategies interpreted as more sustainable over time.
Conclusions: The results can deepen understanding among rehabilitation professionals about different
work-related strategies in depressed and anxious workers. Increased awareness of the meaning and char-
acteristics of strategies can inform a person-oriented approach in rehabilitation. The knowledge can be
used in clinical encounters to reflect together with the patient, exploring present options and introducing
modifications to their particular work and life context.
äIMPLICATIONS FOR REHABILITATION
Self-managed work functioning in common mental disorders involves diverse strategies.
Strategies interpreted as sustainable over time, seem to be reflective in the sense that the worker
consciously applies and adapts the strategies. However, at the onset of illness, such reflection is diffi-
cult to develop as the worker might not want to realize their reduced functioning.
Rehabilitation professionals’awareness of different strategies can facilitate a person-centered
approach and understanding of the vocational rehabilitation process.
ARTICLE HISTORY
Received 27 July 2017
Revised 17 November 2017
Accepted 20 November 2017
KEYWORDS
Depression; anxiety; work
functioning; qualitative
research
Introduction
Being depressed or anxious vastly affects the working life of the
individual in terms of reduced work functioning and wellbeing,
impaired productivity and increased risk of sickness absence [1].
Besides the consequences for the worker and their family, there is
also a negative impact on the work organization. Given that mild
to moderate depression and anxiety disorders (referred to as
“common mental disorders (CMDs)”) have a life-time prevalence of
about 30% [1], and are leading causes of disability [2], they
present a challenge to society, with both immediate and future
concerns.
There is substantial knowledge about predictors of sickness
absence and trajectories of return to work among workers with
CMD [3–5]. Some interventions, such as cognitive behavioral ther-
apy or workplace adjustments and support, have been suggested
to improve work capacity [6–9]. However, the question of how
workers try to self-manage their work while feeling depressed and
anxious is yet underexplored. Since most people affected by
CMDs are in fact employed and working, this focus demands
increased attention.
Conceptual understanding of work functioning in common
mental disorders
This study assumes that work functioning in CMDs is a multifac-
torial concept, which is dynamic over time and is, furthermore,
affected by the interaction of several dimensions (e.g., personal
attributes, as well as work, health care and community mesosys-
tems, and macro-infrastructures) that influence each other
through different structural levels (individual, organizational, and
societal) [10]. Moreover, a person’s general ability to work
and their situational ability in the specific, real-life environment
and context can be vastly divergent [11].
The dynamics between the individual and the environment
have been examined in several models, such as the effort–reward
imbalance model [12], the demand–control model [13], and the
CONTACT Louise Danielsson louise.danielsson@vgregion.se Angered Hospital, Box 63, 424 22 Angered, Gothenburg, Sweden
ß2017 Informa UK Limited, trading as Taylor & Francis Group
DISABILITY AND REHABILITATION
2019, VOL. 41, NO. 7, 786–795
https://doi.org/10.1080/09638288.2017.1408711
Person–Environmental–Occupation Model [14], all of which sug-
gest an interplay between individual resources, occupational tasks,
and the physical/psychosocial work environment. A novel angle is
the concept of work instability [15–17], defined as a mismatch
between job demands and the worker’s present abilities.
Furthermore, to understand work functioning in CMDs, it is
important to consider factors in the worker’s private life [18].
Efforts to sustain work can also be described in terms of cop-
ing. Coping is the cognitive and behavioral effort a person makes
to manage demands that tax or exceed their personal resources
[19]. It connects to a person’s appraisal of a situation, their instant
evaluation of what is at stake for them personally, and the pos-
sible ways to overcome difficulties [20]. In this way, coping means
an action-based feature to the transactions we have with the out-
side world, related to personal significance of those transactions
[21]. Coping strategies in turn seem to rely on factors such as
locus of control, social support and self-efficacy [22,23]. In relation
to the present study, coping means the depressed and workers’
efforts to manage exceeding work demands, dependent on their
personal meaning of work and their present options and confi-
dence to act.
To summarize, the underpinnings of this study acknowledge
that work functioning in CMDs is associated with, but is not merely
a consequence of, the condition [24]. Here, we assume a dynamic
interaction between personal resources and symptoms, situated
job tasks and the social environment at and outside work, ultim-
ately aiming at meaningful participation in the community. The
perceived imbalance between abilities and demands, when the
depressed or anxious worker feels that work cannot be managed
as usual, will herein be referred to as “work instability”[15,25].
Experiences of working while affected by common mental
disorders
Working while depressed and anxious has been described as feel-
ing “remote”and “unfamiliar”at work [26], with the private life
crumbling in the quest of keeping up at work [27]. The struggle
depressed workers face at work has been described as condi-
tioned by relationships with managers and coworkers, by the
workload and by the workers’own self-image as a worker [28].
Adjustments of habits and routines can help in managing work
and private life in CMDs [29]. Such adjustments can include reduc-
ing demands, prioritizing, and changing lifestyle habits [29].
Following a work-directed intervention, new strategies to handle
the workload mainly focus on limitations: taking one thing at a
time, delegating, and fostering an accepting or detached attitude
to work [30]. The extent and consequences of limiting strategies
point to an important issue to be further explored [30], and to be
challenged: are there qualitatively different strategies for keeping
up work in CMDs?
In a recent study [31], we found that workers with CMDs expe-
rienced a process of instability, understood as a work dissonance.
The workers felt caught up inside the work stream, as if in a
“bubble”that was both isolating and protective. This experience
disturbed flow and collaboration, but paradoxically it also enabled
work. The work dissonance had a particular impact on situations
that demanded social interaction. Given the complexity of the
work instability process, it is likely that the workers’attempts to
keep working were intricate, which deserves further investigation.
Research rationales and purpose
Although our previous study gave insight into the process of
work instability, it did not sufficiently answer the question of how
workers attempt to manage their jobs. To develop the current
body of knowledge on this aspect, we need to look further into
what the affected individuals actually do and what works from
their perspectives. It is likely that there are things that people do
beyond clinical guidelines that are meaningful in their attempts to
keep working successfully. To support workers with CMDs, learn-
ing from experience-based strategies may provide innovative
ideas to advance the understanding of “what makes work work”.
Based on our previous interviews, we were interested to find out
more about the interviewed workers’pragmatic modifications and
the strategies they utilized to manage their jobs. The purpose of
this study was to explore workers’strategies to keep working,
while affected by CMDs.
Methods
This study was planned and conducted as an elaboration of our
previous study [31]. The present research question arose during
the early data collection. Originally our intention had been to col-
lect data on aspects of work instability, but the detail-rich descrip-
tions allowed us to expand the scope of our research. Therefore,
our present aim developed from the findings and subsequent
data collection, enabling a parallel exploration of two phenomena:
work instability (presented elsewhere) [31] and strategies to keep
working (the present study).
We used a grounded theory approach, theoretically based in
social constructivism and pragmatism [32], mainly inspired by the
methodology put forward by Charmaz [33,34]. In short, this
involves acknowledging a relativist epistemology, co-creating data
through an interaction between the researcher and the partici-
pants, adopting a reflexive stance toward how participants con-
struct meaning and actions, and doing situated research in a
social context [35,36]. The reason for using grounded theory was
our assumption that work functioning in CMDs is a social,
dynamic process. We anticipated that social constructivist
grounded theory would enable a rich, yet practically oriented con-
ceptualization of the participants’constructed meanings and situ-
ated strategies, firmly grounded in empirical data. Moreover,
grounded theory focuses on how people respond and react to
certain conditions or to change [34], which made the approach
suitable for our research focus on strategies.
Reflexivity
The theoretical pre-understanding among the group was mainly
derived from our previous studies on work and CMDs. To enable
a reflexive, “bridling”[37] approach and restrain pre-conceptions,
we used discussions and memos prior to and during the analysis
to outline and question our different perspectives, which may be
latent but may yet impact the research process [36]. Our perspec-
tives were mainly related to embodiment theory, social gender
theory and psychological theories of defense mechanisms, and
to clinical experiences of work capacity assessment and
rehabilitation.
Participants
The study included 27 participants, 19 women and eight men,
recruited through clinical collaborators, a patient organization and
public lectures (Table 1). Criteria for inclusion were: depression
or anxiety syndrome (International Statistical Classification of
Diseases and Related Health Problems, 10th revision (ICD-10),
STRATEGIES TO KEEP WORKING 787
codes F32–33, F41, and F43 [38]), or self-reported mental distress
corresponding to a cut-off <50 on the WHO-5 Mental Well-being
Index [39]. Also, the participants had to be employed and cur-
rently working, or to be on sick leave for a maximum of 6 months.
We wanted variation in this respect, but assumed that longer sick
leave would make it difficult to recall strategies. The rationale for
including both participants at work and participants on sick leave,
was that we anticipated that the workers’strategies would vary at
different stages of reduced functioning: from slight but manage-
able difficulties up until when work was no longer possible. We
wanted to grasp this process of potentially diverse strategies.
Workers in the return to work phase have experienced the whole
process: from the onset of CMD to struggling with reduced func-
tioning leading to sick-leave, and then to partial or full recovery.
Hence, we also included participants who had been on sick leave
the past 12 months but had returned to work (n¼7), assuming
that they could share experiences of remodeled or newly devel-
oped strategies. Criteria for exclusion were psychotic symptoms or
apparent suicide risk, as deemed by the recruiting health care
staff, or, in the case of other recruitment sources, by the
researcher during the initial telephone screening.
Among 30 volunteers, one person was not included because of
an expired job contract, one declined participation because of
increased stress and one did not respond to the researcher’s
attempts to contact him. Volunteers were contacted by phone by
one of the researchers (L.D.), who checked the inclusion and
exclusion criteria and provided study information. The telephone
conversation was also meant to initiate a dialog and establish
trust, preparing for the research interview.
Interviews
The interviews were conducted during December 2015 to June
2016. L.D. conducted 22 of the interviews and a female Master’s
student, working in psychiatric rehabilitation, conducted five inter-
views. To enhance validity, both interviewers started with the
same initial probes and conducted a couple of interviews each,
before they discussed together and compared questions and con-
tent. The probes had been used in a similar way, but one of the
interviewers had followed up more on body experiences and the
other interviewer more on social aspects. Awareness of this ten-
dency, and the joint initial understanding of the data informed
another subsample of interviews. After another round of reflec-
tion, L.D. completed the remaining interviews.
Depending on each participant’s preference, the interviews
took place at a primary care center, at the university, at a public
library or in the participant’s home. The interviews started with
the question: “Can you tell me what an ordinary day at work is
like for you?”Besides using thematic probes to capture experien-
ces of work instability, such as the work environment, adjust-
ments, interactions, lifestyle and bodily experiences [31], we asked
about strategies to manage experiences of change at work.
Typically, this theme was posed as a separate question: “How do
you try to keep up at work?”The theme could also be brought up
through follow-up questions to a specific situation that the partici-
pants talked about, for example, “How do you manage that
task …?”or “Can you give an example of how you make it work?”
Our grounded theory framework assumed a processual phenom-
enon, and we encouraged the participants to exemplify with early
Table 1. Participant characteristics.
Number of participants n¼27
Age (years) 19–25 2
25–35 9
35–45 7
45–55 5
55–65 4
Civil status Single 12
Married/co-habiting 15
Family type Children under the age of 18 6
Children over the age of 18 5
No children 16
Job/work
a
Manufacturing 1
Accommodation, food service activities 2
Information and communication 3
Financial and insurance activities 2
Professional, scientific, technical activities 4
Administrative and support service 4
Education 4
Human health and social work activities 4
Arts, entertainment and recreation 2
Other service activities 1
Working full time 12
Working part time 9
Currently on sick leave 6
Sick leave due to CMDs the past 12 months
b
13
No sick leave due to CMDs the past 12 months 14
Source of recruitment Clinical collaborators in primary care 18
Patient organization 6
Public lectures 3
Main diagnosis
c
Depression 9
Anxiety disorder 13
Elevated symptoms
d
5
a
According to the Swedish Standard Industrial Classification 2007, Swedish Statistics, www.scb.se/en/documentation/classifications-and-
standards/swedish-standard-industrial-classification-sni/.
b
Among these were also the n¼6 currently on sick leave. The remaining n¼7 were considered to be in a return-to-work phase.
c
According to the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10).
d
Scoring <50 on the World Health Organization Mental Well-being Index.
788 L. DANIELSSON ET AL.
and later adaptations during their illness progression. Participants
who were in a return to work phase, were also asked about if they
did things differently now compared to before sick leave.
Also, without there being a pre-defined probe concerning this
topic in the interview guide, the participants reported about strat-
egies outside work that helped them to keep working, for
example, recreational activities. This finding was then incorporated
as a probe in the subsequent interviews, in accordance with the
iterative process of grounded theory. The interviews had a median
duration of 48 min, range 23–96 min. They were audio-recorded
and transcribed verbatim.
Analysis
The textual data used for the constant comparison analysis con-
sisted of the transcribed interviews and handwritten memos from
the interviews. The data analysis was a separate process with
regard to the previous study. Whereas the previous study focused
on the experience of work-related change, the present analysis
extracted data related to behavioral and cognitive strategies to
keep working. Thus, data extraction was guided by a focus on the
participants’efforts to sustain work: what they did and why. Two
analysts, L.D. and M.E., each independently coded the first 10 inter-
views, using open line-by-line coding and extracting all content
that might be relevant to the study purpose. The two analysts
then wrote memos, discussed together and reflected upon the
content, which was summarized broadly in terms of themes, pat-
terns and contradictions in the data for further analysis. Next, the
two analysts coded five interviews each, discussing and forming
tentative sub-categories to describe the empirical data. Informed
by the initial data, the analysts independently arranged the codes
according to onset or recovery phase to look for a potential pro-
cessual pattern. Eleven tentative sub-categories were agreed on,
which were discussed together with the third analyst, G.H., who
had read a subsample of the interviews. From these discussions
and after several more perusals of the raw data, a core category
was loosely formed. The remaining interviews were analyzed (L.D.,
M.E.) using selective coding, bearing the tentative categorization in
mind, looking for nuances, similarities and differences in the data.
This step was meant to challenge and develop the understanding
of the categorization. During this step, the 11 tentative sub-catego-
ries were rearranged into 10 sub-categories forming four catego-
ries, a process interpreted as higher in level of abstraction. A
writing–rewriting process, including reflection among the three
analysts, refined the descriptions of and relation between the cate-
gories. The data analysis is exemplified in Figure 1.
The results were then discussed in a seminar of researchers
from diverse professional backgrounds in the social sciences,
rehabilitation and public health. The discussion concerned the core
category and our proposed use of the term “space”. The research-
ers discussed different meanings of this term, such as the physical
and the psychological sense of the word, and what it proposedly
meant in connection with the explicated strategies and, further,
how these featured in the interpretation based on sustainability.
To validate our results in the working CMD population, we
debriefed patients included in an intervention study to enhance
work capacity in CMDs. As an example of validation, one patient
responded: “Yeah, you know, what I really need right now to func-
tion well is to practise some ways to kind of expand my space.”
Ethics
The ethical principles of the World Medical Association
Declaration of Helsinki [40] guided the conduct of the study.
The interviewers had vast clinical experience of talking to people
with depression and anxiety. All participants were given verbal
and written information about the study before deciding on par-
ticipating and signing a written consent form. They were informed
that participation was voluntary and that they could withdraw
from the study at any time. They were encouraged to contact the
interviewer afterwards, if questions or issues arose. Two partici-
pants contacted the interviewer to add information to the inter-
view, which was recorded as written memos. The study has been
approved by the Regional Ethical Review Board.
Results
The core category, Managing work space, captures the general
pattern of the workers’strategies, which encompass four catego-
ries. These represent the different meanings of the strategies and
consist of 10 sub-categories that describe how the strategies were
carried out at a more concrete level. According to the participants,
the different strategies rendered more or less sustainable possibil-
ities to keep working, shown schematically in Figure 2.
Managing work space
The core category was interpreted as a process of managing work
space in relation to job tasks, expectations and the environment.
Here, “work space”meant not only the physical room where the
workers performed their tasks, but the lived, embodied and social
space that they inhabited in the context of their work, including a
bridge to their private life. Acting on the experience of shrinking
possibilities involved attempts to expand or keep the sense of
space, situated within everyday tasks. The strategies were meant
to release strain or force control as well as to find sustainable
ways to manage work.
During the analytic step where the analysts looked at temporal
aspects of the data, a processual pattern emerged suggesting that
the first two categories, Forcing the work role and Warding off
work strain, occurred more often in the earlier, onset phase of
CMD. The third category, Recuperating from work, involved strat-
egies that occurred both early and in the recovery from illness.
The fourth category, Reflexive adaptation, occurred later in the
process, and more often appeared in accounts of recurrent epi-
sodes and return to work. These categories involved a higher
degree of reflective awareness with strategies that were deliber-
ately carried out to improve function. Thus, they reflected not
only rebalancing but also preventive strategies for workers with
previous experience of CMD. Below, the four categories and their
sub-categories are described.
Forcing the work role
This category reflects strategies where workers pushed them-
selves, extending present capacities and pushing limits. By using
force, distraction and sometimes denial, the participants kept up
their work. The work space was managed by pushing through,
keeping up a front, and stretching boundaries.
To grin and bear it. In this sub-category, the strategies were
characterized by the experience of “just doing it”: sticking with it
and pushing through the work day at all costs. The participants
used variations of common idiomatic expressions when describing
the action of pushing through, for example “putting a lid on”or
“driving my head through the sand”(variations of “banging my
head against the wall”/“burying my head in the sand”), which indi-
cates some denial in the struggle. Participants described using
this strategy periodically, and then needing to follow it up with a
STRATEGIES TO KEEP WORKING 789
less pressured time, such as the weekend, a longer vacation or
another project. One participant described repeatedly using this
strategy, and “coming out at the other end”.
I could go for eight hours straight, without going to the bathroom,
without eating anything, without doing anything else, but just keep
going. (Female community worker with major depressive disorder, on sick
leave)
I would grin and bear it until it was time to go home; then all feelings
and fatigue flooded over me. (Female primary school teacher with major
depression disorder and acute stress reaction, in return to work phase)
To cover it up. The participants described that they kept work-
ing by hiding how they felt on the inside, feeling they had drifted
from their genuine sense of self. It made them feel phoney, pre-
tending to know what they were doing but not feeling it. This
strategy was rarely consciously enacted, but was recalled in retro-
spect. The participants reported that their tasks could to a certain
extent be managed while putting up this front. They also reported
hiding the approaching instability to themselves, by distracting
themselves with tasks. At work, they kept themselves constantly
occupied. At home, they took on duties, keeping the feeling of
inadequacy at arms’length:
It’s like I keep going just to avoid sitting down and thinking …even in
my spare time. I’ve noticed that when I’m busy, for example building a
veranda on our house, and I need to fetch some more material, I don’t
walk: I run to fetch it. I just rush on. (Male social work associate with
depressive symptoms, working full time)
To compensate for shortcomings. The participants tried to com-
pensate for negative changes related to energy, cognition, and
interaction. This could involve starting later in the morning to
make up for sleeping problems. It could mean taking on more
simple tasks to compensate for a lack of concentration and cre-
ativity. To make up for delays, the participants skipped breaks,
worked longer or continued working at home. They took exten-
sive notes in order to remember: one participant wrote herself
detailed instructions for navigating the computer system. Workers
with interpersonal tasks kept these up by reducing other social
elements at work, such as staff meetings or socializing with
colleagues.
Warding off work strain
This category reflects strategies in which the workers “warded off”
work strain to ensure enough room for manoeuver, and allow lee-
way. They talked about ways to withdraw and edge off the dis-
comfort. They managed the work space by stepping back,
removing themselves and thus taking the edge off emerging
symptoms.
To escape and turn away. Participants used strategies to escape
their experience of not functioning well at work. Strategies
involved walking out of the workplace without telling anyone,
calling in sick for a couple of days, or rationalizing with oneself
that the problems were due to one’s coworkers. Eating junk food,
taking painkillers and overeating were among the actions used to
take the edge of the increased strain. Alcohol was used in the
same way, but this was sometimes done to enter another state of
mind, and turn away from the mounting distress. Large amounts
of coffee or energy drinks helped deal with tiredness. The strat-
egies used in this sub-category indicate a high stress level.
Sometimes I’ve just left and stayed away for a few days. It builds up;
there were times when I was supposed to go in when I stopped on the
way and thought like: should I go in or should I call in sick? And then I
continued a bit. And hesitated. Then when I approached work, you
have to turn, either you keep on straight toward (another village) or
you turn (to the workplace). And then I just went straight ahead. (Male
mechanical assembler with major depressive disorder and panic disorder,
on sick leave)
To shield oneself at work. This sub-category reflects the strategy
of shielding oneself from others at work. Sometimes, a very tan-
gible shield was used, for example the person closed a door or
Figure 1. Example of the process of analysis, resulting in the sub-category To grin and bear it.
790 L. DANIELSSON ET AL.
moved into a less crowded room, often to avoid stimuli. The par-
ticipants detached themselves emotionally and socially, to keep
up the focus and energy for the job tasks at hand. They needed
distance from others’input; as described by one participant, “I’m
going into my cave to dive into my work and be left alone.”
Another reported the experience of deliberately “putting blinkers
on”. The shielding strategy appeared in narratives at both illness
onset and return to work, but in the latter phase it was a more
deliberate choice of action.
Recuperating from work
This category includes strategies for recuperating and recharging
to keep up at work. These strategies involved leisure activities but
also included recuperative moments during the work day. A cen-
tral experience in the recuperative strategies was to find a
moment to be alone, and to be left at peace. Work space was
managed by creating a private space and thus boosting resilience.
To commit to a presumably healthy lifestyle. Physical activity
was mainly used to gain energy and resilience to keep up at
work, and to have a breathing space. For some, however, the
exercise became compulsive. The participants felt compelled to
continue to exercise, either motivated by rational explanations of
the good of exercise, or in a bid to control anxiety. Eastern move-
ment practices were also described, such as yoga and mindful-
ness. Listening to or making music was another strategy, used to
boost energy and feel connected, and as “balm for the soul”. The
participants related that social activities were essential, but they
chose certain persons to socialize with as well as certain activities,
often ones that were not stressful. They put an effort into main-
taining healthy eating and sleeping habits:
I really try it with my sleep and my food and my exercise. But it’s hard,
I think, I don’t get the full hang of it. I need to turn my sleep pattern
around and go to bed earlier. And I really want to eat properly,
breakfast, a little snack, lunch …I was really good at this before./
…/And the exercise, it’s so hard to go to the gym. I take walks in the
forest, I love it, it’s my religion you could say. It makes me feel in a
good mood, like I’m clearing my veins from all the crap. (Female
community worker with major depressive disorder, on sick leave)
To restore and reboot. The participants found ways to recharge
a little during the workday. They created opportunities for a quick
reboot, at different levels. This could be by resting in a peaceful
room or sitting in a corner of the staff room pretending to read.
Use of the bathroom as a solemn and private spot to recollect
oneself was also mentioned in the workers’accounts. At home,
the participants practiced “alone time”, asking for space from, or
simply avoiding, family and friends. They needed to think their
thoughts through, and try to get an overview and a hold of their
situation. One participant described the need for the whole week-
end alone, just to catch up and prepare for the upcoming week.
There were also descriptions of prophylactic boosting. For
instance, one participant took a longer, relaxing route to work in
the morning to get a good start to the work day. Another partici-
pant rebooted by taking her breaks outside:
You wish for some free space, you know. You feel very cornered, in a
way. You step outside [the workplace] so as not to feel pushed in. You
want out to be able to breathe, for real. (Female cook with reaction to
severe stress, working part-time)
Reflexive adaptation
Under this category, participants described developing conscious
adaptive strategies to keep working: for instance, they might
notice signs of instability and, in response, might modify their
work in collaboration with others. These strategies were character-
ized by a long-term view of keeping up at work, despite resurfac-
ing vulnerability. The work space was managed through
continuous reflection and adaptation of time and responsibilities.
To reconsider one’s attitude to work. The accounts of
participants in the return to work phase contained descriptions of
strategies for reconsidering their approach to work tasks, responsi-
bilities and achievements. The participants described committing
less to their tasks in order to save energy and emotional invest-
ment. They challenged themselves to practice to say “no”and
decline assignments and events they would normally have
accepted. They were strict on themselves about respecting work
hours, neither skipping breaks nor working late:
It’s easy to think, “I have to do this first,”but just go home! If you
haven’t finished, you haven’t finished. It’s not your problem: it’s the
company’s problem if they don’t employ enough people. (Male engineer
with panic disorder, working full time)
They also consciously tried to prioritize differently: instead of
giving their all at work, they tried to put their own wellbeing first.
They emphasized the need to reflect with family and health care
professionals: without challenging themselves through reflection,
it was easy to fall back into old patterns. Reconsidering one’s atti-
tude to work also meant learning to act on personal cues of
strain.
To modify the work frame. The participants described planning
and modifying their work for sustainable change. This could mean
reducing their work hours or not working full time. It could mean
Figure 2. Model illustrating the categories of the core pattern “managing work space”in common mental disorders, positioned along a process of sustainability.
STRATEGIES TO KEEP WORKING 791
switching workplaces, or changing jobs and careers. Mainly, the
participants switched from jobs with interpersonal tasks in an
intense environment, such as nurseries, schools or hospitals, to
jobs with more administrative tasks. Some changed from a high-
achievement, competitive job to a job with less career focus. For
some, the modification entailed working as usual between CMD
episodes, but quickly switching when a new episode was
approaching. For example, one participant described taking a few
weeks off work every winter, as soon as she felt that her depres-
sive symptoms increased. On a lesser level, participants could
adapt by rearranging their work tasks and prioritizing them,
depending on their day-to-day wellbeing:
I plan my days, how I structure the meetings. I don’t always manage to
take breaks together with my colleagues. And I sometimes cancel going
out to restaurants for lunch, to save energy. If I had been working
perhaps 70% I might have managed such things. So I need to weigh
these things back and forth. (Female social worker with generalized
anxiety disorder, working full time)
When there are hiccups at work, my anxiety increases. Then I have to
move that task to a different room. I get so affected, when I’ve been
struggling with something for a couple of days that I can’t stay in that
room any more. It’s like the room has been infected with the stress.
Then I need to move my body someplace else to continue. (Male artist
with unspecified anxiety disorder, working full time)
To reach for managerial and collegial support. The participants
gave rich descriptions of turning to their managers for support:
but not before they were at risk of falling short of their duties.
Some felt understood by their manager who planned for immedi-
ate adjustments, while others felt neglected. The participants also
described reaching out to a coworker by sharing the joint experi-
ence of a stressful work environment or by letting someone at
work know how they really felt. One participant had a coworker
appointed as her “support person”she could turn to on a bad
day. To reduce but not shut down all social interaction was essen-
tial: the participants felt a need to be seen without being put
under social pressure.
Discussion
Our main findings describe how workers with CMDs try to keep
up at work by managing the work space: attempting to retain a
sense of freedom and the possibility to manoeuver and perform
in their working life. Diverse practical strategies were described
under the different categories, and it is hoped that our findings
will increase the knowledge of rehabilitation professionals working
with the target population. The strategies presented in “Results”
section could serve as items for future study among depressed
and anxious workers, also in association with sick leave.
The core category bridges the gap between the individual and
the environment as it draws focus to space as the interface
between the subject, their work context and their private sphere.
In this way, our understanding is in line with other models
explaining work functioning as a number of complex, dynamic
interactions [13,14,41]. Connected to our findings is the concept
of margin of maneuver [42], which focuses on disabled workers’
reintegration to work and the features determining “leeway”at
work. Mainly, these features relate to the organizational level in
terms of production demands and options to control and alter-
nate work tasks, but the worker’s self-efficacy and strategies are
also included. Our core category corroborates this conceptualiza-
tion, and potentially expands it: by addressing mental health and
by analyzing experiences from different phases of illness.
Similar to coping models on work stress, our core category
relates to processes and includes cognitive and behavioral efforts
[19,43]. However, our findings in some ways seem to transcend
the traditional distinction between problem and emotion-focused
coping strategies. For example, To reach for managerial and colle-
gial support and To compensate for shortcomings entail both prag-
matic problem-solving and emotional aspects. Moreover, coping
concerns the management of adaptational demands, related to
the emotions instantly generated from a given situation [21]. Our
categories Warding off strain and Forcing the work role relate to
the worker’s emotions of feeling threatened, fearful or ashamed,
resulting in strategies based on affect-based impulses. The per-
sonal significance and meaning of sustaining work is essential
here –there is a lot at stake for the workers –but paradoxically
the high significance seem to block them in cramped or even des-
perate measures, unable to see the risk of trying too hard. This
finding warrant further exploring, for example, connected to the
recent emphasis in coping theory about appraising and the con-
structed relational meaning between the person and their envir-
onment [21].
In fiction literature, the symbols of space and room to reflect
possibilities, agency and independence have been frequently
used, such as in Virginia Woolf’sA Room of One’s Own and E.M.
Forster’sA Room with a View. The conceptualization of “creating
space”has provided interpretative depth in health research from
a feminist perspective, such as in a gender-sensitive intervention
for adolescent girls with stress-related symptoms [44]. In our
study, both women and men reported feeling challenged to
“perform enough”with regard to occupational, social and family
duties, craving “alone time”outside work. The recuperative strat-
egies were not only health-promoting in the obvious sense
(increasing fitness or calming a stressed mind), but also as ways
for the participants to retrieve their own space.
Some strategies were used more often early in the process, i.e.,
at the onset of instability, while others were mainly used in return
to work, for example, after a period of sick leave. It seems that
the strategies Forcing the work role and Warding off work strain
are associated with a fight/flight reaction [45] and as such a reac-
tion to a stressful experience. The strategy Reflexive adaption is
more conscious and thought through, and less reactive in charac-
ter. It is adapted to the circumstances and suggests solutions
based on the individuals’resources and the requirements of work.
This strategy suggests that the stressful experience no longer
occupies the participants. Consequently, the different strategies
pull toward two positions, one characterized by high stress and
physiological reactions (“reactive position”) and the other charac-
terized by reduced stress and the ability to use reflective strat-
egies (“reflective position”). This interpretation suggests that
rehabilitation in the early phase could focus on reducing stress to
enable the worker’s creation of reflective, sustainable strategies.
Similar to previous studies [28,30], we found that the workers
practiced strategies to limit themselves at work, as described in
the category Reflexive adaptation. However, this category involved
other ways of handling vulnerability, for example working as usual
(i.e., without limitations) until the first signs of a new episode, or
changing jobs or careers.
Previous concerns have been raised that too much emphasis
on limitations can reduce joy and commitment at work [30]. We
share this concern and suggest that numerous strategies may be
helpful in the rehabilitation process, in which modifications are
reflected on and created with regard to keeping the individual’s
sense of meaning at work. We argue that interpersonal strategies,
such as obtaining social support from the manager and coworkers
[46,47], are particularly interesting as they have the potential to
create a sense of belonging and coherence, but may
792 L. DANIELSSON ET AL.
simultaneously hold a risk of draining energy. This knowledge
should be of interest also for employers.
We were careful not to let our understanding from previous
work and clinical guidelines pre-define the strategies into “good”
versus “bad”strategies. Rather, we tried to view the workers’strat-
egies as a palette of maneuvers: some were reflected upon and
consciously practiced, others emerged out of frustration and need.
Although it must be pointed out that the participants themselves
claimed variation in sustainability, suggesting that the categories
in the upper half of Figure 2 would facilitate a more sustainable
working life, we cannot rule out the possibility that some individu-
als go through their working life using the strategies from the
lower part of the figure. From an organizational perspective, these
strategies may be valuable as they suggest high work ethics. A
different study design investigating the long-term prevalence of
strategies in relation to sick leave, but also to productivity and
quality of life, would give more insight into how strategies in
CMDs are to be valued from different perspectives.
Following this line of thought, we suggest that an individual’s
strategies are to be approached by rehabilitation professionals
with openness and empathic creativity. People do what they can
to keep up at work and their possibilities to manoeuver insuffi-
ciencies partly depend on factors beyond the scope of health
care. We see a need for further investigation into the impact of
socioeconomic factors, education levels and health literacy in rela-
tion to the “palette”of strategies presented here. For example, we
noticed in the interviews that a manager and an engineer (i.e.,
workers with higher education and status) expressed knowledge
about their rights and entitlement to work adjustments, while a
cook did not. It is likely that the palette does not provide a full
and equal range of strategies for all. According to Bourdieu’s
sociological theories [48,49], workers have habitual dispositions to
respond to situations in everyday life. The social room provides a
space where they are intertwined with, but not completely bound
to, their economic and cultural capital. This suggests dialectics
between social determinants and the freedom to act, between
structure and agency, in the process of keeping working in CMDs.
Our results could increase employers’knowledge about more
or less visible strategies that the workers apply. In particular, the
category that highlights the benefit of managerial and collegial
support, entails strategies that the employers can facilitate at the
work place. Moreover, the strategy that some workers need to
“shield off”would be of interest for the employer to learn about,
so that they can try and facilitate less crowded rooms for those
workers. Although the results reflect strategies in the CMD popu-
lation, increased awareness of the strategies might facilitate
prevention in healthy workers, for example, knowledge of recu-
perative strategies, social support at work and reflection on atti-
tudes to work.
Strengths and limitations
The extensive in-depth exploration [36] using purposive sampling
and the process-oriented analysis based on comparing and con-
trasting data [50] and the parallel discussions among the authors
can be considered strengths. All three authors had previous
experience of using grounded theory, but the authors provided
different input to the analysis based on diverse clinical and theor-
etical backgrounds. Two of the authors had a prolonged commit-
ment to the data [51] having been researchers in the previous
study [31]. Transparency of the analysis was enhanced by outlin-
ing researchers’reflexivity and by exemplifying the stepwise con-
densation and discussion of data (Figure 1). Another aspect of
reflexivity was the two interviewers’joint discussions during data
collection, regarding their follow up questions. To show that the
conceptualization had “earned its way”into the analysis [36], we
have illustrated with direct quotes from the participants in the
subcategories and in Figure 1. Validation was enhanced through
debriefing with patients with CMDs.
This study used data from interviews that were primarily done
to answer a different research question, which can be considered
a limitation. However, the present research question about strat-
egies caught our attention and was gradually explored in the co-
constructive conversations between the interviewer and the par-
ticipants. We believe that this manner of discovering content and
meaning connected to a new research question, during the pro-
cess of data collection, is in line with grounded theory principles
and justifies our performance of a parallel analysis. Repeated inter-
views and using several data sources may have enabled deeper
insight into the participants’working life [34,36].
Another limitation is that few of the participants were manual
workers. Different sources of recruitment may have been better at
reaching a diversity of workers. However, since sick leave is cur-
rently increasing mainly in the welfare sector, in jobs with inter-
personal tasks [52,53], the present sample was suitable for
providing important knowledge of immediate relevance.
Conclusions
This study conceptualizes depressed and anxious workers’
attempts to keep up at work as managing work space, using strat-
egies to manoeuver and to gain enough space for their work per-
formance. In our interpretation, the notion of work space goes
beyond the physical room, to involve the lived, social space of
work, including the bridge to private life. It is hoped that our find-
ings will deepen the understanding among rehabilitation profes-
sionals and increase their awareness of the meaning and
characteristics of different work-related strategies in these
patients. This knowledge can be used to reflect together with the
patient, exploring present options and introducing modifications
in their particular work and life context.
Disclosure statement
The authors report no conflict of interest.
Funding
This study was supported by the Local Research and
Development Board for Gothenburg and S€
odra Bohusl€
an,
Gothenburg, Sweden and by The Healthcare Committee, Region
V€
astra G€
otaland.
ORCID
Louise Danielsson http://orcid.org/0000-0002-7089-3006
References
[1] Steel Z, Marnane C, Iranpour C, et al. The global prevalence
of common mental disorders: a systematic review and
meta-analysis 1980–2013. Int J Epidemiol. 2014;43:476–493.
[2] Whiteford HA, Degenhardt L, Rehm J, et al. Global burden
of disease attributable to mental and substance use disor-
ders: findings from the Global Burden of Disease Study
2010.Lancet2013;382:1575–1586.
STRATEGIES TO KEEP WORKING 793
[3] Arends I, van der Klink JJL, van Rhenen W, et al. Predictors
of recurrent sickness absence among workers having
returned to work after sickness absence due to common
mental disorders. Scand J Work Environ Health. 2014;
40:195–202.
[4] Netterstrøm B, Eller NH, Borritz M. Prognostic factors of
returning to work after sick leave due to work-related com-
mon mental disorders: a one-and three-year follow-up
study. BioMed Res Int. 2015;2015:596572.
[5] Ubalde-Lopez M, Arends I, Almansa J, et al. Beyond return
to work: the effect of multimorbidity on work functioning
trajectories after sick leave due to common mental disor-
ders. J Occup Rehabil. 2017;27:210–217.
[6] Bejerholm U, Larsson ME, Johanson S. Supported
employment adapted for people with affective disorders—
a randomized controlled trial. J Affect Disord. 2017;
207:212–220.
[7] Reme SE, Grasdal AL, Løvvik C, et al. Work-focused cogni-
tive-behavioural therapy and individual job support to
increase work participation in common mental disorders: a
randomised controlled multicentre trial. Occup Environ
Med. 2015;72:745–752.
[8] van Vilsteren M, Boot CR, Twisk JW, et al. Effectiveness of
an integrated care intervention on supervisor support and
work functioning of workers with rheumatoid arthritis.
Disabil Rehabil. 2017;39:354–362.
[9] van Vilsteren M, van Oostrom SH, de Vet HC, et al.
Workplace interventions to prevent work disability in
workers on sick leave. Cochrane Database Syst Rev.
2015;10:Cd006955.
[10] Lederer V, Loisel P, Rivard M, et al. Exploring the diversity
of conceptualizations of work (dis)ability: a scoping review
of published definitions. J Occup Rehabil. 2014;24:242–267.
[11]
€
Ust€
un TB, Chatterji S, Bickenbach J, et al. The International
Classification of Functioning, Disability and Health: a new
tool for understanding disability and health. Disabil
Rehabil. 2003;25:565–571.
[12] Siegrist J. Adverse health effects of high-effort/low-reward
conditions. J Occup Health Psychol. 1996;1:27–41.
[13] Theorell T, Karasek RA. Current issues relating to psycho-
social job strain and cardiovascular disease research. J
Occup Health Psychol. 1996;1:9–26.
[14] Law M, Cooper B, Strong S, et al. The Person-Environment-
Occupation Model: a transactive approach to occupational
performance. Can J Occup Ther. 1996;63:9–23.
[15] Gilworth G, Carey A, Eyres S, et al. Screening for job loss:
development of a work instability scale for traumatic brain
injury. Brain Inj. 2006;20:835–843.
[16] Gilworth G, Smyth G, Smith J, et al. The development and
validation of the Office Work Screen. Occup Med (Lond).
2008;58:289–294.
[17] Gilworth, G, Smyth, M G, Smith J, et al. The manual work
instability scale: development and validation. Occup Med
(Lond). 2016;66:300–304.
[18] Clark C, Pike C, McManus S, et al. The contribution of work
and non-work stressors to common mental disorders in the
2007 Adult Psychiatric Morbidity Survey. Psychol Med.
2012;42:829–842.
[19] Lazarus RS. Coping theory and research: past, present, and
future. Psychosom Med. 1993;55:234–247.
[20] Folkman S, Lazarus RS, Gruen RJ, et al. Appraisal, coping,
health status, and psychological symptoms. J Personal Soc
Psychol. 1986;50:571–579.
[21] Lazarus RS. Emotions and interpersonal relationships:
toward a person-centered conceptualization of emotions
and coping. J Personal. 2006;74:9–46.
[22] Bandura A. Social cognitive theory: an agentic perspective.
Annu Rev Psychol. 2001;52:1–26.
[23] Dalgard OS, Bjork S, Tambs K. Social support, negative
life events and mental health. Br J Psychiatry. 1995;
166:29–34.
[24] Stucki G, Cieza A, Ewert T, et al. Application of the
International Classification of Functioning, Disability and
Health (ICF) in clinical practice. Disabil Rehabil. 2002;
24:281–282.
[25] McFadden E, Horton MC, Ford HL, et al. Screening for the
risk of job loss in multiple sclerosis (MS): development of
an MS-specific Work Instability Scale (MS-WIS). Mult Scler.
2012;18:862–870.
[26] Bertilsson M, Petersson E-L, Ostlund G, et al. Capacity to
work while depressed and anxious—a phenomenological
study. Disabil Rehabil. 2013;35:1705–1711.
[27] Bertilsson M, L€
ove J, Ahlborg G, et al. Health care professio-
nals' experience-based understanding of individuals' cap-
acity to work while depressed and anxious. Scand J Occup
Ther. 2015;22:126–136.
[28] Hjarsbech PU, Nielsen MBD, Andersen MF, et al. Struggling
at work –a qualitative study of working Danes with
depressive symptoms. Disabil Rehabil. 2015;37:1674–1682.
[29] Ekbladh E, Sandqvist J. Psychosocial factors’influence on
work ability of people experiencing sick leave resulting
from common mental disorders. Occup Ther Ment Health.
2015;31:283–297.
[30] Jansson I, Perseius K-I, Gunnarsson AB, et al. Work and
everyday activities: experiences from two interventions
addressing people with common mental disorders. Scand J
Occup Ther. 2014;21:295–304.
[31] Danielsson L, Bertilsson M, Holmgren K, et al. Working in
dissonance: experiences of work instability in workers with
common mental disorders. BMC Public Health. 2017;17:472.
[32] Corbin JM, Strauss A. Grounded theory research: proce-
dures, canons, and evaluative criteria. Qual Sociol.
1990;13:3–21.
[33] Charmaz K. 'Discovering' chronic illness: using grounded
theory. Soc Sci Med. 1990;30:1161–1172.
[34] Charmaz K, Belgrave LL. Qualitative interviewing and
grounded theory analysis. In: The SAGE handbook of
interview research: the complexity of the craft; 2012.
p. 347–366.
[35] Charmaz K. Constructivist grounded theory. J Positive
Psychol. 2017;12:299–300.
[36] Hallberg LRM. The “core category”of grounded theory:
making constant comparisons. Int J Qual Stud Health Well-
Being. 2006;1:141–148.
[37] Dahlberg KM, Dahlberg HK. Description vs. interpretation –
a new understanding of an old dilemma in human science
research.Nurs Philosophy2004;5:268–273.
[38] Organization WH. The ICD-10 classification of mental and
behavioural disorders: clinical descriptions and diagnostic
guidelines. Geneva: World Health Organization; 1992.
[39] Topp CW, Østergaard SD, Søndergaard S, et al. The WHO-5
well-being index: a systematic review of the literature.
Psychother Psychosom. 2015;84:167–176.
[40] World Medical Association Declaration of Helsinki: ethical
principles for medical research involving human subjects.
JAMA. 2013;310:2191–2194.
794 L. DANIELSSON ET AL.
[41] Sandqvist JL, Henriksson CM. Work functioning: a concep-
tual framework. Work. 2004;23:147–157.
[42] O'Hagan F. Work, organisational practices, and margin of
manoeuver during work reintegration. Disabil Rehabil. 2017
[Sep 29]; [10 p.]. DOI:10.1080/09638288.2017.1383520
[43] Dewe P. Work stress and coping: theory, research and prac-
tice. Br J Guid Counsel. 2004;32:139–142.
[44] Str€
omb€
ack M, Malmgren-Olsson EB, Wiklund M. 'Girls need
to strengthen each other as a group': experiences from a
gender-sensitive stress management intervention by youth-
friendly Swedish health services –a qualitative study. BMC
Public Health. 2013;13:907.
[45] Niermann HC, Figner B, Roelofs K. Individual differences in
defensive stress-responses: the potential relevance for psy-
chopathology. Curr Opin Behav Sci. 2017;14:94–101.
[46] de Vries G, Koeter MWJ, Nabitz U, et al. Return to
work after sick leave due to depression: a conceptual
analysis based on perspectives of patients, supervisors
and occupational physicians. J Affect Disord. 2012;136:
1017–1026.
[47] Pranjic N, Bilic L. Work ability index, absenteeism and
depression among patients with burnout syndrome. Mater
Sociomed. 2014;26:249–252.
[48] Bourdieu P. Practical reason. On the theory of action.
Stanford (CA): Stanford University Press; 1998.
[49] Bourdieu P, Wacquant L. Symbolic capital and social
classes. J Class Sociol. 2013;13:292–302.
[50] Boeije H. A purposeful approach to the constant compara-
tive method in the analysis of qualitative interviews. Qual
Quant. 2002;36:391–409.
[51] Yardley L. Dilemmas in qualitative health research. Psychol
Health. 2000;15:215–228.
[52] Hubertsson J, Turkiewicz A, Petersson IF, et al.
Understanding occupation, sick leave, and disability pen-
sion due to knee and hip osteoarthritis from a sex perspec-
tive. Arthritis Care Res (Hoboken). 2017;69:226–233.
[53] Vision, Sjukt stressigt. Arbetsmilj€
on i v€
alf€
arden måste
f€
orb€
attras [Sick and stressed. Work environment needs to
improve]. Forsakringskassan [Swedish Social Insurance
Agency]; 2016.
STRATEGIES TO KEEP WORKING 795
