“Everything is so relaxed and personal” – The construction of helpful relationships in individual placement and support

ABSTRACT

The relationship with professionals is an important factor in relation to the outcome of interventions directed to persons with severe mental problems. However, the current knowledge regarding the development of helpful relationships within Individual Placement and Support (IPS) services is limited. The aim of the study was to investigate how participants in IPS services described their relationship with their IPS coach. The article is based on interviews from a Swedish government evaluation of IPS services, thematically analyzed. The results showed that the relationship with the coach is central for the participants’ success in the service. The main theme, “something different - as a human being” highlighted that the conditions for the relationship are different within IPS as compared to traditional services. The other themes were “here and now action,” “closer to wish-fulfilment – impact on the self,” and “from role to person.” The principles of IPS parallel the results from research about helpful relationships and offers good preconditions for the occurrence of such relationships. This can represent a bridge between evidence based methods and research on helpful relationships, and should be possible to implement in the development of evidence based methods as well as of treatment as usual.

KEYWORDS:

• Alliance
• helpful relationships
• individual placement and support
• persons with severe mental health problems

Background

The development and implementation of interventions targeting individuals with severe mental problems is increasingly based on outcome data obtained in randomized, controlled trials (RCTs). Simultaneously, current research indicates that the specific factors associated with various therapeutic methods have limited explanatory value when it comes to assessing efficacy and identifying what actually helps. Instead it has been suggested that common factors found across the board, regardless of theoretical approach or technique, may be of greater importance (Wampold & Imel, 2015). With this in mind, it has been proposed that an evidence-based understanding of these common factors be integrated and deployed in the development and design of practices, methods and manuals (Anthony & Mizock, 2013).

One common factor that has received a lot of attention in the research community is the relationship between client and professional—referred to by terms like “helping relationship,” “therapeutic relationship,” “therapeutic alliance,” or “working alliance.” This relationship was first conceptualized within the realm of psychotherapy and has proved effectual when it comes to predicting the outcome of psychotherapeutic interventions (Horvath, Del Re, Flückiger, & Symonds, 2011; Martin, Garske, & Davis, 2000). In later years there has been an increased interest in this relationship within services targeting persons with severe mental problems. The importance of the relationship for clinical, social, and psychological outcomes has been seen in treatment-as-usual practices in the mental health care of patients with severe mental problems (DeLeeuw, van Meijel, Grypdonck, & Kroon, 2012; Ljungberg, Denhov, & Topor, 2015; Priebe, Richardson, Cooney, Adedeji, & McCabe, 2011), and its importance to clients has also been observed in vocational rehabilitation services (Catty et al., 2008; Catty et al., 2010; Donnell, Strauser, & Lustig, 2004).

Researchers have also delved deeper into the relationship between professional caregivers and patients with severe mental problems. Studies examining the helpful elements of these relationships from the perspective of the latter have established several recurring themes regardless of differences in organizational context and type of professional role (Ljungberg, Denhov, & Topor, 2015). To a large extent, the professionals and their way of being and acting is the central theme in users’ descriptions of these relationships. The professional competence and skills of these professionals and the support they provide is greatly appreciated (Berggren & Gunnarsson, 2010; Ljungberg, Denhov, & Topor, 2015; Williams & Tufford, 2012), and the way in which they manifest these in cooperation with the user (Borg & Kristiansen, 2004; Galon & Graor, 2012; Green et al., 2008; Ware, Tugenberg, & Dickey, 2004). Furthermore, the professional caretakers are valued for being “like a friend” and a human being within the relationship (Borg & Kristiansen, 2004; Berggren & Gunnarsson, 2010; Denhov & Topor, 2012; Green et al., 2008), for treating the user as an individual and not just as a patient (Ware et al., 2004; Williams & Tufford, 2012), and displaying care and concern for the user (Galon & Graor, 2012; Green et al., 2008; Williams & Tufford, 2012). Some contextual factors, such as continuity and the absence of time constraints have also been described as crucial in helpful relationships with professionals (Borg & Kristiansen, 2004; Denhov & Topor, 2012; Green et al., 2008; Topor & Denhov, 2012).

Individual placement and support

Individual placement and support (IPS) is a vocational rehabilitation model that has proven effective in helping people with severe mental problems return to competitive employment (Bond, Drake, & Becker, 2008; Crowther, Marshall, Bond, & Huxley, 2001; Kinoshita et al., 2013; Twamley, Jeste, & Lehman, 2003). The model has been implemented in a number of countries around the world, and has shown to be effective also outside North America (Bond, Drake, & Becker, 2012).

The approach is based on eight empirically derived principles designed to help people with severe mental problems return to competitive employment: (1) the objective of participation is paid employment on the mainstream labor market; (2) job-seeking activities commence immediately; (3) participation is a personal decision, and no one is excluded due to personal circumstances; (4) vocational rehabilitation is integrated with psychiatric care; (5) support is personalized and has no time limit; (6) support is determined by participant preference and not professional assessment; (7) participants are continually advised on security and social benefits; (8) job coaches work systematically to recruit, involve and build networks with local employers (Drake, Bond, & Becker, 2012).

In the IPS model the relationship between job coach and participant plays an important role. Each participant is assigned a coach who remains with him or her throughout the rehabilitation process. This design aims to promote a good working relationship and to increase the probability of the participant remaining in the process, as well as to achieve better outcomes (Becker & Drake, 2003, p. 75). In qualitative studies, the job coach and the relationship to the participant emerged as an important part of the vocational rehabilitation process. The relationship to the job coach is characterized by an alliance that empowers participants and fosters control (Areberg, Björkman, & Bejerholm, 2012) as a partnership where the participant, by accepting the coach’s expertise and support, acquires a better self-image and an enhanced feeling of well-being (Liu, Hollis, Warren, & Williamson, 2007). Furthermore, the relationship to the job coach has been described as a supportive relationship in which the job coach is a caring and accessible helper committed to the participant (Johnson et al., 2009), and as a trusting relationship in which the coach takes on a role as guide for the participant (Nygren, 2012).

In addition, quantitative studies that have analyzed the relationship between job coach and participant in IPS programs have confirmed the importance of this relationship. Participant appraisal of the therapeutic relationship is more positive among those participating in IPS programs than among those taking part of traditional train and place vocational rehabilitation (Catty et al., 2011; Kukla & Bond, 2009). Favorable participant assessment of the relationship is linked to job acquisition outcomes as a result of participation in the IPS program (Catty et al., 2008; Catty et al., 2010). However, favorable participant assessment of the relationship is not necessarily linked to job tenure (Kukla & Bond, 2009), or with positive clinical or social outcomes resulting from IPS intervention (Catty et al., 2010).

Numerous studies have highlighted the relationship between coach and participant for intervention outcomes in connection with IPS supported employment, but we still lack comprehensive knowledge as to how these helpful relationships are established in the specific context that IPS represents. Consequently, the aim of this article is to investigate the mechanisms behind helpful relationships in IPS services, and the connection between these mechanisms and the IPS approach from the participants’ perspective. To what extent do the participants describe their relationship with the coach as helpful? To what extent are the contextual preconditions of IPS services apparent in their narratives?

IPS in Sweden

In recent years, the Swedish state has reserved development funds to implement IPS and to make necessary adjustments of the IPS model prior to deployment under Swedish conditions. During the period 2011 to 2013 32 IPS programs were therefore initiated and assessed (Swedish National Board of Health, 2014). Two contextual aspects relating to operations design proved to play a pivotal role in the evaluation.

• Due to organizational constraints in the Swedish care and support system IPS has become the responsibility of municipalities and not of psychiatric services. The former lacks psychiatric expertise and their IPS programs are run by the social care services.

• The project approach meant that coaches had relatively few participants to work with; between eight and 15 per coach, depending on the activities involved. The way in which the project was set up also meant that coaches were not compelled to carry out any extensive documentation.

Method

The authors of this article participated in the evaluation carried out by the Swedish authorities. The evaluation was based on a questionnaire sent to all the IPS programs involved and study visits were made to three of these. During these visits, job coaches, management and a number of individual participants were interviewed.

The empirical basis for this article consists of interviews with nine participants from three different IPS projects. These interviews focused on their experiences with the IPS program they were enrolled in and the extent to which they felt that participation in an IPS intervention had helped them. Contact with the interviewees was established via the IPS teams. When they enrolled in the program, and prior to the actual interview, participants were informed of the purpose behind the interview, were told that participation in the evaluation and the interview was voluntary and that the interviews would be recorded and transcribed and that excerpts would be anonymized before publication. Interviews lasted between 20 and 50 minutes. Two of the interviewees were men and seven were women. As the social services interventions were not diagnostically based but took the needs of clients as starting point, the services had no access to individual diagnoses. All participants had an ongoing contact with the psychiatric services and a specialized team in municipality-run social services for persons with psychiatric disabilities—which term in this instance can be considered as proxy for severe mental illness (Arvidsson, 2008). All were currently enrolled in an IPS program. At the time of the interviews two had subsidized employment, five had a job placement, or had just finished one, and two had begun studying. Nobody, therefore, was holding down a regular job on the open labor market. All, however, were currently occupied in an activity they regarded as having something to do with their employment preferences. All the coaches were trained social workers—none had any formal training or experience of working in psychiatric care. Eight of the nine coaches were women.

One aspect underlined by the interviewees was the importance of the relationship with a designated coach. This aspect was not analysed in any depth in the government evaluation. The present article is based on a thematic reanalysis of the nine interviews.

The data collected was analysed according to the precepts of thematic analysis, a qualitative analytic method (Braun & Clarke, 2006). The first author read the collected interviews and excerpts to specific questions relevant to the analysis were extracted to a new data set. Further analysis of the data was conducted separately by both authors and the emerging initial codes were discussed until agreement was reached. The third step in the analysis was to refine the codes to themes and subthemes, constantly switching back and forth between data and themes. In the final discussion these themes were linked to the IPS model principles and the specific modifications that were made in Sweden.

Results

An analysis of the interviews with the participants shows a strong corollary between IPS as method and the emergence of personal relations between coach and participant. The thrust of the IPS model seems to facilitate relationships, and these relationships are the focus of participant narratives.

There is a risk that the division into different themes may make the connections between them difficult to grasp. We have therefore chosen to present extended interview excerpts to link together these themes.

The overall theme of the analysis is “Something different—as a human being.” The other themes are “Here and now action,” “Closer to wish-fulfilment—impact on the self,” and “From role to person.”

Something different—as a human being

The special working conditions possible under IPS, compared to the somewhat more limited scope of action that is possible with conventional interventions, means that caseworkers can directly and actively support the endeavors of individual participants, “I can only say this … Most people see you as either a cipher or a disease, and here they see you as a human being. And that’s the difference. Things start to happen when you are treated like a human being.”

Participants consistently compare their meeting with IPS with their experiences of other interventions used to care for people with severe mental problems. The comparisons indicate clear differences that can be analysed spatially and temporally.

Encounters in a variety of places

In several cases, the first encounter with IPS took place in a neutral location, neither in the job coach’s office nor in the participant’s home, but in a public venue such as a café, where the coach chatted with the participants in a friendly and relaxed manner over a cup of coffee,

It is the best thing that ever happened to me. We meet once a week, or every other week. We sit down and have a cup of coffee and talk a little. It’s really pleasant, you feel you can relax and be yourself. No stress or pressure, but it allows you to concentrate and focus all your energy on what you yourself want.

Meetings took place in a variety of places, often in a public setting, but also at the participants’ workplace. More than one participant mentioned the fact that the professional left his own arena, often on their first meeting. This seemed to represent a symbolic departure from the normal rules and procedures they were used to.

Take the time it takes

Deviation from the norm could also be found in the length of the meeting, which seemed to have been adapted to fit individual circumstances. Meetings could vary in length and frequency but contact could also be maintained outside the coach’s regular working hours:

Last summer I started working just when she went on holiday, but she left me her phone number and address, in case anything happened. “If you’re in a fix I’ll help you! We’ll work things out! You don’t have to worry while I’m away.” She’s really good.

This availability of time was in stark contrast to previous experiences, “I’ve become a bit sensitive to people saying things like ‘We’ve got an awful lot to do.’ I’ve never heard Anne say that.”

The limited time at previous case workers disposal also gave rise to the feeling that routines were more important than the needs of participants,

Otherwise it’s about making an appointment and then just waiting and waiting and waiting … never-ending waiting. “We have patient processing times that must be fitted in and everyone must wait their proper turn.” Nothing ever happens. What am I supposed to do in the meantime, just stand and wait? Sit and stare at the wall? When it comes down to it that’s pretty much what it’s all about. The system doesn’t really work. Here, there’s a direct connection.

Beyond illness

According to the tenets of IPS, interventions should be integrated in psychiatry. In Sweden they have been placed under the social services. Several interviewees found this positive. They felt they had not just been reduced to symptoms and diagnoses,

When I go to see her at the psych clinic we focus exclusively on my problems. The people there try to support me in my ups and downs, but Erika does so much more. The psychiatric services don’t address all the issues. They concern themselves with your mental state, medication and sick leave. Everything else you have to take care of yourself.

Getting away from a medicalized focus on individual shortcomings was a positive experience, which harmonized with IPS’s emphasis on the individual’s own wishes without tests or appraisals of (in) abilities,

It was a chance to be in healthy surroundings and meet people who believe in you, and it has given me an awful lot. They think we can make something of our lives, that’s very important. Not like you just getting a prescription—take this medicine and see if it works.

Psychiatry’s focus on addressing “disorders” and shortcomings in the individual stands in contrast to the IPS approach.

Here and now action

In the participants narratives spatial and temporal mobility was linked to rapid action. The step from words—the participants’ words—to action was short. In Anneli’s case a lot of positive things happened:

We were looking at a course that I wanted to go on and discovered that the deadline was the very same day. Lotta was on to it straight away: “Let’s go there at once!” She made some calls. “Where should the application be delivered? Where can we get hold of the necessary form?”. … If she had not done all of this it would never have got there in time, I can tell you! Then they misplaced my application. She helped me to call round to those in charge and managed to find it, so I got the place. She accompanied me on the first day I was there, looked around a little and gave me support.

Anneli’s narrative illustrates not only on the focus on quickly bringing about change, but also that the coach’s work is based partly on the participant’s wishes, and partly on concrete and targeted action. Several interviewees emphasized this concrete approach:

How do you know the other person really hears what you say? When I say: “Astrid I want to do this” she says, “Okay, I’ll check it out by the next time we meet.” I know she’s listening to me, she cares, and she wants to do what I want to do. It is important to have a bash at doing all the practical stuff. Not like when you try and talk to a psychologist. They listen to you, but you don’t really know whether they have heard you or not. There is no feedback. But here you get a response.

Words and discussions about participants’ goals don’t just stay words. The transition from words to action isn’t left solely to the participant but is part of a joint agenda designed to achieve the participant’s own goals. Here also, time is of great importance. Words were translated into action.

Closer to wish fulfilment—impact on the self

According to participants spatial and temporal mobility and the emphasis on rapid action result in two outcomes that are often—though not inescapably—intertwined. The first was getting closer to wish fulfilment—a step towards competitive employment on the labor market. The second was a changed sense of self.

Concrete results

Although none had acquired a job on the mainstream labor market, the participants had taken a step toward the goals they had set for themselves. These goals ranged from getting a subsidized job, a work placement at a regular workplace, or to have begun studying as a step towards getting a desired job.

They felt as though they were on the way to achieving what they wanted:

Last week I got a placement at a service centre. It was impossible to get a position there because they already had enough staff and enough trainees a well, but anyway I got to practice a week there. And this week was great and very important for me.

At the same time, progress did not mean that contact with the coach ceased, the relationship continued even after the participants were well on the way to realizing their goals.

The concrete steps taken in getting back onto the labor market and the relationship with the coach contributed to another outcome that was a significant part of participant narratives. They describe various stages in their own development.

The symbolism of the practical

Many participants also described an outcome that was not solely a concrete result in the form of work or study. They also cited a personal development that impacted the psychiatric problems they were suffering from at the outset:

I had felt bad almost all my life, low self-esteem and never managed to make a go of anything. I got in touch with Karl at IPS and we looked at whether it was possible for me to get some work experience, and I got a job placement at a supermarket, and I’m still there! What a turnaround! I stopped taking medication. I’ve become much more self-confident. Now I can do everything. My speech has improved—before I mumbled so much no one could hear what I said. It has meant a lot to me. Now I work half time, in the beginning I only worked a few hours a week and when I was packing up goods I wasn’t sure if I was doing things properly. Now I stand in the checkout, I accept deliveries, I order goods and … so now I’m ready for the world of work for real. Now I feel great.

Even though the changes this individual experienced after contact with IPS were not always quite so dramatic for everyone, they seemed to involve some degree of personal development:

In the morning when I come here I feel quite normal. My self-confidence starts to rise when I’m together with Astrid and she is putting through calls for me. This self-confidence is somewhere down inside me; perhaps it’s asleep—just curled up there. But she’s helping it to wake up. She has a particular way of presenting me for people. She helps me write my CV—and with the contacts I have to take, the workplaces I have to get in touch with. I need this. It gives me energy.

The practical consequences of this makeover dissolve the boundary between “treatment” and “rehabilitation,” and appeared in a number of cases to impact the whole spectrum of the individual’s personality, “I have been working now for seven weeks, more or less. It’s had a big effect on my voices. My voices are a part of work, too. But now I hear nice voices.”

An enhanced sense of self emerged from the alliance with the coach, and when the individual concerned obtained the job or embarked on the studies he or she longed for. The consequences of this change affect the individual’s sense of self but also symptoms and treatment, because voices can become less disruptive and drug therapy can be stopped.

From role to person

Enrolling on a course or getting a job is a result of coach and participant working in tandem to achieve the latter’s goals. Realizing that your own utopias are in actual fact achievable goals plays an important role in the development of the individual, but in the participant narratives this transformation starts before the first active steps are taken to reach these goals.

The professional as person

The process of change is seen as having its basis in a social interaction where the first step is taken by the coach. All participants highlighted the role the coach played: “Karl has helped me.” The coach is usually also referred to by first name as is seldom the case with other professionals encountered during the passage through the mental care system, these are usually referred to by their professional titles.

The coach stands out by virtue of professional effectiveness. She or he has helped to quickly achieve tangible results. But there is a double role at work here, in the interaction with the participant the person behind the professional begins to emerge:

Of course I’ve only ever met Karl. He’s very sensitive, just as I am, and understands me pretty well. Not many people are like that. I think this quality has been very important. He’s very understanding and listens extremely carefully.

As the coach emerges as a person it becomes possible to compare yourself with him or her and to discover the character traits you have in common. In the interaction with the participant the coach is not reduced to an impersonal professional of the type previously encountered,

She’s got a nice personal touch, so I’ve got a pretty good relationship with her. We don’t just sit down and do the paperwork … we sit and talk about a lot of things … about life, what we have been up to—pretty much like when you meet family or friends, gossip about what’s been happening. I’ve never been able to do at that at the job center.

Active listening on the part of the coach makes it possible for the participant to discover personal characteristics they share—awareness on the part of the coach that lays a foundation for mutual understanding. Common traits are a way to break through the barrier between normal/professional and deviant/sick they had previously run up against.

The participant as person

The pivotal role the participants’ own wishes play in the interaction with the coach makes it easier for them to see the person behind the professional. The contrast here with previous experiences of professional care is something many emphasize in their narratives. This focus enables the participants to turn to themselves, and to begin to formulate their aspirations in alliance with another person sympathetic to these,

We’ve dealt with the issues pretty much on my terms … how I want things to be, how I feel. I met Ninni for the first time in a cafe. Then we started to brainstorm and to get to know each other, so she could see where I was at … the support and help I needed, these were the things we took up in the beginning. So she pretty much realized the difficulties I was having, how big they were and … for me it was pretty new because I’ve always had caseworkers who’ve more or less decided for me, and I’ve found it quite hard to make any decisions on my own … so I’ve pretty much done what other people have told me to do.

The initial meeting with the coach does not begin by focusing on the participant’s problems and the filling in of assessment forms to identify these, but is about “brainstorming and getting to know each another.” In interaction with the coach participants regain control over aspects of their own lives and a sense of self that allows them to exercise power. Several speak of how the meeting with the IPS coach enhanced their sense of the self as a whole person in contrast to being reduced to a mere diagnosis:

I think these people see both sides of us. There is a background—this is someone who is sick, depressed, and all these mental illnesses you’re suffering from. But at the same time they don’t forget that you’re a person, a human being, someone who knows things—has hidden powers inside themselves. That’s what’s important. I think they see both sides of us, they know we are sick and that we feel wretched too, but at the same time they treat us with respect and they believe in us—that we can be something. We know that for a depressed person it’s not enough with happy pills or sleeping pills, there is something else—you need to give your life meaning.

It is not a question of denying problems and difficulties but in alliance with the coach rediscovering that they are players in an immense and multifaceted world. They too possess knowledge and skills, and in the right circumstances can put these to good use. IPS and the coach seem to be able to make this possible.

Through this commitment the coach increasingly emerges as a person in the eyes of participants. This process in which the professional increasingly emerges as a person becomes an important facet in another process, in which the participant starts to perceive himself or herself as a person in the eyes of the coach. This experience is then integrated into the participants’ sense of self. It is in their discourse in a field of action bound by few constraints—compared to those that prevail in many other workplaces—that participants and coaches are all too familiar with, that they help each other to break down institutional definitions of the roles of the sick person and the expert (Parsons, 1951).

Discussion

The study clearly shows that participants attribute a pivotal role to coaches when it comes to the headway they have made in achieving their goals, and the relationship they have with the coaches is seen as very different from that which they have had with professionals in other care instances.

IPS and common factors in helpful relationships

The way participants in the study describe this helpful relationship is in line with much of the knowledge we already possess about the mechanisms at work in the relationship between professional and client/service user/patient. Thus the existence of common traits among professionals that is identified as helpful in this sort of relationship that has been found to cut across different services (Ljungberg, Denhov, & Topor, 2015) seems also to apply to these IPS services.

An important aspect of the coachs’ facilitating role is without doubt the professional assistance they are able to bestow. The fact that they have special skills, an extensive professional network, and authority and competence, that they are able to grant access to specific resources as a vital and integral part of the relationship, means that the coach/participant relationship differs in kind from relationships with friends and family, and this contributes significantly to the supportive nature of the former relationship (Ljungberg, Denhov, & Topor, 2015). Quick access to practical and concrete support in contacts with potential employers and various authorities that could help them get a job or find some other form of occupation, clearly emerged in participant narratives as an important component of the help coaches were able to provide for them.

At the same time, earlier research into the mechanisms behind helpful relationships and the findings of the present study suggest that supportive relationships of this kind are much more than the sum of the competence displayed by professionals and the resources they command. The relationship is also personal and when the professional and client come together in this way they are able to enter into a working alliance which allows them to break away from stereotypes and perceive themselves as individuals in a reciprocal learning process.

Participants in the study describe relationships with the coach as personal, and as extending beyond what they are accustomed to with other professionals.

In these narratives the coach clearly emerges as an individual who by virtue of his commitment and way of acting plays a significant role for the participant. The fact that the coaches care about the participants and are committed to their welfare has also been stressed as an important factor in previous IPS studies (Johnson et al., 2009). The participants also described how coaches have stepped outside their professional roles, and done more than they were “required” to. These actions, which constitute the “little extras” that go beyond what can be expected from primary care professionals, have also been highlighted in previous studies of helpful relationships as something out of the ordinary, and a valued testimony to the dedication of the professional concerned (Borg & Kristiansen, 2004; Denhov & Topor, 2012; Topor & Denhov, 2015; Ware et al., 2004).

The opportunity to work on issues together with a professional, to influence the course the relationship takes, and to have a say about the nature of the support provided, has been seen as beneficial in studies on relationships with professional caregivers (Borg & Kristiansen, 2004; Galon & Graor, 2012; Green et al., 2008; Ware et al., 2004). This type of partnership is also seen as positive by the participants (Areberg et al., 2012; Liu et al., 2007), and by employment specialists in previous qualitative studies of IPS services as an important part of effective job development (Glover & Frounfelker, 2011). The participants in the present study appreciated the fact that their opinions and views to some extent defined the relationship and its contents, and the relationship can best be described as collaboration toward a common goal.

The results are also in alignment with the present state of knowledge about recovery-orientated services and professionals. Farkas, Gagne, Anthony, and Chamberlin (2005) specify five key values for recovery-orientated services; person orientation, person involvement, self-determination/choice and growth potential, which is well in line with the experiences of participants in IPS. Slade and Longden (2015) observe that psychiatric diagnoses are an unreliable foundation for recovery orientated interventions and that “The overarching aim is a re-orienting of the mental health system around the goal of ensuring access for people experiencing mental health problems to the normal entitlements of citizenship.” (p. 9). Central to these services is that they tend to normalize the living conditions of the individuals concerned (and not normalization of the person) and that, therefore, “the service user is the ultimate decision-maker other than where legal issues over-ride” (Slade, 2009, p. 8). The role of the professional should be reoriented to harmonize with the increased emphasis in recovery-orientated services on cooperation and reciprocity. These general principles and approaches are applied in the activities and the practices described in the interviews.

An organizational ground for helpful relationships

Although there were several themes in common with what previous studies in other services have shown to be helpful in relationships with professionals, participants have stressed the dissimilarities between their relationships with IPS coaches and other professionals. This can indicate that there are significant differences in the coach’s role and approach that create favorable conditions for the development of a strong and positive relationship.

However, helpful professional relationships do not develop in a social vacuum. Although such relations cannot be analyzed without taking into account individual character traits, the participants’ experiences of the coaches and the relationship they establish with them underline the importance of organizational conditions existing outside individuals.

It is possible to find connections between some of the guiding principles behind IPS and the factors highlighted by research into helpful professional relationships, factors that have been taken up in this study.

The fact that participation in an IPS program is voluntary, and that the stated goal of IPS is paid employment made it easier to select motivated participants and proved important for the outcomes of different interventions. The emphasis on each participant’s own preferences and his or her participation in the decision process brings out the individual beyond the diagnosis. This is further facilitated by the absence of professional assessments. These assessments would constitute a time-consuming review of participants’ preferences and make it more difficult to start job-seeking activities immediately.

Although the number of participants allocated to each coach is not expressly dictated by IPS guidelines, this number is far less than that common in traditional activities. The project form in the activities studied helped further reduce the number of participants each coach worked with. This increased the time available for interaction, as did the fact that the documentation burden was greatly reduced. The availability of time made it possible to be flexible in relation to the needs of each individual and to take advantage of opportunities as soon as they arose, as also noted in other contexts (Topor & Denhov, 2012). The participants were not subjected to lengthy periods of waiting and were instead able to see tangible and immediate results. The availability of time also provided the coaches with a real opportunity to recruit and build networks with local employers.

IPS principles impact the time aspect in another way; there is an undertaking of support without a time limit. This is something difficult to guarantee under any circumstances and even more so in an activity carried out as a time-limited project. But the promise was there.

The focus on implementing the personal projects of highly motivated participants, without the compulsion to undergo new professional judgments and in contact with personnel that had an unusual amount of time at their disposal, making it possible to realize the principle that job-seeking activities should commence immediately seems to provide the organizational conditions that permit the development of helpful relationships.

The implementation of IPS in Sweden deviated in one respect from core IPS principles in that operations were not integrated with traditional psychiatric care institutions, but with the outlying social services instead. This organizational locus brought with it a weakening of the psychiatric culture (diagnostics, medical treatment orientation) within the project. The fact that the coaches were not focused on diagnosis and medication and had no psychiatric expertise was seen as something positive. This also seems to have contributed to a freedom of action in the coach–participant relationship that can be seen in the choice of the venue and the direction conversations took when the protagonists met—outside the institutional arenas and with a willingness to talk about things other than finding work and mental health problems. Social workers had no or little access to traditional psychiatry concepts and frames of reference and were forced to build their own in interaction with the participants.

It appears that the principles underlying IPS are able to contribute to the creation of an organizational base that favors the formation of helpful relationships. These principles offer participants and coach alike a shared goal and a practical environment in which this goal can be achieved without them reducing one other to a formal role. Thus the coaches are able to make use of their formal positions and the resources linked to organizational affiliations and the possibility of going beyond this formal situation and creating “the little extras” that characterize the construction of helpful relationships (Topor & Denhov, 2015). These principles are, however, in stark contrast to the principles that regulate and structure much of the care and the support that has been developed within traditional services. In these a heavy workload rests on the shoulders of the professional caretaker, and demands for standardized professional assessments and interventions frustrate rapid individualized interventions based on participant experience and preference. Mounting demands for comprehensive documentation further limit the amount of time the coach has to interact with participants.

The experience-based knowledge displayed by participants testifies to the divide that exists between traditional and IPS activities. This awareness is also confirmed in the research literature. Aspects such as motivation as the only criterion for inclusion, personalized and unlimited time support (Drake et al., 2012), and guidelines limiting the number of participants per coach (Becker, Swanson, Bond, & Merrens, 2008), are evident in the praise that wells up in participant narratives.

Methods, organizations, and relations

This speaks to the familiar debate on the role of specific and common factors and method contra the importance of interpersonal relations for the outcome of interventions (Wampold & Imel, 2015). The results of this study suggest instead that both these components are important, as intervention design and the logic and structure of the methods employed proved to have great impact on the conditions under which relations to the professional responsible for the intervention developed. The IPS approach facilitates the rise of this kind of helpful relationship. Knowledge of the important role played by the client/professional relationship and of the constituents of helpful relationships should not be seen as contradictory to the development of an evidence-based methodology but rather as an important insight that should lie at the basis of new evidence-based approaches (Anthony & Mizock, 2013).

When evidence-based interventions and models are developed and evaluated the focus is often on RCTs, which are the gold standard when it comes to healthcare evaluations. Several RCT studies have shown IPS to be an effective model for helping people with severe mental problems return to competitive employment (Bond et al., 2008; Crowther et al., 2001; Kinoshita et al., 2013; Twamley et al., 2003).

However, these kinds of studies are limited insofar as they are restricted to evaluating predefined outcomes. Although it is important to ascertain how effective an intervention is with regards to particular outcomes, qualitative studies such as the one at hand reveal how the individuals concerned actually rate not only the interventions they are subject to, but also the process itself and how successful it has been in producing the desired outcome (Roberts, 2000). Although previous quantitative studies of the working alliance’s importance for the various outcomes of IPS activities have been ambiguous (Catty et al., 2008; Catty et al., 2010; Kukla & Bond, 2009), the present study, along with other qualitative studies on IPS (Areberg et al., 2012; Johnson et al., 2009; Liu et al., 2007; Nygren, 2012) helps to highlight not only how the IPS model facilitates relationships, but also that these relationships in themselves may have value and be positive for the participants and their integration in the labor market. The study emphasizes the importance of simple everyday gestures and events for a person’s sense of self. Often these have a symbolic significance far beyond their prima facie import as they are in stark contrast to what the individual in question has become accustomed to expect from the professional caregiver—they are evidence of a tangible resurgence the individual as the primary agent in his or her own life that cannot be reduced to merely that of a “patient” (Borg & Davidson, 2007; Davidson & Strauss, 1992; Ljungberg, Denhov, & Topor 2015).

In summary, this study seems to indicate that IPS lifts the relationship between participant and coach to a higher level by providing an environment in which it is able to flourish. The relationship with the coach is seen to contain a range of elements previously regarded as significant for the development of helpful relationships with professionals.

The importance of relationships in this context has been emphasized in several studies. Research on common factors has focused on identifying contributing factors other than the particular therapeutic approach taken. In this study we looked for factors within the IPS approach that encourage the development of interpersonal aspects. They are (1) showing sensitivity to the desires and concerns of each individual participant; (2) extending the amount of time caseworkers are able to devote to a particular individual by limiting the number of participants he or she is responsible for, this is leveraged by reducing the scope of action by inhibiting assessments and documentation requirements; and (3) broad latitude for the interaction between participant and professional. The question now is whether these success factors can be applied within the treatment-as-usual context.