“What an eye-opener” – a qualitative study of vulnerable citizens participating in a municipality-based intervention

ABSTRACT

Purpose: To explore how psychologically vulnerable citizens experienced performing their everyday-life activities, identify activities experienced as particularly challenging and evaluate the significance of the Acceptance and Commitment Theory-based (ACT)-based program, Well-being in Daily Life, had on the participants everyday-life activities. Methods: Semi-structured interviews were conducted with eight participants from the Well-being in Daily Life program. Data were analysed using Systematic Text Condensation. Results and Conclusion: The participants experienced anxiety, fatigue, lack of structure, and chaos when performing their everyday-life activities; in addition to being uncertain about the limitations of their own resources. Furthermore, balancing between demands and resources was challenging, also leading to uncertainty and identity conflicts that contributed to the participants’ concerns about re-entering the workforce. The program enabled the participants to develop social skills and trust which contributed to providing the participants with confidence, individually-tailored-possibilities for developing new competencies and courage; thus, facilitating their recovery process.

KEYWORDS:

• Everyday-life challenges
• group-based intervention
• health intervention
• health promotion
• Acceptance and Commitment Theory-based (ACT)
• recovery
• interview
• well-being

Introduction

Background

Approximately 20% of the world’s working-age population will suffer from a mental health disorder and possibly subsequent physical and psychological symptoms, and social problems (OECD, 2013). This population of citizens with a mental health disorder is considered to be more vulnerable, and poses challenges for society (Barnes, Murphy, Fowler, & Rempfer, 2012; Borg, Nexø, Kolte, & Andersen, 2010; Evans, Banerjee, Leese, & Huxley, 2007). Barriers for well-being and participation in everyday-life activities can be challenging for these individuals, as this can lead to maintenance of their mental health disorder and a lower quality of life (Borg et al., 2010). Mental health disorders are estimated to cost 55 billion DKK, including direct and indirect costs, and 90% of the indirect costs are due to early retirement, reduced work productivity, and long-term sick leave due to long-term illness (Borg et al., 2010). Decreased energy levels and lack of initiative are common symptoms for these vulnerable citizens; moreover, their functional capacity may also be decreased (Borg et al., 2010). Individuals with a mental health disorder may also experience social activities as being demanding, thereby decreasing their energy levels and potentially reducing their ability to work (Borg et al., 2010). Furthermore, vulnerable citizens are more susceptible to unhealthy lifestyle choices, which may increase the risk of other diseases and further complicate their situation (Radke, Parks, & Ruter, 2010; Danish Health Authority, 2014). Therefore, there is a need to offer vulnerable citizens assistance, in order to increase quality of life and participation in everyday-life activities in relation to both psychosocial and health aspects (Barnes et al., 2012).

Since the health care reform in Denmark in 2007, municipalities have been responsible for offering health-promoting group interventions free of charge to psychologically-vulnerable citizens.

It is recommended that the intervention consist of practical exercises, theory and exchange of knowledge in order to develop skills, acquire knowledge and experience of health promotion activities, which will result in positive lifestyle and habit changes (Danish Health Authority, 2014).

Soenderborg Municipality in Denmark offers Acceptance and Commitment Therapy-based (ACT) interventions where health professionals support vulnerable citizens in their recovery-process (Harris, 2009). Besides promoting well-being, quality of life and participation in everyday-life activities, interventions may also allow participants to process cognitive challenges; thus, increasing their ability to improve other social and health problems (Due, Waldorff, Aarestrup, Laursen, & Curtis, 2008). The intervention programme was based on the theory of ACT, which is essentially behavioural therapy with the intent of guiding, motivating, and inspiring behavioural change. Thus, the rationale for the intervention programme was to facilitate the learning process related to acceptance, diffusing negative thoughts and feelings, and gaining more control (self-empowerment) in order to allow the participant to live a better/good/more successful/satisfactory life (Harris, 2009). Well-being in Daily Life, is an ACT-based group intervention programme for psychologically-vulnerable citizens with decreased participation in everyday-life activities due to lack of energy and mental resources to perform everyday-life activities.

Health professionals at a local health care centre referred participants to the intervention programme. The participants volunteered to participate in the programme and the majority were participating because they wanted to return to work.

The purpose of the intervention programme was to: (1) increase participants’ awareness of their restrictions in relation to participating in everyday-life activities; (2) facilitate participants in acquiring knowledge and teaching them how to translate this knowledge into their everyday lives; and (3) motivate participants to improve their well-being.

Recent studies have shown ACT to be effective in the promotion of health and improving the quality of life among people suffering from various disorders; such as, anxiety, depression and chronic back pain (Forman, Herbert, Moitra, Yeomans, & Geller, 2007; Hann & McCracken, 2014; A-Tjak et al., 2015). However, evidence for impact of an ACT intervention among people with a mental health disorder is scarce and there is a need for more knowledge about the processes and impact of ACT-based interventions.

The focus of this study was to generate knowledge about the impact of an ACT-based intervention Well-being in Daily Life on people with mental health disorders.

Aim

The aim of the present study was to: (1) explore how vulnerable citizens experienced performing their everyday-life activities and identify citizens experienced as particularly challenging; and (2) evaluate the significance Well-being in Daily Life intervention programme had on the vulnerable citizens’ everyday-life activities.

Method

Study design and setting

This design of the study was based on individual qualitative semi-structured interviews with eight citizens who participated in the Well-being in Daily Life intervention programme.

This approach allowed for a detailed description of the participants’ experiences (Maxwell, 2013, Chapter 5). The intervention programme took place at a Health Care Centre in Sonderborg Municipality, a municipality in the Region of Southern Denmark. Yearly the intervention programme includes six intervention groups with approximately two to 12 participants in each group. A description of the intervention programme can be seen in Table I

Table I. Well-being in Daily Life—intervention programme: main topic, content and exercises.

Session no.	Main topic	Content	Exercise
1	Welcome	Clarification of purpose, structure, dates and content of the intervention. Expectations to group dynamic and collaboration. Oral presentation of the participants.	Exercise: Filling out the Life-wheel, based on the intervention themes.
2	Values	Follow-up from last session. Introduction to the theme “Values”	Exercise: Working with values-cards, rephrasing individually. Working in pairs.
3	Activities of daily-living	Follow-up from last session. Maslows hierarchy of needs, introduction.	Exercise: Mapping activities of everyday life, individually and in pairs. Focus on activities with value.
4	Food and well-being	Follow-up from last session. Oral presentation: “Food and well-being” with participants experiences and group exercises. Websites with healthy meals/food-guidance.	Exercise in groups: How does food and meals have an effect on your well-being?
5	Food and routines —practical exercises	Participants are working together to make a meal (breakfast). Healthy food, collaboration with others and social development is the focus.	Practical exercise
6	Energy-balance	Follow-up from last session. Introduction to “Energy-balance and well-being” In plenum: Why is this theme important? Introduction to “The Battery-model”.	Exercise individually and in pairs: Identification of three activities, which gives energy and three, which takes energy from the participants.
7	Energy-balance (follow-up) and Sleep	Focus on their balance of energy. Clarification of the importance of: - Having focus on both kinds of activities (gives and takes energy). - Having short-term goals and structure is important. - Living in the moment. Group discussion regarding new theme “Sleep”. - How does sleep effect our energy and well-being? - Why is sleep important?
8	Sleep (follow-up)	Group-work: what effects sleep in a positive way regarding … - Daily activities - Evening activities - Food - Physical environment Introduction to music, relaxing- and mindfulness-exercises.	Exercise: Relaxing exercise
9	Physical activities, practical exercises	Introduction to physical activities: - Experiences’ of the participants - Recommendation of physical exercise - Routines - Categorizing activities (household, exercising and sports) - The benefits of walking 10–15 min everyday - Distribution of 8 hours of sleep, 16 hours of sitting, standing walking and exercising.	Exercise: 2 × 10 min 1) Warming-up the body, cardio, balance-exercises. 2) Games, laugh and focus on cognition.
10	Physical activities (follow-up) and Network	Follow-up from last session. Introduction to the theme “Network” - What is a network? - What importance does it have? Social needs in regard to self-esteem and self-image?	Exercise in pair: -“What can I do to be more physical active in my everyday life?” Exercise in groups: Plan an exercise for all participants in the next session. Exercise: All participants chooses a mood-card which identifies the feeling they experiencing when being with others. Optional if they want to present their card in plenum. Exercise in groups: Mapping of their network, close or distanced relationships.
11	Network (follow-up)	Follow-up from last session. In plenum: - The importance of network? - Why is it important to have focus on network? - What does it give you meeting the intervention-group? - How can you use your experiences afterwards? - Which activities/offers do you know that can create a network? - How can you make contact? - How do you move on? How to make my network stronger? Information about networking. A walk in the park Life-wheel is returned to the participants. Has there been a change?
12	Evaluation	Follow-up from last session. Evaluation of the intervention in groups: - The content - The process - The group - What are you taking home? Presentation of the evaluation in the groups. Evaluation in plenum.

Participants

During recruitment of participants the aim was to achieve maximum variation to gain a broad understanding of the participants. The participants recruited for the interviews were either currently participating in the Well-being in Daily Life intervention programme or had completed the programme. The instructor of the intervention programme either recruited volunteers for the interviews at group sessions or contacted former participants. A total of eight participants were interviewed in the present study. Characteristics of the participants can be seen in Table II

Table II. Participant characteristics.

ID no.	Gender	Age	Mental health problem	Current work status	Previous work status	Social status
1	Female	31	Bipolar affective mental health disorder	Vocational rehabilitation programme	Pedagogue	Single, Children
2	Male	37	Social anxiety	Vocational rehabilitation programme	Unskilled (Former employed at a call centre)	Single
3	Female	40	Bipolar affective mental health disorder	Disability pensioner	Pedagogue	Single, Children
4	Female	46	PTSD	Vocational rehabilitation programme	Social and healthcare assistant	Married, Children
5	Male	53	Depression	Employment and support allowance	Unskilled (Former fitter)	Single
6	Female	53	Chronic pain	Rehabilitation program	Tailor and beauty therapist (Recently unskilled work)	Married, Children
7	Female	59	Depression and stroke sequelae	Vocational rehabilitation programme	Pedagogue (Recently unskilled work)	Single, Adult children
8	Male	62	Alcohol abuse	Pensioner	Special Forces and radiography	Single

Intervention: Well-being in Daily Life

The intervention programme contained educational elements concerning health and well-being and included 12-group sessions lasting 90-minutes each, over a six-week period with six to 12 participants per session. The intervention was based primarily on ACT (Harris, 2009) and was led by health care personals; such as, psychologists, nurses or occupational therapists trained in the ACT-based approach. Each of the sessions was tailored to the specific intervention group through participant involvement, which included; working in groups, dialogue, and experience-orientated practice exercises. This approach made it possible for the participants to reflect on to their own everyday lives and well-being; as well as setting individual goals for change, and facilitating the participants’ individual recovery process. The intervention was organized and managed by the psychologist at the participating health care centre.

The six ACT core therapeutic processes that the intervention was based on are as follows: (1) Contacting the Present Moment (Be Here Now) means being conscious about whatever is happening right now, not getting absorbed in thoughts about the past or the future; (2) Diffusion (Watch Your Thinking) means taking a step back in order to watch your thinking instead of getting tangled-up in it; (3) Acceptance (Open-Up) means allowing painful feelings, sensations, urges and emotions to be as they are instead of fighting them; (4) Self-as-Context (Pure Awareness) is the aspect of us that is aware of whatever we are thinking, feeling, sensing, or doing at any moment; (5) Values (Know What Matters) are desired qualities of ongoing actions; and (6) Committed Action (Do What It Takes) means doing what it takes to live by our values even if that brings up pain and discomfort (Harris, 2009).

Data collection and analysis

Participants participated in the Well-being in Daily Life intervention programme between 2014 and 2015, and the interviews were conducted between November and December in 2015.

Data was collected using individually semi-structured qualitative interviews. An interview guide (Table III) was developed through observations from Well-being in Daily Life, review of the literature, written evaluations of the interventions from the participants and informal talks with participants and the instructors. The questions in the interview guide were open-ended and follow-up questions were asked if clarification was needed. The interview guide was modified during data collection to further explore identified themes.

Table III. Interview guide.

Research questions	Interview questions
The participant and his/her challenges: The participant perspective of life?	I would like you to tell me about yourself (name, age, family structure, occupation/education, interests, etc.)? Can you tell me about why you are unemployed at the moment? What is your personal goal for participating in Well-being in Daily Life? What has been the biggest personal challenge for you, in relation to participating in Well-being in Daily Life?
Changes resulting from participating in Well-being in Daily Life: What changes did the participant experience? What changes were not experienced? How did the participant use the changes? How did the participant not use the changes?	How will you describe what you have learned about your challenges from participating in Well-being in Daily Life? After participation, have you started doing something different? For moving on and achieve your goals and expectations, which kind of knowledge and learning do you need? Is there anything you have achieved due to participating, that I have not asked you about?
What role does the participant want to play in order to achieve his or her goal? What role do other people, institutions, rules, etc. have on achieving his/her goal?	What is your biggest challenge right now? What do you think is needed to achieve your goal? (Goal for participating and on a larger perspective)

All the interviews were conducted in person by the same researcher (MK) at the health care centre in an undisturbed setting and were all audio-recorded. The duration of the interviews varied from 19 to 80 minutes. The interviews were transcribed verbatim and the interview transcripts were analysed using Malterud’s systematic text condensation, which is a descriptive and explorative step-by-step method for analysing qualitative data (Malterud, 2012). The method is inspired by phenomenology and presents the experiences of the informants in their own words. The procedure consists of the following steps: (1) total impression and identification of themes; (2) identification and sorting of meaning units, developing from themes to codes; (3) condensation, going from code to meaning; and (4) synthesizing of condensation, developing of descriptions and concepts. Analysis was data-driven and quotations from participants were used to support the study findings (Malterud, 2012). MK performed analysis in cooperation with LNA. The interviews were conducted in Danish; however, the quotations used in the present paper were translated from Danish to English by a professional translator.

Approval from the Regional Ethic Committee was not required for this study, but verbal informed consent was obtained from all participants and they were assured anonymity and confidentiality. All interviews began with a briefing and ended with a de-briefing, where participants had the opportunity to ask questions if needed.

Results

Through interview analysis, three main themes and six subthemes were identified: (1) Everyday challenges (including two subthemes: Clarification and challenges and Balancing demands and resources); (2) Well-being in Daily Life and development processes (including two subthemes: Trust and possibilities for change and Development of social skills); and (3) New courage (including two subthemes: Facing fear and Courage in life).

Everyday challenges

Clarification and challenges

A majority of the participants either wanted to return to the workforce, wanted a more functional everyday life, or both. Many of the participants mentioned that an important part of their future personal development process was to clarify what type of job they might be able to handle with their limitations and identify their needs.

I really need to be better at putting myself first. I need to focus on self-awareness, and ask myself if this is something I want to do or don’t want to do. (ID no. 1)

One participant worried that finding an employer who would only hire him for three hours per week would be challenging, while another participant expressed that completing an internship was an important stepping stone in furthering her process. In summary, finding an employer and having the courage to complete an internship was a challenge for the participants. Furthermore, clarification following an internship was also important and one participant described that she saw her internship as being essential to what her future would look like.

Other participants described individual challenges, which needed to be clarified before being able to start an internship or return to work. In general, the challenges were related to confusing and difficult tasks; for example, feeling and dealing with their symptoms, identifying their personal needs, participating despite experiencing anxiety, fatigue and chaos:

Again, it is about listening to myself (self-awareness); whether it’s how I feel emotionally or what my body is trying to tell me (physical feelings/sensations) because it’s telling me one thing or another (about myself). I have not been very good about doing that in the past. I know it is a long process and it is something I have to keep working on throughout my life. (ID no. 4)

Participants, who felt that they were not yet ready for an internship or job, experienced a progression in relation to their everyday function through their participation in Well-being in Daily Life. At the same time, the participants also progressed in relation to identifying their need to participate in; for example, other group interventions, which would be important to the ongoing development of their personal challenges.

Balancing demands and resources

Fear of failure affected the participants’ actions and they consequently avoided challenges. When participants had too many tasks or tasks that were too demanding, they doubted their own abilities; thus, they experienced feelings of fatigue, failure and performance anxiety as challenges. On one side, the participants’ expectations to their own performance were a challenge; for example, not respecting their physical limitations due to a desire to keep order at home, as one of the participants described:

… my husband is usually responsible for hanging laundry up, but when the weather is nice and I know he [my husband] isn’t coming home until 3 p.m., I’ll do it myself [hang laundry up], because then the clothes will be dry by the time he gets home. But then, I can really feel the consequences the next day when I have pain in my shoulders and back, it’s all so ARGH! Then I think: “Why did I do that!” I am so frustrated with myself. I could have just waited until 3 p.m. and let my husband do it. (ID no. 6)

Another participant felt that everything becomes chaotic if she does not follow her desired health behaviours, keep her house in order, and work a few hours per week. However, a fear that their available resources would not match the demands of the employer in a workplace is of great concern for the participants in relation to their return to work:

… and he [employer] would really like me to start working 4-hours a day 3-days a week, which equals 12-hours a week. … I would prefer to work only one-day a week, if I am expected to be at work five-days a week, I won’t be able to last very long because of my illness. Maybe it is just something I convinced myself of, but I have had a depression several times now. (ID no. 6)

There is a fine line between participants having to balance several demands at once and at the same time try to participate in everyday-life activities, because they are going through a personal development.

Well-being in Daily Life and development processes

Trust and possibilities for change

The instructor of Well-being in Daily Life was a key factor for the participants to experiencing changes. The instructor facilitated behavioural changes regarding diet, exercise and relationships.

A lot of these things [topics] are really eye-openers, perhaps I might have known about some of them, but once they are written down [on the board] and you hear the instructor talk about them, then it really starts making sense. (ID no. 8)

The participants felt that the instructors challenged them, understood them and accepted their individual situations; which the participants experienced as supportive and trusting. The participants experienced changes including; increasing inner peace, an awareness of their diet and how to make healthier diet choices, exercise and relationships. One participant described that learning about diffusion allowed her to change her way of thinking:

The part that I thought was the most gripping was probably the part about a thought only being a thought, unless you react to it. A thought is only a thought as long as you don’t react to it … (ID no. 7)

Development of social skills

Socializing was an important part of participating in the group-based intervention. The participants experienced bonding with others, mutual respect, sharing the same sense of humour, harmony and pleasant togetherness. Some participants experienced that the awareness of not being the only one who was faced with difficult challenges in their everyday lives was the best part of the intervention.

… hearing other people describe how they felt, which is exactly how you feel. If you couldn’t find the words for it [to describe how you feel], then there was someone else there who could [and I thought]: “ Yes, it’s exactly like that.” I think that was the best thing [about the courses]. (ID no. 2)

The participants used one another to recognize and verbalize their feelings and contributed to the group; for example, one participant inspired others in the group because of her high level of mental energy. Thereby, participants developed and rediscovered their social skills, which also impacted how they looked at their future. Subsequently, several participants began participating in social leisure activities.

New courage

Facing fear

The majority of participants changed and improved the way in which they handled challenges in their everyday lives, because they had learned about living in the moment and learned not to suppress suffering related to their symptoms; thus, enabling them to participate in activities they otherwise feared:

I guess I am less timid in that way. I stand my ground and face my fears right in the eye and then I walk right up to it [my fear] and say hello … it doesn’t make my fear go away, but I am doing something about it so it doesn’t take over and make me want to run away from it. (ID no. 8)

Some participants are worried about what other people think of them, which was a huge challenge for them when they interacted with others. Due to the knowledge they achieved from Well-being in Daily Life, participants were more likely to do things on their own terms—by accepting their situation and taking responsibility for dealing with the situation, while other participants still struggled with their fears.

Courage in life

Some participants may have experienced participating in Well-being in Daily Life as challenging as first; however, the success participants achieved through participating in the programme gave them courage to overcome other challenges. Furthermore, the importance of taking small steps was significant. Participants described that they not only experience relief now, but also joy, increased self-confidence, self-esteem and self-respect in relation to successfully solving a difficult challenge.

Their ability to accept their situation has changed in a positive direction; as well as, developing the courage to recognize their own needs, which was an important lesson to learn because it gave the participants a feeling of success.

Participants also experienced success when they verbalized their feelings instead of hiding them and overcame challenges they have not expected to overcome. Such positive feelings related to success increased their courage in life, as described by this participant:

But when I went ahead and did it anyway, I got something out of it … but then I realized that it really wasn’t that difficult and then I wanted to do more. Yeah definitely give me more of those eye-opening experiences because that’s what I want, I want to become smarter and learn more … (ID no. 3)

Discussion

From the results of the study, it is clear that participants in the municipality-based intervention programme, Well-being in Daily Life, experienced problematic everyday-life challenges with particular emphasis on challenges related to anxiety, fatigue, lack of structure and chaos. Furthermore, participants experienced a significant uncertainty in both their relation to their own resources and the possibility for re-entering the workforce. However, the majority of the participants experienced challenges when balancing demands, and resources and these challenges also negatively affected their ambition to re-enter the workforce. The group-based intervention Well-being in Daily Life provided a confidential environment, which gave the participants the possibility of receiving individually tailored possibilities for developing and learning new competencies, e.g., related to social challenges. Likewise, participants in Well-being in Daily Life experienced success which was significant to them developing courage which they used to face their fears, allowing them to consequently seek new challenges in life, including the courage to re-entering the workforce.

Hope and optimism for the future are reflected in the participants’ belief in recovery, their motivation to improve function in everyday life and their desire to return to work (Doroud, Fossey, & Fortune, 2015). Returning to work may provide participants with economic independence and restore their daily routines and activities. Returning to work require new skills which can be interpreted as the facilitation of Meaning of life in the recovery process (Leamy, Bird, Le Boutillier, Williams, & Slade, 2011). Restoring daily routines and activities can lead to increased quality of life (Borg et al., 2010). The process of Hope and optimism for the future during recovery is also related to interpersonal relationships, which can inspire hope and should also include having role models (Leamy et al., 2011), but this aspect was not unequivocally clear in the results. The participants’ descriptions of other participants’ inspiring qualities, may indicate that participants with inspiring qualities were seen as role models. Being connected with others and having role models can be a significant aspect of the recovery process (Leamy et al., 2011) and it seems these aspects were provided through the intervention programme.

The results showed that personal challenges impeded the participants’ ability to return to work. From the results it can be interpreted, that participants underwent an identity process because their limited resources followed the uncertainty of their ability to meet the demands of an employer and threatened the individual process of Hope and optimism for the future (Doroud et al., 2015). There is a fine line between the demands one places on one’s self (internal demands), the demands placed on one by others (external demands), and the person’s resources as described in the literature (Doroud et al., 2015; Gillard, Turner, & Neffgen, 2015). The process includes recognizing and fulfilling one’s own needs, but also requiring taking small steps may as a strategy in the recovery process for vulnerable citizens and this process is in accordance with the results of the present study. Furthermore, taking small steps was significant when making health-promoting lifestyle changes (Andersen, Andersen, Muurholm, & Roessler, 2014), and was an essential strategy for some participants to achieve increased well-being.

The instructors of Well-being in Daily Life facilitated the changes, which the participants experienced as being healthy and positive. Receiving the instructors trust can be interpreted as a way of supporting vulnerable citizens to take on new roles and responsibility (Davidson & Chan, 2014; Deegan, 1996; Young, Green, & Estroff, 2008) and the feeling of mutual trust may also be interpreted as an explanation for why the participants appreciated the instructors’ ability to personally challenge them during their participation in the intervention.

From the analysis, it emerged that participants felt connected to one another. It was important for them to develop the feeling of awareness, knowing they were not the only one inhibited by social anxiety (among other things), which is consistent with the findings of Wong et al. (Wong, Stanton, & Sands, 2014). Furthermore, it has also been previously shown that helping other participants is an important aspect of being included in a group and creating a new identity (Jensen & Wadkins, 2007; Mathias, Parry-Jones, & Huws, 2014). The fact that some participants engaged in new social activities and established new relationships improved their opportunity to re-develop social skills, and was seen as a positive development because experiencing meaningful social roles can provide meaning in life (Wong et al., 2014).

Acceptance of the situation was an important part of the Well-being in Daily Life programme. Some of the participants described that they were able to accept their situation, which may be the reason they were able to get closer to their goals because acceptance is important in understanding their illness, for participation in social activities and for work life (Cunningham, Wolbert, Graziano, & Slocum, 2005). On the contrary, lack of acceptance is associated with being dominated by negative symptoms, reduced confidence, and reduced hope (Siqueira & Oades, 2015).

It can be understood, that participants developed the ability to face their fears; thereby, taking control over their situation through the Core therapeutic processes of ACT—contacting the present moment, acceptance and diffusion (Harris, 2009). When participants took control over their situation they experienced a feeling of empowerment by increasing their belief in their own abilities (Conger & Kanungo, 1988); which can in turn, increase confidence and self-esteem (Mathias et al., 2014). Challenges of living in the moment can be a barrier for acceptance (Harrison, 2012), as well as an expression of lack of empowerment. A possible reason why some participants still struggle with facing their fears and are not yet ready for returning to the workforce. Empowerment is constructed of the following; control over one’s own situation, self-management, positive risk-taking and responsibility of one’s own situation (Leamy et al., 2011). The ACT–based intervention included educating participants on health-related topics, which contributed to enabling the participants to take control over their situation; in addition, the instructor challenged the participants to attempt facing appropriate challenges during their recovery process. The results of the present study indicate, to a lesser extent, the development of independence and sense of responsibility among the participants, making it possible for them to depend on other people. Vulnerable citizens will be in need of additional assistance to handle the situation and facilitate the recovery process.

The participants valued their experiences of success, which is an important element in the recovery process (Leamy et al., 2011). This experience gave participants courage in life and facilitated energy and joy, and can be interpreted as having a positive effect on vulnerable citizens self-perception, which underlies the recovery process Development of identity (Leamy et al., 2011). Stigma may also have influence on the recovery process (Leamy et al., 2011), since some of the participants in this study were inhibited by thoughts of what other people thought of them. This may be understood as a result of self-stigma, as these thoughts were reflected in feelings of being wrong and dissatisfied with themselves. If positive self-perception is in contrast with self-stigma, the increased courage in life reduces self-stigma; for example in situations where participants overcome their social anxiety. Furthermore, self-stigma is mutually dependent of empowerment (Brohan, Elgie, Sartorius, & Thornicroft, 2010). When participants learned to face their fears and overcame some of their challenges, it was related to empowerment learned from participation in the intervention and this empowerment was essential for their experience of increased courage in life. Participants achieved new courage and they described participating in Well-being in Daily Life as an eye-opening experience.

Limitations

Some participants voluntarily participated in Well-being in Daily Life, whereas other participants were obligated to participate as part of a vocational rehabilitation programme. This might have influenced their overall motivation for participating in the intervention; however, this was not a focus of the present study.

The group of interviewed participants was heterogeneous, which is important when exploring recovery (Anthony, 1993).

The instructors recruited participants who they considered were capable of taking part in an interview. This approach may have resulted in excluding weakest participants in the Well-being in Daily Life programme; and they consequently were not represented in the results. However, the conclusion of this study does not refer to an existence of an objective truth, but gives a knowledge and understanding of vulnerable citizens and their development process when participating in Well-being in Daily Life.

Conclusions and implications

This study provided knowledge about how psychologically-vulnerable citizens experienced participating in a municipality group-based intervention focused on coping with challenges in everyday life. It can be concluded that the citizens were challenged in regard to their personal recovery process; including re-establishing participation in social activities and returning to the workforce. Furthermore, citizens expressed that it was hard to balance demands and resources; and with that follows uncertainty and identity conflicts. Participation in Well-being in Daily Life enabled the participants to develop social skills due to the characteristics of the group-based intervention, because of trust and possibilities for change, as well as the relationships between the group members, including the instructor, who had a significant impact on the development of social skills. The participants gained courage to face their fears and experienced increased courage in life, which facilitated the recovery process. The results of this study indicates that an ACT group-based intervention can facilitate the psychologically-vulnerable citizens’ recovery process, which may enable them to successfully participate in everyday-life activities, including returning to the workforce, thereby increasing the participant’s quality of life. However, further research is required to investigate the long-term effects of an ACT-based intervention Well-being in Daily Life compared to other interventions based on different approaches.

Acknowledgements

We wish to thank the interview participants and the health care professionals at the Health Care Centre in Sonderborg Municipality for participating in the study.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Pia Maria Ilvig

Pia Maria Ilvig Graduated in 2014 from VIA University College in Aarhus, Denmark with a Bachelor Degree in Occupational Therapy. Worked as an occupational therapist at Frederiksberg Hospital. Graduated in 2016 from University of Southern Denmark with a Master of Science in Health (in Occupational Therapy). Currently working with treatment evidence in the rehabilitation department in Hvidovre municipality. Further working as a research assistant at the Department of Public Health at University of Southern Denmark

Michaela Kjær Graduated as physical therapist from University College Lillebælt, Denmark, in 2014. She continued with her master in physical therapy at University of Southern Denmark the same year, while working as physical therapist in a privat practice.

Dorrie Jones Graduated in 1998 from the University of Oklahoma with a Bachelors of science in occupational therapy. Worked as an occupational therapist in the USA from 1998 to 2002 and in Denmark from 2004 to 2016. Currently employed at The Research Unit of General Practice – Department of Public Health at the University of Southern Denmark.

Jeanette Reffstrup Christensen Head of Studies for Master of Science in Occupational Therapy. Dr Christensen has published several articles concerning workplace interventions, disabilities, musclescletal pain and overweight and obesity issues. Job groups have, among others been healthcare workers, as they represent a high-risk population with high physical work demands. Healthcare work is mostly performed by females with high prevalence of overweight and obesity, musculoskeletal pain, and low physical capacities.

Lotte Nygaard Andersen Associate professor at the Department of Sports Science and Clinical Biomechanics at the University of Southern Denmark. Her research focus is on understanding difficult life situations and her research is also focusing on understanding how citizens experience participation in rehabilitative intervention primarily in a municipality setting.