Mastering Everyday Life in Ordinary Housing for People with Psychiatric Disabilities

Rosita Brolin, David Brunt, Mikael Rask, Susanne Syrén, Anna Sandgren
Linnaeus University, Sweden

Abstract

The aim of this study was to develop a classic grounded theory about people who have psychiatric disabilities and live in ordinary housing with housing support. Interviews and observations during the interviews were analyzed, and secondary analyses of data from previous studies were performed. The impossible mission in everyday life emerged as the main concern and mastering everyday life as the pattern of behavior through which they deal with this concern. Mastering everyday life can be seen as a process, which involves identifying, organizing, tackling, challenging and boosting. Before the process is started, avoiding is used to deal with the main concern.  The community support worker, providing housing support, constitutes an important facilitator during the process, and the continuity of housing support is a prerequisite for the process to succeed. If the process mastering everyday life is interrupted by, for example, changes in housing support, the strategy of avoiding is used.

Keywords: grounded theory, housing support, impossible mission, mastering, psychiatric disabilities

Introduction

The focus of this study is on people who have psychiatric disabilities and live in ordinary housing with housing support. Internationally, the provision of housing and housing support, which has replaced inpatient care for people with psychiatric disabilities, varies greatly (Fakhoury, Murray, A., Shepherd, G., & Priebe, 2002). In Sweden, the mental health reform in 1995, led to the development of two community-based housing support models for people with psychiatric disabilities: supported housing facilities, and housing support in the individual’s own apartment or house, in this paper termed “ordinary housing” (Brunt, 2002).

A psychiatric disability is defined by the Swedish National Board of Health and Welfare (2006) as a lasting psychiatric condition (> 2 years) that involves not being able to manage everyday life on one’s own. The most common diagnoses among people with psychiatric disabilities in Sweden are psychosis, affective disorders, and neuropsychiatric disabilities (Swedish National Board of Health and Welfare, 2012). The needs for care and support that have been identified among people with psychiatric disabilities are related to universal human needs as, for example, activities of daily living, social relationships, physical health, information, household chores, food and personal finances (Kulhara et al., 2010; Ochoa et al., 2003; Zahid & Ohaeri, 2013). People with psychiatric disabilities have expressed a desire to have a housing situation that satisfies their desire to live similar to what other people do (Warren & Bell, 2000), and ordinary housing is preferred to supported housing (Forchuk, Nelson, & Hall, 2006; Harvey, Killackey, Groves, & Herrman, 2012; Tsai, Bond, Salyers, Godfrey, & Davis, 2010).

Approximately 17 000 people with psychiatric disabilities receive housing support in ordinary housing in Sweden (Swedish National Board of Health and Welfare, 2011). Housing support consists of practical and social support with the aim of facilitating for the individual to manage his/her daily life (Swedish National Board of Health and Welfare, 2010). It is a scheduled multi-faceted support, which is based on mutual interaction between the resident and the community support worker providing housing support, termed hereafter the “supporter”, and includes activities in and outside the home (Andersson, 2009).

International research into residents’ satisfaction with their housing situation has revealed that important factors for satisfaction with housing situation are security and privacy, choice and proximity (Tsemberis, Rogers, Rodis, Dushuttle, & Skryha, 2003), and the ability to have control (Nelson, Sylvestre, Aubry, George, & Trainor, 2007). The importance of security and privacy was confirmed in a Swedish study which also revealed that the amount of information when selecting dwelling, as well as other people’s influence on the choice of residential area and dwelling, were important predictors for housing satisfaction (Brolin, Rask, Syrén, Baigi, & Brunt, 2015). People with psychiatric disabilities have reported a moderate to high degree of satisfaction with their housing situation (Brolin et al., 2015; Hanrahan, Luchins, Savage, & Goldman, 2001; Tsemberis et al., 2003). However, these positive results also need to be considered in the light of findings showing that previous negative experiences of psychiatric care settings led to low expectations for housing solutions and thus to satisfaction with, and gratitude for, poorer housing conditions that would not be acceptable to others in the community (Walker & Seasons, 2002).

The focus of the studies in the research field has mainly been on describing symptoms and needs related to psychiatric disabilities, the characteristics of housing support or on the residents’ estimated satisfaction with their housing situation. There is thus a lack of research that focuses on how people with psychiatric disabilities, who are living in ordinary housing, experience the housing support they receive, and how they cope with their situation. The aim of the present study was thus to develop a grounded theory about people with psychiatric disabilities, living in ordinary housing with housing support. The research question guiding the study was as follows: What is the main concern for people with psychiatric disabilities, living in ordinary housing with housing support, and how do they resolve this concern?

Method

The methodology of grounded theory aims to discover the participants’ main concern and to conceptualize patterns of human behavior (Glaser, 1978, 1998). In this study the patterns of behavior of people with psychiatric disabilities, living in ordinary housing with housing support, are explained.

The data collection was carried out in 2015 in one urban community (total population >130 000) and one rural community (total population <60 000) in Sweden. The study was conducted in accordance with the Declaration of Helsinki (WMA, 2009). It was approved by the managers of social services in each municipality and by the Regional Ethical Review Board in Linköping (Reg. no. 2014/164-32).

There were some difficulties in recruiting participants for the study. The original plan was to recruit participants through the social service managers in each community. The social managers delegated the recruitment procedure to the community support workers, who informed presumptive participants about the study and asked them if they were interested in participating. Having recruited ten participants, the social managers announced that they could not find any more participants. The first author (RB) was then invited to inform users at two-day centers about the study. In connection with these two information occasions, six further participants were recruited. Those recruited by the social service managers demonstrated an awareness of social issues and support services; they reflected freely during the interviews and had no difficulties in verbally expressing their thoughts and feelings. Four of these had been cared-for in inpatient psychiatric services for one or several short periods, and on a voluntary basis. The majority of the participants recruited through the day centers did not, however, demonstrate such an awareness of social issues; they did not reflect as freely as the others during the interviews and had some difficulties in expressing themselves. Four of the six had been treated for long periods in psychiatric care services, one in voluntary care, and three in compulsory care.

A total of 16 interviews were conducted with residents, living in ordinary housing with housing support. The participants were 23-60 years old, with as many men as women. They had lived in their current residence for 2-25 years and had received housing support for 6 months to 13 years. The current level of housing support varied, from once every two weeks to four times per week, 1-2 hours on each occasion.

The interviews lasted 45-150 minutes and were conducted in the participants’ apartments or in a room at the day center, except for one interview, which was conducted in an apartment that belonged to the participant’s relative. Prior to the interviews, the participants received oral and written information about the study, that these interviews would be treated confidentially, that participation was voluntary, that they could withdraw at any time and that non-participation or withdrawal would not affect their housing support or other services. The participants then gave written consent.

During the interviews field notes were written in accordance with the methodology of classic grounded theory (Glaser, 1998, 2001). In an ambition to encourage the participants to talk about their situation in their own words, the interviews began with an open question: “Would you like to tell me what it’s like to live here?” or “Would you like to tell me about your housing situation?” The interviews continued with follow-up questions as “What does that mean to you?” or “How do you feel about that?” in order to encourage the residents to talk more about what is important to them. The interviews were thus more like open conversations than formal interviews.

More detailed field notes and memos about incidents and ideas of concepts were written immediately after each interview. The field notes were then analyzed line by line, and incidents in data were identified, compared, and coded. While analyzing field notes, the constant comparative process served as guidance for theoretical sampling on what data to collect and where, in order to saturate emerging concepts and the emerging theory (Glaser, 1978). For example, analyses of interviews with residents in urban areas led to recruitment of residents in rural areas; similarly, residents who had had housing support for many years lead to recruiting residents who had had housing support for a shorter time. New and more specific questions to ask emerged during the analysis process, for example: “Where do you prefer to spend your leisure time?” and “What happens when your supporter is on holiday or becomes ill?” These questions were then used in subsequent interviews, to saturate the concepts in the theory.

In order to avoid description and to maintain theoretical sensitivity while collecting, coding, and analyzing data, a set of questions were put to the data during the open coding process: What are these data a study of? Which category does this incident indicate? What is actually happening in the data? What is the residents’ main concern? How do they continually resolve this concern? The open codes were then compared to each other and new concepts were compared to other concepts in a constant comparative process, in order to abstract the concepts. Memos about concepts and possible inter-relationships were written during the whole process. Once the main concern, the impossible mission in everyday life, had emerged, the focus of the continuing process was on finding a core concept that relates to as many of the other concepts as possible and consequently explains, with as much variety as possible, how the main concern is continuously resolved. When the core concept mastering everyday life emerged, selective coding began to delimit the coding to concepts related only to the core concept. The core concept was thus a template for further data collection and theoretical sampling (Glaser, 1978, 1998).

In order to saturate the concepts, secondary analyses were conducted on data from a previous survey with 370 participants’ estimated satisfaction with their housing situation (Brolin et al., 2015) and a study in which 364 participants responded to open-ended questions about what they considered the best and the worst in their housing situation (Brolin et al., unpubl. data). These analyses led to further clarifications of the concepts. The memos that were written during the analysis process were hand-sorted; memos were written on memos, developing a rich memo bank, which was repeatedly sorted while writing additional memos on memos. In the theoretical coding phase, further memos were written, especially focused on relationships between the concepts and the core concept. In this final phase, the theory mastering everyday life was formulated. A literature review was then performed and used as a further source of data, which was integrated into the constant comparative process in accordance with classic grounded theory (Glaser, 1998).

The Theory of Mastering Everyday Life

The impossible mission in everyday life emerged as the main concern of people with psychiatric disabilities who live in ordinary housing with housing support. It consists of experiences of a complex everyday life with a massive flow of information, constant demands for attention, concentration, and decision making, complicated by time pressure, unexpected interferences, and sudden changes. The complex everyday life, in combination with phobias, fatigue, attention deficits, start-up or concentration difficulties, compulsive disorders, and difficulties with time perception, is perceived as more or less impossible to manage. The difficult combination requires a constant awareness of each individual choice and action in everyday tasks as well as in interaction with others. The difficult combination leads to a fear of not being able to meet the requirements of life in the community, to miss something important, to get into trouble, or not to be good enough. The fear drains energy, reduces the ability to cope with the requirements of everyday life, and leads to feelings of chaos, paralysis, anxiety, guilt, shame, and loneliness. Everyday life is a daily struggle, driven by a desire to be able to function like most other people do in their lives.

The main concern, the impossible mission in everyday life, is resolved by mastering everyday life, which means taking command of and control over everyday life, even though it seems more or less impossible. Mastering everyday life can be seen as a process which is performed by avoiding demands and difficulties, identifying activities, barriers and possibilities in everyday life, organizing everyday life, tackling everyday tasks, challenging tasks that are perceived as impossible to perform, and, boosting everyday life. Before the process of mastering everyday life is started, avoiding is used in order to deal with the impossible mission in everyday life. The strategy of identifying is a prerequisite for the process. Identifying facilitates organizing, which facilitates tackling and challenging.  If the strategies work well, they lead to an increasingly functioning daily life and to possibilities for boosting everyday life. In many situations throughout the entire process, the housing support, provided by the supporter, is a prerequisite for being able to proceed. If the process is interrupted by, for example, changes in housing support, the strategy avoiding is used. The strategies and their sub-strategies are presented below.

Avoiding
Avoiding is a strategy that is used in order to deal with the impossible mission in everyday life, before the process of mastering everyday life is started. During the process, avoiding is used to deal with the parts of everyday life that have not yet been mastered, while failing in mastering everyday life leads to a return to avoiding. Avoiding includes keeping away from demands and difficulties, and going around them instead of encountering them and thus avoiding the consequences that arise when meeting the demands of everyday life. This is done by ignoring and using emergency solutions.

Ignoring means disregarding tasks and activities. Ignoring is performed by refraining from everyday tasks such as going to work, cleaning the dwelling, cooking, doing the dishes, caring for personal hygiene, doing the laundry, opening letters, paying bills, or answering the phone. In situations when ignoring cannot be used, avoiding is performed by using emergency solutions, for example employing a cleaning company, buying takeaways, eating fast food or sandwiches, and using social media or online-games instead of going out to socialize with other people.

Avoiding is often successful since it temporarily bypasses the current difficulties. If one emergency solution does not work, there are usually others available. The strategy may be a way to save time and/or energy in order to deal with the other strategies later. However, building one’s entire existence on avoiding eventually increases the feelings of chaos. For example, the apartment/house has not been cleaned; laundry, dishes, important papers and other things are stacked in piles; scheduled times and important phone calls are forgotten (dentist, doctor, National Insurance Office, Employment Agency); letters are not opened; and, bills are not paid. The situation soon becomes overwhelming and leads to a sense of paralysis, feelings of failure, worthlessness, guilt and shame for not being able to deal with what other people consider to be elementary. The shame in turn limits social life due to low self-confidence and a reluctance to let anyone come close or enter one’s home. The chaos leads to anxiety, which drains energy and leads to even less capacity to handle everyday life, which in turn, leads to more anxiety; there is a great need for support to be able to break this downward spiral. Support from a community support worker serves as a catalyst and a trigger for engaging in mastering everyday life.

Identifying
The process of mastering everyday life starts by identifying, which includes investigating and establishing how everyday life works and how to optimize it. Identifying is done by mapping out everyday life, discerning barriers, and detecting possibilities.

Mapping out everyday life is used in order to gain an overview of everyday activities, and how they are related to each other. Examples of everyday activities are cooking, eating, sleeping, showering, brushing teeth, shopping, going to work, school or day center, making phone calls, paying bills, interacting with others, participating in leisure activities, and so on. Mapping out everyday life is usually done in conversations with the supporter.

While mapping out is a way of gaining an overview of the activities that belong to everyday life, discerning barriers means detecting what does not work in everyday life and what the causes can be. The barriers may be environmental or individual. Examples of environmental barriers are disturbing noises and lights, unstructured and untidy environment, unclear messages, and guidelines. Examples of individual barriers are phobias, increased sensitivity for sensory impressions, difficulties in concentrating, abstract thinking, and seeing the whole picture. Discerning barriers is usually carried out together with the supporter, but also in dialogue with physicians, other health professionals or relatives, as well as by reading research literature or newspaper articles.

In order to discover factors that can be used to overcome identified barriers, detecting possibilities is used. Detecting possibilities involves environmental factors such as blackout curtains, lighting equipment options, storage furniture, headphones, and alternatives for traveling and communicating with others. Possibilities may also concern personal capabilities and strengths, such as accuracy, artistic talent, mathematical skills, and ability to seek information or to memorize details. Detecting possibilities is usually performed together with the supporter. If identifying is successful it facilitates organizing.

Organizing
Organizing means systematizing and structuring everyday life. This is done by scaling down, creating spatial order, and structuring time.

Scaling down is an effective way to clear away as much as possible of unnecessary energy waste. Scaling down is done by determining what tasks and activities to prioritize, as well as what things to keep and what to get rid of, by selling, giving away, or throwing away. Scaling down the number of tasks to perform, activities to engage in, and things to keep, is sometimes carried out together with relatives, but more often together with the supporter, who is also a facilitator for creating spatial order, that is, sorting and systematizing possessions. Creating spatial order is performed by replacing patterned wallpapers and furnishings with non-patterned ones, putting things away into cupboards and drawers, labelling cupboards and drawers, putting important papers in folders, and arranging a specific place for unpaid bills.

Structuring time means structuring seven days a week and creating routines for everything that is included in everyday life such as food, sleep, work/studies, housekeeping, laundry, personal hygiene and physical activities. Structuring time includes writing memos and “to-do lists”, planning and writing weekly schedules, planning routines and daily rhythm (that is, having the same hours for eating, sleeping and working, the same day of the week for cleaning and washing, and the same day of the month for paying bills). Structuring time is usually done together with the supporter.

Organizing is a prerequisite to continue the process of mastering everyday life. As order is created, everyday life gradually functions better with fewer complications. Feelings of chaos are reduced and replaced by a sense of gaining control over some areas of everyday life, which leads to increased self-confidence and facilitates the continued efforts to organize. During the process of organizing, it becomes clear which areas need to be tackled and challenged in order to achieve a functioning everyday life. The feeling of mastering some areas of everyday life facilitates tackling and challenging areas where the individual does not yet function well.

Tackling
Tackling means to set about and carry out everyday tasks that one does not know how to handle, how to manage, or how to find energy and time for. Tackling is carried out by focusing, testing, and practicing.

Focusing means concentrating on one thing at a time which is initially performed together with the supporter, by selecting one of the points on the “to-do list” and then devoting time entirely to this point. When it is completed, it is then removed from the list. Focusing can involve single events, such as making a specific phone call, recurrent everyday activities such as washing dishes or doing the laundry, or activities that need to be processed for a long time by testing and practicing. Examples of the latter are travelling by public transport, or making decisions on what clothes to wear or what food to eat each day.

By testing, various ways of dealing with a barrier or a recurrent problem in everyday life are examined, until a functional solution is found. Various means of transportation are tested at various times during the day, and various ways of facilitating decisions about clothes and food are tested, together with the supporter. For example, a weekly menu may be written and tested, and clothes may be chosen for the whole week, and placed in one pile or one bag for each day. The supporter is valuable while testing various solutions, trying different ways to carry out daily routines, or testing in which order daily routines should be carried out to be optimal.

Practicing involves practicing tasks as well as where, when, how, and in what order routines should be implemented. Practicing is initially carried out together with the supporter. However, while practicing, the need for support gradually decreases. Tasks that may need practicing to become a matter of routine are cleaning, shopping, and cooking. Routines that may need to be practiced are getting up at the same time every day, having meals at the same time every day, taking a walk at the same time every day, and reserving the same day for laundry every week.

As increasingly more areas are tackled, they can be organized into the everyday structure; everyday life thus becomes more and more possible to handle.

Challenging
As everyday life becomes increasingly more manageable, there is energy, time, and courage enough for challenging tasks that are perceived as impossible to perform. Challenging is done in several steps and often continues for a long time, by shielding oneself, approaching the challenge, encountering the challenge, performing parts of the challenge, and finally completing the challenge.

There is a need for shielding oneself to feel as safe and secure as possible while undertaking challenging tasks that are perceived as impossible to perform. Shielding oneself is done by using another person or pet, as a facilitator when challenging. For example, the supporter, a relative or a dog may accompany the person on walks and group activities. Shielding oneself is also done through preventing eye contact with others by looking at the ticket machine on the bus, or using the self-scanner in the store. Being anonymous among others is another way of shielding oneself. For example, it may be perceived as less frightening to live in a big city than in a small village, or to participate in a big festival, where you can “disappear” in a large crowd, than to participate in a small private party.

Shielding facilitates challenging and starts with approaching the challenge. Approaching the challenge involves planning when to begin dealing with a task that is perceived as impossible, and how to do it. The plan, which is usually made together with the supporter, may include time for encountering the challenge, the location where it is most appropriate to encounter the challenge, if any tool is to be used, and if anyone should be there for support.

The next step of challenging is encountering the challenge: considering the impossible task more closely but without beginning to work on it. Several examples are as follows: fear of going out can be encountered by standing in the doorway for a moment. The discomfort of brushing teeth can be encountered by looking at and touching different kinds of toothbrushes, selecting, and buying a toothbrush. Encountering the challenge is often done together with the supporter.

After encountering the challenge, performing parts of the challenge is done in several steps and initially only a small part of the challenge is performed. Once this part has been performed a number of times and no longer feels uncomfortable, a greater part of the challenge is performed, to gradually overcome what initially was perceived as impossible. Performing parts of the challenge is usually done together with the supporter and may involve leaving the doorway and taking a few steps outside the house. Over time, the walk outside the house becomes gradually longer. In a similar way, discomfort when brushing teeth can be challenged by inserting the toothbrush briefly in the mouth and touching it with the tongue. Gradually a few teeth can be brushed.

Performing more and more parts makes completing the challenge possible. Completing the challenge means performing the entire task and involving it in the daily routines (for example, taking long walks several times a week and brushing all the teeth every day). If challenging is successful, it leads to increased self-confidence and, eventually, the task may be feasible without support. However, if challenging is not successful, it leads to feelings of failure and decreased self-confidence. In the continuing process, the supporter plays an important role in motivating and supporting the resident to try and find new ways to approach, encounter, perform and complete the challenge.

If the four strategies—identifying, organizing, tackling, and challenging—work well, they can lead to an increasingly functional daily life, more self-confidence, increased self-esteem, and the courage to move forward in the struggle to master more and more in everyday life.

Boosting
An increasingly functioning daily life leads to possibilities for boosting everyday life, in order to make it even more positive. Boosting is done by making oneself important, healthy living, and enriching life.

Making oneself important involves striving to contribute to society, and finding a place or a way in which one has an important role to play; it is performed by helping others, being a support for others, and spreading joy among others, but also by searching for education or work, studying, taking driving lessons, performing important tasks at work, and doing a good job. The supporter is valuable while searching for education and work. Sometimes assistance from the supporter is a precondition for the resident to be able to include work or studies in everyday life. Helping, supporting, and spreading joy among others is usually successful, while it may be harder to succeed in searching for work. If the strategy is successful it leads to feelings of being important and capable, which contributes to a feeling of having an everyday life similar to what other people have. If not successful, it leads to feelings of failure and not being capable; it leads to an increased need of support for finding new ways to make oneself important.

Healthy living includes various ways of taking care of one’s body, such as eating nutritious and varied foods, exercising, detoxifying, and medicating. Healthy living is performed by cooking instead of buying fast food, avoiding fats and sugar, taking daily walks, training weekly at a gym, or swimming weekly in a pool, using medicines prescribed by a physician, and not using addictive substances (such as alcohol, tobacco and drugs as well as medicines with inconveniencing side effects). Initially, the encouragement and assistance provided by the supporter is a facilitator for healthy living. For example, he or she may accompany the person to the gym or swimming pool, encourage and support when planning, shopping and cooking healthy food. If the strategy healthy living is successful it may lead to weight loss, sobriety, improved physical condition and a sense of increased health and wellbeing. If not successful, it leads to feelings of failure and an increased need of being encouraged and supported to try new ways of healthy living.

Enriching life means investing in the good and bright sides of life, in order to make everyday life as positive as possible. Enriching life is performed by thinking positively and feeling grateful, surrounding oneself with nice and beautiful things, planning for positive events, engaging in hobbies, engaging in social activities, being with loved ones, and, staying in places where one feels comfortable and relaxed (such as the summer house, the garden, the balcony, the forest or the seaside). The supporter is valuable for socializing with others and making new friends. For example, the supporter may encourage and accompany the person to social activities. Some of the ways of enriching life (for example engaging in hobbies) are more likely to succeed, while engaging in social activities is more likely to fail.  Failure leads to ending the activity and not having the courage to try again. If the strategy is successful it leads to pleasure and a sense of well-being, gives a positive dimension to everyday life, and contributes to an experience of having an everyday life that is similar to that which others have.

If the process of mastering everyday life is successful and continues for a long time, the mission in everyday life is no longer perceived as impossible to manage. When everyday life has become manageable, when the person feels confident and capable, experiencing an increased health and wellbeing, and when life has begun to be lived positively, feelings of being able to master everyday life on one’s own arise. It may then be time to reduce the housing support gradually and to plan for a future without this assistance. However, if the process of mastering everyday life is interrupted or disturbed by interrupted support, the previously created order and structure is gradually broken down; everyday life returns to be perceived as an impossible mission, and avoiding is used to handle it. In turn, the idea of avoiding leads to a downward spiral of chaos and anxiety. However, continuous support can help to break the spiral and to re-engage in the process of mastering everyday life.

Facilitators and triggers
Continuity and time are essential for the process of mastering everyday life to be successful. The longer the process is ongoing without interruption, the greater part of everyday life is mastered. Important facilitators during the process are the supporter, and relatives or friends. However, sudden and unexpected changes can be triggers leading to interruptions or complications in the process. Examples of such triggers are changes of times, unexpected occurrences, changes in the personal financial situation, changes in the housing support scheme, changes in who provides the housing support.

The continuity of housing support is a prerequisite for the process of mastering everyday life for the target group; there is an ever-present fear that the support may be withdrawn. The need for continuity applies to the time when housing support is provided as well as the person who provides it. It is particularly difficult to cope when an unknown supporter arrives unannounced, when the ordinary supporter is ill or on leave. Letting an unknown person into one’s home is associated with worry, insecurity or even fear. If the continuity is interrupted, for example when the supporter is on leave, the progression in the process of mastering everyday life stops; tasks that have been manageable may return to being unmanageable. Once accustomed to the new times and/or the new supporter, the process of mastering everyday life continues. During longer breaks in housing support, or if the housing support ceases, the process of mastering everyday life stops;the previously created order and structure is gradually broken down; the mission in everyday life is re-experienced as impossible and avoiding is used to handle it.

Discussion

Participants were recruited with the assistance of social service managers, who could be seen as gatekeepers, potentially hindering some residents from participating in the study. This limitation could, however, be said to be counterbalanced through the recruitment of participants from two day centers, where all the attendees were invited to receive information about the study. This recruitment method generated participants with a greater severity in terms of disability compared to those who were recruited through the social service managers. The diversity of the participants’ disabilities and experiences of psychiatric care could be considered to be a positive aspect that provided an increased opportunity to gain a broader perspective on living in ordinary housing with housing support. Multiple recruitment strategies are thus recommended for further studies in the research field.

The literature review, which was performed once the theory mastering everyday life was formulated, revealed that there is a considerable lack of research into how people with psychiatric disabilities who receive housing support in ordinary housing deal with their everyday life. Through its explanatory structure this grounded theory contributes to fill this knowledge gap.

The main concern, the impossible mission in everyday life, has similarities to “a collapsed everyday life” (Andersson, 2009, p.159) which was found to be one consequence of psychiatric disorders in a study about housing support for people with psychiatric disabilities who live in ordinary housing in the community. The study does not, however, focus on how the residents cope with everyday situations. The impossible mission in everyday life is also similar to “problems of living” (Barker, 2001, p.84) and “difficulties in everyday life” (Ahlström & Wentz, 2014, p. 1), which have been used to describe consequences of living with psychiatric disabilities.

The concept “impossible mission” or “mission impossible” has been frequently used in research literature in order to describe experiences in psychiatric care contexts from the perspective of staff, service managers and administrators (e.g. Berland, 2003; Hörberg, Benzein, Erlingsson, & Syrén, 2015; Oeye, Bjelland, Skorpen, & Anderssen, 2009). This grounded theory, however, is based on the residents’ experiences of having psychiatric disabilities and living in the community with housing support. Their main concern, the impossible mission in everyday life, is resolved by mastering everyday life, which can be seen as being similar to “To take charge of one’s life” (Berglund, 2011) when suffering from long-term illness, or to master the unpredictable life that follows after one’s partner has had a stroke (Gosman-Hedström & Dahlin-Ivanoff, 2012). Furthermore, mastering everyday life could, to some extent, be considered as similar to the concepts “self-management” (Barker & Buchanan-Barker, 2010, p. 173; Barker & Buchanan-Barker, 2011, p. 354) and “being fit and ready to act” (Barker & Buchanan-Barker, 2011, p. 353), which have been used to define mental health and recovery.

It should be emphasized that mastering everyday life does not represent all the patterns of behavior of the target group, but is one important pattern of behavior in which they engage. Mastering everyday life is performed by the strategies identifying, organizing, tackling, challenging, boosting, and avoiding. These concepts have all been used one at a time, in various research contexts, and a few examples of this are as follows:

The importance of identifying needs as well as personal and interpersonal resources has been emphasized in psychiatric contexts (Barker & Buchanan-Barker, 2005). In the current theory, identifying is a prerequisite for organizing everyday life, which in turn leads to a sense of gaining control. “Planning and organizing” (van de Ven, Post, de Witte, & Heuvel, 2008, p. 250) has been found to be a useful strategy for people with cervical spinal cord injury in their effort to reach autonomy and, in this theory, organizing is one important step towards mastering everyday life, which, if successful may lead to increased autonomy. Tackling and challenging have been used in the context of physical disabilities and environmental obstacles (Pound, Gompertz, & Ebrahim, 1998; Rydström, Hartman, & Segesten, 2005; van de Ven et al., 2008). If successful, the four strategies (identifying, organizing, tackling and challenging) lead to an increasingly functional daily life and possibilities for boosting everyday life. Boosting well-being via positive emotions, positive thoughts, positive behaviors and need satisfaction has been suggested to constitute a protective factor against mental health conditions (Layous, Chancellor, & Lyubomirsky, 2014). Avoiding is reminiscent of avoidance behavior, which is a well-known concept, and a central component in cognitive behavioral theories that are frequently used in psychiatric care contexts. For example, social avoidant behavior was found to characterize the lives of people with schizophrenia (de la Asuncion, Docx, Sabbe, Morrens, & de Bruijn, 2015). Anxious avoidance and depressive avoidance were found to be associated with symptoms of prolonged grief disorder, depression and posttraumatic stress disorder (Boelen & van den Bout, 2010). A temporary use of avoiding may be a way of saving time or energy, while the consequences of its use may lead to a downward spiral of increased feelings of chaos, anxiety, and less capacity to handle everyday life. It is thus important to provide as much of the needed support as possible in the residents’ use of the five strategies (identifying, organizing, tackling, challenging, and boosting).

The concepts are not new but during the literature review, no study was found in which these concepts were used together in an explanatory theory of human behavior patterns. The theory mastering everyday life can, through its explanatory structure, contribute to a greater understanding for the life situation of people with psychiatric disabilities and how they can be supported to overcome their difficulties. The theory may serve as a tool for people with psychiatric disabilities to reflect about their own situation. Increased knowledge of their main concern, and their patterns of behavior in dealing with that concern, may also serve as a tool for community support workers and family to facilitate the residents’ process in mastering everyday life.

Furthermore, when planning for housing support services for people with psychiatric disabilities, social service managers need to pay great attention to continuity and time, as these were found to be essential factors for success in mastering everyday life. The community support workers were found to be important facilitators for starting the process of mastering everyday life, and continuity over time was found to be a prerequisite for being able to continue the process. A long interruption, or withdrawal of the housing support, leads to a return to the previous avoidance behavior, which eventually results in a return to the everyday chaos that prevailed in the individual’s life prior to receiving housing support.

We emphasize the importance of planning housing support services in such a way that interruptions to continuity are avoided. In order to provide safety and security, every new supporter should be thoroughly introduced before they begin to provide support to a resident. Furthermore, the supporters’ work schedules should be planned so that each recipient of housing support is familiar with at least two supporters, and that these two replace each other during sick leave and vacations. The support should be given continuously without interruption, until the resident feels ready to handle daily life without support. The support should then be gradually decreased. If the resident does not feel ready to handle everyday life without housing support, the support should be continued. In order to prevent worry, a long-term plan should be made for each resident. The plan should include an agreement that any future withdrawal of housing support will only be done if the resident feels ready for it, and that withdrawal will be preceded by a gradual and slow reduction in the number of housing support hours, before ceasing.

In conclusion, the theory mastering everyday life contributes to the knowledge about how people with psychiatric disabilities, who are living in ordinary housing in the community, deal with their everyday life. The theory reveals that community support workers are important facilitators for the target group when dealing with their main concern, the impossible mission in everyday life, and continuity in housing support is crucial for their progression in the process of mastering everyday life. Supporting the process of mastering everyday life is important since, if successful, it leads to experiences of increased health, well-being, and a capability to deal with everyday life without support, which, in turn, may lead to autonomy and a reduced need for housing support. The theory mastering everyday life and the importance of continuity in housing support can be used over time as a basis for future intervention studies in the research field.

References
  • Ahlström, B. H. & Wentz, E. (2014). Difficulties in everyday life: Young persons with attention-deficit/hyperactivity disorder and autism spectrum disorders perspectives. A chat-log analysis. International Journal of Qualitative Studies On Health And Well-Being, 9, Retrieved from http://www.ijqhw.net/index.php/qhw/article/view/23376
  • Andersson, G. (2009). Vardagsliv och boendestöd: En studie om människor med psykiska funktionshinder [Everyday life and housing support: a study of people with psychiatric disabilities] (Doctoral dissertation, Stockholm University, Stockholm: US-AB).
  • Barker, P. (2001). The Tidal Model: Developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric & Mental Health Nursing, 8(3), 233-240. doi:10.1046/j.1365-2850.2001.00391.x
  • Barker, P., & Buchanan-Barker, P. (2005). The tidal model: A guide for mental health professionals. London, UK: Routledge.
  • Barker, P., & Buchanan-Barker, P. (2010). The tidal model of mental health recovery and reclamation: Application in acute care settings. Issues in Mental Health Nursing, 31(3), 171-180. doi:10.3109/01612840903276696
  • Barker, P. J., & Buchanan-Barker, P. (2011). Review article: Mental health nursing and the politics of recovery: A global reflection. Archives of Psychiatric Nursing, 25, 350-358. Retrieved from http://www.sciencedirect.com/science/article/pii/S0883941711000434
  • Berglund, M. (2011). Att ta rodret i sitt liv: lärande utmaningar vid långvarig sjukdom [To take charge of one’s life: learning challenges during prolonged illness] (Doctoral dissertation, Växjö, Kalmar: Linnaeus University Press).
  • Berland, A. (2003). Modernizing mental health services: Mission impossible? Administration and Policy In Mental Health, 30(3), 219-229. Retrieved from http://link.springer.com/article/10.1023%2FA%3A1023528225611
  • Boelen, P. A., & van den Bout, J. (2010). Anxious and depressive avoidance and symptoms of prolonged grief, depression, and posttraumatic stress-disorder. Psychologica Belgica, 50(1–2), 49–67. Retrieved from http://www.psychologicabelgica.com/articles/abstract/10.5334/pb-50-1-2-49/
  • Brolin, R., Rask, M., Syrén, S., Baigi, A. & Brunt, D. (2015). Satisfaction with housing and housing support for people with psychiatric dsabilities. Issues in Mental Health Nursing, 36, 21–28. Retrieved from http://www.tandfonline.com/doi/abs/10.3109/01612840.2014.930216
  • Brunt, D. (2002). Supported housing in the community for persons with severe mental illness: Psychosocial environment, needs, quality of life and social network (Doctoral dissertation, Lund: University, KFS).
  • de la Asuncion, J., Docx, L., Sabbe, B., Morrens, M., & de Bruijn, E. R. (2015). Converging evidence of social avoidant behavior in schizophrenia from two approach-avoidance tasks. Journal of Psychiatric Research, 69, 135-141. Retrieved from http://www.sciencedirect.com/science/article/pii/S0022395615002411

    Fakhoury, W. H., Murray, A., Shepherd, G., & Priebe, S. (2002). Research in supported housing. Social Psychiatry and Psychiatric Epidemiology, 37(7), 301-315. Retrieved from http://link.springer.com/article/10.1007/s00127-002-0549-4

    Forchuk, C., Nelson, G., & Hall, G.B. (2006). “It’s important to be proud of the place you live in”: Housing problems and preferences of psychiatric survivors. Perspectives in Psychiatric Care, 42(1), 42-52. doi: 10.1111/j.1744-6163.2006.00054.x

  • Glaser, B. (1978). Theoretical sensitivity. Mill Valley, CA: Sociology Press.
  • Glaser, B. (1998). Doing grounded theory: Issues and discussions. Mill Valley, CA: Sociology Press.
  • Glaser, B. (2001). The grounded theory perspective: Conceptualization contrasted with description. Mill Valley, CA: Sociology Press.
  • Gosman-Hedström, G., & Dahlin-Ivanoff, S. (2012). ‘Mastering an unpredictable everyday life after stroke’- Older women’s experiences of caring and living with their partners. Scandinavian Journal of Caring Sciences, 26(3), 587-597. doi:10.1111/j.1471-6712.2012.00975.x
  • Hanrahan, P., Luchins, D., Savage, C., & Goldman, H. (2001). Housing satisfaction and service use by mentally ill persons in community integrated living arrangements. Psychiatric Services, 52(9), 1206. Retrieved from http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.52.9.1206

    Harvey, C., Killackey, E., Groves, A., & Herrman, H. (2012). A place to live: Housing needs for people with psychotic disorders identified in the second Australian national survey of psychosis. Australian & New Zealand Journal of Psychiatry, 46(9), 840-850. Retrieved from http://anp.sagepub.com/content/46/9/840

    Hörberg, U., Benzein, E., Erlingsson, C., & Syrén, S. (2015). Engaging with families is a challenge: Beliefs among healthcare professionals in forensic psychiatric care. Nursing Research & Practice, 20, 151-10. Retrieved from http://www.hindawi.com/journals/nrp/2015/843717/

    Kulhara, P., Avasthi, A., Grover, S., Sharan, P., Sharma, P., Malhora, S., & Gill, S. (2010). Needs of Indian schizophrenia patients: An exploratory study from India. Social Psychiatry and Psychiatric Epidemiology, 45, 809-818. doi:10.1007/s00127-009-0126-1

    Layous, K., Chancellor, J., & Lyubomirsky, S. (2014). Positive activities as protective factors against mental health conditions. Journal of Abnormal Psychology, 123(1), 3-12. doi:10.1037/a0034709

    Nelson, G., Sylvestre, J., Aubry, T., George, L., & Trainor, J. (2007). Housing choice and control, housing quality, and control over professional support as contributors to the subjective quality of life and community adaptation of people with severe mental illness. Administration and Policy In Mental Health, 34(2), 89-100. Retrieved from http://link.springer.com/article/10.1007%2Fs10488-006-0083-x

  • Ochoa, S., Haro, J., Autonell, J., Pendás, A., Teba, F., & Márquez, M. (2003). Met and unmet needs in schizophrenia patients in a Spanish sample. Schizophrenia Bulletin, 29 (2), 201-210. Retrieved from http://schizophreniabulletin.oxfordjournals.org.proxy.lnu.se/content/29/2/201.short
  • Oeye, C., Bjelland, A. K., Skorpen, A., & Anderssen, N. (2009). User participation when using milieu therapy in a psychiatric hospital in Norway: A mission impossible? Nursing Inquiry, 16(4), 287-296. doi:10.1111/j.1440-1800.2009.00463.x
  • Pound, P., Gompertz, P., & Ebrahim, S. (1998). A patient-centred study of the consequences of stroke. Clinical Rehabilitation, 12(4), 338-347. Retrieved from http://cre.sagepub.com.proxy.lnu.se/content/12/3/255.short
  • Rydström, I., Hartman, J., & Segesten, K. (2005). Not letting the disease get the upper hand over life: Strategies of teens with asthma. Scandinavian Journal Of Caring Sciences, 19(4), 388. doi: 10.1111/j.1471-6712.2005.00365.x

  • Swedish National Board of Health and Welfare (2006). Vad är psykiskt funktionshinder? [What is a psychiatric disability?]. Stockholm: Socialstyrelsen [The Swedish National Board of Health and Welfare]. Retrieved from https://www.personligtombud.se/publikationer/pdf/vad%20ar%20psyk%20fh%20nat%20ps.pdf
  • Swedish National Board of Health and Welfare (2010). Det är mitt hem – Vägledning om boende och boendestöd för personer med psykisk funktionsnedsättning [It is my home – Guidance on housing and housing support for people with psychiatric disabilities]. Stockholm: Socialstyrelsen 2010-12-26 [The Swedish National Board of Health and Welfare]. Retrieved from http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/18214/2010-12-26.pdf

  • Swedish National Board of Health and Welfare (2011). Insatser för personer med psykiska funktionsnedsättningar – Kommunernas användning av stimulansbidragen 2007- 2010. [Interventions for people with mental disabilities – Local use of incentive grants 2007-2010] Stockholm: Socialstyrelsen [The Swedish National Board of Health and Welfare] 2011-6-29. Retrieved from https://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/18378/2011-6-29.pdf
  • Swedish National Board of Health and Welfare (2012). Att inventera behov. Inventering av gruppen personer med psykisk funktionsnedsättning. [Identifying needs – A focus on people with psychiatric disabilities] Stockholm: Socialstyrelsen [The Swedish National Board of Health and Welfare] 2012-1-34. Retrieved from https://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/18586/2012-1-34.pdf
  • Tsai, J., Bond, G., Salyers, M., Godfrey, J., & Davis, K. (2010). Housing preferences and choices among adults with mental illness and substance use disorders: A qualitative study. Community Mental Health Journal, 46(4), 381-388. Retrieved from http://link.springer.com/article/10.1007%2Fs10597-009-9268-6

    Tsemberis, S., Rogers, E., Rodis, E., Dushuttle, P., & Skryha, V. (2003). Housing satisfaction for persons with psychiatric disabilities. Journal of Community Psychology, 31(6), 581-590. doi:10.1 002/jcop.10067

    van de Ven, L., Post, M., de Witte, L., & Heuvel, W. d. (2008). Strategies for autonomy used by people with cervical spinal cord injury: A qualitative study. Disability & Rehabilitation, 30(4), 249. doi:10.1080/09638280701265687

    Walker, R., & Seasons, M. (2002). Supported housing for people with serious mental illness: Resident perspectives on housing. Canadian Journal of Community Mental Health, 21(1), 137-151. Retrieved from http://www.cjcmh.com/doi/abs/10.7870/cjcmh-2002-0010

    Warren, R., & Bell, P. (2000). An exploratory investigation into the housing preferences of consumers of mental health services. Australian & New Zealand Journal of Mental Health Nursing, 9(4), 195-202. doi:10.1046/j.1440-0979.2000.00172.x

    WMA (World medical Association Declaration of Helsinki). (2009). Ethical principles for medicals research involving human subjects. Retrieved from http://www.wma.net/en/30publications/10policies/b3/

    Zahid, M., & Ohaeri, J. (2013). Clinical and psychosocial factors associated with needs for care: An Arab experience with a sample of treated community-dwelling persons with schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 48, 313-323. doi:10.1007/s00127-012-0514-9

    Declaration of Conflicting Interests

    The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

    Acknowledgements

    Financial support has been given by The Faculty of Health and Life Sciences, Linnaeus University; and The Swedish National Association for Social and Mental Health.

    © The Authors 2016

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