Abstract

Mental disorders cause impact in the work environment. Investigations of interaction among stakeholders who are involved in the return to work are scarce. Meta-ethnography serves to synthesize qualitative studies by means of ongoing interpretation and comparison of the ideas presented in the articles. The goal of this study is to present a meta-ethnography of the interactions among the stakeholders involved in the return to work process after leave of absence due to mental disorders. It aims: (1) to investigate the interactions among stakeholders involved in return to work; (2) to identify enablers or obstacles for the return to work. The database search found 619 articles, 16 of which met the inclusion criteria. Analysis of the articles revealed six second-order concepts that resulted in two syntheses. The first is about performance ethos in the return to work, and the second shows return to work as a catalyst of new life styles. Models that favor the worker’s performance ethos, as well as a perspective oriented by psychosocial aspects may enable return to work practices after leave of absence due to mental disorders.

Return to Work; Mental Disorders; Occupational Health; Qualitative Research

Introduction

Mental disorders is a major health problem, that causes impact also in the work environment, particularly in the return to work of workers who had long leave of absence due to mental disorders. Blank et al. ¹1. Blank L, Peters J, Pickvance S, Wilford J, Macdonald E. A systematic review of the factors which predict return to work for people suffering episodes of poor mental health. J Occup Rehabil 2008; 18: 27-34. have shown that between 1985-2005 in North America and England, only 50% of those who took leave of absence from work due to mental disorders for more than six months returned to work.

To understand the complexity of this problem, some authors have studied predictors of return to work, which include different sorts: personal, environmental, organizational and relational ¹1. Blank L, Peters J, Pickvance S, Wilford J, Macdonald E. A systematic review of the factors which predict return to work for people suffering episodes of poor mental health. J Occup Rehabil 2008; 18: 27-34.. Based on the latter, Nielsen et al. ²2. Nielsen MBD, Madsen IEH, Bültmann U, Christensen U, Diderichsen F, Rugulies R. Predictors of return to work in employees sick-listed with mental health problems: findings from a longitudinal study. Eur J Public Health 2011; 21:806-11. (p. 807) presented the “expectations about the return to work” as a return to work predictor. The authors explain that individual perceptions and beliefs about the external conditions and skills, such as the concern with performance at work, and interaction with co-workers and other stakeholders involved in the return to work process may affect the behavior of the worker and contribute to the success or failure of their return to work. However, expectations about the return to work are not determined for the worker’s perception alone. In fact, the interactions that are established among the stakeholders involved in the return to work process may also nurture these expectations.

Gewurtz & Kirsh ³3. Gewurtz R, Kirsh B. Disruption, disbelief and resistance: a meta-synthesis of disability in the workplace. Work 2009; 34:33-44. emphasize that the support and understanding of co-workers and supervisors may be instrumental in job maintenance, performance and satisfaction. Andersen et al. ⁴4. Andersen MF, Nielsen KM, Brinkmann S. Meta-synthesis of qualitative research on return to work among employees with common mental disorders. Scand J Work Environ Health 2012; 38:93-104. highlight the role health professionals may play by reinforcing the image of being ill on the worker on leave of absence, and how this delays and negatively affects the return to work. MacEachen et al. ⁵5. MacEachen E, Clarke J, Franche R-L, Irvin E. Systematic review of the qualitative literature on return to work after injury. Scand J Work Environ Health 2006; 32:257-69. mention the conflicts between the worker who is returning and the health practitioner, particularly in their disagreement as to when to return to work. These authors also mention the role of unions in negotiating adjustments in the work environment, and make evident the role of supervisors for a successful return to work, considering how close they are with the worker who is returning.

However, qualitative reviews that address the problems concerning the interaction of stakeholders in the return to work of workers with mental disorders are scarce ³3. Gewurtz R, Kirsh B. Disruption, disbelief and resistance: a meta-synthesis of disability in the workplace. Work 2009; 34:33-44.^,44. Andersen MF, Nielsen KM, Brinkmann S. Meta-synthesis of qualitative research on return to work among employees with common mental disorders. Scand J Work Environ Health 2012; 38:93-104.^,55. MacEachen E, Clarke J, Franche R-L, Irvin E. Systematic review of the qualitative literature on return to work after injury. Scand J Work Environ Health 2006; 32:257-69.. The development of qualitative syntheses may clear these interactions and therefore systematize the knowledge about this issue.

Thus, one questions how the scientific literature addresses the interactions among the stakeholders involved in the return to work process after the leave of absence due to mental disorders. Particularly: (i) What are the interaction-related issues among the stakeholders involved in the return to work that emerge in the scientific literature? (ii) What are the enablers or obstacles for the return to work in the scientific literature?

Methodological considerations

Our methodology is based on the qualitative meta-synthesis approach, which is used to synthesize qualitative studies in order to provide new insights on a particular issue ³3. Gewurtz R, Kirsh B. Disruption, disbelief and resistance: a meta-synthesis of disability in the workplace. Work 2009; 34:33-44..

Meta-ethnography is a set of techniques and principles whose main characteristic is being inductive and interpretative, rather than aggregative, as it sets off from individual cases, maintaining their particulars and holism, and reaches the synthesis by means of reciprocal translation. This implies examining the main concepts present in the set of articles through a comparative process ⁴4. Andersen MF, Nielsen KM, Brinkmann S. Meta-synthesis of qualitative research on return to work among employees with common mental disorders. Scand J Work Environ Health 2012; 38:93-104.^,66. Campbell R, Pound P, Pope C, Britten N, Pill R, Morgan M, et al. Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care. Soc Sci Med 2003; 56:671-84.^,77. Noblit GW, Hare RD. Meta-ethnography: synthesizing qualitativa studies. Newbury Park: Sage Publications; 1988.. MacEachen et al. ⁵5. MacEachen E, Clarke J, Franche R-L, Irvin E. Systematic review of the qualitative literature on return to work after injury. Scand J Work Environ Health 2006; 32:257-69. reinforce the usefulness of meta-ethnography, since, through an inductive approach, it is possible to mitigate differences in qualitative methodologies and epistemological paradigms, and ensure a comprehensive view of the set of the examined literature.

Process of search and inclusion criteria

With the help of a librarian, a systematic search was carried out in North-American and European electronic databases, in order to identify peer-reviewed qualitative studies published in English. Databases that included studies conducted in Latin America and the Caribbean were also included, particularly those published in Portuguese and Spanish. At the end, the databases used were BIREME, SciELO, PsycInfo, CINAHL, Scopus, EMBASE, Social Sciences Abstracts, and Web of Knowledge (Figure 1).

MacEachen et al. ⁵5. MacEachen E, Clarke J, Franche R-L, Irvin E. Systematic review of the qualitative literature on return to work after injury. Scand J Work Environ Health 2006; 32:257-69. pointed out that good return to work practices were implemented in North America and Europe during the 1990s. This explains the search of articles published between 1990 and 2014. Articles with the following key or related words were selected: return to work, mental disorder, and qualitative methodology (Figure 2). Manual search and cross-reference lists of the main articles were also included.

In this study, we use the idea of Young et al. ⁸8. Young AE, Roessler RT, Wasiak R, McPherson KM, van Poppel MNM, Anema JR. A developmental conceptualization of return to work. J Occup Rehabil 2005; 15:557-68. who see the return to work as a dynamic process influenced by different factors at different points in time, in a non-linear way. The process may be divided into four stages, starting with the worker still out of work (Off work), then moving on to work re-insertion (Re-Entry), in which the necessary work adjustments may be done, so that the work matches the worker’s ability to perform, allowing him/her to keep the job and perform the activities in a satisfactory manner. In the following stage (Maintenance), the worker tries to reach the goals and targets of the daily work, and the possibility of progression is already considered. In the final stage (Advancement), the worker is qualified for higher-qualified tasks and responsibilities, looking forward to a promotion.

This model designs the return to work from a combined action of the stakeholders involved in the process, as this includes not only the worker and other agents at the workplace, but also relations that go beyond the plant floor. Thus, in addition to the concept, the return to work was also the criterion to select the articles that served as basis for this meta-synthesis ⁸8. Young AE, Roessler RT, Wasiak R, McPherson KM, van Poppel MNM, Anema JR. A developmental conceptualization of return to work. J Occup Rehabil 2005; 15:557-68..

We consider that mental disorders are the product and expression, in an individual, of power relations, social contradictions, existential dilemmas, and cultural conflicts. This implies understanding mental disorders as subjectivities that are manifested as ruptures in the process of psychosocial adaptation, and expressed by thoughts, feelings and behavior that vary according to socio-cultural, psychological-subjective, and biological-cerebral dimensions ⁹9. Dalgalarrondo P. Psicopatologia e sintomatologia dos transtornos mentais. Porto Alegre: Artes Médicas do Sul; 2000..

Even though, for their rationality, the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases and Related Health Problems (ICD) do not consider the bio-psycho-socio-cultural aspect of the mental disorders ¹⁰10. Nunes M. Interseções antropológicas na saúde mental: dos regimes de verdade naturalistas à espessura biopsicossociocultural do adoecimento mental. Interface Comun Saúde Educ 2012; 16:903-16., and the uniqueness of the subject’s experience, and favors the alleged neutrality, universality and objectivity of the psychiatric diagnosis ¹¹11. Hernáez AM. La copia de los hechos. La biomedicina, el poder y sus encubrimientos. Quaderns de l’Institut Català d’Antropologia 2011; 11:45-64., we have decided to keep the terminology used by those manuals, as they represent a common basis for the scientific productions in the health area.

However, we have decided to limit the scope of mental disorders to mood disorder diagnoses (ICD-10 codes F30 to F39), neurotic and stress-related disorders (ICD-10 codes F40 to F43) ¹²12. Organização Mundial da Saúde. Classificação de transtornos mentais e de comportamento da CID-10. Descrições clínicas e diretrizes diagnósticas. Porto Alegre: Artes Médicas; 1993., as these are the most prevalent, and are typically associated to sick leaves that lead to return to work, rather than early retirement ¹³13. Noordik E, Nieuwenhuijsen K, Varekamp I, van der Klink JJ, van Dijk FJ. Exploring the return-to-work process for workers partially returned to work and partially on long-term sick leave due to common mental disorders: a qualitative study. Disabil Rehabil 2011; 33:1625-35..

Study selection also took into account: (a) qualitative research-based studies; (b) studies that focused mental disorders-related return to work; (c) studies that focused subjects who returned to work after mental disorders and/or other studies that addressed this process; (d) studies that addressed the interactions among stakeholders in the context of the return to work of people with mental disorders.

Recent qualitative meta-syntheses ³3. Gewurtz R, Kirsh B. Disruption, disbelief and resistance: a meta-synthesis of disability in the workplace. Work 2009; 34:33-44.^,44. Andersen MF, Nielsen KM, Brinkmann S. Meta-synthesis of qualitative research on return to work among employees with common mental disorders. Scand J Work Environ Health 2012; 38:93-104.^,1414. Fossey EM, Harvey CA. Finding and sustaining employment: a qualitative meta-synthesis of mental health consumer views. Can J Occup Ther 2010; 77:303-14. have adopted models to assess the quality of the studies among the selected articles. It is to be mentioned, however, that the use of quality criterion for the selection of articles for meta-syntheses has been importantly criticized ⁶6. Campbell R, Pound P, Pope C, Britten N, Pill R, Morgan M, et al. Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care. Soc Sci Med 2003; 56:671-84.^,1515. Daly J, Willis K, Small R, Green J, Welch N, Kealy M, et al. A hierarchy of evidence for assessing qualitative health research. J Clin Epidemiol 2007; 60: 43-9.. The most important objection is that the guidelines to assess the quality of qualitative articles tend to value hegemonic research models that do not reflect all the existing possibilities. Therefore, even more refined studies could be ruled out for not matching the eligibility criteria ¹⁵15. Daly J, Willis K, Small R, Green J, Welch N, Kealy M, et al. A hierarchy of evidence for assessing qualitative health research. J Clin Epidemiol 2007; 60: 43-9.^,1616. Spencer L, Ritchie J, Lewis J, Dillon L. Quality in qualitative evaluation: a framework for assessing research evidence. London: Government Chief Social Researcher’s Office; 2003..

Thus, we concur that plurality reinforces the evidences when a review is made ⁶6. Campbell R, Pound P, Pope C, Britten N, Pill R, Morgan M, et al. Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care. Soc Sci Med 2003; 56:671-84.^,1616. Spencer L, Ritchie J, Lewis J, Dillon L. Quality in qualitative evaluation: a framework for assessing research evidence. London: Government Chief Social Researcher’s Office; 2003.. Therefore, we will not adopt evaluation criteria to assess the quality of the selected studies; rather, we will use systematic procedures according to which decisions and selections are based, which should maximize the rigor of our work.

Two authors experienced in qualitative investigations and in the field of occupational health selected the articles; whenever consensus was not reached, a third evaluator helped the final decision making. Similar procedure was adopted in other meta-syntheses ³3. Gewurtz R, Kirsh B. Disruption, disbelief and resistance: a meta-synthesis of disability in the workplace. Work 2009; 34:33-44.^,44. Andersen MF, Nielsen KM, Brinkmann S. Meta-synthesis of qualitative research on return to work among employees with common mental disorders. Scand J Work Environ Health 2012; 38:93-104.^,1414. Fossey EM, Harvey CA. Finding and sustaining employment: a qualitative meta-synthesis of mental health consumer views. Can J Occup Ther 2010; 77:303-14..

Data analysis

Noblit & Hare ⁷7. Noblit GW, Hare RD. Meta-ethnography: synthesizing qualitativa studies. Newbury Park: Sage Publications; 1988. propose three possible strategies to synthesize qualitative studies: (1) Reciprocal Translational Analysis, in which each study is considered in an interactive way in relation to their similarities; (2) Refutational Synthesis, when the analysis of each study is oriented towards disagreements among them; (3) Lines-of-Argument Synthesis, that is intended to develop a comprehensive interpretation of the whole (organization, culture, etc.), based on the lines of argument developed in the different studies. For this review, Reciprocal Translational Analysis was the adopted strategy, as the studies that were examined presented a number of similarities among them, which indicated they should be assessed by thoroughly examining and comparing ideas and concepts present in the original studies ⁷7. Noblit GW, Hare RD. Meta-ethnography: synthesizing qualitativa studies. Newbury Park: Sage Publications; 1988..

The development of a meta-ethnography involves three orders of data organization and analysis. In this study, the first order included the identification of the concepts presented in the main findings of the original articles. Our study has prioritized the description of the interaction among stakeholders in the return to work context ⁷7. Noblit GW, Hare RD. Meta-ethnography: synthesizing qualitativa studies. Newbury Park: Sage Publications; 1988.. The second order was related to the interpretation process from comparing findings evidenced in at least two original studies ³3. Gewurtz R, Kirsh B. Disruption, disbelief and resistance: a meta-synthesis of disability in the workplace. Work 2009; 34:33-44.^,44. Andersen MF, Nielsen KM, Brinkmann S. Meta-synthesis of qualitative research on return to work among employees with common mental disorders. Scand J Work Environ Health 2012; 38:93-104.^,77. Noblit GW, Hare RD. Meta-ethnography: synthesizing qualitativa studies. Newbury Park: Sage Publications; 1988.. The third order or synthesis consisted in a re-interpretation of the second-order concepts regarding the issues that guide the subject of the study. The process was guided by some fundamentals of the phenomenological theory, such as meaningful experience, the being-in-the-world and the lifeworld, in addition to the social action theory. We have also used the concept of social rehabilitation to provide the epitome of the literature that was examined, which will be further explained in the discussion of the findings ⁷7. Noblit GW, Hare RD. Meta-ethnography: synthesizing qualitativa studies. Newbury Park: Sage Publications; 1988..

The free Mendeley 1.12.1 reference manager system for Windows (http://www.mendeley.com) was used for the management of the articles. The Nvivo 10 software (QSR International; http://www.qsrinternational.com/) was used to organize the concepts extracted from the original articles into themes, and for comparative analysis among these concepts ¹⁷17. Saur-Amaral I. Curso completo de NVivo 9. Como tirar maior proveito do software para a sua investigação. Aveiro: Bubok; 2011..

Results

After merging the results obtained from the eight databases and removal of the duplicated publications, the active search found 619 articles. From these, 16 articles were selected according to the previously mentioned inclusion criteria (Figure 1). It should be highlighted that most of the studies were related to countries such as the Netherlands, Denmark, Sweden, United Kingdom and Canada, Northern, economically developed and central countries. A summary of the main characteristics and first-order concepts identified in the selected articles is shown in Table 1.

Based on the issues related to the investigation, a consensus was reached among the investigators that resulted in six second-order concepts, as follows:

1) Experience related to the worker’s performance in the return to work process

The articles show that the performance of workers in the return to work seems to be directly influenced by the beliefs the worker who is return to work has about himself/herself, and the ideas others have about him/her and their return to work. These experiences emerge as: weakness, for not being able to manage their workload ¹⁸18. Holmgren K, Dahlin Ivanoff S. Women on sickness absence: views of possibilities and obstacles for returning to work. A focus group study. Disabil Rehabil 2004; 26:213-22.^,1919. Nielsen MBD, Rugulies R, Hjortkjaer C, Bültmann U, Christensen U. Healing a vulnerable self: exploring return to work for women with mental health problems. Qual Health Res 2013; 23:302-12.^,2020. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.; mistrust in themselves, as they do not endure the demands of the job well ¹⁸18. Holmgren K, Dahlin Ivanoff S. Women on sickness absence: views of possibilities and obstacles for returning to work. A focus group study. Disabil Rehabil 2004; 26:213-22.^,2121. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6.; discredit, as they do not deal well with their own expectations of being a successful employee ¹⁸18. Holmgren K, Dahlin Ivanoff S. Women on sickness absence: views of possibilities and obstacles for returning to work. A focus group study. Disabil Rehabil 2004; 26:213-22.^,2121. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6.; sensitivity as to the reactions of others regarding their return to work ²¹21. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6.^,2222. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52.; oppression for feeling forced to satisfy the expectations of others ¹³13. Noordik E, Nieuwenhuijsen K, Varekamp I, van der Klink JJ, van Dijk FJ. Exploring the return-to-work process for workers partially returned to work and partially on long-term sick leave due to common mental disorders: a qualitative study. Disabil Rehabil 2011; 33:1625-35.^,2020. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,2121. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6.; and finally the impression they are being judged by the others for their work capability ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,2323. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303..

These elements may cause even more concerns and distress about the process of return to work ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47., feeling of shame and guilt ²¹21. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6., need for isolation ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47., creating or reinforcing the negative image of a worker with mental disorders ²¹21. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6.^,2424. Saint-Arnaud L, Saint-Jean M, Damasse J. Towards an enhanced understanding of factors involved in the return-to-work process of employees absent due to mental health problems. Can J Commun Ment Health 2006; 25:303-15., and discredit as to the possibility of being well-received and looked after at the workplace ¹⁸18. Holmgren K, Dahlin Ivanoff S. Women on sickness absence: views of possibilities and obstacles for returning to work. A focus group study. Disabil Rehabil 2004; 26:213-22.. Based on these findings, the experience related to the return to work performance is characterized as an obstacle hard to overcome in the process of return, as this seems to depict an ethos, i.e., a way of being that is dominant in the attitude, values and feelings of individuals in a community.

The studies that were reviewed provide some coping strategies regarding work performance: (a) to provide positive feedback as to the current capability and competence of the worker to perform the tasks, highlighting his/her strengths and skills ¹⁸18. Holmgren K, Dahlin Ivanoff S. Women on sickness absence: views of possibilities and obstacles for returning to work. A focus group study. Disabil Rehabil 2004; 26:213-22.^,2525. Pittam G, Boyce M, Secker J, Lockett H, Samele C. Employment advice in primary care: a realistic evaluation. Health Soc Care Community 2010; 18:598-606.; (b) to offer help in reviewing personal performance expectations ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.; (c) to work on self-acceptance of the current condition, in order to make the necessary adjustments to support the efforts to reconnect with co-workers ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52.; (d) to implement affirmative actions in the workplace, such as talking about the mental disorders he/she had ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52.; (e) to learn how to deal with emotions and feelings related to work demands ¹³13. Noordik E, Nieuwenhuijsen K, Varekamp I, van der Klink JJ, van Dijk FJ. Exploring the return-to-work process for workers partially returned to work and partially on long-term sick leave due to common mental disorders: a qualitative study. Disabil Rehabil 2011; 33:1625-35.; (f) to discuss the performance of professional activities among the stakeholders involved in the return to work of employees with mental disorders ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52.; and (g) to reflect and attribute new meaning to the different senses developed, considering the work ethics ²¹21. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6..

2) The impact on the relationship with colleagues in the return to work

The studies indicate that there are some expectations as to how the coworkers and the returning worker will act. The returning worker expects attitudes from coworkers such as: being attentive and sensitive listeners ¹⁸18. Holmgren K, Dahlin Ivanoff S. Women on sickness absence: views of possibilities and obstacles for returning to work. A focus group study. Disabil Rehabil 2004; 26:213-22., having a warm attitude ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,2222. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52., being willing to have contact with the worker on sick leave, even during the period of absence ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47., sincere offering of help with the tasks, and understanding with the arrangements ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.. The attitudes that coworkers value in the worker who is return to work are: not being afraid to ask coworkers for help ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52., and trusting the coworkers ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52.. The outcome is an increase in self-esteem and believing in their own capability ¹⁸18. Holmgren K, Dahlin Ivanoff S. Women on sickness absence: views of possibilities and obstacles for returning to work. A focus group study. Disabil Rehabil 2004; 26:213-22., strengthening of their identity and acknowledgement of the worker’s social status ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47., and the strengthening of the feeling that the worker will have a favorable environment for his/her return to work ²⁴24. Saint-Arnaud L, Saint-Jean M, Damasse J. Towards an enhanced understanding of factors involved in the return-to-work process of employees absent due to mental health problems. Can J Commun Ment Health 2006; 25:303-15..

The development of support in the workplace is hampered by attitudes that harm the relationship between coworkers and the returning worker, in particular: the scorn, the mockery, excessive demands ²⁶26. Olivier M, Perez C, Behr S. Trabalhadores afastados por transtornos mentais e de comportamento: o retorno ao ambiente de trabalho e suas consequências na vida laboral e pessoal de alguns bancários. Revista de Administração Contemporânea 2011; 15:993-1015., refusal to work with someone who had a bout of mental disorders ²⁶26. Olivier M, Perez C, Behr S. Trabalhadores afastados por transtornos mentais e de comportamento: o retorno ao ambiente de trabalho e suas consequências na vida laboral e pessoal de alguns bancários. Revista de Administração Contemporânea 2011; 15:993-1015., and the skepticism of coworkers ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52.. Some authors mention the excessive curiosity of coworkers about the taboo on the confidentiality of medical information ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47., and the self-serving attitudes of those who welcome the returning worker because they want to pass on to him/her the load of work they had taken over. Other factors relate to the worker himself/herself, and include aggressiveness and emotional outbursts prior to the sick leave, or even in the return to work period, in addition to the mere fact of having a psychiatric disorder.

These elements may reinforce the labeling of incapability, and enhance the lack of trust for managing the work and continue the return to work process ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52.^,2626. Olivier M, Perez C, Behr S. Trabalhadores afastados por transtornos mentais e de comportamento: o retorno ao ambiente de trabalho e suas consequências na vida laboral e pessoal de alguns bancários. Revista de Administração Contemporânea 2011; 15:993-1015.. They may even serve as catalyst of stressful situations for the worker who is return to work ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.. The coworkers see the severe psychiatric disorder as a stigma, and that seems not to favor the contact prior to the return ²⁴24. Saint-Arnaud L, Saint-Jean M, Damasse J. Towards an enhanced understanding of factors involved in the return-to-work process of employees absent due to mental health problems. Can J Commun Ment Health 2006; 25:303-15.. In addition, self-serving attitudes of the coworkers may add pressure on the worker, who still does not feel capable of taking over the full workload ²⁴24. Saint-Arnaud L, Saint-Jean M, Damasse J. Towards an enhanced understanding of factors involved in the return-to-work process of employees absent due to mental health problems. Can J Commun Ment Health 2006; 25:303-15.. Thus the importance of investing on strategies to prepare for the moment of return, aiming particularly at establishing or reestablishing the connections among people, in order to mitigate conflicts at the workplace ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303..

The studies present recommendations that may be useful to favor the relationship between the returning worker and his/her coworkers: (a) organizing a preparatory meeting prior to the return to work date. In theory, this meeting may allow the returning worker to voice his/her fear and seek solutions for the necessary adjustments, without breaking the confidentiality of their medical condition ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,2323. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.; (b) developing a communications plan to provide the team that welcomes the worker with mental disorders with the necessary information to help them develop actions to foster the relationship with the returning worker ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.. There is also the need to better understand the role of the work setting, which is oriented towards the maximum efficiency and performance to favor productivity, so that genuine support for the reentry of workers with mental disorders is not undermined ²⁴24. Saint-Arnaud L, Saint-Jean M, Damasse J. Towards an enhanced understanding of factors involved in the return-to-work process of employees absent due to mental health problems. Can J Commun Ment Health 2006; 25:303-15..

3) From perception to action: the modus operandi of the supervisor in the return to work

Studies point to the relation between the thoughts the supervisor has about the worker in sick leave due to mental disorders who is returning and the way the supervisor acts in the return to work process. Commonly, the supervisor has a positive idea about the mental disorders, accepting that the leave is not because the worker is lazy, crazy or ineffective in performing the work tasks ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52.. As a result, the supervisor offers support and guidance for the worker during the return to work process, which may lead to a successful return to work ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52.^,2727. Hees HL, Nieuwenhuijsen K, Koeter MWJ, Bültmann U, Schene AH. Towards a new definition of return-to-work outcomes in common mental disorders from a multi-stakeholder perspective. PLoS One 2012; 7:1-7..

For Hees et al. ²⁷27. Hees HL, Nieuwenhuijsen K, Koeter MWJ, Bültmann U, Schene AH. Towards a new definition of return-to-work outcomes in common mental disorders from a multi-stakeholder perspective. PLoS One 2012; 7:1-7. the fact that the supervisor believes the worker is able to deal with the workload suggests a positive perspective regarding the worker’s capability, but it can also be translated as typical aspirations of the productive ethics, such as vigor to work and fulfillment of tasks, which are parameters of normality typically used at the work environment, but should be taken in perspective, in these cases. According to Lemieux et al. ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303., when the worker returns, the expectations of normal productivity conflicts with the idea of gradual return to work, with limited tasks, need for adjustments, and part-time work. Oftentimes, the supervisor is in the center of this conflict, as they must look after the interests of the capital while trying to transform the workplace into a “therapeutic” environment” ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303..

The positive perspective the supervisor has of the employee who returns after a leave of absence due to mental disorders might have been advanced by open, candid dialogue about the psychological problems that required the distancing from work ²⁷27. Hees HL, Nieuwenhuijsen K, Koeter MWJ, Bültmann U, Schene AH. Towards a new definition of return-to-work outcomes in common mental disorders from a multi-stakeholder perspective. PLoS One 2012; 7:1-7., by having contact with the worker prior to the leave in order to offer support, keep communicating during the period of the leave, and by the perception the supervisor develops as to the expectations of the worker himself/herself about the return to work ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.. Lemieux et al. ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303. add that open dialogue provides an excellent opportunity for the supervisor to explain all the changes that took place in the organization, discuss the work agenda, and provide training for an easier adjustment of the worker to the changes that occurred in the organization. According to Cowls & Galloway ²⁸28. Cowls J, Galloway E. Understanding how traumatic re-enactment impacts the workplace: assisting clients’ successful return to work. Work 2009; 33: 401-11., when the supervisor undergoes an return to work program that advises dialogue and partnership, willingness is elicited to plan the return and carry out the recommended adjustments.

On the other hand, the negative perspective of the supervisor about the employee who is returning is expressed in two ways. The first is the prejudice they have about how the personality of the employee with mental disorders who is returning operates, and that includes inferiority complex, low self-esteem, and elusive, dependent personality ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,2323. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.^,2929. Vries G, Hees HL, Koeter MWJ, Lagerveld SE, Schene AH. Perceived impeding factors for return-to-work after long-term sickness absence due to major depressive disorder: a concept mapping approach. PLoS One 2014; 9:1-10.. The second relates to being wary about the competence of the employee, either by feeling the employee is personally weak and unable to manage the work without relapses, and by not sensing a strong will of the worker about return to work ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,2727. Hees HL, Nieuwenhuijsen K, Koeter MWJ, Bültmann U, Schene AH. Towards a new definition of return-to-work outcomes in common mental disorders from a multi-stakeholder perspective. PLoS One 2012; 7:1-7.^,3030. Caveen M, Dewa C, Goering P. The influence of organizational factors on return-to-work outcomes. Can J Community Ment Health 2006; 25:121-42.. The result of all of that leads to skepticism as to the diagnosis of mental disorders ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52.^,2323. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303., to the prejudice of considering the worker weak, incompetent, and untrustworthy, and disbelief in the possibility of a successful return to work process ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,2121. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6..

Lemieux et al. ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303. suggest there should be more openness and sharing of information among health practitioners, human resources officials, and the supervisors, in order to minimize the influence of early perceptions about the return to work. Furthermore, the authors recommend training the supervisor to lead the return to work process, not only because of the adjustments, but also because of the other factors that interfere with the return to work.

4) The synergistic or antagonic role of management levels

Some authors address the work of management in receiving and reinserting the employee who return to work as an institutional policy. The management-level representatives may play an important role, by sending memos to all employees making them aware of the organization’s commitment to the return to work ³⁰30. Caveen M, Dewa C, Goering P. The influence of organizational factors on return-to-work outcomes. Can J Community Ment Health 2006; 25:121-42.. Despite the clear political nature, this type of engagement is often considered as purely administrative, and related to the adjustment aspects only ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,3030. Caveen M, Dewa C, Goering P. The influence of organizational factors on return-to-work outcomes. Can J Community Ment Health 2006; 25:121-42.^,3131. Muijzer A, Brouwer S, Geertzen JH, Groothoff JW. Exploring factors relevant in the assessment of the return-to-work process of employees on long-term sickness absence due to a depressive disorder: a focus group study. BMC Public Health 2012; 12:103.. Yet, this can serve as an important tool to empower the discourse of the professionals in charge of leading the return to work process in the organization when they have to negotiate with return to work process-resistant employees and managers ³⁰30. Caveen M, Dewa C, Goering P. The influence of organizational factors on return-to-work outcomes. Can J Community Ment Health 2006; 25:121-42.. However, Caveen et al. ³⁰30. Caveen M, Dewa C, Goering P. The influence of organizational factors on return-to-work outcomes. Can J Community Ment Health 2006; 25:121-42. warn that collective communications may be understood as a tool of coercion imposed by management levels, and that may hamper the return to work process.

For Corbière et al. ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47., engagement should go further, with the management holding meetings with the returning worker and other stakeholders to design, negotiate and develop a return to work plan. Lemieux et al. ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303. agree with this statement, and call this way of operation a “concrete action”, through which, despite different values and expectations, the stakeholders negotiate common plans. A possible direct impact of this type of action by the management is minimizing performance demands and concerns of coworkers and supervisors towards the returning worker ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.. This type of action, even if seen with favorable light by the employees, is not well received or used by employers ²⁵25. Pittam G, Boyce M, Secker J, Lockett H, Samele C. Employment advice in primary care: a realistic evaluation. Health Soc Care Community 2010; 18:598-606.. Of note is that the studies analyzed do not clearly establish why the management does not adopt these as valid procedures that can support a successful return to work.

The management may play a negative role when, in their return to work process-related actions, they do not include elements such as warm welcome and understanding ¹⁸18. Holmgren K, Dahlin Ivanoff S. Women on sickness absence: views of possibilities and obstacles for returning to work. A focus group study. Disabil Rehabil 2004; 26:213-22.^,2525. Pittam G, Boyce M, Secker J, Lockett H, Samele C. Employment advice in primary care: a realistic evaluation. Health Soc Care Community 2010; 18:598-606.^,3030. Caveen M, Dewa C, Goering P. The influence of organizational factors on return-to-work outcomes. Can J Community Ment Health 2006; 25:121-42., when their actions are permeated by prejudice and labeling of the worker who was on sick leave due to mental disorders ¹⁸18. Holmgren K, Dahlin Ivanoff S. Women on sickness absence: views of possibilities and obstacles for returning to work. A focus group study. Disabil Rehabil 2004; 26:213-22.^,2020. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,2121. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6., when there is spurious questioning about the authenticity of the disease and integrity of the worker, generating an atmosphere of distrust ¹³13. Noordik E, Nieuwenhuijsen K, Varekamp I, van der Klink JJ, van Dijk FJ. Exploring the return-to-work process for workers partially returned to work and partially on long-term sick leave due to common mental disorders: a qualitative study. Disabil Rehabil 2011; 33:1625-35.^,2424. Saint-Arnaud L, Saint-Jean M, Damasse J. Towards an enhanced understanding of factors involved in the return-to-work process of employees absent due to mental health problems. Can J Commun Ment Health 2006; 25:303-15.^,3030. Caveen M, Dewa C, Goering P. The influence of organizational factors on return-to-work outcomes. Can J Community Ment Health 2006; 25:121-42., when the management uses mechanisms, in particular the engagement of insurance companies, to force the early return of the worker, by sending frequent letters and making phone calls, by asking them to present the company medical reports more often, and finally when they abusively dispute the sick-leave period recommended by the physicians who provide care for the sick worker ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.^,2424. Saint-Arnaud L, Saint-Jean M, Damasse J. Towards an enhanced understanding of factors involved in the return-to-work process of employees absent due to mental health problems. Can J Commun Ment Health 2006; 25:303-15.. These aspects may lead the worker to lose faith in the management, bringing animosity and resentment into the return to work process ²⁴24. Saint-Arnaud L, Saint-Jean M, Damasse J. Towards an enhanced understanding of factors involved in the return-to-work process of employees absent due to mental health problems. Can J Commun Ment Health 2006; 25:303-15., in addition to a feeling of helplessness and neglect ²¹21. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6., elements that may hamper the return to work.

According to Pittam et al. ²⁵25. Pittam G, Boyce M, Secker J, Lockett H, Samele C. Employment advice in primary care: a realistic evaluation. Health Soc Care Community 2010; 18:598-606., some important measures may be adopted to minimize barriers that might come from the management. First of all, to promote direct communication processes between the worker on sick leave and the management, to minimize the above mentioned barriers. Secondly, to have external stakeholders who can mediate the dialogue between worker and employer, and ensure that the process is as fair as possible.

5) The support of health professionals goes beyond the workplace

Health professionals typically provide people on sick leave an important support for the medical stabilization of their symptoms, in the hope of decreasing the chances of relapse ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.^,2828. Cowls J, Galloway E. Understanding how traumatic re-enactment impacts the workplace: assisting clients’ successful return to work. Work 2009; 33: 401-11.. Also of note is the role of these practitioners in having the worker more aware of his/her problems, and the hardships they face at the workplace, thus their need to have a suitable amount of time to solve their problems before return to work ¹³13. Noordik E, Nieuwenhuijsen K, Varekamp I, van der Klink JJ, van Dijk FJ. Exploring the return-to-work process for workers partially returned to work and partially on long-term sick leave due to common mental disorders: a qualitative study. Disabil Rehabil 2011; 33:1625-35.^,2020. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,2323. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.^,2828. Cowls J, Galloway E. Understanding how traumatic re-enactment impacts the workplace: assisting clients’ successful return to work. Work 2009; 33: 401-11.. To that end, they use cognitive approaches based on coping strategies, such as having a conflict-avoidance behavior, establishing limits that are suitable to the condition, and, finally, the training of skills and competences that may be applied in the workplace, such as, for instance, the ability to ask for help ¹³13. Noordik E, Nieuwenhuijsen K, Varekamp I, van der Klink JJ, van Dijk FJ. Exploring the return-to-work process for workers partially returned to work and partially on long-term sick leave due to common mental disorders: a qualitative study. Disabil Rehabil 2011; 33:1625-35.^,2828. Cowls J, Galloway E. Understanding how traumatic re-enactment impacts the workplace: assisting clients’ successful return to work. Work 2009; 33: 401-11..

It should also be highlighted that the support of the health practitioner goes beyond the scope of the work environment, as it also takes into account stressor elements present in the family life of the worker ²²22. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52., includes dealing with insurance companies and social welfare agencies ²¹21. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6.^,2222. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on self-directing mainstream return to work following acute mental illness: reflections on partnerships. Work 2012; 43:43-52., helps the worker to look into themselves, to expand their self-understanding and the personal issues that permeate their relationships, including the ability to set proper limits at work and in their personal lives ¹⁹19. Nielsen MBD, Rugulies R, Hjortkjaer C, Bültmann U, Christensen U. Healing a vulnerable self: exploring return to work for women with mental health problems. Qual Health Res 2013; 23:302-12.^,2121. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence as an interactive process: gendered experiences of young, highly educated women with mental health problems. Patient Educ Couns 2008; 73:300-6.^,2828. Cowls J, Galloway E. Understanding how traumatic re-enactment impacts the workplace: assisting clients’ successful return to work. Work 2009; 33: 401-11. and, finally, they support the development of a healthy and balanced lifestyle ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.^,2828. Cowls J, Galloway E. Understanding how traumatic re-enactment impacts the workplace: assisting clients’ successful return to work. Work 2009; 33: 401-11.. All these elements are present in the comprehensiveness of the return to work process, and strengthen the responsibility of health practitioners and their bond with the worker who is return to work. These set of factors may favor the continuity of the return to work process.

6) The role of the mediator in the return to work

The “mediator” acts as an intermediary among the agents engaged in the return to work process, as he/she has an influential position in the workplace. The mediator is considered case manager, return to work coordinator, job advisor, but they can also be union representatives and members of workers protection and support organizations ¹³13. Noordik E, Nieuwenhuijsen K, Varekamp I, van der Klink JJ, van Dijk FJ. Exploring the return-to-work process for workers partially returned to work and partially on long-term sick leave due to common mental disorders: a qualitative study. Disabil Rehabil 2011; 33:1625-35.^,2020. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47.^,2323. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.^,2525. Pittam G, Boyce M, Secker J, Lockett H, Samele C. Employment advice in primary care: a realistic evaluation. Health Soc Care Community 2010; 18:598-606..

Corbière et al. ²⁰20. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Sauvé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil 2015; 25:335-47. see the mediator as an important stakeholder to follow up the worker in their contact with health practitioners, providing the practitioners information about the workplace. Lemieux et al. ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303. have a similar perspective, and consider the mediator a type of mentor, someone who is connected to the worker and provides external support. They mention that frequently support cannot be provided by other members of the work team, due to lack of impartiality or the difficulty for the health practitioner to go to the workplace. Noordik et al. ¹³13. Noordik E, Nieuwenhuijsen K, Varekamp I, van der Klink JJ, van Dijk FJ. Exploring the return-to-work process for workers partially returned to work and partially on long-term sick leave due to common mental disorders: a qualitative study. Disabil Rehabil 2011; 33:1625-35. see the mediator as a coordinator of the different actions and support provided for the returning worker.

Pittam et al. ²⁵25. Pittam G, Boyce M, Secker J, Lockett H, Samele C. Employment advice in primary care: a realistic evaluation. Health Soc Care Community 2010; 18:598-606. suggest that the role of mediator requires elements such as ability to listen, impartiality, individualized approach, empowering, encouragement and guidance. The mediator supports the worker in the development of strategies to increase self-confidence, highlighting his/her strengths and skills, thus allowing the worker to review and reinforce his/her beliefs on his/her labor capability ¹³13. Noordik E, Nieuwenhuijsen K, Varekamp I, van der Klink JJ, van Dijk FJ. Exploring the return-to-work process for workers partially returned to work and partially on long-term sick leave due to common mental disorders: a qualitative study. Disabil Rehabil 2011; 33:1625-35.^,2525. Pittam G, Boyce M, Secker J, Lockett H, Samele C. Employment advice in primary care: a realistic evaluation. Health Soc Care Community 2010; 18:598-606.. The mediator can also support the worker in having better communication when negotiating with the employer about working arrangements and other related processes; in addition, they can help the worker to identify the source of problems, so that suitable measures to address these issues can be taken; finally, they should work with the worker for the latter to look beyond their current career perspectives, and identify other skills and abilities ²⁵25. Pittam G, Boyce M, Secker J, Lockett H, Samele C. Employment advice in primary care: a realistic evaluation. Health Soc Care Community 2010; 18:598-606.^,3232. Oostrom SH, Anema JR, Terluin B, Venema A, Vet HCW, Mechelen W. Development of a workplace intervention for sick-listed employees with stress-related mental disorders: intervention mapping as a useful tool. BMC Health Serv Res 2007; 7:1-13..

Notwithstanding the importance of the role of the mediator, some difficulties are pointed out: (i) it is typically not within the scope of the mediator to negotiate working conditions; (ii) to be impartial is complex, and depends on the dynamics regarding the position of the mediator with the organization and the worker; and (iii) the individualization of the approach, despite being useful for each particular case, may blur collective problems for which broader negotiations are needed, to include all workers in the same conditions or at the same risks. Yet, Oostrom et al. ³²32. Oostrom SH, Anema JR, Terluin B, Venema A, Vet HCW, Mechelen W. Development of a workplace intervention for sick-listed employees with stress-related mental disorders: intervention mapping as a useful tool. BMC Health Serv Res 2007; 7:1-13. advocate the need for agents to mediate relations during the return to work.

The authors suggest that these individuals should incorporate values that make the return to work less bureaucratic and hierarchic, that the mediation is not a new power order that acts in the return to work, and that the mediator does not replace the important worker-empowering processes for them to negotiate their own needs. Their role, whenever necessary, is to develop and organize a cross-sectional communications plan to dialectically articulate the stakeholders’ perspectives about the return to work ²³23. Lemieux P, Durand M-J, Hong QN. Supervisors’ perception of the factors influencing the return to work of workers with common mental disorders. J Occup Rehabil 2011; 21:293-303.^,3030. Caveen M, Dewa C, Goering P. The influence of organizational factors on return-to-work outcomes. Can J Community Ment Health 2006; 25:121-42..

Discussion

Based on the previously mentioned second-order concepts, in the constructs on psychosocial rehabilitation, and in some theoretical foundations of phenomenology and sociology ³³33. Hirdes A, Kantorski LP. Reabilitação psicossocial: objetivos, princípios e valores. Rev Enferm UERJ 2004; 12:217-21.^,3434. Schutz A. A linha de base fenomenológica. In: Wagner HTR, organizador. Sobre fenomenologia e relações sociais. Petrópolis: Editora Vozes; 2012. p. 65-83.^,3535. Cohn G, organizador. Max Weber. 2a Ed. São Paulo: Editora Ática; 1982. it was possible to consolidate the reviewed literature into two syntheses. The first relates to the return to work performance ethos, the second shows return to work as a catalyst of new lifestyles.

The ethos of performance in the return to work

The analyzed studies show that performance expectations are central for the stakeholders’ relationship in the return to work setting, and may evidence the way social constructs acting on work performance have a broader framework in which return to work should be conceived.

In this review, we adopted the notion of meaningful experience proposed by Schutz ³⁴34. Schutz A. A linha de base fenomenológica. In: Wagner HTR, organizador. Sobre fenomenologia e relações sociais. Petrópolis: Editora Vozes; 2012. p. 65-83., defined as the one which, from an act of reflection, is apprehended, distinguished, highlighted and differentiated from others. This means, an experience that, upon reflection, is made subject of attention as being completed, over, already experienced; it is in the past, but contains present experiences and anticipates future ones. The meaningful experience allows us to understand the expectations of work performance, as it reflects the interactions between the worker’s performance perception in the present time mediated by the perception of performance in the past and by the anticipation of the worker about his/her future performance, without minimizing the influence that relational and contextual aspects have on these perceptions.

Moreover, the “lifeworld” concept seems useful to clarify the place that this expectation has in the return to work setting, since the “lifeworld” is not conceived as a world of natural attitude – a world that has already been interpreted by others. On the contrary, it is an inter-subjective world, object of our actions and interactions, a world that must be dominated, transformed in such a way that is it possible to accomplish what one wants to, in it, among our fellow men ³⁴34. Schutz A. A linha de base fenomenológica. In: Wagner HTR, organizador. Sobre fenomenologia e relações sociais. Petrópolis: Editora Vozes; 2012. p. 65-83..

Therefore, performance expectations are not a passive element of the return to work process. On the contrary, expectations act on the return to work, affecting it, modifying it, and also creating resistances that may lead to new attitudes ³⁴34. Schutz A. A linha de base fenomenológica. In: Wagner HTR, organizador. Sobre fenomenologia e relações sociais. Petrópolis: Editora Vozes; 2012. p. 65-83..

On the other hand, expectations about performance are more than an inter-subjects game of relationships; in fact they reflect the construct of an ideal type of worker who, without considering material and immaterial work conditions and its capability of causing or not disorders, needs to keep faith in some beliefs, such as productivity, competence, acknowledgement of being an efficient worker according to the current modes of production ³⁵35. Cohn G, organizador. Max Weber. 2a Ed. São Paulo: Editora Ática; 1982.^,3636. Franco T, Druck G, Seligmann-Silva E. As novas relações de trabalho, o desgaste mental do trabalhador e os transtornos mentais no trabalho precarizado. Rev Bras Saúde Ocup 2010; 35:229-48..

However, working expectations seem to reflect the inability of the productive system to tend to those who perform differently. It seems easier to reinforce the disciplinary procedures of a “productive worker”, the worker who assimilates and responds to the challenges imposed by production ³⁵35. Cohn G, organizador. Max Weber. 2a Ed. São Paulo: Editora Ática; 1982., rather than accepting the condition of the worker who became ill, reinforcing his/her identity as worker, and making changes in the productive processes so that he/she can properly perform his/her job at work.

Finally, despite the importance of the coping strategies presented in this synthesis, often they seem to reinforce the belief that the problem is of the individual, not considering the social relations of production in the development of performance expectations.

The return to work as catalyst of new ways of life

The phenomenological formulation of “being-in-the-world” ³⁷37. Heidegger M. Prolegómenos para una história del concepto de tiempo. Madrid: Alianza Editorial; 2007. applied to the interaction among the stakeholders involved in the return to work helps us examine these interactions not as a mere return to work-setting component, but as elements that build this setting, and therefore can reveal what the return to work actually is. Based on that, in the contents of the second-order interpretation, and on the theoretical grounds provided by psychosocial rehabilitation, we argue that the return to work may serve as a catalyst to new ways of life.

The findings show that interactions among the stakeholders involved in the return to work include, among others, support, stigma, identity, empowering, and legitimacy of the mental disorders at the work place. Under the phenomenological perspective, these issues may be understood as the return to work senses of self ³⁷37. Heidegger M. Prolegómenos para una história del concepto de tiempo. Madrid: Alianza Editorial; 2007.. However, one should stress that these senses call for other return to work management forms that are not fully included in the current return to work models.

The issues mentioned above reinforce the complexity of the return to work process, which should not be faced only as a technical, individual, bureaucratic process aimed at getting back something that was lost and should be recovered, meaning the return to normalcy after a bout of psychic suffering ³⁸38. Pinto A, Ferreira A. Problematizando a reforma psiquiátrica brasileira: a genealogia da reabilitação psicossocial. Psicol Estud 2010; 15:27-34.. The return to work should be understood under a perspective of rehabilitation, that takes into account the advances of biomedical and ecologic approaches, but further includes new ways of living and working, and that also incorporates a critical perspective.

We propose, therefore, the expansion of the worker’s autonomy, centered in their ability to elaborate projects, i.e., actions that change their actual life conditions, including work. This applies to the management of the environment, the enhancement of work and daily-living capabilities, and the improvement of the quality of life, so that the worker enriches his/her subjective self. These are also the basis of psychosocial rehabilitation, which adds to the discussion about return to work the use of management strategies towards work and the daily life within micro-settings, such as family and community ³³33. Hirdes A, Kantorski LP. Reabilitação psicossocial: objetivos, princípios e valores. Rev Enferm UERJ 2004; 12:217-21..

Moreover, the study also reveals that relational aspects, such as respect, interpersonal relationship, the validation of the worker’s identity and experience, the warm welcome, listening to the other, and sharing daily-life experiences make the return to work process easier, and allow one to infer the appropriateness of the concept of recovery in the development of new return to work-process intervention models related to mental disorders ³⁹39. Duarte T. Recovery da doença mental: uma visão para os sistemas e serviços de saúde mental. Anál Psicol 2007; 1:127-33..

In the literature, there are at least two different ways to understand the process of recovery. One is centered in the remission of symptoms and the reestablishment of the functional status that existed prior to the onset of the disorder ³⁹39. Duarte T. Recovery da doença mental: uma visão para os sistemas e serviços de saúde mental. Anál Psicol 2007; 1:127-33.. The other is related to the psychosocial model, and seems to be more suitable to articulate return to work actions, as it is considered a complex, dynamic process that includes individual components, but it is also influenced by the quality of the relationship and interactions among the individual peers, and settings ³⁹39. Duarte T. Recovery da doença mental: uma visão para os sistemas e serviços de saúde mental. Anál Psicol 2007; 1:127-33.^,4040. Lopes TS, Dahl CM, Serpa Jr. OD, Leal EM, Campos RTO, Diaz AG. O processo de restabelecimento na perspectiva de pessoas com diagnóstico de transtornos do espectro esquizofrênico e de psiquiatras na rede pública. Saúde Soc 2012; 21:558-71.. In the latter approach, one also observes particular emphasis in the role and empowerment of the subject that experience psychic suffering, which disciplines the way they interfere, individually and collectively, in their quest for inclusion in society, in general, and particularly in the work environment.

Study strengths, challenges and limitations

The meta-ethnographic method was used for the investigation of our research questions, and allowed the identification of six second-order concepts that provided an important starting point for the understanding of the multiple factors that impact the interactions among the stakeholders, in the return to work of people with mental disorders, as discussed in the literature. It was, thus, possible to identify coping strategies for some of the problems found in the interactions among stakeholders of the return to work process. This gives this investigation a more pragmatic slant, making it closer to stakeholders who wish to reflect more theoretically about the subject, and stakeholders who reflect upon the care and rehabilitation of workers with mental disorders.

We believe that some procedures we followed, such as having a librarian as a consultant for the selection of databases and article search, and the treatment of the data with the use of the NVivo 10 software have enhanced our processes to validate the collected information, as such procedures have ensured auditing the control on these processes ⁴¹41. Classen S, Winter S, Lopez E. Meta-synthesis of qualitative studies on older driver safety and mobility. OTJR (Thorofare N J) 2009; 29:1-8..

We agree with Andersen et al. ⁴4. Andersen MF, Nielsen KM, Brinkmann S. Meta-synthesis of qualitative research on return to work among employees with common mental disorders. Scand J Work Environ Health 2012; 38:93-104. when they mention that the insufficient description of the settings in qualitative investigations is an important challenge for the carrying out of meta-ethnography analyses. They argue that socio-cultural and law-making rules, socio-economic and political conflicts, and relationships involving interests and power within the working environment may affect the experience of people with mental disorders when they return to work, and should be properly considered. Then we will be able to better understand the different aspect involving the return to work of people with mental disorders.

Among the limitations of this study, two aspects stand out: first, the diversity of diagnoses included, which might have caused some bias in the selection of articles. Secondly, the length of time the worker was in sick leave, which, even though is an important return to work predictive factor ¹1. Blank L, Peters J, Pickvance S, Wilford J, Macdonald E. A systematic review of the factors which predict return to work for people suffering episodes of poor mental health. J Occup Rehabil 2008; 18: 27-34., was significantly different in the studies that were included and, in some cases, was omitted.

Only one Brazilian study complied with the inclusion criteria. Therefore, inferences from the results found for the Brazilian reality, or even among countries of the Northern hemisphere should be made with caution.

Implications for future studies

This review has adopted the return to work stages laid out by Young et al. ⁸8. Young AE, Roessler RT, Wasiak R, McPherson KM, van Poppel MNM, Anema JR. A developmental conceptualization of return to work. J Occup Rehabil 2005; 15:557-68., allowing us to check that only few studies addressed the stages of Maintenance and Advancement, suggesting these should be further detailed in future investigations.

Other aspects seem also to be pressing: the studies show that management levels are not willing to develop and discuss the return to work plan with workers. The same goes for the role of the family in the return to work process of workers with mental disorders, which has not been properly investigated, despite its reiterated importance in some studies. Both aspects should be further examined.

We also consider it may be promising to combine the biomedical and ecological advances to the psychosocial rehabilitation-related practices. Therefore, we encourage the development of future investigations that use the psychosocial rehabilitation concept to expand the understanding about eventual obstacles or enablers of the return to work process.

Acknowledgments

Prodoctoral/UFPB for the scholarship, and Capes for funding an interuniversity exchange doctoral program (process n. 99999,002786/2014-01) for the first author. The School of Occupational Therapy, University of Western Ontario, for the structure and hospitality during the interuniversity exchange doctoral program. Natalia Yanaina Rivas Quarneti, University of Coruña, for the discussions that made this article richer. Sara Chaves da Silva Neves, for reading and commenting on the manuscript, and the personal support for the successful outcome of this investigation.

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