Health Care Analysis

, Volume 20, Issue 3, pp 213–230 | Cite as

The ‘Empowered Client’ in Vocational Rehabilitation: The Excluding Impact of Inclusive Strategies

  • Lineke B. E. van Hal
  • Agnes Meershoek
  • Frans Nijhuis
  • Klasien Horstman
Open Access
Original Article

Abstract

In vocational rehabilitation, empowerment is understood as the notion that people should make an active, autonomous choice to find their way back to the labour process. Following this line of reasoning, the concept of empowerment implicitly points to a specific kind of activation strategy, namely labour participation. This activation approach has received criticism for being paternalistic, disciplining and having a one-sided orientation on labour participation. Although we share this theoretical criticism, we want to go beyond it by paying attention to the practical consequences of understanding empowerment as an activation strategy. Inspired by the field of Science and Technology Studies, we will explore the meaning of empowerment and activation in concrete practices of vocational rehabilitation in the Netherlands. Our analysis is based on the narratives of people with a work disability about their lives and the vocational rehabilitation programmes they participated in. We present five illustrative cases that how empowerment is ‘done’ in the practice of vocational rehabilitation and its unintended effects. Our analysis demonstrates that activation strategies seem to be caught in a paradox: instead of including people in society, they have excluding consequences. Vocational rehabilitation professionals can go beyond this paradox by learning from the ways in which empowerment is ‘done’ by clients in vocational rehabilitation programmes.

Keywords

Activation Empowerment Narrative analysis Health care practices Vocational rehabilitation 

Introduction

In ‘modern Western societies’, people are increasingly expected to shape their lives by making individual choices [10]. The dominant notion of citizenship—i.e. belonging to society—has become associated with the ideal of a reflective [10], independent and productive [26] citizen. Although many are attracted to this ideal of empowerment, little is known about how the discourse of empowerment relates to every-day-practice, whether it delivers its promises and which unintended effects it might stimulate.1 Moreover, the meaning of the concept is often unclear [22]. To define the concept of empowerment, Tengland [22] performed a conceptual analysis, leading to the conclusion that there are two plausible complementary uses: (1) empowerment as a goal (i.e. to have control over the determinants of one’s quality of life) and (2) empowerment as a process or approach (i.e. to create a professional relation where the client takes control over the change process, determining both the goals of this process and the means to use). The last use is the most radical one and since it includes the client-professional relationship, it is a fruitful starting point for exploring how discourses of empowerment affect professional practice. In this paper we will explore the way ‘empowerment’ is used in practices of vocational rehabilitation.

In vocational rehabilitation, empowerment is understood as the notion that people should make an active, autonomous choice to find their way back to the labour process. The ‘Handbook for Empowering Strategies in Social Services and Vocational Rehabilitation’ puts it as follows:

when people possess a certain inner leadership, they are capable of self-reflection and have the capacity to makean informed, independent decision. With this increased autonomy, they are able to make their own choices, and these might lead to better prospects for the rehabilitation process [6, p. 12] [italics added].

The discourse of empowerment in the field of vocational rehabilitation is explicitly connected to expectations and goals. The pursuit of empowerment in vocational rehabilitation programmes expects clients to take part in the programme autonomously, to be actively engaged within vocational rehabilitation, to be reflective on their vocational rehabilitation process and to achieve a goal that combines labour participation with personal wellbeing. This process presumes linearity: a certain chronological order in which the vocational rehabilitation should develop. Following this line of reasoning, within vocational rehabilitation, empowerment becomes a specific activation strategy.

While empowerment is a frequently used ‘activation strategy’ in vocational rehabilitation, the basic principles of this activation approach have received criticism. Departing from the field of disability studies, Oliver [16] for instance criticises the assumption in recent social policy developments that professionals can empower their clients “through the development of appropriate practices” (p. 147). He argues that “the process of empowerment somehow becomes objectified as a thing; what’s more a thing that can be delivered by those who have it to those who don’t” (p. 147). Instead, he defines empowerment as “a collective process on which the powerless embark as part of the struggle to resist the oppression of others, as part of their demands to be included, and/or to articulate their own views of the world” (p. 147). Although we share this theoretical criticism on the devaluation of ‘empowerment’ as an activation strategy, we want to go beyond theoretical criticism by paying attention to the practical consequences of understanding empowerment as an activation strategy. To that purpose this paper explores the practical meaning of activation strategies in vocational rehabilitation and if and how empowerment is done in practice. By putting the stories of clients with a work disability central, we want to bring concrete, practical experiences back in the discussion on empowerment. Moreover, the focus on concrete experiences enables to explore alternative ways of approaching empowerment in the practice of vocational rehabilitation (and other health care practices). In order to explore the practical consequences of understanding empowerment as an activation strategy, we investigate client perspectives on and professional roles in empowerment and activation in the practice of vocational rehabilitation. Therefore we look at different definitions of and perspectives on empowerment. Our conceptual starting point is the broad theoretical notion of empowerment as defined by Tengland [22]. We use this definition to criticise the narrow theoretical notion of ‘empowerment as an activation strategy’ as found in the rhetoric of vocational rehabilitation (e.g. [6]).

We continue this paper by presenting an overview of different perspectives on the policy of activation in general and then we specifically focus on activation strategies. Subsequently, we explain our theoretical framework. In the method section we introduce the narrative approach used in this study and describe the way we analysed the life stories of people involved in a vocational rehabilitation process in the Netherlands. The result section will show the practical and unintended effects of empowerment as an activation strategy by presenting an analysis of how empowerment is ‘done’ in the practice of vocational rehabilitation and how empowerment as an activation strategy paradoxically results in excluding clients from participation. Paradoxically, because in vocational rehabilitation ‘empowerment as an approach’ is intended to include people in society in general and in labour participation in particular. We conclude by suggesting that a more interactive way of clients in vocational rehabilitation may be more inclusive and therefore more empowering than current activation strategies in vocational rehabilitation.

Criticism on Activation Strategies

In vocational rehabilitation practices, empowerment is often considered an activation strategy. ‘Activation’ is regarded a key concept in the current transformation of many welfare states and activation can be understood as “social policies and programmes aimed at promoting the (more or less obligatory) participation of people dependent on unemployment benefits or social assistance in work” [23, p. 332]. According to Van Berkel and Borghi, debates on activation and the provision of activation services take place on the interface of two, conflicting, discourses: (1) the discourse of new governance that aims at involving citizens, their capacity as users of social services, in processes of emancipation and empowerment in their positions vis-à-vis bureaucracies and vis-à-vis professionals; (2) the discourse on “the activation of ‘traditional’, protection oriented welfare states, in which citizens are increasingly considered to be responsible for their own lives, are expected to invest in their employability, and, when dependent on the welfare state, are granted rights and entitlements only on the condition that they fulfil the obligations society imposes on them” [4, pp. 413–414]. They regard the second approach of “the citizen in the context of active welfare state reforms, as far more enforcing and paternalist than [they] generally find in new governance debates” (p. 414). Discussing the individualisation trend in both discourses, they tentatively conclude that more attention should be paid to the diversity of forms of individualisation and user participation in practice. Moreover, they state that in the context of activation, “the dominant social policy discourse on responsibilities and obligations of the unemployed often seems to overrule the governance reform discourse of [empowering and emancipating citizens]” (idem, p. 422).

The distribution of responsibility is a vital aspect of activation policies. As Bonvin [3, p. 367] observed: “most activation policies are based on a simplistic conception of responsibility: behaving responsibly coincides with quickly reintegrating the labour market”. In his analysis, Bonvin problematises the focus on a quick reintegration into the labour market and concludes that the issue of responsibility is far more complex. Also Peck and Theodore [17] present a critique of the ‘employability-based’ approaches to supply-side intervention in the labour market in the UK. They state that in those approaches “the causes of unemployment are conceived in individualistic and behavioural terms: the old problems of demand deficiency and job shortage have been dismissed; policies must now focus on the motivations and expectations of […] the ‘workless class’” (p. 729). As an alternative they suggest a reformed approach to welfare-to-work policy—based on a client-centred and developmental ethos, an enlarged concept of ‘employment’ (embracing the social economy) and active social redistribution.

By critisising activation strategies, the aforementioned scholars describe the eventually paternalistic and disciplining consequences of implementing a one-sided and ‘traditional’ notion of activation. They express the concern that activation support will be too much focused on behavioural changes, aiming at ‘forcing’ the client to return to work. Social and structural issues may get overlooked and support may turn into ‘blaming the victim’.

It is empirically found that in health care practices empowerment is more often defined according to some of its anticipated outcomes rather than with reference to its very nature [1]. Aujoulat et al. [1, p. 13] argue that “the goals and outcomes of empowerment should not be predefined, but discussed and negotiated with every patient or client according to his or her own particular situation and life priorities”. In other words, the perspective of the client should be included in the interpretation of empowerment. In line with this notion, Van Houten and Jacobs [26] argued for a bottom-up approach to empowerment strategies. They state that top-down strategies that are disconnected form social practices—i.e. connections between people—have disempowering consequences. As an alternative, they propose the idea of a ‘varied society’ based on the notions of diverse and ‘careful citizenship’. They argue that

citizenship has been shaped according to a masculine, white and western view of human beings as being autonomous and self-reliant. […] Its language of activity, productivity and capacity does not leave much room for bodies that require care, for needs and vulnerability or rather for differences between people in their abilities, activities and needs [26, pp. 644–645].

The concerns of Van Houten and Jacobs [26] confirm the observation of Aujoulat et al. [2] that studies on patient empowerment tend to overlook aspects of illness experience (such as coming to terms with disrupted identities). They consider patient empowerment as a personal transformation in which the process of relinquishing control is as central as the process of gaining control. Their analysis shows that empowerment is a complex process, that cannot be caught in linear models.

The reflective way in which clients are expected to participate in vocational rehabilitation resembles the process of proto-professionalisation as described by De Swaan [8]. He describes proto-professionalisation as a process in which laypersons learn to become experts in “re-defining everyday troubles as problems amendable to treatment by this or that profession” [8, p. 14]. Subsequently, the people who are able to re-frame their situation to the appropriate professional vocabulary have better access to care, are more likely to be found ‘suitable for treatment’ and thus profit most of health care. In other words, in order to be considered suitable for treatment, individuals have to present their problems and to demonstrate a kind of learning process that is recognisable for professionals. Clients should be able to distance themselves from and reflect on their situation and to be able to demonstrate a specific kind of rational decision-making. This implies that individuals who do not fulfil the professional norms may be excluded from support. Clients who have problems finding their way in society or who are overwhelmed by their life circumstances—i.e. individuals who need the most support—often do not receive the support they need in order to participate in society [25].

The aforementioned critics share the idea that contemporary norms of autonomous, goal-achieving, active and reflective citizens should be revisited in order to reach empowerment that is connected to the person at stake. Taking those critics seriously, in the next parts of this paper we explore how empowerment is ‘done’ in the practice of vocational rehabilitation.

Studying Empowerment as Practice

With this study we join the abovementioned theoretical criticism on activation strategies, but we also aim to go beyond these criticisms by studying the practical effects of understanding ‘empowerment’ as an activation strategy. To this purpose we focus on the case of vocational rehabilitation of people with a work disability in the Netherlands. Our focus on empowerment as a practice is inspired by scholars of Science and Technology Studies (STS).2 In the field of STS it has been demonstrated that it is fruitful to study scientific and professional work by focusing not on concepts and ideals, but on the capricious practices in which those concepts are applied and made tangible. The rationale for this is that concrete practices have their own dynamics and logics and are not a mere reflection or application of theories [5, 14]. Researchers in STS for instance do not study specific scientific ideals like truth and validity as concepts, but perform ethnographic studies in laboratories and professional practices to provide insight in how these ideals are ‘done’ in every day work [5, 13, 14]. Following this, we will not primarily go into the question whether empowerment is desirable or not, but we will demonstrate how empowerment is ‘done’ in every day practice of vocational rehabilitation. The attention to ‘doing’ is particularly valuable since practices are much more diverse than theories assume and because unintended effects of ideals and norms often only can be identified in practice. An exploration of the various ways in which ‘empowerment is done’ makes explicit how different ways of ‘doing’ embody different norms. It makes normative consequences visible that cannot be identified by theoretical criticism.

Our research is especially inspired by the work of STS scholars in the field of health care practices, such as Mol’s [14] analysis of ‘good care’, Moser’s [15] study on the construction of disability and Struhkamp’s [20] research on the practice of physical rehabilitation. Struhkamp used ethnographic stories to reveal “parts of the richness, complexity and difficulties of the care and treatment of people who try to re-adjust to day-to-day life with a severe physical disability” [20, p. 107]. She focused on the tension between theory and clinical practice, especially with respect to issues like independence, patient autonomy, goal setting and suffering. With her analysis of the concrete practice of physical rehabilitation, she shows that theoretical notions are normatively charged and that the use of these notions in policies, rehabilitation programmes and public debates differ from the concrete practices they speak about. While de Koning [6] stated that goal setting is also a part of the activation strategies within vocational rehabilitation, Struhkamp argued that goal setting “requires active [client] participation and individual control that sometimes appears impossible, unrealistic and undesirable” [21, p. 152]. Setting and achieving certain goals, is thus not as self evident as often assumed. In the case of vocational rehabilitation this means that it should be reconsidered whether it can be expected from clients to purposively aim at the achievement of paid work and whether this goal does not prevent them from participation in an other sense. Within vocational rehabilitation those clients are often set apart as ‘passive’ or ‘unmotivated’ (see also [11]). As Struhkamp shows, those labels are not an adequate interpretation of the actual situation of these clients.

Researching Narratives on Empowerment

To study how activation and empowerment is done in practice we performed a narrative analysis. Narratives do not only give insight in how the narrator experiences life, but also tell a lot about the practice—social, cultural, material, political circumstances—in which the story is made and told. In other words: “society and culture ‘speak themselves’ through an individual’s story” (Riesmann 1993, in [19, p. 18]. A narrative approach enables to focus on the life stories of clients, to relate the return-to-work experiences of people to the context of these life stories, and to do justice to the diversity of clients in vocational rehabilitation trajectories [24, 25]. Riesmann [18, p. 4] states that “narratives […] embody a human subject with agency and voice”. The focus on narratives brings the concrete experiences of people back in the debate about empowerment and activation: it gives room to different perspectives, to emotions, to silences and ‘not-knowing’. In line with Ville and Winance [27], we consider people as actors of their own lives and we concentrate on the experiences and perspectives on returning-to-work of clients who do not seem to fulfil the often implicit norms of these strategies. The analysis presented in this paper focuses around the core values mentioned by the ‘Handbook for Empowering Strategies in Social Services and Vocational Rehabilitation’ De Koning [6], namely autonomy, goal setting, linearity, activity and reflection.

The life story interviews were performed between June 2007 and July 2008 in the Netherlands. Access to respondents was gained through the Dutch Social Insurance Institute (UWV). We purposively selected [28] forty-five respondents. The selected population varied regarding gender, age, residential area, health complaints and work situation. All respondents had been receiving a disability benefit for a continuous period of at least 3 years, had recently undergone disability reassessment and had entered a vocational rehabilitation programme. The respondents were informed by telephone about the reason and design of this study and were asked to collaborate. Written informed consent was acquired.

In order to collect an in-depth narrative, the interviewer (first author) spoke with most respondents two to three times. The interviews took place at respondents’ homes and lasted between 40 min and 2 h with an average of 90 min. The first interview started with an invitation to narrate how the respondent had grown up. During the rest of the interviews the respondents could decide themselves what was important to narrate in relation to their life and their vocational rehabilitation. All interviews were recorded and transcribed verbatim in Dutch. Translated excerpts, edited for readability, are featured in this paper. The analysis started with familiarising ourselves with all narratives and subsequently we analysed the narratives on specific themes.

In this paper we will present an analysis of five narratives that explicitly challenge the expectations of activation strategies within vocational rehabilitation programmes. Besides the diversity that those cases represent regarding gender, age, health situation and social circumstances, the main reason for selecting those cases was the relevant differences they show in relation to theoretical notions on activation and empowerment. Those five narratives serve as illustrative cases that clearly show the limits and unintended effects of understanding ‘empowerment’ as ‘activation’ and provide clues for alternative approaches on autonomy, goal setting, linearity, activity, and reflection. In order to strengthen the illustrative power of the narratives, we made the analytical decision to present each alternative with a separate case.

‘Doing Empowerment’ in Vocational Rehabilitation

The cases presented below, describe how empowerment is done in the practice of vocational rehabilitation and how this process affects the life and opportunities of people in an unexpected way. The first case focuses on the ideal of autonomy, the second on the ideal of goal setting, the third on the ideal of linearity, the fourth on the ideal of activity and the fifth on the ideal of reflection.

Autonomy Versus Interdependency

In the conversations I3 have had with Marco,4 his wife Julia takes part as well. This seems the normal routine in their household, especially since Marco suffers from memory loss and low levels of energy because of Organic Psycho Syndrome (OPS). During the first conversation, Julia gives Marco talking space, but interrupts him when he, in her opinion, forgets to tell important things. According to her, Marco tells mainly about the events that affected him personally (for example the mobbing when he was a child and the death of his mother). Other life events, such as the sale of their house as a result of financial problems and the visits to the food bank are not part of his story. Julia tells me later that these were the kind of things she took care of: “He doesn’t speak about these events, he doesn’t see them as problematic since they are solved by me”. For her, it was “funny” (as she expressed it) to hear how her husband makes a story of his life. Normally they perform a story together, and now it strikes her to hear his story: what he tells, and especially what he does not tell.

Marco does not speak about an autonomous life. His story is an interdependent story about a life that is performed through relations with other people. Especially through the relation with his wife Julia. This interdependency is considered problematic by Marco’s vocational rehabilitation counsellor. When our conversations continue, the stories of Marco and Julia make clear that Julia organises a large part of the administrative activities that are part of the vocational rehabilitation programme and social security system. She accompanies him to conversations of the UWV (Dutch Social Insurance Institute), the rehabilitation agency and so on. She performs a lot of ‘Marco’s’ activities, such as filling in the list of job applications each month. Julia explained to me that Marco’s rehabilitation counsellor told her to stop doing this. Because of the activities Julia takes over, the counsellor thinks it is not clear what Marco’s situation is. He does not have any demonstrable injury, so the counsellor expects that Marco’s work related problems will only become visible if he has a job. The counsellor thinks Marco is registered able to work because his wife is ‘compensating’ his limitations. But to stop ‘compensating’ seems no solution for Julia: “I cannot leave him alone in this. That will ruin our marriage”. Nevertheless, the rehabilitation counsellor stressed that Julia should quit filling in the lists of her husband. Julia reacts on this: “But then we will not get any unemployment benefit, and then we are even in bigger trouble”.

Marco and Julia describe a complex household situation. Marco is on the waiting list for psychological care, since he has difficulties dealing with his aggression. Julia has health problems and difficulties with walking. She uses a wheelchair for the most part of the day. Financially they are on the rocks. Julia is not entitled to benefits. Two of their four children have a hereditary disease and have to visit the hospital frequently. “That all counts”, Julia says. Marco adds: “There is no reference point, like ‘now it is over and we start again’. It just continues and continues”. The family has 24 h of personal assistance a week. “It takes all your privacy away”, Julia says. During our conversation the phone rings. It is the vocational rehabilitation agency. Marco will get a new rehabilitation counsellor and she wants to make an appointment with him as soon as possible. She suggests a date of which Marco already had indicated it was impossible for them to come. Their days are full with Julia’s physical therapy sessions and the hospital visits of their children. It turned out to be difficult to make an appointment with the vocational rehabilitation counsellor. The rehabilitation agency should have monthly contact with Marco, that is why, according to Julia, they are pushing for an appointment. The new counsellor plans a conversation of 30 min. Marco and Julia think this is too short. With their former counsellor they had an intake conversation of 2 h.

The story of Marco and Julia shows the possibilities that interdependency can create: thanks to the support of his wife, Marco is included in the social security system. Because of personal assistance, their household is functioning. Moreover, one morning a week Marco works voluntarily as a handyman in a establishment for handicapped people. He performs all kinds of chores. He can structure his working hours independently and the working environment takes his mental and physical situation into consideration. The voluntary work is organised by the Regional Institute for Mental Welfare (RIAGG). He had to get permission of the UWV to start doing volunteer work. Marco thinks that his work as a volunteer is working against him: “at the moment you show you can do volunteer work, they think you can work as well. If you will be sitting around idly, things will be alright [in the sense that you will easily receive a benefit then]. I do not agree with that”.

Autonomy is not a ‘condition’ for participation. On the contrary, this case clearly demonstrates that interdependency can form a base for participating in society. Vocational rehabilitation in Marco’s case is thus not about ‘individualising’ the client from his environment, but about focusing on how interdependency can be (made) ‘productive’.

The Goal of Labour Participation Versus Living a Good Life

According to the vocational rehabilitation agency, Maria finished her rehabilitation programme successfully. Within a year, she got a contract for 6 months at a large do-it-yourself shop. However, Maria herself questions this ‘success’. Working in this branch did not make her life easier. When I wanted to make an appointment with her for a second interview, she asked me to come during her holidays, since then she feels “less tensed”. During the interview, her 25-year old daughter is also present. Maria tells me that her life turned upside-down since she started working again. She feels tired and nervous and has less money to spend compared to the time she was on disability benefit. She explains it is very difficult for her to be financially dependent on her daughter: “I am the adult here, I should be helping her”. Maria adds that the best thing of working is, that there is less time for worrying.

As discussed in the introduction, vocational rehabilitation programmes do mostly focus on a clear, predefined goal: sustainable employment. Within the programme, this goal setting is considered an important instrument to give direction to the vocational rehabilitation programme and to keep it going. However, as the case of Maria illustrates, the predefined goal of employment may conflict with clients’ particular situation and life priorities.

In her process of returning-to-work Maria does not feel supported by her vocational rehabilitation agency:

I often cannot relax my body, that is always totally tensed. Of course, that has to do with my past. It is not about that. But my life was always like this, always all by myself… I always needed to survive. The disability benefit knows nothing, the unemployment benefit knows nothing, the rehabilitation knows nothing. And I will not tell them, because they wouldn’t hear of it. They do not know how my life looks like: it is just about working.

Maria describes that the focus on achieving paid work bypasses her personal situation. Her primary goal is not employment in itself, but, among others, (financially) taking care of her daughter, living with less worries and feeling relaxed. Putting it differently, Maria aims at living a good life. This notion of living a ‘good life’ is often not articulated in clear goals and may therefore become invisible next to the distinct goal of labour participation. In Maria’s case, this diversity in goal setting makes that she does not feel understood by the agency supporting her in her vocational rehabilitation. This perceived lack of understanding makes that Maria did not call her rehabilitation counsellor for assistance during the official conversation regarding her conditions of employment. This shortage of support turned out to be problematic for her: she did not agree with the salary her employer offered to her, but she did not now how to react on this. She actually wanted to discuss this issue with her rehabilitation counsellor. But she did not contact him about it. Since she started working with a lower salary than she wanted, she feels like she failed from the very beginning: “It started with failing. Because of that I entered my job feeling insecure. Even if it was 100 Euros more, I would have had so much more self-assurance”. Maria expresses that sometimes she has the feeling that she is in a circle of negative events that she cannot escape. “All the time that circle”.

Successful returning to work involves so much more than just having a contract for a couple of months. Maria’s case illustrates painfully that a too narrow focus on labour participation can lead to paradoxical situations in which ‘successful’ vocational rehabilitation can mean a life in which a person feels powerless and excluded on different levels. During the vocational rehabilitation programme, more attention could have been paid to Maria’s responsibilities at home, her emotional well-being and her own opinions and priorities regarding successful return-to-work.

Linearity Versus an Erratic Process

Judith, who became work disabled because of depression and burnout, speaks about the difficulty of listing her needs during her vocational rehabilitation programme:

Judith: I think that people do not receive a disability benefit for fun. […] And it’s very unpleasant that you should have a clear aim. That you should be so coherent to address your [needs], while you are just not able to do that. And I think that are serious shortcomings.

Interviewer: Yeah, on a certain moment, things are expected from you that actually cannot be expected from someone.

Judith: Well, I can only speak for myself, but I felt so far away… Then you are just on another level, that almost doesn’t work. […] And it has nothing to do with that you don’t want to work, or that you like to be on disability benefit, or that you are passive. It has nothing to do with that.

Judith case conflicts with the linear process towards employment that is often assumed in activation strategies. This linearity presumes individual control, and as Struhkamp [20, 21] pointed out, this sometimes appears impossible, unrealistic and undesirable. Especially in the case of psychological problems, it may be difficult for people to reflect on their situation and to express and prioritise their needs. The distance and clarity that is part of this process conflicts with the actual, often blurry, presence of psycho-emotional issues. Judith describes a friction between her personal situation and the expectations that were part of her vocational rehabilitation programme:

Judith: If you look at the phase I was in that moment. […] Well, I was not totally stable yet and neither was I mentally and physically on the level I wanted to be. And that is what you have to deal with. That is actually my biggest handicap at that moment. At the same time you should be in top condition, top alertness, to do such a thing [the vocational rehabilitation programme]. And that contradicts. And I think now, at this very moment, I would deal with it differently.

Interviewer: Well, did you had the feeling that the rehabilitation counsellor tried to attune to the phase you were in?

Judith: Oh yes, I think they listened very well. I think that they took the space I offered. But, looking back, when you ask me, I think they were led by my rather strong appearance. […] Whereas I think it was still only skin-deep. I mean it is there, but the solidity of it, well, that was merely exterior. […] Thus I think that they were too much led by, ‘well, she’ll manage’. And it was very clear to me, as they told me, that they will give me advise on business matters. The emotional part and other things, that was not for them. Well, and finally I think that I needed the emotional part more than the business.

Judith expresses that within her vocational rehabilitation programme, she mainly focused on the businesslike aspects of vocational rehabilitation. However, in retrospective, Judith articulates that she needed more emotional support during her process of returning-to-work. With her story she shows that vocational rehabilitation is an erratic process (see also [7]). This may imply that in her case, as in most cases, vocational rehabilitation should have addressed various aspects of life, each with its own logic and chronology. When it is too strongly focused on work-related issues, other important facets of life, such as emotional wellbeing, might be neglected. If the ideal of linearity becomes less of a focus within the programme, more room is created for client’s individual processes of coming to terms with their particular situation.

‘All or Nothing’ Versus Balancing

When I visit Anne for the first time, she is living at her parent’s place in a village 30 kilometres away from her residential town. She is diagnosed with posttraumatic dystrophy. She explains to me that she cannot live on her own at the moment:

I can’t manage myself in [residential town]. I can’t say like: ‘I will go to the cellar and do the laundry’. And cleaning the house, that is such a thing… ugh… that is not working either. So, that kind of things are not working now. And then there was the question: What to do? Well, I said, I will stay here [at parent’s place] for the time being. Until I’ve hopefully made some progress through the [physical] rehabilitation, so I can try it again. But then I’ll need some house adjustments. And I am busy with that as well, but… well, the indication agency has some arrears and problems with the personnel. So, no indication is coming… Indeed, I am well informed about everything.

Due to the posttraumatic dystrophy, Anne’s body hurts and restricts her in her activities. Anne entered the vocational rehabilitation programme with the idea to elaborate her working hours from 18 to 36 h. Due to her health situation, she could not start with the programme. Anne describes a dichotomic approach of her vocational rehabilitation programme. It is about ‘all or nothing’: only when she is in good health, the programme can start. This approach does not resemble the way Anne lives her current life. She is continuously occupied with organising her life with an illness. Anne’s case illustrates the activity of balancing in which organising as much as caring are central aspects.
Anne works 18 h a week as a secretary. She is eager to continue working, since, as she explains, the distraction, social contacts and the fulfilment she gets by working are very important to her: “it makes you belong to society”. To be able to work those hours, she needs to organise her transport to the work place, and that takes time:

They [local taxi company] pick me up by taxi. I work a couple of hours and they bring me back by taxi. Now I do everything by taxi. What must be must be. […] You have to take into consideration that you should leave home at half past six in the morning by taxi, to be at work at eight. And then you are just happy that you could be at work for a couple of hours. Then it takes two, three hours to be back home again. Because I use ‘Tailored Transport’. That’s the cheapest way to get somewhere.

The structure of the ‘Tailored Transport’ demands extra organising in going to work and this takes a lot of time. She has to make a reservation for transport at least 1 h advance and she has to share it with more persons. Anne describes that she created a daily schedule to make her (work) activities possible, as well as the necessary resting to balance her energy level.

Well, I work from Mondays to Thursdays in the morning. And then in the afternoon, it is just resting. […] [Working] costs me a lot of planning and organising. Every morning I wake up at half past four, take a shower, put my clothes on, blow-dry my hair, and then I make sandwiches. And then I need to sit with my legs up for an hour, before leaving to work. Because that gives me just an extra hour of rest. Well, you are just busy all the time with looking how you can manage it all. No-one believes that, but all the time you are busy… well, you want to work, then you should take all the planning into consideration.

Anne’s story shows that rest before and after her work is an essential part of balancing life. Her periods of rest can therefore be seen as part of the activity. In the way Anne speaks about her life, she emphasises that being active implies that she has to take good care of herself.
Besides the caring for herself, that Anne illustrates by the way she organises her life, Anne is also active in caring for others. She describes that, for her, taking care for others is important to get fulfilment out of life. Especially since she had to stop working as a nurse, because of health problems, she is seeking fulfilment in ‘informal’ caring.

Now I try to find satisfaction on other ways. Since last summer one of my aunts stays in a nursing clinic. She had a cerebral infarction and a brain haemorrhage and I visit her regularly. And then you try to get a smile on her face, or to comb her hair nicely, or put some crème on her face. I am not that mobile, but if I sit down I can use my hands. She is also in a wheelchair, well we just try to help each other. And you just do that for that smile, and the ‘thank you’. Such a things, that’s why I do it.

The restrictions Anne experiences in her activities, are no reason for not taking care of her aunt. Moreover, Anne shows that it makes her feel more connected to her aunt because both feel physically restricted (‘We just try to help each other’). Caring is an important activity in Anne’s life. She emphasises that it brings her satisfaction.

Anne describes an active life full of organising and caring. By ‘giving and taking’ she gives shape to her life with a work disability. Living with a work disability asks for both organising and caring, and that are other types of activities than often assumed within vocational rehabilitation programmes. This ‘giving and taking’ is a delicate balance that does not fit into the narrow conception of ‘active citizenship’ that disregards differences and care [26]. The concept of ‘careful citizenship’ as described by Van Houten and Jacobs [26] leaves more room for broadening the view on ‘activity’. When organising and caring are regarded as meaningful activities, Anne’s way of balancing her life may be considered as a valuable part of (social) participation.

Reflection Versus Learning by Doing

Inga, a lady with fibromyalgia, expresses that for her it is important to gain practical experience during her vocational rehabilitation programme. She explains:

For me, it is the most important to learn to write [application letters] or at least that I get an example of it. And that she [the counsellor] will go over it with me. Whether I wrote the letters well enough. That gives me something tangible. Speaking with people about your feelings and so on, that’s nothing for me. I rather keep things with my self. I think it is just too personal to speak with strangers about those things. But clear things, such as writing good letters, well, that’s useful to me. […] Yes, the concrete things. I remember, the first three meetings I came home and I said to [partner], I said, ‘If it stays like this, then I’m not getting anywhere.’ I found it messy, I don’t know if I can name it like this, but it was a bit childish. […] But it was maybe just a kind of introduction to comfort people. […] After the fourth time we started with writing application letters, practicing phone calls. Then I thought, well, I didn’t know that before. This brings me something. So, then it became finally a bit useful.

Inga articulates that the talking did not contribute to her learning process. It were the practicing of skills that helped her in feeling a bit closer to the labour market. There is a tangible friction between Inga’s way of learning and the learning that is expected in many vocational rehabilitation programmes. The motor behind the process of vocational rehabilitation is the expectation that clients are able to reflect on their life. This reflection is considered a vital learning process and an important aspect of self-development during vocational rehabilitation programmes. Reflection is often principally focused on the issue of (returning to) work and is regularly interpreted as learning by thinking. However, this is not for everyone the right way to learn. The case of Inga shows an alternative process of ‘learning by doing’.
When Inga tells me about a test she had to perform, she explicitly positions herself as someone who is not a ‘thinker’:

We had a nice group. I did the career test in another group, since I was the only one from my group doing the test. […] And then I came in a group with, well, deep thinkers, scholars, worriers. Later I told the course instructor that I was happy that I was not placed in that group, because I wouldn’t feel at ease there.

Inga articulates that she does not feel comfortable in a group in which ‘thinking’ dominates. When she continues to speak about the career test, she sounds disappointed:

I had to do that career test since I was out of employment for a long time. And I didn’t really study for something, so I don’t have a true profession. And for that reason I got the career test, that maybe then I would discover the direction I should search in. Well, it didn’t result in a list like, ‘search in this or that direction’. I think, well, for what reason did I make that test. […] I know as much as before, as little as before. No, it didn’t bring me any insight in the kind of vacancies I should look for. It was just a waste of time. I sat there the whole morning and nothing came out.

Inga could not do much with the outcome of the career test. She expected a concrete answer, but the test did not give her any clue about what to do. When Inga speaks about her vocational rehabilitation programme she explains that she entered the programme with the idea to understand her work disability better by starting to work:

I had the expectation […] if they place me somewhere and they just discover that it doesn’t work out for me, then it is a confirmation for me that I am unable to work. But it never came that far. The last time, the rehabilitation counsellor told me that they couldn’t do anything with me. So, on the one side it is finished, the rehabilitation agency also thinks that they cannot do anything with me. But I would have preferred a double confirmation, by starting to work somewhere. And that it would turn out more clearly, that you are ill. But that’s just not the case. […] So maybe for them [rehabilitation agency] it became clear, but for myself it is not hundred percent clear.

Inga points out that she needed to experience whether she is work disabled, before she ‘believes’ it. Only to think about it or to hear it, is for her insufficient to give it a place. A reflective and cognitive approach on learning overlooks the need for doing and experiencing in the process of vocational rehabilitation.

Empowerment: Learning from Practice

This paper presents an empirical analysis of empowerment. Inspired by the ambition of STS to do justice to the dynamics of practices, we aimed at exploring how empowerment gets shape in the concrete practice of vocational rehabilitation and how one can go beyond the notion of empowerment as an activation strategy that solely focuses on labour participation. The narrative analysis shows the capriciousness of daily life with a work disability, the expectations of vocational rehabilitation programmes and the tension between those two domains.

The cases in our paper illustrate how understanding empowerment as an activation strategy affects the everyday day life of people and their concrete opportunities and abilities to participate and to return to the labour market. Starting from the narrated reality of clients in vocational rehabilitation programmes we distinguished five ways in which (dis)empowerment is experienced. Marco feels ‘empowered’ based on his interdependency; Maria states that, since her personal goal of ‘living a good life’ is not achieved, she does not feel empowered by having a job; Anne is able to be active because she knows how to balance life; Judith speaks about the erratic side of vocational rehabilitation; and Inga explains that she learns by doing. These narratives illustrate that ‘being empowered’ cannot be identified or characterised by autonomy, goal setting, activity, linearity and reflection in vocational rehabilitation. In fact, the cases show that ‘doing empowerment’ from a client perspective can result in exactly the opposite of what is intended by the activation strategy of vocational rehabilitation programmes.

Starting with the theoretical starting point of empowerment as a process in which a professional relation is created where the client takes control over the change process and determines both the goals of this process and the means to use [22], our analysis demonstrates the normative character of this understanding empowerment. Activation strategies that aim for labour participation tend to be normative in the sense that they impose specific expectations of how clients should behave in order to be empowered. Moreover, being empowered is equalized to the goal of achieving a paid job. Instead of a professional relation in which the client takes control over the change process, the professional is expected, and in fact disciplined, to direct the client towards a predetermined change in a predetermined way. Activation strategies are disciplining clients in the sense that being empowered is considered a duty. This can be illustrated by the way autonomy is understood. Instead of approaching autonomy as the right to self-determination, it is simplified as the duty to manage one’s life individually. As the case of Marco demonstrates, clients are expected to make independent choices and should not be supported by relevant others in their vocational rehabilitation trajectory. This way of understanding autonomy bypasses the abilities and way of living of the client and may therefore hamper the client’s participation.

The theoretical notion of empowerment as developed by Tengland [22] is a dimensional concept, conversely our study demonstrates that in everyday vocational rehabilitation practices empowerment is understood in a dichotomous way. From our analysis it appears that clients are labelled as either autonomous or dependent; successful or failing; active or passive. This black-and-white notion of empowerment is connected to the psychologization of empowerment. In vocational rehabilitation, empowerment tends to become reduced to a personal characteristic and professional support is limited to changing the person his- or herself. This is problematic since important practical processes and contexts are left out of sight. A one-sided focus on the individual leads the attention away from the social and physical environment that may limit people’s ability to be empowered (see also [9]). Taking the contextuality of empowerment into account makes clear that interdependency, the focus on living a good life, balancing, awareness of irregularity, and learning by doing may help clients to achieve participation much better than to remain focusing on autonomy, goal setting, activity, linearity and reflection.

Our perspective comes with its own normativity. Starting from a STS approach, we explicitly choose to study the practice of vocational rehabilitation from the experiences and perspectives of clients. By putting the narrated reality of clients centre stage, we aim for a less excluding approach on activation, in which empowerment is not predetermined by dichotomous expectations but seen as a process in which the concrete client is the starting point. In fact, the experiences of clients in vocational rehabilitation programmes may give valuable clues for professionals to look beyond the one side of the dichotomy and to develop approaches that are more supportive in practice and do not exclude people from participation. Our analysis illustrates that professionals are restrained by the narrow understanding of ‘empowerment as an activation strategy’. This restricted definition of empowerment evokes tension in the client—professional relationship, since clients often do not fulfil the expectations that are part of this definition. Taking account of client’s life stories may release this tension, since in practice clients go beyond the narrow notion of empowerment (by being interdependent, by learning by doing etc.). More room for interaction between client and professional thus provides opportunities for an ongoing learning process of how empowerment takes shape and may supported in each specific case. This may be a valuable ‘attitude or a “way to work” towards empowerment’ [22, p. 93]. Taking the life story of the client as a starting point in order to escape from the normative and disciplining notion of ‘empowerment as an activation strategy’ might lead to more empowering vocational rehabilitation support. However, to what extent professionals in practice do have enough space to create room for facilitating clients’ processes of empowerment needs further exploration. As part of this, it should be investigated whether the institutional structures in which professionals operate hamper this kind of professional support.

Activation strategies aim at supporting people to participate in society. In other words, they strive for inclusion. In doing so, the goal of labour participation can be seen as ‘the management of normality’ [8] that easily overlooks differences in needs of clients and ways of living. Holmqvist’s study on sheltered employment for activating occupationally disabled people in Sweden, poignantly illustrated that people who ‘are unable to live up to the norms of being a ‘normal’ and hence fully active citizen, are objectified as passive and unemployable persons through the same principle that aim to make them active’ [11, p. 222]. Our analysis illuminates that a dichotomous outlook makes activation strategies highly normative and excludes people who cannot fulfil those expectations. Autonomy, goal setting, activity, linearity and reflection are vital aspects of empowerment. We do not want to dispose of them. However, our analysis emphasises that these concepts are often interpreted in a one-sided way. It creates specific expectations of how clients should behave and develop during their rehabilitation programme. Those expectations often exclude people from the support they need. By doing so, activation strategies achieve exactly the opposite of what they aim at. Activation strategies seem to be caught in a paradox: instead to include people, they have excluding consequences. Professionals can learn from practice how to go beyond this paradox and reflect on their facilitating role to support clients in their processes of empowerment.

Footnotes

  1. 1.

    Lately, more attention is paid to the practical consequences of the empowerment discourse, see e.g. the study of de Souza [9] on local perspectives on empowerment in the new public health.

  2. 2.

    For more information about STS, see the handbook of Science and Technology Studies [12].

  3. 3.

    The ‘I’ that is referred to in the presentation of the cases, is the interviewer and first author of this paper.

  4. 4.

    For the sake of anonymity, fictive names are used.

Notes

Acknowledgments

We are very grateful to the people who shared their life stories with us. We want to thank Ine van Hoywegen for her comments on an earlier draft of this paper.

Open Access

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

References

  1. 1.
    Aujoulat, I., D’hoore, W., & Deccache, A. (2007). Patient empowerment in theory and practice: Polysemy or cacophony? Patient Education and Counseling, 66(1), 13–20.PubMedCrossRefGoogle Scholar
  2. 2.
    Aujoulat, I., Marcolongo, R., Bonadiman, L., & Deccache, A. (2008). Reconsidering patient empowerment in chronic illness: A critique of models of self-efficacy and bodily control. Social Science and Medicine, 66(5), 1228–1239.PubMedCrossRefGoogle Scholar
  3. 3.
    Bonvin, J. M. (2008). Activation policies, new models of governance and the issue of responsibility. Social Policy and Society, 7(3), 367–377.CrossRefGoogle Scholar
  4. 4.
    Borghi, V., & Van Berkel, R. (2007). Individualised service provision in an era of activation and new governance. International Journal of Sociology and Social Policy, 27(9/10), 413–424.CrossRefGoogle Scholar
  5. 5.
    Bowker, G., & Star, L. (1999). Sorting things out: Classifications and its consequences. Cambridge: MIT Press.Google Scholar
  6. 6.
    De Koning, J. (2008). Empowerment facing a complex reality. Handbook for empowering strategies in social services and vocational rehabilitation. Utrecht: Equip(ment).Google Scholar
  7. 7.
    De Kort, S. J., Pols, J., Richel, D. J., Koedoot, N., & Willems, D. L. (2010). Understanding palliative cancer chemotherapy: About shared decisions and shared trajectories. Health Care Analysis, 18(2), 164–174.PubMedCrossRefGoogle Scholar
  8. 8.
    De Swaan, A. (1990). The management of normality: Critical essays in health and welfare. London: Routledge.Google Scholar
  9. 9.
    De Souza, R. (2011). Local perspectives on empowerment and responsibility in the new public health. Health Communication, 26(1), 25–36.PubMedCrossRefGoogle Scholar
  10. 10.
    Giddens, A. (1991). Modernity and self-identity: Self and society in the late modern age. Cambridge: Polity Press.Google Scholar
  11. 11.
    Holmqvist, M. (2010). The ‘active welfare state’ and its consequences. A case study of sheltered employment in Sweden. European Societies, 12(2), 209–230.CrossRefGoogle Scholar
  12. 12.
    Jasanoff, S., Markle, G. E., Petersen, J. C., & Pinch, T. (Eds.). (1995). Handbook of science and technology studies. Thousand Oaks: Sage Publications, Inc.Google Scholar
  13. 13.
    Latour, B. (1999). Give me a laboratory and i will raise the world. In M. Biagioli (Ed.), The science study reader (pp. 258–275). New York: Routledge.Google Scholar
  14. 14.
    Mol, A. (2008). The logic of care: Health and the problem of patient choice. Abingdon: Routledge.Google Scholar
  15. 15.
    Moser, I. (2005). On becoming disabled and articulating alternatives. The multiple modes of ordering disability and their interferences. Cultural Studies, 19(6), 667–700.CrossRefGoogle Scholar
  16. 16.
    Oliver, M. (1996). Understanding disability: From theory to practice. Basingstoke: Palgrave Macmillan.Google Scholar
  17. 17.
    Peck, J., & Theodore, N. (2000). Beyond ‘employability’. Cambridge Journal of Economics, 24(6), 729–749.CrossRefGoogle Scholar
  18. 18.
    Riessman, C. K. (2002). Illness narratives: Positioned identities. Wales, U.K: Invited Annual Lecture Health Communication Research Centre. Cardiff University.Google Scholar
  19. 19.
    Smith, B., & Sparkes, C. (2008). Narrative and its potential contribution to disability studies. Disability & Society, 23, 17–28.CrossRefGoogle Scholar
  20. 20.
    Struhkamp, R. (2004a). Dealing with disability: Inquiries into a clinical craft. Thesis, Technical University Twente.Google Scholar
  21. 21.
    Struhkamp, R. (2004b). Goals in their setting: A normative analysis of goal setting in physical rehabilitation. Health Care Analysis, 12(2), 131–155.PubMedCrossRefGoogle Scholar
  22. 22.
    Tengland, P.-A. (2008). Empowerment: A conceptual discussion. Health Care Analysis, 16, 77–96.PubMedCrossRefGoogle Scholar
  23. 23.
    Van Berkel, R., & Borghi, V. (2008). Introduction: The governance of activation. Social Policy and Society, 7(3), 331–340.Google Scholar
  24. 24.
    Van Der Burg, C., & Deursen, C. (2008). Eindrapportage herbeoordeeld…En dan. Leiden: Astri.Google Scholar
  25. 25.
    Van Hal, L., Meershoek, A., De Rijk, A., Joling, J. and Nijhuis, F. (2009). Een rol om op te bouwen? Zelfbeeld, levensstrategieën en re-integratietrajecten van langduring arbeidsongeschikten. Unpublished report, Maastricht University, Maastricht.Google Scholar
  26. 26.
    Van Houten, D., & Jacobs, G. (2005). The empowerment of marginals: Strategic paradoxes. Disability & Society, 20(6), 641–654.CrossRefGoogle Scholar
  27. 27.
    Ville, I., & Winance, M. (2006). To work or not to work? The occupational trajectories of wheelchair users. Disability and Rehabilitation, 28(7), 423–436.PubMedCrossRefGoogle Scholar
  28. 28.
    Wengraf, T. (2001). Qualitative research interviewing. Biographic narrative and semi-structured methods. London: Sage Publications.Google Scholar

Copyright information

© The Author(s) 2011

Authors and Affiliations

  • Lineke B. E. van Hal
    • 1
  • Agnes Meershoek
    • 1
  • Frans Nijhuis
    • 2
  • Klasien Horstman
    • 1
  1. 1.Research School CAPHRI, Department of Health Ethics and Society, Faculty of Health, Medicine and Life SciencesMaastricht UniversityMaastrichtThe Netherlands
  2. 2.Department of Work and Social Psychology, Faculty of Psychology and NeurosciencesMaastricht UniversityMaastrichtThe Netherlands

Personalised recommendations