Implementing an occupational therapy specific mental health intervention in a multi-professional context – the case of Balancing Everyday Life (BEL)

Abstract Background The occupation-based intervention Balancing Everyday Life (BEL) was found effective under controlled conditions but should also be studied in a natural clinical practice context. Aim The aim was to study the implementation process of BEL when provided in a multi-professional mental health team. The focus was particularly on how BEL was received and functioned. Methods This qualitative study was based on manifest content analysis and used semi-structured telephone interviews with 13 occupational therapists and three managers. Results Three themes were identified: ‘1 – Conditions and opportunities in the setting’, ‘2 – Putting the BEL intervention into practice’ and ‘3 – Experiences of practicing BEL’. BEL was a welcomed alternative, as stated by managers and occupational therapists. The team helped to recruit BEL participants, but the occupational therapists had to give rigorous information to team members and prospective participants for this to work. The social, physical and political contexts were essential for the implementation. Conclusions Successful implementation of an occupational therapy-specific intervention such as BEL requires a reasonable match between existing team policies and the underpinnings of the intervention. It is crucial to repeat information to all stakeholders and make the intervention a matter of urgency for the whole team.


Introduction
Occupational therapy in mental health is steadily progressing, due mainly to developments of different occupational therapy-based and recovery-oriented interventions during the past decades [1]. There is still a scarcity of evidence-based occupational therapy interventions in mental health care, but a literature review concluded that programs based on time use and occupational balance principles seem promising [1]. For example, Action Over Inertia (AOI) was developed in Canada to remedy a negative time-use balance and support personal recovery among people with serious mental illness. It is a ten-week program where people can explore various aspects of everyday occupation and accomplish change by focussing on active doing and meaningful participation. A small randomized controlled trial (RCT) indicated that participants improved their occupational balance and spent less time sleeping [2]. Another example is Balancing Everyday Life (BEL), a group program designed as a course over [16][17][18][19] weeks where participants learn to analyse their patterns of everyday occupations and how to develop activities and strategies to improve their occupational balance and personal recovery. Developed in Sweden, and evaluated for effectiveness in a combined RTC and process evaluation, it has shown to be effective in terms of improved everyday occupations and quality of life [3].
An intervention termed Graduating Living skills Outside the Ward (GLOW) was developed by Birken et al. to support people with psychosis after discharge from hospital [4]. The intervention goals are increased participation in domestic and personal selfcare, leisure, and productive occupations, as well as increased well-being and quality of life and reduced hospital admissions and use of crisis service. Another intervention, Meaningful Activities and Recovery, was devised in Denmark to enable and support engagement in meaningful occupation and strengthen personal recovery among people with severe mental illness. It consists of 11 group sessions and 11 individual sessions distributed over approximately eight months. Methods used include direct experiences with activities, personal exploration, lessons, and peer exchange. A peer supporter and an occupational therapist facilitate the sessions. An RCT is ongoing, aimed to evaluate the effectiveness of Meaningful Activities and Recovery [5]. Interestingly, the here mentioned occupation-based interventions also claim a focus on personal recovery, which is in line with research that has found substantial similarities between occupational engagement and personal recovery [6].
The above referenced studies may indicate an emergent in RCT to evaluate the effectiveness of occupation-based and recovery-oriented interventions. However, even if an intervention has been found to be effective, such as the BEL program, it does not guarantee that it will be successfully implemented in clinical practice. There is often a delay in implementation of a proven effective intervention [7,8]. It is especially apparent in the operationalization and utilization of evidence-informed practice in mental health services, which are influenced by an interplay between individuals, the new evidence-based knowledge and the context [9]. Similarly, leadership, communication culture, organizational learning, teamwork and staff engagement are factors that determine the possibility for successful implementation [7], as do political, social and physical environments [10]. One of the critical aspects when attempting to implement a new intervention may be how well that intervention aligns with existing practices. This may be a complex issue in a multi-professional team, particularly if there is a strong prevailing care paradigm that collides with that underlying the intervention. A typical mental health care team often consists of only one occupational therapist. Insight into the processes of implementing an occupational therapy intervention in a multi-professional context would be valuable for preparing the introduction of new interventions into clinical practice.
This study uses the occupation and recovery-based BEL intervention as a case for studying the implementation of a profession-specific intervention in a multi-professional mental health care team, as viewed from the perspectives of occupational therapists and managers. An evaluation of BEL, based on RCT methodology, indicated that it was more effective than standard occupational therapy in terms of improvements from baseline to completed intervention on occupational engagement, activity level, general occupational balance, psychosocial functioning and level of psychiatric symptoms. The picture of greater improvements in the BEL group remained at a six-month follow-up, and at that time the BEL group had also improved more on quality of life compared to those receiving standard occupational therapy [3]. A study investigating possible predictors of positive outcomes, in terms of well-being factors, sociodemographics and health care level, could not identify any consistent pattern of predictors. BEL appeared to be a suitable rehabilitation alternative in the community as well as in clinical settings for participants with a blend of socio-demographic and clinical characteristics and with varying levels of self-esteem [11]. This was also true when addressing personal recovery specifically [12]. This latter study also found that high levels of self-mastery and occupational engagement enhanced recovery. A process evaluation supplemented the RCT by highlighting the journey of entering and benefitting from a group [13] and showing that participants made substantial meaningful changes in everyday life and developed greater self-compassion [14].
The aim of this study was to investigate how occupational therapists and managers, where the BEL intervention was provided, viewed the implementation process, with a specific focus on how they perceived that a profession-specific intervention such as BEL was received and functioned in a setting staffed with a multi-professional team.

Methods
This was a qualitative study based on telephone interviews. A qualitative method was seen as appropriate for obtaining knowledge about occupational therapists' and managers' experiences and reflections. Since the prospective informants were working in various regions in Sweden, a telephone interview was considered feasible. The study followed the Swedish Act concerning the Ethical Review of Research Involving Humans [15] and the Helsinki Declaration [16] and built upon informed consent. According to the Swedish Act concerning the Ethical Review of Research Involving Humans [15], ethical approval from an ethics committee is not required if the research persons are not asked about senstive information, they are not subject to an intervention, they give their informed consent and all information is kept anonymous, which were the circumstances that prevailed for this study.

The BEL intervention
The BEL intervention is a group and occupationbased program, led by occupational therapists and developed for people using specialized psychiatric services. The target group are those who need to develop a more meaningful and balanced everyday life and foster their personal recovery. Occupational therapists who want to become BEL leaders need to take a three-day training and to follow the BEL manual [17].
The BEL intervention is built on 12 themes, the first three of which reflect motivational aspects and interests. Themes 4-12 are about a variety of everyday activities, including testing activities in real life. Please see Table 1 for examples of themes. A cycle of analysing one's everyday activities, setting goals, finding strategies, testing them in real life, and discussing and evaluating the outcome is repeated in relation to each theme. A cycle starts in one session, includes a reallife experience (home assignment) between sessions and concludes with a follow-up of the home assignment during the next session. Then a new cycle is started, and building upon each other they form a spiral for possible development: the BEL intervention. BEL concludes with two booster sessions with the aim of maintaining achievements made and preparing for an active everyday life on one's own. Please see Table 1 for further details.
The themes were spread over 12 weeks in the original version of BEL, making a total of 16-weeks with two biweekly booster sessions. Evaluation from BEL participants and leaders indicated that using more time for the 12 themes would be favourable. The 12 themes were then spread over 15 sessions, making a total of 19 weeks.
The number of participants in a BEL group is usually 5-8, but drop-out from the program can sometimes entail smaller groups. Informal peer support is encouraged during the program as a whole and becomes particularly accentuated in the booster sessions.

Recruitment of informants
Interviewees were enrolled from the approximately 150 occupational therapists who had completed a three-day BEL training, either in connection with the RCT [3] or as a separate course. Most of them followed the 19-week schedule. The number of themes and booster sessions were the same for all. Recruitment started in late 2019, and in order to allow sufficient time for occupational therapists to start practice BEL in their ordinary clinical context and finish at least one complete round, we recruited occupational therapists who had completed the training in 2018 or earlier.
Maximum variation sampling [18] was applied. We sought ten occupational therapists from various parts of Sweden and working with a variety of target groups with mental health issues. We also sought variation on when the BEL training had been completed, which varied between 2012 and 2018. If possible, we also wanted to interview the occupational therapists' managers.
The selected time span for completing the BEL training entailed that no occupational therapists from northern Sweden were among those enrolled, but the middle, eastern, western and southern parts of Sweden were represented. The clinical settings involved included general specialized psychiatry, psychosis care, community centre, and special clinics for depression/anxiety and neuropsychiatric disorders.

Informants
The ambition was to recruit ten occupational therapists from different clinical settings and their most immediate managers. After having obtained consent from ten settings, it became clear that two The BEL cycle Reflection, goalsetting and choice of strategy are the first steps of a loop that starts in one session, continues with performing the activity between sessions, and concludes with reflection, evaluation and possibly re-negotiation of goals upon follow-up in the next session occupational therapists wanted to participate from three of the settings, resulting in 13 occupational therapists from ten settings recruited. In two settings, they wanted to be interviewed together (OT 5 and 6, and OT 10 and 11), and in one setting they preferred to be interviewed separately (OT 4 and OT 9). Two of the occupational therapists enrolled had completed the BEL training in connection with the RCT project (2012-2014), while the remaining 11 as a separate course (2015-2018). The number of participants in the BEL groups led by these occupational therapists was generally five to six. It was difficult to recruit a manager from each setting, mainly due to them having changed jobs since the occupational therapist started practicing BEL. A total of three managers, from three different settings (a community centre, a neuropsychiatric clinical setting and a clinical unit specialized in ADHD) were enrolled. Prospective informants who were interested in taking part received written information about the study and signed their informed consent. They also provided basic sociodemographic information in a questionnaire. All informants, occupational therapists as well as managers, were female. Further information was missing for one of the occupational therapists, but the 12 who responded to the questionnaire had worked in mental health care for on average (min-max) 12 (1-32) years and in their current position for 9 years. Six of them had further education. One had a MSc in health science, two had training in Cognitive Behavioural Therapy (CBT) and the other three had taken independent university courses. Two of the managers were trained as nurses and one as a psychologist. They had worked in mental health care for on average 27 (6-45) years and in their current position as managers for 11  years. One of them had further education in terms of independent university courses.

Interviews
Semi-structured interviews were performed, using an interview guide informed by the plan for assessing program implementation developed by Saunders et al. [10]. That plan highlights 'fidelity, dose (delivered and received), reach, recruitment, and context' (p. 134) as key elements, and these served as inspiration for developing the interview guide. Based on the specifics of the BEL intervention and the mental health contexts where it was implemented, we decided on the following themes for the interview guide: process and context for implementing BEL, recruitment strategies, fidelity to the BEL manual, delivered dose in relation to the manual, received dose by BEL participants, and target groups reached.
A research assistant (not one of the authors) was employed to conduct the telephone interviews, which were audio recorded. The interview guide had been sent out in advance in order to facilitate the interview. The interviewer aimed to create a relaxed atmosphere and allowed the informants speak freely about the themes, but putting prompting questions when relevant. The interviews were transcribed word by word. The interviews lasted between 45 and 100 min with the occupational therapists and 20-30 min with the managers.

Qualitative analysis
We decided to make an inductive analysis of the transcripts in order not to be limited by the implementation elements proposed by Saunders et al. [9] but making full use of the variations in the interviewees' stories. The analysis adhered to the procedures for a manifest content analysis as suggested by Graneheim and Lundman [19]. A manifest content analysis was considered suitable for the aim of studying the implementation of an intervention in clinical practice. All transcripts were read through and meaning units were identified by the first author. Similarities and differences regarding implementation experiences were discerned. The original wordings were then summarized into condensed meaning units and assigned a label, a so-called code. The two authors then analysed two of the interviews independently of each other to check whether they arrived at similar condensed meanings, and there was convincing agreement. Codes were then grouped together in an iterative process to form categories, which in turn were seen as composing three themes. The first author had the lead in conducting the analysis, and the last author had the role of a critical discussant during the iterative process. No qualitative analysis is without interpretation [20], but since we found a manifest approach suitable we strove to stay close to the interviewees' statements. The process continued until the authors agreed they had arrived at the solution that best fitted the data.
To strengthen the credibility of the findings, quotes from the various informants are provided where each occupational therapist and manager is assigned a number (such as OT 1 and M 1). When two occupational therapists were interviewed together, it was not possible to distinguish the two. This concerns occupational therapists 5 and 6 and occupational therapists 10 and 11, where both numbers are noted. The quotes have been slightly adjusted grammatically, excluding pauses, repetitions, stuttering etc.

Results
Three themes emerged from the analysis process: '1 -Conditions and opportunities in the setting', '2 -Putting the BEL intervention into practice' and '3 -Experiences of practicing BEL'. Each of these main themes encompassed categories, as shown in Table 2. The table also indicates the data sources behind the identified categories, which in most cases involved both occupational therapists and managers.

Theme 1 -Conditions and opportunities in the setting
The four categories under this theme were termed The managers' general expectations about occupational therapy, A positive climate makes the wheels roll, Positive and negative contextual preconditions, and An inbuilt flow of changes affects the implementation process.
The managers' expectations about occupational therapy The manager's expectations about what an occupational therapist should do in the clinic concerned a general belief that occupational therapists worked on the 'rehab track' and would support clients towards a more structured everyday life, while also contributing to the team with their specialty. They spoke of work tasks that included functional assessments, work assessments, group leadership, education for relatives about structure in everyday life, sleep management, and prescribing aids (such as weight blankets). The managers maintained that group interventions formed one of the more important aspects of occupational therapists' work and were willing to approve their participation in the BEL training. The managers also stated that participating in an occupational therapyled group was often one of the first steps for clients to return to work.
Furthermore, the managers found it important that all team members had good knowledge of the occupational therapist's interventions, including BEL. They also found it rewarding for the team as a whole when other team members could be co-leaders of a BEL group. 'This whole clinic profited from when nurses were co-leaders (of BEL)a mutual learning occurred that enriched the whole work group' (M 3). Similarly, another manager said: 'We often work alone in mental health care, and mutual learning among colleagues is something I expect as an employer' (M 2). The managers also wished that other professionals, for example, nurses, could take part in the BEL training. 'It's not that difficult to run it (the BEL group)' (M 2). This was particularly the case where there was only one occupational therapist in the team. The role of the manager vis-a-vis the occupational therapist was that of a sounding board, for example, discussing strategies for how to select participants for the first BEL group, but the managers did not participate in the BEL groups per se.
A positive climate makes the wheels roll Both occupational therapists and managers spoke of different aspects that had a positive effect on the former's endeavour to implement the BEL intervention. One was the confidence the occupational therapists felt after having completed the BEL training; the training made them feel well-prepared. Something that all the occupational therapists endorsed was that a manager who showed an optimistic and encouraging attitude towards the BEL training paved the way for smooth implementation. Another beneficial aspect was if there was congruence between the clinic's plans and goals for their services and the corresponding approach outlined in the BEL manual. Team members were also positive about the BEL intervention. This Table 2. The themes and categories reflecting the process of implementing BEL in a multi-professional context. facilitated recruiting co-leaders among other staff members, such as nurses and psychologists, and both occupational therapists and managers reported a close collaboration between the occupational therapists and the rest of the team. 'It was great because they (coleaders) had pre-knowledge about the group participants, how they functioned' (OT 1). The team showed an interest and would ask about BEL if for some reason there was no group running. There was also an expectation from the team that newly-employed occupational therapists would complete the training. Occupational therapists and managers from clinics that had been part of the RTC conveyed that the research project had been a positive factor. Those who had completed the BEL training after the RCT, as well as their managers, meant that the positive results from that research contributed to their willingness to introduce BEL at their clinic. 'Since it was a good intervention it was not difficult to sell it' (OT 5-6).

Positive and negative contextual preconditions
Some of the settings where BEL was implemented were private clinics, which entailed that an estimation of costs and profit targets needed to be considered. One occupational therapist adjusted the intervention by shortening the group sessions. To still manage to provide the full BEL content to all clients in need of the intervention, she limited each course to 4-5 participants and increased the number of courses. 'They (the clinic) get as many points for a one-hour visit as for a two-hour visit, so my employer wanted me to keep each session to one hour. I negotiated and got another 15 min and ran several (groups) parallelly' (OT 2). A manager at another clinic said 'I need to think economically … They (the occupational therapists) need to include ten participants, which often leads to eight showing up and six who complete … It must be economically profitable' (M 1). Another financial aspect concerned the costs for the BEL training. A few occupational therapists spoke of managers who first said no but consented when learning that the manager at another clinic was very satisfied with the BEL intervention. Related to costs, managers sometimes wanted the occupational therapists to provide an alternative group intervention, such as illness management, stigma prevention, sensory modulation, or art therapy. Such groups were sometimes too timeconsuming to allow for the occupational therapist to run BEL groups as well. When alternative group interventions were run by other professionals at the same time as a BEL group was planned, there was instead a risk for competition about clients. The occupational therapists felt that BEL was seen as an appreciated complement in relation to CBT, especially for clients where CBT had not worked, but on occasions they had to fight to introduce BEL as a possible firsthand choice among others.
The premises were important for to create a dedicated safe space free from interruptions, and all but one of the occupational therapists were well provided in this respect. In one of the clinics the BEL course took place in premises situated a few kilometres away, which the occupational therapists found preferable: 'It gives you freedom from the (interrupting) routines of the clinic, such as when some participant needs to take their medication' (OT 5-6). Furthermore, attendance in the BEL group was negatively affected if their room was also used for drop-in activities. The participants associated that room with non-structured activities and being able to come and go as one pleased. This was accentuated by staff who had insufficient knowledge about the BEL structure and were unable to discern BEL as different from the dropin activities.
Clinical support was mentioned as an important condition when the occupational therapist encountered situations that were difficult to handle, such as how to create the best possible group cohesion with one or more dominant participants in the group. An occupational therapist who received support from a psychologist was very satisfied: 'Last autumn there was someone who became very, very intensive about her childhood and then I needed, sort of, how do I handle her, stop her and how do I monitor the group?' (OT 13). Some had to rely on collegial support where occupational therapists discussed difficult situations together. They found this better than nothing, but desired external clinical support.

An inbuilt flow of changes affects the implementation process
Occupational therapists and managers spoke about the clinic as being subjected to changes and fluctuations that impacted on the implementation of BEL. There could be a variation in the flow of clients for whom BEL was considered relevant, entailing that BEL could not be given on a continuous basis. A change in the managerial position was also influential: 'My previous manager was very much focused on assessments and thought that occupational therapy groups were too small to make a difference. My new boss is more rehab-oriented and requests I do BEL' (OT 8).
Occupational therapists changed positions as well. This could create a gap in the provision of BEL courses, especially if the new occupational therapist had not completed the BEL training. However, when a BEL-trained occupational therapist moved to a new job, BEL could be introduced in a new care context. One occupational therapist had moved to another part of the country and applied for a job within occupational health care, where she planned to test BEL.
Another issue that influenced the implementation of the BEL intervention was the reorganization and introduction of new policies. Policies that increased the prospect of allowing occupational therapists to take the training and implement BEL were, for example, a decision to increase the supply of group interventions or that each team member should receive further training in methods specific to their specialty.
Two of the occupational therapist interviews were conducted after the COVID-19 pandemic had hit Sweden, and the pandemic had obviously affected the BEL groups. A problematic situation related to the premises appeared in one of the settings. They normally used a room in a nearby supported housing unit for old people but needed to pause the intervention when they could no longer use that room. In another setting the occupational therapists could continue BEL by arranging virtual groups using video links.

Theme 2: Putting the BEL intervention into practice
Three categories were identified under this theme: Information received or lost, Recruiting and keeping BEL participants, and Adjusting to BEL and growing with the intervention.

Information received or lost
All types of staff and team meetings were important forums for the occupational therapists to convey information about BEL. 'They (the occupational therapists) used power points to illustrate the structure and contents of BEL' (M 1). The occupational therapists said that it was important to repeat their message and use several communication channels for the information to really reach the other team members. Sending emails was another way of communicating the nature of BEL and how it could contribute to the clinic's provision of interventions. The team needed to understand BEL correctly to be able to help to reach those in need of the intervention. An important message to convey to staff members was also: ' … the clients needed to go in for BEL 100%; it wasn't enough to show up at every other session' (OT 10-11). Although correct information was passed on to the clients in most cases, the occupational therapists were sometimes concerned. Both erroneous information to clients (leading to misconceptions about the BEL) and missing information (resulting in few BEL participants) were seen as a problem: ' … it is more like "you have the possibility to come to a group and it's good to have something to do' or 'you can come and have a cupper and join in if you wish"' (OT 7).

Recruiting and keeping BEL participants
Occupational therapists recruited potential BEL participants by displaying flyers in the waiting room and informing during their various meetings with clients, individually or in groups. Recruitment was also facilitated by other team members informing clients they met. Furthermore, information was often passed on through other clients, who could talk about BEL in the coffee room. There were also a few examples of recruitment occurring via supported housing staff and a social insurance officer. The clients who declared an interest in participating were generally put on a waiting list, although this list was used differently at different clinics. When a group was formed without considering if the participants were likely to work well together, this did not turn out well. The occupational therapists' general opinion was that some type of matching was needed, but that could be done in different ways. One occupational therapist maintained that there needed to be some similarity and/or personal match between the participants: 'I had my sort of match-making lists/ … /perhaps (people) with similar interests and similar levels of functioning' (OT 2), whereas another had experienced that mixing participants with different backgrounds could create dynamics that benefitted the group process. For example: 'It can be quite helpful if they (participants) are a bit dissimilar: someone who is/ … /doing too much and another who's been off sick and doesn't engage so much' (OT 9). Both occupational therapists and managers stated that BEL was suitable for the clients they served, although the target groups varied greatly among the participating clinics, with diagnoses such as depression, psychosis, ADHD, and personality disorders.
The occupational therapists mentioned that initial strategies to make the participants comply with the BEL intervention included a careful assessment to ensure that the participant was motivated and making clear that BEL entails a series of sessions that build on each other. They also maintained that it was important to be active and focussed and having prepared carefully as a group leader, not to lose participants. Most occupational therapists had experienced that participants occasionally did not show up at a group session, and they listed a number of actions to remedy thattext message and/or telephone reminders, sending home course material when participants had missed a session, providing individual sessions as compensation for a missed group session (which turned out to be too weary for the occupational therapist in the long run), and picking up the participant at home. There were also examples of participants pushing each other to come to sessions. The occupational therapists also conveyed that it was essential to make the participants feel they were taking a course, also when they did not show up. Some of the occupational therapists stated that keeping the participants in BEL was not difficult: 'No problems, actually, those who took BEL have been motivated and they have completed it' (OT 12). It was easy to keep them in the intervention since the content was what most of them needed. Many participants had wanted to repeat the BEL intervention and do the course a second time, which had been allowed subject to availability.
The occupational therapists reflected that the BEL intervention perhaps suited women better than men. They had more women than men in their groups, and one of them said: 'It's not about groups -IMR and NECT (recovery-oriented interventions) are also groups. It's more about the content. The exercise about the rag mat is not a problem for the women. Maybe the symbolism is easier for women?' (OT 12).
Adjusting to BEL and growing with the intervention Despite having the BEL training and access to material, such as the manual detailing the contents of the group sessions and homework assignments, a set of power-point presentations, and workbooks for participants, the occupational therapists felt they needed further preparation before starting a group. They needed to study the material and plan thoroughly for the specific participants and the specific setting. This entailed a delay prior to starting the first group. However, once they had started a group, it was easier and more relaxed than they had expected.
The BEL participants could also have a period when they were somewhat puzzled and doubtful before they became accustomed to the BEL structure and contents and to being in a group. 'Some thought it was a bit woolly to start with, that you would find your own balance, no clear template' (OT 3). The participants became increasingly positive towards BEL during the intervention period, according to the occupational therapists. Various exercises for mapping their pattern of everyday activities were a particular eye-opener for them; they saw their everyday life clearer and became aware of their occupational balance.
The occupational therapists discovered that the BEL manual provided a great deal of flexibility and the content could be adjusted and graded in accordance with needs, abilities, and interests of the participants. 'When people were more interested in theoretical aspects, then you could simply pass on some useful information, and when people had difficulty assimilating this then you could summarize it and simplify it a little' OT 2.

Theme 3: Experiences of practicing BEL
The occupational therapists' experiences from running the BEL groups, as well as the managers' views on the BEL groups, formed a theme with four categories: BEL captures the specifics of occupational therapy, Setting and achieving goals, Reflections on the BEL structure and contents, and Outcomes of BEL.
BEL captures the specifics of occupational therapy It was a generally held opinion that BEL captures everyday life and occupational balance, seen as mental health occupational therapists' main focus. One therapist expressed: 'I needed to freshen up occupational therapy theory and to really put activity in focus./ … /That you had time for that and really could strike a blow for groups/ … /-I think some of that has become lost in psychiatry' (OT 4). Another opinion was that something like BEL had been missing in treatments for people with psychosis. They saw BEL as being more flexible, less controlled in details and more focussed on group processes in comparison to other group interventions the occupational therapists had used, where for example illness management and anti-stigma was targeted.

Setting and achieving goals
The individual goals each participant set during the intervention was seen as the linchpin of BEL. The occupational therapists reported that the participants tended to set too ambitious and far-reaching goals, impossible to achieve, such as being able to work to the same extent as before the onset of illness. Breaking down goals into concrete short-term goals, such as having proper meals during the day, was important in order to accomplish sustainable change. 'The goals must be downsized to what is manageable it must be foolproof, so it becomes a success' (OT 13). Working with goals warranted coaching from the group leaders and could cause the participants to feel the type of anxiety associated with school. On the other hand, the occupational therapists felt that the participants were grateful that somebody cared about their struggle to deal with everyday life, otherwise often taken for granted.

Reflections on the BEL structure and contents
Occupational therapists and managers commended the BEL structure and manual, the total setup as well as the individual sessions. 'The BEL manual is thoroughly prepared/ … /and (the workbook) a very good instrument for the clients to work with' (M 3). The occupational therapists meant that the manual contributed to realistic expectations among themselves and the BEL participants, and provided a structure while also opening up for flexibility and adjustments to each participant's needs and wants. The session themes were seen as being of relevance and concern for the participants. 'You (the participants) can get to savor a little of each, which suits our services very well' (OT 8). There were some complaints, however, that it was a bit difficult to overview of all the material.
All therapists stated that they chiefly followed the BEL manual by the book, but there were still reports of making minor adjustments in relation to the contents and/or structure of the manual, for example the number of sessions. Another example was: 'We made some extra slides with info from the manual. It gave better structure for both participants and us' (OT 10-11). Most of those who had been trained to use 19 weeks for the BEL themes meant that it was just right, but a few who had high functioning, working participants had moved on a little faster. The occupational therapists felt that the BEL exercises were on the right level, and that they could deliver the full array of information, discussions, homework and exercises. There was some reflection, however, about failures to do the home assignments. 'The homework was not always donetoo low steering speed or that it was "forgotten"' (OT 8). Forgetting to complete a questionnaire was also mentioned. In case of failures, the occupational therapists would help the participants to somehow complete the task.

Outcomes of BEL
The managers had high hopes regarding BEL: 'My expectations were high, of course, since it was a research project/ … /it was interesting, it was fun, but at the same time untested/ … /I would say it turned out better than I could imagine, actually' (M 3). They meant that the participants showed commitment, as illustrated by statements such as 'the groups are well attended' (M 1) and 'the level of participation is high' (M 2). The managers' impression was that the participants were also satisfied with the intervention. The occupational therapists stated that they felt participants became aware of new things about themselves, and that it was great to see how the group grew and developed. Another view, however, was that the full outcome of the BEL intervention was not visible until it was completed, which made it important to continue to work with the processes that had started during the intervention. This could be carried out by the occupational therapists themselves or by other team members. The concluding booster sessions were seen as vital, as a conclusion of the intervention and as a starting point for maintaining the new lifestyle habits on one's own.
Another type of outcome was that BEL served as an introduction to group participation. Many BEL participants had been intimidated by the idea of being in a group, but their positive experience from BEL had reduced their feelings of stress and made them prepared to take part in other group interventions. In terms of what contributed the most to the participants' satisfaction, the occupational therapists reasoned: 'It was the structure, the routines, the socializing, coming the same weekday and meeting the same peoplemaybe the BEL contents were not the main thing' (OT 12). Similarly, a manager said: 'BEL shows in black and white how your activities versus resting looks' (M 3). One occupational therapist exemplified how a participant benefitted from BEL: There was this man they (the team) had seen within the mental health care for many years./ … /They said they'd not been able to get anywhere with the CBT, couldn't get him going./ … /When he'd done the BEL course, he started a movie circle. And became much more active and then many wanted to know, how come, how had I succeeded with that and so on. It's difficult to explain a whole process like that. Anyhow, they simply saw it (BEL) as an alternative to CBT (OT 2).

Discussion
This study identified a variety of personal and environmental aspects that both facilitated and hindered the implementation of the occupation-based and recovery-oriented BEL intervention. The findings will be discussed from these two aspects and conclude with a section highlighting implications for future implementation of BEL.

Personal factors
The BEL participants, group leaders, managers and other staff were persons with influence on the implementation of BEL. Whether a manager was in favour of assessments or was more rehabilitation-oriented could affect the possibilities of fully implementing BEL. Their expectations for the occupational therapist of working with the structure in the clients' everyday life appeared to be a good basis for introducing and providing BEL. Their opinion that BEL could constitute a first step towards a return to work also entailed an endorsement of the intervention, since work-oriented interventions are recommended by current national guidelines [21]. Although BEL does not have a specific work focus, participants can choose to set goals towards developing their worker role if that is what they wish for in their recovery journey. It has been shown that running an occupation-based intervention such as the BEL program is a specific task that requires a confident leader with good skills and deep knowledge about both groups and occupations in order to achieve good results [13]. The managers' opinion that facilitating BEL was a fairly simple task that did not require a specific professional background could therefore potentially complicate the implementation of BEL. The finding mirrors a dilemma that many occupational therapists in mental health services encounter when attempting to base their work on specific occupational therapy theories. Other theories and an often predominant medical paradigm tend to overrule, resulting in a reduction of the occupational therapist role [22].
The occupational therapists were often dependent on other staff to recruit BEL participants. This procedure worked generally well but could occasionally result in clients being misinformed about the intervention, such as when day hospital staff could not distinguish between drop-in activities and the BEL intervention. It could be that their interest in implementing research results in clinical practice was low; findings have indicated that interested staff are more skilled in applying the intervention, including giving proper information to clients [8]. Although the target groups receiving BEL varied greatly between the participating clinics, both the occupational therapists and the managers found BEL suitable for the clients they served, which indicates a good fit in terms of the guidelines proposed by Saunders et al. [10]. Some initial strategies to make the participants comply with the BEL intervention included a careful assessment of the participant's motivation. Occupational therapists generally stated that it was easy to keep participants in the intervention since the content corresponded to the needs that the majority of the participants had. This supports that a high dose of the BEL intervention was delivered and received, expressed in the terminology used by Saunders et al. [10]. Another factor that appeared to contribute to high dose delivery was that BEL endorses so-called informal peer support, i.e. consumers supporting each other from their own experience [23]. This kind of support between BEL participants also seemed to result in them encouraging each other to attend all sessions in the program.

Environmental factors
The results show that the implementation was contingent on environmental conditions such as the existing supply of care, the political environment, and the physical setting. The services seemed to provide a variety of course-based interventions with foci in line with recovery colleges [24], especially handling stigma and diminishing symptoms impinging on clinical recovery. BEL was seen as an appreciated novel approach that filled an intervention gap and sometimes as a complement, for example for clients where CBT had not worked. However, occupational therapists often had to struggle to introduce BEL as a possible first-hand choice among other more established interventions, emphasizing a political environment that was strong and focussed on already existing types of treatment. New policies for the clinic could steer the rehabilitation focus in new directions, in line with previous implementation research [25]. In clinics where the services were governed by economic considerations, the implementation of BEL was affected, which concurs with Saunders et al. [10], who maintained that the political environment is a factor of substantial relevance for implementation. The physical environment could also facilitate or hamper the possibility of delivering the BEL intervention in a proper course format; in some settings it was not possible to organize seclusion and the risk of disruption was considerable. The importance of having access to a room without risk of being disturbed for a group-based intervention has been highlighted in previous research as well [26].

Implications for future implementation of BEL
The BEL group was a type of intervention that had been lacking in the services. This indicates that BEL was 'fit for purpose', enhancing the possibility of good implementation [10]. But what should be kept and what could be further developed regarding BEL? It seems important to stay with the two-partite framework underpinning BEL, that it is both occupationand recovery-based. Since occupational therapy theory and the recovery approach have many similarities, occupational therapists have a unique role in presenting recovery-oriented interventions that may shift the current mental health care climate towards a stronger focus on each client's recovery journey [6]. The impressions of both the managers and the occupational therapists were that the participants were satisfied with the intervention and that it enhanced their ability for being social through group participation. This aligns with the proposed importance of connectedness in the recovery journey [27].
Focussing on the BEL manual, it seems essential to keep the themes as they are, stay with having home assignments between sessions, and to maintain the structure for sessions and the intervention as a whole. It would also be important to stay with the options for flexible solutions, adjusted to each participant's needs and desires. The indicated amendments concern more power-point presentations and some language editing for better clarity. The home assignments were sometimes difficult to complete for the BEL participants, and the possibility for facilitating this link of the BEL loop should be considered. It could be about further instructions for goal-setting in the manual and/or to possibly link professional peer support to this step.

Methodological considerations
The authors of this study were also the developers of BEL, which makes allegiance a methodological concern. To counteract possible bias, the interviews were performed by a third researcher and the interview was based on topics suggested in implementation literature [10]. Trustworthiness was further augmented by adhering to the criteria proposed by Lincoln and Guba [28]; credibility, dependability, confirmability and transferability. Credibility and confirmability were ensured by (i) letting the two authors analyse some of the transcripts separately, (ii) critical discussions between the authors, (iii) providing quotes where all informants were represented. Dependability was maximized by the maximum-variation selection procedure, where representatives from various BEL trainings, various regions and various types of mental health services were sought. The careful audit trail served to strengthen all of these threecredibility, dependability and confirmability. The final criterion, transferability, is always disputable in a qualitative study, and is ultimately up to the reader to assess [28]. The findings from the current study cannot be generalized to another type of intervention or other care contexts but would be possible to transfer into other instances when an occupation-and recoverybased intervention is to be implemented in a multiprofessional mental healthcare team.
Since the interviews reflected experiences from 13 occupational therapists but only three managers, the therapists' experiences predominate the findings. Both perspectives were, however, represented in all three themes, and it would be natural that not all experiences and impressions of BEL were shared by the different stakeholders. The under-representation of managers, although unintended, did thus not cause any notable drawback as inferred from the findings.

Conclusion
The lessons from this study are that the implementation of BEL was facilitated by realistic expectations from managers and clear and concise information about BEL to the team. This, in turn, formed a good basis for accurate information to prospective participants and a successful recruitment to BEL. Hindering factors were policies and circumstances that were on a collision course with important features of BEL, such as when the length of sessions was challenged by demands for profit, and the need for seclusion was jeopardized by disrupting routines. It appeared, however, that the occupational therapists found strategies for overcoming such hindrances. Effective implementation was also complicated when staff were stuck in old prejudices concerning the aims and goals of occupation-based support. A recommendation based on this study would be that there ought to be a reasonable match between existing policies and the bearing principles of the intervention in order to implement a new occupational therapy-specific intervention in a multi-professional team. It is also extremely important with repeated information at all levels and making the intervention a matter of urgency for the whole team.

Disclosure statement
No potential conflict of interest was reported by the author(s).