Implementing Everyday Life Rehabilitation (ELR) in Supported Housing for Individuals with Serious Mental Illness: Occupational Therapists' Experiences of Professional Discretion During Early Implementation.

Abstract

Background: Everyday Life Rehabilitation (ELR) is a collaborative, person‑centered, activity- and recovery‑oriented intervention model developed for supported housing (SH) for individuals with serious mental illness (SMI). ELR promotes long-term recovery through collaboration between residents, occupational therapists (OTs), and housing staff. While ELR has demonstrated positive effects and cost‑effectiveness in a randomized controlled trial (RCT), implementing collaborative models across health and social care boundaries remains challenging. This study aimed to explore how OTs experienced the interplay between their professional discretionary space, understood as their capacity to act, and the early implementation of ELR within collaborative, cross-sector rehabilitation in SH.

Methods: Semi-structured interviews were used to collect data from 14 OTs across ten Swedish municipalities involved in the ELR RCT; two participants provided written responses to the same interview guide. Data were analyzed using reflexive thematic analysis.

Results: Three themes were identified: (1) Organizational and normative constraints shaping professional discretion in collaborative rehabilitation; (2) Professional identity and method alignment legitimizing professional discretion in rehabilitation; and (3) Relational and reflective practice with participants shaping professional discretion. OTs described how residents with SMI were often a low-priority group within municipal services, limiting opportunities for sustained rehabilitation. Organizational cultures, fragmented collaboration, and competing mandates constrained discretionary space and challenged fidelity to the ELR model.

Conclusions: Sustainable implementation of complex collaborative interventions requires organizational conditions that support professional discretion, trust-based collaboration, continuous engagement with residents, and active leadership. Together, these factors enable the integration of activity- and recovery-oriented rehabilitation into routine practice and reduce dependence on individual champions.