Abstract
The Swedish version of the LGO, with its structured training of time-management skills, contributes to occupational therapy practice with an intervention that clients experience as bringing meaningful and positive changes to daily life functioning.
Time-management skills are crucial to manage daily occupations (Thomack, 2012) and therefore are important targets within occupational therapy. Time management involves cognitive function to understand and interpret time and includes organizational skills, planning of behavior in relation to time, and making effective use of time in daily activities (Claessens et al., 2007; World Health Organization, 2001).
People with neurodevelopmental disorders, such as autism and attention deficit hyperactivity disorder (ADHD), and people with mental disorders, such as affective disorders and psychotic illness (American Psychiatric Association, 2013; Valko et al., 2010), commonly have difficulties managing time in daily life. This issue has several consequences, such as being tardy for or missing appointments, failing to fulfill plans, and having too many or too few planned activities. Difficulties in planning and organization often create obstacles in activities, such as getting laundry or dishes done. Altogether, these difficulties in daily life may result in obstacles to keeping a job, high stress levels, low self-esteem, and broken relationships.
Commonly, interventions to enhance time-management skills in daily life prescribe adapted time-management aids in combination with recommendations for individually tailored strategies for skills development. Moderate evidence supports the effectiveness of such interventions (Gillespie et al., 2012; Lindstedt & Umb-Carlsson, 2013), and the need for evidence-based interventions targeting time-management skills in daily life has been highlighted (Langberg et al., 2008). Skills training in groups has a long history in mental health, and studies support the benefit of enhancing social skills. A study by Eklund et al. (2017) demonstrated the effectiveness of a group intervention to improve engagement and balance in everyday life among people with mental illness. Therefore, it can be assumed that time-management skills can also be successfully taught in a group setting.
Let’s Get Organized (LGO; White, 2007) is a manual-based occupational therapy group intervention that aims to improve time-management and organizational skills. The Swedish version of Let’s Get Organized (LGO–S) is meant to be used in outpatient care for people with mental and neurodevelopmental disorders. The content of LGO–S focuses on developing strategies that compensate for common difficulties related to time management of the target groups (Holmefur et al., 2019; White, 2007). LGO–S was recently evaluated in a pilot study that found promising results with regard to self-rated time-management, organization, and planning skills as well as satisfaction with daily occupations (Holmefur et al., 2019).
A deeper understanding of the mechanisms behind these results, and the participants’ own perspectives and difficulties during and after intervention, can aid in further development of interventions to improve time management. Therefore, it is important to study the participant experience of LGO–S and any differences participants perceive in their daily life. Such knowledge can contribute both to further developing the LGO–S intervention and to identifying crucial components to improve the rehabilitation of poor time-management skills in general. Therefore, the aim of this study was to describe the participant experience and the meaning of attending 10 sessions of the LGO–S intervention.
Method
This study had a qualitative design in which participants who had attended LGO–S were interviewed individually. Data were analyzed with qualitative content analysis aiming to capture the variation in experiences (Graneheim & Lundman, 2004). The study was approved by the Regional Ethical Review Board in Uppsala, Sweden (2015/185).
Intervention
LGO–S consists of 10 sessions. The participants gather once a week for 1.5 hr in a group of 5 to 8 people. Each session is led by two group leaders with 2 days of special training in giving the intervention. LGO–S is an occupational therapy intervention; therefore, at least one of the group leaders must be an occupational therapist. All sessions focus on learning to use a calendar to structure time to handle daily life. In addition, each session has a defined theme, such as estimating activity duration, identifying one’s own occupational patterns, prioritizing in daily life and creating to-do lists, tracking energy expenditure, learning how to get time on one’s side, and planning activities on the basis of one’s own circadian rhythm. Time is allocated for discussions and work with activity sheets (i.e., analysis of one’s own energy levels during the day). The participants have home assignments between some of the sessions, primarily aiming to implement what they learned in daily life; the content of these assignments is followed up during the next session. The pedagogical approach is built on trial and error in a positive manner in which errors are seen as opportunities to learn instead of failures (White, 2007). For detailed content of each weekly session, see Holmefur et al. (2019).
Participants
Participants were recruited from five outpatient clinics, three psychiatric care clinics, and two adult habilitation services in four county councils located in middle Sweden. After finishing the LGO–S intervention, clients were asked by their occupational therapist about participating in this study. Oral and written information was given, and if the person was willing to participate, they signed a written consent. Contact information was then forwarded to the researchers, who contacted each participant and booked the interview. One participant dropped out without providing a reason after giving informed consent but before the interview, resulting in a total of 7 women and 5 men who participated. Participant characteristics can be found in Table 1.
Characteristics of the Participants (N = 12)
Note. ADD = attention deficit disorder; ADHD = attention deficit hyperactivity disorder; ASD = autism spectrum disorder.
Data Collection
A semistructured interview guide was developed. To capture the content of the intervention and as a reminder to the participants, we used the LGO–S intervention manual as a starting point. Questions regarding participants’ experience of different aspects of the intervention were posed together with a question addressing whether and how the content was helpful for them in their daily life. Examples include the following questions:
“How helpful do you think it was to practice using the calendar during the course?”
“Tell me whether and, if so, how you use your calendar now.”
“How does the calendar benefit you?”
“What do you think about the conversations about routines and their importance?”
“Have these conversations benefited you? If so, in what way?”
Questions also pertained to how the participants experienced the format of the intervention and sessions. Questions were expressed in a way that facilitated participants’ descriptions of their thoughts while being narrow and concrete enough to meet their impairment-related needs.
All interviews were conducted by one of the researchers (Anita Tollén), an occupational therapist with experience in performing research interviews but with no previous relationship to the participants. The participants were informed that the interviewer was a researcher and occupational therapist who had interest in knowing about their experiences of LGO–S. The interviews were conducted 1 to 4 mo after the intervention. All interviews took place at the clinic where the participant was treated. No one other than the interviewer and the participant were present. The first 9 interviews added new variations to data continuously, whereas the last 3 interviews mostly repeated the content of previous interviews. Therefore, data collection stopped after 12 interviews (Graneheim et al., 2017). The interviews lasted between 25 and 72 min (M = 55 min) and were audiotaped and transcribed verbatim. No field notes were made. The transcripts were not returned to the participants.
Data Analysis
To analyze the data, we conducted a qualitative content analysis (Graneheim et al., 2017; Graneheim & Lundman, 2004). To facilitate the structuring and analysis of data, we used the software program NVivo (Version 11). All interview transcripts were read several times, and a memo that summarized the content of each interview was written to capture a sense of the whole. Meaning units were identified, condensed, and labeled with a code. The first three interviews were analyzed together by all the authors. Thereafter, the first author (Kajsa Lidström-Holmqvist) continued the coding process.
After coding all data, we discussed possible categorizations. The first author made a tentative categorization based on the discussions and went back to the memos and meaning units to ensure that the categorization reflected participant experience and that probable interpretations of data were made. We then discussed the tentative categorization. Overall, a consensus was reached, but some minor adjustments were made before the final categorization was established. A descriptive theme (Graneheim et al., 2017) that illustrated the latent content connecting all categories was formulated. The participants did not provide feedback on the findings.
Results
The participant experiences were characterized by a process from understanding one’s own difficulties in relation to time management to perceiving changes in daily life. A common feature in these participant descriptions, and the overarching theme, was a roller-coaster process in which success and setbacks were mixed (Table 2). During the LGO–S intervention, the participants learned about their own needs and possible tools in relation to time management, facilitated by the group format. During and after the intervention, participants tried, adopted, and rejected strategies to ascertain which ones were helpful in their own lives.
Theme, Main Categories, and Subcategories
The process of change, or implementing new routines and habits, was described in terms of hard work and a need to persevere and not give up. The process was facilitated by the meaning that the participants found in making life more functional. When new routines were established, the perceived changes in daily life were both emotional and practical, leading to a sense of having control over time in daily life and thus being a person to count on. The main categories with subcategories are listed in Table 2. The first two main categories describe what happened during the sessions of the LGO–S intervention, and the last two main categories describe the work with changes in daily life during and after the intervention (see Table 2).
Understanding Why and Knowing How: A Prerequisite for Change
The participants gained a better understanding of themselves and how their difficulties affected their everyday life and, thus, what they needed to change. They had received explanations for their difficulties, which they found relieving. These factors were a prerequisite for being able to grasp, and find meaning with, the concrete tools that the course introduced.
To Understand and Put Own Difficulties and Needs Into Words
The participants described that discussing and visualizing issues, such as one’s own habits, circadian rhythm, and occupational patterns, opened their eyes to how they used their time and why some things did not work. This insight gave motivation and meaning to work for a change. According to Participant 4, “And then I realized, this doesn’t make sense. Now I am doing a lot of things when I am so low on energy, and then nothing in the evening when my energy levels are high.”
Participants described how they realized that they already used some compensatory strategies. This awareness made the use of strategies intentional and, thus, possible to develop further. For other participants, thinking in terms of compensation was new. Moreover, the participants expressed how they had to continue to work with themselves, change how they perceived themselves, and learn more about themselves. They also described an increased awareness about how emotions affected their ability to manage time effectively. It was important for many participants that the intervention had given them a language to communicate their difficulties to others and express what kind of support they needed.
Participants described issues that they previously had been unaware of, such as the association between fatigue and their own ability to plan and be one step ahead, or the association between lack of routine and feelings of stress. They had discovered their own needs, and some had changed their attitude toward, or perception of, structure and routines. According to Participant 9,
One should not look at routines as something insanely boring, so everyday boring, but one can really benefit from routines as well, and try to angle them so that they will be a help, and “God, so good and nice to have a life with routines,” you know, see it from that perspective.
Getting Concrete Tools for Change
The participants viewed the tools learned during the intervention as a smorgasbord. They tried them and chose the ones they found helpful. Most participants had some previous experience of using a calendar; a common feature of their descriptions of their status before the intervention was that they had stopped using the calendar or used it sporadically in an unstructured way. Learning how to use the calendar effectively had turned it into a meaningful and important planning and organization tool. The participants emphasized the importance of group leaders urging them to use the calendar, that they taught them how to fill out and use it in a practical way, and that this instruction was followed up continuously during the intervention.
The importance of matching the type of calendar with personal needs and preferences was highlighted, and participants had changed the type of calendar they preferred both during and after the intervention. The participants had a common need for visual overview and clarity, which was something most of them discovered during the intervention. For some, it was necessary to combine the calendar with other tools, such as alarms in their cellphone, to be successful.
Unlike the calendar, many other tools or strategies were unknown to the participants before the intervention. They had little experience creating sustainable routines, dividing activities step by step, using priority lists, or planning consistent with their energy levels. The usefulness of these tools or strategies was described in various ways; some found them hard to implement, whereas others found them really useful. A prominent finding was that an awareness of one’s own energy levels was helpful for most participants.
The participants had divided opinions of the tool to reward oneself after having done something exhausting or important. Some found it motivating, whereas others saw this incentive as one of their problems, namely, that they always prioritized fun before boring activities and thus found this tool meaningless.
A Facilitating Learning Environment
The participants were satisfied with the group format, even though it could be challenging to interact with people with different symptoms. For some, a group feeling came immediately, whereas for others, it took several sessions. All participants were satisfied with the group leaders, who were described as catalysts who kept them on track and conveyed a positive and permissive atmosphere. Some participants, however, expressed a wish to complement the group with one or more individual meetings with a group leader. A common opinion was that they wanted regular follow-ups after the intervention to discuss implementation matters and to get motivation to continue their work with applying time-management strategies in daily life.
To Be Among Peers
Many participants expressed nervousness before the first group meeting; afterward, they found this feeling to be groundless. They felt that they were among peers and did not have to explain or justify their problems. Some participants described that they finally felt normal and accepted for who they were. Having similar difficulties created a sense of fellowship. They found relief in being able to talk about things that people outside the group considered uncomplicated but that created major difficulties for the participants; moreover, it was helpful to discuss these issues without feeling worse as a person or embarrassed. According to Participant 11, “It [to not be alone] felt like it was maybe possible to do something about it.”
To Give and Take From Each Other
The meetings were described as both fun and therapeutic, and the participants learned a lot from each other. Sharing experiences and strategies or getting tips was described as important. Those who felt that they had come further on their way toward a functioning everyday life described both satisfaction with and gratitude for the opportunity to share their experiences (e.g., with younger participants with a less functioning way of life). It created a sense that the relationships developed in the group were meaningful. To get tips and experiences from others in the same situation gave more credibility to the strategies. According to Participant 7, “When there are so many sessions, you need to open up and feel comfortable . . . and then I think you have a huge yield from each other.”
Meeting Others Brings Perspective on Own Difficulties
Taking part in other people’s lives was one of the most rewarding aspects of the group format, and it gave the participants new and valuable perspectives. By looking at themselves from the perspective of others, participants gained insights about both themselves and how other people think and act. This perspective was educational and contributed to a greater understanding of people’s differences. According to Participant 8, “It was interesting to hear how other participants had ended up in different situations, and do end up in different situations, because of their difficulties.”
Struggle With Implementation in Daily Life
The intervention helped the participants to manage time in daily life in a better way, but this progress was not something that came easy. Time management was described as a continuous struggle with one’s own emotional obstacles, barriers because of their limited time-management skills, and difficulties going from knowledge of how to do things to concrete action. Participants found it most challenging to make routines and strategies other than the calendar work.
Routines Don’t Come Easy; It Is Hard Work
The participants described how their struggle for a life with working routines and strategies continued after the intervention. They noted challenges in following routines, continuing to use new strategies, and not falling back into old habits. Ongoing work was required to figure out which strategies and routines suited one’s personal life. Some participants found it difficult to break with old routines even though they knew that they were not good for them. Descriptions were also provided of difficulties that arose from the social environment and that made the participants feel discouraged. Incorporating a strategy or routine into daily life was described as an ongoing struggle in which setbacks were a natural feature. According to Participant 1, “There have been periods when I’ve managed [to follow my circadian rhythm], but then I backslide, and then I have to fight [to follow it again].”
Fight Against Own Emotional Obstacles
Some participants described different aspects of emotional resistance to using the strategies learned. Those who were employed used multiple strategies that were necessary to handle work. Their home life, in contrast, could be more or less chaotic with no or almost no routines, even though the participants knew that routines were needed. According to Participant 9, “I use it [calendar and strategies] at work all the time; it’s the only way to keep track of everything. And in turn, I do not use that at home.”
Other participants stated that although they needed routines, they disliked them, or that it felt wrong to be so structured. Most of all, it was difficult to follow routines for boring activities. Some participants also found it strange to plan for such things as rest and fun activities, or they felt stressed by a structure that was too fixed or when an overview made them realize what they needed to do.
Struggle With Time
Some of the difficulties described can be related to the impairments of the participants. Difficulties in abstract thinking and imagination were, for some participants, an obstacle to understanding parts of the intervention content. Some found it difficult to shift and share attention in a group format, such as simultaneously focusing on both the group and the content. Difficulties in time management on a functional level, such as estimating time, were also described, especially in relation to activities in which the time requirements varied. According to Participant 10,
The time required for a planned activity that I have, I perhaps know that it takes this amount of time, but to wash small dishes, what is small? Or to wash large dishes, how long will that take? I do it until I’m finished, and I have no idea.
Perceived Outcomes of Improved Time Management in Daily Life
The participants described what the changes after the intervention had meant for them in daily life, both for activity performance and on an emotional level.
Getting More Things Done
Common for many participants was the perception of getting more things done in daily life. They did not miss as many appointments, they completed initiated activities to a greater extent, and they made wiser prioritizations. Some had also changed daily routines, such as spending less time in front of the computer or starting to exercise.
They described both planned and unplanned uses of the strategies learned. Using strategies in an unplanned way was described as “just popping up” to be used in the moment. Most participants became regular users of their calendars, which they described as a very valuable tool to manage daily life. According to Participant 6,
It has only advantages. Even though it’s easy for me to remember things in my head, [the calendar] kind of gives me a kick in the ass, so to speak. If I have written something down and what time to do it, then I also do it.
A majority of the participants found their new knowledge about their circadian rhythm useful. They described a changed activity pattern in which they considered their own rhythm when planning activities. They also found it easier to plan daily life after learning how much time frequent activities took; moreover, realizing that time was needed for things such as transportation also helped.
Learning how to prioritize and use lists was highlighted as very useful to decrease stress. Some participants concluded that, before the intervention, they prioritized things in a bad way, or not at all, but now they prioritized better. For others, prioritizing was still hard. For some, dividing activities step by step and taking breaks led to finishing activities that had previously been challenging. Others described that the combination of strategies made a difference in daily life. According to Participant 5,
In some ways, less is done, but what is done is almost always finished now. In that way, it has been much, much better. It’s about planning a little better, and having the to-do lists, and then thinking in terms of energy, that I kind of should have energy throughout the day. Well, it has made a huge difference.
Emotional Changes
The participants described how the intervention and the changes they had implemented in daily life had a positive impact on their sense of control, stress, satisfaction, and self-esteem. Many participants described a feeling of calm and security when using the calendar and other strategies, such as lists and prioritization. The use of time had turned into something visual, and thereby, it was possible to control how to use time consciously, even into the distant future. Daily life was described as easier, and the gained control reduced negative stress and contributed to the meaningfulness of using the tools they had learned. Even though life still was stressful from time to time, the stress of not having control over what had to be done was reduced and contributed to well-being. According to Participant 1,
Then I feel better, yes I do. Then I don’t feel like everything is boiling in my head, I can kind of allow myself to relax, because now I have this list, and I know what has to be done . . . this structuring makes me feel better.
The participants also described increased satisfaction with daily life. It was fun and rewarding to cross out completed activities and to get more things done. For some, one result was better order in the home, which was described as satisfying. Some participants described that they had previously had some control at work but not over household activities, and now they had gained control over life as a whole. Using the calendar also reduced the need to remember activities and saved energy for other things. Participants who had difficulties doing boring tasks still found it satisfying to manage these activities because they were necessary.
Participants described how attending the intervention and gaining better control over activities and time had a positive impact on their self-esteem. Self-esteem was improved by meeting others with similar problems, not needing to be ashamed because of forgetfulness, and understanding that some things that had to be done required some planning, even for those who were on sick leave or unemployed.
Discussion
In this study, the experiences and meaning of participating in the LGO–S intervention were described. The results show that participation had a major and positive impact on the daily lives of the participants, although it required active commitment by the participants themselves. The meaning of participating in LGO–S can be viewed through the basic needs to create meaning described by Hammell (2004): purpose, meaning, choice and control, and self-worth. Participation in LGO–S was described as a purposeful occupation that was personally meaningful and valuable. One of the emotional changes described was a sense of control and of being someone to count on. This outcome can be related to choice and control as well as self-worth, which are important aspects of meaning making in daily life (Hammell, 2004; Ikiugu et al., 2012). Thus, participating in LGO–S was a meaning-making occupation for the participants both during and after the intervention.
A common experience was the increased use of a calendar, which was perceived as an important factor in making daily life easier and more satisfying. This finding is positive but not surprising because use of a calendar was at the core of the intervention and was discussed and followed up at all sessions. However, the fact that many participants did not have the ability or motivation to use a calendar before the intervention shows that structured training in its use is needed. Our results show that the participants had more difficulties implementing other tools in daily life such as creating routines or dividing activities into smaller tasks. These tools were in focus for only one or two sessions, meaning that opportunities for practice and support in their use were more limited. A conclusion might be that structured training and support over time are important. This conclusion is further supported by the struggle that the participants described in regard to implementation. Our findings are in line with implementation research that shows that instructions and recommendations are not enough when introducing a complex task. Continuous facilitation is needed to implement something new (Greenhalgh et al., 2004).
The results convey the process of change in the participants. This process was, in many ways, similar to the general process of change described in the literature (Grol et al., 2007). However, for some participants, the decision to adopt a new behavior was not easily implemented because they had to fight against their own emotional obstacles. In other words, their decision to change their behavior was more continuously challenged by their emotions regarding their need for time management strategies compared with people in general. This inner struggle might be related to the stigma connected to having a mental or neurodevelopmental disorder. A literature review of stigma experienced by people with ADHD shows that stigma is an underestimated risk factor that can, among other things, affect treatment adherence and treatment efficacy (Mueller et al., 2012). A clinical implication might be to incorporate discussions on stigma in the intervention.
A key feature of the results is that participants had accepted that an occasional failure to live up to their own ambitions is a natural part of learning and should be seen as a potential to learn more. In the intervention, this concept is explicitly taught as “succeed or learn.” Even though this concept was not explicitly described in the interviews, it is clear from the results that the participants had acquired this attitude, which is very promising. This finding is especially important because clients with neurodevelopmental and mental disorders often have a history of repeated failures in the past that, for many of them, have led to low self-esteem (Dan & Raz, 2015). A change in attitude toward failures might be a prerequisite for positive development and for the motivation to take on the struggle with implementation in everyday life.
Some differences among participants were found in how they perceived the intervention, and these differences seemed to depend on the participant’s specific type of impairment. Group leaders should be sensitive to differences among clients in the challenges they perceive, which might also affect the group process. Overall, however, the participants described the group leaders in a positive way. The leaders conveyed a permissive climate and helped the participants to focus on the content. The permissive climate, in particular, seemed to be important for the outcome. Several participants described feelings of being different from people in general, and not having to try to be normal seemed to be a facilitating factor in the process of change. This finding stresses the importance of highly competent group leaders, who should have solid professional training (e.g., as occupational therapy practitioners), experience working with clients with cognitive difficulties, and specific training in leading the LGO–S intervention.
Limitations
A limitation of this study is that the participants were selected only from those who had completed the LGO–S intervention. Therefore, we have not captured the views of people who, after attending a few sessions, decided that the intervention was not suitable or helpful for them or who dropped out because of increased psychiatric symptoms or for family reasons. As a result, the sample may have been more positive about the intervention compared with the population of all possible intervention participants. In addition, a few study participants participated in as few as four sessions. Their experience was limited to only parts of the intervention. However, because the last interviews did not add more significant variations to the data, and because the participants varied in regard to gender, age, and living conditions, the credibility of the results is strengthened (Graneheim et al., 2017).
The dependability of the analysis process is important to consider, because each researcher had a different preunderstanding and interpretive repertoire (Graneheim et al., 2017). To strengthen the dependability of this study, all authors took active part in the analysis process, and consensus was reached (Graneheim et al., 2017).
The interviews were conducted 1 to 4 mo after the completed intervention. This span was deemed short enough for participants not to have forgotten the intervention and long enough for them to have experienced the implementation of the intervention in daily life. However, participants’ experiences might change during this period. For example, it takes time to create routines, and perhaps 1 mo is too short a period for that. Four months, however, is enough time to lose the strategies learned. The results show that the time span was long enough to capture the participants’ experiences of struggling with implementation. Thus, the results are limited to short-term experience of the LGO–S intervention. More studies are needed to investigate the experiences and usefulness of the LGO–S intervention after a longer period of time.
Implications for Occupational Therapy Practice
The results of this study have the following implications for occupational therapy practice:
The LGO–S contributes to occupational therapy practice through an intervention that clients experience as bringing meaningful and positive changes to daily life functioning.
It is important to give clients the opportunity for structured skills training with support over an extended period of time.
Using a group format and helping clients change their view of failure appear to be important success factors.
Conclusion
The results of this study show that the LGO–S was experienced as a meaningful intervention that produces positive outcomes in daily life in regard to time management as well as planning and organizational skills. The possibility for skills training with support over an extended period, a change in participants’ view of failure, and the group format appear to be important success factors. The results confirm that continuous skills training with support is important in helping clients implement sustainable changes for better performance in daily life. Feelings of stigma should be addressed to overcome barriers to using compensatory strategies.
Footnotes
Acknowledgments
This work was supported by the Faculty of Medicine and Health, Örebro University. The authors report no conflicts of interest.