Dr. Pols is affiliated with the Department of General Practice, Amsterdam Medical Centre, Meibergdreef 15, 1105 AZ Amsterdam, the Netherlands (e-mail: firstname.lastname@example.org). Dr. Kroon is with the Netherlands Institute of Mental Health and Addiction, Trimbos Institute, Utrecht, the Netherlands.
Leisure is defined as time that is not structured by employers, family members, or by self-care needs (1,2,3). The scarce research into the experience of leisure for people with chronic mental health problems indicates that this area of interest is overshadowed by the more common clinical focus on treatment and stability of illness.
However, this specific group gains much satisfaction from engaging in leisure activities (4) and spends a relatively large amount of time on leisure activities (5), which have great potential to improve quality of life (5,6,7). At the same time, leisure is one of the key areas of dissatisfaction for them because they lack possibilities to spend this time in ways that are meaningful to them (8,9). Previous studies on leisure have examined all types of leisure activity together.
This Open Forum describes the experiences of people with chronic mental health problems on holiday trips that were organized by a nonprofit travel agency in the Netherlands called Radar Reizen (Radar Travel in English). The travel agency regards leisure travel as an activity that allows users of mental health care services to participate in a typical community activity. Holiday trips tend to be viewed with suspicion from a clinical perspective, because of the assumption that that these trips may interrupt carefully established routines of care and may exacerbate symptoms.
Radar Travel organizes day trips and holiday trips for people in the Netherlands who are registered as users of mental health care services. Travelers pay for the trip, although part of the expenses related to the support provided by a team of psychiatric nurses is funded by their health insurance. Radar Travel employs three psychiatric nurses and 25 volunteers, ten of whom are psychiatric nurses as well. Apart from Radar Travel, there is only one small travel agency for this specific group in the Netherlands.
In our study we explored three questions. What are the travel experiences of people with mental health problems? What conditions need to be fulfilled in order to have successful trips? And how do these trips contribute to the general aims of psychiatric rehabilitation?
Because there is no literature on this specific subject, we opted for a qualitative research design. Participant observation took place by one of the researchers (JP) on two trips. The first trip, which took place in August 2004, was to a holiday cottage in the Netherlands. Seventeen travelers who were aged 35 to 82 years and two psychiatric nurses went on the trip, which lasted eight days. Excursions were improvised and were not obligatory. The second trip, which took place in September 2004, involved a 24-hour bus ride to a hotel on the Costa del Maresme in Spain. Twenty-seven travelers who were aged 23 to 85 years and four psychiatric nurses went on the trip, which lasted ten days. Excursions were voluntary.
The travelers we studied included residents from psychiatric hospitals and sheltered housing as well as people who lived independently. Radar Travel's policy requires that no information about diagnoses was obtained before the trips. Impressionistic evidence indicated that a broad range of diagnoses were represented, most prominently schizophrenia and borderline personality disorder. Travelers were informed about the presence of the researcher and the aims of the study. They were explicitly given the opportunity to refuse their cooperation. Observations were recorded daily in detailed field notes, which were anonymized and discussed with fellow researchers.
Four psychiatric nurses connected to Radar Travel were interviewed in depth. The interviews lasted between half an hour and one-and-a-half hours. Eleven travelers were interviewed in depth: eight of these travelers were interviewed two to three months after the trip and three traveled with the agency at least once a year. Informed consent was sought through Radar Travel and by selecting spontaneous volunteers to be interviewed from the trips. The respondents were asked to report their experiences, both positive and negative, as well as the significance of the holiday trips in their lives after returning home. Variety in the respondents was sought regarding age, sex, and holiday experiences (theoretical sampling). The interviews were tape recorded, anonymized, and transcribed verbatim. The interviews were in Dutch and were translated by the authors. Names listed in the quotes below are not the interviewees' real names.
For the analysis we ordered the material according to the reported and observed positive experiences of the travelers, the conditions for successful trips, and problems to address in the future. Drafts of the research report were discussed with four fellow researchers and with staff from Radar Travel.
Persons interviewed indicated that that they considered "going on holidays" part of ordinary life. In 2004, 81% of the Dutch population went on a holiday trip (10). To the travelers, being able to go on holiday trips marked a step in their recovery.
One traveler said, "I used to go away for a short time every year, if at all possible. But this [traveling] is something I took up again only recently, since I am doing better. And if you are doing better, you also want to do these things again."
But why do these travelers use a specialized travel agency? For most travelers this was a simple question: they either used this agency, or they did not travel at all. People were anxious about going on vacation without support or were afraid that they would feel like they were "the odd man out" on regular trips.
A traveler said, "When I went with that regular travel agency, I had to explain why I use medication. I told them, 'I have schizophrenia.' [They said,] 'What is that?' I said, 'This is that you think there is a war going on, you have delusions.' And they don't quite understand that. With Radar Travel you don't have to explain. You just say, 'I have schizophrenia.' 'Oh, I have manic depression.'"
Despite the absence of care plans or rehabilitation methods, the holiday trips turned out to support psychiatric rehabilitation aims in important ways. First, the trips resulted in an increase in skills in establishing and maintaining social contacts. This is an important goal in psychiatric rehabilitation that is relatively hard to achieve. Group holidays allow for a variety of forms and intensities of social contacts. Some participants appreciated the opportunity to engage in easy and superficial contacts. Others made friends, kept in touch after the trip, and even visited each other afterward. There were a few romantic affairs as well. Other travelers planned a yearly trip together.
The trips also had an impact on relationships at home. Sending postcards or bringing back souvenirs reinforced existing relations. For example, one traveler said, "In the café [back home] people ask, 'Jane, when will you be off for your next trip?' And then you send them postcards. The woman from the flower booth gets a postcard. One time, I was so silly. I was in Czechia, and I sent 60 postcards, because it was ridiculously cheap—it was 25 cents for a card. I wrote to everyone in my list of addresses. It is so much fun! You keep contact; you write to all the people."
Coming home with travel reports had a positive influence on the self-esteem of participants. Travelers were able to talk about themselves in a positive way, without discussing problems, health care, or worries.
One of the psychiatric nurses said, "It gives them a sense of self-esteem, because they have something special to discuss. And before that, it was always the family that went on trips, and it was they who had the pictures. And they did not show them, because 'that would be sad for the son, because he cannot go.'"
The trips also allowed people to reconnect. For example, a married couple went along on one of the trips. They explained that they were not able to live together, but the holidays allowed them to be together, if only for a week.
The second achievement related to general rehabilitation aims is the influence of these trips on the ability to maintain stability in daily life. Most respondents talked about the very structured and disciplined lives they were living.
One traveler said, "Holidays also imply freedom. My daily life is very structured. My voluntary job four times a week is very structured as well. And in my home, all the domestic duties also bring a lot of structure with them. [It's good] to leave all of that behind for a while, to see other people and things, to get out of this situation of discipline—for a change, to broaden your horizon, to see that there is something outside your home. There is so much you do as a routine."
The focus on one's own worries and daily activities is common in this group, and it helps patients to stabilize their daily lives. However, the trip allowed them to shake off this structured life—albeit temporarily. But the time out also allowed them to return to their normal routines, this time with a fresh perspective.
A traveler said, "I am in daycare. And then it is really nice to be able to travel once or twice a year. Otherwise, everything is so empty. It's all the same. It is a way to get out of the rut. You can notice when a person has been on a trip, because he or she is much more cheerful than an ordinary person. I get inspiration to do things. I clean the house. I do a lot of things."
The holiday trip also provided the opportunity to engage in different behavior and to experiment with social roles. One could be a tourist, a connoisseur of other cultures, or a hiker. Travelers developed skills that they had not often used in daily life, such as speaking foreign languages, using organizational talents by preparing a goodbye party, plotting routes on maps, or collecting information about the new environment on the Internet. This provided them with memories to cherish and gave them the opportunity to develop skills and possible repertoires of behavior, which aided them in imagining different lifestyles.
For example, one of the travelers enthusiastically related how when the group of travelers saw a house for sale on a Spanish boulevard, they began talking about how they could buy it and return every year for a holiday. They brainstormed how they could ask for support from the Spanish mental health care system and sell souvenirs on the boulevard to earn some money.
It is unlikely that this scenario will actually occur, but imagining such alternative futures is important. It can put one's daily life in a new perspective and allows for reflection on daily routines. Discussion of such scenarios can indicate possible directions for development—again a common theme in psychiatric rehabilitation.
Finally, holidays meant an enrichment of life because of the enjoyment they provided. With passion the travelers ate different food, slept in, spent money on souvenirs, and sat in the sun, scarred arms uncovered.
One of the difficulties that many travelers mentioned was dealing with days that were unstructured; this required some initiative on the travelers' part, because some of the travelers were not used to a lack of structure in their lives. For the psychiatric nurses, the organization of these holiday trips led to their having to balance travelers' free time and time organized by others (freedom versus care). On one hand, the psychiatric nurses wanted to grant the travelers the freedom to enjoy their own time in ways that the travelers preferred. Leisure time is not meant to be structured by professional caregivers with therapeutic aims. From this perspective, the psychiatric nurses did not want to structure too many activities for the travelers, so as to not patronize them. On the other hand, the legitimacy of Radar Travel lies in the support offered during the trips. If there were no support, people would not travel or they would not be able to properly manage themselves and their care during the trip. From this line of reasoning the danger is not to patronize people, but rather to neglect them.
Generally, support was needed with managing medication and money in addition to brief counseling conversations. But the most important work of psychiatric nurses was to prevent problems from arising by stimulating some individuals while slowing down others and to induce a feeling of safety by just being there. However, in one instance, problems arose that required the psychiatric nurses' expertise. In Spain one of the travelers experienced a psychotic episode and another wanted to go home before the end of the trip. Every traveler was insured for such an occasion. A local psychiatrist evaluated the situation and decided that the two had to return home with the guidance of a psychiatric nurse sent from the Netherlands. However, the fact that the trip might end abruptly seemed to be a calculated risk for the travelers.
One traveler said, "Well, yes, there was some turbulence. But I thought, 'This is what may happen.' That is how I think. 'Next time it's me,' so to speak. I don't worry, especially because they were all mentally ill people."
For the psychiatric nurses, guiding holiday trips was an important learning experience. As one psychiatric nurse said, "For me it is an essential part of my professional development. You go on a trip with people you don't know, not bothered by medical histories or prejudices. You don't have institutional rules or treatment goals. It makes you think about the way you want to relate to your clients. It happens so often that you take responsibilities out of the hands of our clients, and here you see that people manage all right. I think every psychiatric nurse should do it by way of education."
Mental health research has neglected to investigate the influence of holiday trips on the mental health of individuals with psychiatric problems. Nevertheless, these trips support goals that contribute in important ways toward reaching psychiatric rehabilitation goals. The trips helped travelers establish and maintain social relationships. Going on a trip meant participating in an activity that is undertaken—and talked about—by most of the Dutch population, thus providing positive subjects for these persons to discuss with others. Slumbering creativity and talents were developed, and possibilities in life were reflected on or experimented with. At the same time, the holidays gave this group a break from routine, so they were better able to keep up the discipline needed to maintain stability in daily life. These are all matters that are important in psychiatric rehabilitation.
However, the trips differ from rehabilitation as we know it because there were no methodical approaches or goal-oriented individual programs. The goals attained were not predefined or the object of systematic intervention, but rather stemmed from voluntary and motivated actions.
For the psychiatric nurses these trips turned out to be valuable experiences because they allowed the nurses to experiment with different ways of relating to persons with psychiatric problems who were similar to those who they treated or supported professionally. On these trips, the psychiatric nurses were not familiar with a person's history of treatment. Balancing providing care and allowing freedom on these trips provided the nurses with new ways to reflect on their work.
Because of the qualitative design, it was not possible to generalize our findings in a straightforward way. Because we did not collect data on the characteristics of individual travelers and did not use an experimental design, the study did not allow us to draw conclusions about which groups might benefit most from holiday trips. The only significant selection criteria applied by the travel agency was that travelers received long-term mental health care and that they went on these trips voluntarily. Our study demonstrates the richness of possible meanings of holiday trips and how the trips are linked with rehabilitation goals that are very hard to realize in an institutional setting. The results should be seen against a background of diminishing opportunities for travel for these patients, because mental health care institutions no longer organize trips. Furthermore, rather than celebrating trips as a demonstration of return to a more normal life, as the patients did, clinicians tend to be wary of the stress and the possible exacerbation of symptoms that holiday trips may cause. By traveling with these patients and hearing their stories about the trips, we were able to sketch the contours of an original and promising new practice in the rehabilitation of people with long-term mental health problems.
The research was funded by Fonds Voor Maatschappelijke Initiatieven, Provincie Overijssel, Stichting Radar, Provincie Gelderland, Provinciale Patiënten Consumenten Federatie Gelderland, Vrienden van de Zwolse Poort, de Cliëntenbond, Belangenorganisatie Cliënten Geestelijke Gezondheidszorg, Anoiksis, Stichting Borderline. The authors thank their colleagues Marja Depla, Ph.D., Ingrid Baart, Ph.D., Jacomine de Lange, Ph.D., and Nicole van Erp, M.A., for their comments and suggestions.
The authors report no competing interests.