As a mental health researcher who recently completed a postdoctoral fellowship focused on the relationship between employment and recovery, I believe any discussion of supported employment and vocational services for people with psychiatric disabilities today must take into consideration the broader neoliberal political and economic ideology that has shaped our labour market and work lives since the early 1980s.
Neoliberalism promotes unrestricted markets as the most efficient mechanism for organising all aspects of human life. Thus, in the United States, the concept of disability is structured by one’s ability to perform ‘substantial gainful activity’, in essence, one’s ability to produce in a neoliberal capitalist system. Only those deemed completely incapable of performing substantial gainful activity are allocated financial benefits to sustain their existence. Here, I examine the ways in which this framework has resulted in a vocational services landscape in which people are strongly pressured to obtain jobs, but are primarily funnelled into low-wage positions with little to no job security. Their success or failure is primarily viewed through the lens of individualism and personal responsibility, divorced from broader social and economic forces, despite recent calls for greater attention to be paid to the social and structural determinants of mental health.
People with psychiatric disabilities are the largest category of beneficiaries of public disability benefits in the United States. At least in part due to the heavy emphasis on productivity in capitalist societies alongside the conflation of work with personal worth, employment is often conceptualised as a central pathway to recovery for people with psychiatric disabilities. This stance was pushed forward by many disability advocates themselves, exemplifying how intertwined the notions of independent living and economic self-sufficiency are in capitalist contexts. Many people with serious mental illness (SMI) report that work is central to their survival, social connectedness, self-determination and mental health recovery. Despite this and the fact that about two-thirds of individuals with SMI report a desire to work, more than half are unemployed, relying instead on extremely meagre disability benefits. Among people with schizophrenia, unemployment is even more common; approximately 80–90 per cent of people with this diagnosis are unemployed. As a result, one in three people with a SMI lives in poverty, and the depth of poverty – the extent to which they fall below the poverty line – is more than 50 per cent higher in households with a person with SMI than in households without.
Given the societal valorisation of employment and its purported association with mental health recovery, people with SMI are strongly encouraged to participate in supported employment programmes to help them get back to work. Individual Placement and Support (IPS) is the most studied and widely implemented model. IPS is a highly defined programme based on the following eight principles: 1) focused on competitive employment; 2) zero exclusion policy; 3) consideration of worker preferences; 4) rapid job search; 5) integration of vocational services with clinical services; 6) systematic job development; 7) benefits planning; and 8) time-unlimited services. IPS has consistently been shown to outperform other vocational service models in terms of getting people into competitive employment. However, people with psychiatric disabilities who do work tend to earn less, are less likely to work full-time, face greater job insecurity and have less advancement opportunities than their peers without psychiatric disabilities. This remains true whether they find employment independently, or with the help of IPS services. Furthermore, IPS services have been shown to have no association with improved mental health and quality-of-life outcomes, leading some in the field to question their ultimate purpose.
I assert that the supported employment model fails to consider the mental health effects of broader labour market forces. While laudable in theory, the tenet that obtaining competitive employment improves mental health denies the lived reality of low-wage work in the current economy, with many such workers forced to work multiple part-time jobs without benefits to survive. The reality of a rapid job search and placement before training often means that individuals are encouraged to take the jobs easiest to find, regardless of whether they are in alignment with the needs and skillset of the jobseeker. The most available jobs will tend to be those that offer the least amount of security. Precarious work situations lead to a variety of negative outcomes among the general public (e.g. decreased job satisfaction, job performance, self-esteem and self-efficacy, and increased depression, anxiety and burnout). The notion that these outcomes would be different for people with psychiatric disabilities is dubious. Those with serious mental illnesses who are able to escape the disability trap often do so through pursuing higher education and highly skilled occupations which are seldom the result of receiving vocational services; for the most part it is only people with personal wealth and/or financial support from family who can take this path.
A capitalist economy thrives on maintaining a group of individuals who are available to work low-wage, part-time jobs that generally do not provide employment benefits (e.g. health insurance, retirement funds, etc.) when the market requires such a workforce and who have enough of a social safety net to survive when their labour is no longer needed. This ‘reserve army’ approach allows the labour force to expand and contract to meet the needs of the market without creating a class of people who are unable to survive on the wages of such intermittent work alone. Currently, people with psychiatric disabilities who wish to work fit that role, and dominant models of vocational services provide a smokescreen through which to meet that demand while purporting to improve people’s mental health. I believe that to truly improve the mental health of people with psychiatric disabilities, there is a pressing need for more research to better understand the functions work serves and to create multiple pathways to fulfilling these needs that are more stable than placing people with serious mental illnesses in precarious work situations under the guise of the moral superiority of competitive work in a capitalist society.
Megan Evans has a PhD in Health Behavior and is Associate Research Scientist in the Yale Department of Psychiatry who researches the role of employment in mental health recovery as well the uses of peer support among people with psychosis.
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