Soc Psy chiatry Psychiatr Epi demiol (1990) 25: 108-113
9 Springer-Verlag1990
Work and mental health
Personal, social, and economic contexts*
L. J. Cohen
Department of Psychiatry,Universityof Wisconsin-Madison,Wisconsin,USA
Accepted August10, 1989
Summary. This paper offers a critique of the prevailing
view of the relationship between work and mental health.
The critique is based on an examination of the personal,
social, and economic contexts of work, especially in re-
gard to people with serious mental illnesses. The paper
concludes with a discussion of the implications of these
contexts for necessary changes in social structures, atti-
tudes, and vocational rehabilitation efforts.
The prevailing view of work's role in mental health and
mental illness is idealized and oversimplified. Oversimpli-
fied, because this view fails to account for the broader per-
sonal, social, and economic contexts of work. Idealized,
because it ignores the constraints and contradictions pro-
duced by these contexts. Furthermore, basic concepts of
work and mental health have not been adequately recon-
sidered in the light of the generally poor outcomes of con-
temporary psychiatric vocational rehabilitation efforts
(Anthony and Blanch 1987). This paper addresses some of
these neglected issues, especially as they relate to the vo-
cational rehabilitation of. people with serious mental ill-
nesses.
As currently conceptualized, work failure and in-
ability to work are seen as factors in the development of
mental illness and also as negative consequences of men-
tal illness (Perucci and Perucci, in press). Work success
and work satisfaction, on the other hand, are seen as fac-
tors in maintaining and promoting positive mental health
(Langner and Michael 1963) and a sense of identity
(Erikson 1968). Mental health, in turn, contributes to the
ability to make an adequate work adjustment (Kielhofner
1983). Among mental health professionals, work is often
considered therapeutic and is thus prescribed as a compo-
nent of psychosocial treatment (Neff 1985; Matsutsuyu
1983).
The limitations of this view of work are reflected in the
current status of psychiatric vocational rehabilitation.
* The National Institute of Mental Health (Grant MH14641) sup-
ported this work
Social Psychiatryan~
Psychiatric Epidemiology
From a variety of studies of psychiatric patients dis-
charged from the hospital into the community, Anthony
and Blanch (1987) concluded that the odds of readmission
are greater than the odds of beginning work. Compared to
other forms of disability, psychiatric disorders have the
lowest success rate of vocational rehabilitation (McCue
and Katz-Garris 1983). People with serious mental ill-
nesses are often excluded from vocational services (Solo-
mon et al. 1986), while services that are accessible are
often ineffective (Anthony and Blanch 1987). When fac-
tors such as job duration and job satisfaction are taken
into consideration, the inadequacy of psychiatric voca-
tional rehabilitation becomes even more pronounced.
The economic context
An examination of the economic context of work helps to
explain this systematic failure. The idealized view of
work-as-therapy tends to ignore the historical exploita-
tion of the labor of people with psychiatric diagnoses.
Foucault (1965) has described the exploitation of this
group and other indigent or deviant populations during
the 16th through 18th centuries. Though people with seri-
ous mental illnesses were initially rounded up into institu-
tions simply to isolate them from proper society, these in-
stitutions soon became workhouses. Even beyond the
coercion of their labor, Foucault described the extent to
which the mentally ill population was at the mercy of
economic trends, being driven out of these same institu-
tions, for example, when their cheap labor was too compe-
titive with other segments of the economy.
The unpaid or poorly paid labor of institutionalized
mental patients continued until quite recently. This prac-
tice was typically justified by an appeal to the right of pa-
tients to be productive, as well as to the therapeutic value
of such productivity. "(I)n these (work) assignments pa-
tients were able to experience.., success.., and the sense
of being contributing, productive members of the institu-
tional community" (Tiffany 1983).

Ironically, this very success tended to increase the pa-
tient's dependence on the hospital, since productivity in
the institution was often valued more highly than return to
employment after discharge. As large state-run hospitals
became increasingly dependent on inmate labor, even dis-
charge decisions were sometimes based on the economic
interests of the institution rather than the therapeutic in-
terests of the patient. As recently as the 1960s certain "key
workers" were not released from institutions which
needed their specific skills or experience, even though the
patients were so "rehabilitated" that many staff could not
tell them from employees (Kleymeyer 1970).
Despite claims of therapeutic benefits, the use of
cheap or free inmate labor came to be known as "institu-
tional peonage," or a form of slavery, and was largely abol-
ished by a series of court rulings in the 1970s (Friedman
and Yohalem 1978). These decisions argued that the clear
economic benefits to the institution, the absence of ade-
quate compensation, and the strong possibility of coercion
made any therapeutic benefits irrelevant. Other court rul-
ings in the same period mandated the right to treatment
for individuals involuntarily committed to mental institu-
tions; patient labor on the grounds or in the shops of these
institutions was specifically excluded from being regarded
as treatment (Tiffany 1983).
In the 18th century, Foucault (1965) argued, work-
houses for the mentally ill became controversial only
when they began to compete with non-institutional labor
for scarce resources. In the same manner, contemporary
practices related to patient labor have been greatly af-
fected by broad economic forces such as the level of unem-
ployment and the organization of labor, as well as by
evolving societal attitudes about work, mental illness, and
the relationship between the two. With the legal and fi-
nancial constraints of minimum wage and patients' rights
to treatment, meaningful work in institutions has virtually
disappeared. At the same time, however, the primary
locus for the treatment of mental illness has shifted away
from the institution and into the community. Many of the
old tensions between exploitation and work-as-therapy
have been transferred to the community as well.
Sheltered workshops, for example, typically pay less
than minimum wage, or pay by the piece for work that is
traditionally paid by an hourly wage. Very few people ever
graduate from this "secondary labor market" to competi-
tive employment (Dineen and Sowers 1981). Some pa-
tients are placed in community job positions, but are paid
below the going wage or not paid at all as part of a job
training or trial period (which can be of indefinite dura-
tion, see Forman 1988). Still others are placed in de-
meaning jobs or jobs below their educational or skill level.
While none of these vocational rehabilitation prac-
tices is necessarily exploitative, the potential for exploita-
tion is present in all of them, because of the possibilities
for coercion and for increased profits for employers. The
coercion aspect is especially important because refusal to
work at these jobs may be interpreted as a symptom or as
a sign of poor motivation and may be punished by a termi-
nation of benefits or services.
In addition to exploitation, other economic factors
that constrain the relationship between work and mental
109
health include the impact of economic downturns and the
inflexibility of the traditional work environment. In-
creases in unemployment tend to affect the most marginal
members of the workforce first (Williams 1980). More
specifically, Brenner (1973) found a consistent pattern
since the Civil War of economic instability leading to in-
creased psychiatric hospitalization rates. He attributed
this relationship to the direct impact of economic insta-
bility on mental illness, as well as to an indirect effect
mediated by a decreased tolerance for deviant behavior
during poor economic times.
The nature of work adds to the difficulties that people
with mental illness face, even during stable or expanding
economic periods. Work in the industrial (and post-indus-
trial) age can be characterized as requiring greater atten-
tion span, concentration, and social skills than work in
previous eras (Thompson 1967; Braverman 1974). Fur-
thermore, there is an increasingly abstract and symbolic
relationship between people's work and their daily sub-
sistence (Cohen 1967). In the absence of a clear relation-
ship between work and subsistence, the motivation to
work is easily undermined by factors such as psychiatric
symptoms or workplace intolerance.
Perhaps the most damaging shift for the mentally ill
worker has been the increase in the inflexibility of the or-
ganization of work. Before the shift from family produc-
tion to industrial production, work settings tended to be
more tolerant, to provide a niche for every person's abil-
ities, and to require less social competence or generaliza-
tion of skills (Thompson 1967; Ewen 1976). Recent
changes in these areas have had a dramatic impact on
people with the most serious mental illnesses, in which the
uncertainty, ambiguity, and erratic course of the illness
profoundly mismatches the narrowly defined work envi-
ronment.
The social context
When work failures (either in obtaining or maintaining a
job) are attributed primarily to the psychopathology of
the patient, the role of stigma in the intolerance of the
workplace and in the low self-esteem of the patient
becomes invisible. Similarly, while socialization into a
work role and socialization into the work ethic have been
recognized as predictors of adult work adjustment (Neff
1985), these socialization forces are ignored when work
failures are attributed solely to symptoms or character
flaws.
If the degree of socialization into adult work roles
mediates the effects of mental illness on work adjustment,
then symptoms of schizophrenia may not directly inter-
fere with work, but rather interfere with the development
of a work ethic or of an ego-ideal that includes work. This
formulation has important implications for developing
vocational interventions. A self-concept that includes
positive feelings about work might be fostered by volun-
teer work experience in a community setting, while this
same intervention would not be expected to directly affect
symptoms or level of motivation.
110
Interpersonal relationships are another potential so-
cial mediator of the impact of mental illness on work. The
expectations of families and others can have a powerful ef-
fect on a patient's decision to begin work or to continue
working (Freeman and Simmons 1963). Since the expec-
tations which people hold for the mentally ill are often
negative, understanding the interpersonal context is cru-
cial to understanding and preventing work failure. Just as
family pressure can affect work and other outcomes, the
response of family members, acquaintances, and society
at large to a person receiving benefits can have an impact
on work-related attitudes and behaviors. This response to
psychiatric disability payments is often marked by resent-
ment, stigmatization, and blame (Estroff 1981).
Moving beyond the family into the broader com-
munity, a range of factors can buffer or exacerbate the ef-
fect of a mental illness on an individual's work adjustment.
An ideal community, in terms of minimizing the negative
impact of mental illness on work, might be characterized
by tolerance of deviant behaviors, creative and assertive
activity in developing niches for each individual, and a
value placed on the contributions of each person. Work
possibilities would be maximized while the stigmatization
of both mental illness and vocational disability would be
minimized.
In contrast to this utopian community, the work and
non-work roles of people with mental illness tend to be
characterized by marginalization or exclusion. Consider
the low expectations held for the mentally ill adult: Neff
(1985), for example, described two "extremes" of voca-
tional placements, sheltered workshops and transitional
employment. Both of these are actually at the same ex-
treme of marginal functioning.
The kind of work that the poet and novelist Wendell
Berry (1987) refers to as "good work" - work which con-
nects the individual with family, community, and nature -
is difficult even for mentally healthy people to attain.
Since our society has such a narrow view of work, feelings
of belonging and connectedness are even less available to
people with serious mental illnesses.
The localization of work failure solely in the individual
patient trivializes the impact of family, community, and so-
ciety. This confounding of vocational maladjustment and
mental illness also assumes that social problems are
defined simply by objective states in the world rather than
by social constructions (Spector and Kitsuse 1977). Such
an assumption ignores the effect of changing social agen-
das and changing social definitions on the perception of
social problems.
For example, Foucault (1965) has described how un-
employment of the mentally ill in the Age of Reason was
only "recognized" as a social problem when such a formu-
lation became convenient for various powerful segments
of society. With the current constraints on governmental
spending in the United States, the vocational rehabilita-
tion of this population is once again gaining the status of a
social problem. While the unemployment rates for people
with psychiatric disabilities have not increased dramati-
cally, the increased focus on the cost of entitlement pay-
ments has changed the social definition of this problem
(Perucci and Perucci, in press).
The localization of vocational failure in the individual
also serves to exonerate social forces from their role in
creating and maintaining this failure. For instance, the
theory that vocational difficulties are directly caused by
psychiatric symptoms has not been significantly modified
by the observation that many patients are systematically
excluded from the work force, while others choose to re-
main unemployed as a rational choice among subsistence
strategies (Estroff 1981, p 172).
The interaction of social and personal contexts
The concepts of identity and socialization imply an over-
lap of the social world and the individual world, as social
messages are internalized and aspects of self-definition
are externalized. Consider the contradictory social mes-
sage given to mentally ill adults when society demands
and then prevents their participation in the world of work.
These conflicting pressures are easily internalized as a
personal sense of failure and low self-esteem.
Note also the confusion of the prevailing psychological
conceptions of work. On the one hand, work is considered
to be a royal road to self-actualization and is exemplified
by creative work. On the other hand, work is seen as a
resented requirement of living in a civilized world and is
exemplified by work on the assembly line (Neff 1985;
Cohen 1967). Neither side of this contradiction provides
any comfort for the person with a major mental illness.
Work for these individuals is rarely seen as creative or Self-
actualizing, but rather as structuring their time, keeping
them out of trouble, and/or lessening the financial burden
on families and communities (Linn 1980). The prototype
for the seriously mentally ill worker is not the scientist or
the artist, or even the factory worker, but the day laborer
or sheltered workshop employee.
Nevertheless, when mentally ill individuals reject
work they are seldom seen as boldly reacting against the
meaningless activity of the post-industrial workplace or
against the alienating routine of "putting in one's time."
Rather, they are seen as unmotivated, either because of
their illness or because they are manipulatively using their
illness to avoid an honest day's work. Since people with
serious mental illnesses are excluded from the roles of dili-
gent worker, eager consumer, or gentleman/woman of
leisure, it should not be surprising that they often actively
embrace the more marginal life-role of chronic patient-
hood (Estroff 1981).
Mentally ill adults who are clients of the mental health
and/or vocational rehabilitation systems are often caught
in another bind that overlaps the social and the personal
arenas. While vocational professionals typically insist that
one has to be well to work, many mental health workers
insist just as strenuously that one must work in order to
become well (Gendlin 1967). The individual is caught in
the cross-fire, denied services unless they are not needed.
The personal context
Moving to the personal end of the social-individual spec-
trum, people with mental illness have been incorrectly
viewed as fundamentally different from others in terms of

their vocational needs or vocational development.
Knowledge of a person's diagnosis is presumed to be
enough to plan a job placement or to understand a job
failure. Other considerations - such as interests, values, or
goals - tend not to be addressed when the individual in
question is mentally ill. Anthony et al. (1984), for
example, note that the critical area of career counseling
(the clarification of goals, interests, and opportunities) is
routinely ignored in psychiatric vocational rehabilitation,
presumably because the presence of mental illness is
thought to make these issues irrelevant.
Two contradictory views of work often co-exist in clini-
cal settings for the treatment of serious mental illness. The
first is that work is a straightforward activity with inherent
human and therapeutic value. This view neglects the fact
that the individual patient, like any other potential
worker, weighs a wide range of factors in making a deci-
sion about work. These factors include the societal desira-
bility or value of a job; the wages and benefits; the diffi-
culty and stress level; the tolerance of co-workers and
employers for one's special needs and behaviors; the dis-
crepancy between an available job and one's education,
social class, prior work history, or expectations; and alter-
native sources of income and personal fulfillment. All of
these issues are ignored each time a job failure is at-
tributed to "poor motivation" or "uncooperativeness with
the treatment plan."
The competing view observed in clinical settings also
neglects the complex set of issues listed above, in this case
because work is seen as "too stressful" for a mentally ill
person. This apparent protection of clients for their own
good persists in spite of data that some programs have
been quite successful in helping a wide variety of seriously
ill patients to maintain competitive work activities with-
out inducing stress-related relapses or symptoms (Strauss
et al. 1985).
Numerous social critics have noted that modern
workers are estranged from their own work-related acti-
vities. Ironically, the eradication of exploited labor in
mental institutions has made this estrangement especially
pervasive for people with serious mental illnesses. Rou-
tinized, non-contributory, make-work activities can
undermine the very feelings they are designed to promote,
namely productivity and engagement with the social
world. Because funds are not available to pay for
meaningful work, many patients, especially in inpatient or
other institutional settings, end up making gimp keychains
or leather change purses. While occupational and recre-
ational therapy are often beneficial, this effect is more
likely due to the therapeutic relationship and to the sen-
sory stimulation than to the "work" activity per se.
Vocational failure by people with serious mental ill-
nesses is often attributed to the adoption of the role of
chronic patienthood. This attribution is often made in a
blaming or derogatory manner. In adopting this role,
however, Estroff (1981) argues that people with chronic
mental illness do not get a "free ride." On the contrary,
they work for their disability and/or welfare payments
by engaging in the profession of patienthood. Instead of
making a product or providing a service, their work in-
volves the production of stigma, symptoms, deviance,
111
and inability to function. Their work also involves a sac-
rifice of normality, especially in the area of social rela-
tionships.
In exchange for this work, "professional patients" re-
ceive a wage which is inadequate for a decent quality of
life and is seen by the outside world as unearned and a
burden on the community. These patients also turn over
their autonomy to the mental health establishment, which
has been described in this regard as an agent of social con-
trol (Szasz 1961; Brenner 1973). Estroff's analysis has re-
vealed that the supposed "life of leisure lived at the tax-
payer's expense" is in fact a constant struggle between
"losses in personal and interpersonal dignity . . . and . . .
failure, anxiety, and destitution" (1981, p 169-170).
Recommendations
When the social and personal contexts of work are exam-
ined, a pattern emerges of patients being blamed for voca-
tional failures that are shaped by societal forces, economic
pressures, and caregiver attitudes. Nevertheless, voca-
tional difficulties are still seen primarily as symptoms. The
radical changes that are needed to re-shape the personal,
social, and economic contexts in which work is embedded
must, of course, extend to the social fabric as a whole and
not just to the treatment of mental illness. With large num-
bers of non-mentally ill adults unemployed, our society is
a long way from providing a valued niche for every person
with a serious mental illness. The eradication of the in-
tolerance and stigma that isolates and excludes the men-
tally ill is another major step that must be taken as a pre-
requisite to meaningful changes in the structure of work.
The self-actualizing nature of creative and productive
work is an unkept promise even for most mentally healthy
people, much less for people with special needs and spe-
cial obstacles. In terms of freedom from routinized and
alienating work, Cohen (1967) suggested that because of
increasing mechanization, the disabled "person who gets
a pension and can use his time well at home may be a pre-
cursor of the (person) of the future" (p 10). However, if
the current discrimination against vocationally disabled
adults (Dineen and Sowers 1981) is any indication, this
person of the future will be condemned and isolated,
rather than integrated into a community and liberated
from drudgery.
Though we may be a long way from valuing the con-
tributions of each individual, from not blaming disabled
people for their disabilities, from basic economic justice,
or from an ideal community that integrates each member,
there are still many practical changes that can be made in
the interim. The following suggestions are based largely
on the philosophy and practice of psychiatric vocational
rehabilitation of PACT (Program of Assertive Com-
munity Treatment, also known as Training in Community
Living), a model outreach program of the Mendota Men-
tal Health Institute in Madison, Wisconsin (Test et al.
1985).
On an attitudinal level, the PACT model stresses high
expectations for each vocationally disabled client while
accepting differences and special obstacles to competitive
112
employment, focusing on growth rather than stability
(even for those individuals most seriously ill), and maxi-
mizing normalization rather than minimizing stress. On a
more concrete level, changes that can help promote suc-
cessful work outcomes for people with serious mental ill-
nesses include integrating vocational rehabilitation with
other areas of treatment and recognizing the interaction
between work and all other areas of a client's life.
Many programs carefully screen potential clients and
then close cases shortly after a job placement. This prac-
tice excludes the people in most need and creates a situ-
ation in which people are likely to "fail out" of a program.
PACT's alternative is an emphasis on pre-vocational in-
terventions, job maintenance, and long-term ongoing sup-
port, with minimal or no prerequisites for receiving ser-
vices and no chance of failing out.
Another factor is the creative use of community jobs
rather than a reliance on limited institutional settings.
With the range of available jobs widened, vocational
counselors and clients can consider important factors such
as skills, interests, goals, wages, responsibility, autonomy,
and tolerance of co-workers in the matching of workers
with jobs. Most importantly, vocational services, like all
psychosocial rehabilitation services, must be individ-
ualized. Programs which provide every client with the
same type or amount of support or services, or which as-
sign jobs on the basis of available slots in a sheltered work-
shop or business, cannot expect to maximize independent
competitive employment.
The recognition that work can be an impetus for
change as well as a positive outcome measure is another
important attitudinal shift. In this context, entitlements
can be seen as more than simply work disincentives or as
the only viable source of income for the mentally ill.
Rather, entitlements are an important factor in the bal-
ance between meeting basic needs, developing a stable en-
vironment and a stable self-image, and maximizing moti-
vation to work.
Another change involves separating two issues that
are often confounded: expectations in regard to work per-
formance and expectations in regard to non-work behav-
iors. When these issues are confounded, employers and
treatment staff may feel that the only options are firing the
client or ignoring poor work performance. Some clients
are never placed because their non-work behaviors are
seen as too bizarre or disruptive. In fact, however, it is
possible to maintain high standards of work productivity
while making special allowances in other areas, such as
tolerance of unusual behaviors, increased emotional sup-
port, flexible work hours, or frequent consultation be-
tween staff and employers.
A long-term commitment to clients is another critical
element, since successful outcomes in the vocational area
may take many years of intensive effort for people with
the most serious mental illnesses. An ongoing relationship
is necessary not just for this long-term commitment, but
also for a coherent and comprehensive view of a person's
strengths and weaknesses and of the effectiveness of vari-
ous interventions. Finally, a long-term view is an antidote
for the all-or-nothing mentality that is prevalent in many
vocational rehabilitation efforts (Newman 1970).
This paper has focused on problems and deficiencies in
existing theoretical and practical approaches to work and
mental health and has, therefore, given little attention to
the programs and individuals that have overcome these ob-
stacles and have done excellent work in this area. At its
best, psychiatric vocational rehabilitation has transcended
the choice between non-work and alienating work, adding
a third choice of meaningful work in a community that
values and respects the contribution of the mentally ill
worker. Even more deserving of acclaim are those individ-
uals who alone or despite the efforts of well-meaning pro-
fessionals have created this choice for themselves.
Esso Leete (1988) was told that she would never be
able to work again after she was diagnosed as having schi-
zophrenia. At the same time she was denied disability pay-
ments, on the grounds that she could do "piece work."
Happily, she rejected both 0f these messages and found a
salaried job. She offers a powerful statement of the
meaning of this work in her own life:
A community support program can help residents devel-
op a predictive daily schedule to offset their chaotic inner
e x i s t e n c e . . . Any number of structured activities could sa-
tisfy this need, but I have found work - a paying job - to be
the most helpful. My job gives me something to look for-
ward to every day, a skill to learn and improve, and an
earned income. It is my motivation for getting up each
morning, not always an easy task for psychiatric patients.
My hours at work are spent therapeutically as well as pro-
ductively, for through steady employment I have learned
to value myself and trust in my ability to overcome my
disease (Leete 1987, p 489).
Acknowledgements. I thank Steven Clayman, Roberta Braun Cur-
tin, Jonathan Fay, James Greenley, and Daniel Kleinman for com-
ments on earlier drafts. Thanks are also due to the Program of Asser-
tive Community Treatment of the Mendota Mental Health Institute,
Madison, Wisconsin.
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L. J. Cohen, Ph.D.
Wisconsin Institute for Psychotherapy
1906 Monroe Street
Madison, W153 711
USA